Management of malignant biliary obstruction: nonoperative and palliative techniques

Biliary tract drainage, with or without placement of an endoprosthesis, is used as a palliative therapy for malignant biliary obstruction. The first truly internal endoprostheses represented a distinct improvement over internal-external catheters but still remained patent for only 4 to 6 months. Metallic stents have a long-term patency of 6 to 8 months. At present, it appears that patients with unresectable pancreatic cancer should be palliated with endoscopically placed plastic or metal stents, whereas those with malignant obstructions higher in the biliary tree are probably better managed with transhepatically placed stents. The combination of brachytherapy plus external-beam radiation followed by implantation of a Gianturco metal stent may be a viable approach to treating obstructions in patients with cholangiocarcinoma. For those with other noncholangiocarcinomas, particularly when life expectancy exceeds anticipated stent patency duration, the Wallstent may be the device of choice.