Thread by @DrAnuraagJ

1/15

📢The recent ACG Guidelines on biliary strictures

👉Focus on DRAINAGE principles

🔥A Tweetorial #GITwitter @AmJGastro

2/15
Goals of drainage

▶️to alleviate symptoms (when present),

▶️to reduce serum bilirubin for chemotherapy can be safely administered (typically 2.5–3.5 mg/dL) and

▶️to optimize surgical outcome

3/15
Extrahepatic stricture due to a benign condition,

👉fcSEMS over multiple plastic stents(MPS)

▶️12 months MPS or
▶️6 months fcSEMS,
🔥some evidence suggests 12 months of fcSEMS therapy is advantageous (exchange at 6 months).

4/15
In patients with benign biliary stricture and GB in situ,

▶️MPS instead of fcSEMS

because of possible increased risk of acute cholecystitis (1%).

5/15 In extrahepatic stricture due to resectable pancreatic cancer or cholangiocarcinoma, the guidelines suggest

🚫AGAINST routine preoperative biliary drainage (conditional recommendation, low-quality evidence)

6/15
preoperative biliary drainage is warranted in --

👉those with acute cholangitis,
👉severe pruritus,
👉very high serum bilirubin levels, and
👉those undergoing neoadjuvant therapy or
👉delay to surgery (>2 weeks)

7/15
In patients with a malignant extrahepatic biliary stricture unresectable or borderline resectable,

▶️SEMS over PS placement

😖Insufficient to recommend for or against uSEMS vs fcSEMS

8/15 In patients with a malignant extrahepatic biliary stricture who are candidates for pancreaticoduodenectomy and undergo uSEMS placement

🎯Place proximal (upstream) end of the prosthesis at least 1.5 cm below biliary confluence.

9/15
obstructive jaundice due to malignant perihilar stricture who are otherwise asymptomatic and who have declined or are not candidates for additional treatment,

🙅‍♂️Palliative drainage is NOT MANDATORY and decided on an case basis.

10/15
Perihilar stricture due to suspected malignancy,

😖insufficient to recommend for or against ERCP vs PTBD.

11/15
Perihilar stricture:
✅Drainage in a volumetric sectorial fashion and
🚫not in terms of unilateral vs bilateral.

🧐Goal is to drain 50% of nonatrophic liver,
with each sector contributing 1/3rd of liver’s volume

12/15
In patients with a malignant perihilar stricture,

😖insufficient to recommend for or against PS vs uSEMS placement.

🧐If SEMS is chosen for drainage, an effective drainage strategy using plastic stent should be proven first

13/15
Malignant perihilar stricture due to cholangiocarcinoma who are not candidates for resection or transplantation

✅adjuvant endobiliary ablation ( PDT or RFA) plus plastic stent over plastic stent alone

14/15 In patients with a biliary stricture, in whom ERCP was unsuccessful or impossible,

👉EUS-guided biliary access/drainage over PTBD,

✅based on fewer adverse events, when performed by an experienced endoscopists

15/15 Thank you for reading this amazing work on @AmJGastro

Link for the full article

journals.lww.com/ajg/Fulltext/2…

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