Biliary Strictures

Question 1

In patients w/ extra hepatic biliary stricture due to apparent or suspected pancreatic mass, we recommend EUS w/ fine-needle sampling (aspiration or biopsy) over ERCP as the preferred method for evaluating malignancy

Answer 1

strong, moderate evidence

Question 2

In patient w/ extra hepatic biliary stricture due to an apparent or suspected pancreatic mass, we suggest EUS w/ FNB or EUS w/ FNA plus ROSE over FNA w/o ROSE as the preferred method for evaluating malignancy

Answer 2

conditional, very low evidence

Question 3

In patients w/ suspected malignant perihilar stricture, we recommend multimodality sampling over brush cytology alone at the time of the index ERCP

Answer 3

strong, low evidence

Question 4

In patients w/ extra hepatic stricture due to a benign condition, we recommend fcSEMS placement over multiple plastic stents in parallel to reduce the number of procedures required for long-term treatment

Answer 4

conditional, low evidence

Question 5

In patients w/ extra hepatic structure due to resectable pancreatic cancer or cholangiocarcinoma, we suggest against routine preoperative biliary drainage. In select patients, including those w/ acute cholangitis, severe pruritus, very high bile, and those undergoing neoadjuvant therapy or experiencing another anticipated delay to surgery, preoperative biliary drainage is warranted

Answer 5

conditional, low evidence

Question 6

In patients w/ malignant extra hepatic biliary stricture that is unresectable or borderline resectable, we recommend SEMS placement over plastic stent placement

Answer 6

strong, moderate evidence

Question 7

In patients w/ a malignant extra hepatic biliary stricture that is unresectable or borderline resectable, the evidence is insufficient to recommend for or against uSEMS vs fcSEMS placement

Answer 7

insufficient

Question 8

In patients w/ perihilar stricture 2/2 suspected malignancy, the evidence is insufficient to recommend for or against ERCP vs PTBD

Answer 8

insufficient

Question 9

In patients w/ malignant perihilar stricture, the evidence is insufficient to recommend for or against PS vs uSEMS placement

Answer 9

insufficient

Question 10

In patients w/ malignant perihilar stricture due to cholangiocarcinoma who are not candidates for resection or transplantation, we suggest the use of adjuvant endobiliary ablation + plastic stent placement over plastic stent placement alone

Answer 10

conditional, low evidence

Question 11

In patients w/ biliary stricture, in whom ERCP is indicated but unsuccessful or impossible, we suggest EUS-guided biliary access/drainage over PTBD, based on fewer adverse events, when performed by an endoscopist w/ substantial experience in these interventional EUS procedures

Answer 11

conditional, very low evidence