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Palliation: Hilar cholangiocarcinoma.
[cholangiocarcinoma]
Hilar
cholangiocarcinomas
are
common
tumors
of
the
bile
duct
that
are
often
unresectable
at
presentation
.
Palliation
,
therefore
,
remains
the
goal
in
the
majority
of
these
patients
.
Palliative
treatment
is
particularly
indicated
in
the
presence
of
cholangitis
and
pruritus
but
is
often
also
offered
for
high
-grade
jaundice
and
abdominal
pain
.
Endoscopic
drainage
by
placing
stents
at
endoscopic
retrograde
cholangio-pancreatography
(
ERCP
)
is
usually
the
preferred
modality
of
palliation
.
However
,
for
advanced
disease
,
percutaneous
stenting
has
been
shown
to
be
superior
to
endoscopic
stenting
.
Endosonography-guided
biliary
drainage
is
emerging
as
an
alternative
technique
,
particularly
when
ERCP
is
not
possible
or
fails
.
Metal
stents
are
usually
preferred
over
plastic
stents
,
both
for
ERCP
and
for
percutaneous
biliary
drainage
.
There
is
no
consensus
as
to
whether
it
is
necessary
to
place
multiple
stents
within
advanced
hilar
blocks
or
whether
unilateral
stenting
would
suffice
.
However
,
recent
data
have
suggested
that
,
contrary
to
previous
belief
,
it
is
useful
to
drain
more
than
50
%
of
the
liver
volume
for
favorable
long
-term
results
.
In
the
presence
of
cholangitis
,
it
is
beneficial
to
drain
all
of
the
obstructed
biliary
segments
.
Surgical
bypass
plays
a
limited
role
in
palliation
and
is
offered
primarily
as
a
segment
III
bypass
if
,
during
a
laparotomy
for
resection
,
the
tumor
is
found
to
be
unresectable
.
Photodynamic
therapy
and
,
more
recently
,
radiofrequency
ablation
have
been
used
as
adjuvant
therapies
to
improve
the
results
of
biliary
stenting
.
The
exact
technique
to
be
used
for
palliation
is
guided
by
the
extent
of
the
biliary
involvement
(
Bismuth
class
)
and
the
availability
of
local
expertise
.
Diseases
Validation
Diseases presenting
"limited role in palliation"
symptom
cholangiocarcinoma
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