Editor: Peter B. Cotton
4. The role of ERCP in pancreatico-biliary malignancies
Gulshan Parasher & John G. Lee
Approximately 30 000 new cases of pancreatic cancer and 7000 biliary tract cancers are diagnosed annually in the United States . The most common cause of malignant biliary obstruction is pancreatic adenocarcinoma, followed by cholangiocarcinoma, ampullary
neoplasm, and extrinsic compression by metastatic lymphadenopathy in the liver hilum. The role of ERCP in pancreatico-biliary
malignancies is to  confirm diagnosis of obstructive jaundice in patients with suspected pancreatic carcinoma or biliary tumors ; obtain tissue for histopathologic diagnosis ; establish the exact site of obstruction, i.e. ampullary, pancreatic, or bile duct ; decompress the bile duct; and  facilitate palliative therapy such as intraluminal brachytherapy or intraductal photodynamic therapy. This review describes
various current and emerging applications of ERCP in the management of pancreatico-biliary malignancies.
ERCP in diagnosis of pancreatico-biliary malignancies
Significance of 'double duct stricture' sign
The radiographic features of ERCP cannot reliably distinguish between benign and malignant diseases. Although the double duct
sign with simultaneous narrowing of the common bile duct and the pancreatic duct has been regarded traditionally as predictive
of pancreatic cancer (Fig. 1) recent studies showed that its specificity is much lower than previously thought, with 1537% of such patients having benign disease on long-term follow-up [2,3]. Stricture length > 14 mm was highly predictive of malignancy in one study  while in another study the pancreatic duct stricture length measured on ERCP correlated with both size (P < 0.001) and staging (P < 0.002) of the pancreatic cancer . The cholangiographic appearance was non-specific as benign-appearing strictures were usually found to be malignant on follow-up
Histopathological confirmation of pancreatico-biliary malignancy permits more accurate decision-making with reference to comprehensive
management including the potential use of radiation and/or chemotherapy.
Brush cytology, biopsy, and FNA
Endoscopic wire-guided brush cytology and endoscopic needle aspiration or forceps biopsy can be successfully performed during
ERCP for cytological diagnosis (Fig. 2). Wire-guided brushing cytology is performed initially by passing the cytology catheter sheath beyond the proximal margin
of the stricture; the brush is then advanced out of the sheath. The brush and sheath are then withdrawn to the distal margin
of the stricture and the brush is passed back and forth across the stricture.
Earlier studies of brush cytology (usually from the bile duct) showed sensitivity of approximately 40% and specificity of
100% for diagnosis of malignancy [6,7]. Sampling of both ducts and dilating the bile duct stricture before brushing have been shown to improve the sensitivity of
diagnosing pancreatic and biliary cancers to approximately 5070% in several studies [8,9]. Pancreatic duct brushing appears to be safe without an increased risk of pancreatitis in these studies.
Finally, combining the results of brush cytology, fine needle aspiration, and/or forceps biopsy improves the overall sensitivity of ERCP in diagnosing pancreatic and biliary cancers to 7085%, which is higher than any single method of tissue sampling . We recommend performing at least two different types of tissue sampling procedures to improve the diagnostic accuracy of
ERCP in patients with suspected pancreatico-biliary cancers.
Tumor markers in bile or pancreatic juice
A number of molecular and genetic markers have been studied alone or in combination in bile or pancreatic juice for the diagnosis
of pancreatico-biliary malignancies (Fig. 3). Molecular-based tests may be helpful in diagnosing pancreatic cancer and other biliary malignancy at an early stage when
surgical cure is still possible. Addition of DNA image analysis to routine cytology has been reported to increase the diagnostic
sensitivity as compared to results of cytology alone . Other studies focused their attention on mutations in codon 12 of the K-ras oncogene, because they are seen in up to 95% of pancreatic adenocarcinoma and in the premalignant conditions of the pancreas
. Bile obtained during ERCP can yield positive results in K-ras mutational analysis, even when results of conventional bile cytology are negative. One study reported a sensitivity of 33%,
and specificity and positive predictive value of 100%, for the diagnosis of malignancy by K-ras mutational analysis in bile samples obtained during ERCP .
Most recent studies, however, suggest that K-ras mutational analysis is not specific for the diagnosis of pancreatic cancer as this mutation is also seen in a number of patients
with chronic pancreatitis [16,17]. The specificity of K-ras mutational analysis may be increased by additional molecular genetic analysis. For example combination of K-ras mutation and telomerase activity or p53 immunostaining has been reported to increase the specificity for diagnosis of cancer
to 100% [18,19]. Another study showed that detection of antigen 90K in pancreatic juice in combination with serum CA 199 correctly identified 84.2% of pancreatic cancers and 90% of chronic pancreatitis cases . In conclusion, the presence of K-ras mutations in pancreatic juice (and other material obtained during ERCP) is not specific enough to justify its use in clinical
practice. Although combining K-ras mutational analysis with other tumor markers such as p53 and telomerase may further increase its specificity, the sparse
data available are preliminary and therefore such analysis should be considered investigational at this time.
Direct endoscopic examination of pancreatico-biliary malignancies
Choledochoscopy using the mother and baby scope system is used to visualize the bile duct, obtain specimens, and to treat
stones and tumors . In a series of 61 patients who underwent choledochoscopy for various indications, three patients with suspected choledocholithiasis
were diagnosed with benign epithelioid tumor, large cell lymphoma, and cholangiocarcinoma . Of six patients with suspected cholangiocarcinoma, four had cholangiocarcinoma, one had ampullary cancer, and one had an
eroding surgical suture. Choledochoscopy showed intraductal metastasis from colorectal cancer, bleeding hepatoma, cholangiocarcinoma,
and angiodysplasia of the bile duct in four patients with hemobilia. Finally, choledochoscopy-guided ND:YAG laser was used
to debulk tumor ingrowth in several patients with blocked Wallstents .
Pancreatoscopy has been shown to be an effective tool in the diagnosis of cystadenoma and cystadenocarcinoma of the pancreas
. Pancreatoscopy was successful in 30 of 41 patients (73.2%) and showed villous or vegetative elevations in patients with
dysplastic adenoma or adenocarcinoma. Pancreatoscopy led to partial resection in 7 of 30 patients with non-malignant tumors
resulting in favorable outcomes . Pancreatoscopy was also useful for detecting and distinguishing benign from malignant intraductal papillary mucinous tumor
(IPMT) and in determining the extent of tumor involvement of the main pancreatic duct in planning for resection .
Intraductal ultrasound [IDUS]
IDUS is performed by selectively cannulating the bile duct using a 6 French gauge, high-frequency (20 MHz) mini-probe during ERCP. This technique can visualize the extra hepatic and right and left intrahepatic ducts and is useful
for performing tumor staging during the initial ERCP. IDUS can assess portal vein and right hepatic artery invasion at the
liver hilum and is more accurate than conventional endoscopic ultrasound (EUS) in assessing pancreatic parenchymal invasion
by bile duct cancer .
IDUS has been used in combination with other methods to increase the diagnostic yield for cancer. In one study, a combination
of peroral pancreatoscopy and IDUS was helpful in differentiating malignant from benign IPMT and resulted in an improvement
in postoperative survival . Tamada et al. showed that the presence of sessile tumor, tumor size > 1 cm, and interrupted wall structures was helpful in predicting malignancy in 62 patients with malignant biliary strictures
and prior negative biopsies .
Magnetic resonance cholangiopancreatography
Magnetic resonance cholangiopancreatography (MRCP) is an emerging application of magnetic resonance imaging (MRI) applied
to the pancreatico-biliary tree. MRCP relies on heavily T2weighted sequences. Fluid-containing structures have a much longer T2 than solid tissue, resulting in higher signal intensity.
Stationary fluid in the biliary and pancreatic ducts serves as an intrinsic contrast medium and the ductal system appears
white against a black background, similar to ERCP.
MRCP vs. ERCP
The major advantages of MRCP are that it does not require endoscopy, contrast injection, or exposure to radiation. MRCP has
been reported to distinguish between benign and malignant bile duct obstruction, with sensitivity between 50 and 86% and specificity
between 92 and 98% . MRCP has been reported to be similar to ERCP in distinguishing between malignant and benign biliary obstruction with respect
to sensitivity (86% vs. 89%), specificity (82% vs. 94%), and likelihood ratios for positive (4.9 vs. 15.1) and negative tests
(0.2 vs. 0.1), respectively .
In another comparative study, the sensitivity of ERCP for diagnosing pancreatic cancer was lower (70% vs. 84%) because it
missed 11 lesions < 3 cm, most of which were in the head of the pancreas . ERCP was associated with several mild cases of pancreatitis, fever, and epigastric pain while MRCP was free of complications
. MRCP is also helpful in visualizing the main pancreatic duct in patients with IPMT, especially when ERCP fails because of
copious intraductal mucin .
Finally, MRCP can be used to confirm the presence and location of a biliary stricture in a patient with obstructive jaundice
before therapeutic ERCP, particularly in those with complex hilar lesions, thus minimizing the risk of contamination and infection.
MRCP-guided endoscopic unilateral stent placement was associated with lower morbidity and mortality as compared with standard
method of stent insertion in 35 patients with Bismuth types III and IV hilar tumors .
In conclusion, MRCP is a safe, non-invasive, and accurate, but operator-dependent technique for imaging the pancreatico-biliary
system. MRCP should be used instead of purely diagnostic ERCP when available and before attempting stenting in patients with
Palliation of inoperable pancreatico-biliary malignancies
ERCP is the preferred method of palliating patients with malignant obstructive jaundice. Successful biliary drainage by endoscopic
stenting can be achieved in more than 90% of patients with low procedure-related morbidity and mortality [36,37]. Although only surgery offers potential for a cure, endoscopic palliation continues to remain the therapeutic goal in most
patients, because the majority of pancreatico-biliary cancers present at an advanced stage in elderly patients, who are poor
surgical candidates. Several randomized trials comparing surgical bypass to endoscopic stenting in patients with unresectable
lesions showed similar success rates for biliary decompression and overall survival, but lower morbidity and 30-day mortality
for the ERCP-treated patients .
ERCP also reduced the cost and shortened hospital stay (P < 0.001) compared to surgery  and improved the quality of life . Although the percutaneous approach is another alternative to ERCP for biliary drainage, it should be reserved for patients
with duodenal obstruction or failed ERCP, because a randomized comparative study showed it to be less successful and causing
more complications compared to ERCP . Pancreatic duct stenting has been reported to be helpful in relieving 'obstructive' pain from pancreatic cancer in some patients . In conclusion, endoscopic palliation is highly successful, has a lower morbidity and mortality, and costs less compared
with other approaches to pancreatico-biliary malignancies.
Endoscopic stenting for malignant jaundice
Technique of endoscopic stent insertion
ERCP and endoscopic stent insertion require deep cannulation of the common bile duct with a catheter and guidewire. A diagnostic
ERCP is mandatory prior to stent insertion to evaluate the pancreatico-biliary system. The length and the location of the
stricture should be carefully determined and the proximal biliary tree should be assessed.
The procedure may prove to be technically difficult in cases where tumors distort the duodenal or the ampullary anatomy. The
stent is usually placed through a therapeutic duodenoscope with an instrument channel of at least 4 mm. A prior sphincterotomy is usually only needed for placement of multiple large stents or to facilitate future stent exchanges
in patients with difficult access. Difficult cannulation at times may require precutting of the ampulla using a needle knife
sphincterotome (needle knife sphincterotomy) to gain access into the biliary system.
Dilatation prior to stent insertion is required only for extremely tight strictures, but we recommend routinely dilating hilar
strictures prior to stenting (Fig. 4).
For insertion of a plastic stent, a basic three-layer coaxial system consisting of a 0.035-inch guidewire and a 6 Fr guiding
catheter is used. These are placed sequentially across the stricture and the stent is deployed with the help of a pusher tube.
A modified stenting system (OASIS, Wilson Cook) combines the pusher and inner catheter into one system to minimize the number
of exchanges. In patients with bifurcation obstruction, two wires should be placed first into the right and left systems,
before attempting double stenting into the right and left hepatic ducts.
Types of stents
Plastic stents are mostly made of polyethylene. Other materials used are polyurethane and Teflon. The mean patency of a plastic
stent is approximately 24 months [43,44]. Important complications associated with plastic stents include stent occlusion, sepsis, stent migration, stent fracture,
and, rarely, acute cholecystitis related to occlusion of the cystic duct .
The major disadvantage of plastic stents is occlusion from bacterial biofilm, which is comprised of protein, deconjugated
bilirubin, microcolonies of bacteria, and amorphous debris . Stent occlusion leads to recurrence of jaundice or cholangitis, necessitating stent exchanges in 3060% of patients . Unfortunately, attempts to improve the patency rates of plastic stents by alternative stent design, oral administration
of bile acids, antibiotics, and aspirin have not been clinically successful .
The self-expandable metal stent (SEMS) was developed to overcome the short patency of the plastic stent. SEMSs are made of
either stainless steel alloy monofilaments (Wallstent, Boston Scientific, Natick, MA and Spiral Z stent, Wilson Cook, Winston
Salem, NC) or nickel titanium alloy (Diamond Stent, Boston Scientific, Natick, MA and Za stent, Wilson Cook, Winston Salem,
The comparative efficacy of each design is not well known and their use is guided more by physician preference. SEMSs can
be compressed on to a 3-mm delivery system and expanded to 10 mm after deployment. The larger luminal diameter of these stents offers a prolonged patency of up to 1012 months. However, the cost per device is significantly higher than plastic stents ($10001500 vs. $50100).
SEMSs can also occlude but through different mechanisms, including biliary sludge, dietary fiber, tumor ingrowth or overgrowth,
epithelial hyperplasia, or a combination of these. Management of an occluded metal biliary stent includes mechanical dislodgement
of the obstructing material, placement of a plastic stent within the metal stent, and placement of a second overlying or overlapping
stent to improve drainage. Electrocoagulation or laser therapy to destroy the ingrowing tumor has not been effective .
Metal vs. plastic stents
Metal stents have been compared with plastic stents in different studies. In 47 patients with pancreatic cancer with a mean
survival of 6.2 months from the time of endoscopy, metal stents were shown to have a longer patency than plastic stents8.2 months vs. 3.5 months (P < 0.001) .
A prospective randomized trial in France evaluated 97 patients with malignant strictures of the bile ducts (64% with pancreatic
cancer), who were randomized to receive either an 11.5 Fr stent to be exchanged on demand or every 3 months, or a self-expanding
metallic wall stent . Mean duration of follow-up was 166 days. Cost effective analysis suggested that metal stents were advantageous for patients
surviving longer than 6 months, whereas plastic stents were advantageous for patients surviving less than 6 months. This study
showed initial metal stenting to be the most cost effective approach, provided that the patient survived for longer than 6
The US Wallstent multicenter randomized trial evaluated the Wallstent compared with 10F plastic stents for the palliation
of malignant biliary obstruction . Early stent occlusion was reported in 30% of the plastic group and in 0% of the Wallstent group. Sludge occlusion and stent
migration were seen in 28% of plastic stents and 6% of Wallstents. The overall complication rate was significantly lower in
the Wallstent group (P < 0.05) for both hilar and distal biliary strictures. Wallstents did not offer any survival advantage over the plastic stent
but were less expensive because they required fewer repeat ERCPs and stent exchange.
A prospective study from Amsterdam compared Wallstents with plastic stents in distal malignant biliary obstruction and reported
a lower occlusion rate (33% vs. 54%), longer stent patency (273 vs. 126 days), and 28% reductions in ERCPs per patients in
the Wallstent group . These studies show that Wallstents can be deployed successfully in most patients and occlude less frequently and less rapidly
than the conventional 10 Fr and 11.5 Fr plastic stents.
Logically, therefore, Wallstent use reduces hospitalization and repeated interventions leading to a lower cost. In conclusion,
the most cost effective approach to palliating malignant obstructive jaundice is to place a SEMS at the initial ERCP in patients
with unresectable cancer who have a life expectancy of at least 6 months.
Covered and uncovered metal stents
Metal stents partially covered with silicone or polyurethane membrane have been introduced to overcome the problem of tumor
ingrowth and epithelial hyperplasia. Shim et al. compared endoscopically placed polyurethane-covered Z-stent to non-coated Wallstent or Strecker stent . The median patency of both covered and uncovered stents was comparable (267 vs. 233 days), but tumor ingrowth was seen in
two patients with the covered stents compared to six in the non-covered stent group. Early and late complications were the
same in both groups .
Reported complications associated with covered stents include tumor ingrowth or overgrowth, sludge accumulation, stent migration,
pancreatitis, and gangrenous cholecystitis [44,5456]. Finally, covered biliary metal stents have not uniformly shown a significant advantage in terms of greater patency rates
Self-expanding mesh stents made of biodegradable materials behave similarly to their wire mesh counterparts, but disintegrate
and disappear over time. Polylactic acid is used in one such bioabsorbable stent. Post implantation, body heat and water degrade
the polymer to lactic acid, then via the Krebs cycle to CO2 and H2O.
Animal studies of the canine bile duct using the bioabsorbable biliary mesh stent made from polylactic acid have shown that
the stent becomes embedded within the bile duct epithelium within 1 month of implantation . There was minimal inflammatory reaction after 6 months and the histology reverted to baseline, with complete disintegration
of the stent after 2 years. These stents offer long-term palliation without precluding subsequent resection in patients with
suspected but unproven malignant stricture, or for those in whom curative resection is unlikely but not ruled out. The exciting
potential applications in the future for these devices include delivery of chemotherapeutic agents or cellular gene therapy
and tissue remodeling.
Endoscopic stenting for hilar strictures
Most malignant hilar strictures are related to cholangiocarcinoma, metastatic lymphadenopathy, large pancreatic cancer, or
gallbladder carcinoma . Hilar lesions or Klatskin tumors are classified according to the degree of involvement of the intrahepatic ducts .
Bismuth classification for hilar obstruction
Bismuth type I tumors involve the common hepatic duct, type II involve the right and left intrahepatic ducts, type III involve
either the right (IIIA) or left (IIIB) secondary intrahepatic ducts, and type IV involve the secondary intrahepatic ducts
bilaterally. Palliation of hilar strictures involving the bifurcation or its branches (Bismuth types II or type III) is technically
difficult. Cholangitis can develop after ERCP in 040% of patients, depending on the complexity of the lesion and completeness of drainage .
Unilateral vs bilateral drainage for hilar obstruction
There is considerable debate in the literature about whether unilateral drainage is sufficient in patients with hilar strictures.
Deviere et al. suggested draining both of the obstructed lobes in types II and III hilar lesions to maximize reduction in bilirubin and
reduce the likelihood of developing cholangitis  (Fig. 5) They showed a decrease in biliary sepsis rate from 38% to 17% and an increase in the survival in types II and type III strictures
from a mean of 119 days to 176 days by performing bilateral stenting .
Others recommend unilateral stenting as long as one-quarter to one-third of the liver volume is drained by the single endoprosthesis,
leaving the option of a second stent for the 20% who do not respond favorably [61,62]. Polydorou et al. evaluated this selective approach in 190 consecutive patients with hilar malignancies .
A single prosthesis was placed in 89% of patients with successful drainage in 82%; 4% had additional stents due to insufficient
response. Seven per cent required a combined procedure with percutaneous transhepatic access. Stenting was technically successful
in 93% of type 1, 94% of type II, and 84% of type III patients, with successful drainage in 91%, 83%, and 73% of patients,
respectively. Early complications were seen in 7%, 14%, and 31% of types I, II, and III patients, and the mortality rates
for these groups were 14%, 15%, and 32%, respectively . The authors concluded that a single prosthesis provides good palliation in 80% of the patients, whereas a second stent should
be reserved for stent failures. A small prospective randomized comparative trial showed significantly higher technical success
and lower complication for patients treated by unilateral stenting .
Another study recommended bilobar drainage in patients when both of the lobes were filled during the ERCP, as patients with
incomplete drainage had the worst survival among all patients with hilar tumors . All things being equal, it probably makes more sense to drain the left system because the left hepatic duct has fewer side
branches near the hilum, but this anatomical advantage has not been clearly proven to confer any clinical benefit .
In our opinion, the most elegant and physiological approach to stenting hilar tumor is to first map the lesion using MRCP
and document its function using CT prior to determining which duct to stent. With these data in hand, it may be possible to
selectively cannulate and stent the desired duct without contaminating the other ducts. Both plastic and SEMSs have been used
for palliation of hilar malignancies with varying success and complication rates .
Metal stents in hilar strictures have the advantage over plastic stents in ease of insertion and drainage of side branches
through the stent meshwork. If both lobes of the liver should be drained, two SEMSs can be placed either endoscopically or
percutaneously, most often fashioned into a Y configuration or placed parallel to each other.
Other techniques of endoscopic palliation
Intraductal photodynamic therapy
Photodynamic therapy involves intravenous administration of a photosensitizing compound, usually a hematoporphyrin derivative
that preferentially accumulates within the tumor cells, followed by activation using laser lights. This releases reactive
oxygen species leading to tumor necrosis. Photodynamic therapy has been studied in cholangiocarcinoma as the cancer cells
have been shown to be sensitive to photodynamic therapy. Photofrin 11 (Porfimer sodium) and 5-aminolevulinic acid (5-ALA)
have been studied in humans [65,66]. These drugs are given intravenously and 24 to 48 h later endoscopic or percutaneous transhepatic cholangiography is performed
and biliary catheters are advanced through the working channel of the duodenoscope and placed across the malignant stricture.
Subsequently flexible laser fibers are advanced through the biliary catheters. The tumor is treated sequentially from proximal
to distal margin. Laser light (630 nm) is delivered to activate the Photofrin with a total energy of 180 J/cm2.
One study evaluated PDT for cholangiocarcinoma in patients with unresectable Bismuth types III and IV tumors, who had an inadequate
decrease in bilirubin despite adequate biliary stent placement . The patients received up to three monthly treatments. Patients had a significant decrease in serum bilirubin and improvement
in the quality of life, including on the Karnofsky index, WHO index, and biliary obstruction scale and improved survival.
However, another recent study did not show any benefit to intraductal PDT using 5-ALA in patients with unresectable cholangiocarcinoma
. An important toxicity associated with photodynamic therapy is photosensitization, which occurs in 2040% of patients  despite avoidance of sunlight. Less common side-effects include infusion reaction and stricture, and fistula formation in
the treated areas [68,69].
Brachytherapy involves the intracavitary placement of a radioactive source within a malignant stricture. 192Ir has been studied in patients with cholangiocarcinoma to improve stent patency and survival. Intraluminal brachytherapy
can be accomplished either endoscopically via a previously placed nasobiliary tube or by the percutaneous transhepatic route
Radiation therapy is then applied to the area in calculated doses depending on the various radiation therapy protocols. Patients
are hospitalized and given either low-dose brachytherapy using 3045 Gy (30004500 rad) over 2460 h or high-dose brachytherapy as an outpatient. In certain cases radiosensitizing chemotherapeutic agents such as 5 Flurouracil
(5 FU) are also administered simultaneously . Effective biliary drainage is maintained after treatment using plastic or metal stents. Important early complications include
cholangitis and duodenal ulcers, and less common long-term complications include biliary enteric fistula and hematobilia [71,72]. Brachytherapy should be administered as part of an experimental protocol, because available data are preliminary and based
on treatment of very few patients, with only questionable benefit in survival [66,73].
ERCP in management of ampullary neoplasms
A number of benign tumors arise at the major papilla, including adenoma, lipoma, leiomyoma, lymphangioma, and hamartoma. Amongst
these lesions adenoma is the most common benign but premalignant tumor. These tumors can cause symptoms of biliary colic,
obstructive jaundice, recurrent pancreatitis, and, rarely, gastrointestinal bleeding . Ampullary adenoma may be sporadic or occur as part of familial adenomatous polyposis (FAP) and Gardner's syndrome . Ampullary adenoma may contain foci of adenocarcinoma  and can be excised surgically or endoscopically in many instances.
The surgical options include transduodenal local excision and pancreatico-duodenectomy .
Endoscopic treatment involves the combination of snare excision and thermal ablation. ERCP should be performed before ampullectomy
to identify intraductal extension and to rule out other intraductal lesions. Tissue sampling after biliary sphincterotomy
may increase the diagnostic yield for cancer [74,78]. There is accumulating evidence that endoscopic resection, ablation, or both, performed by an experienced endoscopist is
a safe and effective treatment for sporadic or FAP-associated periampullary adenoma [77,78].
Endoscopic snare papillectomy is indicated for tumor size < 4 cm without evidence of malignancy as suggested by endoscopic and histological findings, and absence of intraductal extension
on ERCP or EUS. Ampullectomy is performed by snare resection using blended electrosurgical current either en bloc or in a piecemeal fashion .
Some suggest placing pancreatic stents in all patients after snare papillectomy; however, others advocate performing stenting
only when the pancreatic duct fails to drain after papillectomy [77,78]. In general, extension of the adenoma into either duct warrants surgical excision, because of the increased likelihood of
carcinoma and the difficulty of endoscopic excision.
The role of endoscopic treatment of ampullary carcinoma is to adequately palliate those patients unsuitable for surgery using
endoscopic sphincterotomy with stent insertion to relieve obstructive jaundice. In select patients a large sphincterotomy
may provide adequate drainage without a stent. Endoscopic palliation can then be achieved by a combination of snare excision
and Nd:YAG laser ablation of the tumor tissue. ERCP-assisted ablation of ampullary neoplasm using ultra high-frequency ultrasound
probes may be a promising alternative to thermal ablation in the future . Finally, application of new imaging methods during ERCP, such as optical coherence tomography (OCT), may lead to improved
diagnostic accuracy of ampullary neoplasm. One recent study reported preliminary experience with this technique in five patients,
with OCT identifying the characteristic epithelial morphology in two cases of papillary cholangiocarcinoma .
Outstanding issues and future trends
The management of pancreatico-biliary malignancies involves a multidisciplinary approach combining the expertise of the gastroenterologists,
radiologists, and surgeons. ERCP is an important diagnostic and therapeutic modality and plays a crucial role in the management
of these patients. Emerging newer diagnostic modalities are helpful in defining the finite role of ERCP in the management
of pancreatico-biliary malignancies.
At the present time ERCP is an effective, safe, and cost efficient treatment for the palliation of these tumors. ERCP in combination
with EUS and FNA offers an effective means of tissue sampling. This coupled with the new molecular technology may improve
the early diagnosis and staging of pancreatico-biliary malignancies. Although endoscopic stenting is an established palliation
for malignant obstructive jaundice, major complications, including blockage of plastic stents by bacterial biofilm and biliary
sludge, still limit its clinical benefits. Prolonged palliation of jaundice is achieved by the use of SEMSs but they too are
limited by tissue and tumor ingrowth. Better innovations in technology and future studies will further widen the scope of
this technique in the management of pancreatico-biliary malignancies.
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