Malignant pancreaticobiliary strictures: Techniques for diagnosis and management

Malignant pancreaticobiliary strictures create both a diagnostic and therapeutic challenge for the interventional endoscopist. Traditionally, malignant strictures have been managed with surgical intervention; however, the development of endoscopic retrograde cholangiopancreatoscopy, specialized endoscopic accessories, and pancreaticobiliary endoprostheses have largely replaced surgical techniques for patients with unresectable or inoperative tumors. Pancreaticobiliary malignancies include pancreatic ductal adenocarcinomas, ampullary neoplasms, gallbladder tumors, and cholangiocarcinomas. Most of these patients present with locally advanced disease precluding curative surgical resection secondary to either local vascular invasion or metastatic disease. Discerning between benign and malignant disease is a crucial first-step in the appropriate management of pancreaticobiliary strictures. Tissue sampling techniques, cholangiopancreatoscopy, confocal laser endomicroscopy, and intraductal ultrasound can assist in differentiating between benign and malignant disease. Occasionally, conventional endoscopic management of malignant pancreaticobiliary strictures may be hampered by altered surgical anatomy or invasive tumors precluding retrograde access with endoscopic retrograde cholangiopancreatoscopy. Traditionally, these patients were managed with either percutaneous or surgical drainage. The development of linear array endosonography and evolution of interventional endoscopic ultrasound have provided alternative means for both biliary and pancreatic decompression. Novel endoscopic devices and techniques are emerging for both the diagnosis and management of malignant pancreatobiliary strictures.