Endoscopic management of hilar stricture

Hilar biliary strictures pose a special dilemma in terms of both diagnosis and therapy. Although most are malignant, differentiating them from benign strictures is not straightforward. Endoscopy is the preferred first approach to diagnosis and therapy, although technical and functional success rates are uniformly poorer when compared with distal biliary strictures. We review the different endoscopic techniques and address some of the contentious issues including metal vs plastic stents, unilateral vs bilateral stenting, routine use of sphincterotomy, and alternative routes for biliary access. We will summarize the evidence for use of different endoscopic therapeutic options including radiofrequency ablation, photodynamic therapy, intraluminal brachytherapy etc. Finally, we discuss benign hilar strictures and their most common etiologies and management thereof.