Difficult endoscopic retrograde cholangiopancreatography in cancer patients

Endoscopic drainage of malignant biliary obstruction can be challenging. For patients in whom conventional wire-guided cannulation or precut attempts are unsuccessful, an endoscopic ultrasound-guided approach may be helpful. Concomitant duodenal strictures occur in 10–20% of patients with malignant biliary obstruction from pancreatic cancer. Gastric outlet obstruction due to a duodenal stricture can be relieved either by endoscopic gastroduodenal stent placement or gastrojejunostomy. In this setting, simultaneous stenting of the bile duct and duodenal strictures should be considered. In this review article, we highlight the issues involved in performing endoscopic retrograde cholangiopancreatography in patients with malignancy and present a review of literature describing techniques to overcome the challenges.