ERCP for Hilar Malignancy

Hilar Cholangiocarcinoma. Technical tips and tricks during ERCP.

Cannulation and Access.

Sphincterotomy: A limited sphincterotomy is usually performed to facilitate stent placement and exchanges.

Cholangiography: The "Less is More" Principle

· DO NOT OVER-FILL! This is the single most important trick. Inject just enough contrast to map the stricture and identify target ducts.

· Puff Technique: Use small, gentle puffs of contrast under fluoroscopy to avoid forcing contaminated contrast into undrained segments, which precipitates cholangitis. 

· Once a target duct is selected, advance the wire and avoid further contrast injection.

Guidewire Manipulation and Stricture Traversal

· Choice of Wire: A hydrophilic wire is essential. A stiffer, angled-tip wire may help traverse very tight or angulated strictures.

· Use a Catheter for Support: A 5-6F catheter advanced over the wire to the level of the stricture provides stability and direction for the wire.

· Patience and Torque: Use slow, deliberate movements with torque to steer the wire. Avoid aggressive pushing, which can create false passages or perforations.

· Target the Right Duct: Use your pre-procedural MRCP as a roadmap. Aim for a duct that drains a large portion of the liver

Stent Selection and Placement

1. Type of Stent

· Uncovered Metal Stents (UMS/SEMS):Gold standard for palliative care.** They have superior patency (6-9 months) and lower rates of cholangitis compared to plastic stents. They are not removable.

· Plastic Stents (PS): Used for pre-operative drainage (as they are removable) or if life expectancy is very short (<3 months).

2. Size:

· Metal Stents: 6-8cm long, 8-10mm diameter. It's better to measure a bit longer than shorter.

· Plastic Stents: 10-12 French is the minimum; 2-3 may be placed in parallel ("stent stacking") if needed.

3. Deployment:

· For unilateral drainage place a single metal stent across the hilum into the target duct.

· For bilateral drainage: The approach is debated.

- Side-by-Side (SBS): Place two stents, one into the right and one into the left system. This can be technically challenging.

- Stent-in-Stent (SIS) / Y-Stent: Deploy one stent through the mesh of another. Easier technically but can make re-intervention more difficult.

- Trick: If placing bilateral stents, place the *more difficult* side first (usually the right system), as deploying the first stent can make accessing the contralateral system impossible

4. Post-Procedural Management

· Monitor Closely: Watch cardinal signs of cholangitis,

· Continue Antibiotics: Typically for 3-5 days post-procedure,

· Labs: Check liver enzymes and bilirubin in 24-48 hours to trend improvement.