Clin Endosc.  2023 Mar;56(2):155-163. 10.5946/ce.2022.218.

Role of radiofrequency ablation in advanced malignant hilar biliary obstruction

• Takenaka M
• Lee TH

• KMID: 2540730
• DOI: http://doi.org/10.5946/ce.2022.218

Abstract

Malignant hilar biliary obstruction (MHO), an aggressive perihilar biliary obstruction caused by cholangiocarcinoma, gallbladder cancer, or other metastatic malignancies, has a poor prognosis. Surgical resection is the only curative treatment for biliary malignancies. However, the majority of patients with MHO cannot undergo surgery on presentation because of an advanced inoperable state or a poor performance state due to old age or comorbid diseases. Therefore, palliative biliary drainage is mandatory to improve symptomatic jaundice and the quality of life. Among the drainage methods, endoscopic biliary drainage is the current standard for palliation of unresectable advanced MHO. In addition, combined with endoscopic drainage, additional local ablation therapies, such as photodynamic therapy or radiofrequency ablation (RFA), have been introduced to prolong stent patency and survival. Currently, RFA is commonly used as palliative therapy, even for advanced MHO. This literature review summarizes recent studies on RFA for advanced MHO.

Keyword

Endoscopy; Hilar; Obstruction; Radiofrequency ablation

Figure

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  Fig. 1. Device of intraductal radiofrequency ablation (ID-RFA). (A) Habib EndoHPB catheter (EMcision Ltd., London, UK). The use of an adapter cable enables bipolar RFA and prevents the need for electrode grounding pads. It has two 8-mm long electrodes, compatible with commonly available RF generators, and endoscopes with a working channel of ≥3.2 mm. The usable total length is 180 cm and 8 Fr (2.7 mm) in diameter. (B) Endo Luminal Radiofrequency Ablation (ELRA) RF catheter (STARmed, Goyang, Korea) and VIVA Combo generator (VCS10; STARmed). The exposed tip length of the catheter is 11, 18, 22, and 33 mm in size according to the anatomy or length of the stricture (left). For example, in the 33-mm electrode, after a 9-mm leading tip and 7-mm insulated portion, four 6-mm electrodes are separated by 3-mm insulated segments. The catheter diameter is 7 Fr, and the total length is 175 cm (center). The temperature-sensing system of ensuring consistent temperature in the ablation area with VIVA Combo generator’s impedance monitoring system prevents overapplication of energy (right).

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  Fig. 2. Intraductal radiofrequency ablation in advanced malignant hilar biliary obstruction. After placing guidewires bilaterally (A), the radiofrequency ablation catheter (Endo Luminal Radiofrequency Ablation [ELRA] RF catheter, STARmed; 11 mm probe; 80°, 7 W, 120 seconds) was advanced to both intrahepatic ducts over the guidewire sequentially. Then, bilateral strictures were ablated (B-D). Finally, plastic stents were inserted bilaterally, then exchanged with uncovered self-expandable metal stent bilaterally after 3 months (E, F).

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