Nonsurgical drainage for biliary obstruction.

Biliary obstruction is a common and potential fatal condition. Its pathological effects include depressed immunity, impaired phagocytic activity and reduced Kupffer cell function with consequent endotoxemia, septicemia and renal failure. Over the last decade however, non-surgical biliary drainage procedures performed with radiologic or endoscopic guidance emerged as alternative to surgical of therapy in many situations, particularly palliation of malignant strictures because of their lower morbidity and mortality rates. Endoscopic stent placement is preferred over percutaneous transhepatic catheter drainage in general. If endoscopic procedure is not possible or fails percutaneous transhepatic biliary drainage or combined radiological-endoscopic procedure should be employed. Surgery is currently reserved only for curative resection/palliative drainage in young and fit patients. Preoperative biliary drainage aimed at reducing post-operative morbidity and mortality is not universally accepted and needs further study. Benign strictures are increasingly being dilated non-surgically with temporary stenting, especially in patients with failed surgery, recurrent strictures, contraindication to surgery and pre-liver transplant strictures eg primary sclerosing cholangitis. A cohesive team consisting of a surgeon, a radiologist and an endoscopist is required to achieve the best possible results.