(Pre)malignant lesions of the biliary tree:Beyond conventional endoscopic management

Abstract

Patients with (pre)malignant lesions of the biliary tree often present with biliary obstruction requiring endoscopic drainage. This thesis explores clinical research aimed at optimising conventional endoscopic management of these lesions and beyond.The first part focuses on the treatment of papillary adenomas, rare precursors to papillary carcinomas. Endoscopic papillectomy is the preferred method, but due to the rarity of these lesions, there is limited consensus on the optimal approach. This thesis proposes a treatment algorithm based on expert consensus and underscores the need for long-term follow-up, given that up to 20% of patients experience recurrence.The second part explores a promising new technique for biliary drainage of the distal bile duct: EUS-guided choledochoduodenostomy (EUS-CDS). Although EUS-CDS using a lumen-apposing metal stent (LAMS) achieves high technical and clinical success rates, stent dysfunction remains a common issue. The thesis evaluates EUS-CDS as an alternative to the current standard ERCP, considers options for improved stent design to reduce dysfunction, and shows that EUS-CDS is safe and effective even in a preoperative setting.The third part addresses the diagnosis and drainage of perihilar and intrahepatic cholangiocarcinoma, tumours that are challenging due to their location and growth patterns. By optimising cytology and the use of next-generation DNA sequencing (NGS), diagnostic sensitivity can be enhanced. While metal stents are preferred over plastic stents for biliary drainage, tumour ingrowth remains a problem. A novel technique, endobiliary radiofrequency ablation (eRFA), seems safe and shows promising results in preventing tumour ingrowth, justifying further clinical research