Safety and Efficacy of Percutaneous Biliary Covered Stent Placement in Patients with Malignant Biliary Hilar Obstruction; Correlation with Liver Function

Different percutaneous transhepatic biliary stent placements and catheter drainage in the treatment of middle and low malignant biliary obstruction

BACKGROUND

For cases of middle and low biliary obstruction with left and right hepatic duct dilatation, the type of approach and whether different approaches affect the difficulty of puncture operation and intraoperative and postoperative complications have not been discussed in detail.

AIM

To compare the efficacy of different percutaneous transhepatic biliary stent placements and catheter drainage in treating middle and low biliary obstruction.

METHODS

A retrospective analysis was performed on the medical records of 424 patients with middle and low biliary obstruction who underwent percutaneous liver puncture biliary stent placement and catheter drainage at the Department of Interventional Radiology, Shaanxi Provincial People's Hospital between March 2016 and March 2022. Based on the puncture path, patients were categorized into two groups: Subxiphoid left hepatic lobe approach group (Group A, 224 cases) and right intercostal, right hepatic lobe approach group (Group B, 200 cases). Liver function improvement, postoperative biliary bleeding incidence, postoperative pain duration, and abdominal effusion leakage around the drainage tube were compared between the two groups at 3 d and 1 wk after the surgery. Patient survival time was recorded during follow-up.

RESULTS

All 424 surgeries were successful without adverse events. Group A comprised 224 cases, and Group B had 200 cases. There was no statistically significant difference in basic data between Group A and Group B (P > 0.05). No significant difference in postoperative biliary bleeding incidence was observed between the groups (P > 0.05). The decreased rates for total bilirubin (Group A: 69.23 ± 4.50, Group B: 63.79 ± 5.65), direct bilirubin (Group A: 79.30 ± 11.19, Group B: 63.62 ± 5.64), and alkaline phosphatase (Group A: 60.51 ± 12.23, Group B: 42.68 ± 23.56) in the 1st wk after surgery were significantly faster in Group A than in Group B. The decreased rate of gamma-glutamyl transpeptidase was also significantly faster in Group A at both 3 d (Group A: 40.56 ± 10.32, Group B: 32.22 ± 5.12) and 1 wk (Group A: 73.19 ± 7.05, Group B: 58.81 ± 18.98) after surgery (P < 0.05). Group A experienced significantly less peritoneal effusion leakage around the drainage tube than Group B (P < 0.05). The patient survival rate was higher in Group A compared to Group B (P < 0.05).

CONCLUSION

In treating jaundice patients with middle and low biliary obstruction, a percutaneous left liver puncture demonstrated better clinical efficacy than a percutaneous right liver puncture.

Safety and efficacy of percutaneous transhepatic-endoscopic rendezvous procedure in a single session

PURPOSE

To demonstrate the feasibility and safety of PTE-RV performed in a single session.

MATERIALS AND METHODS

This is a retrospective review of a prospective database on ERCP between January 2014 and December 2018. PTE-RV was performed in case of second ERCP failure. Technical success was defined as the establishment of an intestinal access to the biliary tract using a PTE-RV procedure allowing an immediate internal biliary drainage. Safety endpoints included intra-operative complications, morbidity and mortality occurring within 30 days after the procedure.

RESULTS

Eighty-four patients (44 M/40F) with a median age of 69 years (range 40-91 years) underwent combined PTE-RV. The PTE-RVs were successfully performed in the same session in 80 subjects, resulting in an overall technical success rate of 95.2%. Adverse events were observed in 19% (16/84) of cases. The mortality rate within 30 days after the procedure was 9.5%.

CONCLUSION

Percutaneous transhepatic-endoscopic rendezvous technique is feasible in a single session with acceptable level of risk. A randomized trial is required to compare EUBD and PTE-RV.

Early Warning Models to Estimate the 30-Day Mortality Risk After Stent Placement for Patients with Malignant Biliary Obstruction

PURPOSE

To develop, validate, and compare early warning models of the 30-day mortality risk for patients with malignant biliary obstruction (MBO) undergoing percutaneous transhepatic biliary stent placement (PTBS).

MATERIALS AND METHODS

Between January 2013 and October 2018, this multicenter retrospective study included 299 patients with MBOs who underwent PTBS. The training set consisted of 166 patients from four cohorts, and another two independent cohorts were allocated as external validation sets A and B with 75 patients and 58 patients, respectively. A logistic model and an artificial neural network (ANN) model were developed to predict the risk of 30-day mortality after PTBS. The predictive performance of these two models was validated internally and externally.

RESULTS

The ANN model had higher values of area under the curve than the logistic model in the training set (0.819 vs 0.797), especially in the validation sets A (0.802 vs 0.714) and B (0.732 vs 0.568). Both models had high accuracy in the three sets (75.9-83.1%). Along with a high specificity, the ANN model improved the sensitivity. The net reclassification improvement and integrated discrimination improvement also demonstrated that the ANN model led to improvements in predictive ability compared with the logistic model.

CONCLUSIONS

Early warning models were proposed to predict the risk of 30-day mortality after PTBS in patients with MBO. The ANN model has higher accuracy and better generalizability than the logistic model.

No evidence of improved efficacy of covered stents over uncovered stents in percutaneous palliation of malignant hilar biliary obstruction: results of a prospective randomized trial

OBJECTIVE

To investigate whether covered stents show a higher efficacy than uncovered stents in percutaneous treatment of malignant hilar biliary obstruction.

METHODS

Patients with obstructive jaundice caused by an unresectable hilar malignancy were included after failed endoscopic intervention in a prospective randomized trial comparing expanded polytetrafluoroethylene and fluorinated ethylene propylene (ePTFE-FEP)-covered nitinol stents with uncovered nitinol stents. Exclusion criteria were as follows: primary tumors existing more than 3 months, a biliodigestive anastomosis, previous stenting, and a Karnofsky score of less than 50. Safety, clinical success, and adjuvant chemotherapy were compared as well as occlusion rate, patency, and survival.

RESULTS

A total of 120 patients were included. One patient was post hoc excluded. Fourteen patients who died within 7 days and one patient without patency data were excluded from patency analysis. Serious adverse events (p = 0.4), 30-day mortality (p = 0.5), and clinical success (p = 0.8) were equivalent for both stent groups. Twenty-one out of 61 (34%) patients in the covered and 24/58 (41%) in the uncovered stent groups received adjuvant chemotherapy (p = 0.5). Occlusion rate was 54% (27/50) in the covered stent group and 57% (31/54) in the uncovered stent group (p = 0.8). Median patency was 229 days (95% CI 113-345) for covered stents and 130 days (95% CI 75-185) for uncovered stents (p = 0.1). Median survival in patients with covered stents was 79 days (95% CI 52-106) and with uncovered stents 92 days (95% CI 60-124) (p = 0.3).

CONCLUSION

In malignant hilar biliary obstruction, there is no evidence that ePTFE-FEP-covered stents are superior to uncovered stents in terms of safety, clinical success, adjuvant chemotherapy, patency, or survival.

KEY POINTS

• Percutaneous palliation of hilar biliary obstruction is feasible with both uncovered and covered stents. • Clinical success in terms of bilirubin decrease and adjuvant chemotherapy is achievable with both stents. • Thirty-day mortality is considerable when stenting is also offered to patients with a low performance status.

Albumin-Bilirubin Grade as a Novel Predictor of Survival in Advanced Extrahepatic Cholangiocarcinoma

Aim

Child-Pugh (CP) grade has been used to assess liver function and postoperative outcomes in biliary tract neoplasms. The aim of this study was to preliminarily explore the prognostic significance of an alternative model of liver function, called albumin-bilirubin (ALBI) grade, in patients with extrahepatic cholangiocarcinoma (EHC).

Methods

A total of 109 advanced EHC patients, who received percutaneous transhepatic biliary stenting combined with iodine-125 seed implantation from January 2012 to April 2017 in our department, were enrolled. Preoperative clinical data were collected to calculate the CP and ALBI grades. The performance of ALBI score in predicting postoperative death was compared with that of CP score by using the receiver operating characteristic (ROC) curve. Kaplan-Meier analysis and Cox regression model were performed for overall survival (OS) analysis.

Results

The median survival time of our cohort was 12 months, and the 1-year and 2-year survival rates were 56.9% and 12.8%, respectively. The area under the ROC curve of ALBI score for predicting death was significantly greater than the CP score (0.751, 95% CI: 0.641-0.861, P < 0.001 vs. 0.688, 95% CI: 0.567-0.809, P < 0.001). The univariate analysis revealed that the factors related to overall survival of EHC were carbohydrate antigen 19-9, total bilirubin, albumin, ALBI grade, and CP score. In multivariate analysis, ALBI grade (HR = 1.65, 95% CI: 1.04-2.61, P = 0.032), but not CP score, was identified as an independent prognostic model.

Conclusion

We demonstrated that the ALBI grade could be used as a predictor of survival in unresectable EHC patients.

Percutaneous Metallic Stent Placement for Palliative Management of Malignant Biliary Hilar Obstruction

Objective

To investigate the outcomes of percutaneous metallic stent placements in patients with malignant biliary hilar obstruction (MBHO).

Materials and Methods

From January 2007 to December 2014, 415 patients (mean age, 65 years; 261 men [62.8%]) with MBHO were retrospectively studied. All the patients underwent unilateral or bilateral stenting in a T, Y, or crisscross configuration utilizing covered or uncovered stents. The clinical outcomes evaluated were technical and clinical success, complications, overall survival rates, and stent occlusion-free survival.

Results

A total of 784 stents were successfully placed in 415 patients. Fifty-five patients had complications. These complications included hemobilia (n = 19), cholangitis (n = 13), cholecystitis (n = 11), bilomas (n = 10), peritonitis (n = 1), and hepatic vein-biliary fistula (n = 1). Clinical success was achieved in 370 patients (89.1%). Ninety-seven patients were lost to follow-up. Stent dysfunction due to tumor ingrowth (n = 107), sludge incrustation (n = 44), and other causes (n = 3) occurred in 154 of 318 patients. The median overall survival and the stent occlusion-free survival were 212 days (95% confidence interval [CI], 186-237 days) and 141 days (95% CI, 126-156 days), respectively. The stent type and its configuration did not affect technical success, complications, successful internal drainage, overall survival, or stent occlusion-free survival.

Conclusion

Percutaneous stent placement may be safe and effective for internal drainage in patients with MBHO. Furthermore, stent type and configuration may not significantly affect clinical outcomes.

Palliative Percutaneous Biliary Interventions in Malignant High Bile Duct Obstruction

The optimal palliative intervention for malignant biliary obstruction is internal drainage by placement of a metallic stent. For patients with hilar biliary obstruction or low bile duct obstruction in whom endoscopy is not feasible, a percutaneous transhepatic approach in interventional radiology is preferred. This article reviews the rationale for this approach, periprocedural management, and techniques to optimize stent patency.