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Kim HS, Kang MJ, Kang J, Kim K, Kim B, Kim SH, Kim SJ, Kim YI, Kim JY, Kim JS, Kim H, Kim HJ, Nahm JH, Park WS, Park E, Park JK, Park JM, Song BJ, Shin YC, Ahn KS, Woo SM, Yu JI, Yoo C, Lee K, Lee DH, Lee MA, Lee SE, Lee IJ, Lee H, Im JH, Jang KT, Jang HY, Jun SY, Chon HJ, Jung MK, Chung YE, Chong JU, Cho E, Chie EK, Choi SB, Choi SY, Choi SJ, Choi JY, Choi HJ, Hong SM, Hong JH, Hong TH, Hwang SH, Hwang IG, Park JS. Practice guidelines for managing extrahepatic biliary tract cancers. Ann Hepatobiliary Pancreat Surg 2024; 28:161-202. [PMID: 38679456 PMCID: PMC11128785 DOI: 10.14701/ahbps.23-170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 05/01/2024] Open
Abstract
Backgrounds/Aims Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021. Methods Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop. Results In November 2021, the finalized draft was presented for public scrutiny during a formal hearing. Conclusions The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.
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Affiliation(s)
- Hyung Sun Kim
- Department of Surgery, Pancreatobiliary Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Mee Joo Kang
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Jingu Kang
- Department of Internal Medicine, Kangdong Sacred Heart Hospital of Hallym University Medical Center, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Bohyun Kim
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Seong-Hun Kim
- Department of Internal Medicine, Jeonbuk National University Medical School and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Soo Jin Kim
- Department of Radiology, National Cancer Center, Goyang, Korea
| | - Yong-Il Kim
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Young Kim
- Department of Pathology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jin Sil Kim
- Department of Radiology, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo Jung Kim
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Ji Hae Nahm
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Suk Park
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Eunkyu Park
- Division of HBP Surgery, Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Joo Kyung Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Myung Park
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Byeong Jun Song
- Department of Internal Medicine, Myongji Hospital, Goyang, Korea
| | - Yong Chan Shin
- Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Keun Soo Ahn
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Sang Myung Woo
- Center for Liver and Pancreatobiliary Cancer, Hospital, Immuno-Oncology Branch Division of Rare and Refractory Center, Research Institute of National Cancer Center, Goyang, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoungbun Lee
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Myung Ah Lee
- Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Eun Lee
- Department of Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Huisong Lee
- Department of Surgery, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Jung Ho Im
- Department of Radiation Oncology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kee-Taek Jang
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Young Jang
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun-Young Jun
- Department of Pathology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hong Jae Chon
- Department of Medical Oncology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Min Kyu Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yong Eun Chung
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Uk Chong
- Department of Surgery, National Health Insurance Services Ilsan Hospital, Goyang, Korea
| | - Eunae Cho
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Sae Byeol Choi
- Department of Surgery, Korea Universtiy Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seo-Yeon Choi
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Ji Choi
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye-Jeong Choi
- Department of Pathology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hyung Hong
- Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Ho Hong
- Division of Hepato-Biliary and Pancreas Surgery, Department of Surgery, Seoul St. Mary’s Hospital College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Shin Hye Hwang
- Department of Radiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - In Gyu Hwang
- Division of Hemato-Oncology, Department of Internal Medicine, Chung-Ang University Hospital Chung-Ang University College of Medicine, Seoul, Korea
| | - Joon Seong Park
- Department of Surgery, Pancreatobiliary Clinic, Yonsei University College of Medicine, Seoul, Korea
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de Jong DM, Gilbert TM, Nooijen LE, Braunwarth E, Ninkovic M, Primavesi F, Malik HZ, Stern N, Sturgess R, Erdmann JI, Voermans RP, Bruno MJ, Koerkamp BG, van Driel LMJW. Preoperative endoscopic biliary drainage by metal versus plastic stents for resectable perihilar cholangiocarcinoma. Gastrointest Endosc 2024; 99:566-576.e8. [PMID: 37866710 DOI: 10.1016/j.gie.2023.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/26/2023] [Accepted: 10/17/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND AND AIMS Adequate preoperative biliary drainage (PBD) is recommended in most patients with resectable perihilar cholangiocarcinoma (pCCA). Most expert centers use endoscopic plastic stents rather than self-expandable metal stents (SEMSs). In the palliative setting, however, use of SEMSs has shown longer patency and superior survival. The aim of this retrospective study was to compare stent dysfunction of SEMSs versus plastic stents for PBD in resectable pCCA patients. METHODS In this multicenter international retrospective cohort study, patients with potentially resectable pCCAs who underwent initial endoscopic PBD from 2010 to 2020 were included. Stent failure was a composite end point of cholangitis or reintervention due to adverse events or insufficient PBD. Other adverse events, surgical outcomes, and survival were recorded. Propensity score matching (PSM) was performed on several baseline characteristics. RESULTS A total of 474 patients had successful stent placement, of whom 61 received SEMSs and 413 plastic stents. PSM (1:1) resulted in 2 groups of 59 patients each. Stent failure occurred significantly less in the SEMSs group (31% vs 64%; P < .001). Besides less cholangitis after SEMSs placement (15% vs 31%; P = .012), other PBD-related adverse events did not differ. The number of patients undergoing surgical resection was not significantly different (46% vs 49%; P = .71). Complete intraoperative SEMSs removal was successful and without adverse events in all patients. CONCLUSIONS Stent failure was lower in patients with SEMSs as PBD compared with plastic stents in patients with resectable pCCA. Removal during surgery was quite feasible. Surgical outcomes were similar.
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Affiliation(s)
- David M de Jong
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Timothy M Gilbert
- Department of Surgery, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Lynn E Nooijen
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Eva Braunwarth
- Department of Visceral, Transplant, and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Marijana Ninkovic
- Department of Visceral, Transplant, and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Florian Primavesi
- Department of Visceral, Transplant, and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Innsbruck, Austria; Department of General, Visceral, and Vascular Surgery, Salzkammergutklinikum, Vöcklabruck, Austria
| | - Hassan Z Malik
- Department of Surgery, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Nick Stern
- Digestive Diseases Unit, Aintree University Hospitals, NHS Foundation Trust, Liverpool, United Kingdom
| | - Richard Sturgess
- Digestive Diseases Unit, Aintree University Hospitals, NHS Foundation Trust, Liverpool, United Kingdom
| | - Joris I Erdmann
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, the Netherlands; Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam Gastroenterology Endocrinology Metabolism, Medical University, University of Amsterdam, Amsterdam, the Netherlands; Department of Gastroenterology and Hepatology, Amsterdam UMC, Cancer Center Amsterdam, Medical University, University of Amsterdam, Amsterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Lydi M J W van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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3
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Makki M, Bentaleb M, Abdulrahman M, Suhool AA, Al Harthi S, Ribeiro Jr MAF. Current interventional options for palliative care for patients with advanced-stage cholangiocarcinoma. World J Clin Oncol 2024; 15:381-390. [PMID: 38576598 PMCID: PMC10989261 DOI: 10.5306/wjco.v15.i3.381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/18/2024] [Accepted: 02/27/2024] [Indexed: 03/22/2024] Open
Abstract
Primary biliary tract tumors are malignancies that originate in the liver, bile ducts, or gallbladder. These tumors often present with jaundice of unknown etiology, leading to delayed diagnosis and advanced disease. Currently, several palliative treatment options are available for primary biliary tract tumors. They include percutaneous transhepatic biliary drainage (PTBD), biliary stenting, and surgical interventions such as biliary diversion. Systemic therapy is also commonly used for the palliative treatment of primary biliary tract tumors. It involves the administration of chemotherapy drugs, such as gemcitabine and cisplatin, which have shown promising results in improving overall survival in patients with advanced biliary tract tumors. PTBD is another palliative treatment option for patients with unresectable or inoperable malignant biliary obstruction. Biliary stenting can also be used as a palliative treatment option to alleviate symptoms in patients with unresectable or inoperable malignant biliary obstruction. Surgical interventions, such as biliary diversion, have traditionally been used as palliative options for primary biliary tract tumors. However, biliary diversion only provides temporary relief and does not remove the tumor. Primary biliary tract tumors often present in advanced stages, making palliative treatment the primary option for improving the quality of life of patients.
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Affiliation(s)
- Maryam Makki
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Sheikh Shakhbout Medical City, Abu Dhabi 11001, United Arab Emirates
| | - Malak Bentaleb
- Department of Surgery, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi 11001, United Arab Emirates
| | - Mohammed Abdulrahman
- Department of Surgery, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi 11001, United Arab Emirates
| | - Amal Abdulla Suhool
- Department of Surgery, Division of Hepato-Pancreato-Biliary (HPB) Surgery, Sheikh Shakhbout Medical City, Abu Dhabi 91888, United Arab Emirates
| | - Salem Al Harthi
- Department of Surgery, Division of Hepato-Pancreato-Biliary (HPB) Surgery, Sheikh Shakhbout Medical City, Abu Dhabi 91888, United Arab Emirates
| | - Marcelo AF Ribeiro Jr
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Sheikh Shakhbout Medical City, Abu Dhabi 11001, United Arab Emirates
- Department of Surgery, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi 11001, United Arab Emirates
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4
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Dar FS, Abbas Z, Ahmed I, Atique M, Aujla UI, Azeemuddin M, Aziz Z, Bhatti ABH, Bangash TA, Butt AS, Butt OT, Dogar AW, Farooqi JI, Hanif F, Haider J, Haider S, Hassan SM, Jabbar AA, Khan AN, Khan MS, Khan MY, Latif A, Luck NH, Malik AK, Rashid K, Rashid S, Salih M, Saeed A, Salamat A, Tayyab GUN, Yusuf A, Zia HH, Naveed A. National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma. World J Gastroenterol 2024; 30:1018-1042. [PMID: 38577184 PMCID: PMC10989497 DOI: 10.3748/wjg.v30.i9.1018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/03/2024] [Accepted: 01/29/2024] [Indexed: 03/06/2024] Open
Abstract
A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.
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Affiliation(s)
- Faisal Saud Dar
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Zaigham Abbas
- Department of Hepatogastroenterology and Liver Transplantation, Dr. Ziauddin University Hospital, Karachi 75600, Sindh, Pakistan
| | - Irfan Ahmed
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
- University of Aberdeen, Aberdeen B24 3FX, United Kingdom
| | - Muhammad Atique
- Department of Pathology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Usman Iqbal Aujla
- Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | | | - Zeba Aziz
- Department of Oncology, Hameed Latif Hospital, Lahore 54000, Pakistan
| | - Abu Bakar Hafeez Bhatti
- Division of Hepatopancreatic Biliary Surgery & Liver Transplantation, Shifa International Hospital, Islamabad 44000, Pakistan
| | - Tariq Ali Bangash
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Shaikh Zayed Hospital and Post Graduate Medical Institute, Lahore 54000, Pakistan
| | - Amna Subhan Butt
- Department of Medicine, Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Osama Tariq Butt
- Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Abdul Wahab Dogar
- Department of Liver Transplant, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences, Gambat 66020, Pakistan
| | - Javed Iqbal Farooqi
- Department of Medicine & Gastroenterology, Lifecare Hospital and Research Centre, Peshawar 25000, Khyber Pakhtunkhwa, Pakistan
| | - Faisal Hanif
- Department of Hepatopancreatobiliary & Liver Transplant, Bahria International Hospital, Lahore 54000, Pakistan
| | - Jahanzaib Haider
- Department of Surgery, Hepatopancreatobiliary & Liver Transplant, Dow University of Health Sciences, Karachi 74800, Pakistan
| | - Siraj Haider
- Department of Surgery, Hepatopancreatobiliary & Liver Transplant, Dow University of Health Sciences, Karachi 74800, Pakistan
| | - Syed Mujahid Hassan
- Department of Gastroenterology, Hepatology & Nutrition, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences, Gambat 66020, Pakistan
| | | | - Aman Nawaz Khan
- Department of Radiology, Rehman Medical Institute, Peshawar 25000, Pakistan
| | - Muhammad Shoaib Khan
- Army Liver Transplant Unit, Pak Emirates Military Hospital, Rawalpindi 46000, Pakistan
| | - Muhammad Yasir Khan
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Amer Latif
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Shaikh Zayed Hospital and Post Graduate Medical Institute, Lahore 54000, Pakistan
| | - Nasir Hassan Luck
- Department of Gastroenterology, Sindh Institute of Urology and Transplantation, Karachi 75500, Pakistan
| | - Ahmad Karim Malik
- Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Kamran Rashid
- Rashid Nursing Home and Cancer Clinic, Rashid Nursing Home and Cancer Clinic, Rawalpindi 46000, Pakistan
| | - Sohail Rashid
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Mohammad Salih
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Islamabad 44000, Pakistan
| | - Abdullah Saeed
- Department of Radiology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Amjad Salamat
- Department of Gastroenterology and Hepatology, Quaid-e-Azam International Hospital, Rawalpindi 44000, Pakistan
| | - Ghias-un-Nabi Tayyab
- Department of Gastroenterology and Hepatology, Post Graduate Medical Institute, Lahore 54000, Pakistan
| | - Aasim Yusuf
- Department of Internal Medicine, Division of Gastroenterology, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore 54000, Pakistan
| | - Haseeb Haider Zia
- Division of Hepatopancreatic Biliary Surgery & Liver Transplantation, Shifa International Hospital, Islamabad 44000, Pakistan
| | - Ammara Naveed
- Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
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Pietrzak J, Przybyłkowski A. Endoscopic Treatment of Malignant Hilar Biliary Obstruction. Cancers (Basel) 2023; 15:5819. [PMID: 38136363 PMCID: PMC10741735 DOI: 10.3390/cancers15245819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/01/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
Stent implantation is an effective approach for palliative treatment of Bismuth-Corlette type III-IV malignant hilar biliary obstructions (MHBOs). In this article, we reviewed the currently used access methods for biliary stent placement (percutaneous transhepatic biliary drainage, endoscopic biliary drainage, endosonography guided biliary drainage), the available stent types (plastic stent, self-expanding metallic stent, full cover self-expanding metallic stent, radioactive self-expanding metallic stent), major approaches (unilateral, bilateral) and deployment methods (stent-in-stent, stent-by-stent). Finally, this review gives an outlook on perspectives of development in stenting and other palliative methods in MHBO.
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Affiliation(s)
| | - Adam Przybyłkowski
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland;
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ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures. Am J Gastroenterol 2023; 118:405-426. [PMID: 36863037 DOI: 10.14309/ajg.0000000000002190] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/13/2022] [Indexed: 03/04/2023]
Abstract
A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.
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7
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Nakshabandi AA, Lee JH. Contemporary advances in the endoscopic management of cholangiocarcinoma: a review of accomplished milestones and prospective opportunities. Expert Rev Gastroenterol Hepatol 2023; 17:175-187. [PMID: 36683580 DOI: 10.1080/17474124.2023.2170875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Cholangiocarcinoma, a primary malignancy of epithelial cells of the bile ducts, has been shown to have increasing incidence rates globally. Many of the current advances aim to improve the accuracy of differentiation between benign biliary strictures and cholangiocarcinoma, which include endoscopic techniques, devices, image processing, and the use of genomic sequencing in acquired specimens. AREAS COVERED In this review, the authors explore the historical timeline of changes leading to modern management of cholangiocarcinoma, with special emphasis on endoscopic modalities and novel therapeutic interventions. The authors also expand on the strengths and shortcomings of endoscopic diagnostics and techniques in biliary drainage and finally discuss potential areas to focus for future research and development. EXPERT OPINION Despite the advances in diagnosis and management of cholangiocarcinoma, there remain multiple tasks that are still awaiting to be completed. Next-generation sequencing in the diagnosis of cholangiocarcinoma needs to be further tested, validated, and easily obtainable. Other innovative diagnostic modalities, such as the use of artificial intelligence in cholangioscopy, may provide an effective complementary modality to existing techniques. A consensus on biliary drainage needs to be defined and account for longevity and patient convenience.
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Affiliation(s)
- Ahmad Al Nakshabandi
- Department of Gastroenterology, Hepatology & Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology & Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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8
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Abstract
PURPOSE OF REVIEW To summarize the current status and future perspectives of the endoscopic management of biliary strictures. RECENT FINDINGS In addition to conventional diagnostic modalities, such as cross-sectional imaging and endoscopic ultrasonography (EUS), per-oral cholangioscopy is helpful for indeterminate biliary strictures. It allows direct visualization of the biliary tract and targeted biopsy. For distal malignant biliary obstruction (MBO), a self-expandable metal stent (SEMS) via endoscopic retrograde cholangiopancreatography (ERCP) is a standard of care. EUS-guided biliary drainage (EUS-BD) is an emerging alternative to percutaneous transhepatic biliary drainage in cases with failed ERCP. EUS-BD is also an effective salvage option for perihilar MBO, which can not be managed via ERCP or percutaneous transhepatic biliary drainage. Preoperative drainage is necessary for most jaundiced patients as neoadjuvant chemotherapy is widely administered for resectable and borderline resectable pancreatic cancer, and a SEMS is preferred in this setting, too. For benign biliary strictures, a covered SEMS can improve stricture resolution and reduce the number of endoscopic sessions as compared to plastic stents. SUMMARY ERCP and EUS play a central role in the diagnosis and drainage for both malignant and benign biliary strictures.
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Petit S, Puyade M, Pichon M, Wangermez M, Velasco S, Roblot F, Isambert N, Evrard C, Rammaert B. Risk factors for biliary stent infections in malignant biliary obstruction secondary to unresectable malignancies. Support Care Cancer 2022; 30:6937-6946. [PMID: 35543817 DOI: 10.1007/s00520-022-07106-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/29/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Palliative biliary drainage in patients with unresectable malignant biliary obstruction (MBO) frequently leads to biliary stent infection (BI), which could impact medical care. The aim of this study was to assess the risk factors for BI occurrence in patients after stenting procedure and the impact of BI on patient survival. METHODS All consecutive patients hospitalized from 2014 to 2018 for MBO and biliary stenting were retrospectively included. Demographic, clinical, and microbiological characteristics of each BI episode during a 1-year follow-up were described. Documented BI was defined as the association of BI episode and confirmed blood stream infection (BSI). Univariate and multivariate analyses were performed to evaluate risk factors for the first BI occurrence. RESULTS Among 180 patients, 56% were men (mean age of 69±12), and 54% have pancreatic cancer, 16% biliary cancer, 2% hepatic cancer, and 28% lymph node or metastatic compression; metallic stent was placed in 92%. A total of 113 BI episodes occurred in 74 patients, 55% of the first episodes occurring within 3 months after stenting. BI was documented in 56% of the episodes. Enterobacteriaceae were the most frequent pathogens found, while no yeasts were documented. Mortality rate in patients with BI was 64%. Multivariate analysis showed a significant difference in BI occurrence for two criteria: WHO score 3-4 (OR=8.79 [1.79-42.89]; p=0.007) and transpapillary stenting location (OR=3.72 [1.33-10.44]; p=0.013). CONCLUSION Since transpapillary stenting is a risk factor for BI, preserving the papilla as much as possible is a priority so as to avoid BI.
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Affiliation(s)
- Sébastien Petit
- Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France
| | - Mathieu Puyade
- Service de Médecine Interne et Maladies Infectieuses et Tropicales, CHU Poitiers, 2 rue de la Milétrie, CS 90577, 86021, Poitiers Cedex, France
| | - Maxime Pichon
- Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France
- Laboratoire de Bactériologie et Hygiène Hospitalière, Département des Agents Infectieux, CHU Poitiers, Poitiers, France
- INSERM U1070, Poitiers, France
| | - Marc Wangermez
- Service d'Hépato Gastro-Entérologie, CHU Poitiers, Poitiers, France
| | - Stéphane Velasco
- Service de Radiologie Interventionnelle, CHU Poitiers, Poitiers, France
| | - France Roblot
- Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France
- Service de Médecine Interne et Maladies Infectieuses et Tropicales, CHU Poitiers, 2 rue de la Milétrie, CS 90577, 86021, Poitiers Cedex, France
- INSERM U1070, Poitiers, France
| | - Nicolas Isambert
- Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France
- Service d'Oncologie Médicale, Pôle Régional de Cancérologie, CHU Poitiers, Poitiers, France
| | - Camille Evrard
- Service d'Oncologie Médicale, Pôle Régional de Cancérologie, CHU Poitiers, Poitiers, France
| | - Blandine Rammaert
- Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France.
- Service de Médecine Interne et Maladies Infectieuses et Tropicales, CHU Poitiers, 2 rue de la Milétrie, CS 90577, 86021, Poitiers Cedex, France.
- INSERM U1070, Poitiers, France.
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10
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Lanza D, Casty A, Schlosser SH. Endobiliary Radiofrequency Ablation for Malignant Biliary Obstruction over 32-Month Follow-Up. Gastrointest Tumors 2022; 9:12-18. [PMID: 35528744 PMCID: PMC9021661 DOI: 10.1159/000522363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/30/2021] [Indexed: 08/16/2023] Open
Abstract
Hilar cholangiocellular carcinoma (CCC) is a malignant neoplasm of epithelial origin occurring at the confluence of the right and left hepatic bile ducts. Typically, these tumors are small, poorly differentiated, exhibit aggressive biologic behavior with non-specific symptoms and tend to obstruct the intrahepatic bile ducts. Surgery is the only available curative option. Unfortunately, in less than half of the patients a complete resection is possible with poor survival rate in unresectable cases. In this report, we present the case of a 58-year-old woman with a history of unresectable hilar cholangiocarcinoma. Initially she was treated with intraductal dilatation of malignancy and placement of a plastic stent and chemotherapy (Gemcitabin® and Platinol®). Two years later she underwent a second-line chemotherapy with Gemcitabin® and Oxyplatin® because of tumor progression. Despite a second line chemotherapy and placement of an uncovered self-expandible metal stent (ucSEMS) that was extended later on by stent-in stent technique, there was tumor progression which led to a complex course with relapsing obstructive cholangiosepsis and cholestasis. Because of tumor ingrowth, endobiliary radiofrequency ablation of the malignant stenosis was performed in repeated sessions. This case illustrates that radiofrequency ablation of solitary malignant biliary obstruction is feasible, safe and allows an improvement of quality of life in non-operable patients.
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Affiliation(s)
- Davide Lanza
- Department of Gastroenterology and Hepatology, Regional Hospital Oberargaau, Langenthal, Switzerland
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11
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Perihilar cholangiocarcinoma: What the radiologist needs to know. Diagn Interv Imaging 2022; 103:288-301. [DOI: 10.1016/j.diii.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/02/2022] [Indexed: 11/17/2022]
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12
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Madhusudhan KS, Jineesh V, Keshava SN. Indian College of Radiology and Imaging Evidence-Based Guidelines for Percutaneous Image-Guided Biliary Procedures. Indian J Radiol Imaging 2021; 31:421-440. [PMID: 34556927 PMCID: PMC8448229 DOI: 10.1055/s-0041-1734222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.
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Affiliation(s)
| | - Valakkada Jineesh
- Department of Radiology, Sree Chitra Tirunal Institute of Medical Sciences and Technology (Thiruvananthapuram), Kerala, India
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13
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Lee TH, Moon JH, Park SH. [A Recent Update on Endoscopic Drainage of Advanced Malignant Hilar Obstruction]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 78:94-104. [PMID: 34446632 DOI: 10.4166/kjg.2021.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/11/2021] [Indexed: 11/03/2022]
Abstract
Malignant hilar obstruction (MHO) is considered an aggressive perihilar obstruction caused by cholangiocarcinoma, gallbladder cancer, or metastatic malignancies and has a poor prognosis. Although surgical resection is the only curative treatment method, the majority of patients with MHO do not undergo surgery due to an advanced inoperable state at presentation. Currently, effective biliary drainage provides the necessary palliation for symptomatic improvement. Among the drainage methods, percutaneous access may be preferred, especially for advanced MHO because of the technical difficulty involved with other techniques. Recently, primary endoscopic palliation using plastic or metal stents has been shown to have higher technical feasibility and clinical success without increasing adverse events even in patients with high-degree MHO. The development of various accessories, endoscopic ultrasonography, and advances in techniques have facilitated primary endoscopic intervention. However, some aspects continue to be debated such as the palliation methods, appropriate stents, the number of stents, the deployment methods, and additional local ablation therapies. Therefore, this review discusses the current optimal endoscopic treatment methods for advanced MHO based on reported literature.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, SoonChunHyang University College of Medicine, Cheonan, Korea
| | - Jong Ho Moon
- Division of Gastroenterology, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, SoonChunHyang University College of Medicine, Bucheon, Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, SoonChunHyang University College of Medicine, Cheonan, Korea
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14
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Qumseya BJ, Jamil LH, Elmunzer BJ, Riaz A, Ceppa EP, Thosani NC, Buxbaum JL, Storm AC, Sawhney MS, Pawa S, Naveed M, Lee JK, Law JK, Kwon RS, Jue TL, Fujii-Lau LL, Fishman DS, Calderwood AH, Amateau SK, Al-Haddad M, Wani S. ASGE guideline on the role of endoscopy in the management of malignant hilar obstruction. Gastrointest Endosc 2021; 94:222-234.e22. [PMID: 34023067 DOI: 10.1016/j.gie.2020.12.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 12/11/2022]
Abstract
This clinical guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the management of patients with malignant hilar obstruction (MHO). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses primary drainage modality (percutaneous transhepatic biliary drainage [PTBD] vs endoscopic biliary drainage [EBD]), drainage strategy (unilateral vs bilateral), and stent selection (plastic stent [PS] vs self-expandable metal stent [SEMS]). Regarding drainage modality, in patients with MHO undergoing drainage before potential resection or transplantation, the panel suggests against routine use of PTBD as first-line therapy compared with EBD. In patients with unresectable MHO undergoing palliative drainage, the panel suggests PTBD or EBD. The final decision should be based on patient preferences, disease characteristics, and local expertise. Regarding drainage strategy, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placement of bilateral stents compared with a unilateral stent in the absence of liver atrophy. Finally, regarding type of stent, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placing SEMSs or PSs. However, in patients who have a short life expectancy and who place high value on avoiding repeated interventions, the panel suggests using SEMSs compared with PSs. If optimal drainage strategy has not been established, the panel suggests placing PSs. This document clearly outlines the process, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.
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Affiliation(s)
- Bashar J Qumseya
- Department of Gastroenterology, University of Florida, Gainesville, Florida, USA.
| | - Laith H Jamil
- Section of Gastroenterology and Hepatology, Beaumont Health, Royal Oak, Michigan, USA, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Badih Joseph Elmunzer
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ahsun Riaz
- Department of Vascular and Interventional Radiology, Northwestern Medicine, Chicago, Illinois, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nirav C Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Mariam Naveed
- Advent Health Medical Group, Department of Gastroenterology/Hepatology, Advent Health Hospital Altamonte Springs, Altamonte Springs, Florida, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Joanna K Law
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Richard S Kwon
- Department of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Terry L Jue
- Department of Gastroenterology, The Permanente Medical Group, San Francisco, California, USA
| | - Larissa L Fujii-Lau
- Department of Gastroenterology, The Queen's Medical Center, Honolulu, Hawaii, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Audrey H Calderwood
- Department of Gastroenterology and Hepatology, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Stuart K Amateau
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Mohammed Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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15
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Yuan XL, Ye LS, Zeng XH, Tan QH, Mou Y, Liu W, Wu CC, Yang H, Hu B. New anti-reflux plastic stent to reduce the risk of stent-related cholangitis in the treatment of biliary strictures. World J Gastroenterol 2021; 27:4697-4709. [PMID: 34366630 PMCID: PMC8326253 DOI: 10.3748/wjg.v27.i28.4697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/08/2021] [Accepted: 07/07/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is little data available on the role of new anti-reflux plastic stents (ARPSs).
AIM To compare the use of ARPSs with that of traditional plastic stents (TPSs) for patients with biliary strictures.
METHODS Consecutive patients with biliary strictures who underwent first endoscopic biliary stenting between February 2016 and May 2019 were included. The onset of stent-related cholangitis, stent patency, clinical success, and other adverse events were evaluated.
RESULTS Sixty-seven patients in the ARPS group and 66 patients in the TPS group were included in the final analyses. Fewer patients experienced stent-related cholangitis in the ARPS group than that in the TPS group (8 patients vs 18 patients; P = 0.030). The median time till the onset of first stent-related cholangitis was later in the ARPS group than that in the TPS group (128.5 d vs 76 d; P = 0.039). The cumulative median stent patency in the ARPS group was 185 d, which was significantly longer than that in the TPS group (133 d; P = 0.001). The clinical success rates and other adverse events did not significantly differ between both groups.
CONCLUSION Placement of new ARPS might be a safe and effective optional therapeutic strategy to reduce the risk of stent-related cholangitis and prolong stent patency.
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Affiliation(s)
- Xiang-Lei Yuan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Lian-Song Ye
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xian-Hui Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Qing-Hua Tan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yi Mou
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wei Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Chun-Cheng Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hang Yang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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16
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Kawai J, Ogura T, Takenaka M, Shiomi H, Ueshima K, Ueno S, Okuda A, Matsuno J, Minaga K, Omoto S, Nakai A, Ikegawa T, Hakoda A, Higuchi K. Prospective multicenter evaluation of moving cell metallic stents in endoscopic multiple stent deployment for hepatic hilar obstruction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:1195-1203. [PMID: 34110699 DOI: 10.1002/jhbp.1009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/21/2021] [Accepted: 05/29/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Bilateral stent deployment for malignant biliary obstruction (MHBO) can be achieved using side-by-side (SBS) or stent-in-stent (SIS) procedures. Compared with SBS techniques, the procedural steps of SIS are technically complex due to the necessity of introducing the delivery system into a contralateral biliary tract through the mesh of the SEMS. To overcome this issue, a novel uncovered SEMS, the HILZO Moving Cell Stent (MCS) has been released. The present study examined the technical feasibility of treating MHBO using bilateral deployment of this novel stent without dilating the mesh of the first stent to achieve insertion of the second stent within a single session, using a prospective, multicenter setting. METHOD The primary outcome in the present study was the technical success rate. Technical success was defined as deployment of bilateral MCSs into two or more biliary tracts using SIS without a dilation device in a single-session. RESULTS A total of 27 patients with complications of MHBO were enrolled in this study. Bilateral SIS using two MCS was successfully performed in 23 patients without using dilation devices among 27 patients (initial technical success rate; 85.2%). Median time to recurrent biliary obstruction (TRBO) was 271 days. Stent dysfunction was observed in 12 patients (44.4%), and re-intervention was successfully performed in all patients without one patient who instead received best supportive care. CONCLUSIONS The SIS technique using MCS without dilation of the mesh may be technically feasible and safe. In addition, this may be useful for re-intervention. Further comparative randomized trials are needed.
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Affiliation(s)
- Junichi Kawai
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Takeshi Ogura
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Mamoru Takenaka
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Departments of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Hideyuki Shiomi
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazuya Ueshima
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Saori Ueno
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Atsushi Okuda
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Jun Matsuno
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kousuke Minaga
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Departments of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Shunsuke Omoto
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Departments of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Atsushi Nakai
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Departments of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Takuya Ikegawa
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Akitoshi Hakoda
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kazuhide Higuchi
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
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17
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Kim JY, Lee SG, Kang D, Lee DK, Park JK, Lee KT, Lee JK, Lee KH. The Comparison of Endoscopic Biliary Drainage in Malignant Hilar Obstruction by Cholangiocarcinoma: Bilateral Metal Stents versus Multiple Plastic Stents. Gut Liver 2021; 15:922-929. [PMID: 34053917 PMCID: PMC8593498 DOI: 10.5009/gnl20257] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/15/2020] [Accepted: 12/10/2020] [Indexed: 11/04/2022] Open
Abstract
Background/Aims For the management of hilar malignant biliary obstruction (HMBO), endoscopic biliary drainage (EBD) is preferred over percutaneous transhepatic biliary drainage (PTBD) because of its convenience. However, there is no established guideline for malignant hilar obstruction that requires multiple stenting. In this study, we compared the efficacy of bilateral metal stents (BMS) versus multiple plastic stents (MPS). Methods In this retrospective study, we analyzed 102 patients who underwent EBD with either BMS or MPS due to HMBO caused by hilar cholangiocarcinoma between 1996 and 2018 at Samsung Medical Center. We compared the successful drainage rates, cholangitis events, overall complications, mortality, and conversion rates to PTBD between the two groups. Results The successful drainage rates in the BMS group and the MPS group were 71.4% (25/35) and 65.6% (44/67), respectively, with no significant difference. The MPS group had a higher cholangitis risk (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.21 to 3.58) and higher 6-month mortality (HR, 2.91; 95% CI, 1.26 to 6.71) than the BMS group. There were no significant differences in overall complications or the conversion rate to PTBD between the groups. Conclusions In patients with malignant HMBO, the BMS group showed better outcomes in terms of the cholangitis rate and 6-month mortality than the MPS group. Therefore, if possible, bilateral metal stenting is recommended for HMBO caused by hilar cholangiocarcinoma.
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Affiliation(s)
- Jun Young Kim
- Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Sang-Geul Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Danbee Kang
- Department of Clinical Research and Evaluation, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
| | - Dong Kyu Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Kyung Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Taek Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Kyun Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Hyuck Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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18
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Park CH, Park SW, Jung JH, Jung ES, Kim JH, Park DH. Comparative Efficacy of Various Stents for Palliation in Patients with Malignant Extrahepatic Biliary Obstruction: A Systematic Review and Network Meta-Analysis. J Pers Med 2021; 11:jpm11020086. [PMID: 33573288 PMCID: PMC7912345 DOI: 10.3390/jpm11020086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/20/2021] [Accepted: 01/27/2021] [Indexed: 11/16/2022] Open
Abstract
Although many studies have investigated the efficacy of stent placement for patients with malignant extrahepatic biliary obstruction, the clinical outcomes and adverse events of biliary stenting have not been comprehensively evaluated. We searched all relevant randomized-controlled trials that evaluated the comparative efficacy of biliary stents, including the plastic stents, uncovered self-expandable metal stents (SEMSs), and covered SEMSs in patients with malignant extrahepatic biliary obstructions. Twenty-one studies with 2326 patients were included. Both uncovered and covered SEMSs had a lower risk of recurrent biliary obstruction (RBO) compared to plastic stents (risk ratio (RR) (95% confidence interval [CI]): uncovered vs. plastic, 0.46 (0.35–0.62); covered vs. plastic, 0.46 (0.34–0.62)). A comparison of the groups using SEMSs revealed that tumor ingrowth was common in the uncovered SEMS group, while stent migration, tumor overgrowth, and occlusion by sludge were common in the covered SEMS group; however, the overall risk of RBO did not differ between these groups (RR (95% CI): uncovered vs. covered: 1.02 (0.80–1.30)). Although the main causes of RBO vary across stents, RBO risk was similar between uncovered and covered SEMS groups. Both SEMSs have superior efficacy in terms of RBO compared to plastic stents.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri 11923, Korea;
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
- Correspondence: ; Tel.: +82-31-8086-2858
| | - Jang Han Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
| | - Eun Suk Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
| | - Jung Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
| | - Da Hae Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
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Katanuma A, Kin T, Hayashi T. Unresectable hilar biliary malignant strictures: What is the best way to prolong the overall survival? Dig Endosc 2021; 33:95-97. [PMID: 33026695 DOI: 10.1111/den.13826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Akio Katanuma
- Center for Gastroenterology, Teine-Keijinkai Hospital, Hokkaido, Japan
| | - Toshifumi Kin
- Center for Gastroenterology, Teine-Keijinkai Hospital, Hokkaido, Japan
| | - Tsuyoshi Hayashi
- Center for Gastroenterology, Teine-Keijinkai Hospital, Hokkaido, Japan
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Xia MX, Pan YL, Cai XB, Wu J, Gao DJ, Ye X, Wang TT, Hu B. Comparison of endoscopic bilateral metal stent drainage with plastic stents in the palliation of unresectable hilar biliary malignant strictures: Large multicenter study. Dig Endosc 2021; 33:179-189. [PMID: 32249460 DOI: 10.1111/den.13680] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/26/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoscopic stenting to manage malignant hilar biliary obstruction has no consensus regarding the optimal stenting strategy. In this multicenter study, we compared transpapillary parallel-style bilateral metal stenting with bilateral plastic stenting, and evaluated short- and long-term outcomes. METHODS We recruited 262 consecutive patients (Bismuth classification types II-IV) who underwent either bilateral metal or plastic stenting as primary therapy at four tertiary centers. To overcome selection bias, we performed 1:1 propensity score matching. Our primary outcome was overall survival. RESULTS After propensity score matching, each group comprised 96 patients, with no significant differences in any baseline characteristics. The median survival was significantly longer in the metal stenting group than in the plastic stenting group (7.2 months [95% CI 6.0-8.5] vs. 4.1 months [95% CI 2.9-5.3]; P = 0.015). The clinical success rates were significantly higher in the metal stenting group than in the plastic stenting group (99.0% vs. 71.9%, respectively; P < 0.001), and lower post-procedure cholangitis incidence (7.3% vs. 26.0%; P < 0.001), longer median symptom-free stent patency (9.2 months [95% CI 7.6-10.6] vs. 4.8 months [95% CI 4.2-5.3]; P < 0.001), and fewer total interventions (1.3 ± 0.6 vs. 2.0 ± 1.4; P < 0.001). In multivariate Cox analysis of the overall survival, metal stenting (HR 0.589, P = 0.002), hilar cholangiocarcinoma (HR 0.419, P = 0.009), and adjuvant treatment (HR 0.596, P = 0.006) were independent predictors of death. CONCLUSIONS Endoscopic therapy using bilateral metal stenting is superior to bilateral plastic stenting, with prolonged overall survival, higher clinical success, and longer stent patency in patients with advanced hilar biliary malignancies.
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Affiliation(s)
- Ming-Xing Xia
- Departments of, Department of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Yang-Lin Pan
- Department of, Gastroenterology, Xijing Hospital Affiliated to Fourth Military Medical University, Xi'an, China
| | - Xiao-Bo Cai
- Department of, Gastroenterology, Shanghai First People's Hospital, Shanghai, China
| | - Jun Wu
- Department of, Gastroenterology, Third Affiliated Hospital, Second Military Medical University, Shanghai, China
| | - Dao-Jian Gao
- Departments of, Department of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Xin Ye
- Departments of, Department of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Tian-Tian Wang
- Departments of, Department of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Bing Hu
- Departments of, Department of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China.,Department of, Gastroenterology, Third Affiliated Hospital, Second Military Medical University, Shanghai, China
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Zhu J, Feng H, Zhang D, Li R, Li J, Peng H, Tang W, Hu D, Wu W, Hu K, Cai W, Yin G. Percutaneous transhepatic cholangiography and drainage and endoscopic retrograde cholangiopancreatograph for hilar cholangiocarcinoma: which one is preferred? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:893-897. [PMID: 33118356 DOI: 10.17235/reed.2020.6937/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION both percutaneous transhepatic cholangiography and drainage (PTCD) and endoscopic retrograde cholangiopancreatography (ERCP) with SEMS implantation have been used for unresectable hilar cholangiocarcinoma (HC) in the clinic for many years. However, which one is preferred is still unknown. OBJECTIVE to study the effects of biliary drainage of self-expanding metal stents (SEMS) implantation under PTCD or ERCP to treat HC. METHODS the clinical data of 82 patients with HC from January 2006 to January 2015 were recorded retrospectively. Patients were treated with biliary implantation of self-expanding metal stents (SEMS) under PTCD (PTCD group, 40 patients) or ERCP (ERCP group, 42 patients). Clinical data, including total bilirubin concentrations, complications and survival time were analyzed. RESULTS the remission of jaundice was similar in both groups (p > 0.05). The median survival time of the ERCP group and PTCD group were 237 d and 252 d respectively, with no significant differences (p > 0.05). The biliary infection rates under ERCP and PTCD procedure were 52.4 % and 20.0 % respectively, with a significant statistical difference (p < 0.05). For those HC patients of Bismuth III/IV, the infection rates under ERCP and PTCD procedure were 58.3 % and 14.3 %, respectively (p < 0.05). CONCLUSIONS both PTCD and ERCP with SEMS implantation were effective to prolong the survival time of HC patients. The biliary infection rates were higher in the ERCP group, especially for Bismuth III/IV HC patients.
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Affiliation(s)
- Jianghong Zhu
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Huang Feng
- Gastroenterology, the First Affiliated Hospital of Soochow University
| | - Deqing Zhang
- Gastroenterology, the First Affiliated Hospital of Soochow University
| | - Rui Li
- Gastroenterology, the First Affiliated Hospital of Soochow University
| | - Jing Li
- Gastroenterology, the Second Affiliated Hospital of Soochow University, China
| | - Hongwei Peng
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Wen Tang
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Duanmin Hu
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Wei Wu
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Kewei Hu
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Wei Cai
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Guojian Yin
- Gastroenterology, the Second Affiliated Hospital of Soochow University
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Gemcitabine Plus Cisplatin Chemotherapy Prolongs the Survival in Advanced Hilar Cholangiocarcinoma: A Large Multicenter Study. Am J Clin Oncol 2020; 43:422-427. [PMID: 32118610 DOI: 10.1097/coc.0000000000000682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Gemcitabine plus cisplatin (GC) is recommended as first-line treatment for advanced cholangiocarcinoma. We investigated the impact of GC in patients with unresectable hilar cholangiocarcinoma (HC) based on the time taken for effective biliary drainage (EBD). MATERIALS AND METHODS We retrospectively enrolled 113 patients with unresectable HC. Thirty-nine and 74 patients received GC chemotherapy and best supportive care (BSC), respectively. EBD was defined as a reduction in total bilirubin >50% or to a value <2 mg/dL after the drainage procedure. Early EBD (eEBD) and delayed EBD (dEBD) were separated by 2 weeks. Overall survival (OS) was estimated. RESULTS The GC group showed a significantly longer median OS than the BSC group (12.8 vs. 6.1 mo; P<0.001). Moreover, the eEBD group experienced a significantly longer OS than the dEBD group (8.2 vs. 4.3 mo; P<0.001). GC led to improved OS in the eEBD (12.8 vs. 6.8 mo; P=0.003) and dEBD (12.2 vs. 3.4 mo; P=0.009) groups. In multivariate analysis, dEBD (adjusted hazard ratio [aHR], 1.785; 95% confidence interval [CI], 1.183-2.691; P=0.006), BSC (aHR, 2.409; 95% CI, 1.579-3.675; P<0.001), and an ECOG status ≥2 (aHR, 3.721; 95% CI, 2.093-6.615; P<0.001) were associated with poor prognosis. In GC group, the older (70 y and above) patients did not have a higher risk of death than younger patients. CONCLUSIONS GC prolongs the survival of patients with unresectable HC, even those with dEBD or elderly.
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Lee TH, Moon JH, Park SH. Biliary stenting for hilar malignant biliary obstruction. Dig Endosc 2020; 32:275-286. [PMID: 31578770 DOI: 10.1111/den.13549] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/29/2019] [Indexed: 02/08/2023]
Abstract
Although endoscopic intervention is the mainstay for palliation of malignant biliary obstruction, a percutaneous approach has been preferred, particularly in patients with advanced high-grade hilar malignant biliary obstruction, because of the technical difficulty and risk of complications. However, recently, primary endoscopic palliation using plastic or metal stents has had higher technical and clinical success with fewer adverse events than the percutaneous approach. Endoscopic interventions are being done more and more frequently because of advances in metal stents, accessories, and techniques. However, several concerns, such as optimal stent type, number, and deployment method, remain to be resolved. Therefore, we reviewed the literature in order to identify the optimal biliary stenting strategy for patients with hilar malignant biliary obstruction, focusing on stent type (plastic vs metal), number (unilateral [single] vs bilateral [multiple]), and deployment method (stent-in-stent vs stent-by-stent).
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Jong Ho Moon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon Hospital, Bucheon, Korea
| | - Sang-Heum Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan Hospital, Cheonan, Korea
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Step-wise endoscopic approach to palliative bilateral biliary drainage for unresectable advanced malignant hilar obstruction. Sci Rep 2019; 9:13207. [PMID: 31519930 PMCID: PMC6744501 DOI: 10.1038/s41598-019-48384-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/22/2019] [Indexed: 02/07/2023] Open
Abstract
The ideal type of stent utilized at index endoscopic retrograde cholangiopancreatography (ERCP) in management of malignant hilar obstruction (MHO) remains unclear. We aimed to determine the ideal stent choice in patients with MHO. In this retrospective study, patients with unresectable MHO were separated into the plastic stent (PS) group and the self-expandable metal stent (SEMS) group. The primary outcome was the risk and rate of rescue percutaneous transhepatic biliary drainage (PTBD). The secondary outcomes were the progression-free survival, the overall survival and the PTBD-free period (days). Thirty-six patients in the PS group and 38 patients in the SEMS group were enrolled. The risk for PTBD was higher in SEMS group (HR = 2.205, 95% C.I. 0.977–4.977, P = 0.057). The rate of PTBD was significantly lower in the PS group. (22.2% vs 50.0%, P = 0.017) There were no differences in overall survival and progression-free survival (410 and 269 in the PS group, 395 and 266 in the SEMS group, P = 0.663 and P = 0.757). The PTBD-free period was significantly longer in the PS group. (836.43 vs 586.40, P = 0.039) Although comparable in clinical efficacy, utilization of PS at index ERCP may reduce patient’s discomfort by avoiding PTBD and prolonging PTBD-free period in patients with MHO.
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McKinley SK, Chawla A, Ferrone CR. Inoperable Biliary Tract and Primary Liver Tumors: Palliative Treatment Options. Surg Oncol Clin N Am 2019; 28:745-762. [PMID: 31472917 DOI: 10.1016/j.soc.2019.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Primary liver tumors are most commonly hepatocellular carcinoma and intrahepatic cholangiocarcinoma. Although surgical resection offers a chance for cure, these tumors generally present at a late, inoperable stage, necessitating an understanding of noncurative and palliative treatment options. These options include ablative therapies, including radiofrequency ablation; intra-arterial therapies, including transcatheter chemoembolization; biliary decompression; radiotherapy; systemic therapies, including traditional chemotherapeutic agents; and molecular therapies, such as sorafenib. Selection of nonoperative treatment depends on patient and tumor factors as well as institutional resources and expertise.
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Affiliation(s)
- Sophia K McKinley
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRB-425, Boston, MA 02114, USA
| | - Akhil Chawla
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, WAC 4-460, Boston, MA 02114, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, WAC 4-460, Boston, MA 02114, USA.
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Son JH, Lee HS, Lee SH, Bang S, Kang J, Paik WH, Ryu JK, Kim YT. Revision of bilateral self-expandable metallic stents placed using the stent-in-stent technique for malignant hilar biliary obstruction. Hepatobiliary Pancreat Dis Int 2018; 17:437-442. [PMID: 30082195 DOI: 10.1016/j.hbpd.2018.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 07/13/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Endoscopic biliary decompression using bilateral self-expandable metallic stent (SEMS) placed using the stent-in-stent (SIS) technique is considered favorable for unresectable malignant hilar biliary obstruction (MHBO). However, occlusion of the bilateral SIS placement is frequent and revision can be challenging. This study was performed to investigate the efficacy, the long-term patency and the appropriate approach for revision of occluded bilateral SIS placement in unresectable MHBO. METHODS From January 2011 to July 2016, thirty-eight patients with unresectable MHBO underwent revision of occluded bilateral SIS placement. Clinical data including success rates and patency of revision, were retrospectively analyzed. RESULTS The technical success rate of revision was 76.3%. The clinical success rate of revision was 51.7% and mean patency of revision was 49.1 days. No significant predictive factor for clinical failure of revision was observed. The cell size of SEMS was not found to have significant effects on clinical success rates or revision patency. CONCLUSIONS Revision of occluded bilateral SIS placement for MHBO showed fair patency and clinical success rate. Revision method and cell size of SEMS were not found to influence clinical outcomes.
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Affiliation(s)
- Jun Hyuk Son
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea; Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hee Seung Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Seungmin Bang
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jinwoo Kang
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea; Department of Gastroenterology and Hepatology, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yong-Tae Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Heo JY, Lee HS, Son JH, Lee SH, Bang S. Clinical Outcomes of Bilateral Stent-in-Stent Placement Using Self-Expandable Metallic Stent for High-Grade Malignant Hilar Biliary Obstruction. Yonsei Med J 2018; 59:827-833. [PMID: 30091315 PMCID: PMC6082981 DOI: 10.3349/ymj.2018.59.7.827] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 06/16/2018] [Accepted: 06/21/2018] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Endoscopic bile duct decompression using bilateral self-expandable metallic stents (SEMSs) deployed via a stent-in-stent (SIS) method is considered a preferred procedure for malignant hilar biliary obstruction (MHBO). However, occlusion thereof occurs frequently. Here, we investigated stent patency duration and risk factors related to stent obstruction with bilateral SIS placement for MHBO at two large centers. MATERIALS AND METHODS The present study reviewed data on patients with MHBO who underwent endoscopic biliary drainage using the SIS method. Clinical outcomes, including stent patency duration and patient overall survival, were analyzed. Factors associated with stent patency were evaluated using Cox proportional hazards models. RESULTS Seventy patients with MHBO underwent endoscopic biliary drainage using the SIS method. Median age was 68 years old, and median follow-up duration was 140 days (interquartile range, 57-329). The proportion of high-grade MHBOs (Bismuth type IV) was 57.1%. Median stent patency duration with the SIS method was 108 days according to Kaplan-Meier curves. Median patient survival analyzed by the Kaplan-Meier method was 181 days. Multivariate analysis indicated that higher baseline bilirubin (> 6.1 mg/dL) as an independent risk factor related to stent patency (p<0.05). CONCLUSION In endoscopic biliary decompression using SEMS placed with the SIS method, obstructive jaundice was a risk factor for stent patency. The SIS method for high-grade MHBO showed short stent patency.
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Affiliation(s)
- Ja Yoon Heo
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Seung Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Hyuk Son
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Seungmin Bang
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.
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Wang AY, Yachimski PS. Endoscopic Management of Pancreatobiliary Neoplasms. Gastroenterology 2018; 154:1947-1963. [PMID: 29458151 DOI: 10.1053/j.gastro.2017.11.295] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/16/2017] [Accepted: 11/17/2017] [Indexed: 12/14/2022]
Abstract
Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are the mainstays of interventional endoscopic practice. EUS occupies a central role in the diagnosis of pancreatobiliary neoplasms and offers a platform for a wide range of direct tumor therapies. Initial steps have demonstrated the feasibility of such applications in animal models and pilot studies. Larger clinical trials and incorporation of EUS-based therapies into cooperative cancer studies might demonstrate an impact in the clinical prognosis of patients with pancreatic cancer. ERCP plays an important role in elucidating indeterminate biliary strictures and in treating patients with malignant biliary obstruction who are symptomatic or have borderline-resectable or unresectable disease. ERCP-directed ablative therapies enable neoadjuvant and palliative intervention in patients with malignant biliary obstruction, in particular perihilar cholangiocarcinoma. Additional comparative, multicenter studies are needed to better understand the safety and efficacy of endobiliary brachytherapy, photodynamic therapy, and radiofrequency ablation in patients with pancreatobiliary malignancies.
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Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia.
| | - Patrick S Yachimski
- Division of Gastroenterology, Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
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Nennstiel S, Tschurtschenthaler I, Neu B, Algül H, Bajbouj M, Schmid RM, von Delius S, Weber A. Management of occluded self-expanding biliary metal stents in malignant biliary disease. Hepatobiliary Pancreat Dis Int 2018; 17:49-54. [PMID: 29428104 DOI: 10.1016/j.hbpd.2018.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/02/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Occlusion of self-expanding metal stents (SEMS) in malignant biliary obstruction occurs in up to 40% of patients. This study aimed to compare the different techniques to resolve stent occlusion in our collective of patients. METHODS Patients with malignant biliary obstruction and occlusion of biliary metal stent at a tertiary referral endoscopic center were retrospectively identified between April 1, 1994 and May 31, 2014. The clinical records were further analyzed regarding the characteristics of patients, malignant strictures, SEMS, management strategies, stent patency, subsequent interventions, survival time and case charges. RESULTS A total of 108 patients with biliary metal stent occlusion were identified. Seventy-nine of these patients were eligible for further analysis. Favored management was plastic stent insertion in 73.4% patients. Second SEMS were inserted in 12.7% patients. Percutaneous transhepatic biliary drainage and mechanical cleansing were conducted in a minority of patients. Further analysis showed no statistically significant difference in median overall secondary stent patency (88 vs. 143 days, P = 0.069), median survival time (95 vs. 192 days, P = 0.116), median subsequent intervention rate (53.4% vs. 40.0%, P = 0.501) and median case charge (€5145 vs. €3473, P = 0.803) for the treatment with a second metal stent insertion compared to plastic stent insertion. In patients with survival time of more than three months, significantly more patients treated with plastic stents needed re-interventions than patients treated with second SEMS (93.3% vs. 57.1%, P = 0.037). CONCLUSIONS In malignant biliary strictures, both plastic and metal stent insertions are feasible strategies for the treatment of occluded SEMS. Our data suggest that in palliative biliary stenting, patients especially those with longer expected survival might benefit from second SEMS insertion. Careful patient selection is important to ensure a proper decision for either management strategy.
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Affiliation(s)
- Simon Nennstiel
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Isolde Tschurtschenthaler
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Bruno Neu
- Medizinische Klinik II, Krankenhaus Landshut-Achdorf, Academic Teaching Hospital, Technische Universität München, Achdorferweg 3, Landshut 84036, Germany
| | - Hana Algül
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Monther Bajbouj
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Roland M Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Stefan von Delius
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Andreas Weber
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany.
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Wan X, Chen S, Zhao Q, Li T, Luo S, Cai X, Ren Y, Yu L, Li B. The efficacy of temporary placement of nasobiliary drainage following endoscopic metal stenting to prevent post-ERCP cholangitis in patients with cholangiocarcinoma. Saudi J Gastroenterol 2018; 24:348-354. [PMID: 30027911 PMCID: PMC6253912 DOI: 10.4103/sjg.sjg_94_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIMS Although endoscopic metal biliary endoprosthesis (EMBE) is widely accepted as the most suitable drainage method for patients with unresectable malignant obstruction, uncontrolled post-procedural cholangitis is still a problem. We aimed to validate a new treatment modality to prevent post-ERCP cholangitis in patients with unresectable cholangiocarcinoma. PATIENTS AND METHODS A total of 378 patients who were diagnosed with unresectable malignant biliary obstruction and underwent EMBE or temporary endoscopic nasobiliary drainage (ENBD) following EMBE placement, from January 2010 to July 2016, were enrolled in this retrospective study. Incidence of cholangitis, related infectious indicators, success rate of biliary drainage, and occurrence of complications were evaluated. RESULTS The risk of overall cholangitis and related infectious indicators was significantly lower in EMBE plus ENBD group than that in EMBE group. The occurrence of cholangitis was 2.4% versus 11.9% (P = 0.004). On further analysis of subgroups, although no difference was detected in nonhilar cholangiocarcinoma subgroup, the incidence of cholangitis and related infectious indicators in hilar cholangiocarcinoma subgroup with EMBE modality were distinctly higher than that with EMBE plus ENBD modality (type I + II was 18.5% vs 0%, P < 0.05; type III + IV was 19.8% vs 3.8%, P < 0.05). No significant difference was found in successful biliary drainage rate and procedure-related complications when all subgroups were compared. CONCLUSIONS The temporary placement of ENBD following EMBE is a simple and effective treatment modality to prevent post-ERCP cholangitis, especially in patients with hilar cholangiocarcinoma.
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Affiliation(s)
- Xinjian Wan
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sumin Chen
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiuyan Zhao
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tian Li
- Department of Gastroenterology, Weihai Municipal Hospital, Weihai, China
| | - Shengzheng Luo
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaobo Cai
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingchun Ren
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lanting Yu
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Baiwen Li
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Address for correspondence: Dr. Baiwen Li, Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, New Songjiang Road No. 650, Shanghai - 200080, China. E-mail:
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Gao DJ, Hu B, Ye X, Wang TT, Wu J. Metal versus plastic stents for unresectable gallbladder cancer with hilar duct obstruction. Dig Endosc 2017; 29:97-103. [PMID: 27431375 DOI: 10.1111/den.12700] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/14/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Metal stents usually have a longer stent patency than plastic stents for malignant biliary obstruction. However, stent patency and patient survival may differ depending on the causative disease and stent type. There are no data regarding the selection of stents for unresectable gallbladder cancer (GC) with hilar duct obstruction. The aim of the present study was to evaluate the efficacy of metal versus plastic stents for unresectable GC with hilar duct obstruction. METHODS Fifty-nine unresectable GC patients with jaundice were divided into metal stent group (MSG) and plastic stent group (PSG) depending on stent deployment. Clinical outcomes and approximate costs were assessed retrospectively. RESULTS No significant difference was found between MSG (n = 28) and PSG (n = 31) for clinical success, early adverse events and later cholangitis. Median patency and survival were 119 and 112 days in MSG versus 93 and 118 days in PSG, respectively (P > 0.05). However, the overall cost was higher in MSG than in PSG (P = 0.00). Cox proportional hazards model analysis showed that the lower Bismuth type was associated with a longer stent patency (P = 0.046), whereas older age (P = 0.041) and lower TNM stage (P = 0.002) were associated with longer survival. CONCLUSION Although metal and plastic stents have similar clinical efficacy, it seems reasonable to choose plastic stents as the treatment of choice for unresectable GC when cost-effectiveness is taken into account.
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Affiliation(s)
- Dao-Jian Gao
- Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China
| | - Bing Hu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China
| | - Xin Ye
- Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China
| | - Tian-Tian Wang
- Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China
| | - Jun Wu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China
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[Diagnostics and treatment of cholangiocellular carcinoma]. Internist (Berl) 2016; 57:1191-1205. [PMID: 27822622 DOI: 10.1007/s00108-016-0128-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cholangiocellular carcinoma (CCA) is the second most frequent primary liver carcinoma and is an aggressive tumor, which is mostly diagnosed in advanced stages. The overall survival is poor. Histpathological analysis of tumor biopsies or cytological analysis of biliary brushings can be used to confirm the diagnosis. A differentiation is made between distal, perihilar and intrahepatic CCA. The anatomical position determines the diagnostic and therapeutic strategy. Before diagnostic or therapeutic measures are undertaken it is essential to resolve biliary obstruction via endoscopic stenting or percutaneous biliary drainage. Depending on the tumor stage curative treatment options comprise radical surgical resection with hepaticojejunostomy or in selected cases liver transplantation. For intrahepatic or distal CCA liver transplantation is not indicated. In the palliative setting systemic chemotherapy with gemcitabine and cisplatin leads to a significant improvement in survival time.
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Are self-expandable metal stents superior to plastic stents in palliating malignant distal biliary strictures? A meta-analysis and systematic review. Med J Armed Forces India 2016; 73:42-48. [PMID: 28123244 DOI: 10.1016/j.mjafi.2016.08.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 08/27/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Palliation for inoperable malignant distal biliary strictures can be achieved with self-expandable metal stents (SEMS) and plastic stents (PS). This is a meta-analysis to compare PS and SEMS. The aim of the study is to compare clinical outcomes in patients with SEMS and PS. METHODS Study selection criteria were studied using SEMS and PS for palliation in patients with malignant distal biliary stricture. For data collection and extraction, articles were searched in Ovid journals, Medline, Cochrane database, and Pubmed. Pooled proportions were calculated using both Mantel-Haenszel method and DerSimonian Laird method for statistical analysis. RESULTS Initial search identified 1376 reference articles, of which 112 were selected and11 studies (N = 947) were included in this analysis. Pooled analysis showed SEMS patency to be 167.7days (95% CI = 159.2-176.3) compared to 73.3days (95% CI = 69.8-76.9) in PS. SEMS have lower odds of occlusion when compared to PS with an odds ratio of 0.48 (95% CI = 0.34-0.67). SEMS has a lower odds of cholangitis compared to SP, with an odds ratio of 0.46 (95% CI = 0.30-0.69). CONCLUSION SEMS seem to be superior to PS with better patency periods and survival duration. SEMS have lower occlusion rates, re-intervention rates, and cholangitis.
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Yoshida T, Hara K, Imaoka H, Hijioka S, Mizuno N, Ishihara M, Tanaka T, Tajika M, Niwa Y, Yamao K. Benefits of side-by-side deployment of 6-mm covered self-expandable metal stents for hilar malignant biliary obstructions. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:548-55. [PMID: 27345771 DOI: 10.1002/jhbp.372] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 06/24/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The best way to perform endoscopic stenting for hilar malignant biliary obstruction (HMBO) is under discussion. Recently, a 6-mm covered self-expandable metal stent (CSEMS) has become available. In this article, the results of side-by-side (SBS) 6-mm CSEMS deployment for HMBO are reported. METHODS A total of 22 patients, 32 procedures of SBS 6-mm CSEMS [16 fully covered (FCSEMS), 16 partially covered (PCSEMS)] deployment for HMBO, were prospectively enrolled from November 2011 to June 2015 and retrospectively analyzed. Technical and clinical success rates, stent patency period, complications, and re-intervention success rates were analyzed. RESULTS The overall/FCSEMS/PCSEMS technical and clinical success rates were 96.9%/93.8%/100% and 93.5%/100%/87.5%, respectively. The mean stent patency period was 95/113/68 days. Early and late complication rates were 3.1%/0%/6.3% and 6.3%/12.5%/0%, respectively. Stent exchange was attempted in 12 procedures, and the stent exchange success rate was 83.3%/100%/75%. CONCLUSIONS This is the first report of SBS 6-mm CSEMS deployment for HMBO. This procedure has high technical and clinical success rates and the advantages of ease of performance and a high success rate of re-intervention. Outcomes appear better with FCSEMS than with PCSEMS deployment. Since stent patency is still controversial, large-sample studies are needed.
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Affiliation(s)
- Tsukasa Yoshida
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa Ward, Nagoya, Aichi, 464-0021, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa Ward, Nagoya, Aichi, 464-0021, Japan.
| | - Hiroshi Imaoka
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa Ward, Nagoya, Aichi, 464-0021, Japan
| | - Susumu Hijioka
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa Ward, Nagoya, Aichi, 464-0021, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa Ward, Nagoya, Aichi, 464-0021, Japan
| | - Makoto Ishihara
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Tsutomu Tanaka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Yasumasa Niwa
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa Ward, Nagoya, Aichi, 464-0021, Japan
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Inoue T, Okumura F, Naitoh I, Fukusada S, Kachi K, Ozeki T, Anbe K, Iwasaki H, Mizushima T, Kobayashi Y, Ishii N, Ito K, Kondo H, Hayashi K, Yoneda M, Sano H. Feasibility of the placement of a novel 6-mm diameter threaded fully covered self-expandable metal stent for malignant hilar biliary obstructions (with videos). Gastrointest Endosc 2016; 84:352-7. [PMID: 27060713 DOI: 10.1016/j.gie.2016.03.1501] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Uncovered self-expandable metal stents (USEMSs) are used to treat unresectable malignant hilar biliary obstructions (MHBOs). However, ingrowth is not prevented, and reintervention is often troublesome. A novel 6-mm threaded fully covered self-expandable metal stent (T-FCSEMS) is available that may mitigate these issues. We aimed to clarify the safety and efficacy of T-FCSEMS placement for MHBO. METHODS Thirty patients underwent T-FCSEMS placements for MHBOs between 2014 and 2015. T-FCSEMSs were used for initial stenting in 17 patients (initial group) and for reinterventions for USEMS occlusions caused by ingrowth in 13 patients (reintervention group). The technical success rates, times to recurrent biliary obstruction, and the reintervention success rates were evaluated. RESULTS The technical success rates were 94% (16/17) and 92% (12/13) in the initial group and reintervention group, respectively. Intrahepatic bile duct occlusions caused liver abscesses 8 days and 22 days after T-FCSEMS placements in 2 cases (7%) in the initial group, in which T-FCSEMSs were placed across the intrahepatic bile duct bifurcation. The median times to recurrent biliary obstruction were 210 days in the initial group after bilateral placement and 112 days and 152 days in the reintervention group after bilateral and unilateral placements, respectively. During reintervention, T-FCSEMS removal was successful in all patients in whom it was attempted, and the success rate of endoscopic reintervention was 100% in both groups. CONCLUSIONS T-FCSEMS placement is a promising option for both initial stenting and reintervention for MHBO. However, we should consider the possibility of intrahepatic bile duct occlusion.
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Affiliation(s)
- Tadahisa Inoue
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan; Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Fumihiro Okumura
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shigeki Fukusada
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Kenta Kachi
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takanori Ozeki
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Kaiki Anbe
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Hiroyasu Iwasaki
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takashi Mizushima
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Yuji Kobayashi
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Norimitsu Ishii
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kiyoaki Ito
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Hiromu Kondo
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kazuki Hayashi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masashi Yoneda
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Hitoshi Sano
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
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Self-expandable metal stents versus plastic stents for malignant biliary obstruction. Gastrointest Endosc 2016; 83:852-3. [PMID: 26975289 DOI: 10.1016/j.gie.2015.10.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 10/28/2015] [Indexed: 12/11/2022]
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Gulati A, Thakkar P, Thakkar S. Endoscopic management of hilar stricture. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2016; 18:67-74. [DOI: 10.1016/j.tgie.2016.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
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Salgado SM, Gaidhane M, Kahaleh M. Endoscopic palliation of malignant biliary strictures. World J Gastrointest Oncol 2016; 8:240-7. [PMID: 26989459 PMCID: PMC4789609 DOI: 10.4251/wjgo.v8.i3.240] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 10/19/2015] [Accepted: 12/18/2015] [Indexed: 02/05/2023] Open
Abstract
Malignant biliary strictures often present late after the window for curative resection has elapsed. In such patients, the goal of therapy is typically focused on palliation. While historically, palliative measures were performed surgically, the advent of endoscopic intervention offers minimally invasive options to provide relief of symptoms, improve quality of life, and in some cases, increase survival of these patients. Some of these therapies, such as endoscopic biliary decompression, have become mainstays of treatment for decades, whereas newer modalities, including radiofrequency ablation, and photodynamic therapy offer additional options for patients with incurable biliary malignancies.
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Lu Y, Liu L, Wu JC, Bie LK, Gong B. Efficacy and safety of photodynamic therapy for unresectable cholangiocarcinoma: A meta-analysis. Clin Res Hepatol Gastroenterol 2015; 39:718-24. [PMID: 26070572 DOI: 10.1016/j.clinre.2014.10.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 09/09/2014] [Accepted: 10/06/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Photodynamic therapy with the placement of a biliary stent may improve the prognosis in patients with unresectable cholangiocarcinoma. The aim of this research is to determine the hazard ratio of photodynamic therapy with stent compared to biliary stenting alone or other therapies for the treatment of cholangiocarcinoma. METHODS Several databases were searched from inception to December 31 2013 for trials comparing photodynamic therapy+stent vs. stent-only or other treatments for cholangiocarcinoma. The outcomes of interest included patient survival, the changes of serum bilirubin levels, the quality of life (Karnofsky performance status), and adverse events. The hazard ratios (HR) were extracted from the survival curves using Tierney's Method. LnHR and its variance were pooled using an inverse variance-weighted average. Inconsistency was quantified using I(2) statistics. RESULTS In all, 8 trials comparing PDT+stent with other therapeutic methods were selected. We made a meta-analysis based on the 7 trials, which compared the result of PDT+stent and the stent-only group. HR summarizes the survival for the two groups. Overall survival was significantly better in patients who received photodynamic therapy than those who did not [HR=0.49, 95% confidence interval (CI), 0.33∼0.73, P=0.0005]. Among the 8 trials (642 subjects), 5 assessed the changes of serum bilirubin levels, and/or Karnofsky performance status, as other indications for improvement. In all, the incidence for phototoxic reaction is 11.11%. The incidence for other events in photodynamic therapy and the stent-only group was 13.64% and 12.79%, respectively. CONCLUSION The palliative treatment of cholangiocarcinoma, with photodynamic therapy, is associated with an increased survival benefit, an improved biliary drainage, and a better quality of life. However, the quality of this evidence is low.
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Affiliation(s)
- Yi Lu
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197, Ruijin Er Road, Shanghai 200025, China
| | - Lei Liu
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197, Ruijin Er Road, Shanghai 200025, China
| | - Jia-chuan Wu
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197, Ruijin Er Road, Shanghai 200025, China
| | - Li-Ke Bie
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197, Ruijin Er Road, Shanghai 200025, China
| | - Biao Gong
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197, Ruijin Er Road, Shanghai 200025, China.
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Sawas T, Al Halabi S, Parsi MA, Vargo JJ. Self-expandable metal stents versus plastic stents for malignant biliary obstruction: a meta-analysis. Gastrointest Endosc 2015; 82:256-267.e7. [PMID: 25982849 DOI: 10.1016/j.gie.2015.03.1980] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/31/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Malignant biliary obstruction frequently portends a poor prognosis. Palliative treatment with stenting is often required to alleviate symptoms and potentially prevent adverse events. OBJECTIVES The aims of our study were (1) to evaluate the clinical difference between self-expandable metal stents (SEMSs) and plastic stents (PSs) in both hilar and distal malignant biliary obstruction on occlusion rate and 30-day mortality rate (primary outcomes) and stent insertion success rate, therapeutic failure, reintervention rate, and adverse events (secondary outcomes); (2) to compare unilateral stenting with bilateral stenting in hilar malignant obstruction in terms of occlusion rate and 30-day mortality rate (primary outcomes) and insertion success rate, therapeutic failure, and adverse events (secondary outcomes). METHODS PubMed, Embase, and Cochrane databases were searched for studies that provided data about malignant biliary obstruction and stent therapy. We included randomized, controlled trials (RCT), prospective observational cohort, and retrospective case-control studies. The quality of each included RCT study was assessed by the Jadad scale. Mantel-Haenszel odds ratios (ORs) and mean differences were calculated by using a random-effects model. RESULTS Nineteen studies involving 1989 patients (1045 SEMSs and 944 PSs) were included for the comparison of SEMSs and PSs. We also included 7 studies that compared unilateral with bilateral stenting involving 634 patients (346 unilateral and 268 bilateral). Our meta-analysis confirmed that SEMSs are associated with a statistically significant lower risk of occlusion compared with PSs in the short term (OR 0.27; 95% confidence interval [CI], 0.13-0.60) and long term (OR 0.38; 95% CI, 0.28-0.53). SEMSs had a lower 30-day occlusion rate than PSs in both hilar malignant obstruction (OR 0.16; 95% CI, 0.04-0.62) and distal malignant obstruction (OR 0.36; 95% CI, 0.14-0.93). SEMSs had a lower long-term occlusion rate compared with PSs in hilar malignant obstruction (OR 0.28; 95% CI, 0.19-0.39) and distal malignant obstruction (OR 0.42; 95% CI, 0.27-0.64). The 30-day mortality rate was similar with SEMSs and PSs (OR 0.74; 95% CI, 0.47-1.17). Therapeutic failure was more likely when using PSs (13%) compared with SEMSs (7%) (OR 0.43; 95% CI, 0.27-0.67). SEMSs required fewer reinterventions compared with PSs (mean difference, -0.49; 95% CI, -0.8 to -0.19). The incidence of cholangitis was statistically lower with SEMSs (8% vs 21%) (OR 0.41; 95% CI, 0.22-0.76). Bilateral stenting for hilar obstruction was not associated with a lower obstruction rate than unilateral stenting (OR 1.49; 95% CI, 0.77-2.89) or a lower 30-day mortality rate (OR 0.73; 95% CI, 0.29-1.79). There was no statistical difference in therapeutic failure (OR 1.47; 95% CI, 0.77-2.89) or cholangitis incidence (OR 0.61; 95% CI, 0.27-1.38). CONCLUSION SEMSs are associated with a statistically significantly lower occlusion rate, less therapeutic failure, less need for reintervention, and lower cholangitis incidence. There was no statistically significant difference in occlusion rate, therapeutic failure, and cholangitis incidence with bilateral stenting. Guideline recommendations may need to be modified to reflect clear and compelling data demonstrating the benefit of SEMSs in patients with malignant biliary obstruction. Bilateral stenting should be avoided because it has no benefit over unilateral stenting in terms of occlusion rate or therapeutic failure.
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Affiliation(s)
- Tarek Sawas
- Department of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Shadi Al Halabi
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mansour A Parsi
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Uppal DS, Wang AY. Advances in endoscopic retrograde cholangiopancreatography for the treatment of cholangiocarcinoma. World J Gastrointest Endosc 2015; 7:675-687. [PMID: 26140095 PMCID: PMC4482827 DOI: 10.4253/wjge.v7.i7.675] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 01/22/2015] [Accepted: 02/11/2015] [Indexed: 02/05/2023] Open
Abstract
Cholangiocarcinoma (CCA) is a malignancy of the bile ducts that carries high morbidity and mortality. Patients with CCA typically present with obstructive jaundice, and associated complications of CCA include cholangitis and biliary sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable treatment modality for patients with CCA, as it enables internal drainage of blocked bile ducts and hepatic segments by using plastic or metal stents. While there remains debate as to if bilateral (or multi-segmental) hepatic drainage is required and/or superior to unilateral drainage, the underlying tenant of draining any persistently opacified bile ducts is paramount to good ERCP practice and good clinical outcomes. Endoscopic therapy for malignant biliary strictures from CCA has advanced to include ablative therapies via ERCP-directed photodynamic therapy (PDT) or radiofrequency ablation (RFA). While ERCP techniques cannot cure CCA, advancements in the field of ERCP have enabled us to improve upon the quality of life of patients with inoperable and incurable disease. ERCP-directed PDT has been used in lieu of brachytherapy to provide neoadjuvant local tumor control in patients with CCA who are awaiting liver transplantation. Lastly, mounting evidence suggests that palliative ERCP-directed PDT, and probably ERCP-directed RFA as well, offer a survival advantage to patients with this difficult-to-treat malignancy.
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Jang SI, Lee DK. Update on Pancreatobiliary Stents: Stent Placement in Advanced Hilar Tumors. Clin Endosc 2015; 48:201-8. [PMID: 26064819 PMCID: PMC4461663 DOI: 10.5946/ce.2015.48.3.201] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/11/2015] [Accepted: 05/11/2015] [Indexed: 12/23/2022] Open
Abstract
Palliative drainage is the main treatment option for inoperable hilar cholangiocarcinoma to improve symptoms, which include cholangitis, pruritus, high-grade jaundice, and abdominal pain. Although there is no consensus on the optimal method for biliary drainage due to the paucity of large-scale randomized control studies, several important aspects of any optimal method have been studied. In this review article, we discuss the liver volume to be drained, stent type, techniques to insert self-expanding metal stents, and approaches for proper and effective biliary drainage based on previous studies and personal experience.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Percutaneous Irreversible Electroporation of Unresectable Hilar Cholangiocarcinoma (Klatskin Tumor): A Case Report. Cardiovasc Intervent Radiol 2015; 39:117-21. [PMID: 25994516 PMCID: PMC4689746 DOI: 10.1007/s00270-015-1126-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 04/21/2015] [Indexed: 12/15/2022]
Abstract
Irreversible electroporation (IRE) is a novel image-guided ablation technique that is rapidly gaining popularity in the treatment of malignant tumors located near large vessels or bile ducts. The presence of metal objects in the ablation zone, such as Wallstents, is generally considered a contraindication for IRE, because tissue heating due to power conduction may lead to thermal complications. This report describes a 66-year-old female with a Bismuth-Corlette stage IV unresectable cholangiocarcinoma with a metallic Wallstent in the common bile duct, who was safely treated with percutaneous IRE with no signs for relapse 1 year after the procedure.
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Takahashi E, Fukasawa M, Sato T, Takano S, Kadokura M, Shindo H, Yokota Y, Enomoto N. Biliary drainage strategy of unresectable malignant hilar strictures by computed tomography volumetry. World J Gastroenterol 2015; 21:4946-4953. [PMID: 25945008 PMCID: PMC4408467 DOI: 10.3748/wjg.v21.i16.4946] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 12/31/2014] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify criteria for predicting successful drainage of unresectable malignant hilar biliary strictures (UMHBS) because no ideal strategy currently exists.
METHODS: We examined 78 patients with UMHBS who underwent biliary drainage. Drainage was considered effective when the serum bilirubin level decreased by ≥ 50% from the value before stent placement within 2 wk after drainage, without additional intervention. Complications that occurred within 7 d after stent placement were considered as early complications. Before drainage, the liver volume of each section (lateral and medial sections of the left liver and anterior and posterior sections of the right liver) was measured using computed tomography (CT) volumetry. Drained liver volume was calculated based on the volume of each liver section and the type of bile duct stricture (according to the Bismuth classification). Tumor volume, which was calculated by using CT volumetry, was excluded from the volume of each section. Receiver operating characteristic (ROC) analysis was performed to identify the optimal cutoff values for drained liver volume. In addition, factors associated with the effectiveness of drainage and early complications were evaluated.
RESULTS: Multivariate analysis showed that drained liver volume [odds ratio (OR) = 2.92, 95%CI: 1.648-5.197; P < 0.001] and impaired liver function (with decompensated liver cirrhosis) (OR = 0.06, 95%CI: 0.009-0.426; P = 0.005) were independent factors contributing to the effectiveness of drainage. ROC analysis for effective drainage showed cutoff values of 33% of liver volume for patients with preserved liver function (with normal liver or compensated liver cirrhosis) and 50% for patients with impaired liver function (with decompensated liver cirrhosis). The sensitivity and specificity of these cutoff values were 82% and 80% for preserved liver function, and 100% and 67% for impaired liver function, respectively. Among patients who met these criteria, the rate of effective drainage among those with preserved liver function and impaired liver function was 90% and 80%, respectively. The rates of effective drainage in both groups were significantly higher than in those who did not fulfill these criteria (P < 0.001 and P = 0.02, respectively). Drainage-associated cholangitis occurred in 9 patients (12%). A smaller drained liver volume was associated with drainage-associated cholangitis (P < 0.01).
CONCLUSION: Liver volume drainage ≥ 33% in patients with preserved liver function and ≥ 50% in patients with impaired liver function correlates with effective biliary drainage in UMHBS.
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Moy BT, Birk JW. An Update to Hepatobiliary Stents. J Clin Transl Hepatol 2015; 3:67-77. [PMID: 26357636 PMCID: PMC4542081 DOI: 10.14218/jcth.2015.00040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 01/31/2015] [Accepted: 02/05/2015] [Indexed: 12/14/2022] Open
Abstract
Endoscopic stent placement is a common primary management therapy for benign and malignant biliary strictures. However, continuous use of stents is limited by occlusion and migration. Stent technology has evolved significantly over the past two decades to reduce these problems. The purpose of this article is to review current guidelines in managing malignant and benign biliary obstructions, current endoscopic techniques for stent placement, and emerging stent technology. What began as a simple plastic stent technology has evolved significantly to include uncovered, partially covered, and fully covered self-expanding metal stents (SEMS) as well as magnetic, bioabsorbable, drug-eluting, and antireflux stents.(1).
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Affiliation(s)
| | - John W. Birk
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
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Hong W, Zhu Y, Dong Y, Wu Y, Zhou M, Ni H. Predictors for occlusion of the first inserted metallic stent in patients with malignant biliary obstruction. Saudi J Gastroenterol 2015; 21:386-90. [PMID: 26655134 PMCID: PMC4707807 DOI: 10.4103/1319-3767.164204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic biliary stent drainage plays an important role in the palliative treatment of malignant biliary obstruction. The aim of this study was to investigate predictors of occlusion of first metal inserted stent in patients with malignant biliary obstruction. PATIENTS AND METHODS The retrospective analysis was performed in 178 patients with malignant biliary obstruction. Factors associated with stent occlusion were analyzed by Cox regression analysis. RESULTS Median overall stent patency was 178 days. Total cumulative obstruction rate of the first stents during the follow up was 33%, 57%, 83%, and 96% at 90, 180, 360, and 720 days. Multivariate analysis revealed that hilar obstruction (hazard ratio [HR] =3.26, 95% confidence interval [CI, 2.31-4.61), metastasis cancer (HR = 2.61, 95% CI, 1.79-3.80), and length of stent (HR = 1.74, 95% CI, 1.24-2.46) were independent predictors of stent occlusion. CONCLUSIONS Hilar biliary stricture, metastatic cancer, and length of stent were important predictors of occlusion of first-inserted metal stent in patients with malignant biliary obstruction.
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Affiliation(s)
- Wandong Hong
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, PR China,Address for correspondence: Dr. Wandong Hong, Department of Gastroenterology and Hepatology, The First Affiliated Hospital, Wenzhou Medical University, No 2, Fu Xue Road, Wenzhou, Zhejiang - 325 000, PR China. E-mail:
| | - Yunfei Zhu
- Department of Emergency Surgery, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, PR China
| | - Yanyan Dong
- Ultrasound, The Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Yanqing Wu
- Department of Reproductive Medicine, Family Planning Research Institute, Tongji Medical College, Wuhan, Hubei, PR China
| | - Mengtao Zhou
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Haizhen Ni
- Department of Vascular Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
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Liang H, Peng Z, Cao L, Qian S, Shao Z. Metal Stenting with or without Endobiliary Radiofrequency Ablation for Unresectable Extrahepatic Cholangiocarcinoma. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/jct.2015.611106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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50
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Kawakubo K, Kawakami H, Toyokawa Y, Otani K, Kuwatani M, Abe Y, Kawahata S, Kubo K, Kubota Y, Sakamoto N. Risk factors for technical failure of endoscopic double self-expandable metallic stent placement by partial stent-in-stent method. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:79-85. [PMID: 25308061 DOI: 10.1002/jhbp.170] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Endoscopic double self-expandable metallic stent (SEMS) placement by the partial stent-in-stent (PSIS) method has been reported to be useful for the management of unresectable hilar malignant biliary obstruction. However, it is technically challenging, and the optimal SEMS for the procedure remains unknown. The aim of this study was to identify the risk factors for technical failure of endoscopic double SEMS placement for unresectable malignant hilar biliary obstruction (MHBO). METHODS Between December 2009 and May 2013, 50 consecutive patients with MHBO underwent endoscopic double SEMS placement by the PSIS method. We retrospectively evaluated the rate of successful double SEMS placement and identified the risk factors for technical failure. RESULTS The technical success rate for double SEMS placement was 82.0% (95% confidence interval [CI]: 69.2-90.2). On univariate analysis, the rate of technical failure was high in patients with metastatic disease and unilateral placement. Multivariate analysis revealed that metastatic disease was a significant risk factor for technical failure (odds ratio: 9.63, 95% CI: 1.11-105.5). The subgroup analysis after double guidewire insertion showed that the rate of technical success was higher in the laser-cut type SEMS with a large mesh and thick delivery system than in the braided type SEMS with a small mesh and thick delivery system. CONCLUSIONS Metastatic disease was a significant risk factor for technical failure of double SEMS placement for unresectable MHBO. The laser-cut type SEMS with a large mesh and thin delivery system might be preferable for the PSIS procedure.
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Affiliation(s)
- Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
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