A Case Series: Outcomes of Endoscopic Biliary Self-Expandable Metal Stent for Malignant Biliary Obstruction with Surgically Altered Anatomy

Endobiliary Radiofrequency Ablation Using a Short-Type Balloon Enteroscope in Patients with Surgically Altered Anatomy

BACKGROUND

Endoscopic radiofrequency ablation (RFA) is expected to prolong stent patency for malignant biliary obstruction (MBO). However, its feasibility when used in conjunction with a balloon enteroscope (BE) in patients with surgically altered anatomy (SAA) remains unknown.

AIMS

This study aimed to investigate the feasibility of RFA combined with metal stent insertion under BE guidance for MBO in patients with SAA.

METHODS

Thirty-seven patients who underwent treatment between October 2016 and January 2021 and met the eligibility criteria were investigated retrospectively. Study outcomes included technical and clinical success, recurrent biliary obstruction (RBO), and other adverse events besides RBO associated with RFA with metal stent placement using BE.

RESULTS

Technical and clinical success rates were 100% (37/37) each. The rates of early and late adverse events were 8.1% (3/37) and 8.1% (3/37), respectively. RBO occurred in 32.4% (12/37) of the patients, and the median time to RBO was 296 days. The cause of RBO was ingrowth in eight patients, overgrowth in three patients, and indeterminate in one patient. All reinterventions for RBO were successful using the BE approach; all ingrowths, except one, were recanalized using additional RFA without additional stent placement. The frequency of reintervention-related adverse events was 9.1% (1/11). The median time to RBO after reintervention was 166 days.

CONCLUSIONS

This study demonstrated the technical safety and feasibility as well as good long-term outcomes of endobiliary RFA combined with metal stent placement under BE guidance. This approach may be a useful option for treating MBO in patients with SAA.

Malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer

Malignant biliary obstruction generally results from primary malignancies of the pancreatic head, bile duct, gallbladder, liver, and ampulla of Vater. Metastatic lesions from other primaries to these organs or nearby lymph nodes are rarer causes of biliary obstruction. The most common primaries include renal cancer, lung cancer, gastric cancer, colorectal cancer, breast cancer, lymphoma, and melanoma. They may be difficult to differentiate from primary hepato-pancreato-biliary cancer based on imaging studies, or even on biopsy. There is also no consensus on the optimal method of treatment, including the feasibility and effectiveness of endoscopic intervention or surgery. A thorough review of the literature on pancreato-biliary metastases and malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer is presented. The diagnostic modality and clinical characteristics may differ significantly depending on the type of primary cancer. Different primaries also cause malignant biliary obstruction in different ways, including direct invasion, pancreatic or biliary metastasis, hilar lymph node metastasis, liver metastasis, and peritoneal carcinomatosis. Metastasectomy may hold promise for some types of pancreato-biliary metastases. This review aims to elucidate the current knowledge in this area, which has received sparse attention in the past. The aging population, advances in diagnostic imaging, and improved treatment options may lead to an increase in these rare occurrences going forward.

The Evolution of Device-Assisted Enteroscopy: From Sonde Enteroscopy to Motorized Spiral Enteroscopy

The introduction of capsule endoscopy in 2001 opened the last "black box" of the gastrointestinal tract enabling complete visualization of the small bowel. Since then, numerous new developments in the field of deep enteroscopy have emerged expanding the diagnostic and therapeutic armamentarium against small bowel diseases. The ability to achieve total enteroscopy and visualize the entire small bowel remains the holy grail in enteroscopy. Our journey in the small bowel started historically with sonde type enteroscopy and ropeway enteroscopy. Currently, double-balloon enteroscopy, single-balloon enteroscopy, and spiral enteroscopy are available in clinical practice. Recently, a novel motorized enteroscope has been described with the potential to shorten procedure time and allow for total enteroscopy in one session. In this review, we will present an overview of the currently available techniques, indications, diagnostic yield, and complications of device-assisted enteroscopy.

Usefulness of self-expandable metal stents for malignant biliary obstruction using a short-type single-balloon enteroscope in patients with surgically altered anatomy

OBJECTIVES

To evaluate the efficacy and safety of self-expandable metal stent (SEMS) placement for unresectable malignant biliary obstruction (MBO) using a short-type single-balloon enteroscopy (short SBE) in patients with surgically altered anatomy (SAA).

METHODS

The technical success rate, clinical success rate, recurrent biliary obstruction (RBO), time to RBO (TRBO), procedure related adverse events, and reintervention after RBO were evaluated from September 2011 to June 2020.

RESULTS

Thirty-seven patients (11 patients with distal MBO and 26 with hilar MBO) who underwent SEMS placement were included in the analysis. The technical and clinical success rates were 100% and 94.6%. Seven patients underwent bilateral stenting (partial stent-in-stent placement) for hilar MBO. The RBO rate was 13.5% (5/37) and the median TRBO was 212 (interquartile range [IQR], 154-296) days. No food impaction occurred in this study. Procedure related adverse events occurred in 5.4% (2/37) of cases. Reintervention was attempted in five patients and all succeeded (four patients underwent SEMS replacement, and one underwent plastic stent placement).

CONCLUSIONS

SEMS placement for unresectable MBO using a short SBE in patients with SAA is effective and safe in similar ways to that in patients with normal anatomy in terms of bilateral stenting, stent patency, and reintervention.

The safety and efficacy of self-expandable metallic stent placement for malignant biliary obstruction with surgically altered anatomy

BACKGROUND

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (SBE-ERCP) has been increasingly performed for the treatment of malignant biliary obstruction (MBO) in patients with surgically altered anatomy (SAA), however evidence is scarce. Therefore, we conducted this study to evaluate the efficacy and safety of self-expandable metallic stent (SEMS) placement using a short type SBE.

METHODS

We retrospectively examined consecutive patients with SAA who received initial SEMS for MBO at our institution between February 2016 and February 2019. We evaluated patient characteristics, technical and functional success rates, time to recurrent biliary obstruction (TRBO) and complications according to the location of the biliary stricture.

RESULTS

A total of 26 patients were included in this study. The primary tumor was gastric cancer in 12, pancreatic cancer in 6, cholangiocarcinoma in 6 and gallbladder cancer in 2. The biliary stricture site was distal bile duct in 14, hilar bile duct in 3 and hepaticojejunostomy (HJ) anastomosis in 9. Technical and functional success rates were 92 and 88%, respectively. TRBO, median survival time, overall rate of RBO and early complications were not different according to the stricture site (p=.36, .67, .67 and .12, respectively), whereas late complications were significantly different among the three groups (Distal vs. Hilar vs. HJ anastomosis; 0 vs. 67 vs. 22%, p<.05). Furthermore, stent patency was not different between fully covered and uncovered SEMS in distal MBO.

CONCLUSIONS

SEMS placement via SBE-ERCP was safe and effective for the management of MBO in patients with SAA, especially in distal MBO.

Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy must be performed by a highly experienced endoscopist. The challenges are accessing the afferent limb in different types of reconstruction, cannulating a papilla with a reverse orientation, and performing therapeutic interventions with uncommon endoscopic accessories. The development of endoscopic techniques has led to higher success rates in this group of patients. Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction; however, these success rate is lower in long-limb reconstruction. ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length; however, it must be performed by a highly experienced and skilled endoscopist. Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography, but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy. Laparoscopic-assisted ERCP has an almost 100% success rate in long-limb reconstruction because of the use of a conventional side-view duodenoscope, which is compatible with standard accessories. This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy. This review focuses on the advantages, disadvantages, and outcomes of various procedures that are suitable in different situations and reconstruction types. Emerging new techniques and their outcomes are also discussed.

Device-assisted enteroscopy: An update on techniques, clinical indications and safety

After more than 15 years since its introduction into clinical practice, indications for device-assisted enteroscopy have greatly expanded. Alongside the consolidated indications such as the diagnosis and treatment of small bowel bleeding, Crohn's disease, hereditary polyposis, small-bowel tumors and complicated celiac disease, device-assisted enteroscopy is nowadays largely used to perform endoscopic retrograde cholangiopancreatography in patients with altered anatomy, stent placement, retrieval of foreign bodies, direct insertion of jejunal feeding tubes, and in selected cases of incomplete colonoscopy. This has been made possible by the technical improvements of the enteroscopes and accessories and by the widespread use of the method. Device-assisted enteroscopy endotherapy currently offers a safe and effective alternative to major surgery and often represents the preferred option for treatment of small-bowel pathology. Its safety profile is favourable even in the elderly patient, provided that it is performed in high-volume and experienced centers. The evolution of the enteroscopy technique is a challenge for the future and could be facilitated by the new enteroscopes models. These prototypes need a thorough clinical and safety assessment especially for the complex therapeutic procedures. Large prospective, multicenter studies should be performed to assess whether the use of device-assisted enteroscopy leads to improved patients' long-term outcomes.

Efficacy and Long-Term Outcomes of Side-by-Side Self-Expandable Metal Stent Placement Using a 2-Channel Endoscope for Unresectable Malignant Hilar Biliary Obstruction Occurring After Billroth II Reconstruction (with Video)

BACKGROUND

Long-term studies evaluating self-expandable metal stents in patients who have unresectable malignant hilar biliary obstruction (UMHBO) after surgical reconstruction of the intestine remain inadequate. We developed a side-by-side (SBS) technique using a two-channel endoscope to place self-expandable metal stents in patients with UMHBO occurring after Billroth II reconstruction.

AIMS

We validated the long-term outcomes obtained with this technique.

METHODS

The study group comprised seven patients with UMHBO in whom we attempted to place metal stents by the SBS technique using a two-channel scope. The procedure was validated retrospectively.

RESULTS

The technical success rate was 86% and functional success rate was 100%. The median time to recurrent biliary obstruction (RBO) was 222 days (95% CI 4.9-439.1). Besides RBO, there were no other complications.

CONCLUSIONS

The SBS procedure performed using a two-channel scope is a safe and useful new technique for the treatment of UMHBO occurring after Billroth II reconstruction.

Update in enteroscopy: New devices and new indications

The present review provides an update of the currently available (proto-) types of device-assisted enteroscopy (DAE). In recent years, newly designed double- and single-balloon enteroscopes have emerged. They aim to improve insertion depth into the small bowel, and they also allow more efficient endoscopic interventions. Nowadays, almost all conventional endoscopic procedures are feasible using DAE, opening the door to new indications. Recently, more data have become available on pediatric DAE, DAE-assisted colonoscopy, and DAE in patients with altered anatomy, including DAE-assisted endoscopic retrograde cholangiopancreatography and direct cholangioscopy. Although new enteroscopes are being developed, few comparative studies are available in order to define which DAE suits best for each indication. It is the duty of the international endoscopy community to set up clinical research projects to provide answers to these open questions.

Endoscopic Retrograde Cholangiopancreatography in Post Gastrectomy Patients

Endoscopic retrograde cholangiopancreatography (ERCP) in post-gastrectomy patients with Billroth II (BII) reconstruction and Roux-en-Y (RY) reconstruction presents a challenge to therapeutic endoscopists. Major difficulties, including intubation to the ampulla of Vater, selective cannulation, and ampullary intervention, must be overcome in these patients. Recent data have shown that device-assisted ERCP allows for high success rates in these patients because various devices are useful for overcoming major difficulties. Therefore, good knowledge of postoperative anatomy and various devices is mandatory before performing ERCP procedures for post-gastrectomy patients.