Endoscopic treatment of malignant biliary strictures

Efficacy and safety of palliative endobiliary radiofrequency ablation using a novel temperature-controlled catheter for malignant biliary stricture: a single-center prospective randomized phase II TRIAL

BACKGROUND

Endobiliary radiofrequency ablation (EB-RFA) has emerged as a palliative treatment for malignant biliary strictures (MBSs); however, concerns about complications related to thermal injury remain. In this study, we evaluated the efficacy and safety of EB-RFA with a novel catheter for MBS.

METHODS

Patients with inoperable cancer causing MBS were randomly assigned to either the radiofrequency ablation (RFA) group or the non-RFA group. The RFA group underwent EB-RFA at the stricture site with a temperature-controlled catheter (ELRA™; STARmed Co., Goyang, Korea) followed by deployment of a self-expanding metal stent (SEMS). For the non-RFA group, only SEMS placement was performed. The duration of stent patency, overall survival (OS), and 30-day complication rate were evaluated. This trial was registered at ClinicalTrials.gov (number NCT02646514).

RESULTS

A total of 48 patients were enrolled (24 in each group). During a median follow-up period of 135.0 days (RFA group) and 119.5 days (non-RFA group), the 90-day stent patency rate, median duration of stent patency, and median OS were not different between the groups (58.3% vs. 45.8% [P = 0.386], 132.0 days vs. 116.0 days [P = 0.440], and 244.0 days vs. 180.0 days [P = 0.281], respectively). In the RFA group, procedure-related complications including thermal injury-related complications, such as bile duct perforation or hemobilia, were not reported. The early complication (< 7 days) rates were not different between the groups (4.2% vs. 12.5%, P = 0.609), and there were no late complications (7-30 days) in both groups.

CONCLUSION

EB-RFA with a temperature-controlled catheter followed by SEMS placement for patients with inoperable MBS can be safe and feasible with acceptable biliary patency.

Dilatation Therapy and Demographic Characteristics Significantly Influence the Amount of Propofol for Therapeutic Endoscopic Retrograde Cholangiography

BACKGROUND AND STUDY AIMS

Patients undergoing therapeutic endoscopic retrograde cholangiography (ERC) may require different amounts of sedative agents depending on demographic characteristics, indication of ERC, and/or endoscopic intervention.

PATIENTS AND METHODS

We retrospectively analyzed all patients undergoing therapeutic ERC from 2008 - 2014 who received deep sedation with propofol ± midazolam.

RESULTS

A total of 2448 ERC procedures were performed in 781 patients. The cumulative per procedure propofol dose in the different groups was as follows: PSC 479 mg (±256), bile duct stones 356 mg (±187), benign stenosis/cholestasis 395 mg (±228), malignant stenosis 401 mg (±283), and postliver transplant complications 391 mg (±223) (p < 0.05). Multivariable analysis showed that dilatation therapy (p = 0.001), age (p = 0.001), duration of the intervention (p = 0.001), BMI (p = 0.001), gender (p = 0.001), platelet count (p = 0.003), and bilirubin (p = 0.043) influence independently the propofol consumption.

CONCLUSIONS

Demographic characteristics and endoscopic interventions have a distinct influence on the amount of sedation required for therapeutic ERC. Although the sedation-associated complication rate is low optimization of sedative regimens is a prime goal to further reduce adverse events of therapeutic ERC.

Survey study on the practice patterns in the endoscopic management of malignant distal biliary obstruction

BACKGROUND AND STUDY AIM

 Endoscopic biliary drainage for malignant distal biliary obstruction (MDBO) is a common practice. Controversy persists with regard to its role in resectable MDBO, the optimal technical method and type of stent. The aim of this study was to evaluate practice patterns in the treatment of MDBO among endoscopists with varying levels of experience and practice backgrounds.

METHODS

 Electronic survey distributed to members of the American Society for Gastrointestinal Endoscopy (ASGE). The main outcome measures included practice setting (academic vs. community), volume of endoscopic retrograde cholangiopancreatographies (ERCPs), reasons for endoscopic drainage in MDBO, and technical approach.

RESULTS

 A total of 335 subjects (54 % community-based endoscopists) completed the survey. Most academic physicians (69 %) reported performing ≥ 150 ERCPs annually compared to 18.8 % of community physicians ( P  < 0.001). In aggregate, 13.1 % of respondents performed ERCP in resectable MDBO because of surgeon preference or as the standard of care at their institution. The use of metal vs. plastic stents in MDBO varied based on practice setting. Routine sphincterotomy for MDBO was more common among community (78 %) vs academic endoscopists (61.1 %) ( P  < 0.001). Over half (58 %) of the subjects avoided covering the cystic duct take-off during stenting MDBO if there was a gallbladder in situ.

CONCLUSION

 There is significant variability in practice patterns for the treatment of MDBO. In spite of the recent ASGE guideline recommendations, some patients with resectable MDBO still undergo preoperative ERCP. Current clinical practices are not clearly supported by available data and underscore the need to increase adherence to gastrointestinal societal recommendations and an evidence-based approach to standardized patient care.

Endoscopic palliation of malignant biliary strictures

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.

Endoscopic management of malignant biliary stenosis. Update and highlights for standard clinical practice

The present review describes the various indications of biliary stent placement in patients with biliary malignancies. It deals in depth with biliary accesses and their effectiveness, as well as with the use of different stents according to lesion type and expected patient survival. For liver hilum lesions, which are somewhat more complex, the usefulness of and need for unilateral or bilateral drainage is assessed, as it is the most appropriate method. All in all, this is an up-to-date literature review that may help clinicians in their daily decision-making, as well as to improve and optimize patient outcomes.