Treatment of biliary obstruction caused by metastatic cancer

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.

Is metallic stenting worthwhile for biliary obstruction due to lymph node metastases?

BACKGROUND

The indications for metallic stents have widened from primary hepatobiliary cancers to the other diseases such as lymph node metastases from distant organs. The present study aimed to evaluate the results and establish the efficacy of metallic stenting in patients with obstructive jaundice due to metastatic lymph nodes.

METHODS

Stent patency, survival and cost per patient until death were retrospectively compared between patients with primary carcinoma of the biliary tract (PC group; n = 71) and lymph node metastases from the gastric and colorectal carcinomas. (LN group; n = 26).

RESULTS

Stent occlusion occurred in 17 patients in the PC group (24%). In contrast, stent occlusion was significantly more frequent in the LN group (P = 0.0293), occurring in 13 patients (50%). Cumulative stent patency was also significantly shorter in the LN group than that in the PC group (P = 0.0016). However, survival was almost the same between the two groups. The mean medical fee was 27% higher for the LN group than for the PC group, which was attributable to additional treatment for stent occlusion.

DISCUSSION

The indications for metallic stent placement for biliary obstruction caused by lymph node metastases from the gastrointestinal tract seem limited. Further investigation of the treatments alternative to metallic stents would be required.

Long-term results of percutaneous transhepatic biliary drainage for benign and malignant bile duct strictures

BACKGROUND

Long-term percutaneous transhepatic biliary drainage (PTBD) is a valid alternative to surgery in patients with benign or malignant bile duct strictures in whom endoscopic drainage has failed. However, few data are available on the long-term outcome with percutaneous drainage, specially when the application of Yamakawa-type prostheses is considered.

METHODS

During 1996, 48 patients who were either treated with primary PTBD insertion followed by PTBD exchanges (n = 15) or who presented only for exchange of an earlier PTBD (n = 33) were included in the study. Thirty-one patients had malignant strictures, and 17 had benign ones. The PTBD catheters were scheduled for exchange every 3 months or earlier if signs and symptoms of obstruction or other problems were present. The data were collected prospectively during each follow-up visit and included both symptoms and the status and function of the PTBD at the time of exchange.

RESULTS

Although PTBD was highly effective in relieving jaundice (progression of cholestasis was observed in only 2 cases), 73 of the 157 PTBD exchanges (47%) had to be carried out earlier than scheduled. Premature exchange was needed for clinical reasons, such as fever indicating PTBD dysfunction, in only 19% of these cases. The other reasons were related to the PTBD catheter and consisted of bile leakage alongside the drain (33%), PTBD disconnection or complete dislocation (30%), or occlusion suspected during regular flushing of the drain (15%). In most cases exchanging the drain was sufficient to solve the problem; in cases of complete dislocation, dilation of the same tract (n = 6) or fresh puncture and establishment of a new drainage site (n = 2) were necessary. Reducing the PTBD exchange interval from 3 to 2 months would have decreased the number of premature stent exchanges by 26%.

CONCLUSIONS

Although PTBD is an effective method of biliary drainage, there are frequently minor problems-mostly catheter-related-which require premature exchange of the drain in almost half of the cases, and this may affect the patients' quality of life. Improvements in PTBD materials and catheter design are therefore needed. The effectiveness of reducing the intervals between PTBD exchanges should also be examined.

Biliary drainage in obstructive jaundice: experimental and clinical aspects

Jaundiced patients undergoing invasive diagnostic and therapeutic procedures are at increased risk of complications and death. Despite the large number of clinical and experimental investigations carried out to identify relevant risk factors, no single parameter has been found to be consistently useful in predicting morbidity or mortality. Biliary decompression was initially employed by surgeons and subsequently by interventional radiologists. More recently, endoscopic retrograde cholangiopancreatography has provided an alternative route for decompression of the biliary tree and preliminary data using this method are encouraging. Although there are enthusiastic proponents of various therapeutic techniques, controlled trials have not been convincing in highlighting the benefits of biliary drainage or in determining the best approach. This article reviews the literature pertaining to this complex surgical problem; an attempt has been made to balance the advantages and disadvantages of biliary decompression as palliation and/or preliminary treatment for extrahepatic biliary obstruction.

Relief of metastatic biliary obstruction by stent placement: is it worthwhile?

Twenty-one patients undergoing stent placement for extra-hepatic biliary obstruction by metastatic disease were reviewed. Primary tumours (colorectal 8, stomach 4, breast 2, ovary 2, others 5) had been diagnosed 13 months (median) before presentation with bile duct obstruction, which was at the porta hepatis or common hepatic duct in 14 patients and in the common bile duct in seven. Endoscopic stent placement was achieved in 14 out of 20 patients in whom it was attempted. A percutaneous trans-hepatic procedure was necessary in five patients. Two patients could not be stented. Median survival was 5 months (range 1 month to 6 years) in patients stented successfully but only 1 month (2 weeks to 3 months) in unsuccessful cases (P < 0.01). Nine patients survived more than 4 months. Patients with proximal obstruction fared less well than those with distal obstruction; they required more procedures and survived for shorter periods (median 1 month versus 5 months, P < 0.05). Worthwhile palliation is afforded to almost half these patients by endoscopic stent placement and individual patients may achieve prolonged, symptom-free survival.