Salvage hepatectomy for perihilar malignancy treated initially with biliary self-expanding metallic stents

Preoperative endoscopic biliary drainage by metal versus plastic stents for resectable perihilar cholangiocarcinoma

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.

Lower incidence of complications in endoscopic nasobiliary drainage for hilar cholangiocarcinoma

AIM: To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma.

METHODS: In total, 118 patients with hilar cholangiocarcinoma underwent endoscopic management [endoscopic nasobiliary drainage (ENBD) or endoscopic biliary stenting] as a temporary drainage in our institution between 2009 and 2014. We retrospectively evaluated all complications from initial endoscopic drainage to surgery or palliative treatment. The risk factors for biliary reintervention, post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis, and percutaneous transhepatic biliary drainage (PTBD) were also analyzed using patient- and procedure-related characteristics. The risk factors for bilateral drainage were examined in a subgroup analysis of patients who underwent initial unilateral drainage.

RESULTS: In total, 137 complications were observed in 92 (78%) patients. Biliary reintervention was required in 83 (70%) patients. ENBD was significantly associated with a low risk of biliary reintervention [odds ratio (OR) = 0.26, 95%CI: 0.08-0.76, P = 0.012]. Post-ERCP pancreatitis was observed in 19 (16%) patients. An absence of endoscopic sphincterotomy was significantly associated with post-ERCP pancreatitis (OR = 3.46, 95%CI: 1.19-10.87, P = 0.023). PTBD was required in 16 (14%) patients, and Bismuth type III or IV cholangiocarcinoma was a significant risk factor (OR = 7.88, 95%CI: 1.33-155.0, P = 0.010). Of 102 patients with initial unilateral drainage, 49 (48%) required bilateral drainage. Endoscopic sphincterotomy (OR = 3.24, 95%CI: 1.27-8.78, P = 0.004) and Bismuth II, III, or IV cholangiocarcinoma (OR = 34.69, 95%CI: 4.88-736.7, P < 0.001) were significant risk factors for bilateral drainage.

CONCLUSION: The endoscopic management of hilar cholangiocarcinoma is challenging. ENBD should be selected as a temporary drainage method because of its low risk of complications.

Use of stents in treatment of malignant biliary obstruction

Stents are now recognized as the first choice of palliative therapy for malignant biliary obstruction. Since stents can effectively relieve obstruction, reduce jaundice, and improve the quality of life, their usage in inoperable biliary tract cancer patients has broad prospects. This paper reviews the use of stents in the treatment of malignant biliary obstruction with regards to stent type, selection, placement and the combination of stenting with other means of treatment.

Clinicopathological analysis and prognosis of extrahepatic bile duct cancer with a microscopic positive ductal margin

BACKGROUND

The fate of a microscopic positive ductal margin (MPDM) of extrahepatic bile duct (EHBD) cancer is unclear. The purpose of this study was to analyse the clinicopathological features of EHBD cancer with MPDM and to identify the prognostic factors associated with survival.

METHODS

Between 1995 and 2007, a retrospective analysis of 464 patients who had undergone surgical resection for EHBD cancer was conducted. Clinicopathological factors likely to influence survival were assessed using univariate and multivariate analysis.

RESULTS

One hundred twenty-four patients had MPDM which included invasive carcinoma (IC) (n =85) and carcinoma in situ (CIS)/ high-grade dysplasia (HGD) (n = 39). The median survival (MS) of R0, R1 as CIS/ HGD, and R1 as IC were 41 months, 29 months, and 18 months, respectively. Adverse prognostic factors were 'IC' on the resection margin [HR = 1.66, 95% confidence intervals (CIs) 1.06-2.59, P = 0.026], and no use of adjuvant chemoradiotherapy (HR = 1.57, 95% CIs 1.04-2.39, P = 0.033). Adjuvant chemoradiotherapy was beneficial in patients with MPDM as IC (5-year survival rate 19.7 compared with 2.8%, P = 0.011).

CONCLUSIONS

The presence of MPDM is an important prognostic factor in EHBD cancer. When a ductal resection margin is positive, discrimination between 'IC' and 'CIS/ HGD' is important.