Endoscopic palliation and survival in malignant biliary obstruction

Randomized trial in malignant biliary obstruction: plastic vs partially covered metal stents

AIM

To compare efficacy and complications of partially covered self-expandable metal stent (pcSEMS) to plastic stent (PS) in patients treated for malignant, infrahilar biliary obstruction.

METHODS

Multicenter prospective randomized clinical trial with treatment allocation to a pcWallstent(®) (SEMS) or a 10 French PS. Palliative patients aged ≥ 18, for infrahilar malignant biliary obstruction and a Karnofsky performance scale index > 60% from 6 participating North American university centers. Primary endpoint was time to stent failure, with secondary outcomes of death, adverse events, Karnofsky performance score and short-form-36 scale administered on a three-monthly basis for up to 2 years. Survival analyses were performed for stent failure and death, with Cox proportional hazards regression models to determine significant predictive characteristics.

RESULTS

Eighty-five patients were accrued over 37 mo, 42 were randomized to the SEMS group and 83 patients were available for analyses. Time to stent failure was 385.3 ± 52.5 d in the SEMS and 153.3 ± 19.8 d in the PS group, P = 0.006. Time to death did not differ between groups (192.3 ± 23.4 d for SEMS vs 211.5 ± 28.0 d for PS, P = 0.70). The only significant predictor was treatment allocation, relating to the time to stent failure (P = 0.01). Amongst other measured outcomes, only cholangitis differed, being more common in the PS group (4.9% vs 24.5%, P = 0.029). The small number of patients in follow-up limits longitudinal assessments of performance and quality of life. From an initially planned 120 patients, only 85 patients were recruited.

CONCLUSION

Partially covered SEMS result in a longer duration till stent failure without increased complication rates, yet without accompanying measurable benefits in survival, performance, or quality of life.

Gastroduodenal outlet obstruction and palliative self-expandable metal stenting: a dual-centre experience

Background. Self-expandable metal stents (SEMs) are increasingly being utilised instead of invasive surgery for the palliation of patients with malignant gastroduodenal outlet obstruction. Aim. To review two tertiary centres' experience with placement of SEMs and clinical outcomes. Methods. Retrospective analysis of prospectively collected data over 12 years. Results. Ninety-four patients (mean age, 68; range 28–93 years) underwent enteral stenting during this period. The primary tumour was gastric adenocarcinoma in 27 (29%) patients, pancreatic adenocarcinoma in 45 (48%), primary duodenal adenocarcinoma in 8 (9%), and cholangiocarcinoma and other metastatic cancers in 14 (16%). A stent was successfully deployed in 95% of cases. There was an improvement in gastric outlet obstruction score (GOOS) in 84 (90%) of patients with the ability to tolerate an enteral diet. Median survival was 4.25 months (range 0–49) without any significant differences between types of primary malignancy. Mean hospital stay was 3 days (range 1–20). Reintervention rate for stent related complications was 5%. Conclusion. The successful deployment of enteral stents achieves excellent palliation often resulting in the prompt reintroduction of enteral diet and early hospital discharge with minimal complications and reintervention.

Mortality in patients undergoing covered self-expandable metal stent revisions in malignant biliary stricture: does pathology matter?

BACKGROUND AND AIMS

Partially covered metal stents have been extensively used for palliation of obstructive jaundice in malignant distal biliary strictures and can be removed in cases of malfunction or need for tissue diagnosis. We investigated independent predictors of mortality in patients undergoing partially covered metal stents revision (i.e., removal and replacement).

METHODS

Patients with a distal malignant biliary obstruction palliated with a partially covered metal stent were followed-up prospectively over 5 years until malfunction or death. All patients who required removal of their partially covered metal stents were captured in a specific database. Multivariate analysis was performed on non-surgical patients to assess for independent predictors of death using known risk factors including type of malignancy (adenocarcinoma versus all others), age greater than 55, gender, and exposure to adjuvant chemotherapy and/or radiotherapy.

RESULTS

Forty-two patients (28 men, mean age of 62±12 years) underwent partially covered metal stents removal. Of these, biliary drainage was achieved in 38 patients by placement of a new partially covered metal stent (n=32) or plastic stent (n=6). The remaining 4 patients did not undergo stent replacement because of refusal (2), resolution of obstruction (1) and unrelated death (1). Long-term follow-up post removal in patients who were not surgical candidates (n=31) was 35 weeks (95% CI 28-40), with a survival rate of 29% at 10 months. Logistic regression analysis in the 31 patients with unresectable disease showed that a histologic diagnosis of adenocarcinoma was associated with increased mortality post partially covered metal stents revision.

CONCLUSIONS

Partially covered metal stents revision should be undertaken especially when dealing with a non-adenocarcinoma type cancer.

Magnetic compression biliary-enteric anastomosis for palliation of obstructive jaundice: initial clinical results

PURPOSE

To report initial clinical experience with a nonsurgical method for sutureless biliary-enteric anastomosis with use of two magnetic elements that potentially overcomes the disadvantages of other palliative methods.

MATERIALS AND METHODS

The technique involves percutaneous transhepatic insertion of one magnet into the bile duct under fluoroscopic guidance and insertion of a second magnet endoscopically into the duodenum. The adherence of the two magnets creates ischemic necrosis of bile duct and duodenal walls. When these tissues slough, the resulting hole allows enteric passage of the magnets and creates a biliary-enteric fistula for decompression of an obstructed biliary system. A magnetic compression biliary-enteric anastomosis (MCBEA) was created in 34 patients (nine men; mean age, 64 years; age range, 46-82 y) with malignant obstructive jaundice at the level of the middle or distal common bile duct.

RESULTS

There was no recurrent jaundice during the initial 30 postprocedural days. Total bilirubin levels decreased significantly in all patients 1 week after MCBEA formation (P < .0001), with normalization of bilirubin levels in eight of 34 patients. There was temporary occlusion caused by partial clogging of the bypass with coarse food in two cases, which was successfully revised endoscopically. Three patients required surgical revision as a result of tumor ingrowth. Median survival time was 10 months. The cause of death in all patients was progression of underlying malignancy.

CONCLUSIONS

Creation of a biliary-enteric anastomosis with magnetic compression is a feasible alternative for palliative treatment of obstructive jaundice with satisfactory results.

Covered expandable nitinol stents for malignant gastroduodenal obstructions

BACKGROUND AND AIM

The aim of the present study was to investigate the clinical effectiveness, safety, and outcome associated with the use of covered expandable Nitinol stents (Taewoong Medical, Seoul, Korea) for the treatment of malignant gastroduodenal obstructions.

METHODS

Between March 2001 and October 2004, covered expandable Nitinol stents were placed in 68 consecutive patients under endoscopic and fluoroscopic guidance for the following reasons: gastric carcinoma (n = 49), recurrent carcinoma after partial gastrectomy (n = 7), or another malignant neoplasm involving the duodenum (n = 12).

RESULTS

Technical success was achieved in 60 of the 68 patients (88.2%). After stent placement, mean dysphagia score improved from a mean of 3.5 to 1.2 (P < 0.001). The mean period of primary stent patency was 107.2 days. During follow up (mean 4.4 months; range, 1-15 months), major complications (migration [6], bleeding [3], perforation [1], ingrowth [1], overgrowth [7], fistula [1]) occurred in 19 patients (27.9%), and stent migration occurred in six (8.8%) (proximal migration into the stomach [n = 3], or distal migration [n = 3]). Recurrent dysphagia (mainly due to tumor ingrowth/overgrowth) occurred in eight patients (11.8%).

CONCLUSION

Covered expandable Nitinol stents appear to offer an effective and feasible palliative therapy in patients with a malignant gastroduodenal obstruction.

Expandable metal biliary stents before pancreaticoduodenectomy for pancreatic cancer: a Monte-Carlo decision analysis

BACKGROUND & AIMS

Endoscopic placement of plastic or self-expandable metal biliary stents (SEMS) relieves obstructive jaundice from pancreatic cancer. Short-length, distally placed SEMS do not preclude subsequent pancreaticoduodenectomy. We sought to determine whether SEMS placement in patients whose surgical status is uncertain is cost-effective for management of obstructive jaundice.

METHODS

A Markov model was constructed to evaluate costs and outcomes associated with endoscopic biliary stenting for obstructive jaundice. Strategies evaluated were: (1) initial plastic stent with plastic stents for subsequent occlusions in nonsurgical candidates after staging (plastic followed-up by [f/u] plastic), (2) initial plastic with subsequent SEMS (plastic f/u metal), (3) initial short-length SEMS with subsequent plastic (metal f/u plastic), and (4) initial short-length SEMS with subsequent expandable metal stent (metal f/u metal). Published stent occlusion rates, ERCP complication rates and outcomes, cholangitis rates and outcomes, pancreatic cancer mortality rates, and Whipple complication rates were used. Costs were based on 2004 Medicare standard allowable charges and were accrued until all patients reached an absorbing health state (death or pancreaticoduodenectomy) or 24 cycles (24 mo) ended.

RESULTS

Average costs per patient from Monte Carlo simulation were: (1) metal f/u metal, $19,935; (2) plastic f/u metal, 20,157 dollars; (3) metal f/u plastic, 20,871 dollars; and (4) plastic f/u plastic, 20,878 dollars. For initial plastic stents to be preferred over short-length metal stents, 70% or more of pancreatic cancers would need to be potentially resectable by pancreaticoduodenectomy.

CONCLUSIONS

In patients undergoing ERCP before definitive cancer staging, short-length SEMS is the preferred initial cost-minimizing strategy.

Self-expanding metal stents for the palliation of malignant gastroduodenal obstruction in patients unsuitable for surgical bypass

BACKGROUND

The primary therapeutic goals in patients with gastroduodenal obstruction secondary to advanced malignancy are the re-introduction of an enteral diet and early discharge. The endoscopic placement of expandable metal stents has been proposed as an alternative technique for palliation in patients not suitable for surgery.

AIM

To review our experience with gastroduodenal metal stent insertion for the palliation of malignant gastric and duodenal obstruction.

METHODS

A retrospective review was conducted of the notes of all patients who underwent gastroduodenal stent insertion in our unit.

RESULTS

Forty patients (mean age, 64.5 years; range, 34-93 years) underwent insertion of an enteral stent for malignant gastroduodenal obstruction. The primary tumour was gastric in 20 patients, pancreatico-biliary in 15 and metastatic in five. A stent was successfully placed in all cases. Thirty-two patients have subsequently died, the median (range) survival being 7 weeks (1 week to 10 months). Thirty-three patients (82.5%) were discharged from hospital. During follow-up, 12 patients (30%) returned to a solid diet, 20 (50%) required a soft diet, six (15%) tolerated liquids and two (5%) were unable to tolerate any enteral nutrition.

CONCLUSION

The use of enteral stents achieves good palliation, allowing discharge from hospital and re-introduction of an enteral diet.