Efficacy and Safety of Radiofrequency Ablation Plus Stent Versus Stent-alone Treatments for Malignant Biliary Strictures: A Systematic Review and Meta-analysis

Biliary stents for active materials and surface modification: Recent advances and future perspectives

Demand for biliary stents has expanded with the increasing incidence of biliary disease. The implantation of plastic or self-expandable metal stents can be an effective treatment for biliary strictures. However, these stents are nondegradable and prone to restenosis. Surgical removal or replacement of the nondegradable stents is necessary in cases of disease resolution or restenosis. To overcome these shortcomings, improvements were made to the materials and surfaces used for the stents. First, this paper reviews the advantages and limitations of nondegradable stents. Second, emphasis is placed on biodegradable polymer and biodegradable metal stents, along with functional coatings. This also encompasses tissue engineering & 3D-printed stents were highlighted. Finally, the future perspectives of biliary stents, including pro-epithelialization coatings, multifunctional coated stents, biodegradable shape memory stents, and 4D bioprinting, were discussed.

Assessment of safety and adverse events in endoscopic radiofrequency ablation for malignant biliary obstruction

Background

Endoscopic radiofrequency ablation (RFA) is used for the treatment of unresectable malignant biliary obstruction (MBO). The postoperative adverse events associated with RFA treatment have gained importance.

Objective

To investigate the early adverse events and their risk factors associated with RFA for the treatment of MBO.

Design

Observational retrospective study.

Methods

We collected data from patients diagnosed with MBO and treated with endoscopic RFA at our hospital between January 2010 and June 2022. Based on the collected data, the patients were divided into two groups: the adverse event group and the nonadverse event group. Early postoperative adverse events were recorded, and risk factors were assessed.

Results

One hundred and twenty patients with MBO underwent endoscopic RFA, with 20 developing adverse events (16.6%; 20/120). Among these, 13 patients (10.8%) developed biliary infection after RFA treatment, while 7 (5.8%) developed acute pancreatitis, and no bleeding or perforation occurred. Type 2 diabetes mellitus, bile duct stricture length >2.5 cm, segmental RFA, and the proportion of patients receiving single stent drainage were all significantly greater in the adverse event group compared to the nonadverse event group (p < 0.05). The results of the logistic regression analysis showed that type 2 diabetes, segmental RFA, and single stent drainage were the three independent risk factors for getting a biliary infection after RFA therapy.

Conclusion

Unresectable MBO combined with type 2 diabetes mellitus, segmental RFA, and postoperative single stent drainage can be the risk factors for adverse events after RFA. More attention should be paid to patients with multiple risk factors and preventive measures should be taken.

Pancreatoscopy-Guided Lithotripsy for Pancreatic Duct Stones: A Systematic Review and Meta-Analysis

Background/Aims

Pancreatic duct stones (PDS) are one of the leading complications of chronic pancreatitis, causing intractable upper abdominal pain, aggravating the underlying disease, and even increasing the risk of pancreatic cancer. At present, pancreatoscopyguided lithotripsy is considered the second-line endoscopic treatment for pancreatic duct stones. In this systematic review and metaanalysis, we evaluated the efficacy and safety of pancreatoscopy-guided lithotripsy.

Materials and Methods

A systematic search was conducted across several medical electronic databases, including PubMed, Web of Science, Medline, and Embase, encompassing publications up to December 2022. Studies reporting complete stone clearance rate, clinical success rate, and adverse event rate were included for analysis. We further aimed to compare the outcomes between electrohydraulic lithotripsy and laser lithotripsy treatment groups.

Results

A total of 17 studies (5 prospective studies and 12 retrospective studies) with 441 patients were included in the meta-analysis. Pooled complete stone clearance rate was 81% (95% CI, 0.74-0.88), pooled clinical success rate was 90% (95% CI, 0.84-0.95), while the pooled adverse event rate was 12% (95% CI, 0.07-0.19).

Conclusion

Pancreatoscopy-guided lithotripsy is a safe and effective treatment for pancreatic duct stones. This is evidenced by high pooled rates of complete stone clearance and clinical success, combined with a relatively low incidence of adverse events.

Percutaneous transhepatic cholangiography: An effective option for endo-biliary radiofrequency ablation before stent insertion in unresectable biliary cancer?

Biliary cancer is a highly aggressive disease that is typically diagnosed at advanced stages when surgical removal is no longer an option. In these cases, palliative care and mechanical widening of the blocked biliary system are preferred. The insertion of a stent is often necessary to prevent the recurrence of blockages caused by cancer progression. Prior to stent placement, endo-biliary radiofrequency ablation (EB-RFA) appears to result in longer-lasting stent effectiveness without increasing the risk of severe complications. However, its impact on overall survival is not yet clear. Additionally, while endoscopic retrograde cholangiopancreatography is the most common method for performing EB-RFA, percutaneous transhepatic cholangiodrainage seems to be a safe and potentially more efficient alternative, particularly for long, angulated, or significantly narrowed bile ducts.

Safety and efficacy of side-by-side versus stent-in-stent stenting for malignant hilar biliary obstruction: a systematic review and meta-analysis

Objectives

Stenting of the malignant hilar biliary obstruction (MHBO) area for bile drainage is challenging. Bilateral stenting techniques of stent-in-stent (SIS) and stent-by-stent (SBS) have shown promising results. This study evaluates the efficacy of different stenting methods for MHBO.

Design

A meta-analysis was performed to determine the efficacy of SIS and SBS stenting strategies for MHBO.

Data sources and methods

Medical databases such as PubMed, Web of Science, Embase, and Scopus, were searched up to August 2023. We selected eligible studies reporting the data on technical and clinical success, adverse events, and incidence of re-obstruction (RO) of SBS and SIS groups in MHBO patients. We compared the outcomes of SBS and SIS groups.

Results

A total of 9 studies comparing the data of 545 patients (268 in the SBS group and 277 in the SIS stenting group) were analyzed. There was no significant difference (p > 0.05) in the odds ratio (OR) of Re-obstruction (RO) 0.87 (95% confidence interval (95% CI) 0.6-1.25), technical success 0.58 (95% CI 0.16-2.11), clinical success 1.13 (95% CI 0.62-2.07), and adverse events 1.53 (95% CI 0.88-2.64). The mean difference in procedure time was -12.25 min (95% CI -18.39, -6.12), and the hazard ratio of stent patency was 1.22 (95% CI 1.01-1.47), favoring SBS, with high heterogeneity (I 2 = 94%). There was no significant difference in HR for survival 1.05 (95% CI 0.95-1.16) with high heterogeneity (I 2 = 84%).

Conclusion

Compared with SIS, SBS showed better stent patency with comparable technical and clinical success and adverse events.

Prospero registration

The registration number for this study on PROSPERO is CRD42024523230.

Percutaneous endobiliary radiofrequency ablation and stent placement for unresectable malignant biliary obstruction: a propensity score matching retrospective study

BACKGROUND

Whether endobiliary radiofrequency ablation (EB-RFA) changes the standard role of stent placement in treating unresectable malignant biliary obstruction (MBO) remains unclear. The aim of this study is to compare percutaneous EB-RFA and metal stent placement (RFA-Stent) with metal stent placement alone (Stent) in treating unresectable MBO using a propensity score matching (PSM) analysis.

METHODS

From June 2013 to June 2018, clinical data from 163 patients with malignant biliary obstruction who underwent percutaneous RFA-Stent or stenting alone were retrospectively analyzed using a nearest-neighbor algorithm to one-to-one PSM analysis to compare primary and secondary stent patency (PSP, SSP), overall survival (OS) and complications between the two groups.

RESULTS

Before matching, for whole patients, RFA-Stent resulted in longer median PSP (8.0 vs. 5.1 months, P = 0.003), SSP (9.8 vs. 5.1 months, P < 0.001) and OS (7.0 vs. 4.5 months, P = 0.034) than the Stent group. After matching (54 pairs), RFA-Stent also resulted in better median PSP (8.5 vs. 5.1 months, P < 0.001), SSP (11.0 vs. 6.0 months, P < 0.001), and OS (8.0 vs. 4.0 months, P = 0.007) than Stent. RFA-Stent was comparable with Stent for complication rates. In Cox analysis, RFA-Stent modality and serum total bilirubin level were independent prognostic factors for PSP. RFA-Stent modality, performance status score and combination therapy after stent were independent prognostic factors for OS.

CONCLUSION

Percutaneous RFA-Stent was superior to Stent in terms of PSP, SSP, and OS in selected patients with unresectable MBO.

Multimodal treatment with endoscopic ablation and systemic therapy for cholangiocarcinoma

Cholangiocarcinoma (CCA) are primary malignancies of biliary system and usually unresectable at the time of diagnosis. As a consequence, majority of these cases are candidates for palliative care. With the advances in chemotherapeutic agents and multidisciplinary care, the survival rate has improved in cases with inoperable malignant biliary obstruction. As a consequence, there is a need to provide effective and durable palliative care in these patients. The main role of endoscopic palliation in the vast majority of CCA includes biliary stenting for obstructive jaundice. Recent advances in the endoscopic palliation and multimodal approach appear promising in imparting durable relief of symptoms. Use of radiofrequency ablation, photodynamic therapy and intraluminal brachytherapy has been shown to improve the survival rates as well as the patency of biliary stents. Infact, intraductal ablation may act synergistically with chemotherapy by modulating tumour signalling pathways and immune microenvironment.

Intraductal radiofrequency ablation plus biliary stent versus stent alone for malignant biliary obstruction: a systematic review and meta-analysis

Background and study aims Recurrent biliary stent occlusion and tumor ingrowth remain a major concern among patients with malignant biliary obstruction (MBO) with significant impact on patient morbidity and survival. Intraductal radiofrequency ablation (RFA) has emerged as a promising treatment that seeks to extend stent patency. This study aimed to evaluate the impact of RFA on overall survival (OS) and stent patency among patients with unresectable MBO. Methods A comprehensive search of electronic databases was performed for randomized controlled trials (RCTs) comparing RFA plus biliary stent (RFA+S) versus biliary stent alone (S-alone). Outcomes assessed included overall survival, stent patency, and adverse events (AEs) with mean difference (MD) calculated from pooled proportions. Subgroup analyses were performed for hilar strictures and cholangiocarcinoma (CCA). Results Six RCTs (n=439 patients) were included and demonstrated improved survival among patients who received RFA+S (MD 85.80 days; 95% confidence interval [CI] 35.02-136.58; I 2 =97%; P <0.0009). The pooled MD for total stent patency was 22.25 days (95% CI 17.38-61.87; I 2 =97%; P =0.27). There was no difference in AEs between RFA+S vs S-alone ( P >0.05). On subgroup analyses, RFA+S was associated with improved stent patency (MD 76.73 days; 95% CI 50.11-103.34; I 2 =67%; P <0.01) and OS (MD 83.14 (95% CI 29.52-136.77; I 2 =97%; P <0.01] for CCA. For hilar strictures, stent patency was improved among patients with RFA+S [MD 83.71 days (95% CI 24.85-142.56; I 2 =84%; P <0.01]. Conclusions RFA+S improved OS in the treatment of MBO when compared with S-alone. Moreover, the RFA therapy prolonged stent patency in hilar strictures and CCA, with similar rates of AEs.

Consensus statements on endoscopic radiofrequency ablation for malignant biliary strictures

Endoscopy-guided endobiliary radiofrequency ablation has emerged as a novel treatment for malignant biliary strictures in recent years. When combined with biliary stenting and systemic chemotherapy, it can effectively postpone local tumor progression, improve patient's quality of life, and prolong their survival, which is mainly indicated for patients with inoperable extrahepatic cholangiocarcinoma and ampullary cancer. Based on the existing clinical evidence, the Digestive Endoscopology Branch of Chinese Medical Association, the Digestive Endoscopy Professional Committee, Endoscopic Physicians Branch of Chinese Medical Doctor Association, and the National Clinical Research Center for Digestive Diseases (Shanghai) organized relevant experts to discuss the indications, contraindications, technical operation specifications, and prevention and treatment of the complications during endoscopy-guided endobiliary radiofrequency ablation. Consensus statements were established, trying to provide references for standard treatment of malignant biliary tumors in clinical practice.

Efficacy and safety of endoscopic drainage versus percutaneous drainage for pancreatic fluid collection; a systematic review and meta-analysis

BACKGROUND/AIMS

Pancreatic fluid collections (PFC) are debris or fluid of the pancreas that needs to be drained out. This may result from surgery or necrotizing pancreatitis. This meta-analysis compared the outcomes of PFC through endoscopic and percutaneous interventions.

METHODS

A medical database was searched up to June 2022, comparing the outcomes of endoscopic drainage (ED) and percutaneous drainage (PD) for the PFC. Eligible studies reporting clinical and technical success and adverse events were selected.

RESULTS

Seventeen studies with 1170 patients were included for meta-analysis, of which 543 patients underwent ED and 627 underwent PD. The odd ratio (OR) of technical success was 0.81 (95% confidence interval (CI) 0.31, 2.1) and clinical success was in the favor of the ED group at OR 2.23 (95% CI 1.45, 3.41). Adverse events OR 0.62 (95% CI 0.27, 1.39) and stent migration OR 0.61 (95% CI 0.10, 3.88) were the same in both groups, but hospital stay pooled mean difference of 15.02 days (95% CI 9.86, 20.18), mortality OR 0.24 (95% CI 0.09, 0.67), and re-interventions OR 0.25 (95% CI 0.16, 0.40) favored ED.

CONCLUSIONS

ED is safe and efficient for PFC with higher clinical success, lower mortality rate, hospital stay, and re-interventions compared with PD.

Endoscopic versus minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND/AIMS

Acute pancreatitis is a common condition of the digestive system, but sometimes it develops into severe cases. In about 10-20% of patients, necrosis of the pancreas or its periphery occurs. Although most have aseptic necrosis, 30% of cases will develop infectious necrotizing pancreatitis. Infected necrotizing pancreatitis (INP) requires a critical treatment approach. Minimally invasive surgical approach (MIS) and endoscopy are the management methods. This meta-analysis compares the outcomes of MIS and endoscopic treatments.

METHODS

We searched a medical database until December 2022 to compare the results of endoscopic and MIS procedures for INP. We selected eligible randomized controlled trials (RCTs) that reported treatment complications for the meta-analysis.

RESULTS

Five RCTs comparing a total of 284 patients were included in the meta-analysis. Among them, 139 patients underwent MIS, while 145 underwent endoscopic procedures. The results showed significant differences (p < 0.05) in the risk ratios (RRs) for major complications (RR: 0.69, 95% confidence interval (CI): 0.49-0.97), new onset of organ failure (RR: 0.29, 95% CI: 0.11-0.82), surgical site infection (RR: 0.26, 95% CI: 0.07-0.92), fistula or perforation (RR: 0.27, 95% CI: 0.12-0.64), and pancreatic fistula (RR: 0.14, 95% CI: 0.05-0.45). The hospital stay was significantly shorter for the endoscopic group compared to the MIS group, with a mean difference of 6.74 days (95% CI: -12.94 to -0.54). There were no significant differences (p > 0.05) in the RR for death, bleeding, incisional hernia, percutaneous drainage, pancreatic endocrine deficiency, pancreatic exocrine deficiency, or the need for enzyme use.

CONCLUSIONS

Endoscopic management of INP performs better compared to surgical treatment due to its lower complication rate and higher patient life quality.

Correlation between prescribing doctor attributes and intestinal cleanliness in colonoscopy: a study of 22522 patients

OBJECTIVE

This study aimed to analyze the correlation between different attributes of doctors who prescribe colonoscopies and the cleanliness of the intestine to guide the development of colonoscopy application protocols.

METHODS

Data on colonoscopy cases conducted in the gastroenterology department of Hangzhou First People's Hospital between April 2018 and March 2021 were collected. The gender, age, professional attributes of the prescribing doctors, and Boston Bowel Preparation Scale (BBPS) score were recorded. In addition, the correlation between the prescribing doctors' characteristics and the intestine's cleanliness was analyzed.

RESULTS

The study included 22,522 patients with a mean BBPS score of 6.83 ± 1.94. There were 16,459 male and 6,063 female doctors with similar BBPS scores (p = 0.212). The study found no significant difference in BBPS scores between 19,338 internist and 3,184 non-internist (p = 0.154). However, BBPS scores differed significantly between 18,168 gastroenterologists and 4,354 non-gastroenterologists (p = 0.016) and between 19,990 intestinal-related specialties(gastroenterology and gastrointestinal surgery) and 2,532 non-intestinal-related specialties (p = 0.000). In addition, BBPS scores were significantly different between 18,126 prescribing endoscopiests and 4,396 non-endoscopiests (p = 0.014). However, there was no significant difference in BBPS scores among doctors of different ages (p = 0.190). The study found significant differences in BBPS scores between male and female patients and those under or over 40 years (p = 0.000).

CONCLUSION

To improve colonoscopy preparation quality, priority should be given to doctors in gastroenterology, intestinal-related specialties, and endoscopiests. Their expertise may result in better education and improved bowel cleanliness.

Radiofrequency ablation for pancreatobiliary disease: an updated review

Endoscopic radiofrequency ablation (RFA) has emerged as a minimally invasive treatment option in cases of malignant biliary obstruction, pancreatic cancer, and other pancreatic cystic neoplasms. Intraductal biliary RFA is safe, effective, and confers a survival advantage over stenting alone, where it should be used an adjunct to biliary stenting. Endoscopic ultrasound-guided RFA can also provide pancreatic cyst resolution in patients who are not ideal operative candidates. The aim of this review is to describe the endoscopic applications and associated outcomes of RFA.

A Practical Guide for the Systemic Treatment of Biliary Tract Cancer in Canada

Biliary tract cancers (BTC) are rare and aggressive tumors with poor prognosis. Radical surgery offers the best chance for cure; however, most patients present with unresectable disease, and among those receiving curative-intent surgery, recurrence rates remain high. While other locoregional therapies for unresectable disease may be considered, only select patients may be eligible. Consequently, systemic therapy plays a significant role in the treatment of BTC. In the adjuvant setting, capecitabine is recommended following curative-intent resection. In the neoadjuvant setting, systemic therapy has mostly been explored for downstaging in borderline resectable tumours, although evidence for its routine use is lacking. For advanced unresectable or metastatic disease, gemcitabine-cisplatin plus durvalumab has become the standard of care, while the addition of pembrolizumab to gemcitabine-cisplatin has also recently demonstrated improved survival compared to chemotherapy alone. Following progression on gemcitabine-cisplatin, several chemotherapy combinations and biomarker-driven targeted agents have been explored. However, the optimum regimen remains unclear, and access to targeted agents remains challenging in Canada. Overall, this article serves as a practical guide for the systemic treatment of BTC in Canada, providing valuable insights into the current and future treatment landscape for this challenging disease.