1
|
Kongkam P, Orprayoon T, Boonmee C, Sodarat P, Seabmuangsai O, Wachiramatharuch C, Auan-Klin Y, Pham KC, Tasneem AA, Kerr SJ, Romano R, Jangsirikul S, Ridtitid W, Angsuwatcharakon P, Ratanachu-Ek T, Rerknimitr R. ERCP plus endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage for malignant hilar biliary obstruction: a multicenter observational open-label study. Endoscopy 2021; 53:55-62. [PMID: 32515005 DOI: 10.1055/a-1195-8197] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) may not provide complete biliary drainage in patients with Bismuth III/IV malignant hilar biliary obstruction (MHBO). Complete biliary drainage is accomplished by adding percutaneous transhepatic biliary drainage (PTBD). We prospectively compared recurrent biliary obstruction (RBO) rates between combined ERCP and endoscopic ultrasound-guided biliary drainage (EUS-BD) vs. bilateral PTBD. METHODS Patients with MHBO undergoing endoscopic procedures (group A) were compared with those undergoing bilateral PTBD (group B). The primary outcome was the 3-month RBO rate. RESULTS 36 patients were recruited into groups A (n = 19) and B (n = 17). Rates of technical and clinical success, and complications of group A vs. B were 84.2 % (16/19) vs. 100 % (17/17; P = 0.23), 78.9 % (15/19) vs. 76.5 % (13/17; P > 0.99), and 26.3 % (5/19) vs. 35.3 % (6/17; P = 0.56), respectively. Within 3 and 6 months, RBO rates of group A vs. group B were 26.7 % (4/15) vs. 88.2 % (15/17; P = 0.001) and 22.2 % (2/9) vs. 100 % (9/9; P = 0.002), respectively. At 3 months, median number of biliary reinterventions in group A was significantly lower than in group B (0 [interquartile range] 0-1 vs. 1 [1-2.5]), respectively (P < 0.001). Median time to development of RBO was longer in group A than in group B (92 [56-217] vs. 40 [13.5-57.8] days, respectively; P = 0.06). CONCLUSIONS Combined ERCP and EUS procedures provided significantly lower RBO rates at 3 and 6 months vs. bilateral PTBD, with similar complication rates and no significant mortality difference.
Collapse
Affiliation(s)
- Pradermchai Kongkam
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Pancreas Research Unit, Chulalongkorn University, Bangkok, Thailand.,Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand
| | - Theerapat Orprayoon
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand
| | - Chaloemphon Boonmee
- Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand.,Department of Surgery, Tha-Bo Crown Prince Hospital, Ministry of Public Health, Nong Khai, Thailand
| | - Passakorn Sodarat
- Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand.,Department of Surgery, Roi-Et Hospital, Ministry of Public Health, Roi-Et, Thailand
| | - Orathai Seabmuangsai
- Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand.,Department of Surgery, Roi-Et Hospital, Ministry of Public Health, Roi-Et, Thailand
| | - Chatchawan Wachiramatharuch
- Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand.,Department of Surgery, Roi-Et Hospital, Ministry of Public Health, Roi-Et, Thailand
| | - Yutthaya Auan-Klin
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Khanh Cong Pham
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Abbas Ali Tasneem
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand
| | - Stephen J Kerr
- Biostatistics Excellence Centre, Chulalongkorn University, Bangkok, Thailand
| | - Rommel Romano
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand
| | - Sureeporn Jangsirikul
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand
| | - Wiriyaporn Ridtitid
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand
| | - Phonthep Angsuwatcharakon
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand
| | - Thawee Ratanachu-Ek
- Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand.,Department of Surgery, Rajavithi Hospital, Ministry of Public Health, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Thai Association for Gastrointestinal Endoscopy, Bangkok, Thailand
| |
Collapse
|
2
|
Kongkam P, Tasneem AA, Rerknimitr R. Combination of endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography-guided biliary drainage in malignant hilar biliary obstruction. Dig Endosc 2019; 31 Suppl 1:50-54. [PMID: 30994233 DOI: 10.1111/den.13371] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/06/2019] [Indexed: 12/13/2022]
Abstract
Adequate biliary drainage (BD), defined as more than 50% of liver volume drained, is an ideal BD method in patients with advanced and unresectable malignant hilar biliary obstruction (MHBO). Endoscopic retrograde cholangiopancreatography (ERCP) with multi-segmental BD is technically challenging. ERCP with percutaneous biliary drainage (PTBD) or PTBD alone has cumbersome maintenance of PTBD line and external bag. The utility of EUS-guided BD (EUS-BD) has risen significantly over last 5 years mostly in the clinical setting of distal bile duct obstruction. Information on EUS-BD for malignant hilar biliary obstruction (MHBO) is thus far limited to only two small studies. This review suggests a new concept of a combination of ERCP and EUS-BD (CERES) for BD in MHBO as a primary BD method whereby ERCP with a single self-expandable metal stent (SEMS) is placed into either the right or the left intrahepatic bile duct (IHD). If SEMS is placed in the right biliary system, EUS-guided hepaticogastrostomy (EUS-HGS) can subsequently be carried out. However, if the stent is placed into the left biliary system, EUS-guided hepaticoduodenostomy (EUS-HDS) is done. For MHBO with non-functioning right lobe of the liver, EUS-HGS is carried out after failed ERCP, or primary HGS can be carried out in the left lobe of liver. For MHBO with non-functioning left lobe of the liver, EUS-HDS is carried out after failed transpapillary stenting of the right lobe by ERCP. Based on our experience, CERES is promising as it can fulfil gaps of both PTBD and ERCP by allowing internal drainage that can circumvent the inconvenience associated with PTBD and offer higher technical success rate compared to ERCP with bilateral SEMS placement.
Collapse
Affiliation(s)
- Pradermchai Kongkam
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Pancreas Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Abbas Ali Tasneem
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Rungsun Rerknimitr
- Gastrointestinal Endoscopy Excellence Center and Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| |
Collapse
|
3
|
Lu J, Guo JH, Zhu HD, Zhu GY, Wang Y, Zhang Q, Chen L, Wang C, Pan TF, Teng GJ. Palliative treatment with radiation-emitting metallic stents in unresectable Bismuth type III or IV hilar cholangiocarcinoma. ESMO Open 2017; 2:e000242. [PMID: 29018577 PMCID: PMC5604711 DOI: 10.1136/esmoopen-2017-000242] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/14/2017] [Indexed: 12/16/2022] Open
Abstract
Background The emerging data for stenting in combination with brachytherapy in unresectable hilar cholangiocarcinoma are encouraging. The aim of this study was to evaluate the efficacy and safety of radiation-emitting metallic stents (REMS) for unresectable Bismuth type III or IV hilar cholangiocarcinoma. Patients and methods Consecutive patients who underwent percutaneous placement with REMS or uncovered self-expandable metallic stent (SEMS) for unresectable Bismuth type III or IV hilar cholangiocarcinoma between September 2011 and April 2016 were identified into this retrospective study. Data on patient demographics and overall survival, functional success, stent patency and complications were collected at the authors’ hospital. Results A total of 59 patients were included: 33 (55.9%) in the REMS group and 26 (44.1%) in the SEMS group. The median overall survival was 338 days in the REMS group and 141 days in the SEMS group (p<0.001). The median stent patency time was 385 days for REMS and 142 days for SEMS (p<0.001). The functional success rate (87.9% vs 84.6%, p=0.722) and incidence of overall complications (27.3% vs 26.9%, p=0.999) did not differ in the two groups. Conclusions Placement with REMS is safe and effective in palliation for unresectable Bismuth type III or IV hilar cholangiocarcinoma, and seems to prolong survival as well as patency of stent in these patients.
Collapse
Affiliation(s)
- Jian Lu
- Department of Radiology, Zhong-Da Hospital, Southeast University, Nanjing, China
| | - Jin-He Guo
- Department of Radiology, Zhong-Da Hospital, Southeast University, Nanjing, China
| | - Hai-Dong Zhu
- Department of Radiology, Zhong-Da Hospital, Southeast University, Nanjing, China
| | - Guang-Yu Zhu
- Department of Radiology, Zhong-Da Hospital, Southeast University, Nanjing, China
| | - Yong Wang
- Department of Radiology, Zhong-Da Hospital, Southeast University, Nanjing, China
| | - Qi Zhang
- Department of Radiology, Zhong-Da Hospital, Southeast University, Nanjing, China
| | - Li Chen
- Department of Radiology, Zhong-Da Hospital, Southeast University, Nanjing, China
| | - Chao Wang
- Department of Radiology, Zhong-Da Hospital, Southeast University, Nanjing, China
| | - Tian-Fan Pan
- Department of Radiology, Zhong-Da Hospital, Southeast University, Nanjing, China
| | - Gao-Jun Teng
- Department of Radiology, Zhong-Da Hospital, Southeast University, Nanjing, China
| |
Collapse
|
4
|
Corvino F, Centore L, Soreca E, Corvino A, Farbo V, Bencivenga A. Percutaneous "Y" biliary stent placement in palliative treatment of type 4 malignant hilar stricture. J Gastrointest Oncol 2016; 7:255-61. [PMID: 27034794 DOI: 10.3978/j.issn.2078-6891.2015.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND This study evaluated the technical and clinical efficacy of percutaneous bilateral biliary stent-in-stent (SIS) deployment technique with a "Y" configuration using open-cell-design stents in type 4 Klatskin tumor patients. METHODS Retrospective evaluation ten patients with type IV Bismuth malignant hilar stricture (MHS) treated with percutaneous bilateral "Y" SIS deployment technique placement followed in our institution between March of 2012 and November of 2014. RESULTS Bilateral SIS deployment was technically successful in all patients. One patient (10%) had major complications (episode of cholangitis); one patient (10%) had minor complications, including self-limiting hemobilia. Successful internal drainage was achieved in nine (90%) patients. Stent occlusion by tumor overgrowth and sludge formation occurred in two patient (20%). The median survival and stent patency time were 298 and 315 days respectively. CONCLUSIONS Percutaneous bilateral metal stenting using a Y-stent is a valid option for the palliative treatment of type 4 Bismuth MHS, improving quality patient' life.
Collapse
Affiliation(s)
- Fabio Corvino
- 1 Department of Advanced Medical Biosciences, University Federico II of Naples (UNINA), Biostructures and Bioimmages Institution (IBB), National Research Council (CNR), via Pansini 5-80131 Naples, Italy ; 2 Department of Radiology and Interventional Radiology, "G. Rummo" Hospital, via dell'Angelo, 1-82100 Benevento, Italy
| | - Luca Centore
- 1 Department of Advanced Medical Biosciences, University Federico II of Naples (UNINA), Biostructures and Bioimmages Institution (IBB), National Research Council (CNR), via Pansini 5-80131 Naples, Italy ; 2 Department of Radiology and Interventional Radiology, "G. Rummo" Hospital, via dell'Angelo, 1-82100 Benevento, Italy
| | - Emilio Soreca
- 1 Department of Advanced Medical Biosciences, University Federico II of Naples (UNINA), Biostructures and Bioimmages Institution (IBB), National Research Council (CNR), via Pansini 5-80131 Naples, Italy ; 2 Department of Radiology and Interventional Radiology, "G. Rummo" Hospital, via dell'Angelo, 1-82100 Benevento, Italy
| | - Antonio Corvino
- 1 Department of Advanced Medical Biosciences, University Federico II of Naples (UNINA), Biostructures and Bioimmages Institution (IBB), National Research Council (CNR), via Pansini 5-80131 Naples, Italy ; 2 Department of Radiology and Interventional Radiology, "G. Rummo" Hospital, via dell'Angelo, 1-82100 Benevento, Italy
| | - Vincenzo Farbo
- 1 Department of Advanced Medical Biosciences, University Federico II of Naples (UNINA), Biostructures and Bioimmages Institution (IBB), National Research Council (CNR), via Pansini 5-80131 Naples, Italy ; 2 Department of Radiology and Interventional Radiology, "G. Rummo" Hospital, via dell'Angelo, 1-82100 Benevento, Italy
| | - Alfonso Bencivenga
- 1 Department of Advanced Medical Biosciences, University Federico II of Naples (UNINA), Biostructures and Bioimmages Institution (IBB), National Research Council (CNR), via Pansini 5-80131 Naples, Italy ; 2 Department of Radiology and Interventional Radiology, "G. Rummo" Hospital, via dell'Angelo, 1-82100 Benevento, Italy
| |
Collapse
|
5
|
Zheng YG, Wang T, Li F, Cheng ZB. Use of stents in treatment of malignant biliary obstruction. Shijie Huaren Xiaohua Zazhi 2014; 22:5279-5284. [DOI: 10.11569/wcjd.v22.i34.5279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
|
6
|
Gwon DI, Ko GY, Kim JH, Shin JH, Kim KA, Yoon HK, Sung KB. Percutaneous Bilateral Metallic Stent Placement Using a Stentin-Stent Deployment Technique in Patients With Malignant Hilar Biliary Obstruction. AJR Am J Roentgenol 2013; 200:909-914. [DOI: 10.2214/ajr.12.8780] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Dong Il Gwon
- All authors: Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Gi-Young Ko
- All authors: Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Jin Hyoung Kim
- All authors: Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Ji Hoon Shin
- All authors: Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Kyung-Ah Kim
- All authors: Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Hyun-Ki Yoon
- All authors: Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Kyu-Bo Sung
- All authors: Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| |
Collapse
|
7
|
Inatomi O, Bamba S, Shioya M, Mochizuki Y, Ban H, Tsujikawa T, Saito Y, Andoh A, Fujiyama Y. Threaded biliary inside stents are a safe and effective therapeutic option in cases of malignant hilar obstruction. BMC Gastroenterol 2013; 13:31. [PMID: 23410217 PMCID: PMC3598933 DOI: 10.1186/1471-230x-13-31] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 02/12/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Although endoscopic biliary stents have been accepted as part of palliative therapy for cases of malignant hilar obstruction, the optimal endoscopic management regime remains controversial. In this study, we evaluated the safety and efficacy of placing a threaded stent above the sphincter of Oddi (threaded inside plastic stents, threaded PS) and compared the results with those of other stent types. METHODS Patients with malignant hilar obstruction, including those requiring biliary drainage for stent occlusion, were selected. Patients received either one of the following endoscopic indwelling stents: threaded PS, conventional plastic stents (conventional PS), or metallic stents (MS). Duration of stent patency and the incident of complication were compared in these patients. RESULTS Forty-two patients underwent placement of endoscopic indwelling stents (threaded PS = 12, conventional PS = 17, MS = 13). The median duration of threaded PS patency was significantly longer than that of conventional PS patency (142 vs. 32 days; P = 0.04, logrank test). The median duration of threaded PS and MS patency was not significantly different (142 vs. 150 days, P = 0.83). Stent migration did not occur in any group. Among patients who underwent threaded PS placement as a salvage therapy after MS obstruction due to tumor ingrowth, the median duration of MS patency was significantly shorter than that of threaded PS patency (123 vs. 240 days). CONCLUSIONS Threaded PS are safe and effective in cases of malignant hilar obstruction; moreover, it is a suitable therapeutic option not only for initial drainage but also for salvage therapy.
Collapse
Affiliation(s)
- Osamu Inatomi
- Division of Gastroenterology, Shiga University of Medical Science, Seta-Tsukinowa cho, Otsu, Shiga, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Ridtitid W, Rerknimitr R. Management of an occluded biliary metallic stent. World J Gastrointest Endosc 2012; 4:157-61. [PMID: 22624066 PMCID: PMC3355237 DOI: 10.4253/wjge.v4.i5.157] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 11/15/2011] [Accepted: 04/27/2012] [Indexed: 02/05/2023] Open
Abstract
In patients with a malignant biliary obstruction who require biliary drainage, a self-expandable metallic stent (SEMS) provides longer patency duration than a plastic stent (PS). Nevertheless, a stent occlusion by tumor ingrowth, tumor overgrowth and biliary sludge may develop. There are several methods to manage occluded SEMS. Endoscopic management is the preferred treatment, whereas percutaneous intervention is an alternative approach. Endoscopic treatment involves mechanical cleaning with a balloon and a second stent insertion as stent-in-stent with either PS or SEMS. Technical feasibility, patient survival and cost-effectiveness are important factors that determine the method of re-drainage and stent selection.
Collapse
Affiliation(s)
- Wiriyaporn Ridtitid
- Wiriyaporn Ridtitid, Rungsun Rerknimitr, Director of Endoscopy Unit, Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | | |
Collapse
|
9
|
Gwon DI, Ko GY, Yoon HK, Kim YJ, Kim TH, Lee WH, Sung KB. Safety and efficacy of percutaneous Y-configured covered stent placement for malignant hilar biliary obstruction: a prospective, pilot study. J Vasc Interv Radiol 2012; 23:528-34. [PMID: 22341884 DOI: 10.1016/j.jvir.2011.12.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 12/08/2011] [Accepted: 12/13/2011] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To investigate the technical and clinical safety and efficacy of percutaneous Y-configured covered stent placement in patients with malignant hilar biliary obstruction. MATERIALS AND METHODS This prospective, pilot study enrolled 20 consecutive patients with malignant hilar biliary obstructions from October 2009 to December 2010. All patients were treated by percutaneous transhepatic placement of partially expanded polytetrafluoroethylene (ePTFE)-covered stents in a Y configuration. RESULTS Bilateral Y-configured covered stent deployment was technically successful in all 20 patients. Minor procedure-related complications occurred in four (20%) patients including self-limiting hemobilia in one patient and rapidly resolving cholangitis in three patients. Successful internal drainage was achieved in 18 (90%) of 20 patients. Mean serum bilirubin level, which was 12.6 mg/dL ± 5.1 before drainage, decreased significantly to 2.5 mg/dL ± 4.5 1 month after stent placement (P < .001). Median patient survival and stent patency times were 218 days (95% confidence interval [CI] 112-324 days) and 375 days (95% CI 55-695 days). Seven (35%) patients presented with stent occlusion, in six owing to sludge incrustation and in one owing to tumor overgrowth, and required repeat percutaneous transhepatic biliary drainage (PTBD). Tumor ingrowth, acute cholecystitis, or stent migration was not observed in any patient. CONCLUSIONS Preliminary results suggest that percutaneous palliative treatment of malignant hilar biliary obstruction with Y-configured covered stents is safe and clinically effective in achieving internal biliary drainage. Y-configured, ePTFE-covered stents can also prevent tumor ingrowth without functional occlusion of hepatic segmental bile ducts.
Collapse
Affiliation(s)
- Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul, 138-736, Korea.
| | | | | | | | | | | | | |
Collapse
|
10
|
Jaganmohan S, Lee JH. Self-expandable metal stents in malignant biliary obstruction. Expert Rev Gastroenterol Hepatol 2012; 6:105-14. [PMID: 22149586 DOI: 10.1586/egh.11.95] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Malignant biliary obstruction can be due to direct tumor infiltration, extrinsic compression, adjacent inflammation, desmoplastic reaction from tumors or, more commonly, a combination of the above factors. Pancreatic cancer is the most common cause of malignant biliary obstruction, and jaundice occurs in 70-90% of the patients during the course of the disease. Compared with the uncovered metal stents, covered metal stents have longer patency and a lower rate of tumor ingrowth, but have a higher rate of stent migration. To combat the occlusion and provide an antitumor effect, drug-eluting stents were developed. A duodenal stricture complicates biliary stent placement in 10-20% of patients with distal biliary obstruction due to pancreatic cancer. When both strictures are considered, a biliary stent can be placed either preceding or following duodenal stent placement. Complications of self-expandable metal stents include stent occlusion, stent migration, cholecystitis and pancreatitis.
Collapse
Affiliation(s)
- Sathya Jaganmohan
- Department of Gastroenterology, Hepatology, and Nutrition, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | | |
Collapse
|
11
|
Zhang NB, Huang NG. Relationship of hilar cholangiocarcinoma Bismuth type with incidence of complications of endoscopic retrograde cholangiopancreatography and jaundice clearance. Shijie Huaren Xiaohua Zazhi 2011; 19:529-532. [DOI: 10.11569/wcjd.v19.i5.529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the relationship of hilar cholangiocarcinoma Bismuth type with incidence of complications of endoscopic retrograde cholangiopancreatography (ERBD) and jaundice clearance.
METHODS: Ninety-seven patients with inoperable hilar cholangiocarcinoma were treated by ERBD. The differences in the incidence of cholangitis, pancreatitis, bleeding, and the rate of jaundice clearance were compared among different types of hilar cholangiocarcinoma.
RESULTS: Patients with Bismuth types III and IV hilar cholangiocarcinoma had a significantly higher incidence of post-ERBD cholangitis (59.52% vs 3.33%; 59.52% vs 4.00%, both P < 0.01) and a lower rate of jaundice clearance (71.43% vs 96.67%; 71.43% vs 100.00%, both P < 0.01) than those with Bismuth types I and II disease. However, there were no significant differences in the incidences of post-ERBD pancreatitis and bleeding among all types of hilar cholangiocarcinoma (P > 0.05).
CONCLUSION: Bismuth types III and IV hilar cholangiocarcinoma is associated with a significantly higher risk of post-ERBD cholangitis and a lower rate of jaundice clearance.
Collapse
|
12
|
Gwon DI, Ko GY, Yoon HK, Kim JH, Lee JM, Ohm JY, Sung KB. Prospective evaluation of a newly designed T-configured stent graft system for palliative treatment of advanced hilar malignant biliary obstructions. J Vasc Interv Radiol 2010; 21:1410-8. [PMID: 20800780 DOI: 10.1016/j.jvir.2010.05.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Revised: 04/10/2010] [Accepted: 05/07/2010] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To investigate the technical and clinical safety and efficacy of using a newly designed T-configured stent graft for palliative treatment of advanced hilar malignant biliary obstructions. MATERIALS AND METHODS This is a prospective study that enrolled 30 patients who had malignant hilar obstructions from May 2007 to November 2008. All patients were treated with percutaneous transhepatic placement of two specially designed stent grafts in a T configuration. Technical success, evaluation of blocked branching ducts, complications, clinical success, stent patency time, and patient survival rates were analyzed. RESULTS Stent graft deployment was technically successful in all patients. The bilirubin level and the bile duct diameter decreases were statistically significant after stent placement (P < .001), and all patients showed clinical improvement. Minor complications, including procedure-related complications (self-limiting hemobilia [n = 3], perihepatic biloma [n = 1], and acute pancreatitis [n = 1]) and rapidly resolving cholangitis (n = 5), occurred in ten patients (33.3%). Major complications, including acute cholecystitis, occurred in three patients (10%). Stent occlusion occurred in 12 patients (40%) after a mean period of 160 days (range, 82-307 days). The median survival and stent patency times were 334 days (range, 195.6-472.4 days) and 279 days (range, 194.7-363.3 days), respectively. There were no statistical differences in age, sex, Bismuth type, or number of blocked branching ducts. CONCLUSIONS The initial results of percutaneous palliative treatment of advanced hilar malignancies with T-configured stent grafts suggest that they are safe and potentially clinically effective.
Collapse
Affiliation(s)
- Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul, 138-736, Korea
| | | | | | | | | | | | | |
Collapse
|
13
|
Atiq M, Javle M, Dang S, Lee JH. Cholangiocarcinoma: an endoscopist's perspective. Expert Rev Gastroenterol Hepatol 2010; 4:601-11. [PMID: 20932145 DOI: 10.1586/egh.10.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The incidence of cholangiocarcinoma is on the rise. This may be related in part to higher detection rates secondary to sophisticated endoscopic modalities. These tumors pose a significant diagnostic dilemma. High index of suspicion, careful interpretation of serum markers and utilization of endoscopic techniques, including endoscopic retrograde cholangiopancreatography and endoscopic ultrasound, help to establish the diagnosis. Imaging modalities are crucial in the evaluation of these tumors. They help to define the extent of the native lesion, which may dictate its resectability, as well as evaluate for metastasis. Therapeutic options are somewhat limited, short of surgical resection. Newer chemotherapeutic agents, as well as endoscopy-targeted therapy, may improve the overall treatment success rate, although experience is somewhat limited at this time. Endoscopic intervention is essential for palliation.
Collapse
Affiliation(s)
- Muslim Atiq
- Divison of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | |
Collapse
|
14
|
Ridtitid W, Rerknimitr R, Janchai A, Kongkam P, Treeprasertsuk S, Kullavanijaya P. Outcome of second interventions for occluded metallic stents in patients with malignant biliary obstruction. Surg Endosc 2010; 24:2216-20. [PMID: 20177930 DOI: 10.1007/s00464-010-0931-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 01/14/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although self-expandable metallic stent (SEMS) has a longer patency than plastic stent (PS) for malignant biliary obstruction, stent occlusion can occur and drainage has to be reestablished in a patient with expected long survival. However, the choices are still controversial among restenting with SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). This study was designed to determine the efficacy and outcome of PS, SEMS, and PTBD for patients with occluded SEMS. METHODS A total of 154 ERCPs with SEMS insertion were performed at the Endoscopy Unit of Chulalongkorn University. The causes of obstructive jaundice were cholangiocarcinoma (n = 110), pancreatic cancer (n = 41), and metastatic carcinoma (n = 3). Thirty-two patients (20.9%) with occluded SEMS (uncovered SEMS = 22 and covered SEMS = 10) were identified. PS, SEMS, and PTBD were used to reestablish drainage in 11, 14, and 7 patients, respectively. The second stent was inserted as stent-in-stent. Patients with less advanced disease were preferably opted to have a second SEMS. RESULTS The median stent patency of second SEMS (100 days) was significantly longer than PS (60 days) and PTBD (75 days; p < 0.05). The median survival time for patients with second SEMS (230 days) was significantly longer than patients with PS (130 days) and PTBD (150 days; p < 0.05). Subgroup analysis in hilar obstructions showed no statistical difference in second stent patency and survival between PS and SEMS. Pain that required oral narcotic developed in 71% (5/7) of PTBD patients. CONCLUSIONS In general, a second SEMS insertion in occluded SEMS provides a significant longer patency time than PS and PTBD. However, the benefit of SEMS as a second intervention in hilar obstructed patients is still doubtful.
Collapse
Affiliation(s)
- Wiriyaporn Ridtitid
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | | | | | | | | | | |
Collapse
|
15
|
Rerknimitr R, Kullavanijaya P. Operable malignant jaundice: To stent or not to stent before the operation? World J Gastrointest Endosc 2010; 2:10-4. [PMID: 21160672 PMCID: PMC2998861 DOI: 10.4253/wjge.v2.i1.10] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 08/26/2009] [Accepted: 09/02/2009] [Indexed: 02/06/2023] Open
Abstract
Traditionally, pre-operative biliary drainage (PBD) was believed to improve multi-organ dysfunction, and for this reason, was practiced worldwide. Over the last decade, this concept was challenged by many reports, including meta-analyses that showed no difference in morbidity and mortality between surgery with, and surgery without PBD, in operable malignant jaundice. The main disadvantages of PBD are seen to be the additional cost of the procedure itself, and the need for longer hospitalization. In addition, many studies showed the significance of specific complications resulting from PBD, such as recurrent jaundice, cholangitis, pancreatitis, cutaneous fistula, and bleeding. However, the results of these studies remain inconclusive as to date there has been no perfect study that equally randomized comparable patients according to the level of obstruction and technique used for PBD. Generally, endoscopic stent insertion (ES) is preferred for common duct obstruction, whereas endoscopic nasobiliary drainage and percutaneous biliary drainage is reserved for hilar obstruction, since ES in hilar block confers a high rate of cholangitis. Although, there is no guideline which either supports or refutes this approach, certain subgroups of patients, including those with symptomatic jaundice, cholangitis, impending renal failure, hilar block requiring preoperative portal vein embolization, and those who need pre-operative neoadjuvant therapy, are suitable candidates for PBD.
Collapse
Affiliation(s)
- Rungsun Rerknimitr
- Rungsun Rerknimitr, Pinit Kullavanijaya, Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok 10310, Thailand
| | | |
Collapse
|