Endoscopic versus Percutaneous Biliary Drainage in Palliation of Advanced Malignant Hilar Obstruction: A Meta-Analysis and Systematic Review

Advances in Endoscopic Ultrasound in Pancreatic Cancer Screening, Diagnosis, and Palliative Care

Pancreatic cancer is a highly aggressive malignancy with a profoundly poor prognosis. Clinically, the condition most frequently manifests with symptoms including painless jaundice, abdominal discomfort, and back pain. Early diagnosis and the implementation of effective therapeutic strategies are critical for improving patient survival outcomes. However, merely 10-20% of patients are diagnosed at an early stage, with the majority presenting at advanced stages, often with metastasis. Consequently, early detection and intervention are crucial for enhancing prognosis. The widespread adoption of endoscopic ultrasonography (EUS) technology in recent years has significantly enhanced the diagnostic accuracy for pancreatic space-occupying lesions. EUS is increasingly recognized for its pivotal role in alleviating malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and refractory pain in advanced pancreatic cancer. This article aims to provide an overall review of the current applications of EUS in the diagnosis and treatment of pancreatic cancer, exploring its advantages and limitations in early screening, diagnosis, and palliative care. Furthermore, this review explores potential future directions in the field, aiming to provide valuable insights to inform and enhance the clinical management of pancreatic cancer.

Efficacy and safety of endoscopic nasobiliary drainage versus percutaneous transhepatic cholangial drainage in the treatment of advanced hilar cholangiocarcinoma: a systematic review and meta-analysis

OBJECTIVE

To evaluate and compare the efficacy and safety of Endoscopic Nasobiliary Drainage (ENBD) and Percutaneous Transhepatic Cholangiography Drainage (PTCD) in patients with advanced Hilar Cholangiocarcinoma (HCCA) through a meta-analysis of clinical studies.

METHODS

We searched Chinese and English databases, including China National Knowledge Infrastructure (CNKI), Wanfang database, PubMed, Embase, Scopus, and Web of Science, for relevant literatures on PTCD and ENBD for advanced HCCA clinical trials. Two investigators independently screened the literatures, and the quality of the included studies was evaluated using the Newcastle-Ottawa Scale (NOS). The primary endpoint was the success rate of biliary drainage operation, while secondary endpoints included Total Bilirubin (TBIL) change, acute pancreatitis, biliary tract infection, hemobilia, and other complications. R software was used for data analysis.

RESULTS

A comprehensive database search, based on predefined inclusion and exclusion criteria, yielded 26 articles for this study. Analysis revealed that PTCD had a significantly higher success rate than ENBD [OR (95% CI) = 2.63 (1.98, 3.49), Z=6.70, P<0.05]. PTCD was also more effective in reducing TBIL levels post-drainage [SMD (95%CI) =-0.13 (-0.23, -0.03), Z=-2.61, P<0.05]. While ENBD demonstrated a lower overall complication rate [OR (95%CI) = 0.60 (0.43, 0.84), Z=-2.99, P<0.05], it was associated with a significantly lower incidence of post-drainage biliary hemorrhage compared to PTCD [OR=3.02, 95%CI: (1.94-4.71), Z= 4.89, P<0.01].

CONCLUSIONS

This meta-analysis compares the efficacy and safety of ENBD and PTCD for palliative treatment of advanced HCCA. While both are effective, PTCD showed superiority in achieving successful drainage, reducing TBIL, and lowering the incidence of acute pancreatitis and biliary infections. However, ENBD had a lower risk of post-drainage bleeding. Clinicians should weigh these risks and benefits when choosing between ENBD and PTCD for individual patients. Further research is needed to confirm these findings and explore long-term outcomes.

Percutaneous endobiliary radiofrequency ablation with stent placement in type IV hilar cholangiocarcinoma: A prospective comparison with stent placement alone

OBJECTIVES

This study aimed to compare the safety and effectiveness of percutaneous endobiliary radiofrequency ablation with stent placement (RFA group) versus stent placement alone (stent group) in patients with type IV hilar cholangiocarcinoma.

METHODS

This prospective nonrandomized study was conducted between October 2021 and April 2023. The study included 56 participants (33 men and 23 women, median age 73 years) who underwent percutaneous endobiliary RFA with stent placement (n = 25) or stent placement alone (n = 31) for type IV hilar cholangiocarcinoma. The primary end point was stent patency, while the secondary end points were procedure-related adverse events (AE) and overall survival.

RESULTS

The percutaneous endobiliary RFA and/or stent placement were successfully completed in all patients in both groups. The median stent patency rate was higher in the RFA group than the stent group (188 days vs. 155 days, p = 0.048). There were no differences in AEs (grade 1 [5 in RFA group vs. 5 in stent group, p = 0.74] and grade 2 AEs [2 vs. 4, p = 0.68]) and patients' survival (median 222 days vs. 214 days, p = 0.49) between the two groups.

CONCLUSIONS

In patients with type IV hilar cholangiocarcinoma, percutaneous endobiliary RFA with stent placement may improve stent patency without increasing the risk of AEs compared to stent placement alone.

Practice guidelines for managing extrahepatic biliary tract cancers

Backgrounds/Aims

Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021.

Methods

Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop.

Results

In November 2021, the finalized draft was presented for public scrutiny during a formal hearing.

Conclusions

The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.

Endoscopic management of malignant biliary obstructions

Malignant biliary obstruction (MBO), both distal and hilar, represents an ensemble of different clinical conditions frequently encountered in everyday practice. Given the frequent unresectability of the disease at presentation and the increasing indications for neoadjuvant chemotherapy, endoscopic biliary drainage is generally required during the course of the disease. With the widespread use of interventional endoscopic ultrasound (EUS) and the introduction of dedicated devices, EUS-guided biliary drainage has rapidly gained acceptance, together with transpapillary endoscopic biliary drainage and the percutaneous approach. This comprehensive review describes the current role of endoscopy for distal and hilar MBO supported by evidence, with a focus on the current hot topics in this field.

Diagnosis and Treatment of Perihilar Cholangiocarcinoma: A National Survey from the Korean Pancreatobiliary Association

Background/Aims

Based on their anatomy, cholangiocarcinomas (CCAs) are classified into intrahepatic, hilar, and distal CCAs. Although the diagnosis and treatment of each type of CCA are thought to be different, real-world data studies on the current practice are limited. Therefore, this study was designed to capture the current practice of diagnosing and treating perihilar CCA in Korea.

Methods

We conducted a survey using an online platform. The questionnaire consisted of 18 questions designed to evaluate the current practice of diagnosing and treating perihilar CCA in Korea. The targets of this survey were biliary endoscopists who are members of the Korean Pancreatobiliary Association.

Results

In total, 119 biliary endoscopists completed the survey. Of the respondents, 89.9% thought that the use of the International Classification of Diseases, 11th Revision (ICD-11) system is necessary to classify CCA. Approximately half of the respondents would recommend surgery or chemotherapy until patients were 80 years of age. For the pathological diagnosis of CCA, endoscopic retrograde cholangiopancreatography with biopsy was the most preferred modality. Routine preoperative biliary drainage was performed by 44.5% of the respondents. For operable CCAs, 64.7% of the respondents preferred endoscopic biliary drainage using plastic stents. For palliative biliary drainage, 69.7% of the respondents used plastic stents. For palliative endoscopic biliary drainage using metal stents, 63% of the respondents preferred the stent-in-stent method.

Conclusions

A new coding system using the ICD-11 is needed for classifying CCAs. Guidelines for diagnosing and treating CCA based on the clinical situation in Korea are needed.

Endoscopic Treatment of Malignant Hilar Biliary Obstruction

Stent implantation is an effective approach for palliative treatment of Bismuth-Corlette type III-IV malignant hilar biliary obstructions (MHBOs). In this article, we reviewed the currently used access methods for biliary stent placement (percutaneous transhepatic biliary drainage, endoscopic biliary drainage, endosonography guided biliary drainage), the available stent types (plastic stent, self-expanding metallic stent, full cover self-expanding metallic stent, radioactive self-expanding metallic stent), major approaches (unilateral, bilateral) and deployment methods (stent-in-stent, stent-by-stent). Finally, this review gives an outlook on perspectives of development in stenting and other palliative methods in MHBO.

The Role of Endoscopy in the Palliation of Pancreatico-Biliary Cancers: Biliary Drainage, Management of Gastrointestinal Obstruction, and Role in Relief of Oncologic Pain

Therapeutic endoscopy permits many and various treatments for cancer palliation in patients with bilio-pancreatic cancers, enabling different options, supporting patients during their route to oncologic treatments, and trying to improve their quality of life. Therefore, both endoscopic and endoscopic ultrasound (EUS)-guided techniques are performed in this scenario. We performed a literature review focusing on the role of endoscopy in the palliation of those advanced pancreatic and biliary cancers developing malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and pain unresponsive to medical therapies. Therefore, we explored and focused on the clinical outcomes of endoscopic procedures in this scenario. In fact, the endoscopic treatment is based on achieving biliary drainage in the case of MBO through endoscopic retrograde cholangiopancreatography (ERCP) or EUS-guided biliary drainage (EUS-BD), while GOO is endoscopically treated through the deployment of an enteral stent or the creation of EUS-guided gastro-entero-anastomosis (EUS-GEA). Furthermore, untreatable chronic abdominal pain is a major issue in patients unresponsive to high doses of painkillers, so EUS-guided celiac plexus neurolysis (CPN) or celiac ganglia neurolysis (CGN) helps to reduce dosage and have better pain control. Therefore, therapeutic endoscopy in the palliative setting is an effective and safe approach for managing most of the clinical manifestations of advanced biliopancreatic tumors.

Biliary drainage in malignant biliary obstruction: an umbrella review of randomized controlled trials

Background

There are still many controversies about biliary drainage in MBO, and we aimed to summarize and evaluate the evidence associated with biliary drainage.

Methods

We conducted an umbrella review of SRoMAs based on RCTs. Through July 28, 2022, Embase, PubMed, WOS, and Cochrane Database were searched. Two reviewers independently screened the studies, extracted the data, and appraised the methodological quality of the included studies. GRADE was used to evaluate the quality of the evidence.

Results

36 SRoMAs were identified. After excluding 24 overlapping studies, 12 SRoMAs, including 76 RCTs, and 124 clinical outcomes for biliary drainage in MBO were included. Of the 124 pieces of evidence evaluated, 13 were rated "High" quality, 38 were rated "Moderate", and the rest were rated "Low" or "Very low". For patients with MBO, 125I seeds+stent can reduce the risk of stent occlusion, RFA+stent can improve the prognosis; compared with PC, SEMS can increase the risk of tumor ingrowth and reduce the occurrence of sludge formation, and the incidence of tumor ingrowth in C-SEMS/PC-SEMS was significantly lower than that in U-SEMS. There was no difference in the success rate of drainage between EUS-BD and ERCP-BD, but the use of EUS-BD can reduce the incidence of stent dysfunction. For patients with obstructive jaundice, PBD does not affect postoperative mortality compared to direct surgery. The use of MS in patients with periampullary cancer during PBD can reduce the risk of re-intervention and stent occlusion compared to PC. In addition, we included four RCTs that showed that when performing EUS-BD on MBO, hepaticogastrostomy has higher technical success rates than choledochoduodenostomy. Patients who received Bilateral-ENBD had a lower additional drainage rate than those who received Unilateral-ENBD.

Conclusions

Our study summarizes a large amount of evidence related to biliary drainage, which helps to reduce the uncertainty in the selection of biliary drainage strategies for MBO patients under different circumstances.

Stent insertion for malignant hilar obstruction: a meta-analysis of percutaneous versus endoscopic approaches

Introduction

In an effort to treat patients with malignant hilar obstruction (MHO), both percutaneous trans-hepatic biliary stenting (PTBS) and endoscopic biliary stenting (EBS) strategies have been implemented in the clinic, but the relative advantages of these techniques remain to be clarified.

Aim

This meta-analysis was designed to compare the relative clinical efficacy of PTBS and EBS in MHO patients.Material and methods: Relevant studies were identified through searches of the PubMed, Web of science, and Wanfang databases, and pooled analyses of these studies were then performed.

Results

In total, this meta-analysis included 11 studies enrolling 530 and 645 patients who underwent PTBS and EBS, respectively. Pooled rates of technical success in the PTBS patients were significantly higher than those for EBS patients (p < 0.0001). PTBS patients also exhibited significantly lower pooled cholangitis (p = 0.03) and pancreatitis (p < 0.0001) rates as compared to individuals in the EBS group. However, there were no significant differences in pooled clinical success rates (p = 0.45), haemorrhage rates (p = 0.57), stent patency (p = 0.96), or overall survival (p = 0.73) when comparing these groups. In a subgroup analysis, PTBS was not found to be superior to EBS as a treatment for Bismuth type III/IV MHO patients. However, PTBS did exhibit superior technical success and complication rates relative to EBS when treating hilar cholangiocarcinoma patients.

Conclusions

PTBS is superior to EBS with respect to many technical success and safety criteria when employed for the management of MHO patients.

Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage

Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments.

Impact of cholangitis on survival of patients with malignant biliary obstruction treated with percutaneous transhepatic biliary drainage

PURPOSE

To evaluate the impact of cholangitis on survival of patients with gastrointestinal cancer and malignant biliary obstruction treated with percutaneous transhepatic biliary drainage (PTBD).

METHODS

A retrospective registry study was performed at a tertiary center from 2000 to 2016 in Northern Finland.

RESULTS

The study included 588 patients, 258 (43.9%) patients with pancreatic cancer, 222 (37.7%) with biliary tract cancer, and 108 (18.4%) with metastasis from gastrointestinal cancers. Patient mean age was 70 years, range 26 - 93 years. There were 288 [49.0%] women. The 30-day mortality rate was 30.8% for 156 patients with cholangitis before PTBD, 19.5% for 215 patients with cholangitis after PTBD and 25.8% for 217 patients without cholangitis (P = 0.039). The median survival was 1.8 months for patients with cholangitis before PTBD, 3.0 months for patients with cholangitis after PTBD, and 3.2 months for patients without cholangitis (P = 0.002). The hazard ratio (HR) for 1-year mortality for patients with cholangitis before PTBD was 1.3 (95% CI 1.06 - 1.67, P = 0.015) compared to patients with cholangitis after PTBD. After successful PTBD, 54 out of 291 patients received chemotherapy; the median survival was 5.2 months with cholangitis before PTBD, 9.4 months with cholangitis after PTBD and 15.3 months without cholangitis.

CONCLUSION

In gastrointestinal cancers with malignant biliary obstruction, survival is poorer if cholangitis occurs before PTBD compared to cholangitis after PTBD. An oncologist's consultation is essential for assessing the possibility of chemotherapy in successfully treated PTBD patients, because of the notable survival benefit.

Percutaneous transhepatic biliary drainage for biliary obstruction in perihilar cholangiocarcinoma: a 10-year analysis of safety and outcomes using the CCI index

PURPOSE

To evaluate percutaneous transhepatic biliary drainage (PTBD) safety and efficacy in patients with perihilar cholangiocarcinoma (PCCA).

METHODS

This retrospective observational study included patients with PCCA and obstructive cholestasis referred for a PTBD in our institution between 2010 and 2020. Technical and clinical success rates and major complication and mortality rates one month after PTBD were used as main variables. Patients were divided and analyzed into two groups: > 30 and < 30 Comprehensive Complication Index (CCI). We also evaluated post-surgical outcomes in patients undergoing surgery.

RESULTS

Out of 223 patients, 57 were included. Technical success rate was 87.7%. Clinical success at 1 week was 83.6%, before surgery 68.2%, 80.0% at 2 weeks and 86.7% at 4 weeks. Mean total bilirubin (TBIL) values were 15.1 mg/dL (baseline), 8.1 mg/dL one week after PTBD), 6.1 mg/dL (2 weeks) and 2.1 mg/dL (4 weeks). Major complication rate was 21.1%. Three patients died (5.3%). Risk factors for major complications after the statistical analysis were: Bismuth classification (p = 0.01), tumor resectability (p = 0.04), PTBD clinical success (p = 0.04), TBIL 2 weeks after PTBD (p = 0.04), a second PTBD (p = 0.01), total PTBDs (p = 0.01) and duration of drainage (p = 0.03). Major postoperative complication rate in patients who underwent surgery was 59.3%, with a median CCI of 26.2.

CONCLUSION

PTBD is safe and effective in the management of biliary obstruction caused by PCCA. Bismuth classification, locally advanced tumors, and failure to achieve clinical success in the first PTBD are factors related to major complications. Our sample reported a high major postoperative complication rate, although with an acceptable median CCI.

Effect of percutaneous stenting strategy of unresectable malignant hilar biliary obstruction by three-dimensional reconstruction volumetry

PURPOSE

To explore clinical outcomes of percutaneous stent implantation using volumetric criteria for unresectable malignant hilar biliary obstruction (MHBO). Additionally, aimed to identify the predictors of patients' survival.

METHODS

Seventy-two patients who were initially diagnosed with MHBO between January 2013 to December 2019 in our center were retrospectively included. Patients were stratified according to the drainage achieved ≥50%, <50% of the total liver volume. Patients were divided into two groups: Group A (≥50% drainage), and Group B (<50% drainage). The main outcomes were evaluated in terms of relief of jaundice, effective drainage rate, and survival. Related factors that affect survival were analyzed.

RESULTS

62.5% of the included patients reached effective biliary drainage. The successful drainage rate was significantly higher in Group B than in Group A (p < 0.001). The median overall survival (mOS) of included patients was 6.4 months. Patients who received drainage ≥50% of hepatic volume achieved longer mOS than those who received drainage <50% of hepatic volume (7.6 months vs. 3.9 months, respectively, p = 0. 011). Patients who received effective biliary drainage had longer mOS than those who received ineffective biliary drainage (10.8 months vs. 4.4 months, respectively, p < 0.001). Patients who received anticancer treatment had longer mOS than those who only received palliative therapy (8.7 months vs. 4.6 months, respectively, p = 0.014). In the multivariate analysis, KPS Score ≥ 80 (p = 0.037), ≥50% drainage achieved (p = 0.038), and effective biliary drainage (p = 0.036) were protective prognostic factors that affected patients' survival.

CONCLUSION

Drainage achieved ≥50% of the total liver volume by percutaneous transhepatic biliary stenting seemed to have a higher effective drainage rate in MHBO patients. Effective biliary drainage may create chances for these patients to receive anticancer therapies that seem to provide survival benefits.

Endoscopic Biliary Darinage (EBD) versus Percutaneous Transhepatic Biliary Drainage (PTBD) for biliary drainage in patients with Perihilar Cholangiocarcinoma (PCCA): A systematic review and meta-analysis

Biliary drainage for Perihilar Cholangiocarcinoma (PCCA) can be performed either by endoscopic retrograde cholangiopancreatography or Percutaneous Transhepatic Biliary Drainage (PTBD). To date there is no consensus about which method is preferred. Taking that into account, the aim of this study is to compare Endoscopic Biliary Drainage (EBD) versus percutaneous transhepatic biliary drainage in patients with perihilar cholangiocarcinoma through a systematic review and metanalysis. A comprehensive search of multiple electronic databases was performed. Evaluated outcomes included technical success, clinical success, post drainage complications (cholangitis, pancreatitis, bleeding, and major complications), crossover, hospital length stay, and seeding metastases. Data extracted from the studies were used to calculate Mean Differences (MD). Seventeen studies were included, with a total of 2284 patients (EBD = 1239, PTBD = 1045). Considering resectable PCCA, the PTBD group demonstrated lower rates of crossover (RD = 0.29; 95% CI 0.07‒0.51; p = 0.009 I² = 90%), post-drainage complications (RD = 0.20; 95% CI 0.06‒0.33; p < 0.0001; I² = 78%), and post-drainage pancreatitis (RD = 0.10; 95% CI 0.05‒0.16; p < 0.0001; I² = 64%). The EBD group presented reduced length of hospital stay (RD = -2.89; 95% CI -3.35 ‒ -2,43; p < 0.00001; I² = 42%). Considering palliative PCCA, the PTBD group demonstrated a higher clinical success (RD = -0.19; 95% CI -0.27 ‒ -0.11; p < 0.00001; I² = 0%) and less post-drainage cholangitis (RD = 0.08; 95% CI 0.01‒0.15; p = 0.02; I² = 48%) when compared to the EBD group. There was no statistical difference between the groups regarding: technical success, post-drainage bleeding, major post-drainage complications, and seeding metastases.

Endoscopic versus percutaneous intervention for palliation in malignant hilar bile duct obstruction - A comparative cohort study

BACKGROUND

Biliary drainage in patients managed palliatively for malignant hilar obstruction can be achieved by endoscopic transpapillary stenting using endoscopic retrograde cholangiography (ERC) or percutaneous transhepatic stent or catheter placement using percutaneous transhepatic cholangiography (PTC). This study compares ERC and PTC drainage for malignant hilar bile duct obstruction.

METHODS

A retrospective study of drainage procedures at two academic hospitals was conducted from 2015 to 2020. Procedural success (divided into access-, bridging-, and technical success), therapeutic success, duration of therapeutic success and complications were analysed for different Bismuth-Corlette stricture types.

RESULTS

A total of 293 patients were included, 153 (52.2%) in the ERC group and 140 (47.8%) in the PTC group. Access and bridging success in the ERC and PTC groups were 83.5% vs. 97.2% (p < 0.001) and 90.2% vs. 84.5% (p = 0.119), respectively. Technical and therapeutic success were equivalent between the two groups (98.3% vs. 99.3%, p = 0.854 and 81.7% vs. 73.3%, p = 0.242). Duration of therapeutic success was longer after ERC drainage compared to PTC drainage (p = 0.009) with a 3-month gain in duration of therapeutic success after ERC drainage (p = 0.006, 95% CI [26-160]). Cholangitis rates were equivalent (21.4% vs. 24.7%, p = 0.530), pancreatitis was more common in the ERC group (9.4% vs. 0%, p < 0.001) and procedure-related deaths more common in the PTC group (6.0% vs. 15.8%, p < 0.001).

CONCLUSION

Although ERC and PTC drainage of malignant hilar obstruction were similar regarding technical and therapeutic success, ERC drainage was more durable. Outcome differences for B-C stricture types should be explored in future studies.

Prognostic Nutritional Index (PNI) and Neutrophil to Lymphocyte Ratio (NLR) as Predictors of Short-Term Survival in Patients with Advanced Malignant Biliary Obstruction Treated with Percutaneous Transhepatic Biliary Drainage

BACKGROUND

Effective biliary tree decompression plays a central role in the palliation of malignant biliary obstruction (MBO). When endoscopic drainage is unfeasible or unsuccessful, percutaneous transhepatic biliary drainage (PTBD) is the method of choice and preferred treatment approach in advanced hilar MBO. The prognostic nutritional index (PNI) reflects the patient's immunonutritional status, while the neutrophil to lymphocyte ratio (NLR) reflects the patient's inflammation status. The aim of the present study was to evaluate the prognostic value of preprocedural PNI and NLR on short-term survival in the advanced stage MBO population threatened with PTBD and to characterize the differences in immunonutritional and inflammatory status between 60-day survivors and non-survivors, as well as analyze other variables influencing short-term survival.

METHODS

This single-center retrospective study was conducted on patients undergoing palliative PTBD caused by MBO as a definitive therapeutic treatment between March 2020 and February 2022. After the procedure, patients were followed until the end of August 2022.

RESULTS

A total of 136 patients with malignant biliary obstruction were included in the study. Based on receiver operating characteristic (ROC) curve analysis, optimal cut off-values for NLR (3) and PNI (36.7) were determined. In univariate regression analysis, age, absolute neutrophil count, albumin level, NLR ≤ 3, and PNI ≥ 36.7 were significant predictors of 60-day survival. Level of obstruction and PNI ≥ 36.7 were statistically significant independent predictors of 60-day survival in a multivariate regression model. Using PNI ≥ 36.7 as a significant coefficient from the multivariate regression model with the addition of NLR ≤ 3 from univariate analysis, a 60-day survival score was developed.

CONCLUSIONS

PNI and NLR are easy to calculate from routine blood analysis, which is regularly conducted for cancer patients. As such, they represent easily available, highly reproducible, and inexpensive tests capable of expressing the severity of systemic inflammatory responses in patients with cancer. Our study highlights that preprocedural PNI and NLR values provide predictors of short-term survival in patients with MBO treated with palliative PTBD. In addition, the proposed 60-day survival score can contribute to better selection of future candidates for PTBD and recognition of high-risk patients with expected poor outcomes.

Endoscopic palliation of malignant biliary obstruction

Malignant biliary obstruction often presents with challenges requiring the endoscopist to assess the location of the lesion, the staging of the disease, the eventual resectability and patient preferences in term of biliary decompression. This review will focus on the different modalities available in order to offer the most appropriate palliation, such as conventional endoscopic retrograde cholangiopancreatography, endoscopic ultrasound guided biliary drainage as well as ablative therapies including photodynamic therapy or radiofrequency ablation.

Outcome of primary ERCP versus primary PTC for biliary drainage in malignant hilar biliary strictures: a systematic review and meta-analysis

BACKGROUND

Patients with malignant hilar biliary strictures can suffer from obstructive jaundice. Controversy remains on the optimal approach to obtain preoperative or palliative biliary drainage in these patients. A systematic review and meta-analysis was conducted to compare the two modalities most commonly used in this scenario: endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC).

METHODS

MEDLINE via PubMed was searched for relevant articles published from 2005 to April 2019. Following outcome measures were used to compare ERCP and PTC: therapeutic success rate, cholangitis, pancreatitis, bleeding, tube dislocation, reintervention rate, mortality such as 30d mortality and in-hospital death, median survival time, drainage patency, duration until decompression and hospital stay. Risk of bias assessment for the retrospective studies was conducted by NOS. RoB 2 was used for RCT. A meta-analysis was performed by using Review Manager 5.3. The certainty of evidence was appraised using GRADE.

RESULTS

Eleven articles of which one RCT and ten retrospective cohort studies fulfilled the inclusion criteria for data-analysis (1417 patients; 784 ERCP, 633 PTC). The combined odds ratio (OR) for therapeutic succes was 3.5 times higher in the PTC group (95% CI 2.05-5.97; high certainty). In terms of cholangitis, ERCP carried a 1.7-fold risk as compared to PTC (95% CI 0.92-3.08; moderate certainty). Patients who underwent ERCP were 11.50 times more likely to undergo a reintervention (95% CI 3.51-37.70; moderate certainty). ERCP was comparable to PTC in terms of pancreatitis (low certainty), bleeding (high certainty) and tube dislocation rate (moderate certainty). Mortality tended to be numerically higher in the PTC group but low patient numbers, selection bias and study heterogeneity did not allow uniform comparative analysis.

CONCLUSIONS

In patients with malignant hilar biliary strictures, PTC is associated with a better therapeutic success rate, less cholangitis and lower reintervention rate as compared to ERCP.

Implementing precision medicine in endoscopy practice

In contrast to the "one-size-fits-all" approach, precision medicine focuses on providing health care tailored to individual variabilities. Implementing precision medicine in endoscopy practice involves selecting the appropriate procedures among the endoscopic armamentarium in the diagnosis and management of patients in a logical sequence, jointly considering the pretest probabilities of possible diagnoses, patients' comorbidities and preference, and risk-benefit ratio of the individual procedures given the clinical scenario. The aim of this review is to summarize evidence-supported strategies and measures that may enhance precision medicine in general endoscopy practice.

Role of therapeutic endoscopic ultrasound in gastrointestinal malignancy- current evidence and future directions

Endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to an advanced therapeutic modality. With the advent of better technologies and accessories, EUS has found ground in the management of gastrointestinal (GI) malignancies, not only for diagnosis but also for therapeutic purposes. EUS can tackle a host of conditions, including hepato-pancreatico-biliary malignancies. Advances and experience in various EUS-guided biliary drainage techniques have enabled the endosonologist to tackle biliary obstruction when conventional techniques of endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous transhepatic biliary drainage (PTBD) fails. More and more emerging data not only establishes the safety of EUS-BD but also demonstrates superior efficacy over PTBD and sometimes even ERCP. Malignant gastric outlet obstruction can now be safely managed with EUS-guided gastroenterostomy. Starting from pain management in malignant tumors through celiac plexus neurolysis to various tumor ablative therapies, EUS has forged ahead over percutaneous treatment or surgical options in the management of GI malignancies. Additional data is now coming up on the prospects of EUS-guided immunotherapy and biological therapy for tumor management. The future of EUS therapeutics in the field of GI malignancies is bright. With increasing evidence, this modality becoming a key player in management of a host of complex clinical conditions arising out of GI malignancies is in the offing. This review focuses on elucidating the role of therapeutic EUS in the management of GI malignancies, a synopsis of various techniques, data on its safety and efficacy as well as future advancements in this domain.

Endoscopic or percutaneous biliary drainage in hilar cholangiocarcinoma: When and how?

Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dim prognosis. The role of preoperative and palliative biliary drainage has long been debated. The most common techniques are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD); however, recently developed endoscopic ultrasound-assisted methods are gaining more atention. Selecting the best available method in any specific scenario is crucial, yet sometimes challenging. Thus, this review aimed to discuss the available techniques, indications, perks, pitfalls, and timing-related issues in the management of hCCA. In a preoperative setting, PTBD appears to have some advantages: low risk of postprocedural complications (namely cholangitis) and better priming for surgery. For palliative purposes, we propose ERCP/PTBD depending on the experience of the operators, but also on other factors: the level of bilirubin (if very high, rather PTBD), length of the stenosis and the presence of cholangitis (PTBD), ERCP failure, or altered biliary anatomy.

Endoscopic or percutaneous biliary drainage in hilar cholangiocarcinoma: When and how?

Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dim prognosis. The role of preoperative and palliative biliary drainage has long been debated. The most common techniques are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD); however, recently developed endoscopic ultrasound-assisted methods are gaining more atention. Selecting the best available method in any specific scenario is crucial, yet sometimes challenging. Thus, this review aimed to discuss the available techniques, indications, perks, pitfalls, and timing-related issues in the management of hCCA. In a preoperative setting, PTBD appears to have some advantages: low risk of postprocedural complications (namely cholangitis) and better priming for surgery. For palliative purposes, we propose ERCP/PTBD depending on the experience of the operators, but also on other factors: the level of bilirubin (if very high, rather PTBD), length of the stenosis and the presence of cholangitis (PTBD), ERCP failure, or altered biliary anatomy.

Percutaneous transhepatic drainage is safe and effective in biliary obstruction-A single-center experience of 599 patients

BACKGROUND

Historically, surgical bilioenteric bypass was the only treatment option for extrahepatic bile duct obstruction, but with technological advancements, percutaneous transhepatic drainage (PTD) and endoscopic solutions were introduced as a less invasive alternative. Endoscopic methods may lead to a decreasing indication of PTD in the future, but today it is still the standard treatment method, especially in hilar obstructions.

METHODS

In our retrospective data analysis, we assessed technical success rate, reintervention rate, morbidity, mortality, and the learning curve of patients treated with PTD over 12 years in a tertiary referral center.

RESULTS

599 patients were treated with 615 percutaneous interventions. 94.5% (566/599) technical success rate; 2.7% (16/599) reintervention rate were achieved. 111 minor and 22 major complications occurred including 1 case of death. In perihilar obstruction, cholangitis were significantly more frequent in cases where endoscopic retrograde cholangiopancreatography had also been performed prior to PTD compared to PTD alone, with 39 (18.2%) and 15 (10.5%) occurrences, respectively.

DISCUSSION

The results and especially the excellent success rates demonstrate that PTD is safe and effective, and it is appropriate for first choice in the treatment algorithm of perihilar stenosis. Ultimately, we concluded that PTD should be performed in experienced centers to achieve low mortality, morbidity, and high success rates.

Use of endoscopic ultrasound-guided biliary drainage as a rescue of re-intervention after the placement of multiple metallic stents for malignant hilar biliary obstruction

BACKGROUND/PURPOSE

Endoscopic transpapillary re-intervention (ETP-RI) after multiple self-expandable metallic stent (SEMS) placement for unresectable malignant hilar biliary obstruction (MHBO) is challenging, but endoscopic ultrasound-guided biliary drainage (EUS-BD) could be an alternative following failed ETP-RI. We investigated appropriate re-intervention (RI) methods in MHBO after multiple SEMS placement and evaluated RI with EUS-BD (EUS-RI) benefits following ETP-RI failure.

METHODS

Patients requiring RI after multiple SEMS placement for MHBO between October 2017 and April 2021 were enrolled. Patients' characteristics, metallic-stent type, stent-placement configuration, overall survival, stent patency, re-intervention results, and re-intervention technical and clinical success rates were reviewed.

RESULTS

Forty-nine patients underwent ETP-RI for MHBO. ETP-RI's technical success rate was 69.4%. Of 15 failed ETP-RI cases, all underwent EUS-RI, achieving technical and clinical success rates of 86.7% and 100%, respectively. Time to recurrent biliary obstruction (TRBO) after RI was significantly different between EUS-RI and ETP-RI (212 vs 84 days; P = .01). On multivariate analysis, EUS-RI was the only factor associated with TRBO (odds ratio: 4.48; 95% confidence interval: 1.01-19.91; P = .04). Acute pancreatitis and bile peritonitis were present in 6.1% of ETP-RI and 13.3% of EUS-RI cases, respectively; both improved conservatively.

CONCLUSIONS

EUS-RI was effective and safe in difficult ETP-RI cases after multiple SEMS placement for MHBO.

Advances in the management of cholangiocarcinoma

Cholangiocarcinoma (CCA) is a primary malignancy of the bile ducts with three anatomically and molecularly distinct entities: Intrahepatic CCA (iCCA), perihilar CCA (pCCA), and distal CCA. As a result of phenotypic and anatomic differences they differ significantly with respect to management. For each type of CCA there have been significant changes in management over the last several years which will be discussed in this review. Although resection remains the standard of care for all types of CCA, liver transplantation has been established as curative treatment for selected patients with pCCA and is being evaluated for iCCA with early success. With respect to systemic therapy capecitabine is now first line adjuvant therapy for all biliary tract malignancies after curative intent resection. Progress in exploiting the pathologic mutations and molecular abnormalities has also yielded regulatory approval of targeted therapy for CCA in patients with acquired alterations in the fibroblast growth factor receptor. There is also increased consensus in managing malignant biliary obstruction associated with CCA where pre-operative biliary stenting is not beneficial while self-expanding metal stents have been shown to be superior to plastic stents in patients who are not surgical candidates.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Percutaneous Image-Guided Biliary Procedures

Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.

[A Recent Update on Endoscopic Drainage of Advanced Malignant Hilar Obstruction]

Malignant hilar obstruction (MHO) is considered an aggressive perihilar obstruction caused by cholangiocarcinoma, gallbladder cancer, or metastatic malignancies and has a poor prognosis. Although surgical resection is the only curative treatment method, the majority of patients with MHO do not undergo surgery due to an advanced inoperable state at presentation. Currently, effective biliary drainage provides the necessary palliation for symptomatic improvement. Among the drainage methods, percutaneous access may be preferred, especially for advanced MHO because of the technical difficulty involved with other techniques. Recently, primary endoscopic palliation using plastic or metal stents has been shown to have higher technical feasibility and clinical success without increasing adverse events even in patients with high-degree MHO. The development of various accessories, endoscopic ultrasonography, and advances in techniques have facilitated primary endoscopic intervention. However, some aspects continue to be debated such as the palliation methods, appropriate stents, the number of stents, the deployment methods, and additional local ablation therapies. Therefore, this review discusses the current optimal endoscopic treatment methods for advanced MHO based on reported literature.

Outcome Following Percutaneous Transhepatic Biliary Drainage (PTBD) in Carcinoma Gallbladder: a Prospective Observational Study

INTRODUCTION

Percutaneous biliary drainage (PTBD) is required as palliation and optimization for surgery or chemotherapy in carcinoma gallbladder (GBC) but may be associated with complications. We aimed to study the outcomes, complications, and changes in quality of life in patients with GBC undergoing PTBD.

METHODS

A prospective study from July 2018 to December 2019 in patients of GBC presenting with obstructive jaundice was done. Patients planned for PTBD were included in the study. The progression of the disease, complications of PTBD, reinterventions, effects on initiation or completion of chemotherapy, surgical resection or intervention, and overall survival were recorded. Quality of life (QoL) was assessed using the SF-36 questionnaire before and after 4-6 weeks of intervention.

RESULTS

Of 160 patients assessed for inclusion, 60 (mean age 53.7 ± 10.95 years, 27 (45%) males) were eventually included. Eleven patients (18.3%) had metastatic disease at presentation. Of 60 patients undergoing PTBD, none had immediate procedure-related complications, 41 (68%) patients had at least one, and 18 (30%) patients had more than one complication. The most common complication was peri-catheter bile leak (41.6%), followed by catheter dislodgement (30%), blockage (23.3%), and bleeding (10%). Reintervention was required in 32 (53%) patients. There was a significant decrease in QoL after PTBD (P < 0.0001). Median survival after PTBD was 12 weeks.

CONCLUSION

The high technical success of PTBD does not translate into the improvement of QoL.

A Retrospective Study of Biliary Drainage Strategies for Patients with Malignant Hilar Biliary Strictures

Purpose

The main aim of this study was to compare the efficacy and safety of different biliary drainage strategies, including percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary stenting (EBS) and unilateral versus bilateral stenting, in patients with unresectable malignant hilar biliary strictures (MHBSs).

Patients and Methods

This was a retrospective review of patients with inoperable MHBSs who underwent biliary drainage by either EBS or PTBD. Efficacy and safety were compared between the two pathways and between unilateral and bilateral stenting in the EBS group. The survival duration was analyzed with K-M curves and Log rank tests.

Results

From January 2015 to December 2019, a total of 206 (126: EBS and 80: PTBD) patients with MHBSs were enrolled in our study and underwent 270 procedures (173: EBS and 97: PTBD). Bilateral stenting was superior to unilateral stenting in terms of clinical success (69.6% vs 50.6%, p=0.039), especially for patients with Bismuth type IV (70.0% vs 30.3%, p=0.002). A higher decrease in bilirubin was seen with PTBD in patients with Bismuth types III-IV (66.9 vs 36.7, p=0.006). A survival advantage was seen in successful drainage (227 days vs 82 days, p<0.001), lower tumor-node-metastasis (TNM) scores (I-II) (195 days vs 139 days, p=0.012), and cholangiocarcinoma (184 days vs 84 days, p=0.001).

Conclusion

For patients with advanced MHBSs, bilateral stenting may achieve a better drainage effect than unilateral stenting, and PTBD may have a better performance in relieving cholestasis than EBS. Successful drainage and cholangiocarcinoma may provide greater long-term survival benefits.

Clinical outcomes of biliary drainage of malignant biliary obstruction due to colorectal cancer metastases: A systematic review

BACKGROUND AND AIMS

Malignant biliary obstruction is an ominous complication of metastatic colorectal cancer (mCRC). Biliary drainage is frequently performed to relieve symptoms of jaundice or enable palliative systemic therapy, but effective drainage can be difficult to accomplish. The aim of this study is to summarize literature on clinical outcomes of biliary drainage in mCRC patients with malignant biliary obstruction.

METHODS

We searched Medline and EMBASE for studies that included patients with malignant biliary obstruction secondary to mCRC, treated with endoscopic and/or percutaneous biliary drainage. We summarized available data on technical success, clinical success, adverse events, systemic therapy administration and survival after biliary drainage.

RESULTS

After screening 3584 references and assessing 509 full-text articles, seven cohort studies were included. In these studies, rates of technical success, clinical success and adverse events varied between 63%-94%, 42%-81%, and 19%-39%, respectively. Subsequent chemotherapy was administered in 17%-56% of patients. Overall survival varied between 40 and 122 days across studies (278-365 days in patients who received subsequent chemotherapy, 42-61 days in patients who did not).

CONCLUSIONS

Successful biliary drainage in mCRC patients can be challenging to achieve and is frequently associated with adverse events. Overall survival after biliary drainage is limited, but is significantly longer in patients treated with subsequent systemic therapy. Expected benefits of biliary drainage should be carefully weighed against its risks.

EUS-guided biliary drainage for malignant hilar biliary obstruction: A concise review

EUS-guided biliary drainage (EUS-BD) has emerged as an alternative to ERCP for distal biliary obstruction in expert hands. Various routes for EUS-guided access in distal biliary obstruction include EUS choledochoduodenostomy, EUS-guided rendezvous, and EUS-antegrade (EUS-AG) stent placement. While percutaneous transhepatic biliary drainage and ERCP are established modalities in management of malignant hilar biliary obstruction, the role of EUS-BD is emerging. Various methods of drainage in hilar obstruction include EUS hepaticogastrostomy, EUS hepaticoduodenostomy, EUS-guided bridging stent placement, and combined ERCP and EUS-guided biliary drainage. In this review, we discuss the role of EUS-BD in malignant hilar biliary obstruction with the currently available evidence, along with the limitations and challenges to the use of this modality in management of these patients.

ERCP plus endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage for malignant hilar biliary obstruction: a multicenter observational open-label study

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.

Novel endoscopic technique for trisegment drainage in patients with unresectable hilar malignant biliary strictures (with video)

BACKGROUND AND AIMS

Three or more stents may be needed in patients with extensive stricturing in Bismuth type IIIa/IV hilar malignant strictures. Partial stent-in-stent (PSIS) deployment has been the primary intervention for hilar malignant biliary stricture (MBS). However, simultaneous side-by-side (SBS) stent placement has become feasible with the development of the <6F diameter stent delivery system. Our aim was to assess the efficacy and safety of a new hybrid method combining PSIS and SBS stent placement for trisegment biliary drainage.

METHODS

This study included 17 consecutive patients with Bismuth IIIa or IV malignant strictures who underwent endoscopic drainage using the hybrid method. Diameters of the delivery stents were 5.4F (n = 10) and 5.7F (n = 7).

RESULTS

The technical success rate was 82% (14/17), and the median length of procedures was 54 minutes. Two patients required predilatation for deployment of the third self-expandable metallic stent through the mesh of the first deployed stent. Two patients (12%) developed cholecystitis as early adverse events, and 1 patient (6%) developed liver abscess as a late adverse event. The time to recurrent biliary obstruction among those with successful initial trisegmental drainage was 189 days (95% confidence interval, 124-254).

CONCLUSIONS

The hybrid method for unresectable hilar MBS is an effective endoscopic drainage method, and the ease of these procedures is partly attributed to the thinner stent delivery system.

[Russian consensus on current issues in the diagnosis and treatment of obstructive jaundice syndrome]

The Russian consensus document on topical issues of the diagnosis and treatment of obstructive jaundice syndrome was prepared by a group of experts in various fields of surgery, endoscopy, interventional radiology, radiological diagnosis and intensive care. The goal of this document is to clarify and consolidate the opinions of national experts on the following issues: timing of diagnosis of obstructive jaundice, features of diagnostic measures, the need and possibility of conservative measures for obstructive jaundice, and strategy of biliary decompression depending on the cause and level of biliary block.

Advances in the endoscopic management of malignant biliary obstruction

Biliary obstruction is common in pancreatobiliary malignancies and has a negative impact on the patient’s quality of life, postoperative complications, and survival rates. Particularly in the last decade, there has been enormous progress regarding the diagnostic and therapeutic options in patients with malignant biliary obstruction. Endoscopy has given a new insight in this direction and novel techniques have been developed for the better characterization and treatment of malignant strictures. We herein summarize the available data on the different endoscopic techniques, and clarify their role in the diagnosis and treatment of malignant biliary obstructive disease. Finally, we propose an algorithm that can facilitate management decisions in these patients.

Endoscopic ultrasound-guided versus endoscopic retrograde cholangiopancreatography-guided biliary drainage for primary treatment of distal malignant biliary obstruction: A systematic review and meta-analysis

OBJECTIVES

Current evidence supporting the utility of endoscopic ultrasound-guided biliary drainage (EUS-BD) as primary treatment for distal malignant biliary obstruction (MBO) is limited. We conducted a meta-analysis to compare the performance of EUS-BD and endoscopic retrograde cholangiopancreatography-guided biliary drainage (ERCP-BD) as primary palliation of distal MBO.

METHODS

We searched several databases for comparative studies evaluating EUS-BD vs. ERCP-BD in primary drainage of distal MBO up to 28 February 2019. Primary outcomes were technical success and clinical success. Secondary outcomes included adverse events, stent patency, stent dysfunction, tumor in/overgrowth, reinterventions, procedure duration, and overall survival.

RESULTS

Four studies involving 302 patients were qualified for the final analysis. There was no difference in technical success (risk ratio [RR] 1.00; 95% confidence interval [95% CI] 0.93-1.08), clinical success (RR 1.00; 95% CI 0.94-1.06) and total adverse events (RR 0.68; 95% CI: 0.31-1.48) between the two procedures. EUS-BD was associated with lower rates of post-procedure pancreatitis (RR 0.12; 95% CI 0.02-0.62), stent dysfunction (RR 0.54; 95% CI 0.32-0.91), and tumor in/overgrowth (RR 0.22; 95% CI 0.07-0.76). No differences were noted in reinterventions (RR 0.59; 95% CI 0.21-1.69), procedure duration (weighted mean difference -2.11; 95% CI -9.51 to 5.29), stent patency (hazard ratio [HR] 0.61; 95% CI 0.34-1.11), and overall survival (HR 1.00; 95% CI 0.66-1.51).

CONCLUSIONS

With adequate endoscopy expertise, EUS-BD could show similar efficacy and safety when compared with ERCP-BD for primary palliation of distal MBO and exhibits several clinical advantages.

Biliary stenting for hilar malignant biliary obstruction

Although endoscopic intervention is the mainstay for palliation of malignant biliary obstruction, a percutaneous approach has been preferred, particularly in patients with advanced high-grade hilar malignant biliary obstruction, because of the technical difficulty and risk of complications. However, recently, primary endoscopic palliation using plastic or metal stents has had higher technical and clinical success with fewer adverse events than the percutaneous approach. Endoscopic interventions are being done more and more frequently because of advances in metal stents, accessories, and techniques. However, several concerns, such as optimal stent type, number, and deployment method, remain to be resolved. Therefore, we reviewed the literature in order to identify the optimal biliary stenting strategy for patients with hilar malignant biliary obstruction, focusing on stent type (plastic vs metal), number (unilateral [single] vs bilateral [multiple]), and deployment method (stent-in-stent vs stent-by-stent).

Endoscopic Stenting in Hilar Cholangiocarcinoma: When, How, and How Much to Drain?

Hilar cholangiocarcinoma (HCCA) involves a complex anatomical region where bile ducts, arteries, and veins create a complex network. HCCA can lead to biliary strictures at the main hepatic confluence, involving the right and left radicles. Endoscopic drainage of jaundiced patients with HCCA is challenging and carries a high risk of infective complications. HCCA needs a careful multidisciplinary evaluation to assess the indication and purposes (preoperative/palliative) of the biliary drainage. Biliary drainage in HCCA needs to be planned by magnetic resonance cholangiography in order to study the biliary anatomy and perform a target drainage of the intrahepatic ducts above the malignant hilar stricture; all the opacified intrahepatic ducts above the hilar stricture must be drained to reduce septic complications. Drainage of >50% of the liver volume is important to obtain bilirubin reduction and less complications, but atrophic liver segments (identified by CT scan) do not require drainage due to the increased risk of cholangitis. When preoperative biliary drainage is planned, plastic stents must be inserted. Self-expandable metal stents are indicated for palliative purposes and should be placed only when a complete liver drainage is possible; only uncovered metal stents are indicated to drain malignant hilar strictures to avoid side-branch occlusion.

Early Warning Models to Estimate the 30-Day Mortality Risk After Stent Placement for Patients with Malignant Biliary Obstruction

PURPOSE

To develop, validate, and compare early warning models of the 30-day mortality risk for patients with malignant biliary obstruction (MBO) undergoing percutaneous transhepatic biliary stent placement (PTBS).

MATERIALS AND METHODS

Between January 2013 and October 2018, this multicenter retrospective study included 299 patients with MBOs who underwent PTBS. The training set consisted of 166 patients from four cohorts, and another two independent cohorts were allocated as external validation sets A and B with 75 patients and 58 patients, respectively. A logistic model and an artificial neural network (ANN) model were developed to predict the risk of 30-day mortality after PTBS. The predictive performance of these two models was validated internally and externally.

RESULTS

The ANN model had higher values of area under the curve than the logistic model in the training set (0.819 vs 0.797), especially in the validation sets A (0.802 vs 0.714) and B (0.732 vs 0.568). Both models had high accuracy in the three sets (75.9-83.1%). Along with a high specificity, the ANN model improved the sensitivity. The net reclassification improvement and integrated discrimination improvement also demonstrated that the ANN model led to improvements in predictive ability compared with the logistic model.

CONCLUSIONS

Early warning models were proposed to predict the risk of 30-day mortality after PTBS in patients with MBO. The ANN model has higher accuracy and better generalizability than the logistic model.

RECOMMENDATIONS FOR INVASIVE PROCEDURES IN PATIENTS WITH DISEASES OF THE LIVER AND BILIARY TRACT: REPORT OF A JOINT MEETING OF THE BRAZILIAN SOCIETY OF HEPATOLOGY (SBH), BRAZILIAN SOCIETY OF DIGESTIVE ENDOSCOPY (SOBED) AND BRAZILIAN SOCIETY OF INTERVENTIONAL RADIOLOGY AND ENDOVASCULAR SURGERY (SOBRICE)

Liver and biliary tract diseases are common causes of morbidity and mortality worldwide. Invasive procedures are usually performed in those patients with hepatobiliary diseases for both diagnostic and therapeutic purposes. Defining proper indications and restraints of commonly used techniques is crucial for proper patient selection, maximizing positive results and limiting complications. In 2018, the Brazilian Society of Hepato-logy (SBH) in cooperation with the Brazilian Society of Interventional Radiology and Endovascular surgery (SOBRICE) and the Brazilian Society of Digestive Endoscopy (SOBED) sponsored a joint single-topic meeting on invasive procedures in patients with hepatobiliary diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to guide clinicians, gastroenterologists, hepatologists, radiologists, and endoscopists for the proper use of invasive procedures for management of patients with hepatobiliary diseases.