Self-expandable metallic stents for malignant biliary obstruction: Efficacy on proximal and distal tumors

Is Ultrasound-guided Bedside Percutaneous Transhepatic Biliary Drainage Safe and Feasible in Critically Ill Patients with Severe Cholangitis? A Preliminary Single-center Experience

Background and aim

Severe cholangitis secondary to biliary obstruction carries high mortality unless biliary drainage is performed urgently. Owing to various patient-related and logistical issues, bedside biliary drainage is considered a salvage therapeutic option. This study aims to evaluate the safety and efficacy of ultrasonography (USG)-guided biliary drainage at the bedside in patients with severe cholangitis admitted to the intensive care unit (ICU).

Materials and methods

A total of 20 patients with severe cholangitis admitted to ICU who underwent bedside percutaneous transhepatic biliary drainage (PTBD) under USG guidance were retrospectively evaluated. Clinical outcomes, details about the PTBD procedure, and complications were recorded and analyzed.

Results

Among 20 patients, 13 were male and 7 were female with a mean age of 50.5 years. The most common cause of biliary obstruction was gall bladder malignancy (45%, n = 9) followed by cholangiocarcinoma (25%, n = 5). Left- and right-sided PTBD was performed in 40% (n = 8) and 35% (n = 7) patients, respectively, while 25% (n = 5) of patients underwent bilateral PTBD. The technical success rate was 100%. A total of 65% (n = 13) of patients were discharged from ICU upon improvement while the remaining 35% (n = 7) died despite bedside PTBD. None of the patients had any major procedure-related complications.

Conclusions

Ultrsound-guided bedside PTBD seems to be a safe and effective option in critically ill patients with severe cholangitis when shifting of patients is not feasible.

How to cite this article

Singh J, Tripathy TP, Patel R, Chandel K. Is Ultrasound-guided Bedside Percutaneous Transhepatic Biliary Drainage Safe and Feasible in Critically Ill Patients with Severe Cholangitis? A Preliminary Single-center Experience. Indian J Crit Care Med 2023;27(1):16-21.

Survival benefit of percutaneous transhepatic biliary drainage for malignant biliary tract obstruction-a prospective study comparing external and internal drainage techniques

PURPOSE

To evaluate the clinical results of percutaneous transhepatic biliary drainage (PTBD) in patients with non-operable malignant biliary tract obstruction (MBTO) and the survival benefit of internal drainage.

METHODS

Prospective data of consecutive patients of PTBD from May 2014 to August 2017 was analyzed for 30-day, 90-day and 1-year mortality, and mean survival of patients undergoing external drainage (ED) and internal drainage (ID) using internal-external ring biliary catheterization or biliary stent were compared. Other important variables evaluated were drop in the total bilirubin (TBil) levels, improvement in pain and pruritus, procedure-related complications, and patient satisfaction.

RESULTS

In 87 cases (54 male, 33 female) with mean age 37.3 y (22-70 y; 95% CI: 31.1 y-43.5 y), 10, 45 and 32 patients underwent stenting, external and internal-external catheterization, respectively (total 152 procedures [> 1 in 35.63%, n = 31]). PTBD resulted in decrease in mean TBil by 8.2738 ± 0.912 mg/dL at 30 days (P < 0.001), 55.14% (n = 48) cases reaching 3 mg/dL at mean 45 days, and 35/48 cases received chemotherapy. Overall mortality was 6.89%, 37.93% and 90.80% at 30 days, 90 days and 1 year, respectively. Mean survival with ID (236.40 ± 33.37 days) was better than with ED (110.35 ± 26.16 days) (P < 0.001). Pain (62.06%; n = 54; mean Visual Analog Scale [VAS] score = 6.7) improved significantly (mean VAS score 3.4; P < 0.001). Pruritus (n = 29) was relieved in 100% of the cases. Complication rate of 18.39% (n = 16) and no procedure-related death were seen.

CONCLUSION

PTBD offers a safe and significant improvement in TBil, pain, and pruritus in non-operable MBTO, with ID offering additional survival benefit over ED.

Feasibility and safety of bedside percutaneous biliary drainage in patients with severe cholangitis

Purpose

To evaluate the safety and feasibility of bedside percutaneous transhepatic biliary drainage (PTBD) as a salvage procedure in patients with severe cholangitis in the intensive care unit (ICU).

Methods

This retrospective study evaluated records of consecutive patients with severe cholangitis who were admitted in the ICU. Bedside PTBD was performed using ultrasound guidance. The level and cause of biliary obstruction were recorded. The technical success of the procedure and complications were recorded.

Results

Ten patients (six males, mean age 53.8 years) underwent bedside PTBD. Six patients had distal common bile duct blockade [periampullary carcinoma (n = 2), carcinoma pancreas (n = 2), choledocholithiasis (n = 1), and benign stricture (n = 1)]. Four patients had malignant hilar stricture [cholangiocarcinoma (n = 3) and carcinoma gallbladder (n = 1)]. Technical success was achieved in all. One patient underwent bilateral PTBD. Left and right PTBD were performed in 5 and 4 patients, respectively. There were no major complications. Transient hemobilia occurred in two patients.

Conclusion

Bedside PTBD is safe and technically feasible. Prospective studies are required to establish this procedure into routine clinical practice.

Rescue EUS-guided intrahepatic biliary drainage for malignant hilar biliary stricture after failed transpapillary re-intervention

BACKGROUND

Treatment of unresectable malignant hilar biliary stricture (UMHBS) is challenging, especially after failure of repeated transpapillary endoscopic stenting. Endoscopic ultrasonography-guided intrahepatic biliary drainage (EUS-IBD) is a recent technique for intrahepatic biliary decompression, but indications for its use for complex hilar strictures have not been well studied. The aim of this study was to assess the feasibility and safety of EUS-IBD for UMHBS after failed transpapillary re-intervention.

METHODS

Retrospective analysis of all consecutive patients with UMHBS of Bismuth II grade or higher who, between December 2008 and May 2016, underwent EUS-IBD after failed repeated transpapillary interventions. The technical success, clinical success, and complication rates were evaluated. Factors associated with clinical ineffectiveness of EUS-IBD were explored.

RESULTS

A total of 30 patients (19 women, median age 66 years [range 52-87]) underwent EUS-IBD for UMHBS during the study period. Hilar biliary stricture morphology was classified as Bismuth II, III, or IV in 5, 13, and 12 patients, respectively. The median number of preceding endoscopic interventions was 4 (range 2-14). EUS-IBD was required because the following procedures failed: duodenal scope insertion (n = 4), accessing the papilla after duodenal stent insertion (n = 5), or achieving desired intrahepatic biliary drainage (n = 21). Technical success with EUS-IBD was achieved in 29 of 30 patients (96.7%) and clinical success was attained in 22 of these 29 (75.9%). Mild peritonitis occurred in three of 30 (10%) and was managed conservatively. Stent dysfunction occurred in 23.3% (7/30). There was no procedure-related mortality. On multivariable analysis, Bismuth IV stricture predicted clinical ineffectiveness (odds ratio = 12.7, 95% CI 1.18-135.4, P = 0.035).

CONCLUSIONS

EUS-IBD may be a feasible and effective rescue alternative with few major complications after failed transpapillary endoscopic re-intervention in patients with UMHBS, particularly for Bismuth II or III strictures.

Endoscopic drainage in patients with inoperable hilar cholangiocarcinoma

Hilar cholangiocarcinoma has an extremely poor prognosis and is usually diagnosed at an advanced stage. Palliative management plays an important role in the treatment of patients with inoperable hilar cholangiocarcinoma. Surgical, percutaneous, and endoscopic biliary drainage are three modalities available to resolve obstructive jaundice. Plastic stents were widely used in the past; however, self-expanding metal stents (SEMS) have become popular recently due to their long patency and reduced risk of side branch obstruction, and SEMS are now the accepted treatment of choice for hilar cholangiocarcinoma. Bilateral drainage provides more normal and physiological biliary flow through the biliary ductal system than that of unilateral drainage. Unilateral drainage was preferred until recently because of its technical simplicity. But, with advancements in technology, bilateral drainage now achieves a high success rate and is the preferred treatment modality in many centers. However, the choice of unilateral or bilateral drainage is still controversial, and more studies are needed. This review focuses on the endoscopic method and discusses stent materials and types of procedures for patients with a hilar cholangiocarcinoma.

Self-expandable metal stents in malignant biliary obstruction

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.

One-step percutaneous transhepatic insertion of a balloon-expanding metallic stent for obstructive jaundice

BACKGROUND AND AIM

The aim of this study was to evaluate the efficacy and safety of one-step percutaneous transhepatic insertion of the Express LD stent, a balloon-expanding stainless steel stent used for the management of distal artery stenosis in the treatment of obstructive jaundice caused by various inoperable malignancies.

METHODS

Seventy-one consecutive patients with unresectable malignant biliary obstruction who underwent Express LD stent placement between 2007 and 2010 at our institute were reviewed.

RESULTS

Mean stent patency was 165 ± 144 days and mean patient survival was 180 ± 156 days, while the cumulative stent patency rate and patient survival rate at 6 and 12 months were 79% and 65%, and 38% and 16%, respectively. Stents were successfully placed in all cases without any stent migration or misplacement. Stent failure occurred in 14 patients (20%), and 16 complications were observed, including 12 cholangitis (17%), two cholecysitis (3%), and two pancreatitis (3%). Y-configuration stenting for hilar bile duct obstruction was the only independent prognostic factor for stent failure.

CONCLUSIONS

One-step percutaneous transhepatic insertion of the Express LD stent is effective and safe for the management of obstructive jaundice caused by inoperable malignancies.

Covered Wallstents for palliation of malignant biliary obstruction: primary stent placement versus reintervention

BACKGROUND

Covered self-expandable metallic stents (SEMSs) are designed to prevent tumor ingrowth and can be removed if necessary. Only limited comparative data are available on the performance of covered SEMSs after primary placement versus reintervention.

OBJECTIVE

To assess the effectiveness and safety of covered SEMS placement either as primary treatment or reintervention in patients requiring palliation of malignant biliary obstruction.

DESIGN

Retrospective clinical cohort study.

SETTING

Tertiary referral center.

PATIENTS

This study involved 104 patients with unresectable malignant biliary strictures.

INTERVENTION

Covered biliary SEMS placement.

MAIN OUTCOME MEASUREMENTS

Stent patency, technical success, and patient survival.

RESULTS

Covered SEMSs were placed as primary treatment in 48 patients (46%), and reintervention was performed in 56 patients (54%). At 3, 6, and 12 months thereafter, the Kaplan-Meier estimated fractions of all patients with patent stents were 94%, 84%, and 58%, respectively. Covered SEMSs remained patent until the patient's death in 75 of 89 nonsurvivors (84%). Although patency rates 3, 6, and 12 months after primary placement (100%, 93%, and 82%, respectively) were higher than those after reintervention (90%, 78%, and 48%, respectively), the differences were not statistically significant (P = .057). Overall, the most frequent adverse events were cholangitis (7%) and stent migration (4%).

LIMITATIONS

The distribution of stricture locations differed among the groups, and survival data suggested the presence of more extensive disease in the primary treatment group at baseline.

CONCLUSION

The clinical utility and safety of primary covered SEMS placement were confirmed. This study provides the most extensive evidence to date that reintervention with a covered SEMS can provide a useful palliative option.

Outcome of self-expandable metallic stents in low-grade versus advanced hilar obstruction

BACKGROUND

Self-expandable metallic stents (SEMS) are known to provide a longer patency time than plastic stents for malignant biliary obstructions including hilar obstruction. However, studies that focus on the efficacy of SEMS in low-grade and advanced hilar obstructions are still scanty.

METHODS

Ninety four patients with malignant hilar obstructions were enrolled (six were later excluded). Patients were divided into two groups according to their Bismuth levels. Group A were patients with Bismuth I (n = 53). Group B were patients with Bismuth II, III and IV (n = 35). Technical success, complications, jaundice resolution, stent patency time, and patients' survival were analyzed.

RESULTS

Our intention-to-treat analysis showed that group A had a significant lower rate of post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis than group B; 16.1% versus 44.7%, (P < 0.01). Four patients from group B still had persistent jaundice. Our per protocol analysis demonstrated that median stent patency time in groups A and B were not statistically different (74 vs 60 days). Median survival time in groups A and B were also not statistically different (90 vs 75 days). In both groups, those without liver metastasis had significantly better patency and survival time than those with liver metastasis (P = 0.010 and 0.027, respectively).

CONCLUSIONS

In patients with hilar obstruction, liver metastasis is one of the main factors that determine survival of the patient. Patency times of SEMS in both low-grade and advanced obstructions are comparable. However, in the advanced group, there is a significant risk of post-ERCP cholangitis.

Detection of biliary duct narrowing and choledocholithiasis: accuracy of portal venous phase multidetector CT

PURPOSE

To retrospectively evaluate the sensitivity and specificity of 64-detector computed tomography (CT) in the portal venous phase by using transverse images and both multiplanar and minimum intensity reformations for the detection of biliary duct narrowing and choledocholithiasis, with magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) as the reference standard.

MATERIALS AND METHODS

Approval from institutional review board was obtained for this HIPAA-compliant retrospective study; informed consent was waived. The study included all patients (42 men, 52 women; mean age, 61 years) who underwent abdominal 64-detector CT within 2 months of MRCP and/or ERCP. All patients underwent portal venous phase intravenous contrast material-enhanced abdominal CT. Sixty-one patients underwent MRCP and 54 patients underwent ERCP (21 patients underwent both). Two radiologists, blinded to the reference standard, independently evaluated the CT images, including multiplanar and minimum intensity reformations, for biliary duct narrowing and choledocholithiasis. Standard of reference examinations were used to calculate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

Twenty-three (24%) of 94 patients had a biliary duct narrowing at reference examinations. For detecting biliary duct narrowing, observer 1 had a sensitivity of 78.2%, specificity of 100%, PPV of 100%, and NPV of 93.4% and observer 2 had a sensitivity of 69.6%, specificity of 100%, PPV of 100%, and NPV of 91.0%. In 18 (19%) of 94 patients, choledocholithiasis was detected at reference examinations. For detecting choledocholithiasis, observer 1 had a sensitivity of 77.8%, specificity of 96.1%, PPV of 82.4%, and NPV of 94.8% and observer 2 had a sensitivity of 72.2%, specificity of 96.1%, PPV of 81.2%, and NPV of 93.6%.

CONCLUSION

Portal venous phase multidetector CT images are highly specific and moderately sensitive for the detection of biliary duct narrowing and choledocholithiasis.

Change and significance of T-cell subsets and TNF-α in patients with advanced malignant obstructive jaundice treated by percutaneous transhepatic biliary external and internal drainage

The aim of this article was to study the influence of immunity function of advanced malignant obstructive jaundice (MOJ) treated by percutaneous transhepatic biliary external and internal drainage. Ninety-six cases of MOJ were divided into two groups according to the different ways of biliary drainage. Fifty-two external drainage tubes were placed in 41 cases of percutaneous transhepatic biliary external drainage group and 66 metal stents were placed in 55 cases of percutaneous transhepatic biliary internal drainage group. Liver function, serum TNF-α and cellular function were examined one day before operation and one week after operation and liver function was re-examined two weeks after operation, in order to observe the change and analyze the association among them and compare with the control group. All patients' conditions were improved after operation. In the percutaneous transhepatic biliary external and internal drainage groups, the total level of bilirubin decreased from (343.54±105.56) μmol/L and (321.19±110.50) μmol/L to (290.56±103.46) μmol/L and (283.72±104.95) μmol/L after operation respectively, which were significantly lower than pre-operation (P<0.05), but there was no significant difference between the two groups (P>0.05). Serum alanine aminotransferase (ALT) of all patients one week after operation was significantly lower than that before operation. TNF-α in percutaneous transhepatic biliary external and internal groups decreased from (108.58±19.95) pg/mL, (109.98±16.24) pg/mL of pre-operation to (104.32±19.59) pg/mL, (83.92±13.43) pg/mL of post-operation respectively, there was notable improvement (P<0.01) in internal drainage group after operation. Patients' serum CD4, CD3 and CD4/CD8 were notably increased, but CD8 was notably decreased (P<0.05). There was no difference in external drainage group (P>0.05). There was a significant difference between the two groups. Serum TNF-α and ALT had positive correlation. Percutaneous transhepatic biliary internal or external drainage was an effective and important method to treat MOJ. Patients' immune function was weak when they suffered MOJ, but body's cellular immune function can be notably improved after internal biliary drainage.

Adenosquamous carcinoma of extrahepatic bile duct: a case report

Most malignant tumors originating from the biliary tract are adenocarcinomas, and adenosqamous carcinoma of Klatskin's tumor is a very rare finding. An 83-yr-old man was admitted to our hospital because of jaundice. The abdominal computed tomography and magnetic resonance cholangiopancreatography revealed wall thickening and luminal stenosis of both the intrahepatic duct confluent portion and the common hepatic duct. These findings were compatible with Klatskin's tumor, Bismuth type III. Considering the patient's old age, palliative combined modality therapy was performed. After percutaneous transhepatic biliary drainage, biopsy was performed via percutaneous transhepatic cholangioscopy. The histopathologic findings showed adenosquamous carcinoma. External radiotherapy and intraluminal brachytherapy through the endobiliary Y-type stent were then done. Nine months after the radiotherapy, the laboratory findings and the abdominal computed tomography revealed biliary obstruction and progressive hepatic metastasis. The combined modality therapy of external radiotherapy, intraluminal brachytherapy and stenting assisted him to live a normal life until he finally experienced biliary obstruction.