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Martins BC, Perez CA, Ruas JN, Bento LH, Mendonça EQ, de Paulo GA, Uemura RS, Geiger SN, de Lima MS, Jukemura J, Ribeiro U, Maluf-Filho F. Results of endoscopic biliary drainage in patients with malignant hilar stricture. Clinics (Sao Paulo) 2023; 78:100153. [PMID: 36681072 PMCID: PMC10757274 DOI: 10.1016/j.clinsp.2022.100153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 11/14/2022] [Accepted: 12/07/2022] [Indexed: 01/21/2023] Open
Abstract
In Malignant Hilar Biliary Stricture (MHBS) palliative biliary drainage is a frequent strategy, improving the quality of life, reducing pruritus, loss of appetite and relieving cholangitis. The endoscopic approach is an effective, although challenging procedure. This study aimed to evaluate technical and clinical success rates of biliary drainage by ERCP. This is a retrospective study including all patients with MHBS referred to Instituto do Cancer do Hospital de São Paulo (ICESP) submitted to biliary drainage by ERCP, between January 2010 and December 2017. Multivariable logistic regression was performed to evaluate predictors of clinical failure, as total bilirubin levels, Bismuth classification, number of hepatic sectors drained and presence of cholangitis. In total, 82 patients presenting unresectable MHBS were included in this study. 58.5% female and 41.5% male, with a mean age of 60±13 years. Bismuth classification grades II, IIIA, IIIB and IV were noted in 23.2%, 15.9%, 14.6% and 46.3%, respectively. Technical and clinical success was achieved in 92.7% and 53.7% respectively. At multivariable logistic-regression analyses, Bismuth IV strictures were related to higher clinical failure rates when compared to other strictures levels, with an Odds Ratio of 5.8 (95% CI 1.28‒20.88). In conclusion, endoscopic biliary drainage for malignant hilar biliary stricture had a high technical success but suboptimal clinical success rate. Proximal strictures (Bismuth IV) were associated with poor drainage outcomes.
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Affiliation(s)
- Bruno Costa Martins
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Department of Gastroenterology of Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Caio A Perez
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Department of Gastroenterology of Universidade de São Paulo, São Paulo, SP, Brazil
| | - Jennifer N Ruas
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Department of Gastroenterology of Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luiza H Bento
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Department of Gastroenterology of Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ernesto Q Mendonça
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Department of Gastroenterology of Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gustavo A de Paulo
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Department of Gastroenterology of Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ricardo S Uemura
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Department of Gastroenterology of Universidade de São Paulo, São Paulo, SP, Brazil
| | - Sebastian N Geiger
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Department of Gastroenterology of Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Simas de Lima
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Department of Gastroenterology of Universidade de São Paulo, São Paulo, SP, Brazil
| | - José Jukemura
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo. Department of Gastroenterology of Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ulysses Ribeiro
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo. Department of Gastroenterology of Universidade de São Paulo, São Paulo, SP, Brazil
| | - Fauze Maluf-Filho
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Department of Gastroenterology of Universidade de São Paulo, São Paulo, SP, Brazil
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Alhamid A, Aljarad Z, Sandouk F. Using the stent-in-stent technique to drain the right hepatic duct, passing across a 7-year-old obstructed spiral self-expandable metal stent of the left hepatic duct. Gastroenterol Rep (Oxf) 2020; 8:476-478. [PMID: 33447391 PMCID: PMC7793220 DOI: 10.1093/gastro/goaa019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/29/2019] [Accepted: 01/08/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ahmad Alhamid
- Internal Medicine, Faculty of Medicine, University of Aleppo, Aleppo, Syria
| | - Ziad Aljarad
- Department of Gastroenterology, Aleppo University Hospital, Aleppo, Syria
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Zhu J, Feng H, Zhang D, Li R, Li J, Peng H, Tang W, Hu D, Wu W, Hu K, Cai W, Yin G. Percutaneous transhepatic cholangiography and drainage and endoscopic retrograde cholangiopancreatograph for hilar cholangiocarcinoma: which one is preferred? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:893-897. [PMID: 33118356 DOI: 10.17235/reed.2020.6937/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION both percutaneous transhepatic cholangiography and drainage (PTCD) and endoscopic retrograde cholangiopancreatography (ERCP) with SEMS implantation have been used for unresectable hilar cholangiocarcinoma (HC) in the clinic for many years. However, which one is preferred is still unknown. OBJECTIVE to study the effects of biliary drainage of self-expanding metal stents (SEMS) implantation under PTCD or ERCP to treat HC. METHODS the clinical data of 82 patients with HC from January 2006 to January 2015 were recorded retrospectively. Patients were treated with biliary implantation of self-expanding metal stents (SEMS) under PTCD (PTCD group, 40 patients) or ERCP (ERCP group, 42 patients). Clinical data, including total bilirubin concentrations, complications and survival time were analyzed. RESULTS the remission of jaundice was similar in both groups (p > 0.05). The median survival time of the ERCP group and PTCD group were 237 d and 252 d respectively, with no significant differences (p > 0.05). The biliary infection rates under ERCP and PTCD procedure were 52.4 % and 20.0 % respectively, with a significant statistical difference (p < 0.05). For those HC patients of Bismuth III/IV, the infection rates under ERCP and PTCD procedure were 58.3 % and 14.3 %, respectively (p < 0.05). CONCLUSIONS both PTCD and ERCP with SEMS implantation were effective to prolong the survival time of HC patients. The biliary infection rates were higher in the ERCP group, especially for Bismuth III/IV HC patients.
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Affiliation(s)
- Jianghong Zhu
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Huang Feng
- Gastroenterology, the First Affiliated Hospital of Soochow University
| | - Deqing Zhang
- Gastroenterology, the First Affiliated Hospital of Soochow University
| | - Rui Li
- Gastroenterology, the First Affiliated Hospital of Soochow University
| | - Jing Li
- Gastroenterology, the Second Affiliated Hospital of Soochow University, China
| | - Hongwei Peng
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Wen Tang
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Duanmin Hu
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Wei Wu
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Kewei Hu
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Wei Cai
- Gastroenterology, the Second Affiliated Hospital of Soochow University
| | - Guojian Yin
- Gastroenterology, the Second Affiliated Hospital of Soochow University
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Moryoussef F, Sportes A, Leblanc S, Bachet JB, Chaussade S, Prat F. Is EUS-guided drainage a suitable alternative technique in case of proximal biliary obstruction? Therap Adv Gastroenterol 2017; 10:537-544. [PMID: 28804514 PMCID: PMC5484435 DOI: 10.1177/1756283x17702614] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 03/13/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Results of endoscopic ultrasound-guided biliary drainage (EUBD) are unknown in case of proximal stricture. The aim is to assess clinical outcomes of EUBD in patients with malignant hilar obstruction. METHODS Patients undergoing EUBD with hilar strictures were prospectively included. Primary outcome was clinical success at 7 and 30 days (defined by 50% bilirubin decrease). Secondary outcomes were technical success, procedure-related complications, length of hospital stay, reintervention rate, survival and chemotherapy administration. RESULTS Eighteen patients with a mean age of 68.8 years were included. On 15 classable stenosis, 7 (47%) were noted Bismuth I-II, 7 (47%) Bismuth III, and 1 (6.7%) Bismuth IV. Reasons for EUBD were surgically modified anatomy in 10 patients (55.6%), impassable stricture at ERCP in 7 (38.9%) and duodenal obstruction in 1 (5.6%). Only hepaticogastrostomy was performed. Clinical success was at day 7 and 30 respectively 72.2% and 68.8%. Technical success was 94%. Complications occurred in 3 (16.7%) patients. Median (range) length of hospital stay was 10 (6-35) days. Reintervention rate was 16.7%. Median (range) survival was 79 (5-390) days. Chemotherapy was possible in 10 (55.6%) patients. CONCLUSIONS EUBD is feasible for hilar obstruction for surgically altered anatomy or after ERCP failure. Clinical outcome is satisfactory when considering underlying advanced disease, allowing chemotherapy.
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Affiliation(s)
- Frédérick Moryoussef
- Department of Gastro-Enterology, La Pitié Salpetrière Teaching Hospital, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Adrien Sportes
- Department of Gastro-Enterology, Cochin Teaching Hospital, AP-HP, Université Paris Descartes, Sorbonne Paris Cite, Paris, France
| | - Sarah Leblanc
- Department of Gastro-Enterology, Cochin Teaching Hospital, AP-HP, Université Paris Descartes, Sorbonne Paris Cite, Paris, France
| | - Jean Baptiste Bachet
- Department of Gastro-Enterology, La Pitié Salpetrière Teaching Hospital, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Stanislas Chaussade
- Department of Gastro-Enterology, Cochin Teaching Hospital, AP-HP, Université Paris Descartes, Sorbonne Paris Cite, Paris, France
| | - Frédéric Prat
- Department of Gastro-Enterology, Cochin Teaching Hospital, AP-HP, Université Paris Descartes, Sorbonne Paris Cite, Paris, France
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Abstract
Decompression of the biliary system in patients with malignant biliary obstruction has been widely accepted and implemented as part of the care. Despite a wealth of literature, there remains a significant amount of uncertainty as to which approach would be most appropriate in different clinical settings. This review covers stenting of the biliary system in cases of resectable or palliative malignant biliary obstruction, potential candidates for biliary drainage, technical aspects of the procedure, as well as management of biliary stent dysfunction. Furthermore, periprocedural considerations including proper mapping of the location of obstruction and the use of antibiotics are addressed.
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Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University Medical City, King Saud University, Riyadh 11461, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montréal, Quebec H3G 1A4, Canada
| | - Jeffrey S Barkun
- Division of General Surgery, The McGill University Health Centre, McGill University, 1650 Cedar Avenue, Montréal, Quebec H3G 1A4, Canada
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montréal, Quebec H3G 1A4, Canada; Division of Clinical Epidemiology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montréal, Quebec H3G 1A4, Canada.
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Uppal DS, Wang AY. Advances in endoscopic retrograde cholangiopancreatography for the treatment of cholangiocarcinoma. World J Gastrointest Endosc 2015; 7:675-687. [PMID: 26140095 PMCID: PMC4482827 DOI: 10.4253/wjge.v7.i7.675] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 01/22/2015] [Accepted: 02/11/2015] [Indexed: 02/05/2023] Open
Abstract
Cholangiocarcinoma (CCA) is a malignancy of the bile ducts that carries high morbidity and mortality. Patients with CCA typically present with obstructive jaundice, and associated complications of CCA include cholangitis and biliary sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable treatment modality for patients with CCA, as it enables internal drainage of blocked bile ducts and hepatic segments by using plastic or metal stents. While there remains debate as to if bilateral (or multi-segmental) hepatic drainage is required and/or superior to unilateral drainage, the underlying tenant of draining any persistently opacified bile ducts is paramount to good ERCP practice and good clinical outcomes. Endoscopic therapy for malignant biliary strictures from CCA has advanced to include ablative therapies via ERCP-directed photodynamic therapy (PDT) or radiofrequency ablation (RFA). While ERCP techniques cannot cure CCA, advancements in the field of ERCP have enabled us to improve upon the quality of life of patients with inoperable and incurable disease. ERCP-directed PDT has been used in lieu of brachytherapy to provide neoadjuvant local tumor control in patients with CCA who are awaiting liver transplantation. Lastly, mounting evidence suggests that palliative ERCP-directed PDT, and probably ERCP-directed RFA as well, offer a survival advantage to patients with this difficult-to-treat malignancy.
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Leng JJ, Zhang N, Dong JH. Percutaneous transhepatic and endoscopic biliary drainage for malignant biliary tract obstruction: a meta-analysis. World J Surg Oncol 2014; 12:272. [PMID: 25148939 PMCID: PMC6389255 DOI: 10.1186/1477-7819-12-272] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/23/2014] [Indexed: 12/13/2022] Open
Abstract
Background Various malignant tumors can obstruct the extrahepatic biliary tract. Two major techniques for restoring bile flow in this circumstance are endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD).We conducted a meta-analysis to compare the effectiveness and safety of the two techniques. Methods Medline, EMBASE and the Cochrane Library database were searched for articles published between January 1980 and December 2013. The outcome measures were therapeutic success rate (primary), 30-day mortality rate and overall complications. Results Of 264 screened articles, 3 randomized controlled trials comprising an aggregate total of 183 cancer patients were included in the meta-analysis. Our analysis showed no significant difference in restoration of bile flow between patients treated with EBD and those treated with PTBD (odds ratio (OR) = 2.34, 95% confidence interval (CI) = 0.32 to 17.16, P = 0.401). However, the result of sensitivity analysis indicated that the study conducted by Speer et al. influenced the pooled estimates. After the Speer et al. study was excluded, the therapeutic success rate of patients treated with PTBD was significantly greater than that of those who underwent EBD (OR = 5.48, 95% CI: 2.26 to 13.28, P < 0.001). The 30-day mortality and complication rates were similar in the EBD and PTBD groups. Conclusions The results of our meta-analysis indicate that PTBD had a higher therapeutic success rate than EBD in the treatment of malignancy-induced biliary obstruction. The mortality and complication rates of the two techniques were similar. Electronic supplementary material The online version of this article (doi:10.1186/1477-7819-12-272) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas Queen
- Division of Gastroenterology and HepatologyHuntsman Cancer Center, University of Utah School of MedicineSalt Lake CityUT
| | - Douglas G. Adler
- Division of Gastroenterology and HepatologyHuntsman Cancer Center, University of Utah School of MedicineSalt Lake CityUT
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Pan H, Liang Z, Yin TS, Xie Y, Li DW. Hepato-biliary-enteric stent drainage as palliative treatment for proximal malignant obstructive jaundice. Med Oncol 2014; 31:853. [PMID: 24464214 DOI: 10.1007/s12032-014-0853-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 01/17/2014] [Indexed: 12/18/2022]
Abstract
The proximal malignant obstructive jaundice remains one of the most challenging problems for hepato-biliary surgeons. Particularly when the findings preclude surgical resection at exploration, the next decision seems hard to make. A novel palliative treatment called "hepato-biliary-enteric stent drainage" was designed for these proximal malignant obstructive jaundice patients. Hepato-biliary-enteric stent drainage was performed with silicone tube whose diameter was determined according to the degree of dilated biliary ducts, and the proximal end of the tube was placed to intrahepatic ducts as far as possible, the distal end was placed across the duodenal papilla. Between February 2011 and August 2012, 23 patients with the proximal malignant obstructive jaundice of unresectable tumors at exploration received hepato-biliary-enteric stent drainage. Patient's liver function results, symptoms, complications, and survival time were documented. The bilirubin levels of all 23 patients had a considerable and persistent decrease after operation and remained low or normal before death except for four cases of recurrent jaundice (two resulted from migration of tube and other two resulted from hepatocellular carcinoma extensively involving liver parenchyma). After effective drainage, clinical symptoms of cholangitis such as fever or pain were markedly relieved. No procedure-related bleeding, bile leakage, pancreatitis were observed. The median survival time was 212 days, half-year and 1-year survival rate were 56.5 and 21.7%, respectively. Hepato-biliary-enteric stent drainage with less expense, less complications, and easy operation may be an ideal option for patients with unresectable malignancy in the hilar region at exploration.
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Affiliation(s)
- Hao Pan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
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