Should patients with unresectable gallbladder cancer with hilar involvement undergo unilateral or bilateral percutaneous biliary drainage in the setting of cholangitis?

Outcomes of Self-expandable Metal Stents in Patients With Unresectable Gallbladder Cancer Undergoing Percutaneous Biliary Drainage

Background

Biliary obstruction in gallbladder cancer (GBC) is associated with worse prognosis and needs drainage. In patients with biliary confluence involvement, percutaneous biliary drainage (PBD) is preferred over endoscopic drainage. However, PBD catheters are associated with higher complications compared to endoscopic drainage. PBD with self-expandable metal stents (SEMS) is desirable for palliation. However, the data in patients with unresectable GBC is lacking.

Materials and methods

This retrospective study comprised consecutive patients with proven GBC who underwent PBD-SEMS insertion between January 2021 and December 2022. Technical success, post-procedural complications, clinical success, duration of stent patency, and biliary reinterventions were recorded. Clinical follow-up data was analysed at 30 days and 180 days of SEMS insertion and mortality was recorded.

Results

Of the 416 patients with unresectable GBC, who underwent PBD, 28 (median age, 50 years; 16 females) with PBD-SEMS insertion were included. All SEMS placement procedures were technically successful. There were no immediate/early post-procedural complications/deaths. The procedures were clinically successful in 63.6% of the patients with hyperbilirubinemia (n = 11). Biliary re-interventions were done in 6 (21.4%). The survival rate was 89.3 % (25/28) at 30 days and 50% at 180 days. The median follow-up duration was 80 days (range, 8-438 days).

Conclusion

PBD-SEMS has moderate clinical success and 6-months patency in almost half of the patients with metastatic GBC and must be considered for palliation.

The role of endoscopy in malignant hilar obstruction

Malignant hilar biliary obstruction (MHO) is a medical challenge as regards both forming a correct diagnosis and its adequate management, in terms of treatment alternatives and palliative options. Surgical resection is the only curative treatment for the underlying disease, but the majority of patients are not suitable candidates because of an unresectable tumor or poor performance status. Biliary drainage (BD) can be achieved through the percutaneous transhepatic route or endoscopically, and the choice depends on a host of factors, including biliary anatomy and comorbidity of the patient. Though there is no consensus, the endoscopic approach is usually preferred over the former. Endoscopy can aid in both diagnosis (collection of histological as well as cytological samples, direct visualization of suspected malignant pathology, or use of endoscopic ultrasound [EUS] for evaluation and locoregional staging), and in achieving internal BD. Advances in the development of various stents, accessories and, more recently, the use of EUS have in fact further expanded its application in MHO management. The choice of stents to be used (type, make, and number), palliation methods, deployment techniques and the use of local ablative strategy are still evolving and require more data. The complexity of management of MHO mandates that each patient should receive a "personalized approach", all the way from establishing a diagnosis until final treatment, with the help of a multidisciplinary team effort. Herein, we provide a comprehensive literature review of the current role of endoscopy for MHO, according to its applications in various clinical settings.

Role of Percutaneous Transhepatic Biliary Drainage as an Adjunct to Endoscopic Retrograde Cholangiopancreatography

Background

There is limited literature on the role of percutaneous transhepatic biliary drainage (PTBD) as an adjunct to endoscopic retrograde cholangiopancreatography (ERCP). This study evaluates the role of PTBD in patients with failed ERCP or post-ERCP cholangitis.

Methods

Retrospective evaluation of clinical and intervention records of patients with biliary obstruction referred for PTBD following failed ERCP or post-ERCP cholangitis was performed. The cause of biliary obstruction, baseline serum bilirubin, white blood cell (WBC) count, serum creatinine, and procalcitonin were recorded. Technical success and clinical success (resolution of cholangitis, reduction in bilirubin levels, WBC count, creatinine, and procalcitonin) were assessed.

Results

Sixty-three patients (35 females, mean age 51.4 years) were included. Indications for ERCP included malignant causes in 47 (74.6%) cases and benign causes in 16 (25.4%) cases. Indications for PTBD were failed ERCP in 21 (33.3%) and post-ERCP cholangitis in 42 (66.7%). PTBD was technically successful in all patients. Clinical success rate was 68.2% in the overall group. Mild hemobilia was noted in five (7.9%) patients. There were no major complications or PTBD related mortality. Cholangitis and acute kidney injury resolved following PTBD in 63.1% and 80% of the patients, respectively. Total serum bilirubin reduced by 47.8% and 69.4% after one week and one month of the PTBD, respectively. The average fall in procalcitonin was 5.17 ng/mL after one week of the PTBD.

Conclusion

PTBD is an important adjunctive drainage procedure in patients with ERCP failure or post-ERCP cholangitis.

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.