An audit of metal stent palliation for malignant biliary obstruction

BACKGROUND AND AIMS

Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction. Metal stents have several advantages over the polyethylene alternatives, but are significantly more expensive. It has been reported that patients need to survive beyond 6 months to make metal stents more cost-effective. The aim of this study was to audit the performance of expanding metal biliary stents in our endoscopy unit, and to identify factors that might help with patient selection.

METHODS

The records of all patients who were selected for endoscopic metal stent insertion at the Royal Perth Hospital for malignant biliary obstruction between September 1994 and November 1998 were reviewed.

RESULTS

Thirty-two patients (16 males, mean age 71 years (range 34-88 years) were identified and followed up for a mean 201 days (range 3-810 days). Fifteen (47%) had cholangiocarcinoma, 13 (41%) had pancreatic cancer, and four had metastatic disease as the cause of obstruction. Mortality rates after metal stent insertion were 16, 41 and 55% at 30, 90 and 180 days, respectively. In total, 24 (75%) patients died during the follow-up period. Eleven (34%) stents became obstructed during follow up with a median time to occlusion of 125 days (range 44-729 days). Patients with cholangiocarcinoma had significantly longer survival than pancreatic cancer cases (median 286 vs 58 days, P = 0.04). No other factors were found to correlate with the survival or stent complications.

CONCLUSIONS

Less than half of this mixed cohort survived beyond 6 months. Metal stent palliation of malignant biliary obstruction should probably be targeted at those with cholangiocarcinoma, as these patients tend to survive longer.

Malignant melanoma metastatic to the common bile duct

Metastatic melanoma is renowned for its propensity to spread to almost every organ of the body; however, symptomatic metastases within the biliary tree are very rare. We report two cases of bile duct obstruction from metastatic melanoma. The first case was caused by an intraluminal metastatic melanoma to the common bile duct, while the second case was caused by extraluminal involvement. The unique aspects of these cases include clinical presentations masquerading as biliary colic, cholangitis and obstructive jaundice. Management and follow up for 3 years is presented. Aspects of medical and surgical management, as well as a review of the world's literature are discussed.

Granular cell tumour of the oesophagus: endoscopic ultrasound appearances

A case of granular cell tumour of the oesophagus in a middle-aged woman is reported. The pathological features and appearances on endoscopic ultrasound (EUS) are described, and the role of EUS in the characterization of intramural oesophageal tumours is discussed.

Removal of stones from the bile duct at ERCP without sphincterotomy

The main risks associated with endoscopic stone removal arise from the sphincterotomy that is performed to facilitate stone extraction. The complication rate may be higher when the bile duct is not dilated. Between January 30, 1990, and March 30, 1993, we attempted to remove stones up to 8 mm in diameter through the intact papilla, without performing sphincterotomy, in 24 patients. Nine patients underwent balloon dilation of the sphincter or of a low duct stricture to facilitate stone removal. All patients were treated successfully and are well at follow-up. Two patients (one having had balloon dilation of the sphincter) had mild pancreatitis that required 2 days in the hospital. During the same period, 215 patients were treated for duct stones 8 mm or less through a standard sphincterotomy. Complications occurred in 11 of these patients: five episodes of pancreatitis, three infections, one perforation, and two other complications. Although these two groups of patients are not directly comparable, it appears that selected stones can be extracted from the bile duct without sphincterotomy with relative safety. This technique should be studied further, especially in younger persons where sphincter preservation may be desirable.

Alpha 1-antitrypsin deficiency and pancreatitis in a juvenile

An 18-year-old female with PiSZ phenotype alpha 1-antitrypsin deficiency presented with pancreatitis and a pancreatic pseudocyst. There were no other causative factors. Deficiency of alpha 1-antitrypsin may predispose to pancreatitis or exacerbate existing pancreatic disease.

Estrogen and androgen regulation of sex hormone binding globulin secretion by a human liver cell line

Both estrogens and androgens have been shown to stimulate sex hormone binding globulin (SHBG) secretion in vitro in the hepatocellular carcinoma cell line, Hep G2, in contrast to the expected inhibition by androgens from in vivo studies. However, such in vitro stimulation was only demonstrated at high steroid doses, generally in serum-containing medium, with added Phenol Red. In the present study, Hep G2 cells were grown in serum-free medium, without Phenol Red, under the influence of testosterone (T) (0, 0.5-500 nM) and ethinyl estradiol (EE2) (0, 50 pM-500 nM). Levels of secreted SHBG and albumin were correlated with androgen receptors in cytosolic (ARc) and nuclear (ARn) fractions and with DNA levels. In the presence of increasing T levels, SHBG levels fell to 39% of control values at 5 nM T (P = 0.047), rising to 97% of control at 500 nM. Conversely, incubation with EE2 produced a rise in SHBG secretion of more than 100% at 0.5 nM (P less than 0.02) which was sustained to 50 nM (P less than 0.005). DNA levels did not change with the addition of testosterone or EE2, with the exception of a 15% reduction at 5 nM EE2 (P less than 0.05). Albumin levels in the medium were not significantly altered by either steroid. However, in response to T, androgen receptor (AR) levels were reduced in cytosolic (42% of control) and nuclear (22%) fractions at 5 nM, and these changes in ARc and ARn correlated with SHBG levels over the range of T concentrations (P = 0.04 and P = 0.017, respectively). Nuclear estrogen receptor (ER) increased over 10-fold at 5 and 50 pM EE2 (P less than 0.001) and maintained 50 nM (P less than 0.001). Cytosolic ER was reduced at 0.5 and 5 nM but recovered at 50 nM, correlating with SHBG levels (P less than 0.001). These findings are consistent with the hypothesis that estrogens and androgens regulate SHBG synthesis in man by direct, specific, probably receptor-mediated effects on hepatocytes. Hep G2 cells grown in serum-free medium are a suitable experimental system for further study of this phenomenon.

Protein-losing enteropathy in systemic lupus erythematosus

Two patients with systemic lupus erythematosus (SLE) presented with anasarca, pleural effusions and severe hypoalbuminema. Both were demonstrated to have protein-losing enteropathy, a rare complication of SLE. Other causes of gastrointestinal protein loss were excluded. There were marked similarities in both cases including circulating ANF with speckled staining, anti-(U1)RNP antibodies and low serum complement levels. Complete remission was achieved in both with prednisolone. Anti-(U1)RNP may be a marker for a subset of SLE in which protein-losing enteropathy is a major manifestation.