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Zhu Z, Hu K, Zhao F, Liu W, Zhou H, Zhu Z, Li H. Machine learning-based nomogram for 30-day mortality prediction for patients with unresectable malignant biliary obstruction after ERCP with metal stent: a retrospective observational cohort study. BMC Surg 2023; 23:260. [PMID: 37649027 PMCID: PMC10470194 DOI: 10.1186/s12893-023-02158-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND This study aimed to investigate the risk factors for 30-day mortality in patients with malignant biliary obstruction (MBO) after endoscopic retrograde cholangiopancreatography (ERCP) with endobiliary metal stent placement. Furthermore, we aimed to construct and visualize a prediction model based on LASSO-logistic regression. METHODS Data were collected from 245 patients who underwent their first ERCP with endobiliary metal stent placement for unresectable MBO between June 1, 2013, and August 31, 2021. Univariable and multivariable logistic regression analyses were conducted to identify the risk factors for 30-day mortality. We subsequently developed a logistic regression model that incorporated multiple parameters identified by LASSO regression. The model was visualized and the nomogram was plotted. Risk stratification was performed based on nomogram-derived scores. RESULTS The 30-day mortality rate was 10.7% (23/245 patients). Distant metastasis, total bilirubin, post-ERCP complications, and successful drainage were independent risk factors of 30-day mortality. The variables screened by LASSO regression, including distant metastasis, total bilirubin, post-ERCP complications, and successful drainage, were incorporated into the logistic model. The results were visualized through a nomogram based on the model. To assess the model's performance, discrimination was evaluated using the area-under-the-curve values obtained from receiver operating characteristic analyses with 10-fold cross-validation in the training group and validated in the testing group. The calibration curve showed the good predictive ability of the model. Decision curve analysis is used to evaluate the clinical application of nomogram. Finally, we performed risk stratification based on the risk calculated using the nomogram. Patients were assigned to the low-, moderate-, and high-risk groups based on their probability scores. The Kaplan-Meier survival curves for the different nomogram-based groups were significantly different (p < 0.001). CONCLUSIONS We developed a nomogram using the LASSO-logistic regression model to forecast the 30-day mortality rate in patients who had undergone ERCP with endobiliary metal stent placement due to MBO. This nomogram can assist in identifying individuals at high-risk of 30-day mortality following ERCP.
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Affiliation(s)
- Zongdong Zhu
- Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Jiaxing, Zhejiang, China
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Kaixin Hu
- Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Jiaxing, Zhejiang, China
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Fengqing Zhao
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Wen Liu
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Hongkun Zhou
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Zongliang Zhu
- Henan University of Science and Technology, Luoyang, Henan, China
| | - Huangbao Li
- Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Jiaxing, Zhejiang, China.
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China.
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Sundaram S, Seth V, Patil P, Patkar S, Engineer R, Shetty N, Goel M, Mehta S. Short and long outcomes of endoscopic bilateral metal stent placement for malignant hilar biliary obstruction: Tertiary care oncology centre experience. Indian J Gastroenterol 2023; 42:396-403. [PMID: 37199877 DOI: 10.1007/s12664-022-01337-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 12/27/2022] [Indexed: 05/19/2023]
Abstract
INTRODUCTION Placement of biliary self-expanding metal stents (SEMS) has been effective for palliation of unresectable hilar malignant biliary obstruction. Optimal drainage in hilar obstruction may require placement of multiple stents. Data on multiple SEMS placement in hilar obstruction from India is sparse. METHODS Retrospective review of patients with unresectable malignant hilar obstruction who underwent endoscopic bilateral SEMS insertion from 2017 to 2021 was done. Demographic details, technical success and functional success (decrease in the bilirubin value below 3 mg/dL at four weeks), immediate complications with 30-days mortality, requirement of re-intervention, stent patency and overall survival were studied. RESULTS Forty-three patients were included (mean age 54.9 years, 51.2% females). Thirty-six patients (83.7%) had carcinoma gallbladder as primary malignancy. Twenty-six patients (60.5%) were metastatic at presentation. Cholangitis was seen in 4/43 (9.3%). On cholangiogram, 26 (60.4%) had Bismuth type II block, 12 (27.8%) had type IIIA/B, 5 (11.6%) had type IV block. Technical success was achieved in 41/43 (95.3%) patients (38, side-by-side SEMS placement; 3, SEMS-within-SEMS in Y fashion). Functional success was achieved in 39 patients (95.1%). No moderate-severe complications were reported. Median post-procedure hospitalization was five days. Median stent patency was 137 days (interquartile range [IQR] 80-214 days). Re-intervention was required in four patients (9.3%) after mean 295.7 days. Median overall survival was 153 days (IQR 108-234 days). CONCLUSION Endoscopic bilateral SEMS in complex malignant hilar obstruction has good outcomes in the form of technical success, functional success and stent patency. Survival is dismal despite optimal biliary drainage.
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Affiliation(s)
- Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012, India
| | - Vishal Seth
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012, India
| | - Prachi Patil
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012, India
| | - Shraddha Patkar
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400 012, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400 012, India
| | - Nitin Shetty
- Department of Radiology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400 012, India
| | - Mahesh Goel
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400 012, India
| | - Shaesta Mehta
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012, India.
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Takahashi K, Ohyama H, Takiguchi Y, Kan M, Ouchi M, Nagashima H, Ohno I, Kato N. Endoscopic Transpapillary Stenting for Malignant Hilar Biliary Stricture: Side-by-Side Placement versus Partial Stent-in-Stent Placement. J Pers Med 2023; 13:jpm13050831. [PMID: 37241001 DOI: 10.3390/jpm13050831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/08/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic uncovered metal stent (UMS) placement has been widely performed for unresectable hilar malignant biliary stricture (UHMBS). Two stenting methods are used for the two bile duct branches: side-by-side placement (SBS) and partial stent-in-stent placement (PSIS). However, it remains controversial whether SBS or PSIS is superior. This study aimed to compare SBS and PSIS in UHMBS cases with UMS placement in two branches of the IHD. METHODS This retrospective study included 89 cases of UHMBS treated with UMS placement through the SBS or PSIS technique using endoscopic retrograde cholangiopancreatography at our institution. Patients were divided into two groups, SBS (n = 64) and PSIS (n = 25), and compared. RESULTS Clinical success was achieved in 79.7% and 80.0% in the SBS and PSIS groups, respectively (p = 0.97). The adverse event rate was 20.3% and 12.0% in the SBS and PSIS groups, respectively (p = 0.36). The recurrent biliary obstruction (RBO) rate was 32.8% and 28.0% in the SBS and PSIS groups, respectively (p = 0.66). The median cumulative time to RBO was 224 and 178 days in the SBS and PSIS groups, respectively (p = 0.52). The median procedure time was 43 and 62 min in the SBS and PSIS groups, respectively, which was significantly longer in the PSIS group (p = 0.014). CONCLUSIONS No significant differences were noted in the clinical success rate, adverse event rate, time to RBO, or overall survival between the SBS and PSIS groups, other than the significantly longer procedure time in the PSIS group.
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Affiliation(s)
- Koji Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
| | - Hiroshi Ohyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
| | - Yuichi Takiguchi
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
| | - Motoyasu Kan
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
| | - Mayu Ouchi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
| | - Hiroki Nagashima
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
| | - Izumi Ohno
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
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Rai P, Udawat P, Chowdhary SD, Gunjan D, Samanta J, Bhatia V, Singla V, Mukewar S, Mehta N, Achanta CR, Dalal A, Sahu MK, Balekuduru A, Bale A, Basha J, Philip M, Rana S, Puri R, Lakhtakia S, Dhir V. Society of Gastrointestinal Endoscopy of India Consensus Guidelines on Endoscopic Ultrasound-Guided Biliary Drainage: Part I (Indications, Outcomes, Comparative Evaluations, Training). JOURNAL OF DIGESTIVE ENDOSCOPY 2023. [DOI: 10.1055/s-0043-1761591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
AbstractEndoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreaticography (ERCP). However, even in expert hands the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or more commonly percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreatico-biliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates.EUS-BD, albeit, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD, nor the accessories and stents for EUS-BD have been standardized.Additionally, different countries and regions have different availability of the accessories making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, the Society of Gastrointestinal Endoscopy India deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.
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Affiliation(s)
- Praveer Rai
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Priyanka Udawat
- Institute of Digestive and Liver Care, School of EUS, S. L. Raheja Hospital, Mumbai, Maharashtra, India
| | | | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikas Singla
- Department of Gastroenterology, Max Superspeciality Hospital, New Delhi, India
| | | | - Nilay Mehta
- Department of Gastroenterology, Zydus Hospital, Ahmedabad, Gujarat, India
| | - Chalapathi Rao Achanta
- Department of Gastroenterology, KIMS ICON Hospital, Vishakhapatnam, Andhra Pradesh, India
| | - Ankit Dalal
- Baldota Institute of Digestive Sciences, Global Hospital, Mumbai, Maharashtra, India
| | - Manoj Kumar Sahu
- Institute of GI Sciences, Apollo Hospitals, Bhubaneshwar, Orissa, India
| | - Avinash Balekuduru
- Department of Gastroenterology, MS Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India
| | - Abhijit Bale
- Department of Medical Gastroenterology, Sapthagiri Institute of Medical Sciences, Bengaluru, Karnataka, India
| | - Jahangir Basha
- Asian Institute of Gastroenterology, AIG Hospitals, Hyderabad, Telangana, India
| | - Mathew Philip
- Department of Gastroenterology, Lisie Hospital, Kochi, Kerala, India
| | - Surinder Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Puri
- Institute of Digestive and Hepatobiliary Sciences, Medanta Hospital, Gurugram, Haryana, India
| | - Sundeep Lakhtakia
- Asian Institute of Gastroenterology, AIG Hospitals, Hyderabad, Telangana, India
| | - Vinay Dhir
- Institute of Digestive and Liver Care, School of EUS, S. L. Raheja Hospital, Mumbai, Maharashtra, India
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Fu X, Jiang W, Mu M, Wang G, Qi H, Chen Z, Zuo M, Gao F. Effect of percutaneous stenting strategy of unresectable malignant hilar biliary obstruction by three-dimensional reconstruction volumetry. Cancer Med 2023; 12:9506-9516. [PMID: 36808263 PMCID: PMC10166933 DOI: 10.1002/cam4.5720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/15/2023] [Accepted: 02/08/2023] [Indexed: 02/22/2023] Open
Abstract
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.
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Affiliation(s)
- Xiaobo Fu
- Department of Minimally Invasive & Interventional Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Weiwei Jiang
- Department of Minimally Invasive & Interventional Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Maoyuan Mu
- Department of Minimally Invasive & Interventional Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Guobao Wang
- Department of Endoscopy, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Han Qi
- Department of Minimally Invasive & Interventional Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zixiong Chen
- Department of Minimally Invasive & Interventional Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Mengxuan Zuo
- Department of Minimally Invasive & Interventional Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Fei Gao
- Department of Minimally Invasive & Interventional Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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Lee TH, Moon JH, Stuart S. Role of ERCP in Malignant Hilar Biliary Obstruction. Gastrointest Endosc Clin N Am 2022; 32:427-453. [PMID: 35691690 DOI: 10.1016/j.giec.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Malignant hilar biliary obstruction (MHO), an aggressive perihilar biliary obstruction caused by cholangiocarcinoma, gallbladder cancer, or other metastatic malignancies, has a poor prognosis. Surgical resection is the only curative treatment method for biliary malignancies. However, most of the patients with MHO cannot undergo surgeries on presentation because of an advanced inoperable state or a poor performance state due to old age or comorbid diseases. Therefore, palliative biliary drainage is mandatory to improve symptomatic jaundice and quality of life. Among drainage methods, endoscopic biliary drainage is the current standard for the palliation of unresectable advanced MHO. The development of stents and various accessories and advances in endoscopic techniques including endoscopic ultrasonography have facilitated primary endoscopic intervention in difficult high-grade hilar strictures. However, some issues are still under debate, such as palliation methods, appropriate stents, the number of stents, deployment methods, and additional local ablation therapies. Therefore, this review presents currently optimal endoscopic palliation methods for advanced MHO based on the reported literature.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, SoonChunHyang University School of Medicine, Cheonan, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Jong Ho Moon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, SoonChunHyang University School of Medicine, 170 Jomaru-Ro, Bucheon 14584, Republic of Korea.
| | - Sherman Stuart
- Department of Medicine, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indiana University Health-University Hospital, 550 North University Boulevard, Suite 1634, Indianapolis, IN 46202, USA
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Bilal M, Freeman ML. Endoscopic Retrograde Cholangiopancreatography Stenting for Hilar Cholangiocarcinoma. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2022; 24:190-199. [DOI: 10.1016/j.tige.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Lee TH. Treatment of Malignant Hilar Strictures. GASTROINTESTINAL AND PANCREATICO-BILIARY DISEASES: ADVANCED DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2022:1399-1421. [DOI: 10.1007/978-3-030-56993-8_81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Lee TH, Moon JH, Park SH. [A Recent Update on Endoscopic Drainage of Advanced Malignant Hilar Obstruction]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 78:94-104. [PMID: 34446632 DOI: 10.4166/kjg.2021.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/11/2021] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, SoonChunHyang University College of Medicine, Cheonan, Korea
| | - Jong Ho Moon
- Division of Gastroenterology, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, SoonChunHyang University College of Medicine, Bucheon, Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, SoonChunHyang University College of Medicine, Cheonan, Korea
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Lee TH. Proper management of inoperable malignant hilar biliary obstruction: Endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, or percutaneous approach? INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021; 10:120-127. [DOI: 10.18528/ijgii210035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 01/03/2025] Open
Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, Soon Chun Hyang University School of Medicine, Cheonan, Korea
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Mao X, Wen F, Liang H, Sun W, Lu Z. A preliminary single-center investigation of percutaneous biliary stenting in malignant hilar biliary obstruction: what impacts the clinical success and the long-term outcomes? Support Care Cancer 2021; 29:6781-6792. [PMID: 33990879 DOI: 10.1007/s00520-021-06271-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/04/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study is to investigate the influencing factors that may impact the clinical success, jaundice-free time, and overall survival in patients of malignant hilar biliary obstruction (MHBO) treated with a self-expanding metallic stent (SEMS). MATERIALS AND METHODS Patients diagnosed with MHBO and treated with SEMS through percutaneous access from 1 Jul. 2013 to 1 Jul. 2018 were enrolled in this monocentric study. Demographic information, disease baseline measurements, and interventional strategies were collected and examined. Bilirubin was measured 1-3 days before and 3-7 days after stenting using the unit of "μmol/L." The bilirubin reduction ratio was compared between different study groups, which were separated by specific characteristics. Univariate and multivariate analyses were performed to evaluate each characteristic's impact on jaundice-free time (JF) and overall survival time (OS). Statistical analyses were conducted using SPSS 14.0, p < 0.05 indicated significance. RESULTS Eighty patients were enrolled. Direct bilirubin (DB) and indirect bilirubin (IB) both significantly decreased after stenting (U = 1575.0, p < 0.001; U = 1541.0, p < 0.001). The DB reduction ratio of the "nearby lymph metastases" group was significantly higher (U = 566.0, p = 0.037). The IB reduction ratio in the "single stent" group was significantly higher (U = 554.0, p = 0.018). Sixty-six cases reached jaundice recurrence, the median JF was 6 months, and the 95% confidence interval was 4.411 ~ 7.589 months. Fifty-eight cases ended in death, the median OS was 7 months, and the 95% confidence interval was 5.759 ~ 8.241 months. "Nearby lymph metastases" and "distant metastases" independently impacted OS (OR = 2.344, p = 0.013; OR = 3.239, p = 0.042). "IB reduction ratio" independently impacted both JF and OS (OR = 0.422, p = 0.021; OR = 0.315, p = 0.001). CONCLUSION The goal of treatment in patients with MHBO is to recover liver function. However, the overall survival is greatly impacted by the presence of metastases. Managing to obtain adequate liver function recovery may improve the long-term outcomes in affected patients.
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Affiliation(s)
- Xiaonan Mao
- Department of Radiology, Shengjing Hospital of China Medical University, Huaxiang Road 39, Shenyang City, 110004, Liaoning Province, China
| | - Feng Wen
- Department of Radiology, Shengjing Hospital of China Medical University, Huaxiang Road 39, Shenyang City, 110004, Liaoning Province, China
| | - Hongyuan Liang
- Department of Radiology, Shengjing Hospital of China Medical University, Huaxiang Road 39, Shenyang City, 110004, Liaoning Province, China
| | - Wei Sun
- Department of Radiology, Shengjing Hospital of China Medical University, Huaxiang Road 39, Shenyang City, 110004, Liaoning Province, China
| | - Zaiming Lu
- Department of Radiology, Shengjing Hospital of China Medical University, Huaxiang Road 39, Shenyang City, 110004, Liaoning Province, China.
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Jha AK, Jha P, Jha SK, Keshari R. Plastic versus metal stents for inoperable gallbladder cancer with hilar biliary obstruction: the jury is still out. Ann Gastroenterol 2020; 34:12-19. [PMID: 33414616 PMCID: PMC7774665 DOI: 10.20524/aog.2020.0548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 08/04/2020] [Indexed: 12/09/2022] Open
Abstract
In unresectable malignant hilar obstruction, adequate biliary drainage can be achieved with endoscopic placement of plastic or metal stents. Stent patency and patient survival may differ, depending on the primary disease, disease progression and stent type. Metal and plastic stents were compared in patients with malignant hilar strictures in several studies, but these studies mainly included patients who had cholangiocarcinoma, without taking into consideration potential differences in the invasion properties of tumor cells, histological differentiation and the biological behavior of different tumors. Gallbladder cancer (GBC) is the most common malignancy of the biliary tract, especially in the Indian subcontinent and Latin America. About half the patients with GBC present with jaundice, which usually means the tumor is inoperable. Palliative endoscopic stenting remains the first-line treatment of unresectable GBC with biliary obstruction. Primary disease progression is faster in GBC compared to cholangiocarcinoma. There is a paucity of data on the selection of stents for inoperable GBC with hilar biliary obstruction. This review focuses on the published literature related to the selection of stents for unresectable GBC with hilar obstruction.
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Affiliation(s)
- Ashish Kumar Jha
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Patna, India
| | - Praveen Jha
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Patna, India
| | - Sharad Kumar Jha
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Patna, India
| | - Ravi Keshari
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Patna, India
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Iwasaki A, Kubota K, Kurita Y, Hasegawa S, Fujita Y, Kagawa K, Kato S, Sekino Y, Hosono K, Nakajima A. The placement of multiple plastic stents still has important roles in candidates for chemotherapy for unresectable perihilar cholangiocarcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:700-711. [PMID: 32786134 DOI: 10.1002/jhbp.804] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/07/2020] [Accepted: 07/06/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND/PURPOSE Placement of uncovered self-expandable metallic stents (U-SEMSs) of patients with unresectable perihilar cholangiocarcinoma (UPHC) is recommended as the treatment of first choice to address bile stasis. The aim of this study was to determine which of the following two endoscopic stents might be the stent of first choice for the treatment of biliary stasis in patients with UPHC: plastic stents (PSs) or U-SEMSs. METHODS U-SEMSs, deployed as a stent-in-stent, were selected as the stents of first choice from 2013 and 2014, while PSs began to be selected as the stents of first choice from 2015 onward. RESULTS The median time to recurrent biliary obstruction were 66 days in the PS group (N = 38) and 105 days in the U-SEMS group (N = 37; P = .04). Emergency endoscopy was necessitated in 76.3% (29/38) of patients of the PS group and 54.1% (20/37) of patients of the U-SEMS group (P = .0434). The success rate of the first reintervention was 96.5% (27/29) in the PS group and 55% (11/20) in the U-SEMS group (P = .0002). Sustainable chemotherapy could be carried out in 55.2% of patients in the PS group and 32.4% of patients in the U-SEMS group (P = .0472). Multivariate analysis identified selection of U-SEMS as the stent of first choice as the only independent factor predictive of successful reintervention (P = .0016, odds ratio = 0.058). However, the stent selection was not an independent factor for feasible chemotherapy. CONCLUSIONS Plastic stent placement could enhance the success rate of reintervention in patients with UPHC and might be facilitated by sustainable chemotherapy. However, stent selection might not have an influence on the prognosis.
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Affiliation(s)
- Akito Iwasaki
- Department of Gastroenterology, Hepatology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Kensuke Kubota
- Department of Gastroenterology, Hepatology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yusuke Kurita
- Department of Gastroenterology, Hepatology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Sho Hasegawa
- Department of Gastroenterology, Hepatology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yuji Fujita
- Department of Gastroenterology, Hepatology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Koji Kagawa
- Department of Gastroenterology, Hepatology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Shingo Kato
- Department of Gastroenterology, Hepatology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yusuke Sekino
- Department of Gastroenterology, Hepatology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Kunihiro Hosono
- Department of Gastroenterology, Hepatology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology, Hepatology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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Kim Y, Jang SI, Lee DK. SEMS Insertion for Malignant Hilar Stricture: ERCP Versus the Percutaneous Approach. ADVANCED ERCP FOR COMPLICATED AND REFRACTORY BILIARY AND PANCREATIC DISEASES 2020:87-107. [DOI: 10.1007/978-981-13-0608-2_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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15
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Tringali A. Endoscopic Management in Malignant Biliary Strictures: Tips and Tricks. ENDOTHERAPY IN BILIOPANCREATIC DISEASES: ERCP MEETS EUS 2020:431-461. [DOI: 10.1007/978-3-030-42569-2_40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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16
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Lee TH, Moon JH, Park SH. Biliary stenting for hilar malignant biliary obstruction. Dig Endosc 2020; 32:275-286. [PMID: 31578770 DOI: 10.1111/den.13549] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/29/2019] [Indexed: 02/08/2023]
Abstract
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).
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Jong Ho Moon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon Hospital, Bucheon, Korea
| | - Sang-Heum Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan Hospital, Cheonan, Korea
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17
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Kariya CM, Wach MM, Ruff SM, Ayabe RI, Lo WM, Torres MB, Petrick JL, McNeel TS, Davis JL, McGlynn KA, Hernandez JM. Postbiliary drainage rates of cholangitis are impacted by procedural technique for patients with supra-ampullary cholangiocarcinoma: A SEER-Medicare analysis. J Surg Oncol 2019; 120:249-255. [PMID: 31044430 DOI: 10.1002/jso.25485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/10/2019] [Accepted: 04/14/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal approach to biliary drainage for patients with supra-ampullary cholangiocarcinoma remains undetermined. Violation of sphincter of Oddi results in bacterial colonization of bile ducts and may increase postdrainage infectious complications. We sought to determine if rates of cholangitis are affected by the type of drainage procedure. METHODS We examined the Surveillance, Epidemiology, and End Results-Medicare linked database from 1991 to 2013 for cholangiocarcinoma. Biliary drainage procedures were categorized as sphincter of Oddi violating (SOV) or sphincter of Oddi preserving (SOP). Patients were stratified by resection. RESULTS A total of 1914 patients were included in the final analysis. A total of 1264 patients did not undergo a postdrainage resection (SOP 83, SOV 1181) while 650 did undergo a postdrainage resection (SOP 26, SOV 624). For those patients not undergoing a postdrainage resection, the rate of cholangitis 90 days after an SOP procedure was 19% compared with 34% in the SOV cohort (P = 0.007). For those patients undergoing a postdrainage resection, the rate of cholangitis 90 days after an SOP procedure was less than 42.3% compared with 30% in the SOV cohort (P = 0.66). CONCLUSION For patients with supra-ampullary cholangiocarcinoma that did not undergo resection, biliary drainage procedures that violated the sphincter of Oddi were associated with increased rates of cholangitis.
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Affiliation(s)
- Christine M Kariya
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Michael M Wach
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Samantha M Ruff
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Reed I Ayabe
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Winifred M Lo
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Madeline B Torres
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Jessica L Petrick
- Metabolic Epidemiology Branch, National Cancer Institute, Rockville, Maryland
| | | | - Jeremy L Davis
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Katherine A McGlynn
- Metabolic Epidemiology Branch, National Cancer Institute, Rockville, Maryland
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18
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Sha J, Dong Y, Niu H. A prospective study of risk factors for in-hospital mortality in patients with malignant obstructive jaundice undergoing percutaneous biliary drainage. Medicine (Baltimore) 2019; 98:e15131. [PMID: 30985679 PMCID: PMC6485810 DOI: 10.1097/md.0000000000015131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The in-hospital mortality rate in patients undergoing percutaneous transhepatic biliary drainage (PTBD) for malignant obstructive jaundice (MOJ) is high. There are few reports on the risk factors associated with hospital death after MOJ, with most of them being retrospective analyses of single factors. Therefore, this study aimed to assess pre-, intra-, and post-procedure risk factors that were independently associated with increased in-hospital mortality in MOJ patients who underwent PTBD. METHODS One-hundred fifty-five patients with MOJ who underwent initial PTBD were included in this study. A total of 25 pre-, 4 intra-, and 6 post-procedure factors potentially related to in-hospital mortality were assessed by univariate and multivariate analyses. RESULTS The in-hospital mortality rate was 16.8% (26/155). Of 25 pre-procedure variables analyzed, Child-Pugh classification C, creatinine level ≥6.93 μmol/L, and quality-of-life score (≤30) were found to be significant in univariate and multivariate analyses. Increased mortality was observed in patients with 2 or more risk factors, which was significantly different from patients with no risk factors or one risk factor (P < .01). None of the intra-procedure factors were important in identifying patients at risk of death. Multivariate analysis indicated post-PTBD cholangitis and unsuccessful drainage as post-procedure risk factors that correlated with in-hospital death. CONCLUSION It was identified that in-hospital mortality was associated with 3 pre-procedure and 2 post-procedure risk factors, such as the liver function classification, quality-of-life score of cancer patients, creatinine level, PTBD-associated biliary duct infection, and unsuccessful drainage.
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Kitamura K, Yamamiya A, Ishii Y, Mitsui Y, Yoshida H. Endoscopic side-by-side uncovered self-expandable metal stent placement for malignant hilar biliary obstruction. Ther Adv Gastrointest Endosc 2019; 12:2631774519846345. [PMID: 31192317 PMCID: PMC6537491 DOI: 10.1177/2631774519846345] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/04/2019] [Indexed: 02/05/2023] Open
Abstract
AIM To investigate outcomes of endoscopic bilateral side-by-side placement across the papilla using 10-mm-diameter uncovered self-expandable metal stents for unresectable malignant hilar biliary obstruction. METHODS We retrospectively analyzed 23 patients who underwent endoscopic biliary uncovered self-expandable metal stent placement for unresectable malignant hilar biliary obstruction between January 2015 and September 2016 at our institution. We performed endoscopic side-by-side placement across the papilla using 10-mm-diameter longer-model uncovered self-expandable metal stents. Outcomes included the technical and functional success rates, recurrent biliary obstruction rate, time to recurrent biliary obstruction, reintervention rate, and incidence of adverse events other than recurrent biliary obstruction. RESULTS Of the 23 patients, 10 with malignant hilar biliary obstruction underwent endoscopic side-by-side uncovered self-expandable metal stent placement across the papilla (median age, 83 years; 6 men). The locations of malignant hilar biliary obstruction were Bismuth types II (n = 3), III (n = 3), and IV (n = 4). The median common bile duct diameter was 8 mm. The technical and functional success rates were 100% and 80%, respectively. Seven patients (70%) developed recurrent biliary obstruction because of stent occlusions, including early hemobilia in two patients and late tumor ingrowth in five patients. The median time to recurrent biliary obstruction was 66 (95% confidence interval: 29-483) days. Six patients (60%) required reintervention, and 1 (10%) underwent transcatheter arterial embolization for right hepatic arterial pseudoaneurysm. Early adverse events other than recurrent biliary obstruction occurred in four patients and late adverse event in one patient. CONCLUSION Endoscopic side-by-side placement across the papilla using 10-mm-diameter uncovered self-expandable metal stents was technically feasible for unresectable malignant hilar biliary obstruction; however, it might be better to avoid this method for patients with malignant hilar biliary obstruction because of high recurrent biliary obstruction rate and shorter time to recurrent biliary obstruction.
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Affiliation(s)
- Katsuya Kitamura
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Akira Yamamiya
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yu Ishii
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuta Mitsui
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hitoshi Yoshida
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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20
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Sarkisian AM, Sharaiha RZ. Malignant Biliary Obstruction of the Hilum and Proximal Bile Ducts. ERCP 2019:385-393.e3. [DOI: 10.1016/b978-0-323-48109-0.00040-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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21
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Bruno MJ, Maluf-Filho F. Palliation of Malignant Pancreaticobiliary Obstruction. CLINICAL GASTROINTESTINAL ENDOSCOPY 2019:734-747.e4. [DOI: 10.1016/b978-0-323-41509-5.00063-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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22
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Safety and Efficacy of Low-Dose Single-Agent Capecitabine in Inoperable Gallbladder Cancer with Jaundice Post-Single-System Single-Catheter External Biliary Drainage: a Pilot Study from a Highly Endemic Area. Indian J Surg Oncol 2018; 9:530-537. [PMID: 30538384 DOI: 10.1007/s13193-018-0798-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 07/13/2018] [Indexed: 12/28/2022] Open
Abstract
Gallbladder cancer (CaGB) in the subcontinent belongs to low socioeconomic status, and at the time of diagnosis, a large number is unresectable or inoperable so the palliative treatment remains the only option. In the present study, attempt was made to see the effect and safety profile of single-agent oral capecitabine in inoperable CaGB in presence of low levels of jaundice post-single-catheter transhepatic external biliary drainage. In N = 35 of inoperable jaundiced CaGB, post-biliary drainage capecitabine in low dose was started when their total bilirubin levels fell to 10 mg% or below. Post-external drainage decreased bilirubin level to < 10 mg/dl within 1-4 weeks, mean 2.37 ± 0.80 weeks. Survival was 1-6 months, mean 3.26 ± 1.46 months. Catheter patency time was 1.92 ± 0.64 months (range 0-3 months). Young age, male sex, level of jaundice at presentation, and duration of decrease in jaundice after drainage were significantly associated with progressive disease course. Poor survival was significantly associated with progressive disease course, young age, and level of jaundice at admission. To the best of our knowledge, this is the first study to establish that single-agent capecitabine can be safely given in CaGB in presence of jaundice.
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Kapoor BS, Mauri G, Lorenz JM. Management of Biliary Strictures: State-of-the-Art Review. Radiology 2018; 289:590-603. [PMID: 30351249 DOI: 10.1148/radiol.2018172424] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Biliary strictures can be broadly classified as benign or malignant. Benign biliary strictures are most commonly iatrogenic in nature and are a consequence of hepatobiliary surgery. Cholangiocarcinoma and adenocarcinoma of the pancreas are the most common causes of malignant biliary obstruction. This article reviews state-of-the-art minimally invasive techniques used to manage these strictures. In addition, the roles of (a) recently introduced biodegradable biliary stents in the management of benign biliary strictures and (b) intraprocedural imaging and navigation tools, such as cone-beam CT, in percutaneous reconstruction of the biliary-enteric anastomosis are discussed.
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Affiliation(s)
- Baljendra S Kapoor
- From the Department of Radiology, Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, L10, Cleveland, OH 44195-5243 (B.S.K.); Division of Interventional Radiology, IEO, European Institute of Oncology IRCCS, Milan, Italy (G.M.); and Department of Radiology, University of Chicago Medical Center, Chicago, Ill (J.M.L.)
| | - Giovanni Mauri
- From the Department of Radiology, Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, L10, Cleveland, OH 44195-5243 (B.S.K.); Division of Interventional Radiology, IEO, European Institute of Oncology IRCCS, Milan, Italy (G.M.); and Department of Radiology, University of Chicago Medical Center, Chicago, Ill (J.M.L.)
| | - Jonathan M Lorenz
- From the Department of Radiology, Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, L10, Cleveland, OH 44195-5243 (B.S.K.); Division of Interventional Radiology, IEO, European Institute of Oncology IRCCS, Milan, Italy (G.M.); and Department of Radiology, University of Chicago Medical Center, Chicago, Ill (J.M.L.)
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24
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Teoh AYB, Dhir V, Kida M, Yasuda I, Jin ZD, Seo DW, Almadi M, Ang TL, Hara K, Hilmi I, Itoi T, Lakhtakia S, Matsuda K, Pausawasdi N, Puri R, Tang RS, Wang HP, Yang AM, Hawes R, Varadarajulu S, Yasuda K, Ho LKY. Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel. Gut 2018; 67:1209-1228. [PMID: 29463614 DOI: 10.1136/gutjnl-2017-314341] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 12/22/2017] [Accepted: 01/17/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Interventional endoscopic ultrasonography (EUS) procedures are gaining popularity and the most commonly performed procedures include EUS-guided drainage of pancreatic pseudocyst, EUS-guided biliary drainage, EUS-guided pancreatic duct drainage and EUS-guided celiac plexus ablation. The aim of this paper is to formulate a set of practice guidelines addressing various aspects of the above procedures. METHODS Formulation of the guidelines was based on the best scientific evidence available. The RAND/UCLA appropriateness methodology (RAM) was used. Panellists recruited comprised experts in surgery, interventional EUS, interventional radiology and oncology from 11 countries. Between June 2014 and October 2016, the panellists met in meetings to discuss and vote on the clinical scenarios for each of the interventional EUS procedures in question. RESULTS A total of 15 statements on EUS-guided drainage of pancreatic pseudocyst, 15 statements on EUS-guided biliary drainage, 12 statements on EUS-guided pancreatic duct drainage and 14 statements on EUS-guided celiac plexus ablation were formulated. The statements addressed the indications for the procedures, technical aspects, pre- and post-procedural management, management of complications, and competency and training in the procedures. All statements except one were found to be appropriate. Randomised studies to address clinical questions in a number of aspects of the procedures are urgently required. CONCLUSIONS The current guidelines on interventional EUS procedures are the first published by an endoscopic society. These guidelines provide an in-depth review of the current evidence and standardise the management of the procedures.
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Affiliation(s)
- Anthony Y B Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Vinay Dhir
- Baldota Institute of Digestive Sciences, Mumbai, Maharashtra, India
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara City, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Zhen Dong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Dong Wan Seo
- Department of Gastroenterology, Asan Medical Center, Seoul, Republic of Korea
| | - Majid Almadi
- Department of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Ida Hilmi
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Takao Itoi
- Department of Gastroenterology, Tokyo Medical University, Tokyo, Japan
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Koji Matsuda
- St Marianna University School of Medicine, Yokohama City Seibu Hospital, Kawasaki, Japan
| | - Nonthalee Pausawasdi
- Department of Internal Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rajesh Puri
- Department of Gastroenterology, Institute of Digestive and Hepatobiliary Sciences Medanta, The Medicity, Gurgaon, India
| | - Raymond S Tang
- Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Ai Ming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Dongcheng-qu, Beijing, China
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Kenjiro Yasuda
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
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25
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Takahashi K, Tsuyuguchi T, Saiga A, Horikoshi T, Ooka Y, Sugiyama H, Nakamura M, Kumagai J, Yamato M, Iino Y, Shingyoji A, Ohyama H, Yasui S, Mikata R, Sakai Y, Kato N. Risk factors of ineffective drainage in uncovered self-expandable metal stenting for unresectable malignant hilar biliary strictures. Oncotarget 2018; 9:28185-28194. [PMID: 29963271 PMCID: PMC6021331 DOI: 10.18632/oncotarget.25598] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 05/24/2018] [Indexed: 02/06/2023] Open
Abstract
AIM In this study, we assessed the factors contributing to ineffective drainage in the initial transpapillary uncovered self-expandable metal stent (USEMS) placements in patients with unresectable malignant hilar biliary strictures (UMHBSs) (Bismuth type II or higher). METHODS This was a retrospective, single-center study. A total of 97 patients with UMHBSs who underwent technically successful initial USEMS placements using endoscopic retrograde cholangiopancreatography (ERCP) were classified into the effective drainage group (n = 73) or the ineffective drainage group (n = 24). We then compared group characteristics, clinical outcomes, and drained liver volumes. Drained liver volume was measured by using computed tomography volumetry. The definition of effective biliary drainage was a 50% decrease in the serum total bilirubin level or normalization of the level within 14 days of stent placement. RESULTS Univariate analysis showed that ineffective drainage was associated with the pre-ERCP serum total bilirubin level (P = 0.0075), pre-ERCP serum albumin level (P = 0.042), comorbid liver cirrhosis (P = 0.010), drained liver volume (P = 0.0010), and single stenting (P = 0.022). Multivariate analysis identified comorbid liver cirrhosis (adjusted odds ratio [OR], 5.79; 95% confidence interval [CI], 1.30-25.85; P = 0.022) and drained liver volume < 50% (adjusted OR, 5.50; 95% CI, 1.50-20.25; P = 0.010) as independent risk factors of ineffective drainage. CONCLUSION Comorbid liver cirrhosis and a drained liver volume < 50% contributed significantly to ineffective drainage in the initial transpapillary USEMS placements for UMHBSs.
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Affiliation(s)
- Koji Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Toshio Tsuyuguchi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Atsushi Saiga
- Department of Radiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takuro Horikoshi
- Department of Radiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshihiko Ooka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Harutoshi Sugiyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masato Nakamura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Junichiro Kumagai
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Mutsumi Yamato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yotaro Iino
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ayako Shingyoji
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroshi Ohyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shin Yasui
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Rintaro Mikata
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuji Sakai
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Nakai Y, Yamamoto R, Matsuyama M, Sakai Y, Takayama Y, Ushio J, Ito Y, Kitamura K, Ryozawa S, Imamura T, Tsuchida K, Hayama J, Itoi T, Kawaguchi Y, Yoshida Y, Sugimori K, Shimura K, Mizuide M, Iwai T, Nishikawa K, Yagioka H, Nagahama M, Toda N, Saito T, Yasuda I, Hirano K, Togawa O, Nakamura K, Maetani I, Sasahira N, Isayama H. Multicenter study of endoscopic preoperative biliary drainage for malignant hilar biliary obstruction: E-POD hilar study. J Gastroenterol Hepatol 2018; 33:1146-1153. [PMID: 29156495 DOI: 10.1111/jgh.14050] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 11/08/2017] [Accepted: 11/12/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Endoscopic nasobiliary drainage (ENBD) is often recommended in preoperative biliary drainage (PBD) for hilar malignant biliary obstruction (MBO), but endoscopic biliary stent (EBS) is also used in the clinical practice. We conducted this large-scale multicenter study to compare ENBD and EBS in this setting. METHODS A total of 374 cases undergoing PBD including 281 ENBD and 76 EBS for hilar MBO in 29 centers were retrospectively studied. RESULTS Extrahepatic cholangiocarcinoma (ECC) accounted for 69.8% and Bismuth-Corlette classification was III or more in 58.8% of the study population. Endoscopic PBD was technically successful in 94.6%, and adverse event rate was 21.9%. The rate of post-endoscopic retrograde cholangiopancreatography pancreatitis was 16.0%, and non-endoscopic sphincterotomy was the only risk factor (odds ratio [OR] 2.51). Preoperative re-intervention was performed in 61.5%: planned re-interventions in 48.4% and unplanned re-interventions in 31.0%. Percutaneous transhepatic biliary drainage was placed in 6.4% at the time of surgery. The risk factors for unplanned procedures were ECC (OR 2.64) and total bilirubin ≥ 10 mg/dL (OR 2.18). In surgically resected cases, prognostic factors were ECC (hazard ratio [HR] 0.57), predraiange magnetic resonance cholangiopancreatography (HR 1.62) and unplanned re-interventions (HR 1.81). EBS was not associated with increased adverse events, unplanned re-interventions, or a poor prognosis. CONCLUSIONS Our retrospective analysis did not demonstrate the advantage of ENBD over EBS as the initial PBD for resectable hilar MBO. Although the technical success rate of endoscopic PBD was high, its re-intervention rate was not negligible, and unplanned re-intervention was associated with a poor prognosis in resected hilar MBO.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryuichi Yamamoto
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Masato Matsuyama
- Department of Gastroenterology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuji Sakai
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yukiko Takayama
- Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Jun Ushio
- Department of Gastroenterology, Jichi Medical University Hospital, Shimotsuke, Tochigi, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Katsuya Kitamura
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Tsunao Imamura
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Kouhei Tsuchida
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Jo Hayama
- Department of Gastroenterology and Hepatology, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yoshiaki Kawaguchi
- Department of Gastroenterology, Tokai University School of Medicine, Tokai, Kanagawa, Japan
| | - Yu Yoshida
- Department of Gastroenterology, Kimitsu Chuo Hospital, Chiba, Japan
| | - Kazuya Sugimori
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Kenji Shimura
- Department of Gastroenterology, Asahi General Hospital, Chiba, Japan
| | - Masafumi Mizuide
- Department of Gastroenterology, Gunma University Hospital, Maebashi, Gunma, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara, Kanagawa, Japan
| | - Ko Nishikawa
- Department of Gastroenterology, Ageo Central General Hospital, Saitama, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Masatsugu Nagahama
- Department of Gastroenterology, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Nobuo Toda
- Department of Gastroenterology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, JR Tokyo General Hospital, Tokyo, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Kanagawa, Japan
| | - Kenji Hirano
- Department of Gastroenterology, JHCO Tokyo Takanawa Hospital, Tokyo, Japan
| | - Osamu Togawa
- Department of Gastroenterology, Kanto Central Hospital, Tokyo, Japan
| | - Kenji Nakamura
- Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Naoki Sasahira
- Department of Gastroenterology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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Yang Y, Zhou Z, Liu R, Chen L, Xiang H, Chen N. Application of 3D visualization and 3D printing technology on ERCP for patients with hilar cholangiocarcinoma. Exp Ther Med 2018; 15:3259-3264. [PMID: 29545843 PMCID: PMC5840945 DOI: 10.3892/etm.2018.5831] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 01/16/2018] [Indexed: 12/17/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an important treatment for inoperable hilar cholangiocarcinoma (HCC). The aim of the present study as to evaluate the clinical value of three-dimensional visualization (3DV) and 3D printing (3DP) technologies for ERCP in patients with HCC. The clinical data of 15 patients with HCC admitted for ERCP were analyzed retrospectively, including 9 males and 6 females. Thin-sliced data of computed tomography and magnetic resonance cholangiopancreatography (MRCP) were acquired and imported into Mimics Innovation Suite v17.0 software for 3D reconstruction. Standard Template Library files were exported for 3D printing. The target bile duct and Bismuth-Corlette (BC) classification were selected and performed respectively with the aid of Mimics Innovation Suite v17.0 software. The results were compared with the selected ones in ERCP. 3DV and 3DP models were successfully constructed for all patients, which presented the tumor, bile duct and the spatial relationship between them from multiple perspectives. The ERCP of all patients in the present study were performed successfully. The target bile duct screened by them had a high concordance rate of 86.7% with that in ERCP. The diagnostic accuracy of BC type results by 3DV and 3DP models was 93.3%. 3DV and 3DP technologies can accurately show the tumor and its associations with the surrounding bile duct, and it can be used to guide ERCP in HCC patients and improve the success rate of the operation.
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Affiliation(s)
- Yan Yang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Zhongyin Zhou
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Rong Liu
- Department of Orthopaedic Surgery, Puren Hospital of Wuhan, Wuhan University of Science and Technology, Wuhan, Hubei 430060, P.R. China
| | - Lu Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Hongyu Xiang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Na Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
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Abstract
Cholangiocarcinomas (CC) are rare tumors which usually present late and are often difficult to diagnose and treat. CCs are categorized as intrahepatic, hilar, or extrahepatic. Epidemiologic studies suggest that the incidence of intrahepatic CCs may be increasing worldwide. In this chapter, we review the risk factors, clinical presentation, and management of cholangiocarcinoma.
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Kitamura K, Yamamiya A, Ishii Y, Mitsui Y, Nomoto T, Yoshida H. Side-by-side partially covered self-expandable metal stent placement for malignant hilar biliary obstruction. Endosc Int Open 2017; 5:E1211-E1217. [PMID: 29202005 PMCID: PMC5699902 DOI: 10.1055/s-0043-117955] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/26/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS This study investigated the feasibility of side-by-side (SBS) partially covered self-expandable metal stent (PCSEMS) placement for unresectable malignant hilar biliary obstruction (MHBO). PATIENTS AND METHODS We retrospectively analyzed 33 patients from a single center who underwent endoscopic biliary drainage for unresectable MHBO from July 2013 to June 2015. In all patients with bilateral obstruction during complete bilateral intrahepatic cholangiograms, we performed endoscopic SBS placement of a 6-mm diameter PCSEMS using an 8-French delivery system. All patients underwent endoscopic sphincterotomy. Generally, patients with recurrent biliary obstruction (RBO) after stent placement underwent endoscopic reintervention. Our study outcomes included the technical and functional success rates, RBO rate, time to RBO (TRBO), reintervention rate, and incidence of adverse events. RESULTS Seventeen patients with unresectable MHBO during complete bilateral intrahepatic cholangiograms underwent endoscopic SBS PCSEMS placement (median age, 78 years; men, 9). Lesions were Bismuth types II (n = 10), III (n = 1), and IV (n = 6), including 10 cholangiocarcinomas, 3 gallbladder cancers, and 4 metastatic cancers. In all patients, the PCSEMS was placed across the duodenal papilla. The technical and functional success rates were 100 % and 82 %, respectively. The median procedure time was 43 minutes (interquartile range [IQR]: 36 - 52 minutes). Twelve patients had RBO (71 %), including 9 stent occlusions due to sludge and 3 stent migrations. The median TRBO was 79 days (IQR: 58 - 156 days) during the follow-up period (median 192 days [IQR: 88 - 551 days]). The median TRBO of patients with Bismuth type II lesions was significantly longer than that of patients with Bismuth types III and IV lesions (87 days [IQR: 70 - 244 days] vs. 54 days [IQR: 35 - 100 days]; P = 0.030). Thirteen patients (76 %) required endoscopic reintervention. Endoscopic stent removal was possible in 6 patients without tumor ingrowth into the uncovered distal part of the stent. One late adverse event (≥ 31 days) occurred (cholangitis). CONCLUSIONS Endoscopic SBS placement of a PCSEMS was feasible in patients with unresectable MHBO. Additionally, reinterventional stent removal was possible in the absence of tumor ingrowth.
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Affiliation(s)
- Katsuya Kitamura
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
- Corresponding author Katsuya Kitamura, MD, PhD Division of GastroenterologyDepartment of MedicineShowa University School of Medicine1-5-8, Hatanodai, Shinagawa-kuTokyo, 142-8666Japan+81-3-37847553
| | - Akira Yamamiya
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yu Ishii
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuta Mitsui
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tomohiro Nomoto
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hitoshi Yoshida
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Kwak TW, Lee HL, Song YH, Kim C, Kim J, Seo SJ, Jeong YI, Kang DH. Vorinostat-eluting poly(DL-lactide-co-glycolide) nanofiber-coated stent for inhibition of cholangiocarcinoma cells. Int J Nanomedicine 2017; 12:7669-7680. [PMID: 29089762 PMCID: PMC5655133 DOI: 10.2147/ijn.s141920] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose The aim of this study was to fabricate a vorinostat (Zolinza™)-eluting nanofiber membrane-coated gastrointestinal (GI) stent and to study its antitumor activity against cholangiocarcinoma (CCA) cells in vitro and in vivo. Methods Vorinostat and poly(DL-lactide-co-glycolide) dissolved in an organic solvent was sprayed onto a GI stent to make a nanofiber-coated stent using an electro-spinning machine. Intact vorinostat and vorinostat released from nanofibers was used to assess anticancer activity in vitro against various CCA cells. The antitumor activity of the vorinostat-eluting nanofiber membrane-coated stent was evaluated using HuCC-T1 bearing mice. Results A vorinostat-incorporated polymer nanofiber membrane was formed on the surface of the GI stent. Vorinostat was continuously released from the nanofiber membrane over 10 days, and its release rate was higher in cell culture media than in phosphate-buffered saline. Released vorinostat showed similar anticancer activity against various CCA cells in vitro compared to that of vorinostat. Like vorinostat, vorinostat released from nanofibers induced acetylation of histone H4 and inhibited histone deacetylases 1⋅3⋅4/5/7 expression in vitro and in vivo. Furthermore, vorinostat nanofibers showed a higher tumor growth inhibition rate in HuCC-T1 bearing mice than vorinostat injections. Conclusion Vorinostat-eluting nanofiber membranes showed significant antitumor activity against CCA cells in vitro and in vivo. We suggest the vorinostat nanofiber-coated stent may be a promising candidate for CCA treatment.
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Affiliation(s)
- Tae Won Kwak
- Medical Convergence Textile Center, Gyeongbuk, Republic of Korea
| | - Hye Lim Lee
- Biomedical Research Institute, Pusan National University Hospital, Pusan, Republic of Korea
| | - Yeon Hui Song
- Biomedical Research Institute, Pusan National University Hospital, Pusan, Republic of Korea
| | - Chan Kim
- Amogreentech Co. Ltd. Gyeonggi-do, Republic of Korea
| | - Jungsoo Kim
- Biomedical Research Institute, Pusan National University Hospital, Pusan, Republic of Korea
| | - Sol-Ji Seo
- Biomedical Research Institute, Pusan National University Hospital, Pusan, Republic of Korea
| | - Young-Il Jeong
- Biomedical Research Institute, Pusan National University Hospital, Pusan, Republic of Korea
| | - Dae Hwan Kang
- Biomedical Research Institute, Pusan National University Hospital, Pusan, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Gyeongnam, Republic of Korea
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Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Watanabe K, Nakamura J, Kikuchi H, Waragai Y, Takasumi M, Sato Y, Hikichi T, Ohira H. Predictive factors for the failure of endoscopic stent-in-stent self-expandable metallic stent placement to treat malignant hilar biliary obstruction. World J Gastroenterol 2017; 23:6273-6280. [PMID: 28974893 PMCID: PMC5603493 DOI: 10.3748/wjg.v23.i34.6273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/04/2017] [Accepted: 08/08/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the factors predictive of failure when placing a second biliary self-expandable metallic stents (SEMSs). METHODS This study evaluated 65 patients with an unresectable malignant hilar biliary obstruction who were examined in our hospital. Sixty-two of these patients were recruited to the study and divided into two groups: the success group, which consisted of patients in whom a stent-in-stent SEMS had been placed successfully, and the failure group, which consisted of patients in whom the stent-in-stent SEMS had not been placed successfully. We compared the characteristics of the patients, the stricture state of their biliary ducts, and the implemented endoscopic retrograde cholangiopancreatography (ERCP) procedures between the two groups. RESULTS The angle between the target biliary duct stricture and the first implanted SEMS was significantly larger in the failure group than in the success group. There were significantly fewer wire or dilation devices (ERCP catheter, dilator, or balloon catheter) passing the first SEMS cell in the failure group than in the success group. The cut-off value of the angle predicting stent-in-stent SEMS placement failure was 49.7 degrees according to the ROC curve (sensitivity 91.7%, specificity 61.2%). Furthermore, the angle was significantly smaller in patients with wire or dilation devices passing the first SEMS cell than in patients without wire or dilation devices passing the first SEMS cell. CONCLUSION A large angle was identified as a predictive factor for failure of stent-in-stent SEMS placement.
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Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Ko Watanabe
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Jun Nakamura
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Hitomi Kikuchi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Yuichi Waragai
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
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Endoscopic Drainage of >50% of Liver in Malignant Hilar Biliary Obstruction Using Metallic or Fenestrated Plastic Stents. Clin Transl Gastroenterol 2017; 8:e115. [PMID: 28858292 PMCID: PMC5587843 DOI: 10.1038/ctg.2017.42] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 06/27/2017] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Endoscopic drainage of complex hilar tumors has generally resulted in poor outcomes. Drainage of >50% of liver volume has been proposed as optimal, but not evaluated using long multifenestrated plastic stents (MFPS) or self-expanding metal stents (SEMS). We evaluated outcomes of endoscopic drainage of malignant hilar strictures using optimal strategy and stents, and determined factors associated with stent patency, survival, and complications. METHODS Cross-sectional study was conducted at an academic center over 5 years. MFPS (10 French or 8.5 French) or open-cell SEMS were used for palliation of unresectable malignant hilar strictures, with imaging-targeted drainage of as many sectors as needed to drain >50% of viable liver volume. Risk factors were evaluated using regression analysis. The cumulative risk was assessed using Kaplan-Meier analysis. RESULTS 77 patients with malignant hilar biliary strictures (median Bismuth IV) underwent targeted stenting (41 MFPS and 36 SEMS). Comparing MFPS vs. SEMS, technical success (95.1 vs. 97.2%, P=0.64), clinical success (75.6 vs. 83.3%, P=0.40), frequency of multiple stents (23/41 vs. 25/36, P=0.19), survival and adverse events were similar, but stent patency was significantly shorter (P<0.0001). Factors associated with survival were Karnofsky score and serum bilirubin level at presentation. Outcomes were independent of Bismuth class with acceptable results in Bismuth III and IV. CONCLUSIONS Endoscopic biliary drainage with MFPS or open-cell SEMS targeting >50% of viable liver resulted in effective palliation in patients with complex malignant hilar biliary strictures. Patency was shorter in the MFPS group, but similar survival and complications were found when comparing MFPS and SEMS group.
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Parsi MA. Common controversies in management of biliary strictures. World J Gastroenterol 2017; 23:1119-1124. [PMID: 28275292 PMCID: PMC5323437 DOI: 10.3748/wjg.v23.i7.1119] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 12/10/2016] [Accepted: 01/18/2017] [Indexed: 02/06/2023] Open
Abstract
Biliary strictures are caused by a heterogeneous group of benign and malignant conditions, each requiring a specific treatment approach. Management of biliary strictures often involves endoscopy either for definite treatment, as a bridge to surgery or for palliative purposes. Endoscopic treatment of various types of biliary strictures is not standardized and there are multiple areas of controversy regarding the best treatment options. These controversies are mainly due to lack of well-designed comparative studies to support a specific therapy. This paper reviews three common areas of controversy in the endoscopic management of biliary strictures. The areas discussed in this editorial include the role of biliary drainage in resectable malignant strictures and whether such drainage should be performed routinely prior to surgery, the best endoscopic palliation for unresectable hilar strictures and whether unilateral or bilateral stenting should be attempted, and the optimal endoscopic management for dominant strictures in patients with primary sclerosing cholangitis. The goal of this editorial is twofold. The first is to review the current literature on management of the aforementioned strictures and offer recommendations based on available evidence. The second goal is to highlight the gaps in our knowledge which in turn can encourage future research on these topics.
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Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, Bruining DH, Eloubeidi MA, Fanelli RD, Faulx AL, Gurudu SR, Kothari S, Lightdale JR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85:32-47. [PMID: 27546389 DOI: 10.1016/j.gie.2016.06.051] [Citation(s) in RCA: 517] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 02/07/2023]
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Abstract
The diagnosis of malignant biliary obstruction combines the use of clinical evaluation, diagnostic imaging, tissue sampling, and minimally invasive options with the initial goal of identifying candidates for curative resection. The most common causes of obstruction are pancreatic adenocarcinoma and cholangiocarcinoma, and most cases are too advanced for surgical options. Interventional radiologists and gastroenterologists offer palliative options for biliary drainage such as plastic stents and catheters, bare metal stents, and covered stents. This article provides an updated review of options and outcomes for the management of malignant biliary obstruction.
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Lee JM, Lee SH, Jang DK, Chung KH, Park JM, Paik WH, Lee JK, Ryu JK, Kim YT. Air cholangiography in endoscopic bilateral stent-in-stent placement of metallic stents for malignant hilar biliary obstruction. Therap Adv Gastroenterol 2016; 9:189-98. [PMID: 26929781 PMCID: PMC4749855 DOI: 10.1177/1756283x15618132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Although endoscopic bilateral stent-in-stent (SIS) placement of self-expandable metallic stents (SEMS) is one of the major palliative treatments for unresectable malignant hilar biliary obstruction, post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis can occur frequently due to inadequate drainage, especially after contrast injection into the biliary tree. The aim of this study is to evaluate the efficacy and safety of air cholangiography-assisted stenting. METHODS This study included 47 patients with malignant hilar biliary obstruction who underwent endoscopic bilateral SEMS placement using the SIS technique. They were divided into two groups, air (n = 23) or iodine contrast (n = 24) cholangiography. We retrospectively compared comprehensive clinical and laboratory data of both groups. RESULTS There were no significant differences found between the two groups with respect to technical success (87% versus 87.5%, air versus contrast group, respectively), functional success (95% versus 95.2%), 30-day mortality (8.3% versus 8.7%) and stent patency. Post-ERCP adverse events occurred in 5 (21.7%) of the patients in the air group and 8 (33.3%) of the patients in the contrast group. Among these, the rate of cholangitis was significantly lower in the air group (4.8% versus 29.2%, p = 0.048). In multivariate analysis, air cholangiography, technical success and a shorter procedure time were significantly associated with a lower incidence of post-ERCP cholangitis. CONCLUSIONS Air cholangiography-assisted stenting can be a safe and effective method for endoscopic bilateral SIS placement of SEMS in patients with malignant hilar biliary obstruction.
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Affiliation(s)
- Jae Min Lee
- Departments of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea,Department of Internal Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | | | - Dong Kee Jang
- Departments of Internal Medicine and Liver Research Institute, Seoul, Korea,National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kwang Hyun Chung
- Departments of Internal Medicine and Liver Research Institute, Seoul, Korea,National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Myung Park
- Department of Internal Medicine, Kangwon National University School of Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Ji Kon Ryu
- Departments of Internal Medicine and Liver Research Institute, Seoul, Korea,National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yong-Tae Kim
- Departments of Internal Medicine and Liver Research Institute, Seoul, Korea,National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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Menon S. Hilar stenting for malignant biliary obstruction. Gastrointest Endosc 2016; 83:478-9. [PMID: 26773641 DOI: 10.1016/j.gie.2015.09.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 09/28/2015] [Indexed: 02/08/2023]
Affiliation(s)
- Shyam Menon
- Department of Gastroenterology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
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Esnaola NF, Meyer JE, Karachristos A, Maranki JL, Camp ER, Denlinger CS. Evaluation and management of intrahepatic and extrahepatic cholangiocarcinoma. Cancer 2016; 122:1349-69. [PMID: 26799932 DOI: 10.1002/cncr.29692] [Citation(s) in RCA: 190] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/18/2015] [Accepted: 08/19/2015] [Indexed: 12/13/2022]
Abstract
Cholangiocarcinomas are rare biliary tract tumors that are often challenging to diagnose and treat. Cholangiocarcinomas are generally categorized as intrahepatic or extrahepatic depending on their anatomic location. The majority of patients with cholangiocarcinoma do not have any of the known or suspected risk factors and present with advanced disease. The optimal evaluation and management of patients with cholangiocarcinoma requires thoughtful integration of clinical information, imaging studies, cytology and/or histology, as well as prompt multidisciplinary evaluation. The current review focuses on recent advances in the diagnosis and treatment of patients with cholangiocarcinoma and, in particular, on the role of endoscopy, surgery, transplantation, radiotherapy, systemic therapy, and liver-directed therapies in the curative or palliative treatment of these individuals. Cancer 2016;122:1349-1369. © 2016 American Cancer Society.
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Affiliation(s)
- Nestor F Esnaola
- Department of Surgery, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
| | - Joshua E Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
| | - Andreas Karachristos
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer L Maranki
- Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - E Ramsay Camp
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Crystal S Denlinger
- Department of Hematology/Oncology, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
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Kim HJ, Lee SK, Ryu CH, Park DH, Lee SS, Seo DW, Kim MH. The Clinical Usefulness of Simultaneous Placement of Double Endoscopic Nasobiliary Biliary Drainage. Clin Endosc 2015; 48:542-8. [PMID: 26668802 PMCID: PMC4676662 DOI: 10.5946/ce.2015.48.6.542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 05/28/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND/AIMS To evaluate the technical feasibility and clinical efficacy of double endoscopic nasobiliary drainage (ENBD) as a new method of draining multiple bile duct obstructions. METHODS A total of 38 patients who underwent double ENBD between January 2004 and February 2010 at the Asan Medical Center were retrospectively analyzed. We evaluated indications, laboratory results, and the clinical course. RESULTS Of the 38 patients who underwent double ENBD, 20 (52.6%) had Klatskin tumors, 12 (31.6%) had hepatocellular carcinoma, 3 (7.9%) had strictures at the anastomotic site following liver transplantation, and 3 (7.9%) had acute cholecystitis combined with cholangitis. Double ENBD was performed to relieve multiple biliary obstruction in 21 patients (55.1%), drain contrast agent filled during endoscopic retrograde cholangiopancreatography in 4 (10.5%), obtain cholangiography in 4 (10.5%), drain hemobilia in 3 (7.9%), relieve Mirizzi syndrome with cholangitis in 3 (7.9%), and relieve jaundice in 3 (7.9%). CONCLUSIONS Double ENBD may be useful in patients with multiple biliary obstructions.
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Affiliation(s)
- Hong Jun Kim
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sung Koo Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Choong Heon Ryu
- Department of Internal Medicine, Hanmaeum Hospital, Jeju, Korea
| | - Do Hyun Park
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Soo Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Wan Seo
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Sawas T, Al Halabi S, Parsi MA, Vargo JJ. Self-expandable metal stents versus plastic stents for malignant biliary obstruction: a meta-analysis. Gastrointest Endosc 2015; 82:256-267.e7. [PMID: 25982849 DOI: 10.1016/j.gie.2015.03.1980] [Citation(s) in RCA: 165] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/31/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Malignant biliary obstruction frequently portends a poor prognosis. Palliative treatment with stenting is often required to alleviate symptoms and potentially prevent adverse events. OBJECTIVES The aims of our study were (1) to evaluate the clinical difference between self-expandable metal stents (SEMSs) and plastic stents (PSs) in both hilar and distal malignant biliary obstruction on occlusion rate and 30-day mortality rate (primary outcomes) and stent insertion success rate, therapeutic failure, reintervention rate, and adverse events (secondary outcomes); (2) to compare unilateral stenting with bilateral stenting in hilar malignant obstruction in terms of occlusion rate and 30-day mortality rate (primary outcomes) and insertion success rate, therapeutic failure, and adverse events (secondary outcomes). METHODS PubMed, Embase, and Cochrane databases were searched for studies that provided data about malignant biliary obstruction and stent therapy. We included randomized, controlled trials (RCT), prospective observational cohort, and retrospective case-control studies. The quality of each included RCT study was assessed by the Jadad scale. Mantel-Haenszel odds ratios (ORs) and mean differences were calculated by using a random-effects model. RESULTS Nineteen studies involving 1989 patients (1045 SEMSs and 944 PSs) were included for the comparison of SEMSs and PSs. We also included 7 studies that compared unilateral with bilateral stenting involving 634 patients (346 unilateral and 268 bilateral). Our meta-analysis confirmed that SEMSs are associated with a statistically significant lower risk of occlusion compared with PSs in the short term (OR 0.27; 95% confidence interval [CI], 0.13-0.60) and long term (OR 0.38; 95% CI, 0.28-0.53). SEMSs had a lower 30-day occlusion rate than PSs in both hilar malignant obstruction (OR 0.16; 95% CI, 0.04-0.62) and distal malignant obstruction (OR 0.36; 95% CI, 0.14-0.93). SEMSs had a lower long-term occlusion rate compared with PSs in hilar malignant obstruction (OR 0.28; 95% CI, 0.19-0.39) and distal malignant obstruction (OR 0.42; 95% CI, 0.27-0.64). The 30-day mortality rate was similar with SEMSs and PSs (OR 0.74; 95% CI, 0.47-1.17). Therapeutic failure was more likely when using PSs (13%) compared with SEMSs (7%) (OR 0.43; 95% CI, 0.27-0.67). SEMSs required fewer reinterventions compared with PSs (mean difference, -0.49; 95% CI, -0.8 to -0.19). The incidence of cholangitis was statistically lower with SEMSs (8% vs 21%) (OR 0.41; 95% CI, 0.22-0.76). Bilateral stenting for hilar obstruction was not associated with a lower obstruction rate than unilateral stenting (OR 1.49; 95% CI, 0.77-2.89) or a lower 30-day mortality rate (OR 0.73; 95% CI, 0.29-1.79). There was no statistical difference in therapeutic failure (OR 1.47; 95% CI, 0.77-2.89) or cholangitis incidence (OR 0.61; 95% CI, 0.27-1.38). CONCLUSION SEMSs are associated with a statistically significantly lower occlusion rate, less therapeutic failure, less need for reintervention, and lower cholangitis incidence. There was no statistically significant difference in occlusion rate, therapeutic failure, and cholangitis incidence with bilateral stenting. Guideline recommendations may need to be modified to reflect clear and compelling data demonstrating the benefit of SEMSs in patients with malignant biliary obstruction. Bilateral stenting should be avoided because it has no benefit over unilateral stenting in terms of occlusion rate or therapeutic failure.
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Affiliation(s)
- Tarek Sawas
- Department of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Shadi Al Halabi
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mansour A Parsi
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Moon JH, Rerknimitr R, Kogure H, Nakai Y, Isayama H. Topic controversies in the endoscopic management of malignant hilar strictures using metal stent: side-by-side versus stent-in-stent techniques. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:650-6. [PMID: 26136361 DOI: 10.1002/jhbp.270] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 05/27/2015] [Indexed: 02/06/2023]
Abstract
Endoscopic management of unresectable hilar malignant biliary stricture (MBS) is currently challenging, and the best approach is still controversial. Liver volume is the key to adequate biliary drainage in hilar MBS and multiple stenting is mandatory to drain over 50% of liver volume in most cases. The self-expandable metallic stent (SEMS) has shown superior patency to plastic stents in recent reports. There are two methods of multiple stenting for hilar MBS: stent-in-stent (SIS) and side-by-side (SBS). Advantages of SIS include multiple SEMS placement in one stent caliber at the common bile duct (CBD), which is considered physiologically ideal. The through-the-mesh (TTM) technique with guidewires and the SEMS delivery system can be technically difficult in SIS, although the recent development of dedicated SEMSs having a loose portion facilitating the TTM technique makes SIS technically feasible both at stent deployment and re-interventions. Conversely, the SBS technique, if placed across the papilla, is technically simple at initial placement and re-intervention at stent occlusion. However, SBS has potential disadvantages of overexpansion of the CBD because of parallel placement of multiple SEMS, which can lead to portal vein thrombosis. Given the limited evidence available, a well-designed randomized controlled trial comparing these two techniques is warranted.
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Affiliation(s)
- Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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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: 33] [Impact Index Per Article: 3.3] [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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Jang SI, Lee DK. Update on Pancreatobiliary Stents: Stent Placement in Advanced Hilar Tumors. Clin Endosc 2015; 48:201-8. [PMID: 26064819 PMCID: PMC4461663 DOI: 10.5946/ce.2015.48.3.201] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/11/2015] [Accepted: 05/11/2015] [Indexed: 12/23/2022] Open
Abstract
Palliative drainage is the main treatment option for inoperable hilar cholangiocarcinoma to improve symptoms, which include cholangitis, pruritus, high-grade jaundice, and abdominal pain. Although there is no consensus on the optimal method for biliary drainage due to the paucity of large-scale randomized control studies, several important aspects of any optimal method have been studied. In this review article, we discuss the liver volume to be drained, stent type, techniques to insert self-expanding metal stents, and approaches for proper and effective biliary drainage based on previous studies and personal experience.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Kawakubo K, Kawakami H, Kuwatani M, Kudo T, Abe Y, Kawahata S, Kubo K, Kubota Y, Sakamoto N. Single-step simultaneous side-by-side placement of a self-expandable metallic stent with a 6-Fr delivery system for unresectable malignant hilar biliary obstruction: a feasibility study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:151-155. [PMID: 25345586 DOI: 10.1002/jhbp.173] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bilateral self-expandable metallic stent (SEMS) placement for the management of unresectable malignant hilar biliary obstruction (UMHBO) is technically challenging to perform using the existing metallic stents with thick delivery systems. The recently developed 6-Fr delivery systems could facilitate a single-step simultaneous side-by-side placement through the accessory channel of the duodenoscope. The aim of this study was to evaluate the feasibility of this procedure. METHODS Between May and September 2013, 13 consecutive patients with UMHBO underwent a single-step simultaneous side-by-side placement of SEMS with the 6-Fr delivery system. The technical success rate, stent patency, and rate of complications were evaluated from the prospectively collected database. RESULTS Technical success was achieved in 11 (84.6%, 95% confidence interval [CI]: 57.8-95.8) patients. The median procedure time was 25 min. Early and late complications were observed in 23% (one segmental cholangitis and two liver abscesses) and 15% (one segmental cholangitis and one cholecystitis) patients, respectively. Median dysfunction free patency was 263 days (95% CI: 37-263). Five patients (38%) experienced stent occlusion that was successfully managed by endoscopic stent placement. CONCLUSIONS A single-step simultaneous side-by-side placement of SEMS with a 6-Fr delivery system was feasible for the management of UMHBO.
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Affiliation(s)
- Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
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Kawakubo K, Kawakami H, Toyokawa Y, Otani K, Kuwatani M, Abe Y, Kawahata S, Kubo K, Kubota Y, Sakamoto N. Risk factors for technical failure of endoscopic double self-expandable metallic stent placement by partial stent-in-stent method. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:79-85. [PMID: 25308061 DOI: 10.1002/jhbp.170] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Endoscopic double self-expandable metallic stent (SEMS) placement by the partial stent-in-stent (PSIS) method has been reported to be useful for the management of unresectable hilar malignant biliary obstruction. However, it is technically challenging, and the optimal SEMS for the procedure remains unknown. The aim of this study was to identify the risk factors for technical failure of endoscopic double SEMS placement for unresectable malignant hilar biliary obstruction (MHBO). METHODS Between December 2009 and May 2013, 50 consecutive patients with MHBO underwent endoscopic double SEMS placement by the PSIS method. We retrospectively evaluated the rate of successful double SEMS placement and identified the risk factors for technical failure. RESULTS The technical success rate for double SEMS placement was 82.0% (95% confidence interval [CI]: 69.2-90.2). On univariate analysis, the rate of technical failure was high in patients with metastatic disease and unilateral placement. Multivariate analysis revealed that metastatic disease was a significant risk factor for technical failure (odds ratio: 9.63, 95% CI: 1.11-105.5). The subgroup analysis after double guidewire insertion showed that the rate of technical success was higher in the laser-cut type SEMS with a large mesh and thick delivery system than in the braided type SEMS with a small mesh and thick delivery system. CONCLUSIONS Metastatic disease was a significant risk factor for technical failure of double SEMS placement for unresectable MHBO. The laser-cut type SEMS with a large mesh and thin delivery system might be preferable for the PSIS procedure.
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Affiliation(s)
- Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
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Hong W, Zhu Y, Dong Y, Wu Y, Zhou M, Ni H. Predictors for occlusion of the first inserted metallic stent in patients with malignant biliary obstruction. Saudi J Gastroenterol 2015; 21:386-90. [PMID: 26655134 PMCID: PMC4707807 DOI: 10.4103/1319-3767.164204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic biliary stent drainage plays an important role in the palliative treatment of malignant biliary obstruction. The aim of this study was to investigate predictors of occlusion of first metal inserted stent in patients with malignant biliary obstruction. PATIENTS AND METHODS The retrospective analysis was performed in 178 patients with malignant biliary obstruction. Factors associated with stent occlusion were analyzed by Cox regression analysis. RESULTS Median overall stent patency was 178 days. Total cumulative obstruction rate of the first stents during the follow up was 33%, 57%, 83%, and 96% at 90, 180, 360, and 720 days. Multivariate analysis revealed that hilar obstruction (hazard ratio [HR] =3.26, 95% confidence interval [CI, 2.31-4.61), metastasis cancer (HR = 2.61, 95% CI, 1.79-3.80), and length of stent (HR = 1.74, 95% CI, 1.24-2.46) were independent predictors of stent occlusion. CONCLUSIONS Hilar biliary stricture, metastatic cancer, and length of stent were important predictors of occlusion of first-inserted metal stent in patients with malignant biliary obstruction.
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Affiliation(s)
- Wandong Hong
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, PR China,Address for correspondence: Dr. Wandong Hong, Department of Gastroenterology and Hepatology, The First Affiliated Hospital, Wenzhou Medical University, No 2, Fu Xue Road, Wenzhou, Zhejiang - 325 000, PR China. E-mail:
| | - Yunfei Zhu
- Department of Emergency Surgery, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, PR China
| | - Yanyan Dong
- Ultrasound, The Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Yanqing Wu
- Department of Reproductive Medicine, Family Planning Research Institute, Tongji Medical College, Wuhan, Hubei, PR China
| | - Mengtao Zhou
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Haizhen Ni
- Department of Vascular Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
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Lee TH, Moon JH, Park SH. Bilateral metallic stenting in malignant hilar obstruction. Clin Endosc 2014; 47:440-6. [PMID: 25325005 PMCID: PMC4198562 DOI: 10.5946/ce.2014.47.5.440] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 06/04/2014] [Indexed: 02/07/2023] Open
Abstract
Endoscopic palliative biliary drainage is considered as a gold standard treatment in advanced or inoperable hilar cholangiocarcinoma. Also, metal stents are preferred over plastic stents in patients with >3 months life expectancy. However, the endoscopic intervention of advanced hilar obstruction is often more challenging and complex than that of distal malignant biliary obstructions. In this literature review, we describe the issues commonly encountered during endoscopic unilateral (single) versus bilateral (multiple) biliary stenting for malignant hilar obstruction. Also, we provide technical guidance to improve the technical success rates and patient outcomes, focusing on bilateral metallic stenting techniques such as stent-in-stent or side-by-side deployment.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jong Ho Moon
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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48
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Goenka MK, Goenka U. Palliation: Hilar cholangiocarcinoma. World J Hepatol 2014; 6:559-569. [PMID: 25232449 PMCID: PMC4163739 DOI: 10.4254/wjh.v6.i8.559] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 05/28/2014] [Accepted: 06/14/2014] [Indexed: 02/06/2023] Open
Abstract
Hilar cholangiocarcinomas are common tumors of the bile duct that are often unresectable at presentation. Palliation, therefore, remains the goal in the majority of these patients. Palliative treatment is particularly indicated in the presence of cholangitis and pruritus but is often also offered for high-grade jaundice and abdominal pain. Endoscopic drainage by placing stents at endoscopic retrograde cholangio-pancreatography (ERCP) is usually the preferred modality of palliation. However, for advanced disease, percutaneous stenting has been shown to be superior to endoscopic stenting. Endosonography-guided biliary drainage is emerging as an alternative technique, particularly when ERCP is not possible or fails. Metal stents are usually preferred over plastic stents, both for ERCP and for percutaneous biliary drainage. There is no consensus as to whether it is necessary to place multiple stents within advanced hilar blocks or whether unilateral stenting would suffice. However, recent data have suggested that, contrary to previous belief, it is useful to drain more than 50% of the liver volume for favorable long-term results. In the presence of cholangitis, it is beneficial to drain all of the obstructed biliary segments. Surgical bypass plays a limited role in palliation and is offered primarily as a segment III bypass if, during a laparotomy for resection, the tumor is found to be unresectable. Photodynamic therapy and, more recently, radiofrequency ablation have been used as adjuvant therapies to improve the results of biliary stenting. The exact technique to be used for palliation is guided by the extent of the biliary involvement (Bismuth class) and the availability of local expertise.
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Affiliation(s)
- Mahesh Kr Goenka
- Mahesh Kr Goenka, Institute of Gastro Sciences, Apollo Gleneagles Hospitals, Kolkata 700054, India
| | - Usha Goenka
- Mahesh Kr Goenka, Institute of Gastro Sciences, Apollo Gleneagles Hospitals, Kolkata 700054, India
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Kogure H, Isayama H, Nakai Y, Tsujino T, Matsubara S, Yashima Y, Ito Y, Hamada T, Takahara N, Miyabayashi K, Mizuno S, Mohri D, Kawakubo K, Sasaki T, Yamamoto N, Hirano K, Sasahira N, Tada M, Koike K. High single-session success rate of endoscopic bilateral stent-in-stent placement with modified large cell Niti-S stents for malignant hilar biliary obstruction. Dig Endosc 2014; 26:93-99. [PMID: 23517109 DOI: 10.1111/den.12055] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 01/25/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Endoscopic bilateral self-expandable metallic stent (SEMS) placement in a stent-in-stent method for malignant hilar biliary obstruction is technically challenging. Technical difficulties in the initial placement and reinterventions for stent occlusion are disadvantages inherent to this stent-in-stent method. We previously reported the feasibility of Niti-S large cell D-type biliary stents (LCD). This multicenter prospective consecutive study evaluated the efficacy of bilateral SEMS placement using modified LCD with large and uniform cells, a slimmer delivery system and high radial force. PATIENTS AND METHODS From July 2010 to June 2011, 26 consecutive patients with unresectable malignant hilar biliary obstruction underwent endoscopic bilateral placement of modified LCD in a stent-in-stent method at three tertiary hospitals. Ten patients had gallbladder cancer, eight had cholangiocarcinoma, four had lymph node metastasis, two had intrahepatic cholangiocarcinoma, and two had liver metastasis. RESULTS Single-session and final technical success rate was 96% and 100%, respectively. Functional success rate was 89%. Stent occlusion occurred in 11 patients (42%) because of sludge (n = 7) or tumor ingrowth (n = 4). Endoscopic bilateral reintervention was technically easy and successful: six patients had stent clearance by balloon sweeping and five had plastic stent placement. According to Kaplan-Meier analysis, median survival and stent patency were 220 days and 157 days, respectively. CONCLUSIONS Modified LCD achieved a high technical success rate both in the initial stent-in-stent placement and in bilateral reinterventions in patients with malignant hilar biliary obstruction.
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Affiliation(s)
- Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Matsubayashi H, Kishida Y, Imai K, Hotta K, Kakushima N, Tanaka M, Takizawa K, Ono H. Unilateral multiple metallic stent-in-stent for a case of hilar biliary cancer: an alternative stenting strategy. Saudi J Gastroenterol 2014; 20:199-201. [PMID: 24976285 PMCID: PMC4067918 DOI: 10.4103/1319-3767.133035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The stenting strategy has been discussed in cases with unresectable hilar bile duct cancer (HBDC). We describe here a case of HBDC, 4 cm in size, invading the right portal vein and hepatic artery, which was only treated with repeated metallic stent placement, and the patient survived for a long period (51 months). Against Bismuth type-IV hilar biliary stricture, our strategy was to maintain the drainage of the largest, viable hepatic area (>50% of total liver) by unilateral multiple stent-in-stent.
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Affiliation(s)
- Hiroyuki Matsubayashi
- Division of Endoscdopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan,Address for correspondence: Dr. Hiroyuki Matsubayashi, Chief of Pancreatobiliary Endoscopy, Division of Endoscopy, Shizuoka Cancer Center, 1007, Nagaizumi, Suntogun, Shizuoka 411 - 8777, Japan. E-mail:
| | - Yoshihiro Kishida
- Division of Endoscdopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Kenichiro Imai
- Division of Endoscdopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscdopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Naomi Kakushima
- Division of Endoscdopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Masaki Tanaka
- Division of Endoscdopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscdopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscdopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
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