Advances in minimally invasive treatment of malignant obstructive jaundice

Abstract

Malignant obstructive jaundice (MOJ) encompasses a range of diseases stemming from malignant tumors such as cholangiocarcinoma, pancreatic cancer, and primary liver cancer, among others, which cause obstruction in both intra- and extra-hepatic bile ducts. This obstruction may lead to elevated bilirubin levels, hepatic function impairment, and a low rate of successful surgical resection in clinical settings. There are various minimally invasive treatment options for MOJ, including endoscopic biliary drainage, ultrasound-guided procedures, and percutaneous biliary tract puncture drainage.

Key Words: Malignant obstructive jaundice; Endoscopic retrograde cholangiopancreatography; Ultrasound endoscopy; Percutaneous transhepatic cholangial drainage; Radiofrequency ablation

Core Tip: Malignant obstructive jaundice (MOJ) presents with a subtle onset and poses challenges in early detection. By the time jaundice becomes apparent, the disease has typically advanced to a stage where surgical intervention is no longer feasible. Minimally invasive procedures for jaundice reduction are often the only viable option for the patients, as radical surgery is not feasible. In clinical practice, attention should be paid to the factors such as the underlying cause of MOJ, the degree of bile duct obstruction, the severity of jaundice, the patient’s overall health status and expected prognosis, and the surgical expertise available at the respective medical facility.

INTRODUCTION

Malignant obstructive jaundice (MOJ) typically occurs when bile ducts are invaded or compressed by advancing tumors in the hepatic hilar region and nearby areas, leading to impaired bile drainage and accumulation of bile both inside and outside the liver[1]. This results in symptoms such as yellowing of the skin and sclera, generalized itching, and hepatic dysfunction. Pancreatic cancer, primary hepatocellular carcinoma, and other malignant tumors can cause obstruction in both intra- and extra-hepatic bile ducts[2]. If the obstruction is not promptly relieved, worsening jaundice can manifest with symptoms such as loss of appetite and skin itching. Additionally, bilirubin itself is toxic and can cause systemic damage to multiple organ functions, potentially becoming life-threatening in severe cases[3]. Treatment options for MOJ include radical surgical interventions as the primary choice[4]. However, MOJ often presents insidiously, making early detection challenging. By the time jaundice becomes apparent, the disease has usually progressed to an advanced stage. Furthermore, jaundice can result in failure of organs such as the liver and kidneys, making some patients unsuitable for radical surgical procedures[5].

Minimally invasive jaundice reduction surgery is often the preferred option for most patients, as radical surgery is not feasible[6]. Methods of minimally invasive jaundice reduction surgery include endoscopic biliary drainage, endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous transhepatic cholangial drainage (PTCD). Additionally, there are combination treatments involving minimally invasive techniques, such as intracavitary radiofrequency ablation (RFA) and biliary stenting with particle radiotherapy[7]. MOJ is classified into high-level obstruction and low-level obstruction according to the region of obstruction[8]. Low-level obstruction refers to biliary obstruction located at the distal end of the confluence point of the cystic duct, and the combination of biliary stenting or nasobiliary drainage with endoscopic retrograde cholangiopancreatography (ERCP) has unique advantages in the treatment of low-level biliary obstruction. According to the Bismuth-Corlette typing[9], high-level biliary obstruction can be divided into 4 types: Type I, the obstruction is located in the common hepatic duct without involving the bifurcation; Type II, the obstruction involves the common hepatic duct; Type III, the obstruction involves the right and left hepatic ducts; and Type IV, the obstruction involves the bifurcation of the common hepatic duct and the right and left hepatic ducts simultaneously. PTCD and combined stenting with ¹²⁵I particle beam radiotherapy or intracavitary RFA are more appropriate for patients with types II, III and IV high-level biliary obstructions. This article briefly discusses recent advancements in minimally invasive jaundice reduction surgery, focusing on non-radical resection techniques.

ERCP GUIDED STENT PLACEMENT

Biliary stent placement or nasobiliary drainage, based on ERCP, is commonly utilized in clinical practice[10]. The ERCP procedure involves accessing the descending part of the duodenum using duodenoscopy, inserting a guide wire into the biliopancreatic duct, injecting contrast medium to visualize any lesions or obstructions in the bile duct and pancreatic duct, and then placing plastic and/or metal stents, nasobiliary ducts, or drainage tubes based on the diagnosis. This intervention aims to alleviate symptoms, improve quality of life, and extend survival[11]. ERCP is particularly effective in treating MOJ, especially when the lower part of the common bile duct is obstructed[12]. A comparison of ERCP and PTCD for the treatment of low-level MOJ has been conducted[13], and it was found that ERCP resulted in a lower rate of postoperative complications and shorter hospital stay, and was more cost-effective, suggesting that ERCP may be a better initial treatment option for MOJ. Moreover the minimally invasive methods allow direct observation of the duodenal papilla and enables further examination of the bile duct using specialized tools. ERCP is minimally invasive, reduces the risk of bile leakage, and minimizes disruptions to digestive and metabolic functions[14]. A recent meta-analysis[15] found that both PTCD and ERCP were effective in relieving biliary obstruction and improving liver function, but ERCP was more suitable for treating low-level biliary obstruction, while PTCD was more favorable for treating high-level biliary obstruction. Additionally, ERCP stenting offers the flexibility of double or multiple stenting in cases of complex obstructions, with easy stent replacement if blockage occurs[16].

EUS-BD

EUS-BD is a valuable alternative for patients with MOJ who are not suitable for ERCP procedures. Common methods include transduodenal choledochal puncture and transgastric left hepatic duct puncture biliary drainage[17]. Advances in ultrasound endoscopy technology, innovative stenting techniques, and refined EUS-BD procedures have led to the technical success rate exceeding 90% and a notable reduction in adverse events[18]. In a study[19], EUS-BD performed in 20 patients with MOJ after ERCP failure, was found to be successful in all patients and there were no surgical complications, such as biliary tract infections, suggesting that EUS-BD has a better effect on biliary decompression in MOJ, with a high success rate and good safety. As EUS-BD procedures become more widespread and the puncture technique improves, recent studies have suggested that EUS-BD is an effective option for patients with MOJ after failed ERCP or in those who are unable to undergo ERCP[20,21]. A multicenter randomized controlled study[22] found that both procedures, ERCP and EUS-BD, may be options for initial biliary drainage of unresectable MOJ. EUS-BD has a higher technical success rate associated with shorter operative time compared to ERCP; thus, primary EUS-BD may be the preferred option when a difficult ERCP is anticipated.

PTCD

X-ray or ultrasound-guided PTCD involves puncturing the biliary tract percutaneously and inserting a drainage tube into the bile duct to facilitate bile drainage from the body[5]. This method is commonly used in the clinical treatment of malignant obstructions. PTCD is a minimally invasive technique with unique characteristics that can be combined with percutaneous transhepatic biliary stenting to improve jaundice reduction[23]. The advantages of PTCD are that it is less physically demanding, less painful for the patient, relatively easy and inexpensive, has a higher success rate, and is currently considered to be a remedial method after ERCP tube placement failure[24]. A systematic evaluation and meta-analysis[6] comparing the safety and efficacy of ERCP and PTCD in the treatment of MOJ found that both treatments were safe and effective for MOJ. However, PTCD had a higher technical success rate and a lower incidence of postoperative pancreatitis. However, drawbacks include hindered nutrient absorption due to external bile drainage, potential complications such as bleeding and infections, as well as the inconvenience of managing drainage tubes and bags[25]. These factors limit the widespread application of PTCD in clinical settings.

BILIARY STENT COMBINED WITH ¹²⁵I PARTICLE THERAPY

PTCD plays a crucial role in bile drainage in MOJ. However, it has limitations. The introduction of biliary stents placed via PTCD effectively addresses these issues, converting external drainage to internal drainage, mimicking physiological drainage. This transformation significantly enhances patients’ quality of life. Particularly, when combined with radiation therapy such as ¹²⁵I, and the stent’s role extends beyond bile drainage to include tumor intervention and treatment[26]. A study indicates[27] that the combination of stent and ¹²⁵I particle placement results in a high surgical success rate, reduces bilirubin levels, and extends patient survival. Another study selected 21 patients with MOJ for PTCD combined with ¹²⁵I particle local radiotherapy. The results showed that 3 of the 21 patients had complete remission and 12 had partial remission, with an overall effective rate of 71.43% and a local control rate of 85.71%. Thus, this treatment can effectively improve patient quality of life and prolong the survival period[28]. Adverse effects of this combination treatment include infection, biliary bleeding, acute pancreatitis or hyperamylasemia, and ¹²⁵I displacement. However, the incidence of these adverse effects is not significantly higher than that with metallic biliary stenting alone[29]. Despite this, further validation and support through large-scale, evidence-based medical studies across multiple centers are necessary for clinical application.

BILIARY STENT COMBINED WITH RFA

An important advancement in the minimally invasive treatment of MOJ is the utilization of RFA in combination with stent placement. This innovative approach involves using RFA to thermally denature and necrose malignant tumor tissues in extrahepatic bile ducts, thereby inhibiting tumor growth. This treatment method can be repeated multiple times and has shown promise in treating stent restenosis, leading to improved stent patency time and extended patient survival[30]. However, the disadvantage of this method is that it may cause bile leakage into the abdominal cavity and biliary stricture in a few cases[31]. In this editorial, we comment on the efficacy and safety of percutaneous transhepatic biliary RFA in patients with MOJ as reported by Xing et al[32]. The authors selected 17 patients with unresectable MOJ and performed RFA under PTCD. All patients successfully completed the procedure, which significantly reduced the incidence of postoperative pancreatitis and biliary tract infections compared with ERCP, and the jaundice subsided satisfactorily with effective prolongation of biliary patency time and improvement in patients’ quality of life. Another retrospective analysis[33] was performed on 150 patients who underwent stenting combined with RFA and 127 patients who underwent stenting only. The median duration of stent patency in patients with stenting combined with RFA was 11.2 months, with a median survival time of 12.3 months, which was significantly different from that of patients with stenting alone. Furthermore, clinical research[34] has also confirmed that stenting combined with RFA significantly prolongs stent opening time and improves patients’ overall survival compared with stenting alone, and that there was no increase in the success rate of the procedure or post-procedural complications such as abdominal pain, infection, and bleeding. Despite these promising findings, the limited availability of specialized consumables for biliary RFA has hindered widespread adoption of this technique in clinical practice[35]. In conclusion, the use of stents in conjunction with RFA technology is deemed safe and effective, particularly in cases of stent blockage where recanalization can be achieved through RFA. However, long-term efficacy and postoperative complications need to be observed.

CONCLUSION

In the clinic, according to the MOJ patient’s primary disease, bile duct obstruction site, jaundice level, the patient’s physical status and expected survival, and the operation level of the respective clinical treatment center, comprehensive consideration is necessary by a multidisciplinary team to develop a scientific and reasonable minimally invasive treatment plan for each patient. It is believed that with the development of endoscopic technology, stent technology, drug research and other medical technologies, greater progress will be made in the treatment of MOJ.