The management of high-grade hilar strictures by endoscopic insertion of self-expanding metal endoprostheses

Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents

BACKGROUND

Endoscopic management of malignant hilar biliary obstruction is controversial with respect to optimal types of stents and extent of drainage. This study evaluated outcomes of selective MRCP and CT-targeted drainage with self-expanding metallic stents.

METHODS

Consecutive patients undergoing attempted palliative ERCP for malignant hilar biliary obstruction were prospectively followed. Whenever possible, management strategy included evaluation and staging for potential resectability before ERCP, with primary placement of metallic stents at the first ERCP in nonsurgical candidates, and early conversion to a metallic stent when a tumor proved to be unresectable. MRCP and/or CT were used to plan selective guidewire access, opacification, and drainage only of the largest intercommunicating segmental ducts. Unilateral stent placement was intended in all cases except for selected patients with Bismuth II cholangiocarcinoma.

RESULTS

Thirty-five patients were included. Bismuth classification was I, 10; II, 6; III, 8; and IV, 11. Tumor origin was bile duct (17), gallbladder (5), and metastatic (13). Metallic stents were placed in 27 patients as the initial stent, and in 8 after plastic stent placement. Initial stents were placed endoscopically in 33 patients and percutaneously in 2 patients in whom lumenal tumor precluded ERCP. Stent placement was unilateral in 31 patients and bilateral in 4 patients. There were no episodes of cholangitis or other complications within 30 days after any procedures. Initial metallic stents were clinically effective in 27 (77%) of the 35 patients. Additional percutaneous drainage in 3 patients who did not respond to initial stent placement did not resolve jaundice. Median patency of first metallic stents was 8.9 months for patients with primary bile duct tumors and 5.4 months for all patients, and was not related to Bismuth classification. No further intervention was needed in 25 (71%) patients.

CONCLUSIONS

Unilateral metallic stent placement by using MRCP and/or CT to selectively target drainage provides safe and effective palliation in most patients with malignant hilar biliary obstruction.

Biliary endoscopy

Highlighting this year was the National Institutes of Health (NIH) State-of-the-Science Conference on endoscopic retrograde cholangiopancreatography. The panel addressed controversies in biliary endoscopy and set the framework for future funding for clinical research endeavors. With respect to biliary endoscopy, the literature addressed therapy for malignant biliary obstruction, choledocholithiasis, and biliary complications post-liver transplant.

Malignant biliary obstruction: treatment with ePTFE-FEP- covered endoprostheses initial technical and clinical experiences in a multicenter trial

PURPOSE

To determine and present the initial technical and clinical results of using an expanded polytetrafluoroethylene-fluorinated ethylene propylene (ePTFE-FEP)-covered biliary endoprosthesis to treat malignant biliary obstruction.

MATERIALS AND METHODS

This prospective nonrandomized study included 42 patients with malignant obstruction of the common bile duct, common hepatic duct, and hilar confluence. Unilateral (n = 38) or bilateral (n = 4) bile duct drainage was performed by using fully covered endoprostheses with anchoring fins. To avoid branch duct blockage, endoprostheses with drainage holes at the proximal end were available. Procedure- and device-related complications were recorded. Patient survival and stent patency rates were calculated with Kaplan-Meier survival analysis. Mean follow-up bilirubin and alkaline phosphatase levels were calculated, and differences in means were evaluated with a paired t test.

RESULTS

Successful deployment, correct positioning, and patency of the device were achieved in all patients. Procedure-related complications occurred in two (5%) patients. Thirty-day mortality rate was 20% (eight of 41 patients), and median survival time was 146 days. Laboratory values decreased significantly after the procedure (P <.001). Recurrent obstructive jaundice occurred in six (15%) patients. Primary patency rates at 3, 6, and 12 months were 90%, 76%, and 76%, respectively. Calculation of the composite end point of death or obstruction revealed a median patency duration of 138 days. No endoprosthesis migration was observed. Branch duct obstruction was observed in four (10%) patients. Postmortem examination of one stent revealed a widely patent endoprosthesis with intact covering.

CONCLUSION

Initial results of percutaneous treatment of malignant biliary obstructions with fully covered ePTFE-FEP endoprostheses suggest that they are safe and potentially clinically effective.

Cost-effectiveness analysis of alternative strategies for palliation of distal biliary obstruction after a failed cannulation attempt

OBJECTIVES

Occasionally alternative techniques such as precut sphincterotomy or percutaneous transhepatic cholangiography (PTC) are required to achieve access to the common bile duct. Tradeoffs exist, however, with respect to their complications and costs. Some experts believe that precut sphincterotomy should not be performed at all. We aimed to compare the cost-effectivenesses of metallic biliary stent placement after an initial failed cannulation attempt at ERCP utilizing precut sphincterotomy and placement utilizing PTC for palliation of jaundice. A cost-effectiveness analysis was performed, as viewed from the societal perspective.

METHODS

A decision analysis model was designed comparing precut sphincterotomy and PTC approaches for placement of a metallic biliary stent for palliation of jaundice in a patient with inoperable malignant distal biliary obstruction in whom an initial attempt at ERCP cannulation had failed. Baseline probabilities, obtained from the published literature, were varied through plausible ranges using sensitivity analysis. Charges were based on Medicare professional plus facility fees or diagnosis-related group rates for out- and inpatients, respectively. The outcome measured was cost per year of life.

RESULTS

Sensitivity analysis showed that precut sphincterotomy with subsequent PTC, if necessary, was the most cost-effective strategy provided the precut complication rate was <51% ($9,033/yr), versus $14,741/yr for PTC.

CONCLUSIONS

Precut sphincterotomy followed by PTC (if necessary) is the most cost-effective strategy for palliative biliary stenting in the setting of malignant distal biliary obstruction after a failed ERCP attempt. The endoscopic approach is best practiced by experienced endoscopists who minimize precut complication rates.

Cost analysis of magnetic resonance cholangiography in the management of inoperable hilar biliary obstruction

OBJECTIVE

Palliation of patients with Klatskin tumors involving both hepatic ducts is usually performed with bilateral biliary stent placement. Magnetic resonance cholangiopancreatography (MRCP) offers the ability to visualize the hepatic ducts without injection of contrast, thereby reducing the patient's risk of developing postprocedure bacterial cholangitis. We used decision analysis techniques to quantitate the cost-effectiveness of MRCP before stent placement versus routine placement of bilateral biliary stents in the setting of inoperable malignant hilar obstruction. In addition to determining which strategy was most economical, we used sensitivity analysis to identify the critical factors defining relative costs.

METHODS

A decision analysis model was designed comparing MRCP with subsequent unilateral biliary stent placement and double biliary stent placement approaches for palliation of jaundice in a patient with inoperable malignant hilar obstruction, as viewed from the societal perspective. Baseline probabilities, obtained from the published literature, were varied through plausible ranges using sensitivity analysis. Charges were based on Medicare professional plus facility fees or diagnosis-related group rates for out- and inpatients, respectively.

RESULTS

MRCP with subsequent directed unilateral stent placement was the least costly approach ($3806) compared with bilateral stent placement ($4275), provided the bilateral biliary stent complication rate was >3%. Bilateral stent placement needed to confer a survival advantage of at least 7 days over unilateral stent placement to become the more cost-effective approach.

CONCLUSIONS

The use of MRCP to guide biliary stent placement in a patient with inoperable hilar obstruction reduces the overall cost of treatment. The uncertainty of any survival advantage that bilateral biliary stent placement confers over unilateral stent placement makes cost-effectiveness difficult to assess.

Cost comparison of endoscopic stenting vs surgical treatment for unresectable cholangiocarcinoma

BACKGROUND

Total lifetime costs of endoscopic vs surgical treatment for obstructive jaundice due to cholangiocarcinoma are difficult to assess. The purpose of this study was to compare total costs in these two groups, including all treatment and retreatments.

METHODS

This retrospective study identified patients with biopsy-proven cholangiocarcinoma treated this decade with either endoscopic biliary stenting or surgical biliary-enteric bypass with or without resection. Outcomes and hospital charges were recorded. Ten matched control patients were compared from each group. Costs included those for cost of repeat endoscopy in the endoscopic group and for the management of recurrent obstructive jaundice in the surgical group.

RESULTS

The groups were similar in age and gender ratio. The surgical approach was frequently for cure; therefore, surgical patients were by and large at an earlier stage of their disease than those in the endoscopic group. Mean survival for the endoscopic group was 19 months vs 16.5 months for the surgical group. The median total lifetime cost for surgical therapy was $60,986 vs $24,251 for endoscopic therapy.

CONCLUSION

Endoscopic therapy is an effective palliative therapy for unresectable cholangiocarcinoma. Endoscopic therapy for this entity costs significantly less than surgical treatment. The cost benefit of endoscopic stenting over standard surgical bypass in the management of patients with unresectable cholangiocarcinoma, when considered along with its minimally invasive approach, makes this the procedure of choice for palliative therapy.

Cholangiocarcinoma

Despite overall advances in the ability to diagnose and treat patients with cholangiocarcinoma, the prognosis for patients with this malignancy remains poor. Further improvements in the survival of patients with cholangiocarcinoma will come with the early diagnosis of these lesions. New molecular techniques should improve the ability to screen high-risk patients, such as those with primary sclerosing cholangitis, hepatolithiasis, choledochal cysts, and ulcerative colitis. Improvements in imaging will continue, and spiral CT scanning, duplex ultrasonography, MR imaging and, perhaps, PET scans will improve the ability to stage patients with cholangiocarcinoma noninvasively. Complete surgical resection remains the only curative treatment for malignancies of the biliary tract. Aggressive surgical approaches are likely to continue, and the challenge remains in being able to perform these procedures safely in jaundiced and sometimes septic patients. For patients with unresectable lesions, the optimal form of palliation, whether surgical or nonsurgical, remains to be defined. Finally, multicenter, prospective, randomized trials of chemoradiation need to be performed to delineate an effective adjuvant therapy more precisely, and to improve the overall prognosis of patients with cholangiocarcinoma.

Magnetic resonance cholangiopancreatography-guided unilateral endoscopic stent placement for Klatskin tumors

BACKGROUND

Advanced and incurable Klatskin tumors of Bismuth-type III and IV cause obstructive jaundice. Palliation of patients with Klatskin tumors is usually carried out by bilateral endoscopic stent placement. Endoscopic retrograde cholangiography (ERC) in such patients is associated with a comparatively high morbidity and mortality mainly due to postprocedure bacterial cholangitis. To reduce ERC-related complications the outcome of replacing ERC with magnetic resonance cholangiopancreatography (MRCP) was investigated. Subsequently, unilateral contrast injection and stent placement were performed, thus avoiding bilateral contrast injection and stent insertion.

METHODS

Patients thought to have a Klatskin tumor underwent clinical evaluation, laboratory, and noninvasive imaging studies before ERC. Patients were enrolled in this feasibility study if investigators agreed with the clinical diagnosis of an advanced and incurable Klatskin tumor. MRCP images were used to determine the predominate ductal drainage for the liver segments thus directing stent placement. Based on these findings, unilateral ERC and subsequent unilateral stent placement were performed. Antibiotics were not given before ERC. Amsterdam-type stents (10F) were placed and replaced routinely at 2 months. In cases of earlier occlusion, the stents were replaced immediately.

RESULTS

Thirty-five patients underwent MRCP, ERC, and unilateral stent deployment. Two further patients enrolled after MRCP were withdrawn because ERC could not be carried out. In 35 patients with unilateral stents bilirubin levels decreased (18.9 +/- 6.3 mg/dL to 3.2 +/- 2.3 mg/dL) and jaundice resolved in 86%. After first stent deployment, post-ERC bacterial cholangitis occurred in 6% (2 of 35) of patients.

CONCLUSIONS

This new method of MRCP-guided endoscopic unilateral stent placement could reduce ERC-related complications caused by initial stent deployment. The results of this study justify a randomized prospective comparative trial.

Tumors of the gallbladder and bile ducts

Gallbladder cancer is the fifth most common gastrointestinal cancer in the US (5,000 new cases each year). Primary bile duct cancer (cholangiocarcinoma) is seen most often in patients with risk factors including primary sclerosing cholangitis (PSC), bile duct stones, and fluke infestation. Both cancers have a poor prognosis, in part because they present late. Malignant tumors of the gallbladder and bile ducts are rarely curable by surgery. Benign tumors of the biliary tree are rare, and with the exception of biliary papillomatosis and carcinoids, are not considered premalignant.

Endoscopic ablation therapy for Barrett's esophagus with high-grade dysplasia: a review

Besides esophagectomy and antireflux therapy with intensive endoscopic surveillance, endoscopic ablation therapy is a new treatment modality for Barrett's esophagus (BE) with high-grade dysplasia (HGD). Endoscopic surgical ablation can be performed by either a thermal, chemical, or mechanical method. This article describes the current management of patients with BE and HGD and the various methods of endoscopic ablation, including multipolar electrocoagulation, argon plasma beam coagulation, contact laser photoablation, and photodynamic therapy. It also summarizes the results of 37 patient studies, case reports, and abstracts on experimental endoscopic therapies for BE. The advantages and disadvantages of the various treatment possibilities are considered, and the future direction of the management of BE is discussed.