A survival analysis of patients with malignant biliary strictures treated by percutaneous metallic stenting

Application of intraluminal brachytherapy for malignant obstruction in the porta hepatis: a retrospective control study

Purpose and background

Malignant obstructions in the porta hepatis mainly include malignant obstructive jaundice (MOJ) and portal vein tumor thrombus (PVTT). Stent placement has been one of the most commonly recommended methods to alleviate the physical suffering of these patients, but the long-term outcome has been frustrating in terms of stent occlusion. The aim of this study was to discuss the clinical effect and technical feasibility of intraluminal brachytherapy (ILBT) in patients with malignant obstruction in the porta hepatis.

Methods and materials

From 2016 to 2018, 68 patients diagnosed with malignant obstruction in the porta hepatis were retrospectively included in this study. Twenty-eight patients (group A) received stent placement with iodine-125 seed-strand implantation, and 40 patients (group B) received stent placement only. All patients underwent numerous transarterial chemoembolizations (TACE) after stent implantation. All patients were followed up until death. Clinical data, stent patency and survival time were recorded for further analysis.

Results

There was no significant difference between the two groups in terms of length of malignant obstruction and baseline characteristics. 68 stents were successfully implanted in both groups.Iodine-125 seed strands were successfully deployed and completely covered the length of the stent in group A. Liver function and jaundice improved continuously in the first 9 months after treatment (P<0.05). Compared to group B, the mean stent patency time was significantly longer in group A (5.5 ± 2.09 months versus 6.86 ± 1.82 months, P<0.001). The mean survival time is longer in group A than in patients in group B (10.03 ± 3.04 months VS 7 ± 2.44 months, P<0.001).

Conclusion

ILBT in combination with stent implantation and TACE has proven to be a feasible and effective palliative treatment to maintain stent patency in patients with PVTT and MOJ.

Prognostic factors for survival in patients with advanced cholangiocarcinoma treated with percutaneous transhepatic drainage

Biliary drainage is then one of the necessary procedures to help patients suffering from icterus to reduce serum bilirubin levels and relieve symptoms. The aim of this study was identifying risk factors for survival in patients with cholangiocarcinoma (CCA) treated with percutaneous transhepatic biliary drainage (PTBD) and to develop a simple scoring system predicting survival from PTBD insertion. This single-centre retrospective study included 175 consecutive patients undergoing PTBD for extrahepatic CCA (perihilar and distal). Prognostic factors affecting survival of patients with CCA treated with PTBD were analysed. A multivariate analysis showed that mass forming tumor with mass larger than 5 cm and presence of metastasis at the time of PTBD served as a negative prognostic factor (p = 0.002), better survival was associated with lower preprocedural bilirubin and lower CRP (p = 0.003). Multivariate analysis identified two significant risk factors for 3-month mortality: mass-forming tumors and bilirubin levels exceeding 185 µmol/L. A simple scoring system was developed to predict 3-month mortality after PTBD in patients with advanced CCA, demonstrating 86.3% negative predictive value and 43.2% positive predictive value.

Prognostic Nutritional Index (PNI) and Neutrophil to Lymphocyte Ratio (NLR) as Predictors of Short-Term Survival in Patients with Advanced Malignant Biliary Obstruction Treated with Percutaneous Transhepatic Biliary Drainage

BACKGROUND

Effective biliary tree decompression plays a central role in the palliation of malignant biliary obstruction (MBO). When endoscopic drainage is unfeasible or unsuccessful, percutaneous transhepatic biliary drainage (PTBD) is the method of choice and preferred treatment approach in advanced hilar MBO. The prognostic nutritional index (PNI) reflects the patient's immunonutritional status, while the neutrophil to lymphocyte ratio (NLR) reflects the patient's inflammation status. The aim of the present study was to evaluate the prognostic value of preprocedural PNI and NLR on short-term survival in the advanced stage MBO population threatened with PTBD and to characterize the differences in immunonutritional and inflammatory status between 60-day survivors and non-survivors, as well as analyze other variables influencing short-term survival.

METHODS

This single-center retrospective study was conducted on patients undergoing palliative PTBD caused by MBO as a definitive therapeutic treatment between March 2020 and February 2022. After the procedure, patients were followed until the end of August 2022.

RESULTS

A total of 136 patients with malignant biliary obstruction were included in the study. Based on receiver operating characteristic (ROC) curve analysis, optimal cut off-values for NLR (3) and PNI (36.7) were determined. In univariate regression analysis, age, absolute neutrophil count, albumin level, NLR ≤ 3, and PNI ≥ 36.7 were significant predictors of 60-day survival. Level of obstruction and PNI ≥ 36.7 were statistically significant independent predictors of 60-day survival in a multivariate regression model. Using PNI ≥ 36.7 as a significant coefficient from the multivariate regression model with the addition of NLR ≤ 3 from univariate analysis, a 60-day survival score was developed.

CONCLUSIONS

PNI and NLR are easy to calculate from routine blood analysis, which is regularly conducted for cancer patients. As such, they represent easily available, highly reproducible, and inexpensive tests capable of expressing the severity of systemic inflammatory responses in patients with cancer. Our study highlights that preprocedural PNI and NLR values provide predictors of short-term survival in patients with MBO treated with palliative PTBD. In addition, the proposed 60-day survival score can contribute to better selection of future candidates for PTBD and recognition of high-risk patients with expected poor outcomes.

Percutaneous biliary drainage for obstructive jaundice in patients with inoperable, malignant biliary obstruction

AIM OF THE STUDY

Most of the malignancies leading to obstructive jaundice are diagnosed too late when they are already advanced and inoperable, with palliation being the only treatment option left. Due to progressing hyperbilirubinaemia with its consequent adverse effects, biliary drainage must be established even in advanced malignancies. This study aims to investigate and analyse factors that affect clinical outcomes of percutaneous trans-hepatic biliary drainage (PTBD) in patients with obstructive jaundice due to advanced inoperable malignancy, and identify potential predictors of patient survival. Study design: Observational retrospective cohort study.

MATERIAL AND METHODS

Baseline variables and clinical outcomes were evaluated in 108 consecutive patients treated with PTBD. The study's primary endpoints were significant bilirubin level decrease and survival rates. Secondary endpoints included periprocedural major and minor complication rates and catheter primary and secondary patency rates.

RESULTS

PTBD was technically successful and bile ducts were successfully drained in all 108 patients. Median serum bilirubin level, which was 282 (171-376) µmol/l before drainage, decreased significantly, to 80 (56-144) µmol/l, 15 days after stent placement (p < 0.001). Patient survival ranged from 3 to 597 days and the overall (median) survival time following PTBD was 168 days (90-302). The 1, 3, 6, 12 and 18-month survival rates were 96.3%, 75.9%, 48.1%, 8.3% and 1.9%, respectively. Multivariate analysis revealed that liver metastases and alkaline phosphatase were significantly associated with mortality. The overall complication rate was 9.3%.

CONCLUSIONS

PTBD is a safe and effective method to relieve jaundice caused by advanced inoperable malignant disease. Careful patient selection is necessary when introducing PTBD in order to avoid invasive procedures in patients with a poor prognosis.

Importance of Bile Composition for Diagnosis of Biliary Obstructions

Determination of the cause of a biliary obstruction is often inconclusive from serum analysis alone without further clinical tests. To this end, serum markers as well as the composition of bile of 74 patients with biliary obstructions were determined to improve the diagnoses. The samples were collected from the patients during an endoscopic retrograde cholangiopancreatography (ERCP). The concentration of eight bile salts, specifically sodium cholate, sodium glycocholate, sodium taurocholate, sodium glycodeoxycholate, sodium chenodeoxycholate, sodium glycochenodeoxycholate, sodium taurodeoxycholate, and sodium taurochenodeoxycholate as well as bile cholesterol were determined by HPLC-MS. Serum alanine aminotransferase (ALT), aspartate transaminase (AST), and bilirubin were measured before the ERCP. The aim was to determine a diagnostic factor and gain insights into the influence of serum bilirubin as well as bile salts on diseases. Ratios of conjugated/unconjugated, primary/secondary, and taurine/glycine conjugated bile salts were determined to facilitate the comparison to literature data. Receiver operating characteristic (ROC) curves were determined, and the cut-off values were calculated by determining the point closest to (0,1). It was found that serum bilirubin was a good indicator of the type of biliary obstruction; it was able to differentiate between benign obstructions such as choledocholithiasis (at the concentration of >11 µmol/L) and malignant changes such as pancreatic neoplasms or cholangiocarcinoma (at the concentration of >59 µmol/L). In addition, it was shown that conjugated/unconjugated bile salts confirm the presence of an obstruction. With lower levels of conjugated/unconjugated bile salts the possibility for inflammation and, thus, neoplasms increase.

Clinical Performance Status and Technical Factors Affecting Outcomes from Percutaneous Transhepatic Biliary Interventions; A Multicentre, Prospective, Observational Cohort Study

Purpose

The purpose of this study was to evaluate the predictive value of a ‘Modified Karnofsky Scoring System’ on outcomes and provide real-world data regarding the UK practice of biliary interventions.

Materials and Methods

A prospective multi-centred cohort study was performed. The pre-procedure modified Karnofsky score, the incidence of sepsis, complications, biochemical improvement and mortality were recorded out to 30 days post procedure.

Results

A total of 292 patients (248 with malignant lesions) were suitable for inclusion in the study. The overall 7 and 30 day mortality was 3.1% and 16.1%, respectively. The 30 day sepsis rate was 10.3%. In the modified Karnofsky ‘high risk’ group the 7 day mortality was 9.7% versus 0% for the ‘low risk’ group (p = 0.002), whereas the 30 day mortality was 28.8% versus 13.3% (p = 0.003). The incidence of sepsis at 30 days was 19% in the high risk group versus 3.3% at the low risk group (p = 0.001)

Conclusion

Percutaneous biliary interventions in the UK are safe and effective. Scoring systems such as the Karnofsky or the modified Karnofsky score hold promise in allowing us to identify high risk groups that will need more careful consideration and enhanced patient informed consent but further research with larger studies is warranted in order to identify their true impact on patient selection and outcomes post biliary interventions.

Right-sided versus left-sided percutaneous transhepatic biliary drainage in the management of malignant biliary obstruction: a randomized controlled study

AIM

To compare the technical difficulty, safety, radiation exposure and success rates between right-sided and left-sided percutaneous transhepatic biliary drainage (RPTBD and LPTBD) in patients with malignant biliary obstruction (MBO).

MATERIALS AND METHODS

Fifty patients (28 males, 22 females; mean age 51.78 years) with MBO were randomized to undergo either RPTBD or LPTBD during the study period between June 2016 and May 2018. The procedure time, fluoroscopy time, radiation doses to the operators and patients, technical success, clinical success, complications and effect on quality of life were evaluated and compared between the two groups.

RESULTS

Twenty-five patients were included in each group. The technical success was 100% in both groups. There was no significant difference between RPTBD and LPTBD groups in terms of major complications [4% and 12%, respectively; p = 0.297] and minor complications [40% and 32%, respectively; p = 0.597]. Further, the average procedure time (37.80 ± 13.07 min vs 41.04 ± 14.94 min), fluoroscopy time (5.88 ± 4.2 min vs 5.97 ± 3.8 min), radiation doses to the operator (136.84 ± 106.67 μSv vs 130.40 ± 106.46 μSv) and to the patient (8.23 ± 5.80 Gycm² vs 11.74 ± 11.28 Gycm²) were not significantly different between the groups. Clinical success was achieved in 21 patients (84%) of RPTBD group and 17 patients (68%) of LPTBD group with no significant difference (p = 0.416) between them.

CONCLUSION

There was no significant difference between RPTBD and LPTBD with reference to the technique, safety, radiation dose, success rates and impact on quality of life suggesting no laterality advantage for biliary drainage in cases of MBO.

Percutaneous Intraductal Microwave Ablation and Self-expandable Metallic Stenting: A New Treatment Method for Malignant Extrahepatic Biliary Obstruction

PURPOSE

To evaluate the patency and clinical efficacy of percutaneous intraductal microwave ablation (PIMWA) and uncovered self-expandable metallic stents (USEMs) in inoperable malignant extrahepatic biliary obstruction.

MATERIALS AND METHODS

The procedures to be performed on patients with malignant inoperable extrahepatic biliary obstruction were decided by a multidisciplinary team including an interventional radiologist. In our study, 141 patients were evaluated retrospectively. Twenty-one patients who underwent PIMWA + USEMs with the MedWaves AveCure microwave system (AveCure^® Intelligent Controller and Super-Flex Smart Catheter) and met the inclusion criteria were included in the study. Complications related to the intervention, stent patency, survival time, serum bilirubin levels, and the general condition of the patients were noted.

RESULTS

The median stent patency and the median survival time were 108 and 143 days, respectively. The rates of 30-day, 2-month, 6-month and 8-month survival were 95.2%, 85.7%, 38.1%, and 14.3%, respectively.

CONCLUSION

The PIMWA + USEMs procedure is a safe, effective, and minimally invasive alternative palliative treatment method in patients with malignant inoperable extrahepatic biliary obstruction.

Percutaneous stent placement for malignant hilar biliary obstruction: side-by-side versus stent-in-stent technique

BACKGROUND

Currently, side-by-side (SBS) and stent-in-stent (SIS) are the two main techniques for stent deployment to treat hilar biliary obstructions. Previous studies comparing these two techniques are very limited, and thus, no consensus has been reached on which technique is better. The purpose of this study is to compare the clinical efficacy and safety of SBS and SIS deployment via a percutaneous approach for malignant hilar biliary obstruction.

METHODS

From July 2012 to April 2019, 65 patients with malignant hilar biliary obstruction who underwent bilateral stenting using either the SBS or SIS techniques were included in this study. Among them, 27 patients underwent SIS stent insertion (SIS group), and the remaining 38 patients underwent SBS stent insertion (SBS group). Technical success, improvement of jaundice, complications, duration of stent patency, and overall survival were evaluated.

RESULTS

Technical success was achieved in all patients in the two groups. The serum bilirubin level decreased more rapidly 1 week after the procedures in the SBS group than in the SIS group (P = 0.02). Although the total complication rate did not differ between the two groups, cholangitis was found to be more frequent in the SIS group (P = 0.04). The median stent patency was significantly longer in the SBS group (149 days) than in the SIS group (75 days; P = 0.02). The median overall survival did not significantly differ between the two groups (SBS vs. SIS, 155 days vs. 143 days; P > 0.05).

CONCLUSIONS

Percutaneous transhepatic bilateral stenting using either the SBS or SIS technique is safe and effective in the management of malignant hilar biliary obstruction. However, SBS offers a quicker improvement of jaundice, a lower incidence of cholangitis after the procedure, and a longer stent patency period than SIS.

Stent placement with iodine-125 seeds strand effectively extends the duration of stent patency and survival in patients with unresectable malignant obstructive jaundice

Background: This study aimed to compare the treatment outcomes and safety between stent placement with or without Iodine-¹²⁵ (¹²⁵I) seeds strand for patients with unresectable malignant obstructive jaundice (MOJ).Methods: A total of 84 patients with unresectable MOJ treated in our hospital were retrospectively included and divided into the stent group (n = 54) undergoing biliary stent placement and the stent + seeds group (n = 30) receiving stent placement with ¹²⁵I seeds strand. The therapeutic outcome, postoperative complications, duration of patient survival and stent patency were compared between groups. Kaplan-Meier survival analysis was performed to compare the duration of patient survival and stent patency between groups. Cox-regression analysis was performed to investigate predictive factors for disease-free survival and overall survival.Results: The stent + seeds group had significantly longer duration of patency (231.57 ± 256.54 vs. 110.37 ± 120.52) and overall survival (310.57 ± 330.54 vs. 173.15 ± 219.40) than the stent group (both p < .05). In addition, Kaplan-Meier survival analysis confirmed that the stent + seeds group had longer duration of patency (log-rank test, p = .001) and higher overall survival rate (log-rank test, p = .020) than the stent group. Furthermore, Cox-regression analysis demonstrated that treatment methods was an independent factor associated with disease-free survival (HR: 0.36, 95% CI: 0.19-0.70; p = .003) and overall survival (HR: 1.01, 95% CI: 1.00-1.01; p < .001).Conclusion: The stent placement with ¹²⁵I seeds strand can significantly improve the primary patency rate and overall survival time in MOJ patients.

Percutaneous stenting and chemotherapy for unresectable pancreatic cancer: Comparison of irradiation stents vs conventional metal stents

OBJECTIVES

Percutaneous stenting is a palliative method to relieve obstructive jaundice caused by unresectable pancreatic carcinoma. In this study, we aimed to compare the safety and efficacy of irradiation stents and conventional metal stents.

METHODS

A total of 32 patients who received irradiation stents or conventional metal stents to treat obstructive jaundice caused by locally advanced pancreatic cancer were included in this retrospective study. Chemotherapy using gemcitabine was performed after jaundice subsided. Stent patency, technical success, survival, and complications were compared between groups.

RESULTS

Seventeen patients were enrolled in the irradiation stent group (ISG), and 15 patients were enrolled in the uncovered stent group (USG). Median and mean stent patency time were 9.8 months (95% CI, 7.682-11.981) and 9.506 months (95% CI, 8.0-11.012) in the ISG, respectively, vs 8.8 months (95% CI, 6.528-11.072) and 7.62 months (95% CI, 5.917-9.323) in the USG, respectively (P = 0.019). Median and mean overall survival were 10.4 months (95% CI, 8.383-12.417) and 9.953 months (95% CI, 8.408-11.498), respectively, in the ISG vs 9.7 months (95% CI, 7.901-11.499) and 8.14 months (95% CI, 6.44-9.84), respectively, in the USG (P = 0.027).

CONCLUSIONS

Irradiation stents extend stent patency and overall survival compared with conventional biliary stents for the treatment of pancreatic carcinoma complicated by obstructive jaundice. Irradiation stents combined with chemotherapy may be a better choice for the treatment of obstructive jaundice caused by unresectable pancreatic carcinoma.

Predictors of stent occlusion in patients with unresectable pancreatic cancer after biliary metal stents

BACKGROUND

Self-expandable metal stents (SEMS) are a widely accepted biliary endoprosthesis for patients with unresectable malignant biliary obstruction. Here, we identified predictors for the occlusion of SEMS in unresectable pancreatic cancer patients with biliary tract obstruction.

METHODS

Patients with a distal malignant biliary obstruction caused by unresectable pancreatic cancer who received partially covered SEMS (PC-SEMS) placement for the first time between January 2003 and January 2016 were retrospectively enrolled for analysis. The rates of PC-SEMS occlusion were evaluated. The possible predictors of PC-SEMS occlusion were analyzed using Cox regression analysis.

RESULTS

In total, 120 patients who received PC-SEMS for unresectable pancreatic cancer were identified. The rate of PC-SEMS occlusion was 37%. The median time to occlusion of PC-SEMS was 359 days. The major causes of occlusion included biliary sludge (61%) and tumor ingrowth (30%). Cox multivariate regression analysis revealed that inadequate alkaline phosphatase/gamma-glutamyl transferase decline (defined by a decrease of <50% within 2 wk after PC-SEMS placement) was the only independent predictor of stent occlusion (hazard ratio, 2.86; 95% CI, 1.28-6.25; p = 0.01) CONCLUSION:: Inadequate alkaline phosphatase/gamma-glutamyl transferase decline is a predictor of occlusion of first-time PC-SEMS placement in unresectable pancreatic cancer patients with biliary tract obstruction.

Clinical efficacy of gemcitabine and cisplatin-based transcatheter arterial chemoembolization combined with radiotherapy in hilar cholangiocarcinoma

BACKGROUND

Radical surgical resection is regarded as the best treatment for hepatic hilar cholangiocarcinoma. However, 60%-70% of patients have lost the chance of surgery at the time of diagnosis. Simple biliary stent or drainage tube placement may fail in a short time due to tumor invasion or overgrowth, bile accumulation, or biofilm formation. Effective palliative treatments to extend the effective drainage time are of great significance for improving the quality of life of patients and changing the prognosis of patients.

AIM

To investigate the clinical efficacy of gemcitabine and cisplatin-based transcatheter arterial chemoembolization (TACE) combined with radiotherapy in hilar cholangiocarcinoma.

METHODS

A retrospective analysis was conducted on patients clinically diagnosed with hilar cholangiocarcinoma from June 2014 to January 2017 at the Liaoning Provincial Cancer Hospital. Patients were evaluated by specialists, and those who were not suitable for surgery or unwilling to undergo surgery and met the inclusion criteria were included in the study. There were a total of 72 patients (34 males and 38 females) with an average age of 59.9 years (range, 40-72 years). According to percutaneous transhepatic biliary angiography and the patients’ wishes, stent implantation or biliary drainage tube implantation was used to relieve biliary obstruction. The patients were divided into either a control group or a combined treatment group according to their follow-up treatment. The control group consisted of a total of 35 patients who received simple biliary drainage tube placement and biliary stent implantation (7 patients with bilateral stents and 6 with a unilateral stent) and 22 patients receiving biliary drainage tube placement alone. The combined treatment group received TACE and extracorporeal radiotherapy after biliary drainage or biliary stent implantation and consisted of a total of 37 patients, including 21 patients receiving combined treatment after biliary stent placement (14 patients with bilateral stents and 7 with a unilateral stent) and 16 undergoing combined therapy after implanting the biliary drainage tube. In the combination treatment group, the TACE chemotherapy regimen employed gemcitabine and cisplatin, and the embolic agent was iodized oil. A particular dose was determined according to the patient's body surface area and the tumor staining indicated by DSA. In vitro radiotherapy was performed with intensity-modulated radiotherapy or three-dimensional conformal radiotherapy at an average dose of 48.3 Gy. Both groups were followed from stent implantation or drainage tube implantation until the patient quitted or died. The median length of follow-up observation was 13 mo. The differences in overall survival time and the effect of different jaundice reducing methods (single stent, double stent, or biliary drainage) on the patency time and survival time of biliary stents were compared between the two groups; the related factors affecting overall survival time were analyzed.

RESULTS

The median survival time of the control group was 10.5 mo; the median survival time of patients with biliary stent implantation and those with percutaneous biliary drainage was 9.6 mo and 11.4 mo, respectively, and there was no statistically significant difference between them. The median survival time of the combined treatment group was 20.0 mo, which was significantly higher than that of the control group (P < 0.05). Among patients in the combined treatment group, the median survival time of patients who underwent biliary stent implantation and those who accepted percutaneous biliary drainage before the combination therapy was 19.5 mo and 20.1 mo, respectively, and there was no significant difference between them. In the combination treatment group, the mean time of median stent patency was 15.6 mo, which was significantly higher than that of the control group (7.0 mo; P < 0.05). The independent factors affecting survival time included age, whether to receive combination therapy, percutaneous biliary drainage tube implantation, and Bismuth-Corlette classification as type IV.

CONCLUSION

Gemcitabine and cisplatin-based TACE combined with radiotherapy can prolong the survival of patients with hilar cholangiocarcinoma. Independent predictors of survival include selection of combination therapy, Bismuth-Corlette classification as type IV, selection of percutaneous biliary drainage tube implantation, and age.

Assessment of treatment outcomes in patients with advanced hilar cholangiocarcinoma (stages III-IV): Clinical significance of interventional therapy

The clinical significance of palliative interventional therapy in the management of patients with advanced hilar cholangiocarcinoma (HCCA; stages III-IV) has yet to be studied. The present work was aimed to compare the clinical outcomes of the patients treated with surgery or interventional therapy.A total of 90 patients with advanced HCCA, who admitted Fuyang First People's Hospital from May 2015 to February 2016, were enrolled. Forty-five of them were assigned to the experimental group receiving biliary drainage as the interventional therapy, and the remaining 45 patients were designated as the conventional group receiving radical/palliative surgery. Before and after the treatment total bilirubin from blood was measured. The length of treatment and medical cost were also examined. All patients were followed up for at least 1 year after the treatment.For both the experimental and conventional groups, the serum bilirubin levels after treatment were significantly lower than those before treatment (P < .05); however, no significant differences between groups were seen. There were no significant differences between experimental and conventional groups in the incidence of postoperative complications and survival outcomes. Of note, the length of treatment of the experimental group was substantially shorter than that of the conventional group (P < .05). The medical expense of the experimental group was only about one-third of that of the conventional group (P < .05).Although the interventional therapy does not improve patients' survivals and reduce the incidence of complications, it significantly shortens the treatment length, reducing substantially the medical expense. This finding provides new insights into the treatment strategy for patients with advanced HCCA.

Malignant obstructive jaundice treated with intraluminal placement of Iodine-125 seed strands and metal stents: An analysis of long-term outcomes and prognostic features

PURPOSE

The purpose of this study was to analyze the long-term outcomes, including safety, efficacy, and prognostic features, of intraluminal brachytherapy with Iodine-125 (¹²⁵I) seed strand and stent placement for treatment of patients with malignant obstructive jaundice (MOJ).

METHODS AND MATERIALS

From January 2009 to December 2013, 107 consecutive patients with MOJ were treated with intraluminal placement of ¹²⁵I seed strands and metal stents. A retrospective evaluation of therapeutic outcomes, including overall survival (OS), stent patency rate, complications, and prognostic features, was conducted in 101 patients.

RESULTS

¹²⁵I seed strands and stents were all successfully implanted. The median followup time was 231 (45-1015) days, and the median OS was 394.0 (95% confidence interval: 319.1-468.9) days. The cumulative OS rates at 3, 6, 12, and 24 months were 95%, 77%, 53%, and 20%, respectively. The median stent patency period was 278.0 (95% confidence interval: 164.1-391.9) days, and cumulative patency rates at 3, 6, 12, and 24 months were 92%, 69%, 45%, and 13%, respectively. Multivariate analysis indicated that the serum conjugated/total bilirubin ≥88% before procedure (p = 0.032) and whether the patient receiving further treatment (p = 0.041) appear to be the prognostic factors of OS. There is no statistical prognostic factor for stent patency.

CONCLUSIONS

The intraluminal placement of ¹²⁵I seed strands and stents appears to be a safe and efficient therapy on MOJ. The patient with serum conjugated/total bilirubin ≥88% before procedure and receiving further treatment seems to live longer.

Irradiation stents vs. conventional metal stents for unresectable malignant biliary obstruction: A multicenter trial

BACKGROUND & AIMS

Placement of an irradiation stent has been demonstrated to offer longer patency and survival than an uncovered self-expandable metallic stent (SEMS) in patients with unresectable malignant biliary obstruction (MBO). We aim to further assess the efficacy of an irradiation stent compared to an uncovered SEMS in those patients.

METHODS

We performed a randomized, open-label trial of participants with unresectable MBO at 20 centers in China. A total of 328 participants were allocated in parallel to the irradiation stent group (ISG) or the uncovered SEMS group (USG). Endpoints included stent patency (primary), technical success, relief of jaundice, overall survival, and complications.

RESULTS

The first quartile stent patency time (when 25% of the patients experienced stent restenosis) was 212 days for the ISG and 104 days for the USG. Irradiation stents were significantly associated with a decrease in the rate of stent restenosis (9% vs. 15% at 90 days; 16% vs. 27% at 180 days; 21% vs. 33% at 360 days; p = 0.010). Patients in the ISG obtained longer survival time (median 202 days vs. 140 days; p = 0.020). No significant results were observed in technical success rate (93% vs. 95%; p = 0.499), relief of jaundice (85% vs. 80%; p = 0.308), and the incidence of grade 3 and 4 complications (8.5% vs. 7.9%; p = 0.841).

CONCLUSIONS

Insertion of irradiation stents instead of uncovered SEMS could improve patency and overall survival in patients with unresectable MBO.

LAY SUMMARY

For patients with unresectable malignant biliary obstruction (MBO), placement of a self-expandable metallic stent (SEMS) is a recommended palliative modality to relieve pruritus, cholangitis, pain, and jaundice. However, restenosis is a main pitfall after stent placement. Data from this first multicenter randomized controlled trial showed that insertion of an irradiation stent provided longer patency and better survival than a conventional metal stent. ClinicalTrials.gov ID: NCT02001779.

Palliative Percutaneous Biliary Interventions in Malignant High Bile Duct Obstruction

The optimal palliative intervention for malignant biliary obstruction is internal drainage by placement of a metallic stent. For patients with hilar biliary obstruction or low bile duct obstruction in whom endoscopy is not feasible, a percutaneous transhepatic approach in interventional radiology is preferred. This article reviews the rationale for this approach, periprocedural management, and techniques to optimize stent patency.

Bare-metal stents across the Vater's ampulla is a safe method for patients with lower bile duct obstruction

This study explored the effect of the implant position of stents across the Vater's ampulla on treatment outcomes in patients with lower bile duct obstruction.In the retrospective study, 41 patients with malignant obstruction of the lower bile duct and obstructive jaundice received percutaneous transhepatic biliary placement of bare-metal stents. Basic demographic data on patients, such as sex, age, and primary diseases, and follow-up data, including postoperative complications and jaundice-free survival, were recorded. The follow-up data on patients with an involved ampulla, patients with an uninvolved ampulla, patients with a stent across the ampulla, and patients with a stent at a site other than the ampulla were compared. Furthermore, prognostic factors for jaundice- free survival were investigated using Cox proportional hazards regression analysis.Among the 41 patients, 38 patients experienced subsiding of jaundice, whereas 3 cases had unsuccessful stent patency. Whether or not the ampulla was involved did not influence the incidence rates of postoperative complications and the jaundice-free survival time. Notably, when stents were placed across the ampulla, the jaundice-free survival time was significantly longer than when stents were placed at sites other than across the ampulla (P < .05). Furthermore, placement of the stent across the ampulla or at other sites was an independent prognostic factor (hazard ratio = 0.154, 95% confidence interval 0.042-0.560, P = .005) for jaundice-free survival of patients.The current study revealed that the implant position of a stent across the ampulla resulted in maintenance of stent patency and prolongation of the jaundice-free survival time.

Percutaneous Transhepatic Biliary Stenting with Uncovered Self-Expandable Metallic Stents in Patients with Malignant Biliary Obstruction - Efficacy and Survival Analysis

BACKGROUND

The aim of this study was to assess short- and long-term outcomes of malignant biliary obstruction (MBO) treatment by percutaneous transhepatic biliary stenting (PTBS) with uncovered selfexpandable metallic stents (SEMS), and to identify predictors of survival.

MATERIAL/METHODS

A nine-year, single-centre study from a prospectively collected database included 222 patients with inoperable MBO treated by PTBS with uncovered nitinol SEMS.

RESULTS

Technical and clinical success rates were 95.9% and 82.4%, respectively. The total rate of postprocedural complications was 14.4%. The mean durations of the primary and secondary stent patency were 114.7±15.1 and 146.4±21.2 days, respectively. The 30-day mortality rate was 15.3% with no procedure-related deaths. The mean estimated length of survival was 143.3±20.6 days. Independent predictors increasing the risk of death included higher than 115 μmol/L serum bilirubin 2-5 days after biliary stenting (HR 3.274, P=0.019), distal (non-hilar) obstruction of the bile ducts (HR 3.711, P=0.008), Bismuth-Corlette type IV stricture (HR 2.082, P=0.008), obstruction due to gallbladder cancer (HR 31.029, P=0.012) and only partial drainage of liver parenchyma (HR 4.158, P=0.040).

CONCLUSIONS

PTBS with uncovered SEMS is an effective and safe method for palliative treatment of MBO. Serum bilirubin higher than 115 μmol/L 2-5 days after the procedure has a significant negative impact on patients' survival. Lower survival is also determined by distal bile duct obstruction, Bismuth- Corlette type IV stricture, biliary obstruction caused by gallbladder cancer and when only partial liver drainage is applied.

Safety and Efficacy of Percutaneous Biliary Covered Stent Placement in Patients with Malignant Biliary Hilar Obstruction; Correlation with Liver Function

PURPOSE

To estimate the safety and efficacy of percutaneous ePTFE-covered biliary stent placement and the relationship between underlying liver function and stent patency in patients with malignant hilar obstruction.

MATERIALS AND METHODS

From March 2012 to June 2015, 41 patients [22 females, 19 males; mean age 69.8 (range 34-94) years] with malignant biliary obstruction underwent percutaneous biliary stent placement (31 patients with unilateral, 10 patients with bilateral side-by-side). Cumulative patient survival and stent patency rate curves were derived using the Kaplan-Meier method. A Cox model was used to explore the relationship between liver function and patient survival, and also biliary stent patency. Pearson correlation coefficient was used to analyze the relationship between patient survival and stent patency.

RESULTS

Technical success rate was 100 % and clinical success rate was 95 %. During follow-up, four complications occurred (two bilomas and two cases of acute cholecystitis) and were treated successfully with percutaneous drainage. No other complication occurred. Mean serum bilirubin level was 11.34 ± 7.35 mg/dL before drainage and 5.00 ± 4.83 mg/dL 2 weeks after stent placement. The median patent survival duration was 147 days (95 % CI, 69.6-224.4 days). The median stent patency duration was 101 days (95 % CI, 70.0-132.0 days). The cumulative stent patency rates at 1, 3, 6, and 12 months were 97, 57.6, 30.3, and 17.0 %, respectively. Child-Pugh score was correlated significantly with patient survival (P = 0.011) and stent patency (P = 0.007). MELD score was correlated significantly with stent patency (P = 0.044). There was a correlation between patient survival and stent patency (r = 0.778, P < 0.001).

CONCLUSION

Percutaneous placement of ePTFE-covered biliary stent was a safe and an effective method for malignant biliary obstruction. Underlying liver function seemed to be one of the important factors affecting patient survival and stent patency, and stent patency showed statistically significant correlation with patient survival.

Unilobar Versus Bilobar Biliary Drainage: Effect on Quality of Life and Bilirubin Level Reduction

BACKGROUND

Percutaneous biliary drainage is an accepted palliative treatment for malignant biliary obstruction.

PURPOSE

To assess the effect on quality of life (QOL) and bilirubin level reduction in patients with inoperable malignant biliary obstruction treated by unilobar or bilobar percutaneous transhepatic biliary drainage (PTBD).

MATERIALS AND METHODS

Over a period of 2 years, 49 patients (age range, 22-75 years) of inoperable malignant biliary obstruction were treated by PTBD. Technical and clinical success rates, QOL, patency rates, survival rates, and complications were recorded. Clinical success rates, QOL, and bilirubin reduction were compared in patients treated with complete (n = 21) versus partial (n = 28) liver parenchyma drainage. QOL before and 1 month after biliary drainage were analyzed retrospectively between these two groups.

RESULTS

Biliary drainage was successful in all 49 patients, with an overall significant reduction of the postintervention bilirubin levels (P < 0.001) resulting in overall clinical success rate of 89.97%. Clinical success rates were similar in patients treated with whole-liver drainage versus partial-liver drainage. Mean serum bilirubin level before PTBD was 19.85 mg/dl and after the procedure at 1 month was 6.02 mg/dl. The mean baseline functional score was 39.35, symptom scale score was 59.55, and global health score was 27.45. At 1 month, mean functional score was 61.25, symptom scale score was 36.0 4, and global health score was 56.33, with overall significant improvement in QOL (<0.001). There was a statistically significant difference in the improvement of the QOL scores (P = 0.002), among patients who achieved clinical success, compared with those patients who did not achieve clinical success at 1 month. We did not find any significant difference in the QOL scores in patients according to the amount of liver drained (unilateral or bilateral drainage), the type of internalization used (ring biliary or stent). Overall, minor and major complications rates were 14.3% and 8.1%, respectively.

CONCLUSION

Percutaneous biliary drainage provides good palliation of malignant obstructive jaundice. Partial-liver drainage achieved results as good as those after complete liver drainage with significant improvements in QOL and reduction of the bilirubin level.

Percutaneous transhepatic biliary drainage and stenting for malignant obstructive jaundice: A report of two cases

Malignant obstructive jaundice comprises a group of diseases that can be caused by primary biliary and extra-biliary carcinomas. Generally, surgical resection is the primary treatment for malignant obstructive jaundice; however, for the patients that are unable to undergo surgery, urgent treatment is required to improve hepatic function. Percutaneous transhepatic biliary drainage (PTBD) and stenting are emerging alternative treatments for malignant obstructive jaundice. PTBD and stenting have exhibited good efficacy for the treatment of malignant obstructive jaundice, with few complications and reduced associated pain.

Biliary stenting for unresectable cholangiocarcinoma: A population-based study of long-term outcomes and hospital costs in Taiwan

Few studies have compared percutaneous biliary stenting (PBS) and endoscopic biliary stenting (EBS) in terms of long-term effects on cholangiocarcinoma (CC), and few have systematically evaluated outcome associations in Taiwan. This study aimed to compare long-term outcomes between two treatments for unresectable CC: PBS and EBS. After propensity score matching (PSM) to reduce the effect of selection bias, 1002 CC patients were included in this analysis: 501 in the PBS group and 501 in the EBS group. The Kaplan-Meier method was used to construct the survival curve for all CC patients, and the Cox proportional hazards model was used for multivariate assessment of outcome predictors. After PSM, group comparisons revealed a significantly longer length of stay in the PBS group compared to the EBS group (25 days vs. 19 days, respectively; p < 0.001). Hospital costs were also significantly higher in the PBS group than in the EBS group (US$126,575 vs. US$89,326, respectively; p < 0.001). The median survival time was 3.7 months in all CC patients, 3.5 months in the PBS group, and 4.0 months in the EBS group. The 1-year, 3-year, and 5-year survival rates were 17.6%, 6.1%, and 3.2% in all CC patients; 16.6%, 4.8%, and 3.2% in the PBS group; and 18.6%, 7.27%, and 3% in the EBS group, respectively. The most important predictor of survival is extrahepatic CC. Medical professionals and healthcare providers should carefully consider the use of EBS for initial treatment of obstructive jaundice in patients with unresectable CC.

Percutaneous transhepatic biliary metal stent for malignant hilar obstruction: results and predictive factors for efficacy in 159 patients from a single center

AIM

To investigate and compare the efficacy and safety of percutaneous transhepatic biliary stenting (PTBS) using a one- or two-stage procedure and determine the predictive factors for the efficacious treatment of malignant hilar obstruction (MHO).

METHODS

159 consecutive patients with MHO who underwent PTBS were enrolled between January 2010 and June 2013. Patients were classified into one- or two-stage groups. Independent predictors of therapeutic success were evaluated using a logistic regression model.

RESULTS

108 patients were treated with one-stage PTBS and 51 patients were treated with two-stage PTBS. The stents were technically successful in all patients. Successful drainage was achieved in 114 patients (71.4 %). A total of 42 early major complications were observed. Re-interventions were attempted in 23 patients during follow-up. The cumulative primary patency rates at 3, 6, and 12 months were 88, 71, and 48 %, respectively. Stent placement using a one- or two-stage procedure did not significantly affect therapeutic success, early major complications, median stent patency, or survival. A stent placed across the duodenal papilla was an independent predictor of therapeutic success (odds ratio = 0.262, 95 % confidence interval [0.107-0.642]). Patients with stents across papilla had a lower rate of cholangitis compared with patients who had a stent above papilla (7.1 vs. 20.3 %, respectively, p = 0.03).

CONCLUSIONS

The majority of patients with MHO who underwent one-stage PTBS showed similar efficacy and safety outcomes compared with those who underwent two-stage PTBS. Stent placement across the duodenal papilla was associated with a higher therapeutic success rate.

Percutaneous use of ePTFE/FEP-covered metallic stent for palliation of malignant biliary obstruction

INTRODUCTION

Placement of self-expanding metallic stents has been a standard palliative treatment for patients with inoperable biliary malignancy, aiming at improving quality of life via a minimally invasive procedure. This study aimed to evaluate the efficacy of percutaneous placement of expanded polytetrafluoroethylene/fluorinated ethylene propylene-covered metallic stents for palliation of inoperable biliary malignancy.

MATERIAL AND METHODS

Between February 2012 and April 2013, 11 patients with inoperable malignant biliary obstruction were treated with stent implantation. Serum bilirubin and liver enzyme levels were measured before/immediately after stent placement and at one, three, and six months. Patient survival and stent patency were calculated using Kaplan-Meier analysis.

RESULTS

No migration occurred. Patients showed clinical improvement immediately and one month after stent placement, with a significant reduction in mean serum bilirubin level (p < 0.05). At six months, bilirubin levels were <1.5 mg/dL in all cases. One patient developed acute liver failure four days after stent implantation, leading to death. Survival rates were 90% at three months and 70% at six months. Primary patency rates were 100%, 100%, and 90% at one, three, and six months, respectively.

CONCLUSION

Percutaneous placement of expanded polytetrafluoroethylene/fluorinated ethylene propylene-covered metallic stents offered an effective palliative therapy for patients with inoperable biliary malignancy.

Percutaneous transhepatic biliary drainage in patients with advanced solid malignancies: prognostic factors and clinical outcomes

PURPOSE

Obstructive jaundice (OJ) is a cumbersome complication in late-stage malignancies, and percutaneous transhepatic biliary drainage (PTBD) is often used to relieve symptoms and allow chemotherapy (CT).

METHODS

From July 2008 to August 2011, 71 patients (pts) with OJ due to solid malignancies underwent PTBD in our institution. Baseline characteristics, procedure complications, and outcomes were retrospectively collected. The primary objective was to estimate overall survival (OS) after PTBD.

RESULTS

Median age was 60 years, 63% had an ECOG performance status (PS) of 1-2, and 10% were receiving supportive care (SC). Most had primary gastrointestinal tumors (89%) and metastatic disease at diagnosis (59%). Mean hospital stay was 16.6 days (2-90 days), with bilirubin value decreased (BVD) after 80% of procedures. Cholangitis was observed in 66.2% of pts and 60.6% required readmissions. Only 51.6% of pts not in SC were eligible for CT after PTBD. Median OS was 2.9 months (95% CI 0.62-5.2). Prognostic factors on univariate analysis include ECOG ≤2 (6.8 versus 0.79 months, p < 0.0001), BVD (6.7 versus 0.33 months, p < 0.0001), and CT after PTBD (13.7 versus 1.2 months p < 0.0001). On multivariate analysis, CT after procedure was related to better OS (HR 0.15, CI 0.06-0.38, p < 0.001).

CONCLUSIONS

Malignant OJ is a late event in cancer pts. Thorough evaluation is needed before determining eligibility to PTBD due to its high complication and hospitalization rates. In the current analysis, pts with PS >2 and who are not candidates for further CT had a dismal prognosis and should probably not be offered PTBD.

Clinical outcomes and prediction of survival following percutaneous biliary drainage for malignant obstructive jaundice

The present study aimed to investigate the clinical outcomes of percutaneous transhepatic biliary drainage in patients with obstructive jaundice and identify potential predictors of patient survival. Clinical data from 102 patients (66 males and 36 females; median age, 63.50 years; range, 29–84 years) with a mean (± standard deviation) pre-drainage serum bilirubin level of 285.4 (±136.7 μmol/l), were retrospectively studied. Technical and clinical success, complications and survival time were recorded and their relationship with clinical factors, including age, obstruction level, liver metastases, serum bilirubin level and subsequent treatments following drainage, were analyzed by Fisher’s exact test. Patient survival rate and other predictors were analyzed by Kaplan-Meier survival curves and Cox’s proportional hazard model. The technical and clinical success rates were 100 and 76.5%, respectively. The presence of liver metastases was associated with reduced successful drainage. The overall complication rate was 7.8% and the overall median survival time was 185 days [95% confidence interval (CI), 159–211 days]. A log-rank test showed that age (χ², 4.003; P=0.04), bilirubin levels following procedure (χ², 5.139; P=0.02) and subsequent therapy (χ², 15.459; P=0.00) affected survival time. However, Cox’s regression analysis revealed no administration of additional treatments to be a risk factor of survival (odds ratio, 2.323; 95% CI, 1.465–3.685; P=0.000). Percutaneous transhepatic biliary drainage for malignant biliary obstruction was found to be a safe and effective method to relieve jaundice caused by progressive neoplasms. Subsequent radical therapy following drainage, including surgery, chemotherapy and other local treatment types, are likely to increase patient survival.

One-stage percutaneous triple procedure for treatment of endoscopically unmanageable patients with malignant biliary obstruction and marked ascites

BACKGROUND AND STUDY AIMS

To assess the feasibility, safety and efficacy of one-stage percutaneous triple procedure including; ascites drainage, primary metallic biliary stenting, and tract embolisation with N-butyl 2-cyanoacrylate (NBCA), in treatment of patients with malignant biliary obstruction and marked ascites.

PATIENTS AND METHODS

This study involved 25 patients with malignant biliary obstruction and marked ascites (age range, 46-78y; mean age±SD, 65y±5) for whom endoscopic treatment failed or was unsuitable. Ascites drainage, percutaneous primary metallic biliary stenting, and tract embolisation with lipiodol/NBCA mixture were performed in a one-stage procedure. The mean±SD follow up period was 26±2weeks.

RESULTS

The technical and clinical success rates were 96% and 88% respectively. No procedure related deaths or major complications were observed. The reported minor complications included; moderate pain and vomiting during and after balloon dilation, postprocedural cholangitis, and bile leakage in 44%, 16%, and 8% of the patients respectively. Primary stent patency was achieved in 96%. The 30-days mortality was 8%. The stent obstruction occurred in 3 (13%) of the 23 patients who survived more than 30-days.

CONCLUSIONS

Percutaneous drainage of ascites followed immediately by primary biliary stenting, together with tract embolisation with NBCA is technically feasible, safe, and effective alternative palliative treatment for endoscopically unmanageable patients with malignant biliary obstruction and marked ascites.

Percutaneous metallic stent placement in patients with cancer recurrence at bilioenterostomy site

PURPOSE

To investigate the outcomes of percutaneous metallic stent placement in patients with malignant bilioenterostomy obstruction and to assess the risk factors influencing stent patency.

MATERIALS AND METHODS

From August 2008 to January 2012, 53 patients with malignant bilioenterostomy obstructions were treated with percutaneous placement of biliary metallic stents; this included expanded polytetrafluoroethylene (ePTFE)-covered stent placement in 36 patients and uncovered stent placement in 17 patients.

RESULTS

A total of 75 stents were successfully placed in 53 patients. No major complications occurred in any patients, and minor complications occurred in nine patients (17%). The mean serum bilirubin level, which was 3.6 mg/dL ± 0.7 before drainage, decreased significantly to 2.5 mg/dL ± 0.4 at 1 month after stent placement (P = .041). Successful internal drainage was achieved in 44 of the 53 patients (83%). Kaplan-Meier analysis showed a median overall survival time of 145 days (95% confidence interval, 100-190 d), a median stent patency time of 313 days (95% confidence interval, 46-580 d), and cumulative stent patency rates at 1, 3, 6, 9, and 12 months of 91%, 75%, 64%, 56%, and 45%, respectively. Multivariate Cox regression analysis showed that the use of uncovered stents (odds ratio, 2.924; P = .033) was the only significant independent factor associated with stent occlusion.

CONCLUSIONS

Percutaneous metallic stent placement is a safe and effective method for the treatment of patients with malignant bilioenterostomy obstruction. Moreover, as uncovered stent placement is the only significant independent factor associated with stent occlusion, ePTFE-covered stent placement is preferable in these patients.

Percutaneous placement of self-expandable metallic stents in patients with obstructive jaundice secondary to metastatic gastric cancer after gastrectomy

Objective

To evaluate the outcomes of patients undergoing percutaneous placements of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy.

Materials and Methods

Fifty patients (mean age, 62.4 years; range, 27-86 years) who underwent percutaneous placements of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy were included. The technical success rate, clinical success rate, complication rate, stent patency, patient survival and factors associated with stent patency were being evaluated.

Results

The median interval between the gastrectomy and stent placement was 23.1 months (range, 3.9-94.6 months). The 50 patients received a total of 65 stents without any major procedure-related complications. Technical success was achieved in all patients. The mean total serum bilirubin level, which had been 7.19 mg/dL ± 6.8 before stent insertion, decreased to 4.58 mg/dL ± 5.4 during the first week of follow-up (p < 0.001). Clinical success was achieved in 42 patients (84%). Percutaneous transhepatic biliary drainage catheters were removed from 45 patients (90%). Infectious complications were noted in two patients (4%), and stent malfunction occurred in seven patients (14%). The median stent patency was 233 ± 99 days, and the median patient survival was 179 ± 83 days. Total serum bilirubin level after stenting was an independent factor for stent patency (p = 0.009).

Conclusion

Percutaneous transhepatic placement of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy is a technically feasible and clinically effective palliative procedure.

Comparing percutaneous primary and secondary biliary stenting for malignant biliary obstruction: A retrospective clinical analysis

Purpose:

Percutaneous transhepatic primary biliary stenting (PS) is an alternative to the widely used staged procedure (secondary biliary stenting, SS) for treating obstructive jaundice in cancer patients. To evaluate the efficacy and safety of PS and SS, a retrospective analysis was carried out.

Materials and Methods:

The percutaneous biliary stenting procedures performed between January 2000 and December 2007 at one hepatobiliary center were retrospectively analyzed, comparing the technical success rates, complications, and length of hospitalization of the two procedures. Of 61 patients (mean age 65.5 ± 13.1 years; range 31.1-92.7 years) suffering from obstructive jaundice caused by primary or metastatic tumors, 30 received PS and 31 received SS. The groups were comparable in the anatomical level of the obstruction, stent configuration, or the concurrent presence of cholangitis. Placement of metallic stents required one session for patients in the PS group and an average of 2.6 ± 1.1 sessions for patients in the SS group.

Results:

The overall technical success rate was 98.4% with 1 (1/61) failed approach to transcend the occlusion in the SS group. The rate of minor complications was 10% in the PS group and 6.5% in the SS group. The corresponding rates of major complications were 23.3% and 54.8%, respectively. SS patients had a higher rate of complications in general (P < 0.05), as well as a higher rate of severe complications in particular (P < 0.05). Procedural mortality was 0% for both the groups. The mean overall length of hospitalization was 7.7 ± 9.6 days for PS and 20.6 ± 19.6 days for SS (P < 0.001).

Conclusion:

Primary percutaneous biliary stenting of malignant biliary obstructions is as efficacious and safer than a staged procedure with secondary stenting. By virtue of requiring shorter hospital stays, primary stenting is likely to be more cost-effective.

Radiotherapy prolongs biliary metal stent patency in malignant pancreatobiliary obstructions

BACKGROUND/AIMS

Biliary stenting is the most effective decompressive method for treating malignant biliary obstructive jaundice. Although the main cause of stent occlusion is tumor growth, few studies have investigated whether stent patency is affected by the combination of cancer-treatment modalities. The aim of this study was to evaluate the effects of local radiotherapy on metal-stent patency in patients with malignant biliary obstruction.

METHODS

Patients who underwent self-expandable biliary metallic stenting for malignant biliary obstruction from 1999 to 2007 were included. Forty patients received chemotherapy and radiation therapy (radiation group, RG), and 31 patients received only chemotherapy (nonradiation group, NRG).

RESULTS

The cumulative median stent patency was significantly longer in the RG than in the NRG (17.7 months; 95% confidence interval [CI], 1.8 to 33.6 months vs 8.7 months; 95% CI, 4.9 to 12.5 months; p=0.025). Stent occlusion caused by tumor growth or stent migration occurred in two (5%) and three (7.5%) cases in the RG and in six (19.3%) and two (6.5%) cases in the NRG, respectively.

CONCLUSIONS

The patency of biliary metal stents in pancreatobiliary cancer patients who receive chemoradiation therapy is significantly longer than that in patients who do not receive radiotherapy, which suggests that local cancer control significantly affects stent patency.

Percutaneous trans-hepatic bilateral biliary stenting in Bismuth IV malignant obstruction

AIM

To investigate the clinical efficiency of percutaneous trans-hepatic bilateral biliary metallic stenting for the management of Bismuth IV malignant obstructive disease.

METHODS

Our hospital's database was searched for all patients suffering from the inoperable malignant biliary obstruction Bismuth IV, and treated with percutaneous bilateral trans-hepatic placement of self-expandable nitinol stents. The indication for percutaneous stenting was an inoperable, malignant, symptomatic, biliary obstruction. An un-correctable coagulation disorder was the only absolute contra-indication for treatment. Bismuth grading was performed using magnetic resonance cholangiopancreatography. Computed tomography evaluation of the lesion and the dilatation status of the biliary tree was always performed prior to the procedure. All procedures were performed under conscious sedation. A single trans-hepatic track technique was preferred (T-configuration stenting) and a second, contra-lateral trans-hepatic track (Y-configuration stenting) was used only in cases of inability to access the contra-lateral lobe using a single track technique. The study's primary endpoints were clinical success, defined as a decrease in bilirubin levels within 10 d and patient survival rates. Secondary endpoints included peri-procedural complications, primary and secondary patency rates.

RESULTS

A total of 35 patients (18 female, 51.4%) with a mean age 69 ± 13 years (range 33-88) were included in the study. The procedures were performed between March 2000 and June 2008 and mean time follow-up was 13.5 ± 22.0 mo (range 0-96). The underlying malignant disease was cholangiocarcinoma (n = 10), hepatocellular carcinoma (n = 9), pancreatic carcinoma (n = 5), gastric cancer (n = 2), bile duct tumor (n = 2), colorectal cancer (n = 2), gallbladder carcinoma (n = 2), lung cancer (n = 1), breast cancer (n = 1) or non-Hodgkin lymphoma (n = 1). In all cases, various self-expandable bare metal stents with diameters ranging from 7 to 10 mm were used. Stents were placed in Y-configuration in 24/35 cases (68.6%) using two stents in 12/24 patients and three stents in 12/24 cases (50%). A T-configuration stent placement was performed in 11/35 patients (31.4%), using two stents in 4/11 cases (36.4%) and three stents in 7/11 cases (63.6%). Follow-up was available in all patients (35/35). Patient survival ranged from 0 to 1763 d and the mean survival time was 168 d. Clinical success rate was 77.1% (27/35 cases), and peri-procedural mortality rate was 5.7% (2/35 patients). Biliary re-obstruction due to stent occlusion occurred in 25.7% of the cases (9/35 patients), while in 7/11 (63.6%) one additional percutaneous re-intervention due to stent occlusion resulting in clinical relapse of symptomatology was successfully performed. In the remaining 4/11 patients (36.4%) more than 1 additional reintervention was performed. The median decrease of total serum bilirubin was 60.5% and occurred in 81.8% of the cases (27/33 patients). The median primary and secondary patency was 105 (range 0-719) and 181 d (range 5-1763), respectively. According to the Kaplan-Meyer survival analysis, the estimated survival rate was 73.5%, 47.1% and 26.1% at 1, 6 and 12 mo respectively, while the 8-year survival rate was 4.9%. Major and minor complication rates were 5.7% (2/35 patients) and 17.1% (6/35 patients), respectively.

CONCLUSION

Percutaneous bilateral biliary stenting is a safe and clinically effective palliative approach in patients suffering from Bismuth IV malignant obstruction.

Stent patency using competing risk model in unresectable pancreatic cancers inserted with biliary self-expandable metallic stent

BACKGROUND AND AIM

Biliary self-expandable metallic stents (SEMS) play an important role in the quality of life and palliative treatment in unresectable pancreatic cancer patients. We aimed to determine the factors affecting the patency of biliary SEMS and the survival in unresectable pancreatic cancer with obstructive jaundice.

METHODS

Considering the competing risk and survival, we retrospectively evaluated the patency in 107 unresectable pancreatic cancer patients with obstructive jaundice who were successfully treated with biliary SEMS from January 2000 to April 2010.

RESULTS

There were 107 incidents of biliary drainage that were clinically successful and the overall survival period was a median of 133 days. Stent occlusion before death was observed in 36 (33.6%) of 107 patients. Cumulative stent obstruction rates were 4.7%, 16.8%, and 24.4% at 1, 3, and 6 months, respectively. Lower cancer stage (<5 month's hazard ratio [HR] = 2.327, >5 month's HR = 0.108) was only associated with the longer patency of the stents in a multivariable analysis using a Fine and Gray model that considered competing risk. In multivariable analysis, lower cancer stage, uncovered stent and normalized serum bilirubin level were associated with a longer survival period (HR = 2.335, 1.906 and 1.795 respectively, P < 0.05).

CONCLUSION

The patency of biliary SEMS in unresectable pancreatic cancers might be affected by the stage. Lower cancer stage and normalized bilirubin are associated with longer survival.

Evaluation of high-dose-rate intraluminal brachytherapy by percutaneous transhepatic biliary drainage in the palliative management of malignant biliary obstruction--a pilot study

PURPOSE

To evaluate the role of high-dose-rate intraluminal brachytherapy (ILBT) through percutaneous transhepatic biliary drainage (PTBD) in patients with malignant biliary obstruction, in terms of improvement in symptoms, quality of life (QOL), and survival.

METHODS AND MATERIALS

From August 2004 to October 2006, 18 patients aged 30-70 years, who were found unsuitable for surgical resection or were inoperable because of poor general condition, were taken up for palliative ILBT through PTBD. All patients underwent PTBD followed by internal-external drainage. After a gap of 1 week, high-dose-rate ILBT was performed by delivering a dose of 800cGy prescribed at 1cm from the central axis of the catheter. Two such sessions were given 1 week apart.

RESULTS

The mean fall in bilirubin was 11.37mg% after PTBD and further 2.94mg% after ILBT. The overall response rates were 100% and 80% for pruritus and icterus, respectively. Improvement in appetite and weight gain was seen in 93.3% and 86.7% patients, respectively, at last followup. The median followup and survival duration were 7.3 and 8.27 months, respectively. Actuarial survival at 6 months was 61.11%. Treatment-related major complications were not seen in any of the patients. QOL showed significant improvement in global health status and most functional and symptom scales.

CONCLUSIONS

This prospective pilot study demonstrated that PTBD followed by ILBT is a feasible procedure with good symptom control, definite impact on QOL, and minimal complications in such patients. A prospective randomized study is required to more accurately assess the benefit of ILBT compared with biliary drainage alone.

Placement of metallic biliary endoprostheses in complex hilar tumours

PURPOSE

To assess the technical success, clinical success and complications after 1 month of percutaneous biliary drainage with the placement of several metallic endoprostheses in complex hilar liver tumours.

MATERIALS AND METHODS

This is a retrospective study, on a homogenous target population of 68 consecutive patients, who underwent multiple percutaneous biliary drainage for complex hilar tumour (Bismuth type II, III and IV) between August 1998 and August 2010. Patients benefiting from previous endoscopic drainage were excluded from the study. The clinical data, biological data, imaging and interventional radiology procedures were studied.

RESULTS

The rate of success of the technique was 98.5% and the clinical rate of success was 84% after 1 week and 93% after 1 month. The rate of minor and major complications was 25 and 13% respectively.

CONCLUSION

Multiple percutaneous biliary drainage in complex hilar tumour is a safe and effective first intention procedure.

Safety and efficacy of primary metallic biliary stent placement with tract embolization in patients with massive ascites: a retrospective analysis of 16 patients

PURPOSE

To evaluate the safety and efficacy of primary metallic biliary stent placement with tract embolization in patients with massive ascites.

MATERIALS AND METHODS

Sixteen patients with malignant biliary obstruction and massive ascites (age range, 44-79 y; median age, 59 y) were treated with primary percutaneous stent placement with tract embolization. These patients were unsuitable candidates for endoscopic intervention. Etiologies of biliary obstruction were gastric cancer with hilar nodal metastases (n = 9), pancreatic carcinoma (n = 5), cholangiocarcinoma (n = 1), and gallbladder carcinoma (n = 1). Eight patients had nonhilar lesions and the remaining eight had hilar lesions. Percutaneous accesses to the biliary system and stent placements were performed in a one-step procedure, and catheters were removed with tract embolization with metallic coils.

RESULTS

Stent placement and tract embolization were successful in all patients, without external drainage catheters left in place. Significant reduction of serum bilirubin level was observed in 14 patients (87.5%). No bile peritonitis or intraperitoneal hemorrhage occurred. Major complications included postprocedural cholangitis (12.5%), bloody bowel discharge (6.2%), and right pleural effusion (25.0%). One patient who died 19 days after intervention was deemed to represent a procedure-related mortality. During the survival period (range, 19-175 d; median, 66 d), stent occlusion was noted in two patients at 6 and 159 days after the procedure. Primary stent patency was achieved in 14 patients (87.5%).

CONCLUSIONS

Primary biliary stent placement with tract embolization is technically safe and offers an effective palliative treatment option for patients with malignant biliary obstruction and massive ascites when endoscopic intervention is not possible.

Efficacy of metal and plastic stents in unresectable complex hilar cholangiocarcinoma: a randomized controlled trial

BACKGROUND

Endoscopic biliary stent drainage is effective in the palliative treatment of patients with hilar cholangiocarcinoma (HCA). However, no randomized controlled trial comparing the efficacy of the self-expandable metal stent (SEMS) and the plastic stent (PS) in patients with unresectable complex HCA is available.

OBJECTIVE

To compare the successful drainage rates of endoscopic SEMSs and PSs.

DESIGN

A single-center, open-label randomized controlled trial.

SETTING

University hospital in KhonKaen, Thailand.

PATIENTS

One hundred eight patients with unresectable complex, Bismuth type II-IV HCA.

INTERVENTIONS

Endoscopic retrograde cholangiography with unilateral SEMS or PS insertion.

MAIN OUTCOME MEASUREMENTS

Successful drainage rate.

LIMITATIONS

Diagnosis of HCA was made by clinical presentations, imaging studies, and clinical outcome during follow-up.

RESULTS

One hundred eight patients were randomly allocated to the SEMS and PS groups. Intention-to-treat analysis revealed that the successful drainage rate in the SEMS group was higher than in the PS group (70.4% vs 46.3%, P = .011). The median survival times were 126 and 49 days, respectively, in the SEMS and PS groups. The overall survival rates of the patients in both groups were statistically different by log-rank test (P = .002).

CONCLUSIONS

Endoscopic biliary drainage with the SEMS provides better adequacy of drainage and longer survival compared with the PS in patients with unresectable complex HCA.

Clinical outcomes after percutaneous biliary interventions in patients with malignant biliary obstruction caused by metastatic gastric cancer

BACKGROUND

No report has appeared on the histologic characteristics as influencing factors associated with clinical outcomes and survival of patients who underwent percutaneous biliary interventions to treat malignant biliary obstruction caused by metastatic gastric cancer.

PURPOSE

To investigate the clinical outcomes after percutaneous biliary interventions in patients with malignant biliary obstruction caused by metastatic gastric cancer and to identify prognostic factors associated with clinical outcomes.

MATERIAL AND METHODS

We retrospectively assessed 117 patients who underwent percutaneous transhepatic biliary drainage (PTBD) between January 2005 and December 2009, for treatment of malignant biliary obstructions caused by metastatic gastric cancer. Of these 117 patients, 54 subsequently underwent metallic stent placement.

RESULTS

The technical success rates of PTBD and metallic stent placement were 100% and 100%, respectively. Self-limiting hemobilia after PTBD occurred in eight (7%) patients, and self-limiting hemobilia (n = 4) and acute pancreatitis (n = 3) after stent placement occurred in seven (13%) patients. Successful drainage was achieved in 105 (90%) of the 117 patients who underwent PTBD and in 49 (91%) of 54 patients who underwent metallic stent placement. Multiple Cox's regression analysis showed that the histology of primary gastric cancer (P = 0.011), serum bilirubin after PTBD (P = 0.002) and stenting (P = 0.017), and chemotherapy after PTBD (P < 0.001) and stenting (P = 0.033) were independent predictors of survival.

CONCLUSION

PTBD and subsequent metallic stent placement were safe and effective methods for palliative treatment in patients with malignant biliary obstruction caused by metastatic gastric cancer. Patients with a differentiated histology of primary gastric cancer and serum bilirubin level ≤2 mg/dl after PTBD are probably the best candidates for treatment with a combination of metallic stent placement and chemotherapy.

The biodurability of covering materials for metallic stents in a bile flow phantom

BACKGROUND

Covered biliary metal stents have been introduced for the purpose of overcoming tumor ingrowth and treatment of benign biliary stricture. The aim of this study was to evaluate the biodurability of three commercially available biliary metal stent covering materials [e-PTFE (expanded polytetrafluoroethylene), silicone, and polyurethane] in a bile flow phantom.

MATERIALS AND METHODS

By operation of a peristaltic pump, human bile was circulated continuously in an experimental perfusion system containing covered metal stents. Each stent was removed, respectively, 1, 2, 4, and 6 months after bile exposure. We performed a gross inspection of the covered stents. The covering membrane was detached from the stent and observed by scanning electron microscopy (SEM). Finally, we measured tensile and tear strength of the membranes.

RESULTS

Bile-staining of the membrane showed gradual progression after bile exposure; however, progress was the fastest in e-PTFE. SEM examination showed that the polyurethane surface was smooth, and the silicone surface was relatively smooth. However, e-PTFE had a rough and uneven surface. After bile exposure, there were no significant changes in polyurethane and silicone; however, biofilms and microcracks were observed in e-PTFE. In contrast to a gradual decrease of tensile/tear strength of polyurethane and silicone, those of e-PTFE showed a rapid reduction despite of the strongest baseline tensile and tear strength.

CONCLUSION

e-PTFE tended to form biofilms more frequently than polyurethane and silicone during bile exposure. e-PTFE seemed to be less durable than silicone and polyurethane, however, as clinically applicable material because of strong absolute tensile/tear strengths.

One-step percutaneous transhepatic insertion of a balloon-expanding metallic stent for obstructive jaundice

BACKGROUND AND AIM

The aim of this study was to evaluate the efficacy and safety of one-step percutaneous transhepatic insertion of the Express LD stent, a balloon-expanding stainless steel stent used for the management of distal artery stenosis in the treatment of obstructive jaundice caused by various inoperable malignancies.

METHODS

Seventy-one consecutive patients with unresectable malignant biliary obstruction who underwent Express LD stent placement between 2007 and 2010 at our institute were reviewed.

RESULTS

Mean stent patency was 165 ± 144 days and mean patient survival was 180 ± 156 days, while the cumulative stent patency rate and patient survival rate at 6 and 12 months were 79% and 65%, and 38% and 16%, respectively. Stents were successfully placed in all cases without any stent migration or misplacement. Stent failure occurred in 14 patients (20%), and 16 complications were observed, including 12 cholangitis (17%), two cholecysitis (3%), and two pancreatitis (3%). Y-configuration stenting for hilar bile duct obstruction was the only independent prognostic factor for stent failure.

CONCLUSIONS

One-step percutaneous transhepatic insertion of the Express LD stent is effective and safe for the management of obstructive jaundice caused by inoperable malignancies.

Relapsed acute pancreatitis as the initial presentation of pancreatic cancer in a young man: a case report

In this report, we describe a 31-year-old man in whom acute pancreatitis was the initial feature of a subsequently diagnosed pancreatic adenocarcinoma with multiple metastases. He initially presented at our hospital with acute pancreatitis. Abdominal ultrasonography revealed a mildly dilated pancreatic duct and an enlarged pancreatic head. Although a follow-up abdominal ultrasonography revealed a progressively dilated pancreatic duct and a progressively enlarged pancreatic head, he refused further investigation and was lost to follow-up. Four months later, he returned to our hospital with relapsed acute pancreatitis. Obstructive jaundice was noted and drainage was performed. Because choledochoplasty with multiple balloon catheters was not fully effective, biliary tract bypass surgery was carried out. Intraoperative biopsy confirmed pancreatic adenocarcinoma with multiple metastases. The patient died of massive gastrointestinal bleeding a few weeks later. To our knowledge, this is the youngest case of pancreatic cancer with the uncommon initial presentation of acute pancreatitis reported in the literature. For a patient with acute pancreatitis, particularly recurrent episodes, but with no known risk factors for pancreatitis, a pancreatic neoplasm should be considered as a potential underlying cause, even in a young man.

Clinical outcome of malignant biliary obstruction caused by metastatic gastric cancer

BACKGROUND

The clinical outcome of malignant biliary obstruction caused by metastatic gastric cancer remains unclear. This study was designed to evaluate the clinical outcome and predictive factors of survival in patients who underwent percutaneous transhepatic biliary drainage (PTBD) for malignant biliary obstruction caused by metastatic gastric cancer.

METHODS

Between April 1997 and March 2006, 38 consecutive patients with malignant biliary obstruction caused by metastatic gastric cancer were retrospectively analyzed. All patients underwent PTBD.

RESULTS

After PTBD, serum bilirubin levels significantly decreased in 29 (76%) of 38 patients. Pruritus, fever, jaundice, anorexia, abdominal pain, and general fatigue improved significantly in 100%, 100%, 78%, 64%, 53%, and 48% of patients, respectively. Early complications related to the intervention occurred in ten patients. Seven patients developed symptoms of recurrent jaundice or cholangitis. Overall median survival was 79 days, and 6-month and 1-year survival rates after PTBD were 39.5% and 13.2%, respectively. Serum bilirubin level after PTBD (P < 0.0001), chemotherapy after PTBD (P < 0.0001), and performance status at presentation (P = 0.0363) were found to be independent predictors of survival.

CONCLUSION

PTBD with metallic stent placement is a safe and effective palliation for patients with malignant biliary obstruction caused by metastatic gastric cancer. Our results suggest that patients in good clinical condition are candidates for aggressive treatment with a combination of PTBD with metallic stent placement and chemotherapy.