Metallic stents in malignant biliary obstruction

Percutaneous Metallic Stents in Malignant Biliary Obstruction: Comparison of Nitinol and Wall Stents

INTRODUCTION

Palliation of malign biliary obstruction is important which is commonly carried out by percutaneous biliary stenting. Our primary aim with this study was assessment of performance of wall stents, and nitinol stents for the palliation of malign biliary obstruction.

METHODS

The medical records of 157 patients who underwent biliary stenting in our department between January 1, 1995, and December 31, 2005, were retrospectively analyzed. Technical success, treatment success, mortality in the first 30 days, minor, and major complications were evaluated and compared among the wall stent, and the nitinol stent groups in all patients which constituted the primary study endpoints. Additionally, stent patency, and mean patient survival times after stent implantation were evaluated in patients for whom follow-up information could be obtained.

RESULTS

A total of 213 metallic stents were placed in 157 patients. Wall stent was placed in 83 of the patients with mean age, and SD of 60.4 and 13.5. Nitinol stent was placed in 74 of the patients with mean age of 57.8, and SD of 15.5. Gender ratio was equal in both groups. Biliary stent dysfunction was observed in 13 patients in each of nitinol, and wall stent groups throughout the study period. There was no statistical difference among re-occlusion rates (p = 0.91). For the nitinol stent group median primary patency time was 119 days (90-185 days CI 95%), and for the wall stent group median primary patency time was 81 days (60-150 days CI 95%).

CONCLUSION

Nitinol stents, and wall stents are safe options that can be safely used in the percutaneous treatment of malignant biliary obstruction with similar treatment and therapeutic success, low complication rates, and patency times that can extend beyond expected survival times.

Meta-analysis on clinical outcomes of suprapapillary versus transpapillary stent insertion in malignant biliary obstruction

BACKGROUND/AIMS

Endoscopic biliary stenting is an essential treatment for malignant biliary obstruction (MBO). However, the optimal location for the placement of metal stents (MS) or plastic stents (PS) during the management of MBO, whether above (suprapapillary) or across (transpapillary) the sphincter of Oddi (SO), has not been thoroughly evaluated. This meta-analysis aims to compare the clinical outcomes associated with endoscopic retrograde cholangiopancreatography (ERCP)-guided biliary stents placed above and across the SO in patients with MBO.

METHODS

A comprehensive search of electronic databases was carried out to identify studies published from inception to April 2022. The clinical outcomes examined including stent patency, stent occlusion, and overall adverse events (AEs) such as cholangitis, post-ERCP pancreatitis (PEP), cholecystitis, stent migration, and bleeding. The selection of a random-effects model or fixed-effects model was based on the presence of heterogeneity.

RESULTS

A total of 12 articles involving 751 patients were analyzed. The findings showed that the suprapapillary approach had longer stent patency compared to the transpapillary approach (mean difference: 38.58; 95% confidence interval 16.02-61.14, P < 0.0001). Additionally, the suprapapillary approach was associated with a lower risk of stent occlusion and overall AEs (P = 0.04, P = 0.002, respectively), particularly in the incidence of PEP (P = 0.009). The incidence of cholangitis, cholecystitis, stent migration, and bleeding were similar between the suprapapillary and transpapillary approaches. The subgroup analyses indicated that suprapillary PS had a significant decrease in the incidence of stent occlusion and longer stent patency, while suprapillary MS had a significant decrease in the incidence of overall AEs and PEP than the transpapillary approach.

CONCLUSION

Compared with the transpapillary approach, the suprapapillary stent had superiority in longer stent patency, lower rates of stent occlusion and overall AEs, and notably, a lower incidence of PEP. The incidence of cholangitis, cholecystitis, stent migration, and bleeding were similar between the suprapapillary and transpapillary approaches. Further large-scale randomized controlled studies are needed to confirm our findings.

REGISTRATION NO

CRD42022336435.

Comparison of the Clinical Outcomes of Suprapapillary and Transpapillary Stent Insertion in Unresectable Cholangiocarcinoma with Biliary Obstruction

BACKGROUND AND AIMS

To prevent stent migration, transpapillary stent placement has been recommended for the endoscopic treatment of malignant hilar biliary stricture. However, recent studies have suggested that placement above the papilla achieves better results, because it is believed to prevent reflux and prolong stent patency. The aim of this study was to compare the efficacy and safety aspects of transpapillary and suprapapillary stent placement. In addition, the success rates of stent revision were evaluated.

MATERIALS AND METHODS

The medical records of 73 patients with hilar cholangiocarcinoma who underwent endoscopic metal stent insertion between January 2005 and December 2015 were retrospectively reviewed. Patients were assigned by stent location to a suprapapillary (S group; N = 44) or a transpapillary (T group; N = 29) cohort. Clinical outcomes, stent patency, adverse events, and revision success rates were compared between the two study groups.

RESULTS

Patency periods were similar in the two groups (S; 140 vs. T; 157 days; P = 0.732). Rates of stent obstruction in the S and T groups were 63.4% and 55.2%, respectively (P = 0.470). An adverse event occurred in 15 (20.5%) of total study subjects, with no significant intergroup difference. The endoscopic revision success rate was significantly higher in the T group (P = 0.01), and the time required for revision tended to be shorter in the T group.

CONCLUSIONS

The effectiveness and safety of suprapapillary and transpapillary stent insertion were found to be similar, but the success rate of endoscopic revision was significantly higher for the T group. Therefore, we recommend that transpapillary stent placement be considered for patients with hilar cholangiocarcinoma and biliary obstruction.

Suprapapillary versus transpapillary stent placement for malignant biliary obstruction: which is better?

PURPOSE

To compare the complications, stent patency, and patient survival with self-expandable metal stents (SEMSs) placed above or across the sphincter of Oddi in malignant biliary obstruction.

MATERIALS AND METHODS

From January 2008 to December 2012, 155 patients were treated with percutaneous transhepatic SEMS placement. Seventy-four patients underwent suprapapillary stent placement (group A), and 81 patients underwent transpapillary stent placement (group B). Complications rates, stent patency, and patient survival were evaluated and analyzed for potential predictors.

RESULTS

In group A, 68 covered and 28 uncovered SEMSs were placed, and, in group B, 78 covered and 19 uncovered SEMSs were placed. Thirty-six stent-related early complications were observed in a total of 154 patients (23.4%): pancreatitis (n = 23), cholangitis (n = 12), and cholecystitis (n = 1). The early complication rates for groups A and B were 14.9% (11 of 74) and 31.3% (25 of 80), respectively (P = .016). Pancreatitis occurred in three patients (4.1%) in group A and 20 patients (25.0%) in group B (P = .001). Stent location was a single independent predictor of pancreatitis (P < .001). Stent occlusions by tumor growth was more frequently observed in group A than in group B (P = .007), whereas stent occlusion by sludge incrustation was more frequently found in group B than in group A (P = .007). There was no significant difference in cumulative stent patency (P = .401) or patient survival (P = .792) between groups.

CONCLUSIONS

To decrease the incidence of pancreatitis, suprapapillary placement of SEMSs is recommended for malignant biliary obstruction, but not in the lower 2 cm of the common bile duct.

Comparison of the efficacy of covered versus uncovered metallic stents in treating inoperable malignant common bile duct obstruction: a randomized trial

PURPOSE

To compare patency and overall survival achieved with covered versus uncovered metallic stents among patients with inoperable malignant extrahepatic biliary obstruction.

MATERIALS AND METHODS

There were 40 patients enrolled in this prospective randomized study between January 2012 and July 2013. Mean age of patients was 62.6 years (range, 43-86 y). The malignancies causing extrahepatic biliary obstruction were pancreatic cancer (n = 18), stomach cancer (n = 13), gallbladder cancer (n = 3), common bile duct cancer (n = 2), and other cancer types (n = 4). Uncovered (n = 20) and covered (n = 20) stents were used. Stent patency, overall survival, and complications were evaluated and statistically compared.

RESULTS

Mean patency of uncovered stents (413.3 d ± 63.0) was significantly longer than mean patency of covered ones (207.5 d ± 46.0; P = .041). Mean overall survival was 359.9 days ± 61.5 for uncovered stents, which was statistically similar to survival of 350.5 days ± 43.8 for covered stents (P = .271). Causes of recurrent obstruction included tumor ingrowth (n = 2), tumor overgrowth (n = 5), debris or food material (n = 5), and stent migration (n = 2). One case of acute cholecystitis occurred in covered stent group.

CONCLUSIONS

Uncovered metallic stents had superior patency duration than covered stents for patients with malignant extrahepatic biliary obstruction. However, the overall complication and survival rates achieved with covered and uncovered stents were similar.

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.

Endoscopic metal biliary endoprosthesis combined with endoscopic nasobiliary drainage for palliative treatment of malignant biliary obstruction

AIM: To explore the clinical effect of endoscopic metal biliary endoprosthesis (EMBE) combined with endoscopic nasobiliary drainage (ENBD) in the palliative treatment of malignant biliary obstruction.

METHODS: The clinical data for 68 patients with malignant biliary obstruction who underwent endoscopic retrograde cholangiopancreatography (ERCP) for EMBE and ENBD from April 2010 to October 2012 were reviewed and analyzed.

RESULTS: ERCP and biliary stent placement were successful in 64 of 68 cases, and the success rate was 94.12%. Jaundice obviously subsided in 95.31% of patients one week after stent placement. Postoperatively, liver function was improved significantly. There were 5 cases of complications, including hyperamylasemia in 3 cases, acute pancreatitis in 1 case and acute cholangitis in 1 case. Fifty-eight patients were followed postoperatively, and their average survival time was 10 mo ± 2.30 mo (3-26 mo). The half-year, 1-year and 2-year survival rates were 67.24% (39/58), 43.10% (25/58) and 5.17% (3/58), respectively. The average stent patency time was 4 mo ± 2.26 mo (0-9 mo).

CONCLUSION: EMBE combined with ENBD can effectively relieve biliary obstruction and improve liver function in patients with malignant biliary obstruction, and is a safe and effective palliative treatment with less invasiveness and fewer complications.

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.

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.

Combined percutaneous-endoscopic stenting of malignant biliary obstruction: results from 106 consecutive procedures and identification of factors associated with adverse outcome

BACKGROUND

In patients in whom attempted endoscopic stenting of malignant biliary obstruction fails, combined percutaneous-endoscopic stenting and percutaneous stenting using expandable metallic endoprostheses offer alternative approaches to biliary drainage. Despite the popularity of the percutaneous route, there is no available evidence to support its superiority over combined stenting in this patient group. The objective of this study was to present the short- and long-term results of a large series of combined percutaneous-endoscopic stenting procedures and identify factors associated with adverse outcome.

METHODS

Data were retrospectively collected on patients undergoing combined percutaneous-endoscopic biliary stenting for malignant biliary obstruction between January 2002 and December 2006. Short- and long-term outcomes were recorded, and pre-procedure variables correlated with adverse outcome.

RESULTS

Combined biliary stenting was technically successful in 102 (96.2%) of 106 patients. Procedure-associated mortality rate was 0%. In-hospital morbidity and mortality rates were 24.5% and 16.7%, respectively, with the majority of deaths resulting from biliary sepsis. Median survival was 100 days, with a 13.7% stent occlusion rate. On multivariable analysis, baseline American Society of Anaesthesiologists (ASA) grade, decreasing serum albumin and increasing leucocyte count were independently associated with in-hospital mortality following combined stenting.

CONCLUSION

Combined biliary stenting is associated with short- and long-term outcomes equal to those reported in recent series of percutaneous transhepatic stenting. Randomised control trials, including cost-effectiveness analyses, are required to further compare these techniques. Outcomes following combined stenting may be further improved by early recognition and treatment of sepsis and scrupulous management of co-morbid disease.

Primary patency of Wallstents in malignant bile duct obstruction: single vs. two or more noncoaxial stents

The purpose of this study was to determine the primary patency of two or more noncoaxial self-expanding metallic Wallstents (Boston Scientific, Natick, MA) and to compare this with the primary patency of a single stent in malignant bile duct obstruction. From August 2002 to August 2004, 127 patients had stents placed for malignant bile duct obstruction. Forty-five patients were treated with more than one noncoaxial self-expanding metallic stents and 82 patients had a single stent placed. Two patients in the multiple-stent group were lost to follow-up. The primary patency period was calculated from the date of stenting until the first poststenting intervention for stent occlusion, death, or the time of last documented follow-up. The patency of a single stent was significantly different from that of multiple stents (P = 0.0004). In the subset of patients with high bile duct obstruction, the patency of a single stent remained significantly different from that of multiple stents (P = 0.02). In the single-stent group, there was no difference in patency between patients with high vs. those with low bile duct obstruction (P = 0.43). The overall median patency for the multistent group and the single-stent group was 201 and 261 days, respectively. In conclusion, the patency of a single stent placed for malignant low or high bile duct obstruction is similar, and significantly longer than, that of multiple stents placed for malignant high bile duct obstruction. Given the median patency of 201 days, when indicated, percutaneous stenting of multiple bile ducts is an effective palliative measure for patients with malignant high bile duct obstruction.

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

BACKGROUND

Percutaneous metal stenting is an accepted palliative treatment for malignant biliary obstruction. Nevertheless, factors predicting survival are not known.

METHODS

Seventy-six patients with inoperable malignant biliary obstruction were treated with percutaneous placement of metallic stents. Twenty patients had non-hilar lesions. Fifty-six patients had hilar lesions classified as Bismuth type I (n = 15 patients), type II (n = 26), type III (n = 12), or type IV (n = 3 patients). Technical and clinical success rates, complications, and long-term outcome were recorded. Clinical success rates, patency, and survival rates were compared in patients treated with complete (n = 41) versus partial (n = 35) liver parenchyma drainage. Survival was calculated and analyzed for potential predictors such as the tumor type, the extent of the disease, the level of obstruction, and the post-intervention bilirubin levels.

RESULTS

Stenting was technically successful in all patients (unilateral drainage in 70 patients, bilateral drainage in 6 patients) with an overall significant reduction of the post-intervention bilirubin levels (p < 0.001), resulting in a clinical success rate of 97.3%. Clinical success rates were similar in patients treated with whole-liver drainage versus partial liver drainage. Minor and major complications occurred in 8% and 15% of patients, respectively. Mean overall primary stent patency was 120 days, while the restenosis rate was 12%. Mean overall secondary stent patency was 242.2 days. Patency rates were similar in patients with complete versus partial liver drainage. Mean overall survival was 142.3 days. Survival was similar in the complete and partial drainage groups. The post-intervention serum bilirubin level was an independent predictor of survival (p < 0.001). A cut-off point in post-stenting bilirubin levels of 4 mg/dl dichotomized patients with good versus poor prognosis. Patient age and Bismuth IV lesions were also independent predictors of survival.

CONCLUSIONS

Percutaneous metallic biliary stenting provides good palliation of malignant jaundice. Partial liver drainage achieved results as good as those after complete liver drainage. A serum bilirubin level of less than 4 mg/dl after stenting is the most important independent predictor of survival, while increasing age and Bismuth IV lesions represent dismal prognostic factors.

Self-expandable metallic stents for malignant biliary obstruction: Efficacy on proximal and distal tumors

AIM: To compare the efficacy of self-expandable metallic stents (EMS) in the treatment of distal and proximal stricture of malignant biliary tumors.

METHODS: From March 1995 to June 2004, 61 patients (40 males, 21 females) with malignant biliary obstruction who received self-expandable metallic stent implantation were reviewed retrospectively. The stents were inserted by an endoscopic or percutaneous transhepatic method. We tried to place two stents in the biliary system in T or Y configuration in cases of hilar tumors with bilateral hepatic duct obstruction. The end points of the study were stent occlusion or patient death.

RESULTS: The mean time of stent patency was 421 ± 67 d in the group of proximal stricture( group I) and 168 ±18 d in the group of distal stricture (group II). The difference was significant in borderline between the two groups (P   = 0.0567). The mean survival time was 574 ± 76 d in group I and 182 ± 25 d in group II. There was a significant difference between the two groups (P  = 0.0005).

CONCLUSION: EMS implantation is a feasible, palliative method for unresectable malignant biliary obstruction. The clinical efficacy of EMS in patients with proximal hilar tumors is better than that in patients with distal tumors.

Interventionen bei malignen Gallenwegstenosen

This paper gives an overview of experience and success of percutaneous transhepatic interventions in malignant biliary obstruction. Even after exhaustion of surgical and endoscopic therapy options, the percutaneously inserted stents provide effective palliation. The palliative treatment of malignant jaundice using a stent is an established procedure in clinical practice, particularly whenever the endoscopic, transpapillary approach is not possible due to high obstructions or previous surgery. The technical success rate is very high (about 95-100%), and the complication rate is about 10-30%. Since the patency rate of stents is higher than that of plastic endoprostheses, their primary use is justified despite higher costs, provided the patients are adequately selected.

HDR-192Ir intraluminal brachytherapy in treatment of malignant obstructive jaundice

AIM: To determine the feasibility and safety of intraluminal brachytherapy in treatment of malignant obstructive jaundice (MOJ) and to evaluate the clinical effect of intraluminal brachytherapy on stent patency and patient survival.

METHODS: Thirty-four patients with MOJ were included in this study. Having biliary stent placed, all patients were classified into intraluminal brachytherapy group (group A, n = 14) and control group (group B, n = 20) according to their own choice. Intraluminal brachytherapy regimen included: HDR-¹⁹²Ir was used in the therapy, fractional doses of 4-7 Gy were given every 3-6 d for 3-4 times, and standard points were established at 0.5-1.0 cm. Some patients of both groups received transcatheter arterial chemoembolization (TACE) after stent placement.

RESULTS: In group A, the success rate of intraluminal brachytherapy was 98.0%, RTOG grade 1 acute radiation morbidity occurred in 3 patients, RTOG/EORTC grade 1 late radiation morbidity occurred in 1 patient. Mean stent patency of group A (12.6 mo) was significantly longer than that of group B (8.3 mo) (P < 0.05). There was no significant difference in the mean survival (9.4 mo vs 6.0 mo) between the two groups.

CONCLUSION: HDR-¹⁹²Ir intraluminal brachytherapy is a safe palliative therapy in treating MOJ, and it may prolong stent patency and has the potentiality of extending survival of patients with MOJ.

Management of Biliary Neoplastic Obstruction with Two Different Metallic Stents Implanted in One Session

The efficacy of the "one-step" technique using two different metallic stents (Wallstent and Ultraflex) and associated rate of complications was studied in 87 patients with jaundice secondary to malignant biliary obstruction, with bilirubin level less than 15 mg/dl and Bismuth type 1 or 2 strictures. The study group, composed of 40 men and 47 women with a mean age of 59.4 years (range 37-81 years), was treated with a "one-step" percutaneous transhepatic implantation of self-expanding stents. The cause of the obstruction was pancreatic carcinoma in 38 patients (44%), lymph node metastasis in 20 patients (23%), gallbladder carcinoma in 13 patients (15%), cholangiocarcinoma in 12 patients (14%) and ampullary carcinoma in four patients (5%). A significant reduction in jaundice was obtained in all but one patient, with a drop of total serum bilirubin level from a mean of 13.7 mg/dl to 4.3 mg/dl within the first 4 days. The mean postprocedural hospitalization period was 5.4 days in the Wallstent group and 6.4 days in the Ultraflex group. Mean survival rate was 7.8 months (Wallstent group) and 7.1 months (Ultraflex group). The use of both stents did not reveal any significant difference in parameters tested. The implantation of these self-expandable stents in one session, in selected patients, is clinically effective, devoid of important complications and cost-effective due to the reduction in hospitalization.

Percutaneous self-expandable uncovered metallic stents in malignant biliary obstruction. Complications, follow-up and reintervention in 154 patients

PURPOSE

Evaluation of technique, complications and the long-term follow-up data of 154 patients with inoperable malignant biliary obstruction who underwent percutaneous placement of metallic stents.

MATERIAL AND METHODS

During a 6-year period, 224 self-expanding metallic stents (150 biliary Wallstents and 74 Memotherm nitinol stents) were inserted in 154 patients with inoperable malignant biliary obstruction. 100 patients had obstructions at the proximal (supracystic) level, and 54 at the distal (infracystic) level. The causes of obstructions were hilar cholangiocarcinoma (n = 64), pancreatic carcinoma (n = 34), gallbladder carcinoma (n = 24), metastatic carcinoma (n = 21), common bile duct carcinoma (n = 8), and hepatocellular carcinoma (n = 3). A complete follow-up was available for all patients.

RESULTS

The 30-day mortality was 9%, with no procedure-related deaths. The clinical success rate within the first 30 days was 88%. The total rate of early, procedure-related complications was 28%, and half of them were due to the percutaneous transhepatic catheter drainage procedure. Recurrent jaundice occurred in 28 (18%) patients and in 23 (82%) of these, reinterventions were made in order to relieve reobstructions. The mean length of survival for the entire patient group was 4 months, while the mean period of patency for all stents was 6 months. We found no statistically significant difference in patient survival or stent patency periods in regard to the level and cause of obstruction.

CONCLUSION

Percutaneous metallic stent placement maintains equal palliation in patients with proximal and distal malignant biliary obstructions caused by any tumor type. Most of the early complications were due to procedures performed before stent insertion and could be decreased by direct stent insertions. The most common late complication, reobstruction, is inevitable but can be easily treated in the majority of patients.

The interventional radiological management of cholangiocarcinoma

The successful management of cholangiocarcinoma requires the collaboration of several clinical disciplines. Modern imaging can demonstrate the liver and the surrounding structures in exquisite detail. Complete surgical resection offers the only potential for cure. The judgement of whether resection is feasible requires precise staging of the tumour. Unfortunately, in most cases, imaging delineates an advanced and inoperable tumour, requiring non-surgical palliative treatment, usually by means of endoscopic or percutaneous radiological techniques. The management of hilar lesions can be problematic requiring substantial experience and skill.

Paclitaxel inhibits proliferation of cell lines responsible for metal stent obstruction: possible topical application in malignant bile duct obstructions

RATIONALE AND OBJECTIVES

To evaluate a dose dependent inhibitory effect of paclitaxel to assess a possible local application for biliary tract malignancies in conjunction with stent placement.

METHODS

Cell cultures of the three different cell types (human epithelial gallbladder cells [HEGC], human fibroblasts [HF; PA 314 wt] and pancreatic carcinoma cells [PC; P181]) were incubated for 20 minutes at 37 degrees C with increasing doses of paclitaxel (1.0 x 10(-4) - 1.0 x 10(2) micromol). Half of the cultures were then incubated without paclitaxel, the other half with paclitaxel for 20 minutes, 24 hours, or 72 hours. Cell proliferation was detected by photometric measurements of mitochondrial dehydrogenase activity (MTT assay).

RESULTS

Incubation of cell cultures with paclitaxel resulted in a dose dependent and cell specific inhibition of cell proliferation. Concentrations of 1.0 x 10(-4) (and higher) paclitaxel for 20 minutes resulted in a inhibition of cell proliferation of HEGC (28%), PA (26%), and HF (17%). A prolonged paclitaxel incubation (up to 72 hours) resulted in an inhibitory effect on cell proliferation of HEGC (40%), PA (45%), and HF (39%). Cytotoxic effects, manifested by development of vacuoles and damage of cell integrity were seen at concentrations above 1.0 x 10(1) for both the short and long term incubation.

CONCLUSIONS

Paclitaxel incubation resulted in a dose dependent inhibition of cell proliferation of human epithelial gallbladder cells, human fibroblasts and pancreatic carcinoma cells. This inhibitory effect of paclitaxel on the cell lines could serve as the basis to develop drug coated or drug eluting stents for malignant biliary strictures.

Percutaneous placement of self-expandable metallic biliary stents in malignant extrahepatic strictures: indications of transpapillary and suprapapillary methods

OBJECTIVE

To compare the efficacy of suprapapillary and transpapillary methods of transhepatic biliary metallic stent placement in malignant biliary strictures and to specify the indications of each method applied.

MATERIALS AND METHODS

Stents were placed in 59 patients. Strictures were categorized as type A (within 3 cm of the ampulla, n = 27), type B (over 3 cm from ampulla, n = 7), type C (within 3 cm of the bending portion, n = 9), or type D (over 3 cm above the bending portion, n = 16). The stenting method was suprapapillary in 34 cases and transpapillary in 25. The rates of initial and long-term patency and of early recurrence were compared.

RESULTS

Initial patency rates for the suprapapillary and transpapillary methods were 1/7 (14.3%) and 20/20 (100%) respectively for type A (p <0.0001), 4/5 (80.0%) and 2/2 for type B, 3/7 (42.9%) and 2/2 for type C, and 15/16 (93.8%) and 0/0 for type D. Early recurrence rates were 7/30 (23.3%) using the suprapapillary method and 4/29 (13.8%) using the transpapillary method (p = 0.51). The long-term patency rate did not differ significantly according to either type (p = 0.37) or method (p = 0.62).

CONCLUSION

For good initial patency, the transpapillary method is recommended for strictures of the distal extrahepatic duct near the ampulla and just above the bending portion. Long-term patency is not influenced by the stenting method employed.