Cholangitis prevention in endoscopic Klatskin tumor palliation: air cholangiography technique

Factors predicting 30-day mortality after ERCP in patients with inoperable malignant hilar biliary obstruction: a single tertiary referral centre experience and systematic review

Objective

There is a paucity of studies in the literature body evaluating short term outcomes following endoscopic retrograde cholangiopancreatography (ERCP) in patients with inoperable malignant hilar biliary obstruction (MHBO). We aimed to primarily evaluate 30-day mortality in these patients and secondarily, conduct a systematic review of studies reporting 30-day mortality.

Design

We conducted a retrospective analysis of all patients with inoperable MHBO who underwent ERCP at Leeds Teaching Hospitals NHS Trust between February 2015 and September 2020. Logistic regression models constructed from baseline patient data, the modified Glasgow Prognostic Score (mGPS) and Charlson Comorbidity Index (CCI) were evaluated as predictors of 30-day mortality.

Results

Eighty-seven patients (49 males) with a mean age of 70.4 years (SD ±12.3) were included. Cholangiocarcinoma was the most common aetiology of MHBO affecting 35/87 (40.2%). Technical success was achieved in 72/87 (82.8%). The 30-day mortality rate was 25.3% (22/87), of which 16 were due to progression of underlying malignant disease. On multivariate analysis, only leucocytosis (OR 4.12, 95% CI 2.70 to 7.41, p=0.02) was an independent predictor of 30-day mortality. Neither mGPS (p=0.47) nor CCI with a cut-off value of ≥7 (p=0.06) were significant predictors of 30-day mortality.

Conclusion

We demonstrated that 30-day mortality following ERCP for inoperable MHBO remains high despite technical success. Further studies are warranted to identify patients most appropriate for intervention.

CO2 or air cholangiography reduces the risk of post-ERCP cholangitis in patients with Bismuth type IV hilar biliary obstruction

Background

Endoscopic biliary stenting by endoscopic retrograde cholangiopancreatography (ERCP) is the most common form of palliation for malignant hilar obstruction. However, ERCP in such cases is associated with a risk of cholangitis. The incidence of post-ERCP cholangitis is particularly high in Bismuth type IV hilar obstruction, and this risk is further increased when the contrast injected for cholangiography is not drained. The present study aims to compare the incidence of cholangitis associated with the use of a contrast agent, air and CO₂ for cholangiography in type IV hilar biliary lesions.

Methods

The clinical data of consecutive 70 patients with type IV hilar obstruction, who underwent ERCP from October 2013 to November 2017, were retrospectively analyzed. These patients were divided into three groups based on the agent used for cholangiography: group A, contrast (n = 22); group B, air (n = 18); group C, CO₂ (n = 30). These three methods of cholangiography were chronologically separated. Prior to the ERCP, MRCP was obtained from all patients to guide the endoscopic intervention.

Results

At baseline, there was no significant difference in terms of the patient’s age, gender, symptoms and liver function tests among the three groups (P > 0.05). The complication rates were significantly higher in group A than in groups B and C (63.6% vs. 26.7 and 27.8%, P < 0.05). The incidence of post-ERCP cholangitis was significantly higher in group A (P < 0.05), while the incidence of post-ERCP pancreatitis and bleeding were similar in the three groups. After the ERCP, the mean hospital stay was shorter in groups B and C, when compared to group A (P < 0.05). However, there was no significant difference in the 30-day mortality rate among the three groups (P > 0.05). Furthermore, there was no significant difference between groups B and C in terms of primary end points.

Conclusion

CO₂ or air cholangiography during ERCP for type IV hilar obstruction is associated with reduced risk of post-ERCP cholangitis, when compared to conventional contrast agents.

Comparison of intraductal ultrasonography-directed and cholangiography-directed endoscopic retrograde biliary drainage in patients with a biliary obstruction

BACKGROUND/AIMS

Endoscopic retrograde biliary drainage (ERBD) has become a standard procedure in patients with a biliary obstruction. Intraductal ultrasonography (IDUS) has emerged as a new tool for managing extrahepatic biliary diseases. IDUS-directed ERBD can be performed without conventional cholangiography (CC). The goal of this study was to assess the effectiveness and safety of IDUS-directed ERBD compared to CC-directed ERBD in patients with an extrahepatic biliary obstruction.

METHODS

A total of 210 patients who had undergone IDUS-directed ERBD (IDUS-ERBD, n = 105) and CC-directed ERBD (CC-ERBD, n = 105) between October 2013 and April 2014 were analyzed retrospectively. The primary outcome measure was the procedural success rate. Secondary outcome measures included clinical outcomes, total procedure time, radiation exposure time, and overall complication rates.

RESULTS

The total technical success rate of ERBD was 100% (105/105) in the IDUS-ERBD and CC-ERBD groups. Mean procedure time was slightly prolonged in the IDUS-ERBD group than that in the CC-ERBD group (32.1 ± 9.9 minutes vs. 28.4 ± 11.6 minutes, p = 0.023). Mean radiation exposure time was one-third less in the IDUS-ERBD group than that in the CC-ERBD group (28.0 ± 49.3 seconds vs. 94.2 ± 57.3 seconds, p < 0.001). No significant differences in complication rates were detected between the groups.

CONCLUSIONS

IDUS-ERBD was equally effective and safe as CC-ERBD in patients with an extrahepatic biliary obstruction. Although IDUS-ERBD increased total procedure time, it significantly decreased radiation exposure.

Air cholangiography in endoscopic bilateral stent-in-stent placement of metallic stents for malignant hilar biliary obstruction

BACKGROUND

Although endoscopic bilateral stent-in-stent (SIS) placement of self-expandable metallic stents (SEMS) is one of the major palliative treatments for unresectable malignant hilar biliary obstruction, post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis can occur frequently due to inadequate drainage, especially after contrast injection into the biliary tree. The aim of this study is to evaluate the efficacy and safety of air cholangiography-assisted stenting.

METHODS

This study included 47 patients with malignant hilar biliary obstruction who underwent endoscopic bilateral SEMS placement using the SIS technique. They were divided into two groups, air (n = 23) or iodine contrast (n = 24) cholangiography. We retrospectively compared comprehensive clinical and laboratory data of both groups.

RESULTS

There were no significant differences found between the two groups with respect to technical success (87% versus 87.5%, air versus contrast group, respectively), functional success (95% versus 95.2%), 30-day mortality (8.3% versus 8.7%) and stent patency. Post-ERCP adverse events occurred in 5 (21.7%) of the patients in the air group and 8 (33.3%) of the patients in the contrast group. Among these, the rate of cholangitis was significantly lower in the air group (4.8% versus 29.2%, p = 0.048). In multivariate analysis, air cholangiography, technical success and a shorter procedure time were significantly associated with a lower incidence of post-ERCP cholangitis.

CONCLUSIONS

Air cholangiography-assisted stenting can be a safe and effective method for endoscopic bilateral SIS placement of SEMS in patients with malignant hilar biliary obstruction.

Endoscopic management of hilar biliary strictures

Hilar biliary strictures are caused by various benign and malignant conditions. It is difficult to differentiate benign and malignant strictures. Postcholecystectomy benign biliary strictures are frequently encountered. Endoscopic management of these strictures is challenging. An endoscopic method has been advocated that involves placement of increasing number of stents at regular intervals to resolve the stricture. Malignant hilar strictures are mostly unresectable at the time of diagnosis and only palliation is possible.Endoscopic palliation is preferred over surgery or radiological intervention. Magnetic resonance cholangiopancreaticography is quite important in the management of these strictures. Metal stents are superior to plastic stents. The opinion is divided over the issue of unilateral or bilateral stenting.Minimal contrast or no contrast technique has been advocated during endoscopic retrograde cholangiopancreatography of these patients. The role of intraluminal brachytherapy, intraductal ablation devices, photodynamic therapy, and endoscopic ultrasound still remains to be defined.

Update on Pancreatobiliary Stents: Stent Placement in Advanced Hilar Tumors

Palliative drainage is the main treatment option for inoperable hilar cholangiocarcinoma to improve symptoms, which include cholangitis, pruritus, high-grade jaundice, and abdominal pain. Although there is no consensus on the optimal method for biliary drainage due to the paucity of large-scale randomized control studies, several important aspects of any optimal method have been studied. In this review article, we discuss the liver volume to be drained, stent type, techniques to insert self-expanding metal stents, and approaches for proper and effective biliary drainage based on previous studies and personal experience.

Air cholangiogram is not inferior to dye cholangiogram for malignant hilar biliary obstruction: a randomized study of efficacy and safety

BACKGROUND

Endoscopic biliary drainage is the palliative treatment of choice in patients with malignant hilar biliary obstruction. Contrast injection can lead to cholangitis, whereas air cholangiography may have a lesser incidence of cholangitis.

OBJECTIVE

The objective of the present study is to prospectively compare the efficacy and safety of air vs. dye cholangiogram in malignant hilar biliary obstruction.

METHODS

Patients with type II and III malignant hilar biliary stricture were included in a prospectively randomized manner at a tertiary care center. Unilateral self-expanding metal stent was placed in patients with a malignant hilar block using either air or dye as a contrast medium. Outcome measures were successful deployment, successful drainage, early complications, and procedure-related and 30-day mortality.

RESULTS

Forty-nine patients were randomized to air cholangiogram (25 patients, group A) or dye cholangiogram (24 patients, group B). Most of the patients had type II stricture (19 in group A and 20 in group B). Successful stenting and drainage were achieved in 25 (100 %) and 24 (96 %) in group A and 23 (95.8 %) and 22 (91.6 %) (p = ns), respectively. Cholangitis developed in 1 (4 %) and 4 (16.6 %) in group A and B, respectively (p < 0.05). There was no procedure-related or 30-day mortality.

CONCLUSION

Use of air cholangiography was as safe and as effective as dye cholangiography in patients with malignant hilar biliary obstruction, and it decreased the risk of post-ERCP cholangitis.

Evaluation of the effectiveness of endoscopic retrograde cholangiopancreatography in patients with perihilar cholangiocarcinoma and its effect on development of cholangitis

Objective. We aimed to determine the effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) in patients with inoperable perihilar cholangiocarcinoma and establish the incidence of cholangitis development following ERCP. Material and Method. This retrospective study enrolled patients diagnosed with inoperable perihilar cholangiocarcinoma who underwent endoscopic drainage (stenting) with ERCP. Patients were evaluated for development of cholangitis and the effectiveness of ERCP. The procedure was considered successful if bilirubin level fell more than 50% within 7 days after ERCP. Results. Post-ERCP cholangitis developed in 40.7% of patients. Cholangitis development was observed among 39.4% of patients with effective ERCP and in 60.6% of patients with ineffective ERCP. Development of cholangitis was significantly more common in the group with ineffective ERCP compared to the effective ERCP group (P = 0.001). The average number of ERCP procedures was 2.33 ± 0.89 among patients developing cholangitis and 1.79 ± 0.97 in patients without cholangitis. The number of ERCP procedures was found to be significantly higher among patients developing cholangitis compared to those without cholangitis (P = 0.012). Conclusion. ERCP may not provide adequate biliary drainage in some of the patients with perihilar cholangiocarcinoma and also it is a procedure associated an increased risk of cholangitis.

Risk factors for cholangitis after endoscopic stent placement for malignant biliary obstruction

AIM: To explore the risk factors for cholangitis after endoscopic stent placement for malignant biliary obstruction.

METHODS: Eighty malignant biliary obstructive patients who underwent endoscopic stent placement at Nanjing Medical University Affiliated Suzhou Hospital between January 2008 and December 2013 were divided into two groups: a cholangitis group (n = 40, with post-endoscopic stent placement cholangitis) and a non-cholangitis group (n = 40, without post-endoscopic stent placement cholangitis). The two groups were matched for age and gender. The relationship between post-endoscopic stent placement cholangitis and various factors was investigated by univariate and multivariate analyses.

RESULTS: Univariate analysis showed that the location of obstruction, stent type and history of diabetes were significantly different between the two groups. Multivariate analysis demonstrated that the location of obstruction was significantly related to post-endoscopic stent placement cholangitis (OR = 8.815, 95%CI: 1.575-50.009).

CONCLUSION: Upper biliary obstruction might be an independent risk factor for post-endoscopic stent placement cholangitis.

Effect of CO2 cholangiography on post-ERCP cholangitis in patients with unresectable malignant hilar obstruction - a prospective, randomized controlled study

BACKGROUND

Air cholangiogram has been used in patients with malignant hilar obstruction to reduce cholangitis after endoscopic retrograde cholangiopancreatography (ERCP). However, it still remains unclear whether CO2 could be used as an alternative for air cholangiography in such patients.

OBJECTIVE

To investigate the effect of CO2 cholangiogram on post-ERCP complications.

DESIGN

Prospective, randomized controlled study.

SETTING

Tertiary care referral center.

PATIENTS

36 patients with Bismuth type II, III or IV were randomized into CO2 group or iodine contrast group (control group).

INTERVENTION

Cholangiography was performed by injection of either CO2 or iodine contrast through a sphincterotome. One or two metal stents were placed.

MAIN OUTCOME MEASURES

Post-ERCP complications, length of hospital stay after ERCP, 1-month and 1-year mortality.

RESULT

There was no significant difference in age, gender, symptoms, liver function tests, type of tumor origin and Bismuth type between patients in CO2 and contrast groups (p > 0.05). Compared with one-stent placement, more volume of CO2 and longer operation time were observed when performing two-stent placement (both p < 0.05). The rate of cholangitis in CO2 group was significantly lower than that in control group (5.6% vs. 33.3%, p = 0.04). After ERCP, mean hospital stay time was shorter in CO2 group compared with control (p < 0.05). The difference of 1-month and 1-year mortality between two groups was not significant (both p > 0.05).

CONCLUSION

CO2 cholangiogram could be a safe method to visualize intrahepatic bile duct with low incidence of post-ERCP cholangitis, which could be considered for the patients with malignant hilar obstruction.

Chemoradiation treatment with gemcitabine plus stereotactic body radiotherapy for unresectable, non-metastatic, locally advanced hilar cholangiocarcinoma. Results of a five year experience

BACKGROUND

Hilar cholangiocarcinoma (Klatskin tumor-KT) accounts for about 0.5-1.5% of all gastrointestinal cancers and for 40-60% of all biliary malignancies. Tumor resection is attainable in about 30-50% of patients. When resection is not possible other treatment options have little or no impact on survival. We present the results of hypofractionated Stereotactic Body Radiotherapy (SBRT) on a small series of non resectable locally advanced KT patients.

MATERIALS AND METHODS

Ten patients with histologically proven KT underwent SBRT plus gemcitabine. Radiotherapy (30Gy) was delivered in three fractions. Treatment toxicity was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE v. 3.0). Alive patients with less than 1 year of follow up were excluded from the present study. Local control was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST) criteria.

RESULTS

Two grade 1 and Two grade 2 acute toxicities were observed, moreover one grade 2 late toxicity was recorded. The overall local response ratio was 80% (4 PR+2 SD). SBRT showed a good efficacy in achieving local control. Median time to progression was 30 months. Two-year survival was 80% and four-year survival 30%. Six patients developed metastatic disease. Response to treatment and nodal metastases were the only independent indicators of prolonged survival.

CONCLUSIONS

The chemoradiation given by SBRT plus gemcitabine is a promising treatment for non-metastatic unresectable KT. High local control rates, even compared to historical data from conventional radiotherapy, can be achieved with minimal toxicity.

Air cholangiogram: a new technique for biliary imaging during ERCP

BACKGROUND

Palliation of patients with malignant hilar stenosis by stent insertion is fraught with risk of cholangitis because of contrast injection in the undrained segment.

OBJECTIVE

The purpose of this study was to evaluate the results of unilateral metal stenting in type II and III malignant hilar biliary obstruction by using air as a contrast medium.

DESIGN

Prospective, uncontrolled, single center pilot study.

SETTING

Tertiary care referral center.

PATIENTS

Cohort of 17 patients with malignant hilar obstruction.

INTERVENTION

A single metallic stent was inserted in type II and III malignant hilar obstruction by using air as a contrast medium. Patients were evaluated weekly up to 1 month after stent placement.

MAIN OUTCOME MEASURES

Successful implantation, successful drainage, early complications, procedure-related mortality, 30-day mortality.

RESULT

Successful stent placement and drainage was achieved in 100% of the patients (17 of 17). No patient developed cholangitis or died within 30 days of the procedure.

LIMITATIONS

Small cohort of patients.

CONCLUSION

Air cholangiography provides a safe and effective roadmap for unilateral metallic stenting in type II and III malignant hilar biliary obstruction.