ACR Appropriateness Criteria radiologic management of benign and malignant biliary obstruction

Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition

BACKGROUND

The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014.

METHODS

In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded.

CONCLUSIONS

This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.

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.

Outcomes of Salvage Percutaneous Biliary Drainage after Occlusion of Endoscopic Stents

PURPOSE

To describe outcomes of patients with malignant biliary obstruction who undergo salvage percutaneous biliary drainage after occlusion of endoscopic biliary stents.

MATERIALS AND METHODS

A single-center retrospective review was performed of 47 patients (25 men, 22 women) who underwent percutaneous biliary drainage for recurrent obstruction after endoscopic stent placement between 2005 and 2015. Primary malignancies were bile duct (n = 13), colorectal (n = 11), gallbladder (n = 7), pancreas (n = 5), hepatocellular (n = 4), and other (n = 7). Indication for salvage drain placement was infection (n = 19) and jaundice or need to decrease bilirubin (n = 28). Kaplan-Meier and Cox regression methods were used for survival analysis. Logistic and multivariate regressions were employed to identify factors associated with survival.

RESULTS

Median survival after salvage biliary drain placement was 1.8 months (95% confidence interval [CI], 1.3-2.7). Elevated international normalized ratio (INR) ≥ 1.5 before drainage was associated with poorer survival after drainage (median survival 0.7 months vs 2.4 months, P < .01). Median survival was shorter in 28 patients (64%) with bilirubin ≤ 2 mg/dL (34.2 µmol/L) after drainage (1.2 months vs 5.4 months, P < .001). Left-sided drain placement, elevated bilirubin, and elevated INR correlated with decreased likelihood of achieving bilirubin ≤ 2 mg/dL (34.2 µmol/L) (odds ratio [OR] 0.13, 95% CI, 0.02-0.71, P = .02; OR 0.18, 95% CI, 0.05-0.69, P = .01; OR 0.10, 95% CI, 0.01-0.90, P = .04).

CONCLUSIONS

Survival is limited for most patients who undergo salvage percutaneous biliary drainage. Elevated bilirubin and INR before drainage portend a poor prognosis.