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

Comparison of Bilateral and Trisegment Drainage in Patients with High-Grade Hilar Malignant Biliary Obstruction: A Multicenter Retrospective Study

Background/Aims

Bilateral endoscopic drainage with self-expanding metallic stent (SEMS) can be used to effectively manage hilar malignant biliary obstruction. However, the benefits of using a trisegment drainage method remain unknown.

Methods

This study retrospectively reviewed the data of 125 patients with Bismuth type IIIa or IV unresectable malignant strictures who underwent bilateral endoscopic drainage using SEMSs at four tertiary centers. The patients were divided into the bilateral and trisegment drainage groups for comparison. The primary endpoint was stent patency and the secondary endpoints were technical success, technical and clinical success of reintervention, and overall survival.

Results

The technical success rates of the bilateral and trisegment drainage groups were 95% (34/36) and 90% (80/89) (p=0.41), respectively, with median stent patency durations of 226 and 170 days (p=0.26), respectively. Although the technical success of reintervention was not significantly different between the two groups (p=0.51), the clinical success rate of reintrvention was significantly higher in the trisegment drainage group (73% [11/15] vs 96% [47/49], p=0.009). The median survival times were 324 and 323 days in the bilateral and trisegment drainage groups, respectively (p=0.72). Multivariate Cox hazards model revealed no stent patency-associated factor; however, chemotherapy was associated with longer survival.

Conclusions

Although no significant difference was noted with respect to stent patency, significantly higher clinical success rates were achieved with reintervention using the trisegment drainage method than using the bilateral drainage method alone.

Advances in the management of cholangiocarcinoma

Cholangiocarcinoma (CCA) is a primary malignancy of the bile ducts with three anatomically and molecularly distinct entities: Intrahepatic CCA (iCCA), perihilar CCA (pCCA), and distal CCA. As a result of phenotypic and anatomic differences they differ significantly with respect to management. For each type of CCA there have been significant changes in management over the last several years which will be discussed in this review. Although resection remains the standard of care for all types of CCA, liver transplantation has been established as curative treatment for selected patients with pCCA and is being evaluated for iCCA with early success. With respect to systemic therapy capecitabine is now first line adjuvant therapy for all biliary tract malignancies after curative intent resection. Progress in exploiting the pathologic mutations and molecular abnormalities has also yielded regulatory approval of targeted therapy for CCA in patients with acquired alterations in the fibroblast growth factor receptor. There is also increased consensus in managing malignant biliary obstruction associated with CCA where pre-operative biliary stenting is not beneficial while self-expanding metal stents have been shown to be superior to plastic stents in patients who are not surgical candidates.

Percutaneous biliary approach as a successful rescue procedure after failed endoscopic therapy for drainage in advanced hilar tumors

BACKGROUND AND AIM

Palliative endoscopic or percutaneous biliary drainage is used for unresectable advanced hilar cancer (HC). The best option for drainage in Bismuth type III or IV HC has not been established. The aims of this study are to identify factors predictive of endoscopic stenting failure and evaluate the effectiveness of rescue percutaneous stenting in patients with advanced HC.

METHODS

Data from 110 patients with inoperable advanced HC were retrospectively reviewed. All received bilateral self-expandable metallic stents. Patients were divided into three groups: I, successful initial endoscopic stenting; II, unsuccessful initial endoscopic stenting, followed by percutaneous stenting; and III, initial percutaneous stenting. We analyzed clinical results and radiologic tumor characteristics.

RESULTS

Baseline characteristics and clinical outcomes of all groups were similar, except the hospital stay was longer in group III than group I. Technical success rate was higher in groups II and III (100%) than in group I (72.4%). The functional success rate, stent patency time, patient survival time, and complication rate were similar between groups. Endoscopic stenting failed because of guide-wire passage failure (n = 12) or stent passage failure (n = 7). The only factor significantly associated with endoscopic failure was a smaller left intrahepatic duct-common bile duct angle.

CONCLUSIONS

As clinical outcomes were generally similar between approaches, percutaneous stenting is recommended for patients with Bismuth type III or IV advanced HC. Acute left intrahepatic duct-common bile duct angulation predicts endoscopic stenting failure. If endoscopic stenting fails, immediate conversion to the percutaneous approach is a necessary and effective rescue method.

Current Status of Biliary Metal Stents

Many advances have been achieved in biliary stenting over the past 30 years. Endoscopic stent placement has become the primary management therapy to relieve obstruction in patients with benign or malignant biliary tract diseases. Compared with plastic stents, a self-expandable metallic stent (SEMS) has been used for management in patients with malignant strictures because of a larger lumen and longer stent patency. Recently, SEMS has been used for various benign biliary strictures and leaks. In this article, we briefly review the characteristics of SEMS as well as complications of stent placement. We review the current guidelines for managing malignant and benign biliary obstructions. Recent developments in biliary stenting are also discussed.

Advances in endoscopic retrograde cholangiopancreatography for the treatment of cholangiocarcinoma

Cholangiocarcinoma (CCA) is a malignancy of the bile ducts that carries high morbidity and mortality. Patients with CCA typically present with obstructive jaundice, and associated complications of CCA include cholangitis and biliary sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable treatment modality for patients with CCA, as it enables internal drainage of blocked bile ducts and hepatic segments by using plastic or metal stents. While there remains debate as to if bilateral (or multi-segmental) hepatic drainage is required and/or superior to unilateral drainage, the underlying tenant of draining any persistently opacified bile ducts is paramount to good ERCP practice and good clinical outcomes. Endoscopic therapy for malignant biliary strictures from CCA has advanced to include ablative therapies via ERCP-directed photodynamic therapy (PDT) or radiofrequency ablation (RFA). While ERCP techniques cannot cure CCA, advancements in the field of ERCP have enabled us to improve upon the quality of life of patients with inoperable and incurable disease. ERCP-directed PDT has been used in lieu of brachytherapy to provide neoadjuvant local tumor control in patients with CCA who are awaiting liver transplantation. Lastly, mounting evidence suggests that palliative ERCP-directed PDT, and probably ERCP-directed RFA as well, offer a survival advantage to patients with this difficult-to-treat malignancy.

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.

ERCP-directed radiofrequency ablation and photodynamic therapy are associated with comparable survival in the treatment of unresectable cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma (CCA) is a malignancy with a poor 5-year survival rate (5%-10%). ERCP-directed radiofrequency ablation (RFA) or photodynamic therapy (PDT) can be performed as palliative therapy for unresectable CCA. ERCP with PDT is associated with improved survival compared with stent placement alone. However, ERCP-directed RFA has not been directly compared with PDT in patients with CCA.

OBJECTIVE

To compare overall survival in patients with unresectable CCA who underwent palliative ERCP-directed RFA versus PDT.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care academic medical center.

PATIENTS

Forty-eight patients with unresectable CCA who underwent ERCP-directed ablative therapy for palliation of unresectable CCA.

INTERVENTIONS

ERCP-directed RFA or PDT.

MAIN OUTCOME MEASUREMENTS

Overall survival by Kaplan-Meier analysis after initial treatment with either RFA or PDT.

RESULTS

Patients who underwent RFA (n = 16) demonstrated an overall survival similar to that of those who underwent PDT (n = 32), with a median survival of 9.6 versus 7.5 months, respectively (P = .799). Patient age (P = .45), sex (P = .52), and lead time (P = .59) from presentation to initial RFA or PDT had no significant association with survival. The presence of distant metastasis was inversely associated with survival (hazard ratio 3.55; 95% confidence interval, 1.29-9.77; P = .014). Patients who underwent RFA (compared with PDT) had a lower mean number of plastic stents placed per month (0.45 vs 1.10, P = .001) but also had more episodes of stent occlusion (0.06 vs 0.02, P = .008) and cholangitis (0.13 vs 0.05, P = .008) per month.

LIMITATIONS

Retrospective, single-center design.

CONCLUSIONS

Survival after ERCP-directed RFA and PDT was not statistically different in patients with unresectable CCA. A randomized, controlled trial is warranted to validate these preliminary results.

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.

High single-session success rate of endoscopic bilateral stent-in-stent placement with modified large cell Niti-S stents for malignant hilar biliary obstruction

BACKGROUND

Endoscopic bilateral self-expandable metallic stent (SEMS) placement in a stent-in-stent method for malignant hilar biliary obstruction is technically challenging. Technical difficulties in the initial placement and reinterventions for stent occlusion are disadvantages inherent to this stent-in-stent method. We previously reported the feasibility of Niti-S large cell D-type biliary stents (LCD). This multicenter prospective consecutive study evaluated the efficacy of bilateral SEMS placement using modified LCD with large and uniform cells, a slimmer delivery system and high radial force.

PATIENTS AND METHODS

From July 2010 to June 2011, 26 consecutive patients with unresectable malignant hilar biliary obstruction underwent endoscopic bilateral placement of modified LCD in a stent-in-stent method at three tertiary hospitals. Ten patients had gallbladder cancer, eight had cholangiocarcinoma, four had lymph node metastasis, two had intrahepatic cholangiocarcinoma, and two had liver metastasis.

RESULTS

Single-session and final technical success rate was 96% and 100%, respectively. Functional success rate was 89%. Stent occlusion occurred in 11 patients (42%) because of sludge (n = 7) or tumor ingrowth (n = 4). Endoscopic bilateral reintervention was technically easy and successful: six patients had stent clearance by balloon sweeping and five had plastic stent placement. According to Kaplan-Meier analysis, median survival and stent patency were 220 days and 157 days, respectively.

CONCLUSIONS

Modified LCD achieved a high technical success rate both in the initial stent-in-stent placement and in bilateral reinterventions in patients with malignant hilar biliary obstruction.

Bilateral and unilateral stenting for malignant hilar obstruction: a systematic review and meta-analysis

BACKGROUND

Stents are used for palliating inoperable malignant bile duct hilar obstruction. It is not clear if bilateral stenting provides any advantage over unilateral stenting in these patients. Compare bilateral and unilateral stenting in malignant hilar obstruction.

STUDY SELECTION CRITERIA

Studies using stents for palliation in patients with malignant hilar obstruction were selected.

DATA COLLECTION AND EXTRACTION

Articles were searched in MEDLINE, PubMed, Ovid journals, CINAH, International Pharmaceutical Abstracts, OLDMEDLINE, MEDLINE nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Two reviewers independently searched and extracted data. Any differences were resolved by mutual agreement.

STATISTICAL METHODS

Pooled proportions were calculated using both the Mantel-Haenszel method (fixed effects model) and DerSimonian-Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights. The initial search identified 1,640 reference articles, of which 169 were selected and reviewed. Thirteen studies (n = 340) for bilateral metallic stents, eight studies (n = 575) for unilateral metallic stents, eight studies (n = 367) for bilateral plastic stenting, and seven studies (n = 850) for unilateral plastic stenting which met the inclusion criteria were included in this analysis. Pooled data are shown in Tables 1 and 2. The pooled estimates by the fixed and random effect models were similar. The p for chi-squared heterogeneity for all the pooled accuracy estimates was >0.10. Bilateral metal stenting seems to have lower odds of overall complications when compared to unilateral metallic stenting. Bilateral metal stents seem to have higher odds of lowering bilirubin than unilateral metal stents, but the 30-day mortality was no different. For metal stents, bilateral metal stents are superior in palliating symptoms due to hyperbilirubinemia. Unilateral plastic stenting seems to have similar odds of overall complications, cholangitis, and 30-day mortality when compared to bilateral plastic stenting for malignant hilar strictures. In patients with malignant hilar stricture, unilateral plastic stenting is comparable to bilateral plastic stenting for adverse events.

Bilateral metal stents for hilar biliary obstruction using a 6Fr delivery system: outcomes following bilateral and side-by-side stent deployment

BACKGROUND AND STUDY AIM

Controversy exists on optimal endoscopic management for palliation of malignant hilar obstruction, with advocates for metal "side-by-side" (SBS) and "stent-in-stent" (SIS) techniques. We sought to evaluate the technical feasibility, efficacy, and outcomes of bilateral biliary self-expanding metal stents (SEMS) for treatment of malignant hilar obstruction using a stent with a 6Fr delivery system.

PATIENTS AND METHODS

This was a single-center, retrospective review of all patients who underwent bilateral placement of Zilver® biliary SEMS for malignant hilar obstruction from January 2010 to August 2012. Patients underwent endoscopic retrograde cholangiopancreatography with placement of stents using either the SIS or SBS stent techniques.

RESULTS

Twenty-four patients (19 men, mean age 63 years) underwent bilateral stenting for malignant hilar obstruction during the study period. Seventeen and seven patients underwent the SBS and SIS technique, respectively. Cholangiocarcinoma (n=14) was the most common cause of hilar obstruction. Initial technical success was achieved in 24/24 (100%) of patients; however, 12 (50%) patients required re-intervention during the study period (median 98 days). Comparison of the SBS and SIS groups revealed no statistical difference with respect to need for re-intervention (P=0.31), successful re-intervention (P=0.60), or procedural length (P=0.89).

CONCLUSIONS

Use of bilateral Zilver® SEMS in either the SBS or SIS configuration is safe, technically feasible, and effective for drainage of malignant hilar obstruction; however, duration of stent patency and procedure-free survival remain variable.

Metal stents: a bridge to surgery in hilar cholangiocarcinoma

BACKGROUND

Obstructive jaundice in patients with hilar cholangiocarcinoma is a known risk factor for hepatic failure after liver resection. Plastic stents are most widely used for preoperative drainage. However, plastic stents are known to have limited patency time and therefore, in palliative settings, the self-expanding metal stent (SEMS) is used. This type of stent has been shown to be superior because it allows for rapid biliary decompression and a reduced complication rate after insertion. This study explores the use of the SEMS for biliary decompression in patients with operable hilar cholangiocarcinoma.

METHODS

A retrospective evaluation of a prospectively maintained database at a tertiary hepatobiliary referral centre was carried out. All patients with resectable cholangiocarcinoma were recorded.

RESULTS

Of 260 patients referred to this unit with cholangiocarcinoma between January 2008 and April 2012, 50 patients presented with operable cholangiocarcinoma and 27 of these had obstructive jaundice requiring stenting. Ten patients were initially treated with SEMSs; no stent failure occurred in these patients. Seventeen patients initially received plastic stents, seven of which failed in the interval between stent placement and laparotomy. These stents were replaced by SEMSs in four patients and by plastic stents in three patients. Median time to laparotomy was 45 days and 68 days in patients with SEMSs and plastic stents, respectively.

CONCLUSIONS

Self-expanding metal stents provide adequate and rapid biliary drainage in patients with obstruction caused by hilar cholangiocarcinoma. No re-interventions were required. This probably reflects the relatively short interval between stent placement and laparotomy.

Cholangiocarcinoma treatment

Cholangiocarcinoma (CCA) is a tumor of the bile ducts that usually presents with biliary obstruction and has a poor prognosis. The treatment of CCA is challenging as the tumor is usually diagnosed late and the treatments are not very effective except when complete surgical resection is possible. In carefully selected patients, liver transplant can be a curative therapy. In the majority of cases, complete surgical resection is not possible and palliation is the mainstay of treatment. Stenting, using plastic or metallic stents, allows for biliary drainage. Photodynamic therapy plays a role in palliation and might play a role in adjuvant or neoadjuvant therapy. While radiation and chemotherapy can be beneficial, newer ablative techniques and targeted chemotherapies are promising.

Threaded biliary inside stents are a safe and effective therapeutic option in cases of malignant hilar obstruction

BACKGROUND

Although endoscopic biliary stents have been accepted as part of palliative therapy for cases of malignant hilar obstruction, the optimal endoscopic management regime remains controversial. In this study, we evaluated the safety and efficacy of placing a threaded stent above the sphincter of Oddi (threaded inside plastic stents, threaded PS) and compared the results with those of other stent types.

METHODS

Patients with malignant hilar obstruction, including those requiring biliary drainage for stent occlusion, were selected. Patients received either one of the following endoscopic indwelling stents: threaded PS, conventional plastic stents (conventional PS), or metallic stents (MS). Duration of stent patency and the incident of complication were compared in these patients.

RESULTS

Forty-two patients underwent placement of endoscopic indwelling stents (threaded PS = 12, conventional PS = 17, MS = 13). The median duration of threaded PS patency was significantly longer than that of conventional PS patency (142 vs. 32 days; P = 0.04, logrank test). The median duration of threaded PS and MS patency was not significantly different (142 vs. 150 days, P = 0.83). Stent migration did not occur in any group. Among patients who underwent threaded PS placement as a salvage therapy after MS obstruction due to tumor ingrowth, the median duration of MS patency was significantly shorter than that of threaded PS patency (123 vs. 240 days).

CONCLUSIONS

Threaded PS are safe and effective in cases of malignant hilar obstruction; moreover, it is a suitable therapeutic option not only for initial drainage but also for salvage therapy.

Endoscopic drainage in patients with inoperable hilar cholangiocarcinoma

Hilar cholangiocarcinoma has an extremely poor prognosis and is usually diagnosed at an advanced stage. Palliative management plays an important role in the treatment of patients with inoperable hilar cholangiocarcinoma. Surgical, percutaneous, and endoscopic biliary drainage are three modalities available to resolve obstructive jaundice. Plastic stents were widely used in the past; however, self-expanding metal stents (SEMS) have become popular recently due to their long patency and reduced risk of side branch obstruction, and SEMS are now the accepted treatment of choice for hilar cholangiocarcinoma. Bilateral drainage provides more normal and physiological biliary flow through the biliary ductal system than that of unilateral drainage. Unilateral drainage was preferred until recently because of its technical simplicity. But, with advancements in technology, bilateral drainage now achieves a high success rate and is the preferred treatment modality in many centers. However, the choice of unilateral or bilateral drainage is still controversial, and more studies are needed. This review focuses on the endoscopic method and discusses stent materials and types of procedures for patients with a hilar cholangiocarcinoma.

Endoscopic sphincterotomy associated cholangitis in patients receiving proximal biliary self-expanding metal stents

BACKGROUND

Endoscopic biliary stent placement during the procedure of endoscopic retrograde cholangiopancreatography (ERCP) is preferred to provide biliary drainage for unresectable malignant biliary obstruction. There is considerable controversy over the use of endoscopic sphincterotomy (ES) prior to stent placement. This study aimed to determine whether ES before intraductal self-expanding metal stent (SEMS) placement affects the clinical outcome and complications in patients with proximal malignant obstructive biliary diseases.

METHODS

In a prospective randomized controlled trial, 82 patients with inoperable malignant biliary strictures were randomly assigned to biliary stenting groups with or without ES. Resolution of jaundice and the incidence of complications including acute cholangitis, pancreatitis and stent occlusion within 6 months were evaluated.

RESULTS

SEMSs were successfully deployed in all patients, resulting in clinical and biochemical improvement of obstructive symptoms in both groups. The incidence of cholangitis was higher in the ES group than in the non-ES group (58.5% vs 31.7%, P=0.015). The interval between stent placement and the first acute cholangitis was much shorter in the ES group than in the non-ES group (P=0.024). The use of ES increased the incidence of cholangitis (P=0.004, risk ratio, 8.196). The rate of post-ERCP pancreatitis after stent placement was greater in the non-ES group than in the ES group (31.7% vs 9.8%, P=0.014). No significant differences were found in the rate of restenosis and the mortality rate between the two groups.

CONCLUSIONS

ES prior to intraductal SEMS placement was associated with an increased incidence of acute cholangitis. ES should be carefully evaluated prior to its use in patients with proximal malignant obstructive biliary diseases.

Side-by-side versus stent-in-stent deployment in bilateral endoscopic metal stenting for malignant hilar biliary obstruction

BACKGROUND

The clinical differences between side-by-side and stent-in-stent deployment using a self-expanding metal stent for hilar malignant obstruction have not been evaluated.

AIMS

The purpose of this study was to compare the clinical features between side-by-side and stent-in-stent deployment.

METHODS

We compared side-by-side and stent-in-stent deployment in 52 consecutive patients with malignant hilar biliary obstruction who underwent endoscopic bilateral drainage using self-expanding metal stent. Side-by-side deployment (SBS group) was performed in 28 patients from 2002 to 2005, and stent-in-stent deployment (SIS group) in 24 patients from 2006 to 2010. Technical success, functional success, complications, stent occlusion and cumulative stent patency in the SBS and SIS groups were evaluated and compared retrospectively.

RESULTS

There were no significant inter-group differences in technical success (SBS vs. SIS, 89 vs. 100 %, respectively), functional success (96 vs. 100 %), early complications (11 vs. 4 %), late complications (32 vs. 8 %) or stent occlusion (20 vs. 42 %). The incidence of complications was significantly higher for SBS than for SIS (44 vs. 13 %; p = 0.016). Cumulative stent patency was significantly better for SBS than for SIS (log-rank, p = 0.047). SBS was not associated with significantly longer cumulative stent patency in univariate Cox proportional hazard analysis (HR 0.35; 95 % CI 0.12-1.03; p = 0.056) and multivariate analysis (HR 0.39; 95 % CI 0.13-1.16; p = 0.090).

CONCLUSIONS

The incidence of complications is higher for side-by-side than stent-in stent deployment in bilateral metal stenting. In terms of cumulative stent patency, side-by-side deployment tends to be more effective than stent-in-stent deployment.

Predictors of early stent occlusion among plastic biliary stents

BACKGROUND AND AIMS

A major disadvantage of plastic biliary stents is their short patency rates. The aim of this study was to identify predictors of early stent occlusion among patients receiving conventional plastic biliary stents.

METHODS

Early stent occlusion was defined as worsening cholestatic liver test results of a severity sufficiently significant to warrant ERCP with stent exchange prior to the planned stent exchange, or as symptoms of cholangitis. The association of cumulative stent diameter, demographics, stricture location, procedure indication, Charlson comorbidity index, history of prior early stent occlusion, presence of gallbladder, and performance of sphincteromy with the occurrence of early stent occlusion was studied using logistic regression and multivariate analysis.

RESULTS

Our patient cohort comprised 343 patients (mean age 59.3 years) who underwent 561 ERCP procedures with the placement of one or more plastic biliary stents (mean number of stents per procedure 1.2, mean total diameter of stents per procedure 12 Fr). Early stent occlusion occurred in 73 (13 %) procedures. Female gender was protective against early stent occlusion (adjusted OR 0.54, 95 % CI 0.32-0.90, p = 0.02), while hilar stricture location was independently associated with a significantly increased risk of early stent occlusion (adjusted OR 3.41, 95 % CI 1.68-6.90, p = 0.0007).

CONCLUSIONS

Early occlusion of conventional biliary stents occurred in 13 % of cases. While female gender decreased the risk of early stent occlusion, hilar stricture location was a significant predictor of early stent occlusion. Our results suggest that physicians should consider early elective stent exchange in patients with hilar strictures.

Endoscopic management of hilar cholangiocarcinoma

Hilar cholangiocarcinoma has a poor prognosis and surgery remains the only curative option. However, few patients are diagnosed at a curable stage and palliative therapies are, therefore, mandatory. Endoscopy could have a useful role in the work-up of patients with hilar cholangiocarcinoma who are unsuitable for surgery. Endoscopic retrograde cholangiopancreatography provides an opportunity to collect specimens for cytological or histological diagnosis, yet is often nondiagnostic. Other techniques, including fluorescence in situ hybridization, confocal laser endomicroscopy and endoscopic ultrasonography, are now improving the accuracy of tissue diagnosis. This Review presents an overview of the diagnostic and therapeutic role of endoscopic procedures in the management of hilar cholangiocarcinoma. The use of such procedures in guiding the therapeutic management of patients with hilar cholangiocarcinoma is discussed, and the relative success of endoscopic stenting as the main palliative therapy for obstructive jaundice (a common complication of hilar cholangiocarcinoma) is described. The potential role of photodynamic therapy as a palliative treatment for patients with hilar cholangiocarcinoma is also outlined.

Endoscopic stent placement in the palliation of malignant biliary obstruction

Biliary drainage with biliary stent placement is the treatment of choice for palliation in patients with malignant biliary obstruction caused by unresectable neoplasms. In such patients, the endoscopic approach can be initially used with percutaneous radiological intervention. In patients with unresectable malignant distal bile duct obstructions, endoscopic biliary drainage with biliary stent placement has now become the main and least invasive palliative modality, which has been proven to be more effective in >80% of cases with lower morbidity than surgery, and perhaps may provide a survival benefit. In patients with unresectable malignant hilar obstruction, the endoscopic approach for biliary drainage with biliary stent placement has also been considered as the treatment of choice. There is still a lack of clear consensus on the use of covered versus uncovered metal stents in malignant distal bile duct obstructions and plastic versus metal stents and unilateral versus bilateral drainage in malignant hilar obstructions.

Expandable metal stents for malignant hilar biliary obstruction

Most patients with malignant hilar stenoses are candidates for palliation. For this purpose, biliary drainage plays a major role in improving liver function and managing or avoiding cholangitis. Endoscopic interventions are less invasive than the percutaneous approach and should be considered as the first-line drainage procedures in most cases. Transhepatic interventions should be reserved for endoscopic failures or performed as a complementary approach in a combined procedure. After successful endoscopic access to biliary obstruction, implantation of self-expandable metal stents offers advantages over plastic endoprostheses in terms of stent patency and number of reinterventions.

Newly designed large cell Niti-S stent for malignant hilar biliary obstruction: a pilot study

BACKGROUND

Whether uni- or bilateral drainage should be performed for malignant hilar biliary obstruction remains a matter of debate. Moreover, endoscopic placement of bilateral metallic stents has been considered difficult and complicated. Although the Y-stent with a central wide-open mesh facilitates bilateral stent placement, it has limitations. This study evaluated the feasibility and efficacy of the Niti-S large cell D-type biliary stent (LCD) with a uniform large cell for both uni- and bilateral drainage of malignant hilar biliary obstruction.

METHODS

From April 2008 to March 2009, a total of 12 consecutive patients with unresectable malignant hilar biliary obstruction of Bismuth type 2 or greater underwent placement of LCD. Before LCD placement, all the patients underwent endoscopic unilateral biliary drainage using a plastic stent or a nasobiliary drainage tube. If jaundice improved after the procedure, the plastic stent or nasobiliary drainage tube was replaced with the unilateral LCD. If jaundice did not resolve or contralateral cholangitis occurred, bilateral LCD placement was performed.

RESULTS

Seven patients had unilateral and five patients had bilateral LCD placement. Technical success was achieved for all 12 patients. An early complication occurred for one patient (8%), and stent occlusion occurred for six patients (50%) because of tumor ingrowth (n=4) or sludge (n=2). These patients were managed by insertion of plastic stents (n=4) or percutaneous transhepatic biliary drainage (n=2). The median stent patency period was 202 days.

CONCLUSIONS

The newly designed endoscopic metallic stent may be feasible and effective for malignant hilar biliary obstruction, and endoscopic reintervention is relatively simple.

Photodynamic therapy: Palliation and endoscopic technique in cholangiocarcinoma

Cholangiocarcinoma is the primary malignancy arising from the biliary epithelium. The disease is marked by jaundice, cholestasis, and cholangitis. Over 50 percent of patients present with advanced stage disease, precluding curative surgical resection as an option of treatment. Prognosis is poor, and survival has been limited even after biliary decompression. Palliative management has become the standard of care for unresectable disease and has evolved to include an endoscopic approach. Photodynamic therapy (PDT) consists of administration of a photosensitizer followed by local irradiation with laser therapy. Several studies conducted in Europe and the United States have shown a marked improvement in the symptoms of cholestasis, survival, and quality of life. This article summarizes the published experience regarding PDT for cholangiocarcinoma and the steps required to administer this therapy safely.

Initial performance profile of a new 6F self-expanding metal stent for palliation of malignant hilar biliary obstruction

BACKGROUND

A 6F endoscopic biliary self-expanding metal stent (SEMS) has been newly introduced for intended simultaneous side-by-side bilateral deployment in hilar malignant obstruction.

OBJECTIVE

To report our initial experience with the Zilver 635 biliary SEMS.

DESIGN

Retrospective chart review.

SETTING

Tertiary referral medical center.

PATIENTS

Sixteen consecutive malignant hilar biliary obstruction patients.

INTERVENTIONS

Endoscopic palliative treatment of malignant biliary obstruction with the Zilver 635 SEMS from December 2008 to January 2010.

MAIN OUTCOME MEASUREMENTS

Technical/functional success rates, early complications (within 30 days of stent placement), early/late stent occlusion, and biliary reintervention rates.

RESULTS

A total of 49 Zilver SEMSs were placed in 16 patients (mean age 61 years, 6 men) for Bismuth type II (n = 4), III (n = 5), and IV (n = 7) lesions. Twelve had cholangiocarcinoma, 2 had metastatic colon cancer, 1 had lung cancer, and 1 had pancreatic cancer. The technical success rate was 100%. Side-by-side simultaneous bilateral stent deployment was required and was achieved successfully in 10 cases. Additional transpapillary stents were placed for potential future biliary access. The 30-day mortality rate was 0%. There were 1 early (6%) and 3 late (19%) stent occlusions. Successful overall biliary drainage was 75%.

LIMITATIONS

Small sample size, uncontrolled retrospective study.

CONCLUSIONS

Malignant hilar biliary obstruction endoscopic palliation with the Zilver 635 SEMS offers acceptable initial feasibility, safety, and efficacy profiles. The current design facilitates smaller bile duct negotiation and more precise intrahepatic placement. Expanding available lengths would allow transpapillary bridged bilateral SEMS placement for future reobstructed biliary access. Further long-term studies are required for comparative outcomes with other current SEMS technology.

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.

Usefulness of slimmer and open-cell-design stents for endoscopic bilateral stenting and endoscopic revision in patients with hilar cholangiocarcinoma (with video)

BACKGROUND

Although endoscopic bilateral metal stenting using a "stent-in-stent" method is currently used to treat patients with unresectable hilar cholangiocarcinoma, this method has limited application in cases of tight strictures or endoscopic revision in case of tumor recurrence, especially on the first stent (initial Y stent placed) side.

OBJECTIVE

To evaluate the clinical efficacy of bilateral metal stenting with the use of a slimmer (7F), open-cell-design stent.

DESIGN

Prospective, uncontrolled, single center.

SETTING

Tertiary referral university hospital.

PATIENTS

This study involved 34 patients with unresectable hilar cholangiocarcinoma (Bismuth type II-IV).

INTERVENTION

Endoscopic bilateral metal stenting using a stent-in-stent method was performed. First, a Y stent with a central, wide-open mesh was inserted, then a Zilver stent, with a preloaded delivery system that is slimmer (7F) than those (7.5-8.5F) of conventional stents, was placed into the contralateral hepatic duct through the central portion of the Y stent. The Zilver stent has an open-cell design, and it can be dilated easily. Thus, revision with bilateral plastic stents was tried in cases of stent obstruction.

MAIN OUTCOME MEASUREMENTS

Technical success, functional success, complications, and revision method.

RESULTS

Technical success (bilateral stenting using Y and Zilver stents) was achieved in 29 of 34 (85.3%) patients. Functional success was noted in 29 of the 29 (100.0%) patients who received bilateral stenting. Early complications such as pancreatitis and cholecystitis occurred in 3 (10.3%) patients. Late complications occurred in 11 (37.9%) patients. Cholecystitis, which occurred in 2 patients, was managed by percutaneous transhepatic gallbladder drainage. Stent obstruction by tumor ingrowth or overgrowth occurred in 9 of 29 (31.0%) patients. These patients were managed by placement of bilateral plastic stents (4 of 9), percutaneous transhepatic biliary drainage (4 of 9), and a combined method (1 of 9). Of the 5 patients in whom endoscopic revision was attempted, 4 (80%) were managed endoscopically with bilateral plastic stents.

LIMITATIONS

Small number of patients, uncontrolled study.

CONCLUSION

A slimmer (7F), open-cell-design stent is effective in endoscopic bilateral stenting for advanced hilar cholangiocarcinoma and endoscopic revision in case of tumor recurrence.

Biliary drainage, photodynamic therapy and chemotherapy for unresectable cholangiocarcinoma with jaundice

BACKGROUND AND AIM

The combination of photodynamic therapy and biliary stenting seems to be beneficial in the palliative treatment of unresectable cholangiocarcinoma. We aimed to assess the accuracy of photodynamic therapy in a single centre.

METHODS

Fourteen selected patients, with jaundice related to unresectable cholangiocarcinoma, underwent photodynamic therapy and biliary stenting (with or without chemotherapy). Photofrin was injected intravenously (2 mg/kg) 2 days before intraluminal photoactivation. In case of malignant progression, photodynamic therapy was repeated. The outcome parameters were overall survival and quality of life.

RESULTS

There were eight men and six women (median age: 67 [42-81]). Unresectability was related to a low Karnofski index (n = 2), peritoneal carcinomatosis (n = 4), vascular involvement (n = 3), invasion of the hepatoduodenal ligament (n = 2) and an under-sized liver remnant (n = 3). Biliary stenting was efficient (> or = 50% total bilirubin) in 78.5% of cases. Eight patients developed cholangitis. The mean number of photodynamic therapy procedures was two (1-4). Six (43%) patients needed > or = 2 procedures. No severe toxicity was noted. Photodynamic therapy improved the Karnofski index in 64% of cases. Six (42.8%) patients received concomitant chemotherapy (gemcitabine). The median survival time was 13.8 [0.7-29.2] months. The 3-, 6- and 12-month survival rates were 85%, 77% and 77%, respectively.

CONCLUSION

These results confirm the beneficial effect of biliary drainage, photodynamic therapy and chemotherapy for unresectable cholangiocarcinoma in selected patients with jaundice.

Photodynamic therapy is associated with an improvement in survival in patients with irresectable hilar cholangiocarcinoma

BACKGROUND

The majority of patients with hilar cholangiocarcinoma have irresectable disease and require palliation with biliary stenting to alleviate symptoms and prevent biliary sepsis. Chemotherapy and radiotherapy have proved ineffective, but recent studies suggest photodynamic therapy (PDT) may improve the outlook for these patients. This prospective clinical cohort study has evaluated the efficacy of radical curative surgery, standard palliative therapy (stent +/- chemotherapy) and a novel palliative therapy (stent +/- Photofrin-PDT) in 50 consecutive patients treated for hilar cholangiocarcinoma over a 5-year period.

METHODS

Between January 2002 and December 2006, 50 patients with hilar cholangiocarcinoma were evaluated for treatment. Ten patients were considered suitable for curative resection (Cohort 1). Forty patients with irresectable disease were stratified into Cohort 2 - Stent +/- chemotherapy (n= 17); and Cohort 3 - Stent +/- PDT (n= 23). Prospective follow-up in all patients and data collected for morbidity, mortality and overall patient survival.

RESULTS

The median age was 68 years [range 44-83]. Positive cytology/histology was obtained in 28/50 (56%). One death in Cohort 1 occurred at 145 days after surgical resection. No treatment related-deaths occurred in Cohort 2 or 3, chemotherapy-induced morbidity in three patients in cohort 2, PDT-induced morbidity in 11 patients in cohort 3. Actual 1-year survival was 80%, 12% and 75% in Cohorts 1, 2 and 3, respectively. Mean survival after resection was 1278 days (median survival not reached). Mean and median survival was 173 and 169 days, respectively, in Cohort 2; and 512 and 425 days in Cohort 3. Patient survival was significantly longer in cohorts 1 and 3 (P < 0.0001; Log rank test).

CONCLUSION

This prospective clinical cohort study has demonstrated that radical surgery and palliative Photofrin-PDT are associated with an increased survival in patients with hilar cholangiocarcinoma.

Unilateral versus bilateral endoscopic metal stenting for malignant hilar biliary obstruction

BACKGROUND AND AIM

The extent of liver drainage for palliative treatment of malignant hilar biliary obstruction is controversial. The aim of this study was to compare endoscopic unilateral versus bilateral drainage in patients with malignant hilar biliary obstruction using a self-expanding metal stent (SEMS).

METHODS

We carried out a retrospective review of 46 consecutive patients with malignant hilar biliary obstruction who were treated by endoscopic biliary drainage using SEMS between 1997 and 2005. Unilateral metal stenting (group A) was performed in 17 patients between 1997 and 2000, and bilateral metal stenting (group B) was performed in 29 patients between 2001 and 2005. The successful stent insertion, successful drainage, early complications, late complications, stent patency, and survival rate for groups A and B were evaluated and compared retrospectively.

RESULTS

There were no significant differences between the two groups in successful stent insertion (100% vs 90%, group A vs B, respectively), successful drainage (100% vs 96%), early complications (0% vs 10%), or late complications (65% vs 54%). Cumulative stent patency was significantly better in group B than in group A (P = 0.009). In cases of cholangiocarcinoma, cumulative stent patency was significantly better in group B than in group A (P = 0.009), whereas there were no inter-group differences for gallbladder carcinoma. Cumulative survival did not differ significantly between the groups.

CONCLUSIONS

Endoscopic bilateral drainage using SEMS for malignant hilar biliary obstruction is more effective than unilateral drainage in terms of cumulative stent patency, especially in cases of cholangiocarcinoma.

Palliative treatment with self-expandable metallic stents in patients with advanced type III or IV hilar cholangiocarcinoma: a percutaneous versus endoscopic approach

BACKGROUND AND OBJECTIVE

Endoscopic or percutaneous biliary drainage with self-expandable metallic stents (SEMS) is widely used for the palliation of cholestasis in patients with advanced hilar cholangiocarcinoma. However, little is known about which is the better option in patients with advanced hilar cholangiocarcinoma. We compared the clinical outcomes of these 2 methods of biliary decompression in these patients.

DESIGN AND SETTING

Multicenter retrospective study.

PATIENTS

A total of 85 patients with newly diagnosed advanced hilar cholangiocarcinoma (Bismuth III or Bismuth IV) and who did not receive an operation, chemotherapy, or radiotherapy were retrospectively reviewed. Forty-four of the 85 received endoscopic SEMS and 41 received percutaneous SEMS.

INTERVENTIONS

Endoscopic SEMS or percutaneous SEMS.

MAIN OUTCOME MEASUREMENTS AND RESULTS

Baseline characteristics were similar in the 2 groups, but the rate of successful biliary decompression was significantly higher in the percutaneous SEMS group than in the endoscopic SEMS group (92.7% vs 77.3%, respectively, P= .049). Overall rates of procedure-related complications were similar for the 2 groups, but 1 death (from biliary sepsis) occurred in the endoscopic SEMS group. Median survival of patients in whom biliary drainage was successful initially, regardless of which procedure was performed, was much longer than that of patients who had failed biliary drainage (8.7 months vs 1.8 months, respectively, P< .001). Once successful biliary decompression had been achieved, median survival and stent patency duration were similar in the 2 study groups.

LIMITATION

Retrospective study.

CONCLUSIONS

Percutaneous SEMS may be chosen for initial biliary drainage in patients with advanced type III or IV hilar cholangiocarcinoma, given higher initial success rate and low level of procedure-related cholangitis.

Plastic versus self-expanding metallic stents for malignant hilar biliary obstruction: a prospective multicenter observational cohort study

BACKGROUND

There are few comparative data as to whether plastic or self-expanding metallic stents are preferable for palliating malignant hilar biliary obstruction.

METHODS

Thirty-day outcomes of consecutive endoscopic retrograde cholangiopancreatographies performed for malignant hilar obstruction at 6 private and 5 university centers were assessed prospectively.

RESULTS

Patients receiving plastic (N=28) and metallic stents (N=34) were similar except that metallic stent recipients more often had: Bismuth III or IV tumors (16/34 vs. 5/28 P=0.043), higher Charlson comorbidity scores (P=0.003), metastatic disease (P=0.006), and management at academic centers (P=0.018). The groups had similar rates of bilateral stent placement (4/28 vs. 5/34), and similar frequency of opacified but undrained segmental ducts (7/28 vs. 5/34). Adverse outcomes including cholangitis, stent occlusion, migration, perforation, and/or the need for unplanned endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography occurred in 11/28 (39.3%) patients with plastic versus 4/34 (11.8%) with metal stents (P=0.017). By logistic regression, factors associated with adverse outcomes included plastic stent placement (odds ratio 6.32; 95% confidence interval 1.23, 32.56) and serum bilirubin (1.11/mg/dL above normal: 1.01, 1.22) but not center type or Bismuth class.

CONCLUSIONS

Metallic stent performance was superior to plastic for hilar tumor palliation with respect to short-term outcomes, independent of disease severity, Bismuth class, or drainage quality.

Endoscopic deployment of multiple JOSTENT SelfX is effective and safe in treatment of malignant hilar biliary strictures

BACKGROUND & AIMS

For the treatment of unresectable biliary tract carcinoma with hilar biliary stricture, antitumor therapy and biliary stenting should be addressed in terms of prolonged survival with a good quality of life. However, the endoscopic management of malignant hilar biliary strictures is difficult even for an expert endoscopist. We evaluated the efficacy and safety of the endoscopic deployment of multiple JOSTENT SelfX units in patients with hilar biliary strictures treated with or without chemotherapy.

METHODS

Between November 2003 and December 2006, endoscopic deployment of multiple JOSTENT SelfX units in hilar biliary strictures by using a partial stent-in-stent procedure was performed on 41 consecutive patients with primary cholangiocarcinoma (n = 34) and gallbladder carcinoma (n = 7) at a gastroenterologic center of Okayama University Hospital. Thirty-three patients were treated with gemcitabine (n = 25) or S-1 (n = 8).

RESULTS

Metallic stent deployment was successfully accomplished in all cases via only endoscopic procedures. During the follow-up period (mean, 210 days), mean patency time was 150 days, and metallic stent obstruction occurred in 15 cases (37%). Although a repeat intervention was required in all metallic stent obstructed cases, the deployment of the second metallic or plastic stent was completed successfully. The remaining 26 cases (63%) required no interventions. The median overall survival period was only 235 days. However, that of the patients receiving chemotherapy was 392 days.

CONCLUSIONS

Endoscopic partial stent-in-stent deployment with multiple JOSTENT SelfX prostheses is effective and safe for the treatment of malignant hilar biliary stricture even in patients receiving chemotherapy.

The multidisciplinary management of gastrointestinal cancer. Biliary tract cancers: from pathogenesis to endoscopic treatment

Cholangiocarcinoma is the second most common hepatobiliary tumour. Even if it is a rare tumour, its incidence is increasing over these last decades, probably due in part to a better knowledge of the disease and to an improvement of the diagnosis. Accurate diagnosis and staging are key steps to determine the appropriate treatment. The only curative treatment of this cancer is surgical resection. To date, no neoadjuvant or adjuvant treatments have ever proved any survival benefit, and are not recommended outside clinical trials. Liver transplantation (with or without neoadjuvant treatment) can be an option for highly selected cases. Unfortunately, these tumours are generally diagnosed at an advanced stage or are unresectable. For most of these patients, palliative therapeutic options exist and are in further development, based on multimodal promising combinations including chemotherapy, targeted agents, radiation, endoscopic stenting and photodynamic treatment.

Endoscopic 3-branched partial stent-in-stent deployment of metallic stents in high-grade malignant hilar biliary stricture (with videos)

BACKGROUND

In view of the recent advancement in endoscopic devices for biliary endoscopic intervention, the expert endoscopist can address complex morbidity. However, endoscopic 3-branched partial stent-in-stent deployment of metallic stents (MS) in patients with malignant hilar biliary stricture is technically demanding.

OBJECTIVES

To evaluate the efficacy and safety of endoscopic 3-branched partial stent-in-stent deployment of MS.

DESIGN

Case study.

SETTING

Gastroenterological Center, Okayama University Hospital.

PATIENTS

Nine consecutive patients (mean age 63 years, range 52-84 years, mean follow-up period 5 months) with malignant hilar biliary stricture were enrolled. They had cytologically or histologically proven unresectable biliary-tract carcinoma with hilar biliary stricture type IIIa or IV according to Bismuth's classification.

INTERVENTIONS

Endoscopic 3-branched partial stent-in-stent deployment of MS in hilar biliary strictures by using a JOSTENT SelfX stent.

MAIN OUTCOME MEASUREMENTS

The success rate of the procedure, stent patency time, reinterventions, and complications.

RESULTS

Endoscopic 3-branched partial stent-in-stent deployment was successfully accomplished in all cases. The MS became obstructed in 3 cases (33%), mean 1.5 months, range 1.4 to 2.7 months. However, no MS obstruction occurred in the other 6 patients (67%), mean 11 months, range 4.7 to 16.4 months. In the obstructed cases, the deployment of 2 or 3 tube stents was completed successfully. One case of cholecystitis was observed as a short-term complication.

LIMITATION

The small number of cases.

CONCLUSIONS

Endoscopic 3-branched partial stent-in-stent deployment of a JOSTENT SelfX stent was effective in selected patients with high-grade malignant hilar biliary stricture.

Contrast-free endoscopic stent insertion in malignant biliary obstruction

AIM

To present a case series of MRCP-guided endoscopic biliary stent placement, performed entirely without contrast injection.

METHODS

Contrast-free endoscopic biliary drainage was attempted in 20 patients with malignant obstruction, unsuitable for resection on the basis of tumor extent or medical illness. MRCP images were used to confirm the diagnosis of tumor, to exclude other biliary diseases and to demonstrate the stenoses as well as dilation of proximal liver segments. The procedure was carried out under conscious sedation. Patients were placed in the left lateral decubitus position. The endoscope was inserted, the papilla identified and cannulated by a papillotome. A guide wire was inserted and guided deeply into the biliary tree, above the stenosis, by fluoroscopy. A papillotomy approximately 1 cm. long was performed and the papillotome was exchanged with a guiding-catheter. A 10 Fr, Amsterdam-type plastic stent, 7 to 15 cm long, was finally inserted over the guide wire/guiding catheter by a pusher tube system.

RESULTS

Successful stent insertion was achieved in all patients. There were no major complications. Successful drainage, with substantial reduction in bilirubin levels, was achieved in all patients.

CONCLUSION

This new method of contrast-free endoscopic stenting in malignant biliary obstruction is a safe and effective method of palliation. However, a larger, randomized study comparing this new approach with the standard procedure is needed to confirm the findings of the present study.

Optimal biliary drainage for inoperable Klatskin's tumor based on Bismuth type

AIM: To investigate differences in the effects of biliary drainage procedures in patients with inoperable Klatskin’s tumor based on Bismuth type, considering endoscopic retrograde biliary drainage (ERBD), external percutaneous transhepatic biliary drainage (EPTBD) and internal biliary stenting via the PTBD tract (IPTBD).

METHODS: The initial success rate, cumulative patency rate, and complication rate were compared retrospectively, according to the Bismuth type and ERBD, EPTBD, and IPTBD. Patency was defined as the duration for adequate initial bile drainage or to the point of the patient’s death associated with inadequate drainage.

RESULTS: One hundred thirty-four patients (93 men, 41 women; 21 Bismuth type II, 47 III, 66 IV; 34 ERBD, 66 EPTBD, 34 IPTBD) were recruited. There were no differences in demographics among the groups. Adequate initial relief of jaundice was achieved in 91% of patients without a significant difference in the results among different procedures or Bismuth types. The cumulative patency rates for ERBD and IPTBD were better than those for EPTBD with Bismuth type III. IPTBD provided an excellent response for Bismuth type IV. However, there was no difference in the patency rate among drainage procedures for Bismuth type II. Procedure-related cholangitis occurred less frequently with EPTBD than with ERBD and IPTBD.

CONCLUSION: ERBD is recommended as the first-line drainage procedure for the palliation of jaundice in patients with inoperable Klatskin’s tumor of Bismuth type II or III, but IPTBD is the best option for Bismuth type IV.

Photodynamic therapy of malignant biliary strictures using meso-tetrahydroxyphenylchlorin

OBJECTIVES

The palliation of patients with malignant bile duct obstruction using metal or plastic biliary stents may be limited by stent occlusion. The aim of this study was to determine the safety and efficacy of endoscopically delivered meso-tetrahydroxyphenyl chlorin photodynamic therapy in the treatment of irresectable malignant biliary strictures and recurrent stent occlusion.

METHODS

Thirteen patients with malignant biliary obstruction owing to carcinoma of the biliary tract (n=9), pancreas (n=3) or stomach (n=1), were studied. All had been initially palliated with metal (n=10) or polyethylene (n=3) biliary stents, but presented with recurrent obstructive jaundice because of local tumour progression. Patients received meso-tetrahydroxyphenyl chlorin 0.15 mg/kg intravenously 72 h before endoluminal light activation with an endoscopically placed optical fibre, followed by polyethylene stent insertion.

RESULTS

Before photodynamic therapy, patients had a median of three (range 0-5) stent occlusions in the preceding 11 (2-22) months, with a median patency of plastic stents placed inside metal bile duct stents for recurrent stent occlusion of 3.5 (0.5-13) months. After photodynamic treatment, tumour necrosis and/or metal stent recanalization was seen in all patients, with a median of 0 (0-3) stent occlusions during 7 (1-43) months follow-up. The median patency of plastic stents placed inside metal stents after photodynamic therapy was 5 (1-43) months. The median survival after diagnosis and photodynamic therapy administration was 21 (10-56) and 8 (1-43) months, respectively. Photodynamic therapy was generally well tolerated but two patients developed cholangitis within the first week, complicated in one by a fatal liver abscess and two developed haemobilia within 4 weeks of treatment, one of whom died with a gall bladder empyema.

CONCLUSION

In patients with malignant biliary obstruction, endoscopically delivered meso-tetrahydroxyphenyl chlorin photodynamic therapy causes efficient tumour necrosis and recanalization of blocked metal stents, but there is a significant risk of complications.

Endoscopic palliation of malignant obstructive jaundice: an evidence-based review

Endoscopic stent insertion is considered the method of choice for palliative treatment of malignant biliary obstruction. Nonetheless, relevant studies are often underpowered or outdated and do not compare actual surgical outcomes with latest stent technology. Purpose of this review was to assess, with an evidence-based methodology, the role of endoscopic versus surgical palliation of patients with malignant obstructive jaundice with special reference to clinical effectiveness, safety aspects and economic outcomes.

Endoscopic palliation of cholangiocarcinoma

PURPOSE OF REVIEW

The current endoscopic palliative modalities for unresectable cholangiocarcinoma are reviewed, focusing on the emergent methods of endoscopic palliation.

RECENT FINDINGS

Cholangiocarcinoma is a rare malignant tumor arising from biliary epithelium. Endoscopic retrograde cholangiopancreaticography can provide histological diagnosis through brush cytology of the bile duct, and newer cytologic techniques such as digital image analysis and fluorescent in-situ hybridization may improve the cytologic accuracy for diagnosing cholangiocarcinoma. Endoscopic ultrasonography can play an adjunctive role in the diagnosis and staging by facilitating tissue acquisition through fine needle aspiration of the tumor and surrounding lymph nodes. Most patients present with unresectable disease and features of biliary obstruction. This has led to an emphasis on the role of palliative care. Biliary stent placement is an effective method of palliating obstructive jaundice. Newer modalities such as photodynamic therapy, intraluminal brachytherapy, and high-intensity ultrasound therapy may result in improved survival and play a future role as an adjunctive therapy to surgical resection.

SUMMARY

Several endoscopic palliative modalities have recently emerged. Among these, photodynamic therapy in addition to biliary stent placement appears to be a promising step towards the management of locally unresectable cholangiocarcinoma. Randomized, controlled trials are required, however, to further evaluate these therapies.

Palliation of malignant obstructive jaundice

Palliation of obstructive jaundice can be achieved in most patients using various approaches. The method chosen should be individualized to the patient and based upon performance status, patient preferences, and available expertise. The best approach ideally should be determined by a multi-discipline approach with endoscopists, interventional radiologists, oncologists, and surgeons.

Palliative management of hilar cholangiocarcinoma

Around 80% of the patients with hilar cholangiocarcinoma are candidates for palliative management due to extensive co-morbidity for major surgery, metastases or advanced loco-regional disease. The primary aim of treatment is to provide biliary drainage with long-term relief from pruritus, cholangitis, pain and jaundice. Endoscopically placed self-expanding metallic biliary stent has low procedure-related complications and is probably the modality of choice for patients with unresectable tumour on preoperative assessment. Percutaneous biliary drainage has comparable results and is an alternative when endoscopic expertise is not available or has failed or there are multiple isolated segments with cholangitis. Surgical cholangiojejunostomy provides lasting biliary drainage but has limitations of associated morbidity and mortality. In the absence of high-quality studies, comparing these modalities the choice of biliary drainage procedure should be guided by the available local expertise. Other modalities of treatment like radiotherapy, chemotherapy and photodynamic therapy currently remain investigational.

Cholangiocarcinoma

Cholangiocarcinoma is an uncommon malignant tumor arising from biliary epithelium. The incidence increases with age and usually affects individuals in their sixth or seventh decade of life. Most patients clinically present with features of biliary obstruction. Although surgical resection offers the only hope for cure, the majority of patients are found to have unresectable disease on initial presentation and carry extremely grim prognosis. This has lead to an emphasis on the role of palliative care, with the relief of biliary obstruction being the primary goal in the management of these patients. Surgical bypass was once considered as the primary means of palliating biliary obstruction, but nonsurgical placement of biliary stents is associated with lower morbidity and mortality. Newer modalities such as photodynamic therapy, brachytherapy, and high-intensity ultrasound therapy may result in improved survival and play a future role as an adjunctive therapy to surgical resection.

Pilot study to assess patient outcomes following endoscopic application of photodynamic therapy for advanced cholangiocarcinoma

BACKGROUND

Photodynamic therapy (PDT) has demonstrated promise in the palliative treatment of advanced cholangiocarcinoma. The aim of this pilot study was to assess the outcome in patients with non-resectable cholangiocarcinoma following endoscopic application of PDT directly into the biliary tract.

METHODS

In patients with advanced cholangiocarcinoma, endoscopic retrograde cholangiopancreatography (ERCP) was performed to define the proximal and distal extent of intraductal tumor. Sodium porfimer was administered intravenously to all patients. Forty-eight hours later, a commercially available cylindrical diffusing laser fiber (1-2.5 cm in length, OptiGuide) designed for esophageal use was advanced across the biliary strictures. Laser light was applied at a power of 400 mW/cm fiber for a total energy of 180 J/cm(2) using an argon-pumped tunable dye laser. Patients received endoscopic PDT every 3 months provided they maintained a favorable performance status. Plastic biliary stents were replaced immediately following light application and were maintained in all patients.

RESULTS

Using a preloaded catheter, adequate positioning of the laser fiber was achieved in all patients. Eight patients with advanced cholangiocarcinoma received a total of 19 PDT treatments, range 1-5 treatments/patient. All eight patients were followed until death; mean follow-up was 9.8 months. Median survival from the date of the first PDT treatment was 276 days, which compares favorably with published series that have reported median survival times between 45 and 127 days for patients with bismuth type III and IV tumors treated with stenting alone.

CONCLUSIONS

Endoscopic application of PDT demonstrates promise in prolonging survival in patients with advanced cholangiocarcinoma. Additional randomized clinical trials using commercially available fibers are needed to fully evaluate both the optimum frequency and treatment interval of endoscopic PDT in the management of advanced cholangiocarcinoma.

Contrast-free unilateral endoscopic palliation in malignant hilar biliary obstruction: new method

BACKGROUND

Bilateral endoscopic drainage is difficult in malignant hilar biliary obstruction. Recently, unilateral drainage in malignant hilar biliary obstruction has been shown to be equally effective. However, contrast injection leads to cholangitis. There have been no reported studies on contrast-free metal stenting in malignant hilar biliary obstruction. The present study was undertaken to evaluate the results of contrast-free unilateral metal stenting in type II malignant hilar biliary obstruction.

METHODS

We prospectively studied the results of unilateral metal stenting in type II malignant hilar biliary obstruction without contrast injection in 18 patients.

RESULTS

A successful endoscopic drainage was achieved in 100% (18/18) of patients with hilar strictures. Cholangitis and 30-day mortality occurred in none.

CONCLUSIONS

Unilateral endoscopic metal stenting without contrast in type II malignant hilar biliary obstruction is a safe and effective method of palliation.

Successful photodynamic therapy for nonresectable cholangiocarcinoma: a randomized prospective study

BACKGROUND & AIMS

In nonrandomized trials, photodynamic therapy (PDT) had a promising effect on nonresectable cholangiocarcinoma (NCC). This prospective, open-label, randomized, multicenter study with a group sequential design compared PDT in addition to stenting (group A) with stenting alone (group B) in patients with NCC.

METHODS

In patients with histologically confirmed cholangiocarcinoma, endoscopic or percutaneous double stenting was performed. Patients fulfilling inclusion criteria were randomized to group A (stenting and subsequent PDT) and group B (stenting alone). For PDT, Photofrin 2 mg/kg body wt was injected intravenously 2 days before intraluminal photoactivation (wavelength, 630 nm; light dose, 180 J/cm(2)). Further treatments were performed in cases of residual tumor in the bile duct. The primary outcome parameter was survival time. Secondary outcome parameters were cholestasis and quality of life.

RESULTS

PDT resulted in prolongation of survival (group A: n = 20, median 493 days; group B: n = 19, median 98 days; P < 0.0001). It also improved biliary drainage and quality of life.

CONCLUSIONS

PDT, given in addition to best supportive care, improves survival in patients with NCC. The study was terminated prematurely because PDT proved to be so superior to simple stenting treatment that further randomization was deemed unethical.