Relief of obstructive jaundice through percutaneous transhepatic catheter--a new therapeutic method

A case of an intraabdominal, but extrahepatic ruptured percutaneous transhepatic biliary drainage and its following rescue. A case report and literature review

Percutaneous transhepatic biliary drainage is a well-established technique for the treatment of biliary obstruction in patients with failed endoscopic approaches. We report on an 82-year-old man with a history of cholangiocarcinoma treated with pancreaticoduodenectomy who presented with recurrent cholangitis and sepsis. Percutaneous transhepatic biliary drainage was performed after unsuccessful endoscopic retrograde cholangiography, which initially improved his condition. However, due to an accidental dislodgement, there was an intra-abdominal fracture of the drain which led to biliary peritonitis and clinical deterioration. The fractured intrahepatic drain was successfully extracted in our angio suite, and a novel subcutaneous fixation technique was introduced to prevent similar occurrences in the future. This case study signifies the role of interventional radiology in the management of percutaneous transhepatic biliary drainage complications and the importance of preventative measures to avoid dislodgement.

Esophageal Stenting: How I Do It

Endoscopic esophageal stent placement is an effective palliative treatment for malignant strictures and has also been successfully used for benign indications, including esophageal refractory strictures and iatrogenic leaks and perforations. Despite several decades of evolution and the wide variety of esophageal stents available to choose from, an ideal stent that is both effective and without adverse events such as stent migration, tissue ingrowth, or pressure necrosis has yet to be developed. This paper is an overview of how this evolution happened, and it also addresses the characteristics of some of the currently available stents, like their material and construction, delivery device, radial and axial force pattern, covering and size which may help to understand and avoid the occurrence of adverse events. The insertion delivery systems and techniques of placement of an esophageal self-expandable metal stent are reviewed, as well as some tips and tricks regarding placement and management of adverse events.

Refractory Biliary Catheter Leak Corrected by a Hybrid Closed Loop Catheter-Pump System

The development of inoperable biliary obstruction in patients with liver, biliary, and pancreatic neoplasia is commonplace particularly in the advanced stages of these diseases. Under these circumstances, restoring bile flow to the gut is paramount in reestablishing homeostasis. Hitherto, this has been achieved by utilizing passive, gravity-dependent bilioenteric conduits with the use of perforated plastic catheters or metallic stents inserted either in a percutaneous transhepatic fashion or via endoscopic techniques. A frequent untoward event of biliary decompression utilizing percutaneous transhepatic catheters (PTC) is the development of pain, cholangitis, hyperbilirubinemia, or pericatheter bile leak due to the suboptimal normalization of bile flow. In some instances, the etiology of PTC malfunction can be correctly ascribed to catheter malposition and/or catheter lumen obstruction; however, in the majority, it remains radiographically occult on transcatheter cholangiography-the "gold standard." Regardless of findings, the management remains fluoroscopic repositioning or exchanges for larger diameter catheters to attempt to seal the pericatheter potential space and prevent bile seepage. Unfortunately, these maneuvers are met with limited and unpredictable levels of success. We present the successful management of an instance of recalcitrant external pericatheter bile leak mitigated by employing a hybrid closed loop biliary catheter-pump system by employing an assortment of FDA approved off-the-shelf medical devices.

Radiologic Assessment for Endoscopic US-guided Biliary Drainage

Endoscopic US-guided biliary drainage (BD) is performed for various types of biliary obstruction and is mainly indicated for unsuccessful conventional transpapillary endoscopic retrograde cholangiodrainage. In endoscopic US BD, an extra-anatomic drainage route between the gastrointestinal (GI) tract and the biliary system is created with a covered metallic stent or plastic stent. Procedural types of endoscopic US BD include hepaticogastrostomy, hepaticojejunostomy (after gastrectomy), choledochoduodenostomy, hepaticoduodenostomy, and endoscopic US-guided gallbladder drainage. The technical and clinical success rates of endoscopic US BD are reported to be 94%-97% and 88%-100%, respectively. CT is crucial both in preprocedural assessment and postprocedural monitoring. CT is used to determine the indications for endoscopic US BD, which include the type of biliary obstruction, collateral vessels in the puncture route, ascites, the volume of the liver segment, the distribution of an intrahepatic tumor, and GI tract patency. After endoscopic US BD, common subclinical findings are a small amount of intraperitoneal gas, localized edematous change in the GI tract, a notch in the placed stent, and localized biliary dilatation caused by stent placement. Stent malfunction after endoscopic US BD is caused by impaction of debris and/or food, stent migration into the GI tract, or tumor overgrowth and/or hyperplasia. Complications that can occur include internal stent migration, intraperitoneal biloma, arterial bleeding or pseudoaneurysm, perforation of the GI tract, and portobiliary fistula. The incidence of clinical endoscopic US BD-related complications is 11%-23%. ^©RSNA, 2020.

Lumen-apposing metal stents for malignant biliary obstruction: Is this the ultimate horizon of our experience?

In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic interventions. Among these, EUS-guided biliary drainage (BD) is gaining popularity as a therapeutic approach after failed endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction (MBO), due to the avoidance of external drainage, a lower rate of adverse events and re-interventions, and lower costs compared to percutaneous trans-hepatic BD. Initially, devices created for luminal procedures (e.g., luminal biliary stents) have been adapted to the new trans-luminal EUS-guided interventions, with predictable shortcomings in technical success, outcome and adverse events. More recently, new metal stents specifically designed for transluminal drainage, namely lumen-apposing metal stents (LAMS), have been made available for EUS-guided procedures. An electrocautery enhanced delivery system (EC-LAMS), which allows direct access of the delivery system to the target lumen, has subsequently simplified the classic multi-step procedure of EUS-guided drainages. EUS-BD using LAMS and EC-LAMS has been demonstrated effective and safe, and currently seems one of the most performing techniques for EUS-BD. In this Review, we summarize the evolution of the EUS-BD in distal MBO, focusing on the novelty of LAMS and analyzing the unresolved questions about the possible role of EUS as the first therapeutic option to achieve BD in this setting of patients.

Percutaneous Management of Biliary Enteric Anastomotic Strictures: An Institutional Review

Purpose

Stricture formation at the biliary enteric anastomotic site is a common complication due to fibrotic healing. Few therapeutic options are available for biliary-enteric anastomotic site stricture (BES) including new surgical reconstruction or percutaneous transhepatic biliary drainage followed by balloon dilation of BES or stent placement. The purpose of this study is to assess the technical success, complications and reintervention rate of percutaneous transhepatic balloon dilatation (PTBD) of BES after iatrogenic bile duct injuries (BDI).

Methods

A retrospective review of patients who underwent PTBD for benign resistant BES, previously treated for iatrogenic BDI, from December 2004 to January 2016 was performed. Diagnostic transhepatic cholangiogram was performed to assess the level of obstruction. BES was dilated using 8-12 mm diameter balloons followed by placement of eight to ten Fr internal-external drainage catheters, which were removed after three to six weeks post-PTBD cholangiogram. Follow-up by clinical assessment, liver function tests, and ultrasound was done. Fischer exact test was used to determine if there was a significant association between PTBD sessions and recurrent strictures.

Results

In total, 37 patients underwent 66 sessions of PTBD, including 10 (27%) males and 27 (73%) females. The mean age was 41.3 years (range 23–70 years). Out of these, 29 (78%) were treated with choledochojejunostomy and eight (22%) with hepaticojejunostomy. 100% technical success was achieved in all the PTBD sessions. Nineteen (51.3%) patients were treated with a single PTBD session. Mean follow-up time was 36 months (range 1–75 months). Eighteen (48.7%) patients needed reintervention, out of these, 11 (29.7%) were symptom-free after second session on three-year follow-up, three (8%) were symptom-free after the third session of PTBD. No significant difference was observed in risk of recurrent strictures after first and second PTBD sessions [18 (48%) vs. 7 (39%); p-value 0.495]. In four (11%) patients, the symptoms persisted and BES recurred even after third session and those were treated by placing metallic stent. In total, three (8.1%) patients got complicated with the stone formation; in two (5%) patients stone was successfully removed percutaneously and in one (3%) patient percutaneous attempt failed so it was followed by surgical removal.

Conclusion

PTBD is a safe and useful treatment option for benign BES for long-term symptom-free time-period. However, there is no significant difference in developing recurrent BES after PTBD sessions. Few patients with resistant strictures might require stent placement.

The Utility of a Benign Biliary Stricture Protocol in Preventing Symptomatic Recurrence and Surgical Revision

PURPOSE

To determine whether treating benign biliary strictures via a stricture protocol reduced the probability of developing symptomatic recurrence and requiring surgical revision compared to nonprotocol treatment.

MATERIALS AND METHODS

A stricture protocol was designed to include serial upsizing of internal/external biliary drainage catheters to a target maximum dilation of 18-French, optional cholangioplasty at each upsizing, and maintenance of the largest catheter for at least 6 months. Patients were included in this retrospective analysis if they underwent biliary ductal dilation at a single institution from 2005 to 2016. Forty-two patients were included, 25 women and 17 men, with an average age of 51.9 years (standard deviation ± 14.6). Logistic regression models were used to determine the probability of symptomatic recurrence and surgical revision by stricture treatment type.

RESULTS

Twenty-two patients received nonprotocol treatment, while 20 received treatment on a stricture protocol. After treatment, 7 (32%) patients in the nonprotocol group experienced clinical or laboratory recurrence of a benign stricture, whereas only 1 patient in the stricture protocol group experienced symptom recurrence. Patients in the protocol group were 8.9 times (95% confidence interval [CI] = 1.4-175.3) more likely to remain symptom free than patients in the nonprotocol group. Moreover, patients in the protocol group had an estimated 89% reduction in the probability of undergoing surgical revision compared to patients receiving nonprotocol treatment (odds ratio = .11, 95% CI = .01-.73).

CONCLUSIONS

Establishing a stricture protocol may decrease the risk of stricture recurrence and the need for surgical revision when compared to a nonprotocol treatment approach.

Isolated implant metastasis in chest wall due to seeding of transpleurally placed PTBD catheter tract in a case of hilar cholangiocarcinoma

Percutaneous transhepatic biliary drainage (PTBD) catheter site metastasis in cases of cholangiocarcinoma is reported sporadically. But it is unusual to see left-sided tumour metastasising to the right PTBD catheter site. Metastasis, in general, has a poor prognosis, but recurrence along the catheter tract in the absence of other systemic diseases can be a different scenario altogether. To date, there is no consensus on the management of this form of metastasis. But carefully selected patients can benefit from aggressive surgical resection. We report a case of a young patient with isolated chest wall metastasis 1 year after resection of left-sided hilar cholangiocarcinoma. The metastasis was resected and, on pathological analysis, was confirmed to be due to implantation of malignant cells along the tract of the PTBD catheter placed via a transpleural route.

Temporary duodenal stenting as a bridge to ERCP for inaccessible papilla due to duodenal obstruction: a retrospective study

BACKGROUND AND STUDY AIMS

Duodenal obstruction may prevent performance of endoscopic retrograde cholangiopancreatography (ERCP). Percutaneous transhepatic biliary drainage (PTBD) or Endoscopic ultrasonograhy-guided biliary access (EUS-BD) are alternative treatments but are associated with a higher morbidity and mortality rate. The aim of the study is to report overall technical success rate and clinical outcome with deployment of temporary fully or partially covered self-expanding duodenal stent (pc/fcSEMS) as a bridge to ERCP in case of inaccessible papilla due to duodenal strictures.

PATIENTS AND METHODS

This retrospective study included 66 consecutive patients presenting with a duodenal stricture impeding the ability to perform an ERCP. Provisional duodenal stenting was performed as a bridge to ERCP. A second endoscopic session was performed to remove the provisional stent and to perform an ERCP. Afterward, a permanent duodenal stent was delivered if necessary.

RESULTS

Sixty-six duodenal stents (17 pcSEMS and 49 fcSEMS) were delivered with a median indwelling time of 3.15 (1 - 7) days. Two migrations occurred in the pcSEMS group, 1 of which required lower endoscopy for retrieval. No other procedure-related complications were observed. At second endoscopy a successful ERCP was performed in 56 patients (85 %); 10 patients (15 %) with endoscopic failure underwent PTBD or EUS-BD. Forty patients needed permanent duodenal stenting.

CONCLUSIONS

Provisional removable covered duodenal stenting as a bridge to ERCP for duodenal obstruction is safe procedure and in most cases allows successful performance of therapeutic ERCP. This technique could be a sound option as a step up approach before referring such cases for more complex techniques such as EUS-BD or PTBD.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Percutaneous transhepatic biliary drainage (PTBD) with or without stenting-complications, re-stent rate and a new risk stratification score

OBJECTIVES

To review the success rate and number of complications in patients with obstructive jaundice treated with percutaneous transhepatic biliary drainage (PTBD), and to stratify the procedural risk of both PTBD and biliary stenting.

SUBJECTS AND METHODS

948 procedures performed in 704 consecutive patients with obstructive jaundice over a 7 year period were reviewed: 345 male; 359 females, mean age 70.1 years (range 48-96 years). Statistical analysis included X ( 2 ) test and multivariate logistic regression analysis.

RESULTS

The technical success rate was 99%. The mortality related to the procedure was 2% and the 30-day mortality 13%. 91 (13%) stents inserted occluded during the study period. Predictors for stent failure and re-stenting were a diagnosis of cholangiocarcinoma, a lesion in the distal CBD, a high bilirubin, high urea and high white cell count and post procedure cholangitis. Factors significantly related to complications and 30-day mortality were retrospectively reviewed to devise a risk stratification score.

CONCLUSIONS

PTBD and stenting offer a safe and effective method in providing palliative treatment for patients with biliary obstruction. Patients likely to have high levels of morbidity and mortality can be predicted before PTBD, using a risk stratification score, highlighting the need for closer clinical observation and delayed stent placement.

Interventional radiology in the management of malignant biliary obstruction

Malignant biliary obstruction is commonly due to pancreatic carcinoma, cholangiocarcinoma and metastatic disease which are often inoperable at presentation and carry a poor prognosis. Percutaneous biliary drainage and stenting provides a safe and effective method of palliation in such patients, thereby improving their quality of life. It may also be an adjunct to surgical management by improving hepatic and, indirectly, renal function before resection of the tumor.

Percutaneous Biliary Stent Placement in Palliation of Malignant Bile Duct Obstruction

BACKGROUND

To summarize the experiences with the technique of percutaneous biliary stent placement for treatment of malignant biliary obstruction in patients with different types of biliary obstruction.

METHODS

Percutaneous biliary stent placement was performed in 126 patients with malignant biliary obstruction. The etiology included 56 cases of cholangiocarcinoma, 28 cases of pancreatic cancer, 12 cases of ampullary carcinoma, 10 cases of primary hepatic carcinoma, 8 cases of gastric cancer metastasis, 6 cases of gallbladder carcinoma, and 6 cases of liver metastasis of colon cancer. The obstructed lesion predominantly involved the common bile duct in 42 patients, common hepatic duct in 39 patients, and hilar bile duct in 45 patients. When the bile duct was punctured successfully under fluoroscopy, the guide wire was explored to across the obstruction segment under the assistant of catheter, then the stent was inserted along the super-slippery guide wire. In patients with hilar hepatic duct lesions involving both left and right hepatic ducts, the both ducts were punctured and bilateral stenting was performed. A 8.5 F internal/external drainage catheter was inserted. The liver function test and ultrasound were performed one week after the procedure to observe the decrease of bilirubin and alleviation of biliary obstruction.

RESULTS

A total of 166 stents were implanted in 126 patients. In the 42 patients with common bile duct obstruction, each patient was implanted one stent. In the 39 patients with common hepatic duct obstruction, each patient was impanted one stent. In the 45 patients with hilur bile duct obstruction, 38 patients were placed 2 stents, one patient was placed with 3 stents, and the rest were placed with one stent. The serum total bilirubin decreased from 309.2 ± 158.3 µmol/L before the procedure to148.5 ± 98.0 µmol/L one week after the procedure (P < 0.001). Alkaline phosphatase and alanine aminotransferase significantly decreased (P < 0.001). Five cases died within 1 month (4%) after the procedure. Complications occurred in 9 cases (7.1%). Six patients underwent combined duodenal self-expandable metal stent placement successfully.

CONCLUSIONS

The percutaneous biliary stent placement is a safe and effective palliative therapy for malignant biliary obstruction by improving liver function and 1ife quality.

Palliation of malignant obstructive jaundice

Peri-ampullary and hepatic malignancies will frequently present with obstructive jaundice. For unresectable tumors, effective and lasting decompression of the biliary tree is essential to improve quality of life and survival. An overview of present treatment modalities for palliation of obstructive jaundice is provided, including a systematic review of the English literature regarding the optimum choice of palliation.

Primary patency of percutaneously inserted self-expanding metallic stents in patients with malignant biliary obstruction

BACKGROUND

Effective bile duct drainage is crucial to the health-related quality of life of patients with jaundice caused by obstruction of the bile duct by inoperable malignant tumours.

METHODS

All patients who were treated at Uppsala University Hospital, Sweden with percutaneous stenting between 2000 and 2005 were identified retrospectively. Data on the location of the obstruction and type of stent used, date and cause of death and date of stent failure were abstracted from the patients' notes. Stent patency was defined as the duration from the insertion of the stent to the date of failure. In cases in which the cause of death was directly related to failure of the stent, the date of death was defined as the patency endpoint.

RESULTS

A total of 64 patients (34 women, 30 men) were identified. Their mean age was 71 years (standard deviation 11 years). The median length of patency was 11.4 months. Stent diameter >10 mm and distal stricture were found to be associated with significantly longer patency time in univariate Cox proportional hazard analysis. In multivariate Cox proportional hazard analysis, only location of the stricture was found to be independently and significantly associated with patency time.

DISCUSSION

Percutaneous stenting is a good alternative for patients with obstructive jaundice and a life expectancy < or = 1 year. It may give instant relief from the symptoms associated with jaundice. Patency time may be prolonged by using stents with a diameter > or = 10 mm. However, patency time was found to be lower for hilar tumours.

Long-term outcome of percutaneous transhepatic therapy for benign bilioenteric anastomotic strictures

PURPOSE

To evaluate the long-term outcomes of a percutaneous transhepatic approach in benign bilioenteric anastomoses with calibration of the stenosis to 15 F and extended internal/external drainage.

MATERIALS AND METHODS

Between February 2000 and May 2007, the efficacy of this percutaneous transhepatic procedure was retrospectively studied in 39 patients with benign postoperative bilioenteric anastomotic strictures. The main purpose of the protocol was to repair the anastomosis by calibration of the stenosis to 15 F with a silicone drain and perform internal/external drainage for at least 1 year. The follow-up period ranged from 12 to 65 months (mean, 34.4 months), and outcomes were classified according to the patient's clinical symptoms and laboratory parameters and the need for further interventions.

RESULTS

The procedure was successful in 38 of 39 patients. Four patients were lost to follow-up during or after drainage. The duration of drainage (41 internal catheters in 34 patients) ranged from 126 days to 488 days (mean, 346 d). Twenty-seven patients had positive outcomes during the mean follow-up of 34 months, and six patients had negative outcomes. The bile duct patency probability according to the Kaplan-Meier method was and 70.6% at 34 months after drain removal.

CONCLUSIONS

Percutaneous treatment of benign biliary strictures with calibrated stent implantation and extended drainage has good long-term results and may be an effective alternative to surgery. Advantages over surgery are its minimal invasiveness and reduced risk of complications.

Management of hilar biliary strictures

Biliary strictures at the liver hilum are caused by a heterogeneous group of benign and malignant conditions. In the absence of a clear-cut benign etiology, i.e. bile duct damage during surgery, hilar biliary strictures remain a diagnostic and therapeutic challenge for which a multidisciplinary approach is often necessary. A definitive diagnosis can be achieved in only 40-60% of the patients, while in all the other cases strictures are treated as though they are malignant until surgical pathology determines otherwise. Surgical resection is the only treatment that prolongs survival in patients with malignant strictures. Because these tumors frequently extend longitudinally via the hepatic ducts into the liver parenchyma, partial hepatic resection has been gradually added to biliary resection to ensure tumor-free surgical margins. For unresectable cases, endoscopic stenting of biliary obstruction is considered the preferred palliation modality to relieve pruritus, cholangitis, pain and jaundice, while the percutaneous approach has been reserved for cases of failure. Other modalities of treatment such as radiotherapy, chemotherapy, and photodynamic therapy currently remain investigational. For benign post surgical hilar strictures, surgical repair can be difficult and requires specific skills and experience. As an alternative, a multi-stent technique with endoscopic placement of an increasing number of stents over time until complete resolution of the stricture has been proposed.

Percutaneous drainage and stenting for palliation of malignant bile duct obstruction

Percutaneous biliary drainage and stenting (PTBD) for palliation of malignant obstructive jaundice has evolved to a safe and effective technique. PTBD is equally effective for treatment of distal and proximal bile obstruction. Metal self-expandable stents have proved superior to plastic stents and should therefore be used. Technical success is >90% en clinical success is >75% in all major series. There are a considerable number of complications, but most can be treated conservatively and procedure-related mortality is <2% in most series. Thirty-day mortality after PTBD is >10% in many series, but this is largely due to the underlying disease. About 10-30% of patients will have recurrent jaundice at some point in their disease after PTBD and require re-intervention.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Jaundice secondary to isolated porta hepatis metastasis in colorectal cancer: case report and review of the literature

Colorectal cancer occurs mainly after the age of 50. The liver is the most frequent site of metastases, although isolated metastases to the porta hepatis are rarely reported in the literature. From 1924 to 1993, only 16 cases of periportal lymph nodes metastases were reported. We report a case of jaundice secondary to porta hepatis metastases from primary colorectal cancer. The appearance of symptoms was concurrent with the elevation of carcinoembryonic antigen in our case. This emphasizes the importance of polymerase chain reaction to detect the small amount of carcinoembryonic antigen transcript in blood or in peritoneal fluid before the appearance of symptoms. Polymerase chain reaction allows the prediction of high risk of recurrence and the presence of micrometastases. More trials are needed to assess the outcome after treatment by adjuvant chemotherapy for micrometastases.

Role of radiology in the treatment of malignant hilar biliary strictures 1: Review of the literature

Malignant strictures of the biliary tree are an uncommon cause of obstructive jaundice. There are a number of pathological subtypes, but tumours in this region tend to have similar clinical and diagnostic features and therapeutic and prognostic implications. We review the published literature on this topic discussing diagnostic modalities and treatment options with a focus on radiological intervention. Diagnosis currently is best achieved using a range of procedures. Direct cholangiography remains the gold standard in delineating anatomy, but the invasiveness of this procedure limits its use as a purely diagnostic tool. Magnetic resonance technology, in particular magnetic resonance cholangiopancreatography, has an increasing role as accessibility is improved. Treatment of these tumours is difficult. Surgical resection and palliative biliary enteric bypass are the most common methods used with endoscopic and percutaneous therapies reserved for palliating patients not fit for surgery. There is little firm evidence to suggest that any one palliative modality is superior. Interventional radiology is particularly suitable for palliative management of difficult and expansive lesions as the anatomy can preclude easy access by surgical or endoscopic techniques. Good palliative results with minimal mortality and morbidity can be achieved with percutaneous stenting.

Role of radiology in the treatment of malignant hilar biliary strictures 2: 10 years of single-institution experience with percutaneous treatment

We reviewed the results of percutaneous intervention of hilar biliary malignancy over a 10-year period at a single institution: the Royal Melbourne Hospital. Ninety-nine patients (100 treated in total) were included. Information was retrieved by retrospective examination of patient notes and radiology, combined with interviews with family and relevant physicians. Sixty-nine patients were treated with insertion of semipermanent stents, 19 had external drain tubes, and 25 received percutaneous access for Iridium brachytherapy. Adequate drainage was achieved in 87% of the patients stented, and percutaneous access was successful in 96% of patients planned for brachytherapy. Of those patients undergoing endoprosthesis insertion, early complications occurred in 39% and late complications in 23%. Average survival for the entire patient population was 227.3 days, with a median of 167 days. Longer survival times (213 vs 142 days) and lower complication rates (44 vs 64%) are observed with metal stents in comparison with plastic stents. Percutaneous intervention is an important treatment option in hilar biliary malignancy, particularly in patients unfit for surgery. Reasonable survival with good palliation is the most common outcome, and most patients do not require further intervention.

Single-wall puncture: a new technique for percutaneous transhepatic biliary drainage

OBJECTIVE

The purpose of our study is to evaluate the safety and utility of a new single-wall puncture technique for percutaneous transhepatic biliary drainage in comparison with the conventional double-wall puncture technique.

CONCLUSION

Our results suggest that the single-wall puncture technique is a useful method for percutaneous transhepatic biliary drainage and may be safer than the conventional double-wall puncture technique.

Malignant biliary obstruction: treatment with ePTFE-FEP- covered endoprostheses initial technical and clinical experiences in a multicenter trial

PURPOSE

To determine and present the initial technical and clinical results of using an expanded polytetrafluoroethylene-fluorinated ethylene propylene (ePTFE-FEP)-covered biliary endoprosthesis to treat malignant biliary obstruction.

MATERIALS AND METHODS

This prospective nonrandomized study included 42 patients with malignant obstruction of the common bile duct, common hepatic duct, and hilar confluence. Unilateral (n = 38) or bilateral (n = 4) bile duct drainage was performed by using fully covered endoprostheses with anchoring fins. To avoid branch duct blockage, endoprostheses with drainage holes at the proximal end were available. Procedure- and device-related complications were recorded. Patient survival and stent patency rates were calculated with Kaplan-Meier survival analysis. Mean follow-up bilirubin and alkaline phosphatase levels were calculated, and differences in means were evaluated with a paired t test.

RESULTS

Successful deployment, correct positioning, and patency of the device were achieved in all patients. Procedure-related complications occurred in two (5%) patients. Thirty-day mortality rate was 20% (eight of 41 patients), and median survival time was 146 days. Laboratory values decreased significantly after the procedure (P <.001). Recurrent obstructive jaundice occurred in six (15%) patients. Primary patency rates at 3, 6, and 12 months were 90%, 76%, and 76%, respectively. Calculation of the composite end point of death or obstruction revealed a median patency duration of 138 days. No endoprosthesis migration was observed. Branch duct obstruction was observed in four (10%) patients. Postmortem examination of one stent revealed a widely patent endoprosthesis with intact covering.

CONCLUSION

Initial results of percutaneous treatment of malignant biliary obstructions with fully covered ePTFE-FEP endoprostheses suggest that they are safe and potentially clinically effective.

Endoscopic nasobiliary drain placement facilitates subsequent percutaneous transhepatic cholangiography

BACKGROUND

Percutaneous biliary drainage is an established alternative to ERCP for managing bile duct obstruction. Although generally safe and effective, percutaneous drainage has its risks and is technically more difficult in patients with nondilated bile ducts. We report the use of nasobiliary drains and subsequent nasobiliary drain cholangiography to facilitate percutaneous biliary drainage by providing a target for accessing intrahepatic bile ducts.

METHODS/RESULTS

Nine patients who were identified as requiring percutaneous biliary drainage underwent nasobiliary tube placement at completion of ERCP. Five of 9 patients had generalized intrahepatic ductal dilatation; in 4 patients, dilatation was focal or absent. Following nasobiliary drain cholangiography, percutaneous needle puncture of a bile duct was successful in all patients, in most cases with only a single puncture of the liver capsule. No procedural complications were encountered.

CONCLUSION

Nasobiliary drain placement with subsequent nasobiliary drain cholangiography facilitates percutaneous biliary drainage and may be especially helpful in patients with nondilated intrahepatic bile ducts.

Local delivery of chemotherapy: a supplement to existing cancer treatments. A case for surgical pastes and coated stents

Local application or direct tumor injection of chemotherapeutic drugs has been proposed as a method by which local drug concentrations can be maximized in the immediate tumor environment while systemic exposure and non-target organ toxicity is minimized. Multiple opportunities are available to combine local drug delivery with widely practised, existing medical and surgical therapies. Surgical interventions, including both open and laparoscopic procedures, allow the physician to directly visualize and manipulate pathological tissues. Intraoperative placement of implantable therapeutic compounds (barriers to prevent adhesions, sustained-release antibiotics, tissue 'glues' and hemostatic agents) at or near the disease site is increasingly common in surgical practice. Less invasive therapies assisted by diagnostic imaging (fluoroscopy, ultrasound, CT and MRI scanning) have made accurate needle or catheter placement for drainage (abscesses, cysts, obstructions), injection (contrast media, pharmacological agents, embolic agents) and therapeutic purposes (endoluminal stents, venous filters) widely practised interventional medical procedures. This article describes a chemotherapeutic polymer-based paste we have developed for application at the time of surgery to reduce local recurrence of disease at tumor resection sites and a chemotherapeutic polymer-coated stent for use in the palliative management of malignant obstruction to improve the effective lifespan of the device (e.g., esophageal, biliary, prostate, and pulmonary disease). Despite the growth of local therapy in other disease states, regional cytotoxic drug therapy has not been widely deployed in the management of malignancy due to a clinical bias that local therapy will have limited utility in what is considered to be a systemic disease. In the above manner, local drug delivery could be incorporated into therapeutic protocols designed to enhance, not replace, the efficacy of existing treatment options.

Bacterial adhesion on hydrophilic heparinized catheters, with compared with adhesion on silicone catheters, in patients with malignant obstructive jaundice

To study the inhibitory effects on bacterial adhesion of a newly devised, hydrophilic heparinized catheter to be used in patients with malignant obstructive jaundice, a randomized controlled study of indwelling endoprostheses was performed, using implantable port-connected heparinized catheters (n = 25) and silicone catheters (n = 21). Catheters withdrawn from patients were cultured for bacteria and examined by electron microscopy for the presence of adherent organisms. In vitro examination of the two type of catheters exposed to suspensions of Eschericia coli and Staphylococcus aureus was performed using electron microscopy and a luminometer. The formation of a biofilm coated with glycocalyces was found in silicone catheters, but not in the heparinized catheters. In vitro experiments demonstrated little bacterial adhesion to the heparinized surface, but significant formation of biofilm on the silicone surface. Anionically charged heparinized catheters have inhibitory effects on bacterial adhesion, and the surface charge of the catheter may be a factor in inhibiting this adhesion.

Covered self-expanding transhepatic biliary stents: clinical pilot study

PURPOSE

We report our preliminary results with a new type of self-expanding covered stent for treatment of malignant biliary obstruction.

METHODS

Wallstents, fully covered with high elasticity polyurethane, with an unconstrained diameter of 10 mm and a total length of 69 mm, were placed transhepatically under fluoroscopic guidance in five patients. The length of the biliary obstruction varied between 30-50 mm. At 1 and 3 months (82-98 days) clinical assessment, serum bilirubin measurement, and ultrasound examination of the biliary tree were performed.

RESULTS

Initial uncomplicated deployment of the stents and internal drainage was possible in all patients. Distal stent migration resulted in early biliary reobstruction in one patient. At 3-month follow-up, partial reobstruction, most probably due to sludge formation, was found in another patient.

CONCLUSION

Our initial results indicate that the covered, self-expanding Wallstent endoprosthesis can be reliably and safely deployed transhepatically for malignant biliary obstruction.

Percutaneous palliation of unresectable pancreatic cancer

Percutaneous biliary drainage is one of several methods of palliating patients with unresectable carcinoma of the pancreas. In most cases, patients with unresectable carcinoma of the pancreas causing biliary obstruction are optimally managed by endoscopic stent placement. Percutaneous biliary drainage may be performed when endoscopic biliary drainage is unsuccessful or with obstruction at or above the hepatic duct bifurcation. Patients with common bile duct obstruction today are optimally managed by placement of expandable metal endoprostheses. In such patients with short life expectancies, symptoms of jaundice can be effectively palliated with a low rate of recurrence and with a complication rate no higher than that associated with percutaneous biliary drainage. Metal endoprostheses are associated with less pain during placement than are plastic endoprostheses and may have a lower rate of recurrence of jaundice than plastic endoprostheses in patients with common bile duct obstruction due to carcinoma of the pancreas. Patients with hilar biliary obstruction are better treated with internal-external biliary drainage catheters.

Transhepatic cardiac catheterization in children. Evaluation of efficacy and safety

BACKGROUND

In some children with congenital heart disease, conventional venous access is unavailable for cardiac catheterization. This study investigates a novel transhepatic venous approach to cardiac catheterization in children and evaluates its efficacy and safety.

METHODS AND RESULTS

Percutaneous transhepatic puncture was performed using a 22-gauge Chiba needle under fluoroscopic guidance. After wire exchanges were performed, a 5F to 8F sheath was positioned in the low right atrium and cardiac catheterization was performed. On completion of the catheterization, the sheath was withdrawn and a 3-mm steel coil was placed in the parenchymal tract between the hepatic vein and liver capsule. Liver enzyme studies were obtained before and after transhepatic catheterization, and an abdominal ultrasound was performed to evaluate the liver 24 hours after the procedure. Percutaneous transhepatic cardiac catheterization was performed successfully in 17 of 18 children in whom it was attempted. Patient age was 30 +/- 8 months (mean +/- SEM; range, 1 day to 9 years), weight was 10.5 +/- 1.5 kg (3.1 to 27.5 kg), and mean right atrial pressure was 10 +/- 1 mm Hg (5 to 19 mm Hg). Time from initial needle puncture to right atrial entry was 6.2 +/- 1.2 minutes. Diagnostic catheterization was performed successfully in all 17 children, and additional interventional procedures were performed in 5 children. The total catheterization time was 2.0 +/- 0.2 hours. Serum aspartate aminotransferase increased from 57 +/- 15 to 78 +/- 8 IU/L (P = .06), but alanine aminotransferase and gamma-glutamyl transpeptidase did not change. Ultrasound was performed 24 hours after transhepatic catheterization, and no evidence was found in any patient of hemorrhage or subcapsular hematoma.

CONCLUSIONS

These data suggest that this novel transhepatic approach provides an effective and safe route for diagnostic and interventional cardiac catheterization in children.

Morbidity and mortality after radical and palliative pancreatic cancer surgery. Risk factors influencing the short-term results

OBJECTIVE

To analyze the morbidity and mortality after radical and palliative pancreatic cancer surgery in Norway, especially the risk factors.

SUMMARY BACKGROUND DATA

A prospective multicenter study between 1984-1987 including only histologically or cytologically verified adenocarcinoma of the pancreas (N = 442) or the papilla of Vater (N = 30); 84 patients (19%) with pancreatic carcinoma and 24 patients (80%) with papilla carcinoma underwent radical operations. A palliative procedure was performed in 252 patients (53%).

METHODS

Clinical data, surgical procedures and the following morbidity and mortality were recorded on standardized forms. The risk factors were analyzed by a logistic multiple regression model.

RESULTS

The morbidity, reoperation, and mortality rates were 43, 18, and 11% after radical surgery and 23, 4, and 14% after palliative surgery. Karnofsky's index was the sole independent risk factor for death after radical surgery. Splenectomy, age, and TNM stage influenced morbidity. Diabetes, Karnofsky's index, and liver metastases were risk factors in palliative surgery.

CONCLUSIONS

The morbidity and mortality risks were comparable between total pancreatectomy and a Whipple's procedure and between biliary and a double bypass. Preoperative biliary drainage had no impact on the risks and may be abandoned. High age is a relative and a low Karnofsky's index an absolute contraindication for radical surgery. Nonsurgical palliation of jaundice should be considered according to the presence of independent risk factors.

Palliation of inoperable biliary obstruction with self-expanding metal endoprostheses: a review of 77 patients

Our experience of inserting 90 self-expanding metal endoprostheses in 77 patients with obstructive jaundice is described. All were inserted percutaneously. The longest metal endoprosthesis available was inserted where possible. For local economic reasons most patients had a normal serum albumin, and no evidence of metastases at presentation. Dilatation of biliary occlusions and strictures was not performed. Six re-interventions have been necessary because of tumour ingrowth or overgrowth. Serum bilirubin levels fell to normal in 98.7% of patients within 7 days of insertion. Self-expandable metal endoprostheses offer technical, psychological, physiological and anatomical advantages compared to other forms of palliation in biliary obstructions thought to be unsuitable for surgery. Furthermore, where stents have to be placed percutaneously because endoscopy is not possible, self-expanding metal endoprostheses should be used.

Evaluation of surgical risk in palliation and resection of pancreatic cancer. Perspective study and tables to calculate the risk

High morbidity and mortality rates are reported for bypass and resective surgery of pancreatic cancer. In a retrospective study we correctly predicted the postoperative course in 88% of the patients who underwent bypass surgery and 83% of those who had a resection for pancreatic cancer. Before starting with clinical application of this scoring system, we undertook a prospective study to confirm its predictive value. Sixty-seven consecutive patients with pancreatic cancer were included: 42 patients underwent bypass surgery and 25 pancreatic resections. The operative mortality was 14% for palliative surgery and 0% for resective surgery. Surgical team and nurses were totally unaware of the predicted risk. The preoperative forecast proved to be correct in 81% of bypass surgery and in 88% of resective surgery, although surgical mortality had decreased from 21 to 14% for bypass surgery and from 17 to 0% for resective surgery. Tables are included to calculate the surgical risk for each of 162 combinations of the risk factors considered in the predictive model (81 for bypass surgery and 81 for resective surgery). Calculation of surgical risk is important when evaluating different treatments for pancreatic cancer are available.

The management of problematic biliary calculi

Recent advances in modern medical technology have significantly reduced the number of patients with 'problematic calculi'. When a patient does present with a difficult bile duct stone, various non-surgical treatment options are now available. In experienced hands, with healthy or high-risk patients, percutaneous treatment is as safe and as efficacious as endoscopy or surgery. Since it does not require general anaesthesia, and patients recover much more quickly than after surgery, the percutaneous approach is preferred when endoscopy fails to achieve ductal clearance. Surgery is indicated for patients with lesions requiring surgical removal or correction, but seldom for removal of biliary calculi alone.

Insemination of bile duct carcinoma to the liver after insertion of percutaneous biliary endoprosthesis

Percutaneous transhepatic biliary drainage is widely used to relieve bile duct obstruction which can be caused by bile duct or pancreas carcinomas. Although the incidence is low, insemination of carcinoma along the transhepatic catheter tract is considered to be a serious complication of percutaneous transhepatic biliary drainage. The authors present a case of intrahepatic insemination of bile duct carcinoma along the catheter that subsequently underwent a curative resection consisting of pancreaticoduodenectomy and right hepatic lobectomy. It is suggested that a percutaneous biliary endoprosthesis through the tumor should be avoided in patients in whom a possible curative resection can be considered. External biliary drainage should only be performed in order to minimize the manipulation of the tumor in such patients.