Biliary drainage strategy of unresectable malignant hilar strictures by computed tomography volumetry

Uncovered Self-Expandable Metallic Stent with an Ultra-Thin Delivery Sheath in Unresectable Malignant Hilar Biliary Obstruction: A Multicenter Prospective Observational Study

BACKGROUND

Although various self-expandable metallic stents (SEMSs) for malignant hilar biliary obstruction (MHBO) have been introduced, the optimal SEMS for MHBO has not yet been established.

PURPOSE

This study aimed to evaluate outcomes of the transpapillary placement of an uncovered laser-cut SEMS with an ultra-thin delivery sheath (YABUSAME) for MHBO.

METHODS

This multicenter, prospective study was conducted in 11 hospitals for 10 months (from March 2022 to December 2022). The primary outcome was the stent patency rate at 6 months. Key secondary outcomes were the technical success rate, clinical success rate, time to recurrent biliary obstruction (RBO), overall survival (OS), and adverse events.

RESULTS

Of 45 enrolled patients, 43 patients underwent biliary drainage, including 42 patients who underwent YABUSAME placement; 66.7% of patients received chemotherapy, and 60% had previously undergone biliary drainage. Drainage methods were partial stent-in-stent, side-by-side, and unilateral in 65.1%, 7.0%, and 27.9% of patients, respectively. Technical and clinical success rates were 93.2% (41/45) and 79.1% (34/45), respectively. The incidence rate of early postprocedural adverse events was 2.2%. The stent patency rate at 6 months was 55.3%. The median time to RBO was 231 days. The median OS was 125 days.

CONCLUSION

This study showed that the primary outcome, the 6-month stent patency rate, exceeded the expected rate of 55%, which indicates the efficacy of YABUSAME placement for MHBO.

Unilateral drainage and chemotherapy prolong the patency of a plastic stent placed above the sphincter of Oddi in patients with malignant hilar biliary obstruction

OBJECTIVES

To evaluate the results of inside stent therapy for unresectable malignant hilar biliary obstruction and identify factors related to stent patency duration.

METHODS

Of 44 patients who underwent initial inside-stent placement above the sphincter of Oddi from April 2017 to December 2022, 42 with the resolution of jaundice (clinical success rate, 95.5%) were retrospectively analyzed. Univariate and multivariate logistic regression analysis identified factors associated with stent patency duration.

RESULTS

Univariate analysis revealed significant differences in the drainage method (406 days for unilateral drainage vs. 305 days for bilateral drainage of the right and left liver lobes, p = 0.022) with or without chemotherapy (406 days with vs. 154 days without, p = 0.038). Multivariate analysis (Cox proportional hazards analysis) revealed similar results, with unilateral drainage (p = 0.031) and chemotherapy (p = 0.048) identified as independent factors associated with prolonged stent patency. Early adverse events were observed in two patients (4.8%; one cholangitis, one pancreatitis).

CONCLUSIONS

Inside-stent therapy was safely performed in patients with malignant hilar biliary obstruction. Simple unilateral drainage and chemotherapy may prolong stent patency.

Side-by-side versus stent-in-stent technique for stent deployment during systemic chemotherapy in biliary tract cancer patients with malignant hilar biliary obstruction

Objectives

With the improved prognosis of patients with biliary tract cancer (BTC) owing to advances in chemotherapy, long-term stent patency has become an important goal in patients undergoing biliary stent placement. We compared the duration of stent patency between unresectable BTC patients undergoing multi-stenting for malignant hilar biliary obstruction by the side-by-side (SBS) and stent-in-stent (SIS) techniques during systemic chemotherapy.

Methods

We retrospectively evaluated the data of 62 unresectable BTC patients who underwent multi-stenting before the first or second cycle of first-line chemotherapy. Stent deployment was performed by the SBS technique in 40 patients (SBS group) and by the SIS technique in 22 patients (SIS group).

Results

The median time-to-recurrent biliary obstruction was 147 days in the SBS group and 252 days in the SIS (p = 0.029), being longer in the SIS group. The rates of development of early adverse events were 28% and 9% (p = 0.09) and the rates of development of late adverse events were 26% and 14% in the SBS and SIS groups (p = 0.27). The median overall survival was 480 days in the SBS group and 563 days in the SIS group (p = 0.92).

Conclusion

The duration of stent patency was shorter in the SBS group than in the SIS group; thus, the SIS technique is preferable to the SBS technique for biliary stent deployment in unresectable BTC patients during systemic chemotherapy.

Initial Use Experience of Durvalumab Plus Gemcitabine and Cisplatin for Advanced Biliary Tract Cancer in a Japanese Territory Center

Background: Biliary tract cancers (BTCs), including gallbladder and bile duct cancers, have a poor prognosis. Recent advances in chemotherapy, such as using targeted drugs for specific gene mutations, have improved outcomes. Gemcitabine plus cisplatin chemotherapy has been the standard of care for the primary treatment of BTCs, but secondary treatment had not been established until recently. In recent years, durvalumab plus gemcitabine and cisplatin (GCD) chemotherapy is emerging as a promising regimen, although more evidence is needed for its effectiveness. Methods: This retrospective single-center study involved 44 patients receiving GCD treatment between January 2023 and March 2024 with a median follow-up of 10 months. Outcomes focused on overall survival (OS), progression-free survival (PFS), response rates, and adverse events (AEs). Results: The overall response rate (ORR) was 23%, and the disease control rate (DCR) was 82%. The overall median OS and PFS were 15.3 and 8.0 months, respectively, with patients receiving primary chemotherapy experiencing longer survival compared to a control group. Patients who did not undergo bile duct drainage had statistically different better OS and PFS. Grade 3 or higher AEs occurred in 54.5% of patients, with neutropenia and biliary infections being common. Conclusions: GCD chemotherapy shows potential as an effective treatment for BTCs. The favorable treatment outcome was the response rate, particularly in primary therapy or those cases with no metastasis. Bile duct management is crucial for improving patient outcomes. GCD chemotherapy has a high response rate, PFS, and OS compared to other forms of chemotherapy.

Correlation between liver volume drainage and clinical success after endoscopic biliary drainage of hilar malignant obstruction

BACKGROUND AND AIM

Malignant hilar obstruction usually presents in advanced-stage disease with a poor prognosis. Effective biliary drainage is essential for the beginning of palliative chemotherapy. There is a debate on the amount of liver parenchyma that should be drained to achieve clinical success. This study aimed to correlate the volume of liver drained with clinical success rate.

METHODS

The authors conducted a retrospective study including patients with malignant hilar biliary obstruction who underwent retrograde endoscopic cholangiography for biliary drainage from January 2014 to December 2018. The main outcome was a correlation of clinical success rate with hepatic volume drained. Secondary outcomes were correlation of clinical success rate with the quantity of liver sectors drained and unilateral versus bilateral drainage.

RESULTS

82 patients met inclusion criteria (58.5 % female), with a mean age of 60±13 years. The main cause of hilar obstruction was cholangiocarcinoma (32.9 %) followed by lymph node metastasis (23.2 %). Technical success was achieved in 75 patients (91.5 %), and clinical success in 45 patients (60 %). The authors found a significant correlation between clinical success rate when at least 50 % of viable parenchyma was drained (p = 0.016; OR = 4.15, 95 % CI 1.4-12.5). Considering liver sectors, higher clinical success rates were found when at least 2 sectors were drained (p < 0.001; OR = 8.50, 95 % CI 2.7-26.7). The correlation between unilateral versus bilateral drainage and clinical success was not statistically significant.

CONCLUSION

Drainage of at least 50 % of volume hepatic parenchyma was associated with better outcomes as well as drainage of at least 2 hepatic sectors, regardless of if unilateral or bilateral.

Updates on Endoscopic Stenting for Unresectable Malignant Hilar Biliary Obstruction

Malignant hilar biliary obstruction (MHBO) can cause obstructive jaundice and/or cholangitis necessitating appropriate biliary drainage. Endoscopic biliary stenting is the first-choice treatment, especially in unresectable cases, owing to its minimally invasive nature and utility. However, the hilar region is complex because of the branching and curving of bile ducts, making strictures in this area more complicated. Therefore, MHBO stenting is challenging, and treatment strategies have yet to be established. Furthermore, recent advances in antitumor therapies have altered the background surrounding the development of stenting strategies. Therefore, it is necessary to understand and grasp the current evidence well and to accumulate additional evidence reflecting the current situation. This study reviews the current status, issues, and prospects of endoscopic stenting for MHBO, especially in unresectable cases.

Endoscopic management of malignant biliary obstructions

Malignant biliary obstruction (MBO), both distal and hilar, represents an ensemble of different clinical conditions frequently encountered in everyday practice. Given the frequent unresectability of the disease at presentation and the increasing indications for neoadjuvant chemotherapy, endoscopic biliary drainage is generally required during the course of the disease. With the widespread use of interventional endoscopic ultrasound (EUS) and the introduction of dedicated devices, EUS-guided biliary drainage has rapidly gained acceptance, together with transpapillary endoscopic biliary drainage and the percutaneous approach. This comprehensive review describes the current role of endoscopy for distal and hilar MBO supported by evidence, with a focus on the current hot topics in this field.

Comparison of unilateral and bilateral intraductal plastic stent placement for unresectable malignant hilar biliary obstruction: A propensity score-matched cohort analysis

BACKGROUND

Although intraductal plastic stent (IS) placement is an effective treatment for unresectable malignant hilar biliary obstruction (UMHBO), the effectiveness of unilateral and bilateral IS drainage remains controversial. This retrospective study investigated the effectiveness of bilateral IS placement for UMHBO using the propensity score matching method.

METHODS

Patients who underwent transpapillary endoscopic stenting for UMHBO were analyzed for technical and clinical success, adverse events, and time to recurrent biliary obstruction (TRBO).

RESULTS

A total of 321 patients were enrolled in the study with 27 patients in each unilateral and bilateral IS group in the propensity score-based cohort. Technical success was 100%, while clinical success was 93% and 96% in the unilateral and bilateral IS groups, respectively (p = 1.0). Cholecystitis occurred in 4% and 7%, respectively (p = 1.0). The median TRBO was shorter in the unilateral group (129 [5-383] days) than that in the bilateral group (226 [16-563] days) (p = .0281). Bilateral IS placement was an independent long TRBO factor (hazard ratio [HR] 0.46; 95% confidence interval [CI]: 0.21-0.97; p = .041).

CONCLUSIONS

Unilateral and bilateral IS placement had high technical and clinical success rates in primary stent placement. However, bilateral IS placement showed a longer TRBO. Bilateral IS placement may be a good option for initial UMHBO drainage.

Current interventional options for palliative care for patients with advanced-stage cholangiocarcinoma

Primary biliary tract tumors are malignancies that originate in the liver, bile ducts, or gallbladder. These tumors often present with jaundice of unknown etiology, leading to delayed diagnosis and advanced disease. Currently, several palliative treatment options are available for primary biliary tract tumors. They include percutaneous transhepatic biliary drainage (PTBD), biliary stenting, and surgical interventions such as biliary diversion. Systemic therapy is also commonly used for the palliative treatment of primary biliary tract tumors. It involves the administration of chemotherapy drugs, such as gemcitabine and cisplatin, which have shown promising results in improving overall survival in patients with advanced biliary tract tumors. PTBD is another palliative treatment option for patients with unresectable or inoperable malignant biliary obstruction. Biliary stenting can also be used as a palliative treatment option to alleviate symptoms in patients with unresectable or inoperable malignant biliary obstruction. Surgical interventions, such as biliary diversion, have traditionally been used as palliative options for primary biliary tract tumors. However, biliary diversion only provides temporary relief and does not remove the tumor. Primary biliary tract tumors often present in advanced stages, making palliative treatment the primary option for improving the quality of life of patients.

National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

Retrospective comparative study of new slim-delivery and conventional large-cell stents for stent-in-stent methods for hilar malignant biliary obstruction

OBJECTIVES

Endoscopic management of unresectable hilar malignant biliary obstruction (HMBO) is technically challenging, and effectiveness of stent-in-stent using large-cell, metal stents was reported. A new, large-cell stent with a 6F tapered delivery system was recently developed. The aim of this study was to compare clinical outcomes of slim-delivery and conventional large-cell stents.

METHODS

This was a multicenter retrospective comparative study of stent-in-stent methods using slim-delivery stents (Niti-S Large Cell SR Slim Delivery [LC slim-delivery]) and conventional stents (Niti-S large-cell D-type; LCD) for unresectable HMBO.

RESULTS

Eighty-three patients with HMBO were included; 31 LC slim-delivery and 52 LCD. Overall technical and clinical success rates were 100% and 90% in LC slim-delivery group and 98% and 88% in LCD group. Use of the LC slim-delivery was associated with shorter stent placement time in the multiple regression analysis, with a stent placement time of 18 and 23 min in LC slim-delivery and LCD groups, respectively. The early adverse event (AE) rate of LC slim-delivery was 10%, with no cholangitis or cholecystitis as compared to 23% in the LCD group. Recurrent biliary obstruction (RBO) rates and time to RBO were comparable between the two groups: 35% and 44%, and 8.5 and 8.0 months in LC slim-delivery and LCD groups, respectively. The major cause of RBO was tumor ingrowth (82%) in the LC slim-delivery group and sludge (43%) and ingrowth (48%) in LCD group.

CONCLUSION

Stent-in-stent methods using LC slim-delivery shortened stent placement time with low early AE rates and comparable time to RBO in patients with HMBO.

A Novel Method of Calculating the Drained Liver Volume Using a 3D Volume Analyzer for Biliary Drainage of Unresectable Malignant Hilar Biliary Obstruction

OBJECTIVES

In patients with unresectable malignant hilar biliary obstruction (UMHBO), drainage of ≥ 50% liver volume correlates with better clinical outcomes. Accurately measuring the liver volume to be drained by biliary stents is required. We aimed to develop a novel method for calculating the drained liver volume (DLV) using a 3D volume analyzer (3D volumetry), and assess the usefulness for drainage in patients with UMHBO.

METHODS

Three-dimensional volumetry comprises the following steps: (1) manual tracing of bile duct using 3D imaging system; (2) 3D reconstruction of bile duct and liver parenchyma; and (3) calculating DLV according to the 3D distribution of bile ducts. Using 3D volumetry, we reviewed data of patients who underwent biliary drainage for UMHBO, calculated the DLV, and determined the association between DLV and biliary drainage outcome.

RESULTS

There were 104 eligible cases. The mean DLV was 708 ± 393 ml (53% ± 21%). and 65 patients (63%) underwent drainage of   ≥50% liver volume. The clinical success rate was significantly higher in patients with DLV ≥ 50% than in patients with DLV < 50% (89% vs. 28%, P < 0.001). The median time to recurrence of biliary obstruction (TRBO) and survival time were significantly longer in patients with DLV ≥ 50% than in patients with DLV < 50% (TRBO, 292 vs. 119 days, P = 0.03; survival, 285 vs. 65days, P = 0.004, log-rank test, respectively).

CONCLUSIONS

Three-dimensional volumetry, a novel method to calculate DLV accurately according to bile duct distribution was useful for drainage in UMHBO patients.

Imaging of hepato-pancreato-biliary emergencies in patients with cancer

Hepato-pancreato-biliary (HPB) emergencies in patients with cancer encompass an extensive array of various conditions, including primary malignancies that require prompt treatment, associated severe complications, and life-threatening consequences arising from treatment. In patients with cancer, the liver can be affected by chemotherapy-induced hepatotoxicity, veno-occlusive disease, Budd-Chiari syndrome, liver hemorrhage, and other complications arising from cancer therapy with all these complications requiring timely diagnosis and prompt treament. Cholecystitis induced by systemic anticancer therapies can result in severe conquences if not promptly identified and treated. The application of immunotherapy in cancer therapy is associated with cholangitis. Hemobilia, often caused by medical interventions, may require arterial embolization in patients with severe bleeding and hemodynamic instability. Malignant biliary obstruction in patients with biliary cancers may necessitate palliative strategies such as biliary stenting. In pancreatic cancer, patients often miss surgical treatment due to advanced disease stages or distant metastases, leading to potential emergencies at different treatment phases. This comprehensive review underscores the complexities of diagnostic and treatment roles of medical imaging in managing HPB emergencies in patients with cancer. It illustrates the crucial role of imaging techniques, including magnetic resonance imaging, computed tomography and ultrasound, in diagnosing and managing these conditions for timely intervention. It provides essential insights into the critical nature of early diagnosis and intervention in cancer-related HPB emergencies, ultimately impacting patient outcomes and survival rates.

The Role of Endoscopy in the Palliation of Pancreatico-Biliary Cancers: Biliary Drainage, Management of Gastrointestinal Obstruction, and Role in Relief of Oncologic Pain

Therapeutic endoscopy permits many and various treatments for cancer palliation in patients with bilio-pancreatic cancers, enabling different options, supporting patients during their route to oncologic treatments, and trying to improve their quality of life. Therefore, both endoscopic and endoscopic ultrasound (EUS)-guided techniques are performed in this scenario. We performed a literature review focusing on the role of endoscopy in the palliation of those advanced pancreatic and biliary cancers developing malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and pain unresponsive to medical therapies. Therefore, we explored and focused on the clinical outcomes of endoscopic procedures in this scenario. In fact, the endoscopic treatment is based on achieving biliary drainage in the case of MBO through endoscopic retrograde cholangiopancreatography (ERCP) or EUS-guided biliary drainage (EUS-BD), while GOO is endoscopically treated through the deployment of an enteral stent or the creation of EUS-guided gastro-entero-anastomosis (EUS-GEA). Furthermore, untreatable chronic abdominal pain is a major issue in patients unresponsive to high doses of painkillers, so EUS-guided celiac plexus neurolysis (CPN) or celiac ganglia neurolysis (CGN) helps to reduce dosage and have better pain control. Therefore, therapeutic endoscopy in the palliative setting is an effective and safe approach for managing most of the clinical manifestations of advanced biliopancreatic tumors.

The evaluation of bilateral stenting using braided or laser-cut self-expandable metallic stent for malignant hilar biliary obstruction

OBJECTIVES

Bilateral self-expandable metallic stent (SEMS) placement for unresectable malignant hilar biliary obstruction (UMHBO) is an effective option for biliary drainage with long-term stent patency. Laser-cut and braided SEMS can be used for bilateral SEMS placement. This study aimed to clarify any differences in the clinical features and proper use of the laser-cut and braided SEMS placement using the stent-in-stent method for UMHBO.

METHODS

In this study, 78 patients who underwent bilateral stent-in-stent SEMS placement for UMHBO were included. The patients were divided into the laser-cut (n = 33) and braided groups (n = 45). Both groups were compared for technical and clinical success, adverse events (AEs), time to recurrent biliary obstruction (TRBO), overall survival, and endoscopic reintervention (ERI).

RESULTS

There were no significant differences in technical and clinical success rates (laser-cut vs. braided group, 97% vs. 95.6%, P = 1.0), AEs (21.2% vs. 15.6%. P = 0.56), median TRBO (242 days vs. 140 days, P = 0.36), and median overall survival (654 days vs. 675 days, P = 0.58). ERI was required in 15 patients in the laser-cut group and in 20 patients in the braided group. The technical and clinical success rates of ERI (60% vs. 85%) were not significantly different (P = 0.13); however, the median ERI procedure time was significantly longer in the laser-cut group (38 min) than in the braided group (22 min; P = 0.02).

CONCLUSION

No significant difference in initial SEMS placement was noted between the laser-cut and braided groups; however, the laser-cut group required a longer ERI procedure time than that required by the braided group. The use of braided SEMS may be a convenient option for ERI.

Optimal liver drainage rate for survival in patients with unresectable malignant hilar biliary obstruction using 3D-image volume analyzer

BACKGROUND

Drainage exceeding 50% of total liver volume is a beneficial prognostic factor in patients with unresectable malignant hilar biliary obstruction (UMHBO). However, it is unclear what threshold percentage of total liver volume drained ('liver drainage rate') significantly improves survival in patients with UMHBO who received systemic chemotherapy.

OBJECTIVES

We aimed to assess the optimal liver drainage rate that improves survival in patients with UMHBO receiving chemotherapy using a three-dimensional (3D)-image volume analyzer.

DESIGN

This study was a single-center retrospective cohort study.

METHODS

Data from 90 patients with UMHBO who received chemotherapy after endoscopic biliary drainage using metal stents at Okayama University Hospital from January 2003 to December 2020 were reviewed. The liver drainage rate was calculated by dividing the drained liver volume by the total liver volume using a 3D-image volume analyzer. The primary endpoint was overall survival by liver drainage rate. The secondary endpoints were time to recurrent biliary obstruction (TRBO) and prognostic factors.

RESULTS

The median total liver volume was 1172 (range: 673-2032) mL, and the median liver drainage rate was 83% (range: 50-100). Overall survival was 376 (95% CI: 271-450) days, and patients with >80% drainage (n = 67) had significantly longer survival than those with <80% drainage (n = 23) (450 days versus 224 days, p = 0.0033, log-rank test). TRBO was 201 (95% CI: 155-327) days and did not differ significantly by liver drainage rate. Multivariate Cox proportional hazards regression analysis revealed >80% liver drainage [hazard ratio (HR): 0.35, 95% CI: 0.20-0.62, p = 0.0003] and hilar cholangiocarcinoma (HR: 0.30, 95% CI: 0.17-0.50, p < 0.0001) as significant prognostic factors.

CONCLUSION

In patients with UMHBO scheduled for chemotherapy, >80% drainage is associated with improved survival. Further prospective multicenter studies are needed to verify the results of this study.

TRAIL REGISTRATION

Okayama University Hospital, IRB number: 2108-011.

Machine learning-based nomogram for 30-day mortality prediction for patients with unresectable malignant biliary obstruction after ERCP with metal stent: a retrospective observational cohort study

BACKGROUND

This study aimed to investigate the risk factors for 30-day mortality in patients with malignant biliary obstruction (MBO) after endoscopic retrograde cholangiopancreatography (ERCP) with endobiliary metal stent placement. Furthermore, we aimed to construct and visualize a prediction model based on LASSO-logistic regression.

METHODS

Data were collected from 245 patients who underwent their first ERCP with endobiliary metal stent placement for unresectable MBO between June 1, 2013, and August 31, 2021. Univariable and multivariable logistic regression analyses were conducted to identify the risk factors for 30-day mortality. We subsequently developed a logistic regression model that incorporated multiple parameters identified by LASSO regression. The model was visualized and the nomogram was plotted. Risk stratification was performed based on nomogram-derived scores.

RESULTS

The 30-day mortality rate was 10.7% (23/245 patients). Distant metastasis, total bilirubin, post-ERCP complications, and successful drainage were independent risk factors of 30-day mortality. The variables screened by LASSO regression, including distant metastasis, total bilirubin, post-ERCP complications, and successful drainage, were incorporated into the logistic model. The results were visualized through a nomogram based on the model. To assess the model's performance, discrimination was evaluated using the area-under-the-curve values obtained from receiver operating characteristic analyses with 10-fold cross-validation in the training group and validated in the testing group. The calibration curve showed the good predictive ability of the model. Decision curve analysis is used to evaluate the clinical application of nomogram. Finally, we performed risk stratification based on the risk calculated using the nomogram. Patients were assigned to the low-, moderate-, and high-risk groups based on their probability scores. The Kaplan-Meier survival curves for the different nomogram-based groups were significantly different (p < 0.001).

CONCLUSIONS

We developed a nomogram using the LASSO-logistic regression model to forecast the 30-day mortality rate in patients who had undergone ERCP with endobiliary metal stent placement due to MBO. This nomogram can assist in identifying individuals at high-risk of 30-day mortality following ERCP.

The role of endoscopy in malignant hilar obstruction

Malignant hilar biliary obstruction (MHO) is a medical challenge as regards both forming a correct diagnosis and its adequate management, in terms of treatment alternatives and palliative options. Surgical resection is the only curative treatment for the underlying disease, but the majority of patients are not suitable candidates because of an unresectable tumor or poor performance status. Biliary drainage (BD) can be achieved through the percutaneous transhepatic route or endoscopically, and the choice depends on a host of factors, including biliary anatomy and comorbidity of the patient. Though there is no consensus, the endoscopic approach is usually preferred over the former. Endoscopy can aid in both diagnosis (collection of histological as well as cytological samples, direct visualization of suspected malignant pathology, or use of endoscopic ultrasound [EUS] for evaluation and locoregional staging), and in achieving internal BD. Advances in the development of various stents, accessories and, more recently, the use of EUS have in fact further expanded its application in MHO management. The choice of stents to be used (type, make, and number), palliation methods, deployment techniques and the use of local ablative strategy are still evolving and require more data. The complexity of management of MHO mandates that each patient should receive a "personalized approach", all the way from establishing a diagnosis until final treatment, with the help of a multidisciplinary team effort. Herein, we provide a comprehensive literature review of the current role of endoscopy for MHO, according to its applications in various clinical settings.

Hemostasis using a covered self‐expandable metal stent for pseudoaneurysm bleeding from the perihilar bile duct

Although there are many reports of hemostasis with covered self‐expandable metal stent (CSEMS) for bleeding from the papilla of Vater and the intrapapillary and distal bile duct, there are rare reports of its use for hemostasis in the perihilar bile duct. We report the case of a patient undergoing supportive care for perihilar cholangiocarcinoma with acute cholecystitis after side‐by‐side placement of uncovered SEMS for perihilar bile duct obstruction. Percutaneous transhepatic gallbladder aspiration was performed upon admission, and hematemesis occurred the next day. Since computed tomography scanning showed a pseudoaneurysm in the right uncovered SEMS, hemostasis by interventional radiology (IVR) was performed thrice for massive bleeding; however, hemostasis could not be achieved. When endoscopic retrograde cholangiopancreatography was performed for scrutiny and treatment of melena and increased hepatobiliary enzyme, the endoscopic visual field could not be secured by bleeding, and changes in hemodynamics were observed; thus, IVR was required, but it was difficult to perform. Since bleeding from the right bile duct was expected, hemostasis was performed using CSEMS. This is the first report of hemostasis performed by placing a covered SEMS for bleeding from a pseudoaneurysm of the intrahepatic bile duct.

Effect of percutaneous stenting strategy of unresectable malignant hilar biliary obstruction by three-dimensional reconstruction volumetry

PURPOSE

To explore clinical outcomes of percutaneous stent implantation using volumetric criteria for unresectable malignant hilar biliary obstruction (MHBO). Additionally, aimed to identify the predictors of patients' survival.

METHODS

Seventy-two patients who were initially diagnosed with MHBO between January 2013 to December 2019 in our center were retrospectively included. Patients were stratified according to the drainage achieved ≥50%, <50% of the total liver volume. Patients were divided into two groups: Group A (≥50% drainage), and Group B (<50% drainage). The main outcomes were evaluated in terms of relief of jaundice, effective drainage rate, and survival. Related factors that affect survival were analyzed.

RESULTS

62.5% of the included patients reached effective biliary drainage. The successful drainage rate was significantly higher in Group B than in Group A (p < 0.001). The median overall survival (mOS) of included patients was 6.4 months. Patients who received drainage ≥50% of hepatic volume achieved longer mOS than those who received drainage <50% of hepatic volume (7.6 months vs. 3.9 months, respectively, p = 0. 011). Patients who received effective biliary drainage had longer mOS than those who received ineffective biliary drainage (10.8 months vs. 4.4 months, respectively, p < 0.001). Patients who received anticancer treatment had longer mOS than those who only received palliative therapy (8.7 months vs. 4.6 months, respectively, p = 0.014). In the multivariate analysis, KPS Score ≥ 80 (p = 0.037), ≥50% drainage achieved (p = 0.038), and effective biliary drainage (p = 0.036) were protective prognostic factors that affected patients' survival.

CONCLUSION

Drainage achieved ≥50% of the total liver volume by percutaneous transhepatic biliary stenting seemed to have a higher effective drainage rate in MHBO patients. Effective biliary drainage may create chances for these patients to receive anticancer therapies that seem to provide survival benefits.

Results of endoscopic biliary drainage in patients with malignant hilar stricture

In Malignant Hilar Biliary Stricture (MHBS) palliative biliary drainage is a frequent strategy, improving the quality of life, reducing pruritus, loss of appetite and relieving cholangitis. The endoscopic approach is an effective, although challenging procedure. This study aimed to evaluate technical and clinical success rates of biliary drainage by ERCP. This is a retrospective study including all patients with MHBS referred to Instituto do Cancer do Hospital de São Paulo (ICESP) submitted to biliary drainage by ERCP, between January 2010 and December 2017. Multivariable logistic regression was performed to evaluate predictors of clinical failure, as total bilirubin levels, Bismuth classification, number of hepatic sectors drained and presence of cholangitis. In total, 82 patients presenting unresectable MHBS were included in this study. 58.5% female and 41.5% male, with a mean age of 60±13 years. Bismuth classification grades II, IIIA, IIIB and IV were noted in 23.2%, 15.9%, 14.6% and 46.3%, respectively. Technical and clinical success was achieved in 92.7% and 53.7% respectively. At multivariable logistic-regression analyses, Bismuth IV strictures were related to higher clinical failure rates when compared to other strictures levels, with an Odds Ratio of 5.8 (95% CI 1.28‒20.88). In conclusion, endoscopic biliary drainage for malignant hilar biliary stricture had a high technical success but suboptimal clinical success rate. Proximal strictures (Bismuth IV) were associated with poor drainage outcomes.

Endoscopic palliation of malignant biliary obstruction

Malignant biliary obstruction often presents with challenges requiring the endoscopist to assess the location of the lesion, the staging of the disease, the eventual resectability and patient preferences in term of biliary decompression. This review will focus on the different modalities available in order to offer the most appropriate palliation, such as conventional endoscopic retrograde cholangiopancreatography, endoscopic ultrasound guided biliary drainage as well as ablative therapies including photodynamic therapy or radiofrequency ablation.

Endoscopic management of perihilar cholangiocarcinoma

Endoscopic management for perihilar cholangiocarcinoma (PHCC) is evolving toward more accurate diagnosis and safer drainage. In imaging, it is important to diagnose the entire lesion using multidetector-row computed tomography to determine resectability and optimal surgical planning, followed by local diagnosis using endoscopic retrograde cholangiopancreatography. Video peroral cholangioscopy and probe-based confocal laser endomicroscopy have been newly introduced as diagnostic imaging methods and are being applied clinically. In transpapillary forceps biopsy for PHCC diagnosis, the location in the bile duct (for mapping biopsy) and the number of biopsy samples should be determined depending on resectability, the morphological type, and future surgical planning. Preoperative drainage has shifted from percutaneous transhepatic biliary drainage to endoscopic nasobiliary drainage given the possibility of seeding metastasis. In addition, considering potential patient discomfort from a nasal tube, the usefulness of the placement of a plastic stent above the papilla (inside stent) as a bridging therapy for surgery has been reported. For drainage of unresectable PHCC, the improved prognosis due to advances in chemotherapy has necessitated a strategy that accounts for reintervention. Thus, in addition to uncovered self-expandable metallic stents (SEMS), exchangeable slim fully covered SEMS and inside stents have started to be used. In addition to the conventional transpapillary approach, an endoscopic ultrasonography-guided approach has been introduced, and a combination of both methods has also been proposed. To improve the quality of life and prognosis of PHCC patients, endoscopists need to understand and be able to use the various methods of endoscopic management for PHCC.

Endoscopic re-intervention after stent-in-stent versus side-by-side bilateral self-expandable metallic stent deployment

BACKGROUND AND AIM

Endoscopic bilateral self-expandable metallic stent (SEMS) placement for unresectable malignant hilar biliary obstruction (MHBO) is widely performed; however, re-intervention after recurrent biliary obstruction (RBO) is often challenging. We compared stent-in-stent (SIS) and side-by-side (SBS) SEMS placement for MHBO considering re-intervention for RBO.

METHODS

One hundred five consecutive patients with MHBO who underwent endoscopic bilateral SEMS placement in our hospital and its affiliated institutions were enrolled in this study; 75 patients underwent partial SIS deployment between December 2005 and December 2012; and 30 underwent SBS deployment between January 2013 and March 2019. Initial treatments and re-interventions in each group were retrospectively evaluated.

RESULTS

Technical success rate (92% vs 100%, P = 0.179), procedure duration (46 vs 35 min, P = 0.382), functional success rate (97.1% vs 100%, P = 1.00), complication rate (24.6% vs 20.0%, P = 0.797), time to RBO (260 vs 312 days; Gray test, P = 0.815), and rate of RBO (59.4% vs 70.0%, P = 0.371) were not significantly different between the SIS and SBS groups. However, bilateral re-stenting with plastic stents through SEMS was successful in 63.4% of patients in the SIS group compared with 100% of patients in the SBS group (P = 0.0013). Median time to RBO upon first re-stenting with a plastic stent was 75 days (range, 11-195 days).

CONCLUSIONS

Endoscopic re-stenting after RBO was significantly more successful in the SBS group than in the SIS group. SBS method is suitable for MHBO considering revisionary stent placement.

Recent advances regarding endoscopic biliary drainage for unresectable malignant hilar biliary obstruction

Biliary drainage for unresectable malignant hilar biliary obstruction (UMHBO) is still associated with a number of controversies to be resolved. The superiority of bilateral drainage in comparison to unilateral drainage has not been proven obviously yet. However, bilateral drainage is necessary to treat obstructive jaundice in some UMHBO patients, and this may be connected with preservation of the functional liver volume. The partial stent-in-stent (SIS) method and side-by-side (SBS) method developed as bilateral drainage methods. There is no significant difference in the technical or clinical success rates of the SIS and SBS methods. In addition, these methods are comparable in terms of adverse events, patency period, and survival period. On the other hand, reintervention for recurrent biliary obstruction (RBO) after the SBS method seems to be easier in comparison to cases with RBO after the SIS method; however, there is no remarkable difference in the clinical results of these procedures. Endoscopic ultrasound (EUS)-guided biliary drainage also has become an option for patients with UMHBO. Left hepatic drainage using EUS-guided hepaticogastrostomy (EUS-HGS) has become common; however, few studies have reported the results of bridging drainage for the right lobe using the EUS-HGS route or EUS-guided hepaticojejunostomy. A few studies addressed the results of newly designed stents, such as the 6-mm braided metal stent and inside stent. The development of various drainage methods and new devices is necessary for the further advancement of endoscopic biliary drainage for patients with UMHBO, further studies to evaluate those methods and devices are warranted.

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

Objective

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

Design

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

Results

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

Conclusion

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

Endoscopic Reintervention for Recurrence of Malignant Biliary Obstruction: Developing the Best Strategy

Drainage therapy for malignant biliary obstruction (MBO) includes trans-papillary endoscopic retrograde biliary drainage (ERBD), percutaneous transhepatic biliary drainage (PTBD), and trans-gastrointestinal endoscopic ultrasound-guided biliary drainage (EUS-BD). With the development of chemotherapy, many MBO cases end up needing endoscopic reintervention (E-RI) for recurrent biliary obstruction. To achieve a successful E-RI, it is necessary to understand the various findings regarding E-RI in MBO cases reported to date. Therefore, in this review, we focus on E-RI for ERBD of distal MBO, ERBD of hilar MBO, and EUS-BD. To plan an appropriate E-RI strategy for biliary stent occlusion for MBO, the following must be considered on a case-by-case basis: the urgency of the drainage, the cause of the occlusion, the original route of drainage (PTBD/ERBD/EUS-BD), the initial stent used (plastic stent or self-expandable metallic stent), and in the case of self-expandable metallic stents, the type used (fully covered or uncovered). Regardless of the original method of stent placement, if the inflammation caused by obstructive cholangitis is severe and/or the patient is in shock, PTBD should be considered as the first choice. Finally, it is important to keep in mind that in many cases, performing E-RI will be difficult.

Hilar Malignant Biliary Obstruction Treated with Four Metallic Stents Involving a New Slim Device

Endoscopic hilar multiple stenting is challenging. A 68-year-old patient had self-expandable metallic stents (SEMSs) inserted for unresectable hilar malignant biliary obstruction. After the SEMSs were inserted into the left hepatic duct and bile duct branch of segment (B) 6, a new SEMS with a wide mesh and slim delivery system was inserted into the right anterior hepatic duct. However, liver abscess and dilated B7 were observed on computed tomography; therefore, an additional new SEMS was quickly and easily inserted into B7. After the placement of these four SEMSs, the liver abscess improved. The new SEMS was effective for hilar multiple biliary drainage.

A preliminary single-center investigation of percutaneous biliary stenting in malignant hilar biliary obstruction: what impacts the clinical success and the long-term outcomes?

PURPOSE

The purpose of this study is to investigate the influencing factors that may impact the clinical success, jaundice-free time, and overall survival in patients of malignant hilar biliary obstruction (MHBO) treated with a self-expanding metallic stent (SEMS).

MATERIALS AND METHODS

Patients diagnosed with MHBO and treated with SEMS through percutaneous access from 1 Jul. 2013 to 1 Jul. 2018 were enrolled in this monocentric study. Demographic information, disease baseline measurements, and interventional strategies were collected and examined. Bilirubin was measured 1-3 days before and 3-7 days after stenting using the unit of "μmol/L." The bilirubin reduction ratio was compared between different study groups, which were separated by specific characteristics. Univariate and multivariate analyses were performed to evaluate each characteristic's impact on jaundice-free time (JF) and overall survival time (OS). Statistical analyses were conducted using SPSS 14.0, p < 0.05 indicated significance.

RESULTS

Eighty patients were enrolled. Direct bilirubin (DB) and indirect bilirubin (IB) both significantly decreased after stenting (U = 1575.0, p < 0.001; U = 1541.0, p < 0.001). The DB reduction ratio of the "nearby lymph metastases" group was significantly higher (U = 566.0, p = 0.037). The IB reduction ratio in the "single stent" group was significantly higher (U = 554.0, p = 0.018). Sixty-six cases reached jaundice recurrence, the median JF was 6 months, and the 95% confidence interval was 4.411 ~ 7.589 months. Fifty-eight cases ended in death, the median OS was 7 months, and the 95% confidence interval was 5.759 ~ 8.241 months. "Nearby lymph metastases" and "distant metastases" independently impacted OS (OR = 2.344, p = 0.013; OR = 3.239, p = 0.042). "IB reduction ratio" independently impacted both JF and OS (OR = 0.422, p = 0.021; OR = 0.315, p = 0.001).

CONCLUSION

The goal of treatment in patients with MHBO is to recover liver function. However, the overall survival is greatly impacted by the presence of metastases. Managing to obtain adequate liver function recovery may improve the long-term outcomes in affected patients.

EUS-guided biliary drainage for malignant hilar biliary obstruction: A concise review

EUS-guided biliary drainage (EUS-BD) has emerged as an alternative to ERCP for distal biliary obstruction in expert hands. Various routes for EUS-guided access in distal biliary obstruction include EUS choledochoduodenostomy, EUS-guided rendezvous, and EUS-antegrade (EUS-AG) stent placement. While percutaneous transhepatic biliary drainage and ERCP are established modalities in management of malignant hilar biliary obstruction, the role of EUS-BD is emerging. Various methods of drainage in hilar obstruction include EUS hepaticogastrostomy, EUS hepaticoduodenostomy, EUS-guided bridging stent placement, and combined ERCP and EUS-guided biliary drainage. In this review, we discuss the role of EUS-BD in malignant hilar biliary obstruction with the currently available evidence, along with the limitations and challenges to the use of this modality in management of these patients.

Personalized Endoscopy in Complex Malignant Hilar Biliary Strictures

Malignant hilar biliary obstruction (HBO) represents a complex clinical condition in terms of diagnosis, surgical and medical treatment, endoscopic approach, and palliation. The main etiology of malignant HBO is hilar cholangiocarcinoma that is considered an aggressive biliary tract's cancer and has still today a poor prognosis. Endoscopy plays a crucial role in malignant HBO from the diagnosis to the palliation. This technique allows the collection of cytological or histological samples, direct visualization of the suspect malignant tissue, and an echoendoscopic evaluation of the primary tumor and its locoregional staging. Because obstructive jaundice is the most common clinical presentation of malignant HBO, endoscopic biliary drainage, when indicated, is the preferred treatment over the percutaneous approach. Several endoscopic techniques are today available for both the diagnosis and the treatment of biliary obstruction. The choice among them can differ for each clinical scenario. In fact, a personalized endoscopic approach is mandatory in order to perform the proper procedure in the singular patient.

ERCP plus endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage for malignant hilar biliary obstruction: a multicenter observational open-label study

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) may not provide complete biliary drainage in patients with Bismuth III/IV malignant hilar biliary obstruction (MHBO). Complete biliary drainage is accomplished by adding percutaneous transhepatic biliary drainage (PTBD). We prospectively compared recurrent biliary obstruction (RBO) rates between combined ERCP and endoscopic ultrasound-guided biliary drainage (EUS-BD) vs. bilateral PTBD.

METHODS

Patients with MHBO undergoing endoscopic procedures (group A) were compared with those undergoing bilateral PTBD (group B). The primary outcome was the 3-month RBO rate.

RESULTS

36 patients were recruited into groups A (n = 19) and B (n = 17). Rates of technical and clinical success, and complications of group A vs. B were 84.2 % (16/19) vs. 100 % (17/17; P = 0.23), 78.9 % (15/19) vs. 76.5 % (13/17; P > 0.99), and 26.3 % (5/19) vs. 35.3 % (6/17; P = 0.56), respectively. Within 3 and 6 months, RBO rates of group A vs. group B were 26.7 % (4/15) vs. 88.2 % (15/17; P  = 0.001) and 22.2 % (2/9) vs. 100 % (9/9; P = 0.002), respectively. At 3 months, median number of biliary reinterventions in group A was significantly lower than in group B (0 [interquartile range] 0-1 vs. 1 [1-2.5]), respectively (P < 0.001). Median time to development of RBO was longer in group A than in group B (92 [56-217] vs. 40 [13.5-57.8] days, respectively; P  =  0.06).

CONCLUSIONS

Combined ERCP and EUS procedures provided significantly lower RBO rates at 3 and 6 months vs. bilateral PTBD, with similar complication rates and no significant mortality difference.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Retrospective Comparative Study of Side-by-Side and Stent-in-Stent Metal Stent Placement for Hilar Malignant Biliary Obstruction

BACKGROUND

In patients with unresectable hilar malignant biliary obstruction (MBO), bilateral metal stent placement is recommended. However, treatment selection between partially stent-in-stent (SIS) and side-by-side (SBS) methods is still controversial.

STUDY

Clinical outcomes of bilateral metal stent placement by SBS and SIS methods for hilar MBO were retrospectively studied in four Japanese centers. While large-cell-type uncovered metal stents were placed above the papilla in SIS, braided-type uncovered metal stents were placed across the papilla in SBS.

RESULTS

A total of 64 patients with hilar MBO (40 SIS and 24 SBS) were included in the analysis. Technical success rate was 100% in SIS and 96% in SBS. Functional success rate was 93% in SIS and 96% in SBS. Early adverse event rates were higher in SBS (46%) than in SIS (23%), though not statistically significant (P = 0.09). Post-procedure pancreatitis was exclusively observed in SBS group (29%). Recurrent biliary obstruction rates were 48% and 43%, and the median time to recurrent biliary obstruction was 169 and 205 days in SIS and SBS, respectively.

CONCLUSIONS

Other than a trend to higher adverse event rates including post-procedure pancreatitis in SBS, clinical outcomes of SIS and SBS methods were comparable in patients with unresectable hilar MBO.

Endoscopic Stenting in Hilar Cholangiocarcinoma: When, How, and How Much to Drain?

Hilar cholangiocarcinoma (HCCA) involves a complex anatomical region where bile ducts, arteries, and veins create a complex network. HCCA can lead to biliary strictures at the main hepatic confluence, involving the right and left radicles. Endoscopic drainage of jaundiced patients with HCCA is challenging and carries a high risk of infective complications. HCCA needs a careful multidisciplinary evaluation to assess the indication and purposes (preoperative/palliative) of the biliary drainage. Biliary drainage in HCCA needs to be planned by magnetic resonance cholangiography in order to study the biliary anatomy and perform a target drainage of the intrahepatic ducts above the malignant hilar stricture; all the opacified intrahepatic ducts above the hilar stricture must be drained to reduce septic complications. Drainage of >50% of the liver volume is important to obtain bilirubin reduction and less complications, but atrophic liver segments (identified by CT scan) do not require drainage due to the increased risk of cholangitis. When preoperative biliary drainage is planned, plastic stents must be inserted. Self-expandable metal stents are indicated for palliative purposes and should be placed only when a complete liver drainage is possible; only uncovered metal stents are indicated to drain malignant hilar strictures to avoid side-branch occlusion.

RECOMMENDATIONS FOR INVASIVE PROCEDURES IN PATIENTS WITH DISEASES OF THE LIVER AND BILIARY TRACT: REPORT OF A JOINT MEETING OF THE BRAZILIAN SOCIETY OF HEPATOLOGY (SBH), BRAZILIAN SOCIETY OF DIGESTIVE ENDOSCOPY (SOBED) AND BRAZILIAN SOCIETY OF INTERVENTIONAL RADIOLOGY AND ENDOVASCULAR SURGERY (SOBRICE)

Liver and biliary tract diseases are common causes of morbidity and mortality worldwide. Invasive procedures are usually performed in those patients with hepatobiliary diseases for both diagnostic and therapeutic purposes. Defining proper indications and restraints of commonly used techniques is crucial for proper patient selection, maximizing positive results and limiting complications. In 2018, the Brazilian Society of Hepato-logy (SBH) in cooperation with the Brazilian Society of Interventional Radiology and Endovascular surgery (SOBRICE) and the Brazilian Society of Digestive Endoscopy (SOBED) sponsored a joint single-topic meeting on invasive procedures in patients with hepatobiliary diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to guide clinicians, gastroenterologists, hepatologists, radiologists, and endoscopists for the proper use of invasive procedures for management of patients with hepatobiliary diseases.

Evaluation of endoscopic reintervention for self-expandable metallic stent obstruction after stent-in-stent placement for malignant hilar biliary obstruction

BACKGROUND

Bilateral self-expandable metallic stent (SEMS) placement is effective for long-term management of unresectable malignant hilar biliary obstruction (UMHBO). However, endoscopic reintervention (ERI) for bilateral SEMSs is not well-studied. This study aimed to evaluate ERI efficacy after stent-in-stent placement.

METHODS

Data of 31 patients who underwent ERI from May 2000 to July 2018 were analyzed.

RESULTS

The technical success rate was 80.7% (25/31) and no adverse events occurred. The functional success rate was 100% (25/25). In a multivariate logistic regression analysis, the angle between the bilateral SEMSs (ABBS) >104° (odds ratio 50.49, 95% CI 3.370-2131, P = 0.0039) and overgrowth (odds ratio 25.70, 95% CI 1.121-1234, P = 0.0423) were risk factors for ERI failure. Multiple liver metastases, which sometimes cause overgrowth, were also risk factors. After ERI, some patients underwent additional SEMS (n = 4), plastic stent (n = 14) placement, or internal cleaning of the initial SEMS alone (n = 7). There were no significant intergroup differences in the 50% time to recurrent biliary obstruction.

CONCLUSIONS

ABBS >104° and overgrowth were risk factors for ERI failure after stent-in-stent placement. In the decision-making process for initial SEMS placement for UMHBO, patient condition should be considered, including the angle between bilateral bile ducts and multiple liver metastases.

Clinical Significance of Preoperative Serum CEA, CA125, and CA19-9 Levels in Predicting the Resectability of Cholangiocarcinoma

To explore the clinical significance of preoperative serum CEA, CA125, and CA19-9 levels in predicting the resectability of cholangiocarcinoma. Patients with cholangiocarcinoma diagnosed by radiologic examination and admitted to the Second Affiliated Hospital of Harbin Medical University from September 1, 2011, to November 30, 2017, were retrospectively included. The relationship between the preoperative serum CEA, CA125, and CA19-9 levels and the resectability of cholangiocarcinoma was analyzed by receiver operating characteristic (ROC) curve, as well as the best cut-off point. A total of 112 met the inclusion criteria. In 50 patients with radical surgeries, the levels of preoperative serums CEA, CA125, and CA19-9 were 5.0 ± 13.9 ng/mL, 15.3 ± 11.8 U/mL, and 257.5 ± 325.6 U/mL, respectively, which were lower than those in patients with unresectable tumor. Based on the ROC curve, the ideal CA19-9 cut-off value was determined to be 1064.1 U/mL in prediction of resectability, with a sensitivity of 53.2%, a specificity of 94.0%, and the area under the ROC curve of 0.73 (P < 0.05). The cut-off value of CA125 was 17.8 U/mL with a sensitivity of 72.6%, a specificity of 78.0%, and the area under the ROC curve of 0.81 (P < 0.05). The cut-off value of CEA was 2.6 ng/mL with a sensitivity of 79.0%, a specificity of 48.0%, and the area under the ROC curve of 0.66 (P < 0.05). In addition to this, we found that using the combination of three tumor markers could improve the value in predicting resectability of cholangiocarcinoma. In summary, this study suggested that the preoperative serum CEA, CA125, and CA19-9 levels can help predict the resectability of cholangiocarcinoma.

Endoscopic Ultrasound-Guided Biliary Drainage for Unresectable Hilar Malignant Biliary Obstruction

Endoscopic transpapillary biliary drainage is the current standard of care for unresectable hilar malignant biliary obstruction (MBO) and bilateral metal stent placement is shown to have longer patency. However, technical and clinical failure is possible and percutaneous transhepatic biliary drainage (PTBD) is sometimes necessary. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is increasingly being reported as an alternative rescue procedure to PTBD. EUS-BD has a potential advantage of not traversing the biliary stricture and internal drainage can be completed in a single session. Some approaches to bilateral biliary drainage for hilar MBO under EUS-guidance include a bridging method, hepaticoduodenostomy, and a combination of EUS-BD and transpapillary biliary drainage. The aim of this review is to summarize data on EUS-BD for hilar MBO and to clarify its advantages over the conventional approaches such as endoscopic transpapillary biliary drainage and PTBD.

Risk factors of ineffective drainage in uncovered self-expandable metal stenting for unresectable malignant hilar biliary strictures

AIM

In this study, we assessed the factors contributing to ineffective drainage in the initial transpapillary uncovered self-expandable metal stent (USEMS) placements in patients with unresectable malignant hilar biliary strictures (UMHBSs) (Bismuth type II or higher).

METHODS

This was a retrospective, single-center study. A total of 97 patients with UMHBSs who underwent technically successful initial USEMS placements using endoscopic retrograde cholangiopancreatography (ERCP) were classified into the effective drainage group (n = 73) or the ineffective drainage group (n = 24). We then compared group characteristics, clinical outcomes, and drained liver volumes. Drained liver volume was measured by using computed tomography volumetry. The definition of effective biliary drainage was a 50% decrease in the serum total bilirubin level or normalization of the level within 14 days of stent placement.

RESULTS

Univariate analysis showed that ineffective drainage was associated with the pre-ERCP serum total bilirubin level (P = 0.0075), pre-ERCP serum albumin level (P = 0.042), comorbid liver cirrhosis (P = 0.010), drained liver volume (P = 0.0010), and single stenting (P = 0.022). Multivariate analysis identified comorbid liver cirrhosis (adjusted odds ratio [OR], 5.79; 95% confidence interval [CI], 1.30-25.85; P = 0.022) and drained liver volume < 50% (adjusted OR, 5.50; 95% CI, 1.50-20.25; P = 0.010) as independent risk factors of ineffective drainage.

CONCLUSION

Comorbid liver cirrhosis and a drained liver volume < 50% contributed significantly to ineffective drainage in the initial transpapillary USEMS placements for UMHBSs.

Endoscopic biliary stenting for unresectable malignant hilar obstruction

Palliative drainage is the primary treatment option for unresectable malignant hilar biliary obstruction (UMHBO) to improve the prognosis and quality of life. Currently, endoscopic biliary drainage is considered as a first-line treatment for UMHBO as well as for distal biliary obstruction. Self-expanding metal stents (SEMSs) are preferred over plastic stents (PSs) in patients with life expectancy of >3 months. However, endoscopic treatment of UMHBO is often more challenging and complex than that of distal biliary obstruction. Although no consensus exists on the optimal method for biliary drainage because of the lack of well-designed, large-scale randomized control trials, several essential aspects of various optimal methods have been studied. Presently, technological developments in this field are under way and newly designed or modified stenting devices for UMHBO are being developed. In this review, we assess the optimal stenting strategy for UMHBO based on the previous literature, focusing on the stent type (PS vs SEMS), the liver volume to be drained, unilateral (single) vs bilateral (multiple) stent deployment, and bilateral stenting method (stent-in-stent vs side-by-side).

Application of laparoscopic ultrasound in robot-assisted minimally invasive therapy for abdominal tumors

AIM: To assess the clinical application of laparoscopic ultrasound in robot-assisted minimally invasive therapy for abdominal tumors.

METHODS: A total of 41 patients (16 patients with hilar cholangiocarcinoma, 15 patients with hepatic tumors, 9 patients with pancreatic tumors, and 1 patient with retroperitoneal tumor) underwent laparoscopic ultrasound-guided robot-assisted minimally invasive therapy for abdominal tumors. Laparoscopic ultrasound was used preoperatively to detect the number of lesions, and evaluate their location and relationship with surroundings tissue precisely. Also, by means of laparoscopic ultrasound, the surgical pathways were guided operatively, and preliminary clinical effects were evaluated postoperatively. To assess clinical efficacy, all patients were followed by contrast-enhanced CT/MRI, ultrasound, blood tests, etc.

RESULTS: All laparoscopic ultrasound-guided procedures were performed successfully. Laparoscopic ultrasound discovered undetected lesions in 10 patients, which resulted in a change in operative strategy (10/41, 24.39%). No death occurred during the perioperative period. Abnormalities were not found postoperatively by ultrasound and contrast-enhanced CT/MRI in all patients. Laboratory studies demonstrated that blood biochemical indicators decreased to normal range gradually. No severe complications occurred in both intraoperative and postoperative periods. All patients survived, and their life quality was improved significantly.

CONCLUSION: Laparoscopic ultrasound could not only guide operative strategy, but also help to decrease complications and prolong disease-free survival in the postoperative period. This technique provides a safe surgical procedure, and the therapeutic effects could be improved by application of laparoscopic ultrasound in robot-assisted minimally invasive therapy for abdominal tumors.

Peripheral portal vein-oriented non-dilated bile duct puncture for percutaneous transhepatic biliary drainage

AIM: To evaluate the efficacy of peripheral portal vein (PV)-oriented non-dilated bile duct (BD) puncture for percutaneous transhepatic biliary drainage (PTBD).

METHODS: Thirty-five patients with non-dilated BDs underwent PTBD for the management of various biliary disorders, including benign bilioenteric anastomotic stricture (n = 24), BD stricture (n = 5) associated with iatrogenic BD injury, and postoperative biliary leakage (n = 6). Under ultrasonographic guidance, percutaneous transhepatic puncture using a 21-G needle was performed along the running course of the peripheral targeted non-dilated BD (preferably B6 for right-sided approach, and B3 for left-sided approach) or along the accompanying PV when the BD was not well visualized. This technique could provide an appropriate insertion angle of less than 30° between the puncture needle and BD running course. The puncture needle was then advanced slightly beyond the accompanying PV. The needle tip was moved slightly backward while injecting a small amount of contrast agent to obtain the BD image, followed by insertion of a 0.018-inch guide wire (GW). A drainage catheter was then placed using a two-step GW method.

RESULTS: PTBD was successful in 33 (94.3%) of the 35 patients with non-dilated intrahepatic BDs. A right-sided approach was performed in 25 cases, while a left-sided approach was performed in 10 cases. In 31 patients, the first PTBD attempt proved successful. Four cases required a second attempt a few days later to place a drainage catheter. PTBD was successful in two cases, but the second attempt also failed in the other two cases, probably due to poor breath-holding ability. Although most patients (n = 26) had been experiencing cholangitis with fever (including septic condition in 8 cases) before PTBD, only 5 (14.3%) patients encountered PTBD procedure-related complications, such as transient hemobilia and cholangitis. No major complications such as bilioarterial fistula or portal thrombosis were observed. There was no mortality in our series.

CONCLUSION: Peripheral PV-oriented BD puncture for PTBD in patients with non-dilated BDs is a safe and effective procedure for BD stricture and postoperative bile leakage.