Clinical outcomes and prediction of survival following percutaneous biliary drainage for malignant obstructive jaundice

Clinical effect of percutaneous hepatic puncture biliary drainage combined with metal stent implantation in the treatment of malignant obstructive jaundice

OBJECTIVE

To evaluate the clinical efficacy of percutaneous hepatic puncture biliary drainage combined with metal stent implantation in the treatment of malignant obstructive jaundice, focusing on improvements in liver function, bile duct patency time, and reduction of postoperative complications.

METHODS

181 patients with malignant obstructive jaundice were retrospectively selected from a hospital in Ganzhou City, Jiangxi Province, from April 2021 to May 2024, of which 132 underwent routine percutaneous liver puncture biliary drainage and 49 underwent percutaneous liver puncture biliary drainage combined with metal stent implantation as the observation group.

RESULTS

The clinical efficacy of the observation group was higher (P < 0.05), and the bile duct patency time was longer (P < 0.05). The AST, ALT, DBIL and TBIL levels were decreased 1 week and 1 month after surgery, and the decrease was more significant in the observation group (P < 0.05). In addition, the incidence of postoperative complications (bile duct infection and electrolyte disturbance) in the observation group was lower (P < 0.05).

CONCLUSION

Percutaneous hepatic puncture biliary drainage combined with metal stent implantation has significant clinical efficacy, which can effectively improve the clinical symptoms of patients, prolong the biliary patency time, reduce the level of bilirubin, promote the improvement of liver function, and lower the incidence of postoperative complications.

CLINICAL TRIAL NUMBER

not applicable.

Identifying predictive markers for survival in malignant biliary obstruction following percutaneous transhepatic biliary drainage

AIM

Malignant biliary obstructive disease is commonly managed with percutaneous transhepatic biliary drainage (PTBD). Traditionally, outcomes are evaluated collectively despite substantial variability in the underlying aetiology and extent of disease. The purpose of this study was to investigate whether variability in survival could be explained by different underlying patient and disease factors.

MATERIALS AND METHODS

A single centre, retrospective study was performed looking at first-time malignant PTBD and respective survival outcomes between 2017- 2021. Survival censoring was taken as June 2022. Predictors included aetiology, age, preprocedural serum haemoglobin, and bilirubin. Subgroups were dichotomised with respect to median values. Kaplan-Meier survival analysis and the log rank test were used for univariate analysis and Cox proportional hazards regression for multivariate analysis.

RESULTS

One hundred fifty-six patients were identified, including 62 pancreatic, 19 ampullary/duodenal, 55 hilar cholangiocarcinoma, and 20 non hepatobiliary cancers. Median overall survival for the entire cohort was 136 days. The underlying aetiology significantly impacted median survival with non-hepatobiliary obstruction faring the worst; 53 days, and was in stark contrast to cholangiocarcinoma (347 days, p < 0.001). On multivariate analysis, we found that in addition to aetiology, patients > 70 years, preprocedural haemoglobin (< 110) and bilirubin (> 232) were all independent prognosticators and had significantly worse survival (HR 1.2, 1.8, 1.6, and 1.4, respectively, all p < 0.05).

CONCLUSION

Age, underlying malignant aetiology, preprocedural haemoglobin, and bilirubin were identified as independent predictors of post-PTBD survival. Careful patient selection may therefore improve patient outcomes following PTBD.

Efficacy and influencing factors of percutaneous transhepatic cholangiography and biliary drainage in malignant obstructive jaundice patients

OBJECTIVES

To analyze the efficacy and influencing factors of percutaneous transhepatic cholangiography and biliary drainage (PTCD) in patients with malignant obstructive jaundice (MOJ).

METHODS

The study included 151 MOJ patients admitted from January 2021 to January 2024. Seventy patients in the control group received endoscopic retrograde cholangiopancreatography (ERCP), while 81 patients in the research group underwent PTCD. Clinical outcomes, including surgical success rate, efficacy (overall remission, high- and low-level intestinal obstruction remission), safety (bile leakage, septicemia, hemobilia, pancreatitis, and gastrointestinal bleeding), and clinical-related indicators (hospital stay, surgical cost, treatment cost), as well as serum biochemical markers (alanine aminotransferase [ALT], direct bilirubin [DBIL], and total bilirubin [TBIL]), were compared between the groups. Binary logistic regression was used to identify factors influencing PTCD efficacy.

RESULTS

The surgical success rate was significantly higher in the research group than that in the control group (P < 0.05). Although the overall remission rates were similar between the groups (P > 0.05), the research group had a lower low-level intestinal obstruction remission rate and a higher high-level intestinal obstruction remission rate (P < 0.05). Safety profiles and changes in pre- and post-operative serum biochemical markers did not differ significantly between the groups (all P > 0.05). The research group experienced longer hospital stays and lower surgical costs compared to the control group (both P < 0.05), while treatment costs were similar (P > 0.05). Binary logistic regression identified obstruction site, and preoperative liver dysfunction as factors influencing PTCD efficacy.

CONCLUSIONS

PTCD demonstrated a higher surgical success rate than ERCP in MOJ patients, with comparable overall efficacy, safety, and treatment costs. PTCD was associated with longer hospital stays and lower surgical costs. Both procedures similarly improved ALT, DBIL, and TBIL levels. PTCD showed the greatest therapeutic benefit in cases of high-level intestinal obstruction.

Quality of Life and Clinical Outcomes of Endosonography-Guided Biliary Drainage in Patients with Malignant Biliary Obstruction: A Single-Center, Prospective Analysis

Introduction: Endosonography-guided biliary drainage (EUS-BD) serves as a rescue treatment modality for patients with malignant biliary obstruction when endoscopic retrograde cholangiopancreatography (ERCP) fails. Objectives: This study explores the effects of EUS-BD on liver function and quality of life (QoL). Patients and Methods: Patients with malignant biliary obstruction and failed ERCP were enrolled to undergo EUS-BD. QoL, including pruritus severity, was evaluated using EQ-5D-5L and PSS-10 questionnaires before and after EUS-BD. Serum bilirubin and liver function tests were measured on the procedure day, two days, and at least 14 days post-procedure. Results: During a 20-month study period, 1755 ERCPs were performed, with 595 for malignant cases. Of these, 49 underwent EUS-BD following failed ERCP, and 37 (54% women, age range 34-87 years) completed the 14-day follow-up. Pancreatic cancer was the most common (49%) condition, and the median hospital stay was 4 days. Serum bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyl transferase significantly decreased 2 and 14 days after EUS-BD (all p < 0.001). Pruritus significantly improved, with an average reduction of 5.19 points on the PSS-10 scale two weeks post-procedure (p < 0.001). EUS-BD led to improvements in anxiety and depression according to the EQ-5D-5L (p = 0.013). Conversely, deteriorations were observed in the Mobility, Self-Care, and Usual Activities domains over time (all p < 0.05). Successful EUS-BD enabled the resumption of chemotherapy in 11 (30%) patients. The median post-procedure survival was 112 (range 27-1030) days. Conclusions: EUS-BD improves liver parameters and some aspects of life quality in patients with malignant biliary obstruction, thereby increasing their eligibility for optimal palliative care.

Intrabiliary pressure in the pathophysiology of extra hepatic biliary obstruction

BACKGROUND AND AIM

The aim of this study was to evaluate the role of intrabiliary pressure (IBP) in the pathophysiology of extrahepatic biliary obstruction (EHBO) during percutaneous transhepatic biliary drainage (PTBD).

MATERIALS AND METHODS

Adult patients with EHBO who underwent PTBD were prospectively enrolled. IBP was recorded during primary PTBD. The parameters of interest were age, gender, etiology of EHBO, baseline and post-PTBD liver function tests, duration for resolution of jaundice (decrease in total serum bilirubin ≥30% of baseline or <2 mg/dL), cholangitis, bile cultures, and serum albumin levels. The level of EHBO was divided into three types: Type 1 - secondary biliary confluence involved; Type 2 - primary biliary confluence involved; Type 3 - mid and distal common bile duct obstruction.

RESULTS

IBP was measured in 102 patients, and finally, 87 patients, including 52 (59.77%) females, were analyzed. The mean age of the patients was 56.1±11.6 years. The most common etiology of EHBO was carcinoma of the gallbladder in 44 (50.6%) patients. The mean IBP was 18.41±3.91 mmHg. IBP was significantly higher in Type 3 EHBO compared to Type 1 and 2 (p=0.012). A significant correlation was seen between IBP and baseline total serum bilirubin (p<0.01). There was a negative correlation between IBP and baseline serum albumin (p=0.017). In 56.3% of patients, resolution of jaundice was observed by day 3, but this was not significantly associated with IBP (p=0.19). There was no correlation between IBP and cholangitis (p=0.97) or bacterial cultures (p=0.21).

CONCLUSION

IBP was significantly associated with the type of EHBO, baseline serum bilirubin, and albumin levels. IBP could not predict cholangitis or the resolution of jaundice after PTBD.

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.

Correlation between functional drainage and survival in malignant biliary obstruction after percutaneous biliary drainage

Purpose

Malignant biliary obstruction (MBO) is common in patients with advanced malignant tumors, leading to poor prognosis and hindering antitumor therapy. The purpose of our study was to assess the survival outcomes for patients under therapy after percutaneous transhepatic biliary drainage (PTBD) and identify prognostic factors associated with survival in patients with MBO.

Methods

From July 2010 to February 2021, 269 patients with MBO secondary to malignant tumor were divided into two groups (functional success and non-functional success). Survival time and prognostic factors were analyzed by Kaplan-Meier curves and the Cox model.

Results

The overall median survival time after PTBD was 4.6 months (95 % IC:3.9-5.3). The 3- and 6-month survival rates were 68.0 % and 38.7 %, respectively. The median survival improved from 3.2 months to 8.4 months when the procedure achieved functional success. Multivariate analysis demonstrated that functionally successful drainage and antitumor treatment after PTBD were independent positive prognostic factors, but the total bilirubin after drainage and tumor size were independent negative predictive values.

Conclusions

Functionally successful drainage could prolong survival time in patients with malignant biliary obstruction. Palliative care after drainage can prolong patient survival and improve their quality of life.

Clinical Outcomes of Biliary Drainage in Patients with Malignant Biliary Obstruction Caused by Colorectal Cancer Metastases

BACKGROUND AND AIM

Malignant biliary obstruction is an ominous complication of metastatic colorectal cancer (mCRC) that is challenging to solve. Biliary drainage can be performed to relieve symptoms of jaundice, treat cholangitis, or enable palliative systemic therapy. The aim of this study is to evaluate clinical outcomes of biliary drainage of malignant biliary obstruction in mCRC patients.

METHODS

Consecutive patients with malignant biliary obstruction due to mCRC who underwent endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography were included. Patient, disease, and procedural characteristics and outcomes were retrospectively collected from electronic medical records. Radiological data were prospectively reassessed. Main outcome was functional success, i.e. achievement of the intended goal of biliary drainage. Prognostic factors for functional success and survival were assessed.

RESULTS

Thirty-seven patients were included. Functional success was achieved in 18 (50%) patients. Seventeen (46%) patients experienced adverse events (suspected to be) related to the procedure. Median overall survival after biliary drainage was 61 days (IQR 31-113). No prognostic factors of functional success were identified. Performance status, presence of the primary tumor, ascites, ≥ 5 intrahepatic metastases, estimated hepatic invasion of > 50% and above-median levels of bilirubin and lactate dehydrogenase were significantly associated with poorer survival. Improved survival was seen in patients with technical, functional, or biochemical success, and with subsequent oncologic treatment.

CONCLUSIONS

Functional successful biliary drainage was achieved in half of the patients. Adverse events also occurred in nearly half of the patients. We observed a significantly longer survival in whom biliary drainage allowed palliative oncologic therapy.

Survival prediction for patients with malignant biliary obstruction caused by pancreatic cancer undergoing biliary drainage: the COMBO-PaS model

BACKGROUND

Patients with pancreatic cancer-caused biliary obstruction (PC-BO) have poor prognosis, but we lack of tools to predict survival for clinical decision-making. This study aims to establish a model for survival prediction among patients with PC-BO.

METHODS

A total of 172 patients with PC-BO treated with percutaneous biliary drainage were randomly divided into a training group (n = 120) and a validation group (n = 52). The independent risk factors for overall survival were selected to develop a Cox model. The predictive performance of M stage, hepatic metastases, cancer antigen 199, and the Cox model was determined. Naples prognostic score (NPS), the prognostic nutritional index (PNI), and the controlling nutritional status (CONUT) for 1-month mortality risk were compared with the Cox model.

RESULTS

The Cox model was developed based on total cholesterol, direct bilirubin, hepatic metastases, cancer antigen 199, stenosis type, and preprocedural infection (all P < 0.05), which named "COMBO-PaS." The COMBO-PaS model had the highest area under the curves (AUC) (0.801-0.933) comparing with other predictors (0.506-0.740) for 1-, 3-, and 6-month survival prediction. For 1-month mortality risk prediction, the COMBO-PaS model had the highest AUC of 0.829 comparing with NPS, PNI, and CONUT.

CONCLUSION

The COMBO-PaS model was useful for survival prediction among patients with PC-BO.

Clinical outcomes of percutaneous transhepatic biliary drainage at different Couinaud's hepatic entry segments for treating obstructive jaundice

Introduction

Percutaneous transhepatic biliary drainage (PTBD) is a common procedure for biliary obstructive jaundice caused by biliary tract obstruction. In clinical practice, PTBD can be carried out at right- or left-sided approach. However, different hepatic entry site may affect success rates and complications. Couinaud classification of liver anatomy further divides the liver into functionally independent segments (segment 2/3, segment 5/6, and segment 7/8). Therefore, this study aimed to elucidate whether different Couinaud hepatic segments as PTBD entry site are associated with high PTBD success and low complications.

Methods

A total of 617 patients who underwent PTBD were retrospectively reviewed. Univariate and multivariate logistic regression analyses were performed to identify entry segments associated with PTBD success, bilirubin reduction, and complications.

Results

With higher hepatic segment of PTBD entry site (segment 2/3, 5/6, and 7/8), the trend of PTBD success rate (82.0%, 71.7% and 60.7%; P<0.001) and bilirubin reduction (93.2%, 89.5%, and 82.0%; P=0.012) decreased. Furthermore, PTBD entry at segment 7/8 (42.6%) had highest complication rate than segment 5/6 (6.4%) and 2/3 (9.4%). Univariate and multivariate logistic regression analyses showed that PTBD entry segment was an independent factor associated with PTBD success, bilirubin reduction, and complications. Compared to segment 7/8, segment 2/3 and 5/6 had higher odds of PTBD success (aOR=2.699 and aOR=1.454, respectively) and bilirubin reduction (aOR=3.472 and aOR=2.361, respectively) and associated with lower risk of complications (aOR=0.143 and aOR=0.098, respectively). No independent risk factor for PTBD success and bilirubin reduction were identified in intrahepatic tumors. Moreover, for extrahepatic tumors, PTBD entry at segment 2/3 and segment 5/6 was more likely achieve PTBD success (aOR=3.037 and aOR=1.929, respectively), bilirubin reduction (aOR=3.069 and aOR=3.515) and low complications (aOR=0.102 and aOR=0.126, respectively).

Discussion

Good clinical outcomes were observed for PTBD entry at segments 5/6 and 2/3. In contrast, segment 7/8 had the lowest success rate, smallest bilirubin reduction, and the highest complication rate. For patients with obstructive jaundice, PTBD entry in hepatic segments 2/3 and 5/6 is recommended to achieve high success rates and low complications.

Palliative Care in Cholangiocarcinoma

This chapter details all aspects of the general principles of palliative care for advanced stage cholangiocarcinoma patients. These include symptoms management, communication guide, advance care planning, and management for bereavement. Surgical and intervention techniques of palliative biliary drainage are described in detail for patients with obstructive jaundice with advanced stage CCA. Additionally, details are provided regarding the establishment of a multidisciplinary palliative care team which is critical to provide the most appropriate multimodal treatment for good quality of life and survival of patients.

Prognostic Nutritional Index (PNI) and Neutrophil to Lymphocyte Ratio (NLR) as Predictors of Short-Term Survival in Patients with Advanced Malignant Biliary Obstruction Treated with Percutaneous Transhepatic Biliary Drainage

BACKGROUND

Effective biliary tree decompression plays a central role in the palliation of malignant biliary obstruction (MBO). When endoscopic drainage is unfeasible or unsuccessful, percutaneous transhepatic biliary drainage (PTBD) is the method of choice and preferred treatment approach in advanced hilar MBO. The prognostic nutritional index (PNI) reflects the patient's immunonutritional status, while the neutrophil to lymphocyte ratio (NLR) reflects the patient's inflammation status. The aim of the present study was to evaluate the prognostic value of preprocedural PNI and NLR on short-term survival in the advanced stage MBO population threatened with PTBD and to characterize the differences in immunonutritional and inflammatory status between 60-day survivors and non-survivors, as well as analyze other variables influencing short-term survival.

METHODS

This single-center retrospective study was conducted on patients undergoing palliative PTBD caused by MBO as a definitive therapeutic treatment between March 2020 and February 2022. After the procedure, patients were followed until the end of August 2022.

RESULTS

A total of 136 patients with malignant biliary obstruction were included in the study. Based on receiver operating characteristic (ROC) curve analysis, optimal cut off-values for NLR (3) and PNI (36.7) were determined. In univariate regression analysis, age, absolute neutrophil count, albumin level, NLR ≤ 3, and PNI ≥ 36.7 were significant predictors of 60-day survival. Level of obstruction and PNI ≥ 36.7 were statistically significant independent predictors of 60-day survival in a multivariate regression model. Using PNI ≥ 36.7 as a significant coefficient from the multivariate regression model with the addition of NLR ≤ 3 from univariate analysis, a 60-day survival score was developed.

CONCLUSIONS

PNI and NLR are easy to calculate from routine blood analysis, which is regularly conducted for cancer patients. As such, they represent easily available, highly reproducible, and inexpensive tests capable of expressing the severity of systemic inflammatory responses in patients with cancer. Our study highlights that preprocedural PNI and NLR values provide predictors of short-term survival in patients with MBO treated with palliative PTBD. In addition, the proposed 60-day survival score can contribute to better selection of future candidates for PTBD and recognition of high-risk patients with expected poor outcomes.

The Clinical Benefit of Percutaneous Transhepatic Biliary Drainage for Malignant Biliary Tract Obstruction

Percutaneous transhepatic biliary drainage (PTBD) is a decompression procedure for malignant proximal biliary obstruction. In this research, over a six-year period, 89 patients underwent PTBD procedure for jaundice caused by malignant disease to restart chemotherapy or for palliative intent. Clinical outcomes after PTBD procedure in the two groups of patients, according to the adequate bilirubin decline (ABD) needed for subsequent chemotherapy, are presented in this paper. Survival and logistic regression were plotted and compared using Kaplan−Meier survival multivariate analysis with a long-range test. Results were processed by MEDCALC software. In the series, 58.4% (52/89) of patients were in good performance status (ECOG 0/1), and PTBD was performed with the intention to (re)start chemotherapy. The normalization of the bilirubin level was seen in 23.0% (12/52), but only 15.4% (8/52) received chemotherapy. The median survival time after PTBD was 9 weeks. In patients with ABD that received chemotherapy, the median survival time was 64 weeks, with 30-day mortality of 27.7%, and 6.4% of death within 7 days. The best outcome was in patients with good performance status (ECOG 0−1), low bilirubin (<120 µmol/L) and LDH (<300 µmol/L) levels and elevated leukocytes at the time of the procedures. PTBD is considered in ABD patients who are candidates for chemotherapy.

Development and validation of a risk score for predicting clinical success after endobiliary stenting for malignant biliary obstruction

Background

Endoscopic drainage is the primary treatment for unresectable malignant biliary obstruction (MBO). This study developed and validated a pre-endoscopic predictive score for clinical success after stent placement.

Methods

Patients with unresectable MBO undergoing ERCP-guided endobiliary stent placement between 2007 and 2017 were randomly divided into derivation (n = 383) and validation (n = 128) cohorts. To develop the risk score, clinical parameters were built by logistic regression to predict (1) ≥ 50% total bilirubin (TB) resolution within 2 weeks and (2) bilirubin normalization (TB level <1.2 mg/dL) within 6 weeks following stenting. The scoring scheme was applied to the validation cohort to test its performance.

Results

A ≥ 50% TB resolution within 2 weeks was shown in 70.5% of cases. The risk scoring scheme had areas under the receiver operating characteristic curve (AUROC) of 0.70 (95% CI, 0.64–0.76) and 0.67 (95% CI, 0.57–0.77) in the derivation and validation cohorts, respectively. Thirty-one percent had TB normalization within 6 weeks after stenting. Significant predictors for TB normalization were extrahepatic biliary obstruction (odds ratio [OR] = 2.35), pre-endoscopic TB level (OR = 0.88), and stent type (OR = 0.42). The AUROC of a risk score for predicting TB normalization within 6 weeks was 0.78 (95% CI, 0.72–0.83) and 0.76 (95% CI, 0.67–0.86) in the derivation and validation cohorts, respectively. A score > 1.30 yielded a specificity of 98% and a positive predictive value of 84% for predicting TB normalization. A score of < -4.18 provided a sensitivity of 80%–90% and a negative predictive value of 90%–93% for predicting the absence of TB normalization.

Conclusions

The pre-endoscopic scoring system comprising biliary obstruction level, liver biochemistry, and type of stent provides prediction indices for TB normalization within 6 weeks after stenting. This scheme may help endoscopists identify patients with unresectable MBO suited for palliative stenting.

Percutaneous biliary drainage for obstructive jaundice in patients with inoperable, malignant biliary obstruction

AIM OF THE STUDY

Most of the malignancies leading to obstructive jaundice are diagnosed too late when they are already advanced and inoperable, with palliation being the only treatment option left. Due to progressing hyperbilirubinaemia with its consequent adverse effects, biliary drainage must be established even in advanced malignancies. This study aims to investigate and analyse factors that affect clinical outcomes of percutaneous trans-hepatic biliary drainage (PTBD) in patients with obstructive jaundice due to advanced inoperable malignancy, and identify potential predictors of patient survival. Study design: Observational retrospective cohort study.

MATERIAL AND METHODS

Baseline variables and clinical outcomes were evaluated in 108 consecutive patients treated with PTBD. The study's primary endpoints were significant bilirubin level decrease and survival rates. Secondary endpoints included periprocedural major and minor complication rates and catheter primary and secondary patency rates.

RESULTS

PTBD was technically successful and bile ducts were successfully drained in all 108 patients. Median serum bilirubin level, which was 282 (171-376) µmol/l before drainage, decreased significantly, to 80 (56-144) µmol/l, 15 days after stent placement (p < 0.001). Patient survival ranged from 3 to 597 days and the overall (median) survival time following PTBD was 168 days (90-302). The 1, 3, 6, 12 and 18-month survival rates were 96.3%, 75.9%, 48.1%, 8.3% and 1.9%, respectively. Multivariate analysis revealed that liver metastases and alkaline phosphatase were significantly associated with mortality. The overall complication rate was 9.3%.

CONCLUSIONS

PTBD is a safe and effective method to relieve jaundice caused by advanced inoperable malignant disease. Careful patient selection is necessary when introducing PTBD in order to avoid invasive procedures in patients with a poor prognosis.

Superiority of Self-Expandable Metallic Stents Over Plastic Stents in Treatment of Malignant Distal Biliary Strictures

BACKGROUND & AIMS

Treatment of malignant biliary strictures with endoscopic retrograde cholangiopancreatography (ERCP) guided stent placement is highly effective. Our objective was to compare the efficacy and adverse outcomes between plastic stents (PS) and self-expandable metallic stents (SEMS).

METHODS

A cohort study was performed of all consecutive patients who underwent ERCP with stent placement for the management of malignant biliary stricture. Comparisons on clinical success, patency duration, stent dysfunction, unplanned reintervention and adverse outcomes were performed. Univariate and multivariable analyses were performed to identify factors associated with clinical success, need for reintervention, and stent dysfunction.

RESULTS

From 2012 to 2019, 1139 patients underwent ERCP with PS placement while 1008 patients received SEMS for the management of malignant biliary stricture. In distal strictures, SEMS reported a significantly higher rate of clinical success compared with PS (94.1% vs 87.4%, P < 0.001) and a lower rate of unplanned reintervention (17.1% vs 27.4%, P < 0.001). In hilar strictures, the rates of clinical success and unplanned intervention were comparable. The patency duration and time to unplanned reintervention were significantly longer with SEMS than PS, irrespective of stricture location. In distal stricture, PS was associated with a significantly higher rate of cholangitis than SEMS (6.9% vs 2.4%; P < .001) but a lower rate of pancreatitis (3.6% vs 6%; P = 0.021).

CONCLUSION

Given superior efficacy, durability and lower rates of cholangitis, SEMS should be offered as the first line endoscopic treatment option for malignant distal biliary stricture. For malignant hilar stricture, SEMS is an attractive alternative to PS in some cases by offering a comparable efficacy with a superior durability.

Percutaneous biliary stent combined with brachytherapy using 125I seeds for treatment of unresectable malignant obstructive jaundice: A meta-analysis

BACKGROUND

Malignant obstructive jaundice (MOJ) is a common pathologic manifestation of malignant biliary obstruction. Recently, several clinical trials have explored the clinical effectiveness of intraluminal ¹²⁵I seed-based brachytherapy for MOJ patients, and various outcomes have been reported.

AIM

To assess the efficacy and safety of percutaneous biliary stents with ¹²⁵I seeds compared to conventional metal stents in patients with unresectable MOJ.

METHODS

A systematic search of English-language databases (PubMed, Embase, Cochrane Library, and Web of Science) was performed to identify studies published prior to June 2020 that compared stents with or without ¹²⁵I seeds in the treatment of unresectable MOJ. The outcomes analyzed included primary outcomes (stent patency and overall survival) and secondary outcomes (complications and liver function parameters).

RESULTS

Six randomized controlled trials and four retrospective studies involving 875 patients were eligible for the analysis. Of the 875 included patients, 404 were treated with ¹²⁵I seed stents, while 471 were treated with conventional stents. Unadjusted pooled analysis demonstrated that compared to conventional stents, ¹²⁵I seed stents extended the stent patency time [hazard ratio (HR) = 0.36, 95% confidence interval (CI) = 0.28-0.45, P < 0.0001] and overall survival period (HR = 0.52, 95%CI = 0.42–0.64, P < 0.00001). Subgroup analyses based on the type of ¹²⁵I seed stent and type of study design showed consistent results. However, there were no significant differences in the occurrence of total complications [odds ratio (OR) = 1.12, 95%CI = 0.75-1.67, P = 0.57], hemobilia (OR = 1.02, 95%CI = 0.45-2.3, P = 0.96), pancreatitis (OR = 1.79, 95%CI = 0.42-7.53, P = 0.43), cholangitis (OR = 1.13, 95%CI = 0.60-2.13, P = 0.71), or pain (OR = 0.67, 95%CI = 0.22-2, P = 0.47). In addition, there were no reductions in the levels of serum indices, including total bilirubin [mean difference (MD) = 10.96, 95%CI = -3.56-25.49, P = 0.14], direct bilirubin (MD = 7.37, 95%CI = -9.76-24.5, P = 0.4), alanine aminotransferase (MD = 7.52, 95%CI = -0.71-15.74, P = 0.07), and aspartate aminotransferase (MD = -4.77, 95%CI = -19.98-10.44, P = 0.54), after treatment. Publication bias was detected regarding the outcome overall survival; however, the conclusions were not changed after the adjustment.

CONCLUSION

Placement of stents combined with brachytherapy using ¹²⁵I seeds contributes to a longer stent patency and higher overall survival than placement of conventional stents without extra complications or severe liver damage. Thus, it can be considered an effective and safe treatment for unresectable MOJ.

Palliative Biliary Drainage Has No Effect on Survival in Pancreatic Cancer: Medical Oncology Perspective

PURPOSE

Removal of obstructive jaundice in metastatic pancreatic cancer is an important part of palliative therapy. However, it is not known whether invasive procedures reduce cancer-related mortality. In this study, the effect of palliative biliary drainage on survival outcomes in pancreatic cancer patients was evaluated.

METHODS

Patients diagnosed with pancreatic cancer and undergoing biliary drainage in two different centers between 2010 and 2019 were evaluated retrospectively.

RESULTS

Biliary drainage was applied to 73 patients, constituting 20.6% of 355 patients included in the study. The median progression-free survival (PFS) of patients with biliary stent was 5 months, while the median PFS of patients without stenting was 5.5 months and the median overall survival (OS) was 11.1 and 11.5 months, respectively (p: 0.424, p: 0.802).

CONCLUSIONS

A positive effect of palliative biliary drainage on median PFS and OS could not be demonstrated in our study group. In pancreatic cancer, predictive markers are needed to select patients who can derive a survival benefit from biliary drainage.

Survival benefit of percutaneous transhepatic biliary drainage for malignant biliary tract obstruction-a prospective study comparing external and internal drainage techniques

PURPOSE

To evaluate the clinical results of percutaneous transhepatic biliary drainage (PTBD) in patients with non-operable malignant biliary tract obstruction (MBTO) and the survival benefit of internal drainage.

METHODS

Prospective data of consecutive patients of PTBD from May 2014 to August 2017 was analyzed for 30-day, 90-day and 1-year mortality, and mean survival of patients undergoing external drainage (ED) and internal drainage (ID) using internal-external ring biliary catheterization or biliary stent were compared. Other important variables evaluated were drop in the total bilirubin (TBil) levels, improvement in pain and pruritus, procedure-related complications, and patient satisfaction.

RESULTS

In 87 cases (54 male, 33 female) with mean age 37.3 y (22-70 y; 95% CI: 31.1 y-43.5 y), 10, 45 and 32 patients underwent stenting, external and internal-external catheterization, respectively (total 152 procedures [> 1 in 35.63%, n = 31]). PTBD resulted in decrease in mean TBil by 8.2738 ± 0.912 mg/dL at 30 days (P < 0.001), 55.14% (n = 48) cases reaching 3 mg/dL at mean 45 days, and 35/48 cases received chemotherapy. Overall mortality was 6.89%, 37.93% and 90.80% at 30 days, 90 days and 1 year, respectively. Mean survival with ID (236.40 ± 33.37 days) was better than with ED (110.35 ± 26.16 days) (P < 0.001). Pain (62.06%; n = 54; mean Visual Analog Scale [VAS] score = 6.7) improved significantly (mean VAS score 3.4; P < 0.001). Pruritus (n = 29) was relieved in 100% of the cases. Complication rate of 18.39% (n = 16) and no procedure-related death were seen.

CONCLUSION

PTBD offers a safe and significant improvement in TBil, pain, and pruritus in non-operable MBTO, with ID offering additional survival benefit over ED.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Percutaneous Image-Guided Biliary Procedures

Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.

Clinical outcomes of biliary drainage of malignant biliary obstruction due to colorectal cancer metastases: A systematic review

BACKGROUND AND AIMS

Malignant biliary obstruction is an ominous complication of metastatic colorectal cancer (mCRC). Biliary drainage is frequently performed to relieve symptoms of jaundice or enable palliative systemic therapy, but effective drainage can be difficult to accomplish. The aim of this study is to summarize literature on clinical outcomes of biliary drainage in mCRC patients with malignant biliary obstruction.

METHODS

We searched Medline and EMBASE for studies that included patients with malignant biliary obstruction secondary to mCRC, treated with endoscopic and/or percutaneous biliary drainage. We summarized available data on technical success, clinical success, adverse events, systemic therapy administration and survival after biliary drainage.

RESULTS

After screening 3584 references and assessing 509 full-text articles, seven cohort studies were included. In these studies, rates of technical success, clinical success and adverse events varied between 63%-94%, 42%-81%, and 19%-39%, respectively. Subsequent chemotherapy was administered in 17%-56% of patients. Overall survival varied between 40 and 122 days across studies (278-365 days in patients who received subsequent chemotherapy, 42-61 days in patients who did not).

CONCLUSIONS

Successful biliary drainage in mCRC patients can be challenging to achieve and is frequently associated with adverse events. Overall survival after biliary drainage is limited, but is significantly longer in patients treated with subsequent systemic therapy. Expected benefits of biliary drainage should be carefully weighed against its risks.

Factors predicting recovery of liver function after percutaneous drainage in malignant biliary obstruction: the role of hospital-acquired biliary sepsis

Aim of the study

Prolonged cholestasis adversely affects liver function. Hepatic functional recovery is mandatory prior to any surgical or medical intervention. Serum bilirubin levels correlate well with, and are a surrogate marker for, hepatocyte function. We aimed to ascertain factors responsible for slow decline of bilirubin and delayed recovery of liver function following percutaneous drainage in malignant biliary obstruction.

Material and methods

Sixty-seven patients with malignant jaundice who underwent percutaneous biliary drainage (PTBD) were followed until they achieved target bilirubin ≤ 3 mg/dl. According to duration, patients were divided into early (≤ 6 weeks, n = 43) and late (> 6 weeks, n = 24) groups. Various clinical, tumour-related and procedure-related factors were analysed for their contribution to delayed recovery with the χ² or t-test. Multi-variate logistic regression analysis was used to predict independent associations.

Results

Gallbladder cancer presenting with type I block was the commonest pathology. Overall demographic, clinical, tumour characteristics and procedural details were comparable between groups. Duration of jaundice (p = 0.026), liver involvement (p = 0.041), baseline total (p = 0.001) and direct bilirubin levels (p < 0.001), positive bile cultures with hospital-acquired bacteria (p = 0.031) were significant factors on univariate analysis. Bacterial growth was significantly greater following repeated biliary manipulations. The commonest organisms were Pseudomonas and Citrobacter spp. Number of re-instrumentations, post-procedural biliary sepsis and native biliary organisms were non-contributory. No factor was significant on multivariate analysis.

Conclusions

Factors directly linked to extent and duration of disease are validated as significant contributors to functional recovery after biliary drainage. Biliary sepsis with hospital-acquired organisms, especially following re-interventions is a significant modifiable risk-factor affecting bilirubin decline.

The efficacy of the combination of percutaneous transhepatic biliary drainage and 125I stranded seeds for malignant bile duct obstruction treatment

Purpose

To investigate the efficacy of percutaneous transhepatic biliary drainage (PTBD) combined with iodine-125 (¹²⁵I) stranded seeds for the treatment of malignant bile duct obstruction (MBO).

Material and methods

A retrospective study was performed on 58 consecutive MBO patients. Twenty patients underwent PTBD combined with ¹²⁵I stranded seeds (group A). Thirty-eight patients underwent percutaneous trans-hepatic biliary drainage (group B). Total bilirubin, direct bilirubin, and indirect bilirubin levels were compared preoperatively, 1-week, 1-month, and 3-months post-operatively. Carbohydrate antigen 19-9 (CA19-9), cancer antigen 125 (CA125), and carcino-embryonic antigen (CEA) levels were compared at preoperative and 3-month post-operative stages. The time free from biliary obstruction and survival times were compared.

Results

The differences in total bilirubin, direct bilirubin, and indirect bilirubin levels between the two groups were not significant preoperatively (p = 0.857, p = 0.719, and p = 0.870), and 1-week post-operatively (p = 0.259, p = 0.395, and p = 0.145). However, 1-month (p = 0.012, p = 0.005, and p = 0.049) and 3-months post-operatively (p < 0.001, p = 0.001, and p = 0.001), group A was lower than group B. Differences in CA19-9, CA125, and CEA levels between the two groups were not significant preoperatively (p = 0.229, p = 0.116, and p = 0.273) and 3-months post-operatively (p = 0.159, p = 0.342, and p = 0.306). The median biliary obstruction free time was 7.0 months for group A and 5.0 months for group B (p < 0.001). The median survival time was 9.0 months for group A and 6.0 months for group B (p = 0.001).

Conclusions

PTBD combined with ¹²⁵I stranded seeds seem to reduce bilirubin levels and prevents biliary obstruction, promoting survival.

Stent placement with iodine-125 seeds strand effectively extends the duration of stent patency and survival in patients with unresectable malignant obstructive jaundice

Background: This study aimed to compare the treatment outcomes and safety between stent placement with or without Iodine-¹²⁵ (¹²⁵I) seeds strand for patients with unresectable malignant obstructive jaundice (MOJ).Methods: A total of 84 patients with unresectable MOJ treated in our hospital were retrospectively included and divided into the stent group (n = 54) undergoing biliary stent placement and the stent + seeds group (n = 30) receiving stent placement with ¹²⁵I seeds strand. The therapeutic outcome, postoperative complications, duration of patient survival and stent patency were compared between groups. Kaplan-Meier survival analysis was performed to compare the duration of patient survival and stent patency between groups. Cox-regression analysis was performed to investigate predictive factors for disease-free survival and overall survival.Results: The stent + seeds group had significantly longer duration of patency (231.57 ± 256.54 vs. 110.37 ± 120.52) and overall survival (310.57 ± 330.54 vs. 173.15 ± 219.40) than the stent group (both p < .05). In addition, Kaplan-Meier survival analysis confirmed that the stent + seeds group had longer duration of patency (log-rank test, p = .001) and higher overall survival rate (log-rank test, p = .020) than the stent group. Furthermore, Cox-regression analysis demonstrated that treatment methods was an independent factor associated with disease-free survival (HR: 0.36, 95% CI: 0.19-0.70; p = .003) and overall survival (HR: 1.01, 95% CI: 1.00-1.01; p < .001).Conclusion: The stent placement with ¹²⁵I seeds strand can significantly improve the primary patency rate and overall survival time in MOJ patients.

Malignant obstructive jaundice: approaches to minimally invasive biliary decompression

Modern approaches to surgical treatment of malignant obstructive jaundice are reviewed in the article. The advantages and disadvantages of various types of minimally invasive biliary decompression are emphasized.

Bare-metal stents across the Vater's ampulla is a safe method for patients with lower bile duct obstruction

This study explored the effect of the implant position of stents across the Vater's ampulla on treatment outcomes in patients with lower bile duct obstruction.In the retrospective study, 41 patients with malignant obstruction of the lower bile duct and obstructive jaundice received percutaneous transhepatic biliary placement of bare-metal stents. Basic demographic data on patients, such as sex, age, and primary diseases, and follow-up data, including postoperative complications and jaundice-free survival, were recorded. The follow-up data on patients with an involved ampulla, patients with an uninvolved ampulla, patients with a stent across the ampulla, and patients with a stent at a site other than the ampulla were compared. Furthermore, prognostic factors for jaundice- free survival were investigated using Cox proportional hazards regression analysis.Among the 41 patients, 38 patients experienced subsiding of jaundice, whereas 3 cases had unsuccessful stent patency. Whether or not the ampulla was involved did not influence the incidence rates of postoperative complications and the jaundice-free survival time. Notably, when stents were placed across the ampulla, the jaundice-free survival time was significantly longer than when stents were placed at sites other than across the ampulla (P < .05). Furthermore, placement of the stent across the ampulla or at other sites was an independent prognostic factor (hazard ratio = 0.154, 95% confidence interval 0.042-0.560, P = .005) for jaundice-free survival of patients.The current study revealed that the implant position of a stent across the ampulla resulted in maintenance of stent patency and prolongation of the jaundice-free survival time.

Prediction of Survival Following Percutaneous Biliary Drainage for Malignant Biliary Obstruction

BACKGROUND AND OBJECTIVES

Percutaneous transhepatic biliary drain is an intervention used to relieve malignant biliary obstruction. This study aims to explore survival after biliary drain insertion, predictive factors of survival and effectiveness to reduce total bilirubin level.

METHODS

We conducted a retrospective analysis of 72 patients who had malignant biliary obstruction and received biliary drain during the time period between March 2005 and February 2015.

RESULTS

Median patients' age was 56 years. 38 (52.7%) were males, 34(47.2%) were females. Median survival post biliary drain insertion was 46 days, 95% C/I (37.92-54.02), range (2-453 days). 1, 3, and 6 month survival rates were 64.7%, 26.5%, and 7.4% respectively. Multivariate analysis by Cox proportional hazards regression model showed the presence of ascites to be significant predictors of survival, other factors analyzed were: total bilirubin, serum creatinine, international normalization ratio, serum albumin, pleural effusion and liver metastasis.

CONCLUSION

Survival after biliary drain insertion can vary from few days to few months. Presence of ascites is an independent predictor of survival after this intervention.

Palliative Locoregional Treatment for Unresectable Nonmetastatic Klatskin Tumor: Percutaneous Transhepatic Biliary Drainage Combined With 3-dimensional Conformal Radiotherapy

PURPOSE

This study aimed to identify the effect of percutaneous transhepatic biliary drainage (PTBD) combined with 3-dimensional conformal radiotherapy (3D-CRT) in comparison with PTBD therapy only on the treatment of unresectable Klatskin tumors (KTs).

MATERIALS AND METHODS

Thirty-seven patients with unresectable KTs were included in the study. Twenty-six patients received PTBD and 3D-CRT successively, whereas the other 11 patients received PTBD only. Changes in the clinical symptoms after the PTBD treatment, the radiotherapy effect, and the survival time were recorded and analyzed.

RESULTS

The clinical symptoms of the 2 groups gradually decreased after the PTBD treatment. The radiotherapy effect showed an overall effective rate (complete response+partial response) of 17 (65.38%), and the serum carbohydrate antigen-19-9 levels before and after 3D-CRT were significantly different (P<0.001). The mean survival time of the PTBD group was 11.27 months; the 1- and 2-year cumulative survival rates were 36.4% and 9.1%, respectively. The mean survival time of the combined therapy group was 22.77 months; the 1-, 2-, and 3-year cumulative survival rates were 53.8%, 38.5%, and 11.5%, respectively. The log-rank test showed that the patients who received combined therapy had longer survival time than the patients who only received PTBD (P=0.001).

CONCLUSIONS

Patients with unresectable KTs who underwent PTBD could relieve biliary obstruction effectively. Although this study is not a randomized trial, 3D-CRT combined with PTBD seems to be a promising and an effective method as a palliative treatment for unresectable KTs.

Efficacy and safety of B-mode ultrasound-guided percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy for acute cholecystitis in elderly and high-risk patients

Background

Standards in treatment of acute cholecystitis (AC) in the elderly and high-risk patients has not been established. Our study evaluated the efficacy and safety of B-mode ultrasound-guided percutaneous transhepatic gallbladder drainage (PTGD) in combination with laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) in elderly and high-risk patients.

Methods

Our study enrolled 35 elderly and high-risk AC patients, hospitalized between January 2010 and April 2014 at the Wenzhou People's Hospital. The patients underwent B-mode ultrasound-guided PTGD and LC (PTGD + LC group). As controls, a separate group of 35 elderly and high-risk AC patients who underwent LC alone (LC group) during the same period at the same hospital were randomly selected from a pool of 186 such cases. The volume of bleeding, surgery time, postoperative length of stay, conversion rate to laparotomy and complication rates (bile leakage, bleeding, incisional hernia, incision infection, pulmonary infarction and respiratory failure) were recorded for each patient in the two groups.

Results

All patients in the PTGD + LC group successfully underwent PTGD. In the PTGD + LC group, abdominal pain in patients was relieved and leukocyte count, alkaline phosphatase level, total bilirubin and carbohydrate antigen 19-9 (CA19-9) decreased to normal range, and alanine aminotransferase and aspartate aminotransferase levels improved significantly within 72 h after treatment. All patients in the PTGD + LC group underwent LC within 6–10 weeks after PTGD. Our study revealed that PTGD + LC showed a significantly higher efficacy and safety compared to LC alone in AC treatment, as measured by the following parameters: duration of operation, postoperative length of hospital stay, volume of bleeding, conversion rate to laparotomy and complication rate (operation time of LC: 55.6 ± 23.3 min vs. 91.35 ± 25.1 min; hospitalized period after LC: 3.0 ± 1.3 d vs. 7.0 ± 1.7 d; intraoperative bleeding: 28.7 ± 15.2 ml vs. 60.38 ± 16.4 ml; conversion to laparotomy: 3 cases vs. 10 cases; complication: 3 cases vs. 8 cases; all P < 0.05 ).

Conclusion

Our results suggest that B-mode ultrasound-guided PTGD in combination with LC is superior to LC alone for treatment of AC in elderly and high-risk patients, showing multiple advantages of minimal wounding, accelerated recovery, higher safety and efficacy, and fewer complications.