Stent Patency and Survival after PTBD and Biliary Stenting for Pancreatic Cancer: A 5-Year Retrospective Cohort Study.

Active surveillance as a treatment strategy in metastatic renal cell carcinoma: Results from a prospective registry in Singapore

Percutaneous Self-expandable Metallic Stent Placement for Cancer Recurrence at the Hepaticojejunostomy Site

To determine the safety and efficacy of percutaneous intraductal radiofrequency ablation (RFA) combined with biliary metal stent placement for patients with unresectable malignant biliary obstruction. From a cohort of 70 patients with unresectable malignant biliary obstruction, 28 patients received percutaneous intraductal RFA combined with biliary stent placement (group A) and the remaining 42 were treated with biliary metal stent placement only (group B). Stent patency, overall survival (OS), alleviation of jaundice, and postoperative complications were assessed. The technical success rate for both groups was 100%. No severe complications (e.g., biliary bleeding, perforation) occurred. In both groups, jaundice was relieved and the decrease of the total and direct bilirubin concentration was significant (p < 0.01). The median time of stent patency in group A and group B were 6.6 ± 0.3months (95% CI 6.1-7.1months) and 4.9 ± 0.4months (95% CI 4.2-5.6months), respectively (p < 0.01). The median overall survival times in Group A were 7.2 ± 0.3months (95% CI 6.5-7.9months) versus 5.6 ± 0.4months (95% CI 4.8-6.4months) in group B (p < 0.01). In univariate and multivariate analyses, intraductal RFA, stent patency, and decreased baseline serum direct bilirubin concentration were associated with greater OS (p < 0.05). Percutaneous intraductal RFA combined with stent placement is a safe and effective method for patients with malignant biliary obstruction. As compared to stent placement alone, percutaneous intraductal RFA can significantly prolong stent patency and improve the overall survival of patients with malignant biliary obstruction.

BackgroundPatients with unresectable malignant biliary obstruction have limited life expectancy because of limited stent patency and tumor progression. The aim of our study was to retrospectively evaluate the safety and efficacy of combining intraductal RFA with biliary metal stent placement for patients with malignant biliary obstruction.MethodsPatients who received percutaneous intraductal RFA and biliary stent placement for malignant biliary obstruction between 2013 and 2015 were identified. Outcomes were stent patency, technique and clinical success rate, overall survival (OS) and complication rates. Kaplan-Meier and Cox regression analyses were used to examine the association of various factors with stent patency and OS. Complications and laboratory abnormalities were recorded.ResultsFifty patients were treated with percutaneous RFA and stent placement. The rates of technical success and clinical success were 98% and 92%, respectively. The median stent patency was 7.0 (95% confidence interval [CI]: 5.3, 8.7) months and OS was 5.0 (95% CI: 4.0, 6.0) months. On univariable analysis, previously cholangitis was an independent poor prognosis factor for recurrent biliary obstruction. OS was improved in patients who received more than one intervention compared to those who received only one intervention (log-rank P = 0.007), and in those treated without versus those treated with sequential chemotherapy (log-rank P = 0.017). On multivariable analysis, the occurrence of more than one intervention (P = 0.019) had independent prognostic significance for OS.ConclusionPercutaneous RFA and stent placement is a technically safe and feasible therapeutic option for the palliative treatment of malignant biliary obstruction. The long-term efficacy and safety of the procedure is promising, but further study is required via randomized and prospective trials.

Metal stents for distal biliary malignancy: have we got you covered?

To investigate the technical and clinical efficacy of the percutaneous insertion of a biliary metallic stent, and to identify the factors associated with biliary stent dysfunction in patients with malignant duodenobiliary obstruction. The medical records of 70 patients (39 men and 31 women; mean age, 63 years; range, 38-90 years) who were treated for malignant duodenobiliary obstruction at our institution between April 2007 and December 2018, were retrospectively reviewed. Variables found significant by univariate log-rank analysis (p < 0.2) were considered as suitable candidates for a multiple Cox's proportional hazard model. The biliary stents were successfully placed in all 70 study patients. Biliary stent insertion with subsequent duodenal stent insertion was performed in 33 patients and duodenal stent insertion with subsequent biliary stent insertion was performed in the other 37 study subjects. The median patient survival and stent patency time were 107 days (95% confidence interval [CI], 78-135 days) and 270 days (95% CI, 95-444 days), respectively. Biliary stent dysfunction was observed in 24 (34.3%) cases. Multiple Cox's proportional hazard analysis revealed that the location of the distal biliary stent was the only independent factor affecting biliary stent patency (hazard ratio, 3.771; 95% CI, 1.157-12.283). The median biliary stent patency was significantly longer in patients in whom the distal end of the biliary stent was beyond the distal end of the duodenal stent (median, 327 days; 95% CI, 249-450 days), rather than within the duodenal stent (median, 170 days; 95% CI, 115-225 days). The percutaneous insertion of the biliary metallic stent appears to be a technically feasible, safe, and effective method of treating malignant duodenobiliary obstruction. In addition, a biliary stent system with a distal end located beyond the distal end of the duodenal stent will contribute towards longer stent patency in these patients.

ObjectivesTo evaluate the role of sequential therapy with percutaneous biliary stenting and CT-guided iodine-125 seed implantation for locally advanced pancreatic carcinoma with concomitant obstructive jaundice.MethodsBetween January 2016 and December 2018, 42 patients diagnosed with locally advanced pancreatic carcinoma with concomitant obstructive jaundice were enrolled retrospectively. All patients received biliary stenting via percutaneous transhepatic biliary drainage (PTBD) to alleviate obstructive jaundice. Thereafter, twenty-two patients underwent CT-guided iodine-125 seed implantation (treatment group), and 20 did not (control group). The prescribed dose in the treatment group was 110–130 Gy. The clinical data, duration of biliary stent patency, and overall survival (OS) were evaluated.ResultsOverall, the total bilirubin level decreased from 275.89 ± 115.44 to 43.08 ± 43.35 μmol/L (p < 0.001) 1 month after percutaneous biliary stenting. In the treatment group, the postoperative median dose covering 90% of the target volume was 129.71 Gy. Compared with the control group, the treatment group had a long mean duration of biliary stent patency and median OS (11.42 vs. 8.57 months, p < 0.01; 11.67 vs. 9.40 months, p < 0.01, respectively). The overall positive response rates 6 months post-treatment in the treatment and control groups were 72.7% (16/22) and 30% (6/20), respectively. Adverse events of more than grade 3 were not observed during the follow-up.ConclusionSequential therapy with percutaneous biliary stenting and CT-guided iodine-125 seed implantation is an effective and safe treatment alternative for locally advanced pancreatic carcinoma with concomitant obstructive jaundice, which is worthy of clinical application.Key Points• Obstructive jaundice was alleviated after biliary stent placement in all patients, and the total bilirubin level decreased.• The overall positive response rates at 6 months post-treatment were higher in the treatment group than in the control group, and adverse events of more than grade 3 were not observed during the follow-up period.• Sequential therapy with percutaneous biliary stenting and CT-guided iodine-125 seed implantation can prolong biliary stent patency and improve survival.

Management of occluded self-expanding biliary metal stents in malignant biliary disease

Palliation of malignant extrahepatic biliary obstruction with plastic versus expandable metal stents: an evidence-based approach

ABSTRACTObjectivesEndoscopic duodenal stent (DS) placement has become a primary palliative approach for malignant gastric outlet obstruction (MGOO), offering minimally invasive symptom relief. However, complications and risk factors for stent dysfunction and prognostic indicators of survival are not fully elucidated.MethodsWe retrospectively analyzed 114 patients who underwent initial DS placement for MGOO at Kyushu University Hospital between January 2010 and October 2024. Clinical outcomes, stent patency, and survival predictors were analyzed. The primary endpoint was stent patency; overall survival (OS) was a secondary endpoint.ResultsPancreatic cancer was the most common underlying malignancy (77.2%). Technical and clinical success rates were 99.1% and 84.1%, respectively; the overall clinical success rate reached 91.2% after additional stenting in initially unsuccessful cases. Adverse events occurred in 12.3% of patients. Among 104 patients with overall clinical success, 18 patients (17.3%) experienced stent dysfunction. Median stent patency and OS were 14.8 and 2.8 months, respectively. Pre‐existing biliary stricture and stent placement across the pylorus were significantly associated with reduced stent patency. High neutrophil‐to‐lymphocyte ratio predicted poorer survival, whereas type III stenosis and post‐stenting chemotherapy were linked to improved survival. No significant differences in outcomes were observed between early and late treatment periods. Reintervention with DS was safe and effective, and 93.3% of patients maintained GOO control with DS alone.ConclusionsDuodenal stenting is a safe and effective palliative intervention for MGOO. Incorporating inflammation‐based biomarkers and individualized treatment strategies can help optimize patient selection and improve survival outcomes.

Comparative Study of Percutaneous Transhepatic Biliary Stent Placement with or without Iodine-125 Seeds for Treating Patients with Malignant Biliary Obstruction

To investigate the technical feasibility, safety, and efficacy of a long-covered biliary stent in patients with malignant duodenobiliary stricture. This retrospective study enrolled 57 consecutive patients (34 men, 23 women; mean age, 64years; range, 32-85years) who presented with malignant duodenobiliary stricture between February 2019 and November 2020. All patients were treated with a long (18 or 23cm)-covered biliary stent. The biliary stent deployment was technically successful in all 57 patients. The overall adverse event rate was 17.5% (10 of 57 patients). Successful internal drainage was achieved in 55 (96.5%) of 57 patients. The median patient survival and stent patency times were 99days (95% confidence interval [CI], 58-140days) and 73days (95% CI, 60-86days), respectively. Fourteen (25.5%) of the fifty-five patients presented with biliary stent dysfunction due to sludge (n = 11), tumor overgrowth (n = 1), collapse of the long biliary stent by a subsequently inserted additional duodenal stent (n = 1), or rapidly progressed duodenal cancer (n = 1). A univariate Cox proportional hazards model did not reveal any independent predictor of biliary stent patency. Percutaneous insertion of a subsequent biliary stent was technically feasible after duodenal stent insertion. Percutaneous insertion of a long-covered biliary stent was safe and effective in patients with malignant duodenobiliary stricture. In patients with malignant duodenobiliary stricture, percutaneous insertion of a long-covered biliary stent was safe and effective regardless of duodenal stent placement. • Percutaneous insertion of long-covered biliary stents in patients with malignant duodenobiliary stricture is a safe and effective procedure. • Biliary stent deployment was technically successful in all 57 patients and successful internal drainage was achieved in 55 (96.5%) of 57 patients. • The median patient survival and stent patency times were 99days and 73days, respectively, after placement of a long-covered biliary stent in patients with duodenobiliary stricture.

Complex colovesicular fistula: A severe complication caused by biliary stent migration

To estimate the safety and efficacy of percutaneous ePTFE-covered biliary stent placement and the relationship between underlying liver function and stent patency in patients with malignant hilar obstruction. From March 2012 to June 2015, 41 patients [22 females, 19 males; mean age 69.8 (range 34-94) years] with malignant biliary obstruction underwent percutaneous biliary stent placement (31 patients with unilateral, 10 patients with bilateral side-by-side). Cumulative patient survival and stent patency rate curves were derived using the Kaplan-Meier method. A Cox model was used to explore the relationship between liver function and patient survival, and also biliary stent patency. Pearson correlation coefficient was used to analyze the relationship between patient survival and stent patency. Technical success rate was 100% and clinical success rate was 95%. During follow-up, four complications occurred (two bilomas and two cases of acute cholecystitis) and were treated successfully with percutaneous drainage. No other complication occurred. Mean serum bilirubin level was 11.34±7.35mg/dL before drainage and 5.00±4.83mg/dL 2 weeks after stent placement. The median patent survival duration was 147days (95% CI, 69.6-224.4days). The median stent patency duration was 101days (95% CI, 70.0-132.0days). The cumulative stent patency rates at 1, 3, 6, and 12months were 97, 57.6, 30.3, and 17.0%, respectively. Child-Pugh score was correlated significantly with patient survival (P=0.011) and stent patency (P=0.007). MELD score was correlated significantly with stent patency (P=0.044). There was a correlation between patient survival and stent patency (r=0.778, P<0.001). Percutaneous placement of ePTFE-covered biliary stent was a safe and an effective method for malignant biliary obstruction. Underlying liver function seemed to be one of the important factors affecting patient survival and stent patency, and stent patency showed statistically significant correlation with patient survival.

Springer 2011 We read with a great interest the article by Kawakami et al. [1] about the best preoperative biliary drainage methods in the management of patients with hilar cholangiocarcinoma (HCA). The authors compared the outcomes of endoscopic nasobiliary drainage (ENBD), endoscopic biliary stenting (EBS) and percutaneous transhepatic biliary drainage (PTBD) in a total of 128 patients. They noted that drainage tube occlusions with cholangitis were more common in the EBS group. They also found that the patients in the PTBD group experienced serious complications including portal vein injury (8%) and cancer dissemination (4%). Finally, they concluded that the ENBD procedure is the best and most suitable method for the initial biliary decompressive approach for the patients with HCA before the resective surgery procedure. Although the retrospective design of this study was already noted to be a limitation, we want to underline some concerns with the results of this study. Indeed, portal vein injury during ultrasound guided PTBD is a very rare occurrence [2]. However, in this report, we noticed a high rate of vascular injury associated with PTBD procedure. The authors did not link this high rate of portal vein injury during PTBD with any explanation in the text. However, we suggest that this complication can be associated with the use of 12–16 Fr tubes which were used for transhepatic cholangioscopy in this study. We think that the authors can provide data about this to make it more clear for the readers. The other flaw with the PTBD procedure is the high rate of tube dislodgement (14%) in this series of the patients. Again, we do not see this rate of tube dislodgement in our daily practice since we use a locked catheter system during internal–external drainage catheter placement to prevent the easy tube dislodgment problem. If the physicians doing the PTBD procedure in this study did not use this system, or they placed mostly external biliary drainage catheters, this might explain this high rate of catheter dislodgement. Thus, we wonder in how many cases they put external and internal catheters during the PTBD procedure. Another unclear point in this study is about their cases with cancer dissemination after the PTBD procedure. The authors indicated cancer dissemination in three patients (6.3%) in association with the PTBD. Although, the cholangiocarcinomas are highly fibrotic tumors with desmoplastic stroma, there is a potential risk of catheter tract implantation [3]. Catheter tract implantation metastasis after PTBD usually presents as subcutaneous nodules. However, it is not clearly indicated in the text how the authors diagnosed and linked cancer dissemination in these cases in association with the PTBD procedure.