Drainage For Malignant Biliary Obstruction Research Articles

Sa1470 Does Endosonography-Guided Biliary Drainage Replace Percutaneous Transhepatic Biliary Drainage for Malignant Biliary Obstruction After Failed ERCP?

Although endoscopic ultrasound-guided biliary drainage (EUS-BD) may be a useful alternative method of biliary drainage in patients with failed endoscopic transpapillary biliary drainage, there are limited data on the outcomes and complications of EUS-BD. We compared the efficacy and the safety of EUS-BD to percutaneous transhepatic biliary drainage (PTBD) after failed ERCP in patients with malignant biliary obstruction.

One-step Placement of a Fully-covered Metal Stent in Endosonography-guided Biliary Drainage for Malignant Biliary Obstruction

Although reports on endosonography-guided biliary drainage (ESBD) have been increasing, only a few discuss deployment of a self-expandable metal stent (SEMS) in the first session. To evaluate the safety and efficacy of ESBD with the one-step placement of a newly designed fully-covered SEMS. Five patients with malignant biliary obstruction in whom one-step placement of an anti-migration designed SEMS in the first session of ESBD had been attempted between January 2007 and October 2009 were included in this study. Main outcome measurements were technical and clinical successes, early complications, and short-term results. ESBD was attempted to bridge the extrahepatic bile duct and the duodenum and one-step SEMS placement was successful in all cases. There were no early complications related to ESBD and excellent biliary decompression was obtained in all cases. SEMS dysfunction such as stent migration and occlusion was not seen during the follow-up period (mean follow-up 138 days, range 102-184 days). One-step placement of a fully-covered SEMS in ESBD is possibly a safe and effective treatment for biliary obstruction.

Internal‐external percutaneous transhepatic biliary drainage for malignant biliary obstruction: a retrospective analysis

When percutaneous transhepatic biliary drainage (PTBD) is required for the management of malignant biliary obstruction, the local policy favours the use of internal-external drains. Regular planned drain exchanges are scheduled, and patients have open access back into the system to minimise complications. The aim of this study was to evaluate the success and complication rate of this method for the palliation of malignant biliary obstruction. The hospital records of 43 consecutive patients who underwent PTBD for malignant biliary obstruction at a single institution between 1 February 2004 and 31 January 2006 were reviewed. Outcomes were examined until January 2008. Biliary decompression was achieved in all 43 patients. The level of obstruction was defined as distal in 24 patients and perihilar in 19 patients. There was one procedure-related death. There were 91 routine outpatient drain exchanges performed at a median interval of 45 (range 21-64) days. Overall, 24/43 patients encountered 80 discrete complications related to biliary drainage. Fifty-two non-scheduled drain exchanges (accounting for 65% of all complications) were performed on an outpatient basis. Fourteen patients were readmitted on a median of one (range 1-3) occasion for a median duration of 3 (range 1-12) days. Median survival was 71 (range 7-850) days. PTBD can be performed with low mortality, but long-term morbidity remains high despite an aggressive approach to maintaining biliary patency. Providing patients with an open-access service means the majority of complications can be dealt with on an outpatient basis.

Prospective Study of Outcomes after Percutaneous Biliary Drainage for Malignant Biliary Obstruction

Percutaneous biliary drainage (PBD) is used to relieve malignant bile duct obstruction (MBO) when endoscopic drainage is not feasible. Little is known about the effects of PBD on the quality of life (QoL) in patients with MBO. The aim of this study was to evaluate changes in QoL and pruritus after PBD and to explore the variables that impact these changes. Eligible patients reported their QoL and pruritus before and after PBD using the Functional Assessment of Cancer Therapy-Hepatobiliary instrument (FACT-HS) and the Visual Analog Scale for Pruritus (VASP). Instruments were completed preprocedure and at 1 and 4 weeks following PBD. A total of 109 (60 male/49 female) patients enrolled; 102 (94%) had unresectable disease. PBD was technically successful (hepatic ducts cannulated at the conclusion of procedure) in all patients. There were 2 procedure-related deaths. All-cause mortality was 10% (N = 11) at 4 weeks and 28% (N = 31) at 8 weeks post-PBD with a median survival of 4.74 months. The mean FACT-HS scores declined significantly (P < .01) over time (101.3, 94.8, 94.7 at baseline, 1 week, 4 weeks, respectively). The VASP scores showed significant improvement at 1 week with continued improvement at 4 weeks (P < .01). PBD improves pruritus but not QoL in patients with MBO and advanced malignancy. There is high early mortality in this population.

Preoperative biliary drainage in malignant obstruction: Indications, techniques, and the debate over risk

In patients with malignant biliary obstruction considered suitable for surgical resection, preoperative drainage might be expected to improve surgical outcomes by restoring liver function and improving nutritional status. In practice, however, the benefits of preoperative drainage are far from clear. Studies to date have reported differing outcomes, and some have suggested that morbidity and mortality are greater in patients undergoing drainage than in those proceeding directly to surgery. The development of clinical guidelines has been limited by the lack of convincing randomized data, which in turn has led to variations in practice. This article examines the arguments for and against preoperative biliary drainage, the conflicting data on the subject, and the techniques used.

Initial and long-term outcome after palliative surgical drainage of 269 patients with malignant biliary obstruction

Aims This study aimed to analyse the current outcome after palliative surgical drainage of malignant biliary obstruction. Method From 1992 to 2003, perioperative parameters and the incidence and indications of readmissions were analysed in 269 patients who underwent a palliative biliary bypass for periampullary carcinoma. Results Hospital mortality occurred in seven patients and median postoperative stay was 10 days. Anastomotic leakage occurred in three patients and intraabdominal haemorrhage in eight patients. Overall 75 patients experienced a complication. Nine patients underwent a relaparotomy during initial hospital admission. Overall, 142 patients were readmitted, 13 for indications related to the biliary bypass, 11 for surgery-related indications. Twenty-five patients were readmitted for radiochemotherapy, 112 for progressive disease and 23 for indications not related to the disease. Median survival was 7.5 months and the 3-year survival 3%. Survival was significantly lower in patients with metastases and in those who underwent elective bypass for gastric outlet obstruction. Conclusion Current hospital mortality after palliative biliary bypass as well as readmission rates for complications related to the biliary bypass or surgical procedure are low. Surgical biliary bypass is a safe and effective palliative treatment for patients with malignant biliary obstruction.

Biliary endoscopy

The literature this year contained a number of articles reviewing the different methods of biliary drainage for malignant obstruction, highlighting approaches to unilateral drainage, and stressing the risks of incomplete drainage after contrast injection. A number of articles addressed issues surrounding the differentiation of benign and malignant biliary strictures.

Reply to Dr. Mosca

We are pleased by Dr. Mosca’s interest in our paper on a prospective multicenter evaluation of the Diamond stent for drainage of malignant biliary obstruction [1].

4652 The effectiveness of preoperative drainage for malignant biliary obstruction.

Background :Malignant biliary obstruction carries a very poor prognosis. Preoperative biliary drainage provides a better surgical condition, but some reports show various adverse effects of this procedure.We evaluated the effectiveness of preoperative drainage with the assessment of several factors which might influence clinical outcome. Methods :Forty-four patients with malignant biliary obstruction who underwent Whipple's operation from January, 1996 to March, 1999 were analyzed. The patients were divided into 3 groups: no drainage, PTBD and ENBD groups.We analyzed patient chracteristics, laboratory findings, operating factors, hospital courses and complications. Statistical evaluation was performed using Kruskal-Wallis one-way ANOVA test and Mann-Whitney U-Wilcoxon Rank Sum W test by SPSS programe. Results :There were no differences of basic characteristics, initial or preoperative laboratory data, tumor size and invasiveness. Significant difference couldn't be found between complications, operating factors and hospital courses, however, the duration of jaundice in PTBD group were longer than in ENBD group. The drain itself was well functioning because there was no difference of preoperative bilirubin. To divide the patients according to initial bilirubin >or ≤9.0 mg/dl, there was also no difference of hospital courses and operating factors except day of jaundice, initial bilirubin and alkaine phosphatase expressed a biliary obstructive data. Conclusion :The preoperative biliary drainage in malignant biliary obstruction did not affect postoperative complications, operative difficulty and hospital courses. Careful patient selection could be recommended.

Bacteribilia and cholangitis after percutaneous transhepatic biliary drainage for malignant biliary obstruction.

Cholangitis often develops after percutaneous transhepatic biliary drainage (PTBD) for malignancy. The aims of this retrospective study were to clarify whether or not bacteribilia and cholangitis increase with time after PTBD and to define the pathogenesis of bacteribilia and cholangitis after PTBD. One hundred twenty-eight patients underwent PTBD for malignancy. Both the cumulative incidences of bacteribilia (77%) and cholangitis (28%) showed an increase with time after PTBD. In 78% of patients with bacteribilia, bacteria from intestinal flora were detected in bile. Catheter malfunction (N = 17) or the presence of undrained bile ducts (N = 7) induced cholangitis. Proximal obstruction, because it often accompanied undrained ducts, had higher incidences of bacteribilia (P = 0.04) and cholangitis (P < 0.0001) than did distal obstruction. In conclusion, bacteribilia and cholangitis increase in incidence with time after PTBD. The primary cause of bacteribilia is the transpapillary reflux of intestinal flora. Catheter malfunction or undrained ducts cause cholangitis, provided underlying bacteribilia is present.

Clinical evaluation of percutaneous transhepatic cholangeal drainage for malignant biliary obstruction

Clinical evaluation of percutaneous transhepatic cholangeal drainage for malignant biliary obstruction

Percutaneous transhepatic biliary drainage for malignant biliary obstruction: A report of two cases with five year survival

We report two cases of malignant biliary obstruction in whom percutaneous transhepatic biliary drainage has contributed to patient survival of more than 5 years. To our knowledge, this represents the first such case report in the literature. Both patients suffered biliary obstruction from poorly differentiated adenocarcinoma, in all likelihood from the head of the pancreas. Morbidity has been low with only two episodes of significant sepsis and one episode of GI haemorrhage in one patient and both patients were able to enjoy an excellent quality of life. These cases demonstrate that percutaneous biliary drainage has a place not only in the short term palliation of patients with malignant biliary obstruction, but in the long term as well.

Microbiological analysis of sepsis complicating non-surgical biliary drainage in malignant obstruction

Cholangitis with sepsis is a common complication of non-surgical biliary drainage and represents a difficult management problem. Microbiological data for 18 septic episodes in 15 patients following endoscopic biliary drainage (EBD) and 14 septic episodes in 14 patients following percutaneous transhepatic drainage (PTD) were reviewed. In the EBD group, all 18 patient episodes of sepsis had blood cultures and 10 had bile cultures obtained. In total, 17 gram-negative isolates and 5 gram-positive isolates were grown in the EBD sepsis group. All of the 14 PTD patients had bile cultures and 13 had blood cultures. In total, 23 gram-negative isolates and 26 gram-positive isolates were grown in the PTD sepsis group. When PTD cultures were compared with EBD cultures, there were significantly more gram-positive cultures (26 vs. 5) associated with PTD sepsis than EBD sepsis (p less than 0.0005). Analysis of the antibiotic sensitivities revealed that a combination of ticarcillin clavulanate with gentamicin covered 20 of the 22 (91%) EBD organisms and 38 of the 49 (78%) PTD organisms. Based on this data, ticarcillin clavulanate with gentamicin is the therapy of choice for EBD and PTD sepsis at our institution.

Fracture of Biliary Endoprosthesis after Endoscopic Drainage for Malignant Biliary Obstruction. Report of Two Cases

The authors report two cases of fracture of a biliary endoprosthesis inserted endoscopically to treat malignant biliary obstruction. To their knowledge, such a complication has never been reported. In both cases, the fracture was revealed by cholangitis which occurred three and eight months after insertion. Successful treatment was achieved by replacement of the biliary stent.