Drainage For Malignant Biliary Obstruction Research Articles

Is Palliative Percutaneous Drainage for Malignant Biliary Obstruction Useful?

Malignant biliary obstruction is a challenging problem for cancer patients. Here we evaluate predictive factors for survival following percutaneous drainage for malignant biliary obstruction in patients in whom endoscopic drainage was unsuccessful or insufficient. A retrospective register study in a tertiary-level university hospital. A total of 643 cancer patients (317 females and 326 males) with malignant biliary obstruction were treated with percutaneous drainage at our hospital between 1999 and 2016. Their median overall survival rate was 2.6months, with a 95% confidence interval (CI) of 2.2-3.0. Independent factors predicting poor outcome were metastatic cancer, with a hazard ratio (HR) of 2.2 (95% CI 1.8-2.7); Eastern Cooperative Oncology Group performance status (ECOG PS) of 2 (HR 2.3; 95% CI 1.8-2.8); ECOG PS of 3-4 (HR 3.5; 95% CI 2.8-4.4), American Society of Anesthesiologists physical status classification (ASA) of 4 (HR 2.1; 95% CI 1.5-2.9); and bilirubin of ≥60.0µmol/L within 30days post-drainage (HR 1.3; 95% CI 1.1-1.6). During the time periods 1999-2004 and 2005-2010, patients had poorer outcomes (HR 1.4; 95% CI 1.1-1.7 and HR 1.4; 95% CI 1.2-1.8) than during the last period 2011-2016. Patients with cancer who underwent percutaneous biliary drainage for biliary obstruction had a poor median overall survival. The usefulness of biliary drainage, especially in patients with metastatic cancer, poor ECOG PS, and high ASA class, should be critically considered.

A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction.

Background and Objectives:EUS-guided biliary drainage (EUS-BD) was shown to be useful for malignant biliary obstruction (MBO). However, there is lack of consensus on how EUS-BD should be performed.Methods:This was a worldwide multi-institutional survey among members of the International Society of EUS conducted in February 2018. The survey consisted of 10 questions related to the practice of EUS-BD.Results:Forty-six endoscopists of them completed the survey. The majority of endoscopists felt that EUS-BD could replace percutaneous transhepatic biliary drainage after failure of ERCP. Among all EUS-BD methods, the rendezvous stenting technique should be the First choice. Self-expandable metal stents (SEMSs) were recommended by most endoscopists. For EUS-guided hepaticogastrostomy (HGS), superiority of partially-covered SEMS over fully-covered SEMS was not in agreement. 6-Fr cystotomes were recommended for fistula creation. During the HGS approach, longer SEMS (8 or 10 cm) was recommended. During the choledochoduodenostomy approach, 6-cm SEMS was recommended. During the intrahepatic (IH) approach, the IH segment 3 was recommended.Conclusion:This is the first worldwide survey on the practice of EUS-BD for MBO. There were wide variations in practice, and randomized studies are urgently needed to establish the best approach for the management of this condition.

Clinical outcome after biliary drainage for metastatic colorectal cancer: Survival analysis and prognostic factors

IntroductionBiliary obstruction secondary to colorectal cancer liver metastases is associated with a poor prognosis especially when chemotherapy cannot be re-started. The aim of this study was to determine the survival after biliary drainage and the associated prognostic factors. MethodsPatients from two French centers were included retrospectively after first biliary endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography drainage for biliary obstruction secondary to liver metastases of colorectal cancer, occurring during chemotherapy. ResultsThe final analysis included 69 patients. Overall median survival was 115 days. In univariate analysis, a previous liver surgery, technical and functional success of drainage and restarted chemotherapy were significantly associated with an improved survival. Chemotherapy was restarted after a median of 27 days. When drainage was efficient, survival improved from 33 to 262days (p<0.001). In multivariate analysis, significant protective factors for survival included previous a hepatectomy (HR 0.41) and functional success of the drainage (HR 0.29). Predictive factors for death included increased lines of chemotherapy (HR 1.68) and fever before drainage (HR 2.97). ConclusionsThis is the first study concerning the benefits of biliary drainage for malignant biliary obstruction during the course of chemotherapy for colorectal cancer. A successful biliary drainage leads to improved survival and allows achievement of chemotherapy for 70% of patients.

Prediction of Survival Following Percutaneous Biliary Drainage for Malignant Biliary Obstruction.

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. 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. 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. 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.

Endoscopic ultrasound-guided hepaticogastrostomy versus percutaneous transhepatic drainage for malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatography: a retrospective expertise-based study from two centers.

Background:Percutaneous transhepatic biliary drainage (PTBD) is widely performed as a salvage procedure in patients with unresectable malignant obstruction of the common bile duct (CBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) or in case of surgically altered anatomy. Endoscopic ultrasound-guided hepaticogastrostomy (EU-HGS) is a more recently introduced alternative to relieve malignant obstructive jaundice. The aim of this prospective observational study was to compare the outcome, efficacy and adverse events of EU-HGS and PTBD.Methods:From April 2012 to August 2015, consecutive patients with malignant CBD obstruction who underwent EU-HGS or PTBD in two tertiary-care referral centers were included. The primary endpoint was the clinical success rate. Secondary endpoints were technical success, overall survival, procedure-related adverse events, incidence of adverse events, and reintervention rate.Results:A total of 51 patients (EU-HGS, n = 31; PTBD, n = 20) were included. Median survival was 71 days (range 25–75th percentile; 30–95) for the EU-HGS group and 78 days (range 25–75th percentile; 42–108) for the PTBD group (p = 0.99). Technical success was achieved in all patients in both groups. Clinical success was achieved in 25 (86%) of 31 patients in the EU-HGS group and in 15 (83%) of 20 patients in the PTBD group (p = 0.88). There was no difference in adverse events rates between the two groups (EU-HGS: 16%; PTBD: 10%) (p = 0.69). Four deaths within 1 month (two hemorrhagic and two septic) were considered procedure related (two in the EU-HGS group and two in the PTBD group). Overall reintervention rate was significantly lower after EU-HGS (n = 2) than after PTBD (n = 21) (p = 0.0001). Length of hospital stay was shorter after EU-HGS (8 days versus 15 days; p = 0.002).Conclusions:EU-HGS can be an effective and safe mini invasive-procedure alternative to PTBD, with similar success and adverse-event rates, but with lower rates of reintervention and length of hospitalization.

Long-term outcomes and reintervention of endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction: A multicenter retrospective analysis of 96 cases

Background and Objectives:Although EUS-guided biliary drainage (EUS-BD) for malignant biliary obstruction (MBO) is increasingly reported, its long term outcomes are not fully discussed.Methods:Consecutive patients undergoing EUS-BD for unresectable MBO were retrospectively studied. Data on recurrent biliary obstruction (RBO) including re-intervention and other stent-related complications were extracted.Results:Between Aug 2011 and Dec 2016, EUS-BD was performed in 96 patients (82 EUS-HGS and 14 EUS-CDS, 95 covered metal stent [CMS] and 1 plastic stent) at 4 tertiary referral centers. Biliary drainage prior to EUS-BD had been performed in 54%. The major causes of MBO were pancreatic cancer (52%) and biliary tract cancer (28%). Duodenal invasion (64%) and surgically altered anatomy (25%) were two major reasons for EUS-BD. Technical success rate was 98% with two technical failures (1 stent misplacement and 1 failed insertion of CMS delivery). The incidence of RBO was 36% and a median cumulative time to RBO was 6.8 months. The causes of RBO were non-tumor related (hyperplasia 17%, migration 9%, sludge 5%, reflux 2% and kink 2%), other than de novo stricture (2%). Re-intervention was successfully performed via EUS-BD route in 89% (22 stent-in-stent, 5 balloon sweep, 3 stent exchange and 1 additional antegrade stenting). Other re-interventions were 2 conversion to transpapillary stenting, 1 conversion from CDS to HGS and 1 PTBD. The incidence of other complications was 29%.Conclusions:The incidence of RBO necessitating re-interventions was not rare in EUS-BD for MBO but re-intervention via EUS-BD route was technically feasible in most cases.

Percutaneous Drainage of Malignant Biliary Obstruction: Clinical Outcomes

Introduction: Percutaneous transhepatic biliary drain is an intervention used to relieve malignant biliary obstruction. Most of the times, patients are at an advanced stage of cancer and may not live long enough to get benefit from this invasive procedure. Methods: We conducted a retrospective analysis of 72 patients who had malignant biliary obstruction and received percutaneous biliary drain at the interventional radiology department during the time period between March 2005 and February 2015. The analysis included survival rates using Kaplan Meier estimates. Clinical factors associated with short term survival after biliary drain insertion were assessed. After literature review, the following factors were selected for analysis: presence of ascites, pleural effusion, liver metastasis, serum creatinine level, serum bilirubin, international normalized ratio, and serum albumin level. Cox proportional hazards model was used to test for multivariate analysis. Patients were grouped according to their survival: if they lived for one month or more, and if they lived for less than one month. Difference in serum bilirubin before and after the procedure was calculated. Mann-Whitney test was used to compare group 1 and group 2 in terms of differences in serum bilirubin level after biliary drainage. 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). Multivariate analysis by Cox proportional hazards regression model showed presence of ascites to be significant predictor of survival, other factors analyzed did not show statistical significance. Median total bilirubin level before the intervention was 15.01 mg/dl, median total bilirubin level after the intervention was 6.4 mg/dl, P-value Patients who survived less than 30 days (group 1) had statistically significant different total bilirubin level before and after the intervention, 17.5 mg/dl and 6.8 mg/dl respectively, P value < 0.05. Conclusion: Patients who survived more than 30 days (group 2) had statistically significant different total bilirubin level before and after the intervention, 14.5 mg/dl and 5.8 mg/dl respectively, P value <0.05. Mann-Whitney test was used to compare group 1 and group 2 in terms of difference in serum bilirubin level after biliary drainage; no statistically significant difference was found.Table 1: Survival RatesTable 2: Multivariate Survival Analysis of Clinical Factors Using Cox Proportional Hazards ModelFigure 1

Su1337 Biliary Drainage in Malignant Obstruction: A Comparative Study Between EUS-Guided vs Percutaneous Drainage in Patients With Failed ERCP

Su1337 Biliary Drainage in Malignant Obstruction: A Comparative Study Between EUS-Guided vs Percutaneous Drainage in Patients With Failed ERCP

4:21 PMAbstract No. 390 - Outcomes of salvage percutaneous biliary drainage for malignant obstruction after failure of endoscopic stenting

4:21 PMAbstract No. 390 - Outcomes of salvage percutaneous biliary drainage for malignant obstruction after failure of endoscopic stenting

Mo1444 Long Term Outcomes and Reintervention of EUS-Guided Biliary Drainage for Malignant Biliary Obstruction

Mo1444 Long Term Outcomes and Reintervention of EUS-Guided Biliary Drainage for Malignant Biliary Obstruction

Potential application of interventional endoscopic ultrasonography for the treatment of esophageal and gastric varices.

Interventional endoscopic ultrasonography (EUS) has been developed mainly for the treatment of pancreaticobiliary disorders (e.g. cyst drainage for pancreatic pseudocysts, biliary drainage for malignant biliary obstruction, and celiac plexus neurolysis). Recently, the application of interventional EUS has been expanded to a new field, the treatment of gastrointestinal varices. There have been several studies examining this new technique for the treatment of esophageal and gastric varices. In the present review, we have summarized the current status of interventional EUS for the treatment of esophageal and gastric varices (e.g. EUS-guided coil deployment for gastric varices) and clarified the clinical feasibility of this procedure.

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

The present study aimed to investigate the clinical outcomes of percutaneous transhepatic biliary drainage in patients with obstructive jaundice and identify potential predictors of patient survival. Clinical data from 102 patients (66 males and 36 females; median age, 63.50 years; range, 29–84 years) with a mean (± standard deviation) pre-drainage serum bilirubin level of 285.4 (±136.7 μmol/l), were retrospectively studied. Technical and clinical success, complications and survival time were recorded and their relationship with clinical factors, including age, obstruction level, liver metastases, serum bilirubin level and subsequent treatments following drainage, were analyzed by Fisher’s exact test. Patient survival rate and other predictors were analyzed by Kaplan-Meier survival curves and Cox’s proportional hazard model. The technical and clinical success rates were 100 and 76.5%, respectively. The presence of liver metastases was associated with reduced successful drainage. The overall complication rate was 7.8% and the overall median survival time was 185 days [95% confidence interval (CI), 159–211 days]. A log-rank test showed that age (χ2, 4.003; P=0.04), bilirubin levels following procedure (χ2, 5.139; P=0.02) and subsequent therapy (χ2, 15.459; P=0.00) affected survival time. However, Cox’s regression analysis revealed no administration of additional treatments to be a risk factor of survival (odds ratio, 2.323; 95% CI, 1.465–3.685; P=0.000). Percutaneous transhepatic biliary drainage for malignant biliary obstruction was found to be a safe and effective method to relieve jaundice caused by progressive neoplasms. Subsequent radical therapy following drainage, including surgery, chemotherapy and other local treatment types, are likely to increase patient survival.

Multicenter retrospective study of endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction in Japan

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is considered to be an effective salvage procedure for failed endoscopic retrograde cholangiopancreatography in patients with unresectable malignant biliary obstruction. The aim of this retrospective study was to evaluate the efficacy and feasibility of EUS-BD. From November 2006 to May 2012, a total of 64 patients who underwent EUS-BD (44 EUS-guided choledochoduodenostomy [EUS-CDS] and 20 EUS-guided hepaticogastrostomy [EUS-HGS]) at seven tertiary-care referral centers in Japan were included. The primary outcome was the technical success rate, and the secondary outcomes were the incidence of complications, stent dysfunction rate, time to stent dysfunction, and overall survival. The technical success rate for both EUS-CDS and EUS-HGS was 95%. The reasons for technical failure were two failed dilations of the anastomosis in EUS-CDS and one puncture failure in EUS-HGS. The stent dysfunction rate and 3-month dysfunction-free patency rate were 21% and 80% for EUS-CDS and 32% and 51% for EUS-HGS. There were 12 (six in EUS-CDS and six in EUS-HGS) procedure-related complications (19%): five cases of bile leakage (3/2), three stent misplacements (1/2), one pneumoperitoneum (1/0), two cases of bleeding (1/1), one perforation (1/0), and one biloma (0/1). Bile leakage was more frequently observed in patients who underwent plastic stent placement (11%) than in those with covered metal stents (4%). This Japanese multicenter study revealed a high success rate in EUS-BD. However, the complication rate was as high as that in previous series. Covered metal stents may be useful to reduce bile leakage in EUS-BD.

EUS-guided biliary drainage for malignant biliary obstruction in patients with failed ERCP

Background: Most patients with malignant biliary obstruction are diagnosed at an advanced stage. eUS-guided biliary drainage (eBD) may be an alternative to percutaneous transhepatic or surgical drainage for failed access by endoscopic retrograde cholangiopancreatography (eRcp). Objectives: To evaluate the efficacy and safety of eBD in patients with malignant biliary obstruction. Methods: eUS guided biliary drainage was performed using different approaches depending on the site of entry in patients with malignant obstructive jaundice and failed biliary drainage by eRcp. Assessment included clinical outcomes, quality of life improvement laboratory tests before and after drainage and procedure-related complications. Results: From April 2010 to September 2011, a total of 749 therapeutic eRcp was performed and 32 patients were included in this study. eBD was technically successful in 90.6% (29/32) with clinical improvement in all (29/29) of the patients in whom biliary drainage was successful. Three (9.4%) patients had technical failure at eBD. eUS-guided choledochoduodenostomy was the most common drainage procedure (58.6%). Duodenal self-expandable metallic stent was placed in 7 (24.1%) cases. There was a significant decrease in bilirubin levels (p<0.001) and patients had improved quality of life after the procedure (p<0.05). complications occurred in 6 (20.7%) patients and the median survival was 90 days. Conclusion: In patients with malignant biliary obstruction and failed endoscopic drainage with eRcp, eBD may provide a safe and effective alternative for biliary drainage with acceptable complication rates and significant improvement in the quality of survival.

What is the role of endoscopic ultrasound in palliative drainage of malignant biliary obstruction?

ARTIGOS ORIGINAIS _____________ Qualidade da informacao da internet disponivel para pacientes em paginas em portugues ___________________________________________________________ 645Acesso a informacoes de saude na internet: uma questao de saude publica? ______650 Maus-tratos contra a crianca e o adolescente no Estado de Sao Paulo, 2009_______ 659 Obesidade e hipertensao arterial em escolares de Santa Cruz do Sul – RS, Brasil ___ 666 Bone mineral density in postmenopausal women with and without breast cancer ___ 673 Prevalence and factors associated with thoracic alterations in infants born prematurely __________________________________________________ 679 Analise espacial de obitos por acidentes de trânsito, antes e apos a Lei Seca, nas microrregioes do estado de Sao Paulo ___________________________________685 Sobrevida e complicacoes em idosos com doencas neurologicas em nutricao enteral ______________________________________________________691 Infliximab reduces cardiac output in rheumatoid arthritis patients without heart failure ______________________________________________________ 698 Analise dos resultados maternos e fetais dos procedimentos invasivos geneticos fetais: um estudo exploratorio em Hospital Universitario _______________703 Frequencia dos tipos de cefaleia no centro de atendimento terciario do Hospital das Clinicas da Universidade Federal de Minas Gerais __________________ 709ARTIGO DE REVISAO ______________ Influencia das variaveis nutricionais e da obesidade sobre a saude e o metabolismo __ 714EDITORIALConclusao: como exibir a cereja do bolo 633PONTO DE VISTAOs paradoxos da medicina contemporânea 634IMAGEM EM MEDICINAObstrucao duodenal maligna: tratamento endoscopico paliativo utilizando protese metalica autoexpansivel 636Gossypiboma 638DIRETRIZES EM FOCOHernia de disco cervical no adulto: tratamento cirurgico 639ACREDITACAOAtualizacao em perda auditiva: diagnostico radiologico 644

EUS-guided transluminal versus percutaneous transhepatic biliary drainage in malignant biliary obstruction after failed ERCP; an international multicenter controlled study

EUS-guided transluminal versus percutaneous transhepatic biliary drainage in malignant biliary obstruction after failed ERCP; an international multicenter controlled study

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.