Hilar Biliary Obstruction Research Articles

Safety and Efficacy of Percutaneous Intraductal Radiofrequency Ablation Followed by Dual Stent Placement for Malignant Biliary Hilar Obstruction

Safety and Efficacy of Percutaneous Intraductal Radiofrequency Ablation Followed by Dual Stent Placement for Malignant Biliary Hilar Obstruction

Placement of a Newly Designed Y-Configured Bilateral Self-Expanding Metallic Stent for Hilar Biliary Obstruction: A Pilot Study.

Whether unilateral or bilateral drainage should be performed for malignant hilar biliary obstruction remains a matter of debate. Although a Y-stent with a central wide-open mesh facilitates bilateral stent placement, it has its own limitations. This study aims to evaluate the feasibility and efficacy of a newly designed Y-configured bilateral self-expanding metallic stent (SEMS) for the treatment of hilar biliary obstruction. In this retrospective study, 14 consecutive patients with unresectable malignant hilar biliary obstruction (Bismuth type II or higher), who underwent placement of a newly designed Y-configured bilateral SEMS for hilar biliary obstruction from April 2013 to March 2015, were included into this study. Data on technical success, clinical success, stent patency, complications and patient survival were collected. Technical and clinical success was 100 and 92.9%, respectively. Mean serum bilirubin level was significantly decreased 1month after stent placement (P<0.01). Furthermore, two patients (14.3%) had early complications (one patient had severe hemobilia and one patient had cholangitis), and two patients (14.3%) had late complications (one patient had cholangitis and one patient had cholecystitis). During the mean follow-up period of 298days (range 89-465days), six patients (42.9%) developed stent occlusion caused by tumor ingrowth or overgrowth (n=5) and sludge (n=1). Median stent patency and overall survival times were 281days (95% CI 175.9-386.1days) and 381days (95% CI 291.4-470.6days), respectively. The use of the newly designed Y-configured bilateral SEMS is feasible and effective for hilar biliary obstruction using port docking deployment.

Safety and Efficacy of Percutaneous Biliary Covered Stent Placement in Patients with Malignant Biliary Hilar Obstruction; Correlation with Liver Function.

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.

Tu1525 Air Cholangiography in Endoscopic Bilateral Stent-in-Stent Placement of Metallic Stents for Malignant Hilar Biliary Obstruction

Tu1525 Air Cholangiography in Endoscopic Bilateral Stent-in-Stent Placement of Metallic Stents for Malignant Hilar Biliary Obstruction

Reintervention for stent occlusion after bilateral self-expandable metallic stent placement for malignant hilar biliary obstruction.

Endoscopic reintervention for stent occlusions following bilateral self-expandable metallic stent (SEMS) placement for malignant hilar biliary obstruction (MHBO) is challenging, and time to recurrent biliary obstruction (RBO) of the revisionary stent remains unclear. We aimed to clarify a suitable reintervention method for stent occlusions following bilateral SEMS placement for MHBO. Between 2002 and 2014, 52 consecutive patients with MHBO who underwent endoscopic reintervention for stent occlusion after bilateral SEMS placement were enrolled at two university hospitals and one tertiary care referral center. We retrospectively evaluated the technical and functional success rates of the reinterventions, and the time to RBO of the revisionary stents. Technical and functional success rates of the reinterventions were 92% (48/52) and 90% (43/48), respectively. Univariate analysis did not determine any significant predictive factors for technical and functional failures. Median time to RBO of the revisionary stents was 68days. Median time to RBO was significantly longer for revisionary SEMS placement than for plastic stent placement (131days vs 47days, respectively; log-rank test, P=0.005). Revisionary SEMS placement was the only independent factor that was significantly associated with a longer time to RBO of the revisionary stent in the multivariate Cox proportional hazards analysis (hazard ratio 0.37; 95% confidence interval 0.14-0.95; P=0.039). Revisionary SEMS placement is a suitable endoscopic reintervention method for stent occlusion following bilateral SEMS placement from the perspective of time to RBO of the revisionary stent.

Feasibility of the placement of a novel 6-mm diameter threaded fully covered self-expandable metal stent for malignant hilar biliary obstructions (with videos)

Uncovered self-expandable metal stents (USEMSs) are used to treat unresectable malignant hilar biliary obstructions (MHBOs). However, ingrowth is not prevented, and reintervention is often troublesome. A novel 6-mm threaded fully covered self-expandable metal stent (T-FCSEMS) is available that may mitigate these issues. We aimed to clarify the safety and efficacy of T-FCSEMS placement for MHBO. Thirty patients underwent T-FCSEMS placements for MHBOs between 2014 and 2015. T-FCSEMSs were used for initial stenting in 17 patients (initial group) and for reinterventions for USEMS occlusions caused by ingrowth in 13 patients (reintervention group). The technical success rates, times to recurrent biliary obstruction, and the reintervention success rates were evaluated. The technical success rates were 94% (16/17) and 92% (12/13) in the initial group and reintervention group, respectively. Intrahepatic bile duct occlusions caused liver abscesses 8 days and 22 days after T-FCSEMS placements in 2 cases (7%) in the initial group, in which T-FCSEMSs were placed across the intrahepatic bile duct bifurcation. The median times to recurrent biliary obstruction were 210 days in the initial group after bilateral placement and 112 days and 152 days in the reintervention group after bilateral and unilateral placements, respectively. During reintervention, T-FCSEMS removal was successful in all patients in whom it was attempted, and the success rate of endoscopic reintervention was 100% in both groups. T-FCSEMS placement is a promising option for both initial stenting and reintervention for MHBO. However, we should consider the possibility of intrahepatic bile duct occlusion.

Impact of Preoperative Biliary Drainage on Surgical Outcomes in Periampullary and Hilar Malignancy: A Single-Center Experience.

The role of preoperative biliary drainage (PBD) for periampullary and hilar malignancy is still controversial. We retrospectively studied consecutive 144 patients (92 periampullary and 52 hilar malignancy) undergoing surgical resection to evaluate the effects of PBD on surgical outcomes. The rate of PBD was 59% and 56%, and postoperative complications developed in 27% and 19% in periampullary and hilar malignancy, respectively. Risk factors for postoperative complications were overweight [odds ratio (OR), 7.6] and depression (OR, 8.5) in distal malignancy and American society of anesthesiologists score of 3 (OR, 6.6), depression (OR, 13.8), and portal vein embolization (OR, 6.1) in hilar malignancy. PBD was not associated with postoperative complications but reinterventions for PBD were necessary in 43% and 27% in distal and hilar biliary obstruction. In conclusion, PBD in pancreatobiliary surgery was not associated with postoperative complications, but the improvement of PBD is necessary given the high rate of reinterventions.

The right hepatic artery syndrome – a rare cause of biliary obstruction

Various benign and malignant conditions could cause extraluminal biliary obstruction. Compression of extrahepatic bile duct by the anteriorly overriding right hepatic artery was reported as a right hepatic artery syndrome. On the best of our knowledge, only 7 cases of this entity were reported up to date. The authors present a case of the 54-yr male patient with clinical, laboratory, US and CT signs of hilar biliary obstruction, mimicking Klatskin tumor. During the surgery, right hepatic artery syndrome was confirmed by intraoperative cholangiography. Problem was solved by the careful dissection of the right hepatic artery and deliberation of the common bile duct. The patient remains symptom-free with normal clinical and laboratory data more than 5 years months after surgery.

Multiple metallic stents placement for malignant hilar biliary obstruction: Perspective of a radiologist

Multiple metallic stents placement for malignant hilar biliary obstruction: Perspective of a radiologist

Air cholangiography in endoscopic bilateral stent-in-stent placement of metallic stents for malignant hilar biliary obstruction.

Although endoscopic bilateral stent-in-stent (SIS) placement of self-expandable metallic stents (SEMS) is one of the major palliative treatments for unresectable malignant hilar biliary obstruction, post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis can occur frequently due to inadequate drainage, especially after contrast injection into the biliary tree. The aim of this study is to evaluate the efficacy and safety of air cholangiography-assisted stenting. This study included 47 patients with malignant hilar biliary obstruction who underwent endoscopic bilateral SEMS placement using the SIS technique. They were divided into two groups, air (n = 23) or iodine contrast (n = 24) cholangiography. We retrospectively compared comprehensive clinical and laboratory data of both groups. There were no significant differences found between the two groups with respect to technical success (87% versus 87.5%, air versus contrast group, respectively), functional success (95% versus 95.2%), 30-day mortality (8.3% versus 8.7%) and stent patency. Post-ERCP adverse events occurred in 5 (21.7%) of the patients in the air group and 8 (33.3%) of the patients in the contrast group. Among these, the rate of cholangitis was significantly lower in the air group (4.8% versus 29.2%, p = 0.048). In multivariate analysis, air cholangiography, technical success and a shorter procedure time were significantly associated with a lower incidence of post-ERCP cholangitis. Air cholangiography-assisted stenting can be a safe and effective method for endoscopic bilateral SIS placement of SEMS in patients with malignant hilar biliary obstruction.

Malignant Hilar Biliary Obstruction: Treatment by Means of Placement of a Newly Designed Y-Shaped Branched Covered Stent.

To evaluate the technical feasibility and clinical efficacy of placement of a newly designed Y-shaped branched covered stent for palliative treatment of malignant hilar biliary obstruction. From June 2011 to September 2014, 34 consecutive patients with malignant hilar biliary obstruction underwent percutaneous placement of a Y-shaped branched covered stent for palliative treatment. Technical and clinical success, complications, cumulative patient survival, and stent patency were evaluated. Stent placement was technically successful in all patients. All patients showed adequate biliary drainage on the follow-up cholangiogram. Mean serum bilirubin level (10.9 mg/dl) decreased significantly 1 week (5.7 mg/dl) and 1 month (2.6 mg/dl) after stent placement (p < 0.01). Complications associated with the procedure included hemobilia (n = 3) and biloma (n = 1). During the mean follow-up period of 225 (range 12-820) days, nine patients (26.5%) developed stent occlusion caused by tumor overgrowth (n = 8) and sludge (n = 1). Two of them underwent coaxial placement of a second stent with good results. The median survival time was 281 days and median primary stent patency was 337 days. There were no significant differences in the patient survival and stent patency rates in relation to age, sex, or Bismuth type. Percutaneous placement of the Y-shaped branched covered stent seems to be technically feasible and clinically effective for palliative treatment of malignant hilar biliary obstruction.

Endoscopic ultrasound-guided biliary drainage of hilar biliary obstruction.

Only 20-30% of patients with hilar cholangiocarcinoma (CC) are candidates for potentially curative resection. However, even after curative (R0) resection, these patients have a disease recurrence rate of up to 76%. The prognosis of hilar cholangiocarcinoma (CC) is limited by tumor spread along the biliary tree leading to obstructive jaundice, cholangitis, and liver failure. Therefore, palliative biliary drainage may be a major goal for patients with hilar CC. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is an established method for palliation of patients with malignant biliary obstruction. However, there are patients for whom endoscopic stent placement is not possible because of failed biliary cannulation or tumor infiltration that limits transpapillary access. In this situation, percutaneous transhepatic biliary drainage (PTBD) is an alternative method. However, PTBD has a relatively high rate of complications and is frequently associated with patient discomfort related to external drainage. Endoscopic ultrasound-guided biliary drainage has therefore been introduced as an alternative to PTBD in cases of biliary obstruction when ERCP is unsuccessful. In this review, the indications, technical tips, outcomes, and the future role of EUS-guided intrahepatic biliary drainage, such as hepaticogastrostomy or hepaticoduodenostomy, for hilar biliary obstruction will be summarized.

Comparison of accuracy of CT and MRI in the preoperative evaluation of malignant perihilar biliary obstruction

Objective To summarize the imaging features of computed tomography (CT )and magnetic resonance imaging (MRI) combined with multi-technology imaging and compare its effects in the preoperative evaluation of malignant perihilar biliary obstruction. Methods The clinical data of 20 patients receiving CT and MRI who were diagnosed with malignant perihilar biliary obstruction by pathological examination at the Wuxi Second People's Hospital between January 2008 and April 2014 were retrospectively analyzed. Patients receiving CT combined with negative-contrast CT cholangiopancreatography (nCTCP) and computed tomography angiography (CTA) were allocated into the CT group, and patients receiving MRI combined with magnetic resonance cholangiopancreatography (MRCP) and magnetic resonance angiography (MRA) were allocated into the MRI group. The images of the 2 groups were analyzed by 2 independent reviewers. The classification of malignant perihilar biliary obstruction, hepatic artery and portal vein invasions and lymph node and organ metastases were evaluated respectively, and then the results of evaluation were compared with the results of surgery and pathological examinations. The comparison between the accuracy of imaging examination in the 2 groups and accuracy of perihilar biliary obstruction classification were analyzed by the chi-square test. The comparison of evaluating accuracy (sensitivity and specificity) among vascular invasion and lymph node and organ metastases were done by the receiver operating characteristic (ROC) curve analysis, and the comparison of its accuracy were done by thez-score test. Results The imagings of bile duct involvement of the 2 groups showed that there were irregular thickening bile duct wall combined with retrograde intrahepatic bile duct dilatation. The symptoms of vascular invasion included the stricture and occlusion of blood vessels or more than half of vascular contact surface with tumor. The symptoms of lymph node metastasis included the enlarging short-axis or round-like circular enhanced lesions. The symptoms of organ involvement included the unclear boundary of lesions or low-density necrotic foci within organ. All the 20 patients underwent the surgical treatment, including 13 patients with hilar cholangiocarcinoma and 7 patients with gallbladder carcinoma. Hepatic artery invasions were detected in 5 patients, portal vein invasions in 10 patients, lymph node metastases in 10 patients and organ metastases in 4 patients. The cases of classification of perihilar biliary obstruction, hepatic artery invasion, portal vein invasion, lymph node metastasis and organ metastasis which were evaluated respectively by reviewer 1 and 2 were 18/ 18, 19/ 18, 18/ 18, 17/ 16 and 18/ 19 in the CT group and 17/ 16, 14/ 13, 17/ 16, 15/ 14 and 19/ 18 in the MRI group. The imaging of the 2 groups were compared with the evaluating accuracies of classification of malignant hilar biliary obstruction, hepatic artery and portal vein invasions, lymph node and organ metastases in the 2 groups, showing no significant differences (χ2=12.593, 8.889, z=1.823, 1.956, 0.462, 0.817, 0.977, 0.751, 0.233, 1.403, P >0.05) . Conclusion CT and MRI for malignant hilar biliary obstruction had the same imaging features, meanwhile, they can provide an equivalent performance in the classification of malignant hilar biliary obstruction, hepatic artery and portal vein invasions and lymph node and organ metastases. Key words: Perihilar biliary obstruction; Malignance; Tomography, X-ray computed; Magnetic resonance imaging

Su1642 Unilateral Versus Bilateral Endoscopic Metal and Plastic Stenting for Malignant Hilar Biliary Obstruction: a Single Center Study

Although self-expandable metal stents(SEMS) and plastic stents(PS) are widely used for malignant hilar biliary obstruction, the extent of liver drainage for palliative treatment of malignant hilar biliary obstruction is controversial. The aim of this study was to compare unilateral and bilateral endoscopic metal and plastic stent placement in patients with malignant hilar biliary obstruction.

8-mm versus 10-mm diameter self-expandable metallic stent in bilateral endoscopic stent-in-stent deployment for malignant hilar biliary obstruction.

We aimed to clarify the clinical benefits of using 8-mm versus 10-mm diameter self-expandable metallic stent (SEMS) in bilateral endoscopic stent-in-stent (SIS) deployment for malignant hilar biliary obstruction (MHBO). A total of 72 consecutive patients with MHBO treated by endoscopic bilateral SIS deployment were enrolled. The 8-mm and 10-mm diameter SEMSs were used in 37 patients (8-mm group) and 35 patients (10-mm group), respectively. We retrospectively compared technical success, functional success, complications, successful re-intervention, time to recurrent biliary obstruction (RBO) and survival time between two groups. There were no significant inter-group differences in terms of technical success (8-mm vs. 10-mm group, both 100%), functional success (96% vs. 100%), early (5% vs. 9%) and late (19% vs. 14%) complications other than RBO, and successful endoscopic re-intervention (94% vs. 100%), respectively. Time to RBO (median: 198 days vs. 222 days; log-rank, P = 0.440) and survival time (median: 186 days vs. 235 days; log-rank, P = 0.883) did not differ significantly between the two groups. However, the success rate of endoscopic bilateral revisionary stent insertion for RBO was significantly higher in the 10-mm compared to the 8-mm group (68% vs. 31%; P = 0.044). The 10-mm diameter SEMS is more suitable with regard to endoscopic re-intervention.

悪性肝門部胆管狭窄における内視鏡的減黄術

悪性肝門部胆管狭窄における内視鏡的減黄術

Technical tips and troubleshooting of endoscopic biliary drainage for unresectable malignant hilar biliary obstruction.

Unresectable malignant hilar biliary obstruction (MHBO) occurs in various diseases, such as cholangiocarcinoma, gallbladder carcinoma, hepatocellular carcinoma, pancreatic cancer, and lymph node metastasis of the hilum of the liver. The majority of patients with advanced MHBO are not candidates for surgical resection because of the tumor location in the hepatic hilum and adjacent areas, advanced tumor stage, or comorbidities. Therefore, these patients often have a poor prognosis in terms of survival and quality of life. Most of these patients will require non-surgical, palliative biliary drainage. To date, various biliary drainage techniques for unresectable MHBO (UMHBO) have been reported. Of these techniques, endoscopic biliary drainage is currently considered to be the most safe and minimally invasive procedure. However, endoscopic biliary drainage for UMHBO is still not standardized regarding the optimal stent, drainage area, stenting method, and reintervention technique. Recently, towards standardization of this technique for UMHBO, clinical research and trials including randomized controlled trials have been performed. In this article, we reviewed the most important issues regarding endoscopic biliary drainage for UMHBO, focusing on prospective studies. We also described in detail the techniques and future perspectives of endoscopic biliary drainage in patients with UMHBO.

Single-step simultaneous side-by-side placement of a self-expandable metallic stent with a 6-Fr delivery system for unresectable malignant hilar biliary obstruction: a feasibility study.

Bilateral self-expandable metallic stent (SEMS) placement for the management of unresectable malignant hilar biliary obstruction (UMHBO) is technically challenging to perform using the existing metallic stents with thick delivery systems. The recently developed 6-Fr delivery systems could facilitate a single-step simultaneous side-by-side placement through the accessory channel of the duodenoscope. The aim of this study was to evaluate the feasibility of this procedure. Between May and September 2013, 13 consecutive patients with UMHBO underwent a single-step simultaneous side-by-side placement of SEMS with the 6-Fr delivery system. The technical success rate, stent patency, and rate of complications were evaluated from the prospectively collected database. Technical success was achieved in 11 (84.6%, 95% confidence interval [CI]: 57.8-95.8) patients. The median procedure time was 25 min. Early and late complications were observed in 23% (one segmental cholangitis and two liver abscesses) and 15% (one segmental cholangitis and one cholecystitis) patients, respectively. Median dysfunction free patency was 263 days (95% CI: 37-263). Five patients (38%) experienced stent occlusion that was successfully managed by endoscopic stent placement. A single-step simultaneous side-by-side placement of SEMS with a 6-Fr delivery system was feasible for the management of UMHBO.

Risk factors for technical failure of endoscopic double self-expandable metallic stent placement by partial stent-in-stent method.

Endoscopic double self-expandable metallic stent (SEMS) placement by the partial stent-in-stent (PSIS) method has been reported to be useful for the management of unresectable hilar malignant biliary obstruction. However, it is technically challenging, and the optimal SEMS for the procedure remains unknown. The aim of this study was to identify the risk factors for technical failure of endoscopic double SEMS placement for unresectable malignant hilar biliary obstruction (MHBO). Between December 2009 and May 2013, 50 consecutive patients with MHBO underwent endoscopic double SEMS placement by the PSIS method. We retrospectively evaluated the rate of successful double SEMS placement and identified the risk factors for technical failure. The technical success rate for double SEMS placement was 82.0% (95% confidence interval [CI]: 69.2-90.2). On univariate analysis, the rate of technical failure was high in patients with metastatic disease and unilateral placement. Multivariate analysis revealed that metastatic disease was a significant risk factor for technical failure (odds ratio: 9.63, 95% CI: 1.11-105.5). The subgroup analysis after double guidewire insertion showed that the rate of technical success was higher in the laser-cut type SEMS with a large mesh and thick delivery system than in the braided type SEMS with a small mesh and thick delivery system. Metastatic disease was a significant risk factor for technical failure of double SEMS placement for unresectable MHBO. The laser-cut type SEMS with a large mesh and thin delivery system might be preferable for the PSIS procedure.

Bilateral Versus Unilateral Stenting for Malignant Hilar Obstruction: A Meta-Analysis

Introduction: Malignant hilar biliary obstruction is a dreaded complication of various types of cancers including pancreatic cancer, cholangiocarcinoma, gallbladder carcinoma, and hepatocellular carcinoma. Palliative endoscopic biliary drainage plays an important role in resolving jaundice and cholangitis. The optimal stenting techniques remain to be definitely decided and the necessity to drain both liver lobes in hilar tumors remains uncertain. We report a meta-analysis of studies comparing unilateral versus bilateral stenting for malignant hilar biliary obstruction. Methods: We searched Pubmed, Medline, Embase, and Cochrane for controlled studies that compared unilateral versus bilateral stenting for malignant hilar biliary obstruction. Studies were excluded if they were non-controlled or included patients with non-malignant and non-hilar obstruction. Studies selection and data extraction were done by 2 reviewers. Disagreement was solved by a third reviewer. The quality for each included study was assessed by Consort system. Heterogeneity of the studies was analyzed by Cochran’s Q statistics. Mantel Haenszel relative risk and mean difference were calculated with random effect for outcomes with significant heterogeneity; for all others the fixed effect method was used. Results: Seven studies met the inclusion criteria with a total of 634 patients. After the initial placement of stents, there was no significant difference in the occlusion rate between unilateral and bilateral stenting (odds ratio [OR]: 1.47; confidence interval [CI]: 0.68-3.19). There was moderate heterogeneity among results reported in the studies but the clinical characteristics of the patients and the method of outcome assessment were similar and did not change our inferences. A sensitivity analysis that sorted studies based on the use of metal versus plastic stents found no statistically significant difference in the occlusion rate. Therapeutic failure, defined as the lack of resolution of symptoms post stenting, was noted in 17% with unilateral stenting compared to 22% with bilateral stenting without a statistically significant difference (OR: 0.63; CI: 0.31-1.28). Bilateral stenting was associated with higher incidence of post-stenting cholangitis 22% compared to unilateral stenting 12% (OR 0.52; 95% CI 0.28-0.96). There was no evidence of publication bias among the reported outcomes. Conclusion: When compared to bilateral stenting, unilateral stenting performed for patients with malignant hilar strictures is associated with lower incidence of post-stenting cholangitis, similar success in symptom resolution and no difference in the post stenting occlusion rate. Therefore, in the majority of patients with malignant biliary obstruction, unilateral stenting provides similar outcome to bilateral stenting.