Hilar Obstruction Research Articles

Biliary drainage in palliative and curative intent European patients with hilar cholangiocarcinoma and malignant hilar obstruction: a retrospective single center analysis

Background and aimsRelief of cholestasis in hilar cholangiocarcinoma is commonly undertaken in both curative and palliative treatment plans. There are numerous open questions with regard to the ideal biliary drainage strategy – including what constitutes clinical success (CS). In the existing data, curative patients and patients from the Western world are underrepresented.Patients and methodsWe performed a retrospective analysis of patients with complex malignant hilar obstruction (Bismuth-Corlette II and higher) due to cholangiocarcinoma who underwent biliary drainage at a German referral center between 2010 and 2020. We aimed to define CS and complication rates and directly compare outcomes in curative and palliative patients.Results56 curative and 72 palliative patients underwent biliary drainage. In patients with curative intent, CS was achieved significantly more often regardless of what definition of CS was applied (e.g., total serum bilirubin (TSB) < 2 mg/dl: 66.1% vs. 27.8%, p = < 0.001, > 75% reduction of TSB: 57.1% vs. 29.2%, p = 0.003). This observation held true only when subgroups with the same Bismuth-Corlette stage were compared. Moreover, palliative patients experienced a significantly greater percentage of adverse events (33.3% vs. 12.5%, p = 0.01). Curative intent treatment and TSB at presentation were predictive factors of CS regardless of what definition of CS was applied. The observed CS rates are comparable to published studies involving curative patients, but inferior to reported CS rates in palliative series mostly from Asia.ConclusionsBiliary drainage in complex malignant hilar obstruction due to cholangiocarcinoma is more likely to be successful and less likely to cause adverse events in curative patients compared to palliative patients.

Comparison of stent patency between EUS-guided hepaticogastrostomy with bridging and endoscopic transpapillary biliary drainage for hilar obstruction.

Background and study aims Endoscopic ultrasound-guided hepaticogastrostomy with bridging between the left and right bile ducts is an alternative to endoscopic transpapillary drainage for malignant hilar biliary obstruction. We aimed to analyze the long-term stent patency of endoscopic ultrasound-guided hepaticogastrostomy with bridging. Patients and methods Patients who underwent endoscopic ultrasound-guided hepaticogastrostomy with bridging between April 2018 and July 2023 were retrospectively analyzed. We retrospectively compared the stent patency of these patients with that of the individuals who underwent endoscopic transpapillary drainage-multi-stenting using unmatched (entire) and propensity score-matched cohorts. Results Endoscopic ultrasound-guided hepaticogastrostomy with bridging had a technical success rate of 90% (18/20). Adverse events were minimal. The number of clinical success cases was 17 and 82 for endoscopic ultrasound-guided hepaticogastrostomy with bridging using metallic stent and endoscopic transpapillary drainage-multi-stenting, respectively. The recurrent biliary obstruction rate was 17.6% and 58.5% for endoscopic ultrasound-guided hepaticogastrostomy with bridging and endoscopic transpapillary drainage-multi-stenting, respectively; the median time to recurrent biliary obstruction (days) was significantly longer for endoscopic ultrasound-guided hepaticogastrostomy with bridging in the entire (not reached vs. 104, P =0.03) and propensity score-matched (183 vs. 79, P =0.05) cohorts. The non-recurrent biliary obstruction rate for endoscopic ultrasound-guided hepaticogastrostomy with bridging was 91.6% at 3 and 6 months and 57% at 12 months. Multivariate analyses revealed that endoscopic ultrasound-guided hepaticogastrostomy with bridging contributed to a lower recurrent biliary obstruction incidence (hazard ratio, 0.31, P =0.05) without significant difference. Conclusions Stent patency was significantly better for endoscopic ultrasound-guided hepaticogastrostomy with bridging. However, future prospective studies are needed.

Antimicrobial therapy outcomes in acute cholangitis: Hilar multiple obstructions versus single hilar and common bile duct obstructions.

The appropriate duration of antimicrobial therapy for acute cholangitis (AC) arising from multiple hilar biliary obstructions as opposed to simple obstruction in the extrahepatic bile duct has not been established. This study assessed the efficacy of the duration of antimicrobial treatments in the Tokyo Guidelines 2018 for AC based on the cause and site of obstruction. This single-center retrospective study involved patients with AC who underwent successful biliary drainage and completed a 7-day or shorter antimicrobial treatment. Patients were categorized into three groups: Group 1, bile duct stone or benign obstruction; Group 2, simple biliary obstruction due to malignancy; and Group 3, multiple hilar biliary obstruction due to malignancy. The primary outcome was clinical cure rate, and the secondary outcomes were 3-month recurrence rate and length of hospital stay. A total of 373 patients were selected. Patients in Group 3 were younger or had Charlson Comorbidity Index ≥4, and had fewer positive blood cultures. In Group 3, the clinical cure rate (87.1%) and 3-month recurrence rate (32.3%) were less favorable than those in the other groups. In Group 1, the clinical cure rate was significantly higher (98.1%, P = 0.02) with a much lower 3-month recurrence rate of only 3.4% (P < 0.001) than that in the other groups. The median hospital stay for all groups was 7 days. This study suggests that the outcomes in Group 3 may be worse than those in Groups 1 or 2, regardless of the duration of the antibiotic treatment.

Value of magnetic resonance cholangiopancreatography in the evaluation of biliary obstruction

Background: Obstructive jaundice is a common clinical condition that causes many complications, especially septic shock. Magnetic resonance cholangiopancreatography (MRCP) plays an important role in determining the cause, extent, and complications of biliary obstruction. Purposes: To investigate the value of magnetic resonance cholangiopancreatography in the diagnosis of biliary obstruction. Materials and Methods: A descriptive cross-sectional study was conducted at Hue University of Medicine and Pharmacy Hospital from January 2019 to November 2022. Forty-four patients with biliary obstruction who underwent MRCP, and percutaneous transhepatic cholangiography (PTC, a step in the procedure of percutaneous transhepatic biliary drainage) were retrospectively analyzed. Results: The mean age was 62.75 ± 13.29 years. Male/female ratio was 1.3/1. The most common cause of obstruction was biliary malignancy (56,9%). Bilateral intrahepatic duct dilation (54.5%) and hilar obstruction (65.9%) were predominant. On MRCP, abrupt cut-off of the duct, irregular margin, and asymmetric biliary stricture. There was a good to very good concordance between MRCP and PTC in determining the site of dilatation, site of obstruction, and characteristics of biliary obstruction. Compared with PTC, MRCP had a sensitivity of 100% and a specificity of 89.5% in the evaluation of abrupt cut-off; a sensitivity of 90.5% and a specificity of 100% in detecting biliary stricture. Conclusion: MRCP is useful in a comprehensive evaluation of the biliary tract including anatomy and variations as well as site, degree, extent, etiologies, and complications of obstruction. MRCP should be included in the routine workup of patients with biliary obstruction who might be candidates for percutaneous biliary intervention. Key words: Biliary obstruction, magnetic resonance cholangiopancreatography, percutaneous transhepatic cholangiography, percutaneous transhepatic biliary drainage.

Partial Stent-in-Stent Method with an Uncovered Self-Expandable Metallic Stent for Unresectable Malignant Hilar Bile Duct Obstruction

(1) Background: There is controversy regarding stent placement for unresectable malignant hilar biliary obstruction (UMHBO). We mainly use the partial stent-in-stent (PSIS) method with an uncovered self-expandable metallic stent (UCSEMS) based on the drainage area and patency period. In this study, we investigated the usefulness and safety of the PSIS method. (2) Methods: In total, 59 patients who underwent the PSIS method for UMHBO at our hospital were included in the study. The technical success rate, clinical success rate, time to recurrent biliary obstruction (TRBO) and overall survival (OS) from the first placement, factors affecting TRBO and OS, and early complications within 30 days after the procedure were evaluated retrospectively. (3) Results: The technical and clinical success rates were 100% and 96.6%, respectively, with a TRBO of 121 days [95% confidence interval: 82–231] and an OS of 194 days [95% confidence interval: 113–305] after the first placement. Early complications occurred in nine patients (15.3%), including five cases of cholangitis, three cases of pancreatitis, and one case of cholecystitis. (4) Conclusions: The PSIS method for UMHBO is safe and useful with high technical and clinical success rates.

Revisiting the Malignant Masquerade at the Liver Hilum: Have We Made Progress?

Distinguishing malignant from benign causes of obstruction at the liver hilum can pose a diagnostic dilemma. This study aimed to determine factors that predict benign causes of hilar obstruction and long-term outcomes after resection. Consecutive patients who underwent surgery for hilar obstruction at a single institution between 1997 and 2022 were retrospectively analyzed. Median follow-up was 26months (range 0-281months). Among 182 patients who underwent surgery for hilar obstruction, 25 (14%) patients were found to have benign disease. Median CA19-9 level after normalization of serum bilirubin was 80U/mL (range 1-5779) and 21U/mL (range 1-681) among patients with malignant and benign strictures, respectively (p = 0.001). Cross-sectional imaging features associated with malignancy were lobar atrophy, soft tissue mass/infiltration, and vascular involvement (all p < 0.05). Factors not correlated with malignancy were jaundice upon presentation, peak serum bilirubin, sex, and race. Preoperative bile duct brushing or biopsy had sensitivity and specificity rates of 82% and 55%, respectively. Among patients who underwent resection with curative intent, grade 3-4 complications occurred in 55% and 29% of patients with malignant and benign strictures, respectively (p = 0.028). Postoperative long-term complications of chronic portal hypertension and recurrent cholangitis occurred in ≥ 10% of patients with both benign and malignant disease (p = non-significant). Strictures at the liver hilum continue to present diagnostic and management challenges. Postoperative complications and long-term sequelae of portal hypertension and recurrent cholangitis develop in a significant number of patients after resection of both benign and malignant strictures.

Suprapapillary placement of plastic versus metal stents for malignant biliary hilar obstructions: a multicenter, randomized trial.

The efficacy of the suprapapillary placement of inside plastic stents (iPSs) for unresectable malignant hilar biliary obstructions (MHOs) is unknown compared with that of uncovered inside metal stents (iMSs). This randomized controlled trial was designed to evaluate the outcomes of endoscopic placement of these stents for unresectable MHOs. This open-label, randomized study was conducted at 12 Japanese institutions. The enrolled patients with unresectable MHOs were allocated to iPS and iMS groups. The primary outcome was defined as the time to recurrent biliary obstruction in patients for whom the intervention was both technically and clinically successful. Among 87 enrollments, 38 patients in the iPS group and 46 patients in the iMS group were analyzed. Technical success rates were 100% (38 of 38) and 96.6% (44 of 46), respectively (P= 1.00). After transferring 1 unsuccessful iMS-group patient to the iPS group (since iPSs were deployed), the clinical success rates were 90.0% (35 of 39) for the iPS group and 88.9% (40 of 45) for the iMS group from a per-protocol analysis (P= 1.00). Among the patients with clinical success, the median times to recurrent biliary obstruction were 250 (95% confidence interval, 85-415) and 361 (95% confidence interval, 107-615) days (log-rank test, P= .34). No differences were detected in rates of adverse events. This Phase II randomized trial did not show any statistically significant difference in stent patency between suprapapillary plastic versus metal stents. Considering the potential advantages of plastic stents for malignant hilar obstruction, these findings suggest that suprapapillary plastic stents could be a viable alternative to metal stents for this condition.

Surgical management of intrahepatic and hilar cholangiocarcinoma: liver resection versus liver transplantation

The incidence of cholangiocarcinoma is increasing worldwide. Patients present with abdominal pain, whereas weight loss and malaise are symptoms of advanced disease. Jaundice occurs when there is hilar obstruction by the tumor. Surgical management involves resection of the affected hepatic segments or liver transplantation, which requires a dedicated multidisciplinary team approach, and promising outcomes are seen in high-volume centres. The authors employed a search strategy for databases like PubMed and Google Scholar. The authors then reviewed the articles using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines and compared data concerning postoperative complications, recurrence rates, five-year survival rates and prognosis. Liver resection confers long-term survival in patients with intrahepatic cholangiocarcinoma, though the prognosis and morbidity of this procedure are still gloomy. Liver transplantation could be an option, either in early stages diagnosed in the context of chronic liver diseases or locally advanced tumors, when neoadjuvant treatments have achieved sustained tumor response without extrahepatic tumor spread.

Risk Factors for Early- and Late-Onset Cholecystitis after Y-Configured Metal Stent Placement in Patients with Malignant Hilar Biliary Obstruction: A Single-Center Study.

This study evaluated the prevalence and risk factors of early- (within 7 days of placement) and late-onset (after 7 days of placement) cholecystitis after Y-configured metal stent placement. Between June 2005 and August 2020, 109 patients who had been treated with Y-configured metal stents for malignant hilar obstruction were enrolled in the study. We retrospectively analyzed the potential risk factors for post-stent cholecystitis. The presence of diabetes (p = 0.042), the length of the common part of the Y-stent (p = 0.017), filling of the gallbladder with contrast medium during the procedure (p = 0.040), and tumor invasion of the cystic duct accompanied by filling the gallbladder with contrast medium during metal stent placement (p = 0.001) were identified as important risk factors. In cases of late-onset cholecystitis, stent obstruction (p = 0.004) and repeated endoscopic procedures due to stent malfunction (p = 0.024) were significant risk factors. In the multivariate logistic regression analysis, significant risk factors were the length of the common part of the Y-stent (p = 0.032) in early-onset cholecystitis and stent obstruction (p = 0.007) in late-onset cholecystitis. This study demonstrated that early-onset cholecystitis may occur in patients according to the length of the common portion of the Y-stent. In contrast, late-onset cholecystitis may occur in patients with stent obstruction.

Short and long outcomes of endoscopic bilateral metal stent placement for malignant hilar biliary obstruction: Tertiary care oncology centre experience.

Placement of biliary self-expanding metal stents (SEMS) has been effective for palliation of unresectable hilar malignant biliary obstruction. Optimal drainage in hilar obstruction may require placement of multiple stents. Data on multiple SEMS placement in hilar obstruction from India is sparse. Retrospective review of patients with unresectable malignant hilar obstruction who underwent endoscopic bilateral SEMS insertion from 2017 to 2021 was done. Demographic details, technical success and functional success (decrease in the bilirubin value below 3mg/dL at fourweeks), immediate complications with 30-days mortality, requirement of re-intervention, stent patency and overall survival were studied. Forty-three patients were included (mean age 54.9years, 51.2% females). Thirty-six patients (83.7%) had carcinoma gallbladder as primary malignancy. Twenty-six patients (60.5%) were metastatic at presentation. Cholangitis was seen in 4/43 (9.3%). On cholangiogram, 26 (60.4%) had Bismuth type II block, 12 (27.8%) had type IIIA/B, 5 (11.6%) had type IV block. Technical success was achieved in 41/43 (95.3%) patients (38, side-by-side SEMS placement; 3, SEMS-within-SEMS in Y fashion). Functional success was achieved in 39 patients (95.1%). No moderate-severe complications were reported. Median post-procedure hospitalization was five days. Median stent patency was 137days (interquartile range [IQR] 80-214days). Re-intervention was required in four patients (9.3%) after mean 295.7days. Median overall survival was 153days (IQR 108-234days). Endoscopic bilateral SEMS in complex malignant hilar obstruction has good outcomes in the form of technical success, functional success and stent patency. Survival is dismal despite optimal biliary drainage.

Top tips for endoscopic biliary stenting for hilar obstruction.

Top tips for endoscopic biliary stenting for hilar obstruction.

Effect of Percutaneous Biliary Drainage on Enzyme Activity of Serum Matrix Metalloproteinase-9 in Patients with Malignant Hilar Obstructive Hyperbilirubinemia.

Background and Objectives. Cholestasis activates complex mechanisms of liver injury and as a result has an increased production of matrix metalloproteinases (MMP). Depending on the stage of liver disease, different matrix metalloproteinases expressions have been detected and could serve as indirect biomarkers as well as therapeutic targets. MMP-9 proteolytic activity has a proven role in both liver regeneration and neoplastic cell invasion in various malignancies. The purpose of this prospective cohort study was to evaluate the effect of external biliary drainage on enzyme activity of MMP-9 in the serum of patients with malignant hilar biliary obstruction. Materials and Methods. Between November 2020 and April 2021, 45 patients with malignant hilar biliary obstruction underwent percutaneous biliary drainage following determination of serum MMP-9 enzyme activity (before treatment and 4 weeks after the treatment) by gelatin zymography. Results. MMP-9 values decreased statistically significantly 4 weeks after percutaneous biliary drainage (p = 0.028) as well as the value of total bilirubin (p < 0.001), values of direct bilirubin (p < 0.001), aspartate aminotransferase (AST) (p < 0.001), alanine transaminase (ALT) (p < 0.001), and gamma-glutamyl transferase (GGT) (p < 0.001). Conclusions. In patients with malignant hilar biliary obstruction treated by external percutaneous biliary drainage for cholestasis resolution, a significant reduction in MMP-9 serum values was noted 4 weeks after the treatment.

The role of endoscopy in malignant hilar obstruction.

Malignant hilar biliary obstruction (MHO) is a medical challenge as regards both forming a correct diagnosis and its adequate management, in terms of treatment alternatives and palliative options. Surgical resection is the only curative treatment for the underlying disease, but the majority of patients are not suitable candidates because of an unresectable tumor or poor performance status. Biliary drainage (BD) can be achieved through the percutaneous transhepatic route or endoscopically, and the choice depends on a host of factors, including biliary anatomy and comorbidity of the patient. Though there is no consensus, the endoscopic approach is usually preferred over the former. Endoscopy can aid in both diagnosis (collection of histological as well as cytological samples, direct visualization of suspected malignant pathology, or use of endoscopic ultrasound [EUS] for evaluation and locoregional staging), and in achieving internal BD. Advances in the development of various stents, accessories and, more recently, the use of EUS have in fact further expanded its application in MHO management. The choice of stents to be used (type, make, and number), palliation methods, deployment techniques and the use of local ablative strategy are still evolving and require more data. The complexity of management of MHO mandates that each patient should receive a "personalized approach", all the way from establishing a diagnosis until final treatment, with the help of a multidisciplinary team effort. Herein, we provide a comprehensive literature review of the current role of endoscopy for MHO, according to its applications in various clinical settings.

Stent insertion for malignant hilar obstruction: a meta-analysis of percutaneous versus endoscopic approaches

Stent insertion for malignant hilar obstruction: a meta-analysis of percutaneous versus endoscopic approaches

Bilateral verses bilateral with tri-segmental endoscopic drainage using metal stents for high-grade malignant hilar biliary obstructions: A multicenter, randomized controlled trial: BRAVE study (BRAVE study).

Introduction:Bilateral endoscopic drainage with self-expanding metallic stent (SEMS) can be used to manage hilar malignant biliary obstruction (HMBO) more effectively in comparison to unilateral drainage. An increased drainage area is predicted to prolong stent patency and patient survival. However, few reports have described the utility of trisegmental drainage and the benefits of using trisegmental drainage remain unknown. Thus, we launched a randomized clinical trial (RCT) to compare the clinical outcomes between bilateral and trisegmental drainage using SEMSs in patients with high-grade HMBO.Methods and analysis:This study was conducted as a multicenter randomized control trial (RCT) in 8 high-volume medical centers in Japan, and will prove the non-inferiority of bilateral drainage to trisegmental drainage. Patients with unresectable HMBO with Bismuth type IIIa or IV who pass the inclusion and exclusion criteria will be randomized to receive bilateral or trisegmental drainage at a 1:1 ratio. At each center, the on-site study investigators will obtain informed consent from the candidates, and will use an electronic data capture system (REDCap) to input necessary information, and register candidates with the registration secretariat. The primary endpoint is the rate of non-recurrent biliary obstruction (RBO) at 180 days after SEMSs placement. A −10% non-inferiority margin is assumed in the statistical analysis of the primary endpoint. Secondary endpoints include the rate of technical and clinical success, time to recurrent biliary obstruction (TRBO), causes of RBO, procedure-related adverse events (AEs), procedure time, TRBO with or without endoscopic sphincterotomy, overall survival, and the technical and clinical success rates at reintervention.Discussion:If the non-inferiority of bilateral drainage is demonstrated, it is predicted that the procedure time will be shortened and the medical cost will be reduced, which will be beneficial to the patient and the medical economy.Trial registration:Registered in Japan Registry of Clinical Trial-Registration (trial number. jRCTs062220038). This version number 1. Protocol dated Jun 23, 2022.

S24 Outcomes of Percutaneous vs Endoscopic Biliary Drainage in Malignant Hilar Obstruction: Analysis of a Large Electronic Health Record Dataset

S24 Outcomes of Percutaneous vs Endoscopic Biliary Drainage in Malignant Hilar Obstruction: Analysis of a Large Electronic Health Record Dataset

Endoscopic versus percutaneous intervention for palliation in malignant hilar bile duct obstruction – A comparative cohort study

BackgroundBiliary drainage in patients managed palliatively for malignant hilar obstruction can be achieved by endoscopic transpapillary stenting using endoscopic retrograde cholangiography (ERC) or percutaneous transhepatic stent or catheter placement using percutaneous transhepatic cholangiography (PTC). This study compares ERC and PTC drainage for malignant hilar bile duct obstruction. MethodsA retrospective study of drainage procedures at two academic hospitals was conducted from 2015 to 2020. Procedural success (divided into access-, bridging-, and technical success), therapeutic success, duration of therapeutic success and complications were analysed for different Bismuth-Corlette stricture types. ResultsA total of 293 patients were included, 153 (52.2%) in the ERC group and 140 (47.8%) in the PTC group. Access and bridging success in the ERC and PTC groups were 83.5% vs. 97.2% (p < 0.001) and 90.2% vs. 84.5% (p = 0.119), respectively. Technical and therapeutic success were equivalent between the two groups (98.3% vs. 99.3%, p = 0.854 and 81.7% vs. 73.3%, p = 0.242). Duration of therapeutic success was longer after ERC drainage compared to PTC drainage (p = 0.009) with a 3-month gain in duration of therapeutic success after ERC drainage (p = 0.006, 95% CI [26–160]). Cholangitis rates were equivalent (21.4% vs. 24.7%, p = 0.530), pancreatitis was more common in the ERC group (9.4% vs. 0%, p < 0.001) and procedure-related deaths more common in the PTC group (6.0% vs. 15.8%, p < 0.001). ConclusionAlthough ERC and PTC drainage of malignant hilar obstruction were similar regarding technical and therapeutic success, ERC drainage was more durable. Outcome differences for B–C stricture types should be explored in future studies.

THE IMPACT OF BILIARY DRAINAGE MODE ON BACTERIOBILIA OCCURRENCE IN PATIENTS WITH HILAR MALIGNANT OBSTRUCTION

The purpose of this study was comparative assessment of the frequency of bacterial colonization of the bile in patients with hilar malignant biliary obstruction after the palliative biliary decompression using different methodological approaches. Methods. 50 patients with proximal mechanical jaundice of tumor origin aged of ~ 62 years (25 males and 25 females), who were on steady-state treatment in Main military clinical hospital (Kyiv, Ukraine) were recruited in this prospective study. All patients underwent cholangiostomy using percutaneous transhepatic (PTBD) and external-internal suprapapillary (EISBD) approaches. Bile specimens were taken right after the biliary drainage. Identification of bacterial isolates was performed using standard cultural and biochemical methods. Results. The incidence of cholangitis was almost twice lower in EISBD group (n=26) than in PTBD group (n=24): 25.6% vs 49.1%. The rates of bacteriobilia did not differ significantly in patients from different groups: 23.1% in EISBD group and 25.0% in PTBD group. However, the frequency of biliary bacterial colonization coupled with cholangitis was also 2 times lower in EISBD group in comparison with patients underwent PTBD: 7.7% vs 16.7%. Escherichia coli predominated in bile specimens from patients with bacteriobilia associated with cholangitis in both groups. Conclusions. The use of EISBD for palliative biliary decompression in patients with proximal mechanical jaundice of tumor origin is associated with lower risk of bacterial colonization of the bile as compared to PTBD approach, and as a result with less risk of the development of infectious complications

An Unusual Cause of Obstructive Jaundice

Question: A 45-year-old man presented with painless obstructive jaundice for 1 month. His past medical history was unremarkable. Significant laboratory results included total bilirubin of 73.4 μmol/L (normal 5.1-20 μmol/L), direct bilirubin of 46.5 μmol/L (normal <6.1 μmol/L), alanine transaminase of 168.3 U/L (normal 9-50 U/L), alkaline phosphatase of 438 U/L (normal 50-135 U/L) and gamma-glutamyl transferase of 1321.6 U/L (normal 10-60 U/L). Abdominal ultrasonography showed a gallstone in the common hepatic duct with intrahepatic ductal dilation, and the gallbladder was atrophic. Contrast-enhanced computed tomographic (CT) scan in a dual-energy mode showed luminal distension of gallbladder neck (Figure A, white arrow), with hepatic hilar stenosis (Figure A, blue arrow) and bilateral intrahepatic ductal dilation. Coronal virtual monoenergetic image reconstruction at 40 keV clearly showed an intraluminal lesion with hypodensity in gallbladder neck (Figure B, red arrow). The spectral Hounsfield unit curve showed the decreased attenuation values of the lesion as the energy level decreased (Figure C). What is the most likely diagnosis? Look on page 197 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Dual-energy CT suggested that the lesion was a cholesterol gallstone. Magnetic resonance cholangiopancreatography (MRCP) was then performed and confirmed a stone (Figure D, white arrow) in the gallbladder neck, with external compression of the common hepatic duct and dilation of the intrahepatic biliary duct, highly suggestive of Mirizzi syndrome (MS). In addition, a long cystic duct running parallel to the common bile duct with low insertion was found. Subsequent cholecystectomy confirmed a 1.7-cm cholesterol gallstone in the neck of the gallbladder causing hepatic hilar stricture, which was consistent with MS. The patient had an unremarkable recovery. MS, as a rare complication of gallstone disease, refers to impaction of a gallstone in the gallbladder neck or cystic duct causing obstruction of the extrahepatic bile duct.1Abou-Saif A. Al-Kawas F. Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus.Am J Gastroenterol. 2002; 97: 249-254Crossref PubMed Google Scholar MS can be tricky and may mimic cholangiocarcinoma, especially when gallstones are radiolucent on conventional CT.2Chen Y. Chang C. Liu K. Mirizzi syndrome due to a large radiolucent gallstone.Am J Gastroenterol. 2016; 111: 599Crossref PubMed Scopus (2) Google Scholar With the ability to differentiate materials on the basis of their differential attenuation at 2 different energy levels, dual-energy CT can help to identify the composition of internal body constituents, such as gallstones. Previous studies have reported that dual-energy CT can increase the conspicuity of isoattenuating gallstones.3Soesbe T.C. Lewis M.A. Xi Y. et al.A technique to identify isoattenuating gallstones with dual-layer spectral CT: an ex vivo phantom study.Radiology. 2019; 292: 400-406Crossref PubMed Scopus (15) Google Scholar In this case, dual-energy CT was first used to diagnose MS, clearly showing the gallstone in the gallbladder neck as the cause of the hepatic hilar obstruction, and to provide a diagnostic clue to confirm MS. This technique can potentially reduce the need for further imaging, such as MRCP, leading to a reduction in imaging cost and time to diagnosis for selected patients.

The usefulness of endobiliary radiofrequency ablation before metal stent placement in unresectable malignant hilar obstruction.

EB-RFA with self-expandable metal stent (SEMS) may improve the stent patency and patient survival in malignant extrahepatic biliary obstruction. However, there are few studies on the role of EB-RFA for malignant hilar obstruction (MHO). This study aimed to assess the feasibility, efficacy, and safety of EB-RFA for MHO. We retrospectively compared the stent patency and survival among 79 consecutive patients with MHO who underwent bilateral uncovered SEMS placement without and with EB-RFA between April 2016 and January 2020. Fifty-one patients (64.6%) underwent SEMS placement alone (stent alone group), whereas 28 (35.4%) underwent SEMS placement after EB-RFA (RFA-stent group). All procedures were successful (100%). During follow-up, stent occlusion occurred in 59 patients (74.7%), of which 40 (78.4%) and 19 (67.9%) were in the stent alone and RFA-stent groups, respectively. There was no difference in stent patency (192±39.2days vs 140±53.7days, P=0.41) and survival (311±24.7days vs 311±46.9days, P=0.73) between the stent alone and RFA-stent groups. Multivariate cox analysis showed a hazard ratio (HR) of 2.892 (1.579-5.294, P=0.001) for stent occlusion in patients who did not receive chemotherapy. EB-RFA had no significant effect on stent occlusion (HR, 1.150, 0.644-2.053, P=0.636). SEMS placement after EB-RFA in MHO was not associated with improvement in the stent patency or patient survival. Further prospective randomized studies are necessary to establish the effectiveness of EB-RFA with stents in MHO.