Malignant Biliary Tract Obstruction Research Articles

Improved Survival With Chemotherapy in Patients With Malignant Biliary Tract Obstruction After Percutaneous Transhepatic Biliary Drainage (PTBD).

Introduction Biliary tree stenting for malignant biliary tract obstructions is a routine modality for the relief of jaundice. Treatment is palliative in most circumstances. However, adequate reduction in bilirubin levels after percutaneous transhepatic biliary drainage (PTBD) may help to offer chemotherapy, which may improve survival in a limited number of cases. Materials and methods Between March 2017 and March 2023, patients who were treated with PTBD to relieve malignant biliary tract obstruction were included in the analysis. Patients who achieved bilirubin levels ≤5 mg/dLafter PTBD were considered for chemotherapy. For survival analysis, a comparison was done between patients treated with chemotherapy after PTBD versus patients who did not receive any treatment after PTBD. Results Data was available for 43 (100%) patients. After PTBD, 16 (37.2%) patients responded and were considered for further treatment. One patient who was advised of radical surgery refused treatment and did not return for further treatment or follow-up. The remaining 15 cases (34.9%) received Gemcitabine and platinum-based chemotherapy as a first-line option. Out of 15 cases who received chemotherapy only one patient (6.6%) received neoadjuvant chemotherapy and the rest of14 (32.5.%) cases received palliative chemotherapy in view of metastatic disease. PTBD complications including leakage, dislodgement of PTBD catheter, pain, and bleeding were seen in 16 (37.2%) cases. Overall survival was 57% for the entire population. Patients treated with chemotherapy after PTBD had better overall survival compared to patients who did not receive any treatment after PTBD (73.3% vs 33% (p=0.008)). Conclusion PTBD is an excellent technique for the relief of biliary obstruction. More than one-third (34.9%) of the cases received further cancer-directed treatment after relief of jaundice by PTBD. Chemotherapy after PTBD is associated with improvement in overall survival in malignant biliary obstructions.

PP04 Presentation Time: 4:57 PM: MRI-Guided Intraluminal High Dose Rate Brachytherapy in the Management of Malignant Biliary Tract Obstruction: A Preliminary Analysis

PP04 Presentation Time: 4:57 PM: MRI-Guided Intraluminal High Dose Rate Brachytherapy in the Management of Malignant Biliary Tract Obstruction: A Preliminary Analysis

MSS06 Presentation Time: 4:10 PM: Single Institution Review of Hepatobiliary Brachytherapy for Bridging to Liver Transplant in Cholangiocarcinoma

<h3>Purpose</h3> Hepatobiliary cancers are rare neoplasms that often present in an inoperable state. In 2020 there were an estimated, newly diagnosed 42,810 "liver and intrahepatic bile duct" cancers and 11,980 "gallbladder and other biliary" cancers. Patients often present with malignant biliary tract obstruction in the setting of locally advanced or metastatic disease and radiation is reserved for palliative reasons. In some patients who are dispositioned to liver transplant (LTX), radiation can be used as a bridging therapy. The purpose of this study was to look at our institutions experience in treating patients with a combination of external beam radiation (EBRT) and hepatobiliary brachytherapy (BT) as they await LTX. <h3>Materials and Methods</h3> Medical records were retrospectively reviewed at our institution and patients diagnosed with cholangiocarcinoma who were also treated with hepatobiliary brachytherapy were included. These patients were considered for LTX. <h3>Results</h3> Between 2019 and 2021 a total of 6 patients were treated with EBRT and BT. Median age was 69.5 (range 60-86) and median follow up was 15 months (range 3-33). 3 patients (50%) presented with nodal disease at initial workup while 0 patients were metastatic. The 3 patients with nodal disease all received chemotherapy prior to radiation with median time to RT being 10 months in these patients. In the node negative patients, median time to EBRT was 1 month after diagnosis. 5 patients underwent conventionally fractionated EBRT, 45 Gy in 25 fractions, while 1 patient underwent stereotactic body radiotherapy (SBRT), 30 Gy in 5 fractions. All patients received concurrent chemotherapy. After completion of EBRT or SBRT, all patients underwent BT, 15 Gy in 5 fractions. Afterwards, 5 patients received adjuvant maintenance chemotherapy. While on maintenance chemotherapy, 4 patients progressed to have metastatic disease. 2 patients were able to undergo LTX, 7 months and 13 months after BT. In these patients, final pathology showed that there was no viable tumor in the areas where they were treated with BT. At most recent follow up, 1 of the patients who underwent LTX was alive while the other was deceased from unknown causes. Otherwise, 2 other patients were alive but with metastatic disease, 1 was deceased, and 1 was lost to follow up but with metastatic disease. Median survival in this cohort was 19 months and overall survival was 50%. <h3>Conclusions</h3> In well selected patients whose goal is to undergo LTX, EBRT and BT can be used as a bridging therapy. Though this is a small cohort, BT did demonstrate high rates of local control in patients able to undergo LTX.

The Clinical Benefit of Percutaneous Transhepatic Biliary Drainage for Malignant Biliary Tract Obstruction.

Simple SummaryPercutaneous transhepatic biliary drainage (PTBD) has been widely employed as a biliary decompression procedure for malignant proximal biliary obstruction. Patients underwent PTBD procedures of jaundice caused by malignant disease for restarting chemotherapy or palliative intent. Clinical outcomes following PTBD procedure in the two groups of patients, according to the adequate bilirubin decline (ABD) needed to restart chemotherapy, are presented in this analysis. Median survival time following the PTBD was 9 weeks, but in patients with ABD who received chemotherapy it was 64 weeks. Patients with the longest survival rate were in good performance status (ECOG 0–1) and lower bilirubin (<120 µmol/L) and LDH (<300 µmol/L) levels at the time of the procedures. Improving quality of life is a major goal in this palliative treatment, but we really need to assess the potential benefits and risks and determine how to select patients who would have positive outcome for this procedure.Percutaneous transhepatic biliary drainage (PTBD) is a decompression procedure for malignant proximal biliary obstruction. In this research, over a six-year period, 89 patients underwent PTBD procedure for jaundice caused by malignant disease to restart chemotherapy or for palliative intent. Clinical outcomes after PTBD procedure in the two groups of patients, according to the adequate bilirubin decline (ABD) needed for subsequent chemotherapy, are presented in this paper. Survival and logistic regression were plotted and compared using Kaplan–Meier survival multivariate analysis with a long-range test. Results were processed by MEDCALC software. In the series, 58.4% (52/89) of patients were in good performance status (ECOG 0/1), and PTBD was performed with the intention to (re)start chemotherapy. The normalization of the bilirubin level was seen in 23.0% (12/52), but only 15.4% (8/52) received chemotherapy. The median survival time after PTBD was 9 weeks. In patients with ABD that received chemotherapy, the median survival time was 64 weeks, with 30-day mortality of 27.7%, and 6.4% of death within 7 days. The best outcome was in patients with good performance status (ECOG 0–1), low bilirubin (<120 µmol/L) and LDH (<300 µmol/L) levels and elevated leukocytes at the time of the procedures. PTBD is considered in ABD patients who are candidates for chemotherapy.

MRI-Guided Intraluminal HDR Brachytherapy for Inoperable Malignant Biliary Tract Obstruction

Aim: Malignant biliary tract obstruction (MBTO) leads to abdominal pain, jaundice, poor quality of life and portends a poor prognosis. Management of MBTO is a significant therapeutic challenge given that treatment with chemotherapy or radiotherapy has limited utility and percutaneous biliary drainage or stent insertion provides only transient symptomatic relief. Intraluminal HDR brachytherapy via catheters inserted percutaneously at the time of stent insertion can be effective in the management of inoperable MBTO. Here, we describe the workflow developed within our department for simulation and treatment using an intraluminal brachytherapy technique. Process: Delivery of bile duct brachytherapy requires the participation of multiple disciplines including interventional radiology (IR), medical physics, radiation oncology (RO) and radiation therapy with careful coordination of numerous tasks. A drain/stent and 1-2 treatment catheters are inserted into the patient's bile ducts by IR before the CT and MR simulation (sim). During the CT sim, multiple surview and low dose helical scans are acquired to verify the treatment catheter position and adjustments are made by the RO as needed. Once the position is finalized, a planning CT scan is done with IV contrast and the patient in voluntary breath hold. Then, the CT and MR sim images are fused. The CT is used to digitize the brachytherapy source path, while the MR is used for target and organs at risk delineation. Treatment is delivered 1-2 days after sim, with 15-25 Gy in 3-5 fractions using an Ir-192 HDR source. Radiographs are taken to confirm catheter position prior to each treatment. Benefits/Challenges: Brachytherapy can be used to treat the tumor at the same time as placement of a stent/drain, thus providing both symptom management and disease control. Although the patient is admitted for the IR procedure, the actual brachytherapy treatment is done on an outpatient basis with no anesthesia, thus treatment does not require significant time or resources in the brachytherapy suite. Patients often present with biliary obstruction emergently and stent/drain placement is booked urgently in IR with little notice to the radiotherapy department. The tight time line makes it difficult to facilitate communication between the multidisciplinary team, prepare staff, assemble supplies, and coordinate subsequent appointments. The CT sim process continues to evolve as new issues are identified with each patient. Variations in catheter/stent placement is a potential challenge and 2/8 patients have required reinsertion of angio-sheath by IR after problems were discovered during the CT sim. MR sim is not always possible depending on nature of inserted material (i.e. metallic stent or drainage sheath). Treatment catheters must be secured in place and covered with a dressing between appointments to prevent damage, change in position or obstruction. Patient education and cooperation is crucial to ensure proper care. Impact/Outcomes: In April 2021, our institution became the first in Canada to offer MRI-guided brachytherapy treatment for patients with inoperable MBTO. As of Jan 2022, 8 patients have been treated using this protocol. With each subsequent case, the time required for treatment delivery has decreased from 1 hour to 30 minutes per fraction and sim processes optimized. This treatment option has potential to improve the quality of life in patients with minimal therapeutic options.

79: A Systematic Review of Intraluminal High Dose Rate Brachytherapy in the Management of Malignant Biliary Tract Obstruction and Cholangiocarcinoma

79: A Systematic Review of Intraluminal High Dose Rate Brachytherapy in the Management of Malignant Biliary Tract Obstruction and Cholangiocarcinoma

Survival benefit of percutaneous transhepatic biliary drainage for malignant biliary tract obstruction-a prospective study comparing external and internal drainage techniques.

To evaluate the clinical results of percutaneous transhepatic biliary drainage (PTBD) in patients with non-operable malignant biliary tract obstruction (MBTO) and the survival benefit of internal drainage. Prospective data of consecutive patients of PTBD from May 2014 to August 2017 was analyzed for 30-day, 90-day and 1-year mortality, and mean survival of patients undergoing external drainage (ED) and internal drainage (ID)using internal-external ring biliary catheterization or biliary stent were compared. Other important variables evaluated were drop in the total bilirubin (TBil) levels, improvement in pain and pruritus, procedure-related complications, and patient satisfaction. In 87 cases (54 male, 33 female) with mean age 37.3 y (22-70 y; 95% CI: 31.1 y-43.5 y), 10, 45 and 32 patients underwent stenting, external and internal-external catheterization, respectively (total 152 procedures [> 1 in 35.63%, n = 31]). PTBD resulted in decrease in mean TBil by 8.2738 ± 0.912mg/dL at 30days (P < 0.001), 55.14% (n = 48) cases reaching 3mg/dL at mean 45days, and 35/48 cases received chemotherapy. Overall mortality was 6.89%, 37.93% and 90.80% at 30 days, 90days and 1 year, respectively. Mean survival with ID (236.40 ± 33.37days) was better than with ED (110.35 ± 26.16days) (P < 0.001).Pain (62.06%; n = 54; mean Visual Analog Scale [VAS] score = 6.7) improved significantly (mean VAS score3.4; P < 0.001). Pruritus (n = 29) was relieved in 100% of the cases. Complication rate of 18.39% (n = 16) and no procedure-related death were seen. PTBD offers a safe and significant improvement in TBil, pain, and pruritus in non-operable MBTO, with ID offering additional survival benefit over ED.

Role of PET/computed tomography and biopsy guidance in characterization of malignant biliary obstruction

Objective This prospective study was conducted to evaluate the diagnostic effect of PET/computed tomography (PET/CT) in patients with malignant biliary obstruction and if the metabolic information provided by PET/CT scan adds an incremental benefit while performing image-guided biopsies. Background Malignant biliary tract obstruction is a frequent cause of jaundice. PET/CT is used to evaluate such patients, and information delivered by PET images is used to guide biopsy procedure. Patients and methods This study was carried out from March 2016 to March 2018 on 52 patients diagnosed/suspected to have MTBO. They all were investigated by PET/CT. Results were compared with the results of contrast-enhanced CT in ∼42 cases and with magnetic resonance cholangiopancreatography (MRCP) in ∼15 cases. A group of patients had undergone PET/CT-guided biopsy (15 patients). Results This study revealed that sensitivity, specificity, positive predictive value, and negative predictive value for PET/CT were 92, 75, 96, and 60%, respectively, whereas for CT and for MRCP were 68, 60, 85, and 20% and 60, 50, 85, and 20%, respectively. PET/CT has sensitivity of 90% for detection of lymph nodal metastases compared with 37% for CT and 20% for MRCP. PET/CT is more sensitive than CT and MRCP for distant metastases detection. Conclusion PET/CT is more sensitive and specific than CT and MRCP in primary detection and staging of tumors causing malignant biliary tract obstruction. PET/CT-guided biopsy increases the chance of obtaining a definitive diagnostic result.

Preliminary clinical application of integrated 125I seeds stents in the therapy of malignant lower biliary tract obstruction.

To evaluate the clinical efficacy of percutaneous trans-hepatic integrated 125I seed stents implantation for malignant lower biliary tract obstruction. Thirty-two patients with malignant lower biliary obstruction were randomly divided into two groups. One group underwent the therapy with integrated 125I seed stents (Test group, n = 13), and another group received conventional metal stents implantation for treatment (Control group, n = 19). The pre- and post-operative changes in biochemical indices, white blood cell count, IgG level, stent patency, survival time, tumor size and complications were compared between the two groups. RECIST 1.1 (Response Evaluation Criteria In Solid Tumors) was used to evaluate therapeutic effects. The average follow-up time was 12.3 months. The differences between pre- and post-operative (30 days) intragroup biochemical indices had statistically significant difference (P < 0.05), but there were no significant differences (P > 0.05) in leukocyte counts and IgG levels. As to the median time of stent patency and patients' survival, there were significant differences (P < 0.05) between Control and Test groups (3.9 months vs. 8.1 months, 139 days vs. 298 days, respectively). Three months after the operation, the average tumor size was reduced in the Test group, but was increased in the Control group (P < 0.05). There was no significant difference in the incidence of complications between the two groups. The evaluation results using RECIST 1.1 showed that there were statistically significant differences between the two groups in terms of the rates of remission, control, and progression (χ2 = 17.5, P < 0.05). The study indicates that integrated 125I seed stents are effective in reducing jaundice symptoms, inhibiting tumor growth, improving stent patency and prolonging patient survival, which may serve as a safer and more feasible method in treating malignant lower biliary obstruction with minimal invasiveness.

Efficacy of EUS-guided and ERCP-guided biliary drainage for malignant biliary obstruction: prospective randomized controlled study

ERCP-guided biliary drainage (ERCP-BD) is a criterion standard treatment for malignant biliary obstruction when curative surgery is not an option. Alternative methods such as percutaneous transhepatic biliary drainage would significantly lower the quality of life. EUS-guided biliary drainage (EUS-BD) has been developed and performed by experienced endoscopists. Therefore, the aims of this studywere to evaluate the efficacy and safety of EUS-BD compared with ERCP in malignant biliary obstruction. The prospective randomized controlled study was conducted, and 30 patients were enrolled: 15 for each EUS-BD and ERCP-BD arms. The technical success, procedural time, clinical success, and adverse events were evaluated. Thirty patients had extrahepatic malignant biliary tract obstruction (19 men, 11 women). Twenty-seven patients had unresectable pancreatic ductal adenocarcinomas, 1 patient had distal common bile duct cancer, and 2 patients had metastatic malignant lymphadenopathy. There were no significant differences both in terms of technical success rate and clinical success rate (100% vs 93% and 93% vs 100% in ERCP-BD vs EUS-BD, respectively; P= 1.00, P= 1.00). Four patients (31%) had tumor ingrowth-caused stent dysfunction in the ERCP-BD group, whereas 2 patients had food impaction and 2 patients had stent migration in the EUS-BD group. No significant procedure-related adverse events occurred in either group. This prospective randomized controlled study suggests that EUS-BD has similar safety to ERCP-BD. EUS-BD was not superior to ERCP-BD in terms of relief of malignant biliary obstruction. EUS-BD may have fewer cases of tumor ingrowth but may also have more cases of food impaction or stent migration. (Clinical trial registration number: NCT01421836.).

Efficacy of Endobiliary Radiofrequency Ablation for Malignant Biliary Obstruction

Malignant biliary tract obstruction (MBTO) is caused by a group of neoplasms that compromise bile duct flow, and the clinical presentation includes obstructive jaundice. The optimal treatment depends on both the type of malignancy and the stage of disease. Surgical resection may be the first choice of treatment. However, an operation is often impossible because of locally advanced disease or a high metastatic potential at the time of diagnosis. Considering the unfavorable prognosis of unresectable MBTO, endobiliary radiofrequency ablation (EB-RFA) has emerged as a palliative therapeutic modality that directly ablates malignant tissue in the bile duct. To date, some reports have suggested that EB-RFA is possibly beneficial, but it remains unclear whether EB-RFA prolongs biliary stent patency or overall survival. Nevertheless, EB-RFA is regarded as a promising loco-regional therapy for MBTO. This review focuses on the clinical application of the technique and its appropriate use, along with the benefits afforded and the complications encountered. Keywords: Endoscopic retrograde cholangiopancreatography; Radiofrequency catheter ablation; Biliary tract neoplasms; Pancreatic neoplasms 중심 단어: ë‚´ì‹œê²½ì—­í–‰ì·Œë‹´ê´€ì¡°ì˜ìˆ ; ê³ ì£¼íŒŒ 소작; 담관암; 췌장암

Treatment of malignant biliary tract obstruction: endosco-pic or percutaneous transhepatic biliary drainage

Malignant biliary tract obstruction is a common disease. Nowadays, endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD) have been used to treat such disease. EBD is a first-line intervention for lower segment of biliary duct obstruction caused by pancreatic cancer or other tumors. PTBD is a first-line treatment for gallbladder cancer or other tumors which lead to the hilar and intrahepatic bile duct obstruction and abnormal digestive anatomy. In a word, the proper selection of the drainage should be based on the patients’ condition with minimal trauma and maximum therapeutic effect. Key words: Biliary tract obstruction; Jaundice; Endoscopy; Percutaneous transhepatic biliary drainage; Treatment

PTH-011 Novel Endoscopic Ultrasound-Guided Interventional Techniques for The Palliative Management of Malignant Biliary Tract Obstruction: A Single UK Centre Experience

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is used as the first-line modality for biliary drainage in patients with obstructive jaundice. However, anatomical or technical factors may preclude conventional trans-papillary biliary access in less than 10% of cases. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has recently emerged as an alternative method to percutaneous transhepatic biliary drainage (PTBD) or surgical biliary bypass after unsuccessful ERCP in patients with inoperable pancreatobiliary malignancies. We present initial experience of EUS-BD in our unit. Methods A prospectively collected database, of consecutive patients undergoing EUS-BD in our unit, was analysed. Data was retrieved from electronic, clinical and endoscopy records. All EUS-BD procedures were undertaken in the endoscopy department, under conscious sedation, using Pentax echoendoscopes and Hitachi ultrasound workstations. In all cases, conventional diagnostic EUS procedure was performed followed by trans-luminal EUS-guided placement of metal stents. One of three endoscopists (KO/MN/MD) performed the procedures. The primary outcome measurements were technical success, clinical success and adverse events. Results 4 EUS-BD procedures were performed in 4 patients – ¾ were female (75%) with median age 70 years (range 51–79). The primary indication in all patients was malignant biliary obstruction, which was not amenable to either PTBD or surgery. One patient had symptomatic cystic duct obstruction with gallbladder empyema. 1 patient received a Hot AXIOS™ covered lumen apposing metal stent (cLAMS), 1 had a Wallflex™ biliary fully covered self-expanding metal stent (fcSEMS) and the others had NAGI™ covered self-expanding metal stents (cSEMS) inserted. Technical and clinical success was 100% across all procedures with symptomatic improvement noted in all patients. Serum bilirubin measurements decremented post EUS-BD by median 89% (range 85–98%). No procedure related complications were seen. During follow up, 3/4 patients have died (median 7 months (range 3–8) from date of EUS-BD) of end-stage disease (unrelated to the EUS-BD procedure). The 4th patient remains clinically stable on follow-up (2 months after EUS-BD) with no evidence of further biliary symptoms. Conclusion Our early experience of EUS-BD confirms that it is a safe and effective palliative procedure in patients with malignant biliary tract obstruction, in whom surgery and/or PTBD are less favourable. We recommend that EUS-BD is performed after multidisciplinary team discussion and by experienced therapeutic endosonographers. Disclosure of Interest None Declared

A Case of Malignant Biliary Obstruction with Severe Obesity Successfully Treated by Endoscopic Ultrasonography-Guided Biliary Drainage

Here, we present a case of malignant biliary tract obstruction with severe obesity, which was successfully treated by endoscopic ultrasonography-guided biliary drainage (EUS-BD). A female patient in her sixties who had been undergoing chemotherapy for unresectable pancreatic head cancer was admitted to our institution for obstructive jaundice. She had diabetes mellitus, and her body mass index was 35.1 kg/m2. Initially, endoscopic retrograde cholangiopancreatography (ERCP) was performed, but bile duct cannulation was unsuccessful. Percutaneous transhepatic biliary drainage (PTBD) from the left hepatic biliary tree also failed. Although a second PTBD attempt from the right hepatic lobe was accomplished, biliary tract bleeding followed, and the catheter was dislodged. Consequently, EUS-BD (choledochoduodenostomy), followed by direct metallic stent placement, was performed as a third drainage method. Her postprocedural course was uneventful. Following discharge, she spent the rest of her life at home without recurrent jaundice or readmission. In cases of severe obesity, we consider EUS-BD, rather than PTBD, as the second drainage method of choice for distal malignant biliary obstruction when ERCP fails.

Endoscopic ultrasound-guided biliary drainage as an alternative to percutaneous drainage and surgical bypass.

Endoscopic retrograde cholangiopancreatography had been a treatment modality of choice for both benign and malignant biliary tract obstruction for more than half century, with a very high clinical success rate and low complications. But in certain circumstances, such as advanced and locally advanced pancreatobiliary malignancies (pancreatic cancer, cholangiocarcinoma, ampullary tumor) and tight benign strictures, endoscopic retrograde cholangiopancreatography (ERCP) fails. Up to this point, the only alternative interventions for these conditions were percutaneous transhepatic biliary drainage or surgery. Endoscopic ultrasound guided interventions was introduced for a couple decades with the better visualization and achievement of the pancreatobiliary tract. And it's still in the process of ongoing development. The inventions of new techniques and accessories lead to more feasibility of high-ended procedures. Endoscopic ultrasound guided biliary drainage was a novel treatment modality for the patient who failed ERCP with the less invasive technique comparing to surgical bypass. The technical and clinical success was high with acceptable complications. Regarded the ability to drain the biliary tract internally without an exploratory laparotomy, this treatment modality became a very interesting procedures for many endosonographers, worldwide, in a short period. We have reviewed the literature and suggest that endoscopic ultrasound-guided biliary drainage is also an option, and one with a high probability of success, for biliary drainage in the patients who failed conventional endoscopic drainage.

Comparison of percutaneous transhepatic biliary drainage and endoscopic biliary drainage in the management of malignant biliary tract obstruction: a meta-analysis.

To compare percutaneous transhepatic biliary drainage (PTBD) and endoscopic biliary drainage (EBD) for management of malignant biliary tract obstruction (MBTO). PubMed, Google Scholar, and the Cochrane database were searched to 31 December 2013. Main outcome measurements were therapeutic success rate, 30-day mortality rate, overall complications, cholangitis, and pancreatitis. Eight studies (five retrospective and three randomized controlled trials) were included in the meta-analysis with a total of 692 participants. Combined odds ratio (OR) = 2.18 revealed no significant difference in therapeutic success between PTBD and EBD (95% confidence interval [CI] = 0.73-6.47, P = 0.162). However, after excluding two studies that appeared to be outliers, PTBD exhibited a better therapeutic success rate than EBD (pooled OR = 4.45, 95% CI = 2.68-7.40, P < 0.001). Patients who underwent PTBD were 0.55 times as likely to have cholangitis as those who underwent EBD, whereas the overall complication rate, pancreatitis rate, and 30-day mortality were similar between the two procedures. PTBD may be associated with a better therapeutic success rate and lower incidence of cholangitis than EBD, but the overall complication rate, pancreatitis rate, and 30-day mortality of the two procedures are similar.

Percutaneous transhepatic and endoscopic biliary drainage for malignant biliary tract obstruction: a meta-analysis

BackgroundVarious malignant tumors can obstruct the extrahepatic biliary tract. Two major techniques for restoring bile flow in this circumstance are endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD).We conducted a meta-analysis to compare the effectiveness and safety of the two techniques.MethodsMedline, EMBASE and the Cochrane Library database were searched for articles published between January 1980 and December 2013. The outcome measures were therapeutic success rate (primary), 30-day mortality rate and overall complications.ResultsOf 264 screened articles, 3 randomized controlled trials comprising an aggregate total of 183 cancer patients were included in the meta-analysis. Our analysis showed no significant difference in restoration of bile flow between patients treated with EBD and those treated with PTBD (odds ratio (OR) = 2.34, 95% confidence interval (CI) = 0.32 to 17.16, P = 0.401). However, the result of sensitivity analysis indicated that the study conducted by Speer et al. influenced the pooled estimates. After the Speer et al. study was excluded, the therapeutic success rate of patients treated with PTBD was significantly greater than that of those who underwent EBD (OR = 5.48, 95% CI: 2.26 to 13.28, P < 0.001). The 30-day mortality and complication rates were similar in the EBD and PTBD groups.ConclusionsThe results of our meta-analysis indicate that PTBD had a higher therapeutic success rate than EBD in the treatment of malignancy-induced biliary obstruction. The mortality and complication rates of the two techniques were similar.Electronic supplementary materialThe online version of this article (doi:10.1186/1477-7819-12-272) contains supplementary material, which is available to authorized users.

Prospective clinical study of endoscopic ultrasound-guided choledochoduodenostomy with direct metallic stent placement using a forward-viewing echoendoscope

A prospective clinical study was conducted to evaluate the safety, feasibility, and efficacy of endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) with direct metallic stent placement using a prototype forward-viewing echoendoscope. The indication for EUS - CDS in this study was lower biliary obstruction only, and not failed endoscopic biliary drainage, because the aim was to evaluate EUS - CDS for first-line biliary drainage therapy. The technical and functional success rates were 94 % (17 /18) and 94 % (16 /17), respectively. Early complications (focal peritonitis) were encountered in two patients (11 %). No patients developed late complications. EUS - CDS with direct metallic stent placement using a forward-viewing echoendoscope was generally feasible and effective for malignant distal biliary tract obstruction. The forward-viewing echoendoscope was useful, especially for deploying the metallic stent.

Prognostic relevance of circulating CK19 mRNA in advanced malignant biliary tract diseases

To determine the role of circulating tumor cells (CTCs) in prediction of the overall survival of patients with advanced malignant biliary tract obstruction. We investigated the prognostic value of CTCs by examining two markers, cytokeratin (CK) 19 and human telomerase reverse transcriptase (hTERT) mRNA, in 40 patients diagnosed with advanced malignant biliary tract diseases. Quantitative real-time reverse transcription polymerase chain reaction was used to detect CK19 and hTERT mRNA in the peripheral blood of these patients. Overall survival was analyzed using the Kaplan-Meier method and Cox regression modeling. Positive CK19 and hTERT mRNA expression was detected in 45% and 60%, respectively, of the 40 patients. Univariable analysis indicated that positive CK19 mRNA expression was significantly associated with worse overall survival (P = 0.009). Multivariable analysis determined that positive CK19 mRNA expression, patient's age and serum bilirubin were each independently associated with overall survival. CK19 mRNA expression levels in peripheral blood appear to provide a valuable marker to predict the overall survival of patients with advanced malignant biliary tract obstruction.

Prospective Clinical Study of EUS-Guided Choledochoduodenostomy for Malignant Lower Biliary Tract Obstruction

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has recently been reported as an alternative to percutaneous transhepatic biliary drainage (PTBD) in cases of biliary obstruction, when endoscopic biliary drainage (EBD) is unsuccessful. However, prospective studies of EUS-CDS have not yet been performed. We conducted a prospective study to evaluate the safety, feasibility, and efficacy of EUS-CDS in patients with malignant lower biliary tract obstruction. A prospective study to confirm the safety of EUS-CDS was carried out in 6 patients, followed by a trial to evaluate the feasibility and efficacy of EUS-CDS in 12 additional patients. We placed a plastic stent from the duodenal bulb into the extrahepatic bile duct under EUS guidance using an oblique viewing echoendoscope, needle knife, guidewire, and biliary dilators. The site of extrahepatic bile duct puncture was the common hepatic duct in 15 patients and the common bile duct in 3 patients. Mean diameter of the punctured extrahepatic bile ducts was 10 mm (range: 6-20 mm). Technical and functional success rates were 94% (17/18) and 100% (17/17), respectively. Median procedure time was 30 min (range: 10-52 min). Median duration to first oral intake after the procedure was 1 day (range: 1-3 days). Early complications were encountered in three (17%) patients, including focal peritonitis in two patients and hemobilia in one patient. During the follow-up period (median: 163 days; range: 46-484 days), 12 stent occlusion events were observed in nine patients. Re-intervention with exchange of the occluded stent was successful in 8 of 12 (66%) times. Severe early and late complications were not encountered in any patients in this study. Median duration of stent patency by Kaplan-Meier analysis was 272 days. EUS-CDS is safe, feasible, and effective as an alternative to PTBD and EBD in cases of malignant distal biliary tract obstruction. Prospective randomized studies are needed to compare the safety and efficacy of various kinds of endoscopic devices used in EUS-CDS and to compare EUS-CDS with PTBD or EBD.