Malignant Common Bile Duct Strictures Research Articles

Role of multidetector computed tomography in differentiating benign and malignant common bile duct strictures

Objective: To evaluate the diagnostic features in differentiating malignant from benign common bile duct (CBD) strictures using contrast-enhanced multidetector computed tomography (MDCT). Patients and Methods: An ambispective study from January 1, 2008 to December 31, 2010, on fifty patients with liver function tests suggestive of obstructive jaundice and an ultrasound showing biliary obstruction were included. A nonenhanced computed tomography (CT) was done before the administration of the contrast medium and then scans were routinely obtained in four phases: early arterial , late arterial, portal venous, and delayed phases. The CT scans acquired were reviewed on a picture archiving and communication system workstation. CT findings were interpreted with regard to wall thickness, the location, length involved, enhancement pattern, presence of invasion, and margins of the stricture. These were compared with the attenuation of the normal CBD wall, the maximum CBD diameter proximal, and pancreatic duct dilatation. Results: The mean age ± standard deviation of patients was 62.84 ± 11.61 years (range: 38–82 years). Among the fifty patients included in the study, 31 (62%) had malignant CBD stricture. The involved segments of malignant CBD strictures were significantly longer with significantly larger maximum proximal CBD diameter, considerably thicker and irregular stricture wall and showing more enhancement during delayed phase. No significant differences were found between malignant and benign CBD strictures with respect to stricture location. Conclusions: Presence of irregular margins, invasion into neighboring tissues, long-segment involvement, more proximal CBD dilatation, and hyperenhancement in delayed and portal venous phases in contrast-enhanced MDCT helps in the differentiation of malignant from benign CBD strictures.

Mo1518 One-Step Fluoroless EUS-Guided CBD and Gallbladder Drainage - Change of Paradigm?

EUS-guided drainage of unresectable malignant common bile duct strictures (CBD) after failed ERCP and of the gallbladder (GB) in patients with acute cholecystitis unfit for surgery are alternative minimally invasive treatment modalities to percutaneous drainage. Up to now, available EUS-techniques to perform these procedures have required frequent accessories exchange with risk of dislocation and therefore of bile leak and perforation. Our aim was to investigate one-step fluoroless EUS-guided CBD and GB drainage by using a novel lumen-apposing, self-expanding fully covered metal stent incorporated in an electrocautery enhanced delivery system that allows direct puncture of a target, insertion and release in a one-step-fashion.

Gastric adenocarcinoma associated with lymphangitis carcinomatosa, adrenal metastasis with ectopic ACTH syndrome and malignant common bile duct stricture

Ectopic adrenocorticotrophic hormone (ACTH) syndrome (EAS) commonly occurs secondary to neuroendocrine tumours and small cell carcinoma of lung. EAS has also been reported in association with gastric carcinoids. But, the occurrence of EAS secondary to gastric adenocarcinoma has rarely been reported. A 45-year-old male patient from Bangladesh presented with abdominal pain, jaundice and hyperpigmentation. Extensive work-up revealed poorly differentiating mucin-secreting adenocarcinoma of stomach with lymphangitis carcinomatosa of lung, bilateral adrenal metastasis and malignant common bile duct (CBD) stricture. Laboratory reports were suggestive for ectopic ACTH production. Most of these features are very rare in adenocarcinoma of stomach, and all these rare events occurring in a single patient is probably the rarest.

Percutaneous cystic duct stent placement in the treatment of acute cholecystitis

Percutaneous cholecystostomy is well established as a temporising treatment option in selected patients presenting with acute cholecystitis. However, some patients who undergo cholecystostomy will have persistent discharge, which precludes catheter removal, or may not be medically suitable for future cholecystectomy. In these circumstances, percutaneous cystic duct stenting isa novel treatment option. It may delay or avoid the need for cholecystectomy, and thereby provide definitive treatment in a subset of patients who have acute cholecystitis and a high anaesthetic risk or limited life expectancy. Current application has been limited largely to patients with pre-existing malignant common bile duct strictures, but there is potential for the application to be broadened to include other subsets of patients. In this paper, we describe the technique used for percutaneous cystic duct stenting in a patient and report on its effectiveness. We also explore the technical considerations and consider the application of the procedure on other groups of patients.

Long Duration of Patency with Intrabiliary Plastic Stent Placement for Malignant Biliary Strictures: A Pilot Study

Background/Aim: Stent clogging is a major hindrance to palliative treatment for malignant biliary obstruction. When used for malignant common bile duct strictures, wide-bore, self-expanding metal stents (SEMS) typically remain patent longer than plastic stents. Previous reports have described partial or total occlusion of plastic stents, frequently accompanied by cholangitis, occurring 2-4 months after insertion of standard 10F plastic stents, necessitating their replacement. Because the distal tip of the stent (duodenal side) is located in the duodenal lumen, plastic stents involve sludge deposition from clogging by backward cholangio-infection and food impaction into the stent lumen. Considering these facts, we hypothesized that intrabiliary plastic stent placement (with the distal tip of stent, or the duodenal side, located completely within the bile duct) prolongs the patency of plastic stents, avoiding sludge deposition caused by backward cholangio-infection and food impaction. We performed a pilot study to evaluate the effectiveness of intrabiliary plastic stent placement for upper-middle bile ductal obstruction attributable to cholangiocarcinoma. Patients/Methods: In this study, 33 patients who had malignant proximal and middle biliary obstruction during Jul. 2006 - Aug. 2008 were enrolled: 7 patients for drainage for surgical operation and 26 patients for permanent drainage. Plastic stents (straight type with flaps on both ends) were selected based on the minimal length and degree of the stricture. The distal tip of the stent (duodenal side) was positioned within the bile duct over a guide-wire using a pusher catheter. In cases where it was necessary to remove them, an extraction basket or balloon catheter was used. Diameters of the plastic stents used for this study were 8.5 French (Fr.) in 4 patients, 7 Fr. in 29 patients, and 5 Fr. in 4 patient. Results: In patients who underwent stent placement for drainage related to a surgical operation, all stents were patent until surgical operations. Among patients who underwent permanent drainage, long duration of non-clogged performance was achieved, with one-year patency rate of 49.6%. No directly procedure-related complications were identified. In all cases where it was necessary to remove the indwelled stents, they could be extracted. Conclusions: Our method constitutes another option for endoscopists who treat patients with malignant biliary strictures. Further prospective trials are necessary to assess the efficacy and safety of this method and to develop stents that are designed specifically for intrabiliary placement.

Management of malignant biliary obstruction: Technical and clinical results using an expanded polytetrafluoroethylene fluorinated ethylene propylene (ePTFE/FEP)-covered metallic stent after 6-year experience

To evaluate the efficacy and safety of an expanded polytetrafluoroethylene-fluorinated ethylene-propylene (ePTFE/FEP)-covered metallic stent in the management of malignant biliary obstruction. Eighty consecutive patients with malignant common bile duct strictures were treated by placement of 83 covered metallic stents. The stent-graft consists of an inner ePTFE/FEP lining and an outer supporting structure of nitinol wire. Clinical evaluation, assessment of serum bilirubin and liver enzyme levels were analyzed before biliary drainage, before stent-graft placement and during the follow-up period at 1, 3, 6, 9 and 12 months. Technical success was obtained in all cases. After a mean follow-up of 6.9+/-4.63 months, the 30-day mortality rate was 14.2%. Survival rates were 40% and 20.2% at 6 and 12 months, respectively. Stent-graft patency rates were 95.5%, 92.6% and 85.7% at 3, 6 and 12 months, respectively. Complications occurred in five patients (6.4%); among these, acute cholecystitis was observed in three patients (3.8%). A stent-graft occlusion rate of 9% was observed. The percentage of patients undergoing lifetime palliation (91%) and the midterm patency rate suggest that placement of this ePTFE/FEP-covered stent-graft is safe and highly effective in achieving biliary drainage in patients with malignant strictures of the common bile duct.

The relative roles of magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound in diagnosis of malignant common bile duct strictures: a critically appraised topic

The relative roles of magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) in the investigation of malignant common bile duct (CD) strictures were evaluated using "evidence-based practice" (EBP) methodology. A focused clinical question was constructed. A structured search of primary and secondary evidence was performed. Retrieved studies were appraised for validity, strength and level of evidence (Oxford/CEBM scale: 1-5). Three studies were eligible for inclusion; there were 2 level 3b and 1 level 4 papers. One paper included a patient group appropriate to the question and contained sufficient data to allow analysis. Sensitivity and specificity of MRCP and EUS were (90%, 65%) and (80%, 80%), respectively. In the diagnosis of malignant CD strictures, EUS is more specific than MRCP and may allow cytology to be obtained via a trans-duodenal approach. A multi modality imaging approach is recommended.

Cholecystitis After Metallic Stent Placement in Patients With Malignant Distal Biliary Obstruction

Cholecystitis after metallic stent (MS) placement is an issue requiring attention. From our experience, cholecystitis seemed to occur mainly in patients with tumor involvement to the cystic duct orifice. The aim of the present study was to identify risk factors for cholecystitis in patients treated with covered or uncovered MS. We analyzed 246 patients who received MS placement (covered MS in 171 and uncovered in 75) between August 1997 and May 2005 for the treatment of unresectable distal malignant biliary obstruction. Causative diseases were as follows: pancreatic cancer in 162, papillary cancer in 10, bile duct cancer in 41, and metastatic nodes in 33 patients. Tumor involvement to orifice of the cystic duct (OCD) was diagnosed based on cholangiography and intraductal ultrasonography. Cholecystitis after MS placement was found in 13 patients (5.3%). There was no significant difference in the incidence of cholecystitis between covered (5.8%) and uncovered (4.0%) MS. By univariate analysis, tumor involvement of the OCD, MS placed above the papilla, and stricture located at midportion were associated significantly with cholecystitis. By multivariate analysis, only tumor involvement of the OCD was a risk factor, with an odds ratio of 47.206 (95% confidence interval, 5.84-381.60). Cholecystitis after MS placement is associated with tumor involvement to the orifice of the cystic duct, regardless of the type of stent.

Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial

Most patients with malignant common bile duct strictures are suited only for palliation of jaundice by placement of a polyethylene (PE) stent using an endoscopic retrograde cholangiographic technique. Occlusion of these stents occurs after 3 to 4 months, whereas uncovered self-expanding metal stents (SEMS) remain open twice as long. The initial higher cost of the latter might be balanced by a decreased need for repeat intervention. To compare the patency of 10F PE stents and covered 30F steel SEMS (Wallstent; Boston Scientific Nordic AB, Helsingborg, Sweden). Single-center, prospective, randomized, controlled trial. General hospital in Stockholm, Sweden, which has a catchment area of 0.6 million people. Non-referred, unresectable malignant common bile duct strictures. Endoscopic retrograde cholangiography with plastic stents or covered SEMS. Time to stent failure, requiring a new stent. Similar setting and patients, and costs in Scandinavia. Fifty-one and 49 patients were allocated to the PE stent and SEMS groups, respectively. Fifty-six patients died without stent failure within 10 months (median, 2.6 months). Twenty-two PE stent and 9 SEMS patients (P = .009) developed failure after a median of 1.1 and 3.5 months, respectively (P = .007). Median patency times were 1.8 and 3.6 months in the PE and SEMS groups, respectively (P = .002). Median survival was 4.5 months; in 35 patients with distant metastases, the median survival was 2.5 months (P = .002)(PE group, 1.9 months). The more-effective SEMS are recommended in unresectable patients with malignant common bile duct strictures, who survive a median of 4.5 months. Less costly plastic stents are preferable in the one third of patients who have distant metastases. In our study, the cost was equal.

Covered Wallstent for Palliation of Malignant Biliary Obstruction: Retrospective Single Center Study of 103 Patients

Background: Uncovered metal stents provide longer patency and lower migration rates compared with plastic stents for palliation of malignant common bile duct obstruction. However, stent occlusion due to tumor ingrowth remains a major problem. Wallstent with Permalume covering was designed to overcome this limitation. Aims: To determine the stent patency, survival and incidence of adverse events in patients with unresectable malignant common bile duct stricture who received a covered Wallstent at a single center with a large ERCP practice.

Differentiating Malignant from Benign Common Bile Duct Stricture with Multiphasic Helical CT

To evaluate retrospectively the use of multiphasic helical computed tomography (CT) to differentiate malignant and benign common bile duct (CBD) strictures in patients with only a focal CBD stricture and to determine predictors for this differentiation. Institutional review board approval and informed patient consent were not required. Fifty patients (35 men, 15 women; age range, 35-87 years; mean age, 61.6 years) with only a focal CBD stricture comprised the sample for this study (32 malignant and 18 benign strictures). The diagnosis of all malignant and five benign CBD strictures was confirmed by reviewing patients' surgical and pathology records; in 13 benign CBD strictures, the diagnosis was confirmed by means of clinical features. Multiphasic CT findings were analyzed with regard to the wall thickness, location, length, and enhancement pattern of the involved CBD, the upstream CBD diameter, and other findings. CT features to identify benign and malignant CBD strictures were compared by means of univariate analysis and multivariable stepwise logistic regression analysis. Malignant strictures were longer (17.9 mm +/- 6.6 [+/- standard deviation]) than benign strictures (8.9 mm +/- 6.8) (P < .0001), and upstream CBD diameters were larger in malignant cases (22.0 mm +/- 5.4) than in benign cases (17.8 mm +/- 4.6) (P = .033). The involved wall thickness was more than 1.5 mm in 26 malignant cases and three benign cases (P < .0001). During both hepatic arterial and portal venous phases, greater enhancement than that in the normal CBD were more frequently observed in malignant cases (in 27 and 30 patients for hepatic arterial and portal venous phase scans, respectively) than in benign cases (in two and three patients, respectively) (P < .0001). Results of multivariable stepwise logistic regression analysis showed that hyperenhancement of the involved CBD during the portal venous phase was the only variable that could be used to independently differentiate malignant from benign strictures. Hyperenhancement of the involved CBD during the portal venous phase is the main factor distinguishing malignant from benign CBD strictures.

COVERED WALLSTENT FOR PALLIATION OF MALIGNANT COMMON BILE DUCT STRICTURE: PROSPECTIVE MULTICENTER EVALUATION

Background: Occlusion due to tumor ingrowth is a major drawback in self‐expandable metallic stents. Covering the stent is a probable solution to prevent tumor ingrowth. A manufactured covered self‐expandable metallic stent, Covered Wallstent, has become commercially available. We evaluated the Covered Wallstent in a prospective uncontrolled multicenter setting.Methods: Between October 2001 and October 2003, 97 patients with common bile duct strictures deemed unfit for surgical resection underwent placement of a single Covered Wallstent, and were followed prospectively until April 2004.Results: Placement of the stent was successful in all the patients attempted. As a procedure‐related complication, acute pancreatitis developed in four patients, in one of whom obstruction of the pancreatic duct orifice with the stent body seemed to be a major cause. The 30‐day mortality was 9.3% (nine patients). Stent occlusion occurred in 22 patients as a late (greater than 30 days) complication, due to either tumor overgrowth (14 patients) or encrustation (eight patients). Distal migration of the stent was demonstrated in two other patients. No stent occlusions due to tumor ingrowth were observed. Patency rates of the stent for 3‐, 6‐, and 12‐month periods were, respectively, 90.7, 82.5, and 45.9%.Conclusions: The present results in a large series suggest that placement of the Covered Wallstent is feasible and effective in the palliation of patients with malignant common bile duct strictures. The Covered Wallstent seems to be reliable in eliminating tumor ingrowth. The role of stent covering in promoting stent function should be examined in a prospective comparative study between covered‐ and uncovered Wallstents.

Comparison Study Between Covered and Non-Covered Wallstent for Malignant Common Bile Duct Stricture: Efficacy and Complications

Comparison Study Between Covered and Non-Covered Wallstent for Malignant Common Bile Duct Stricture: Efficacy and Complications

Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study

The systematic use of metal stents to treat biliary obstruction is restricted by high cost compared with plastic stents. The aims of this study were to compare cost and efficacy of plastic stents and metal stents in the treatment of patients with malignant common bile duct strictures and to define factors that predict survival of these patients. One hundred eighteen patients (mean age 75 years) with malignant strictures of the common bile duct were randomized to placement of a plastic stent or metal stent. Comparisons were made with the Mann-Whitney or chi-square test as indicated; survival rates were compared with a Cox proportional hazards model. There was no significant difference in survival between the two groups. Time to first obstruction was longer for patients in the metal stent group (metal stent, median not reached vs. plastic stent, 5 months; p = 0.007). The number of additional days of hospitalization, days of antibiotic therapy, and the numbers of ERCPs and transabdominal US procedures was significantly higher in the plastic stent group. After multivariate analysis, only the presence of liver metastases was independently related to survival (p < 0.0005; OR = 2.25). This variable defined a group with a shorter survival. Median survival of patients with hepatic metastasis at diagnosis was 2.7 months compared with 5.3 months for patients without liver metastasis; in the latter group, the overall cost associated with metal stents was lower than for plastic stents. Metal stent placement is the most effective treatment of inoperable malignant common bile duct stricture. Placement of a metal stent is cost effective in patients without hepatic metastases, whereas a plastic stent should be placed in patients with spread of the tumor to the liver.

Endoscopic retrieval of proximally migrated biliary and pancreatic stents: experience of a large referral center

Background: Proximal migration of a biliary or pancreatic stent is an infrequent event but its management can be technically challenging. Methods: Review of all cases of proximally migrated biliary and pancreatic stents over a 10-year period at a referral pancreatic-biliary center. Data abstracted from patient records included indication for stenting, method of presentation, success of attempt, and method used. Successful methods were determined by reviewing procedure reports. Follow-up was attempted in all patients in whom stent retrieval had failed. Results: Thirty-three proximally migrated bile duct stents, and 26 proximally migrated pancreatic duct stents were identified. Most of the patients were without symptoms. Eighty-five percent of common bile duct stents and 80% of pancreatic duct stents were successfully extracted endoscopically. Seventy-one percent (34 of 48) were retrieved with a basket or balloon. Of the stents not retrieved, two patients did not return for repeat ERCP, three patients with malignant common bile duct strictures were managed with placement of a second stent, three patients with pancreatic duct stents have remained without symptoms with no further retrieval attempts, and three patients with proximally migrated pancreatic duct stents required surgery because of pain and failure of multiple endoscopic retrieval attempts. Conclusion: Over 80% of proximally migrated bile duct and pancreatic duct stents may be extracted endoscopically. Few patients will require surgery. (Gastrointest Endosc 1998;47:486-91.)