Palliation Of Malignant Biliary Obstruction Research Articles

Intrahepatic cholangiojejunostomy for unresectable malignant biliary tumors with obstructive jaundice.

We reviewed our experience with intrahepatic cholangiojejunostomy as a palliative therapy for patients with unresectable malignant diseases involving the ductal confluence or the common hepatic duct. Fifteen patients with malignant biliary obstruction were treated by cholangiojejunostomy at our hospital. Two patients had intrahepatic cholangiocarcinoma, 7 had gallbladder carcinoma, 5 had bile duct carcionoma, and 1 had pancreatic carcinoma. Segment III cholangiojejunostomies were performed in 14 patients and segment V cholangiojejunostomy in 1. Contraindications for surgical resection were locoregional invasion of tumors involving the proper and/or common hepatic artery and portal vein in 15 patients and the presence of hepatic metastases in 6 patients. Liver metastases were detected in 5 of the 7 patients with gallbladder carcinoma. Postoperative complications occurred in 2 patients (13%), but there was no leakage of the cholangioenteric anastomosis in our series. There was no operative mortality after cholangiojejunostomy. Of the 9 patients who survived for more than 6 months after surgery, 7 showed a significant improvement in performance status (PS) (82 +/- 10%) 3 months after the surgery compared with the preoperative PS (70 +/- 7%). Four of the 9 patients had recurrent cholangitis as a late complication, but 4 were completely free from jaundice. Median survival after cholangioenteric bypass was 9 months (range, 2-25 months). With respect to tumor location, the median survival time was 4 months (range, 2-25 months) in patients with gallbladder carcinoma and 15.5 months (range, 12-22 months) in those with bile duct carcinoma. While the median survival period after surgery was only 3 months (range, 2 to 8 months) in the 5 patients with hepatic metastases from gallbladder carcinoma, 2 patients without liver metastasis survived for 9 and 25 months after segment III cholangioenteric bypass. In conclusion, cholangiojejunostomy can provide useful palliation for malignant biliary obstruction when combined with careful patient selection.

Predicting early mortality following percutaneous stent insertion for malignant biliary obstruction: a multivariate risk factor analysis.

Percutaneous stent placement is an accepted method of palliation in malignant biliary obstruction. Factors predicting early mortality after this procedure have not been identified. We performed a retrospective study of 141 patients with malignant biliary obstruction who underwent percutaneous stent placement for biliary decompression to identify the risk factors associated with early mortality (< or = 30 days). Of 14 clinicopathological and laboratory variables analysed blood urea, albumin, haemoglobin and alkaline phosphatase were found to be significant on univariate analysis. The age and gender of the patient along with cancer type, level of obstruction, presence of pyrexia and bilirubin level had no influence on early mortality. Stepwise logistic regression identified the haemoglobin level and blood urea to be independently significant in predicting early mortality. Overall 30-day mortality was 20.5% (29/141). Patients with blood urea over 4.3 mmol/l and a haemoglobin less than 10.9 g/dl had a mortality rate of 52% (12/23) compared with 14% (17/118) in the remainder. Using these two variables a regression equation has been derived which allows calculation of the probability of survival at 30 days after the percutaneous procedure. Laboratory variables in patients with malignant obstructive jaundice can be used to predict mortality following percutaneous stent insertion.

4647 Features of malignant biliary obstruction affecting the short-term patency of metallic stents, a multicenter study.

Background: Metallic stents are an important addition to therapeutic options for the palliation of malignant biliary obstruction. However, little is known about the physical characteristics of tumors which cause the early obstruction of metallic stents. We studied the relationship of certain characteristics of tumors and the patency of metallic stents. Methods: Wallstents (Microvasive, Boston) were inserted endoscopically in 58 patients(mean age; 70.6±8.6, M:F=32:26) with malignant biliary obstruction due to common bile duct, ampullary and pancreatic cancer or due to metastatic lymph node enlargement. The mean follow up duration was 151 days(range: 60-363). Characteristics of malignant strictures, such as length, type and degree of stricture (easy passage of catheter vs. passage of guide wire), were prospectively analyzed between the patent and obstructed groups. Furthermore, the length of the stent, the time needed for full expansion of the stent (≤1day vs. >1day), and the placement site of the distal end of the stent were evaluated as possible factors affecting the patency of the stent. Results: During the follow-up periods, the overall rate of obstruction was 37.9%(22/58).Among the 22 patients with obstruction, the causes of stent blockage were tumor ingrowth(86.5%), distal overgrowth or embedding of cancer(9%) and sludge(4.5%). Two months after stent insertion, we classified 58 patients into obstructed(n=6) and patent groups(n=52).To evaluate the factors affecting the patency of the stent, we compared various physical characteristics of the eventual stricture and the stent between the two groups. No significant differences in patients age, type of tumor, length and type of stricture, and length of the stent, location of the distal end of the stent were found between the two groups. There were, however, significant differences in the degree of stricture (OD; 0.61, 95% C.I.; 0.49-0.77) and the time needed for full expansion (OD; 1.25, 95% C.I.; 1.05-1.50) of the stent. Conclusions: Our study showed that a tighter stricture and refractoriness to full expansion of the stent within 24 hours of placement were related to early stent obstruction. However, biologic factors of the identifiable tumor should also be considered as possible the causes of early dysfunction of biliary metallic stents. Background: Metallic stents are an important addition to therapeutic options for the palliation of malignant biliary obstruction. However, little is known about the physical characteristics of tumors which cause the early obstruction of metallic stents. We studied the relationship of certain characteristics of tumors and the patency of metallic stents. Methods: Wallstents (Microvasive, Boston) were inserted endoscopically in 58 patients(mean age; 70.6±8.6, M:F=32:26) with malignant biliary obstruction due to common bile duct, ampullary and pancreatic cancer or due to metastatic lymph node enlargement. The mean follow up duration was 151 days(range: 60-363). Characteristics of malignant strictures, such as length, type and degree of stricture (easy passage of catheter vs. passage of guide wire), were prospectively analyzed between the patent and obstructed groups. Furthermore, the length of the stent, the time needed for full expansion of the stent (≤1day vs. >1day), and the placement site of the distal end of the stent were evaluated as possible factors affecting the patency of the stent. Results: During the follow-up periods, the overall rate of obstruction was 37.9%(22/58).Among the 22 patients with obstruction, the causes of stent blockage were tumor ingrowth(86.5%), distal overgrowth or embedding of cancer(9%) and sludge(4.5%). Two months after stent insertion, we classified 58 patients into obstructed(n=6) and patent groups(n=52).To evaluate the factors affecting the patency of the stent, we compared various physical characteristics of the eventual stricture and the stent between the two groups. No significant differences in patients age, type of tumor, length and type of stricture, and length of the stent, location of the distal end of the stent were found between the two groups. There were, however, significant differences in the degree of stricture (OD; 0.61, 95% C.I.; 0.49-0.77) and the time needed for full expansion (OD; 1.25, 95% C.I.; 1.05-1.50) of the stent. Conclusions: Our study showed that a tighter stricture and refractoriness to full expansion of the stent within 24 hours of placement were related to early stent obstruction. However, biologic factors of the identifiable tumor should also be considered as possible the causes of early dysfunction of biliary metallic stents.

7261 An audit of metal stent palliation for malignant biliary obstruction.

Background: Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction. Metal stents have several advantages over the polyethylene alternatives but are significantly more expensive. It has been reported that patients must survive beyond 6 months to make metal stents more cost effective. Aims: We audited the performance of expanding metal biliary stents in our endoscopy unit to identify factors that might improve patient selection. Methods: The records of all patients who were selected for endoscopic metal stent insertion at Royal Perth Hospital for malignant biliary obstruction between September 1994 and November 1998 were reviewed. Results: Thirty two patients (16 male, mean age 71yrs (range 34-88)) were identified and followed up for mean 201 days (range 3-810 days). Fifteen (47%) had cholangiocarcinoma, 13 (41%) pancreatic cancer and 4 had metastatic disease. Mortality rates after metal stent insertion were 16%, 41% and 55% at 30, 90 and 180 days. Twenty-four (75%) patients died during the follow-up period and eleven (34%) stents became obstructed with a median time to occlusion of 125 days (range 44 - 729). Patients who died from cholangiocarcinoma had significantly longer survival than pancreatic cancer cases (median 286 v 58 days, p=0.04). No other factors were found to correlate with survival or stent complications. Conclusions: Less than half of this mixed cohort survived beyond 6 months. Metal stent palliation of malignant biliary obstruction should probably be targeted at those with cholangiocarcinoma as these patients tend to survive longer.

4640 A prospective randomised controlled trial of prophylactic versus symptomatic plastic stent exchange for palliation of malignant biliary obstruction.

Background: Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction. Plastic stents are much cheaper than the metal alternatives which are only cost effective in longer surviving patients. However plastic stents are prone to occlusion and the optimal strategy for replacement of plastic stents prior to occlusion remains uncertain. Aim: To compare the outcome of patients with inoperable malignant biliary obstruction palliated by either elective plastic stent exchange or symptomatic exchange when the stent occludes. Methods: Patients with inoperable malignant biliary obstruction that had been successfully treated by ERCP and plastic stent insertion were recruited from 3 centres. They were randomised to either elective plastic stent exchange every 3 months or exchange when symptoms suggestive of stent obstruction developed. All patients were followed up for a minimum of 4 months or until death. Results: Forty patients (18 male, mean age 75 yrs (range 47-90 yrs) were randomised to one of two groups: symptomatic (n=18) or elective (n=22) stent replacement. The cause of biliary stricture was pancreatic cancer in 21 cases, cholangiocarcinoma in 16, ampullary tumor in 2 and metastases in 1. The median follow-up period was 117 days (range 2 435 days) and 34 patients died during follow-up. Overall survival rates were 88%, 63% and 30% at 30, 90 and 180 days. Only 8 (36%) of the elective group actually underwent elective replacement at 3 months, the remainder died before exchange (8), refused exchange (2), occluded before exchange (1) or were unfit for procedure (3). In total, 18 repeat ERCPs were performed in the elective group and 6 in the symptomatic group (p=0.26). Treatment group did not significantly effect survival rates or frequency of stent exchange. Kaplan-Meier analysis showed no significant difference in survival between the two treatment groups (p=0.87). Conclusions: A strategy to electively replace plastic stents in patients with inoperable malignant biliary obstruction does not significantly improve patient survival and is only likely to impact on a minority of patients due to the generally poor survival of such cohorts.

7258 Comparison of metal stents in the management of malignant biliary obstruction.

Background: Studies suggest more technical difficulty and less patency rate for new ultraflex diamond stent (DS) compared to schneider wallstent (WS) for malignant biliary obstruction (MBO). Aim: To report our experience with new DS vs. WS in the management of MBO. Methods: Between 9/95 and 9/97, 14 patients had 18 WS (8 or 10mm in diameter/6.8 or 8cm long) and between 9/97 and 8/99, 19 patients had 26 DS (10mm in diameter/6 or 8cm long)for palliation of MBO. Patients with death due to prior cholangitis, death due to liver failure and those lost to follow-up were excluded. Results: See table below. Conclusion: Our experience suggests that for matched population of patient with MBO, there is no significant difference between DS and WS with the exception of better fluoroscopic visualization with WS over DS.

Tell me more about liver anatomy

Endoscopic palliation of malignant biliary obstruction through the placement of plastic or self-expandable metal stents (SEMS) is the standard treatment for unresectable disease. Endobiliary radiofrequency ablation (RFA) is a therapeutic modality that has been recently used as a primary therapy to restore biliary patency in unresectable biliary malignancies and to treat occluded uncovered biliary SEMS because of tumor ingrowth. Preliminary animal studies have shown the tissue effects of RFA; however, the correlation of histopathologic findings in humans has not been reported. In this paper, we present two patients with a surgically resectable malignant distal biliary obstruction that was secondary to pancreatic adenocarcinoma. After they underwent biliary decompression, endobiliary RFA was performed. This was immediately followed by the placement of an uncovered biliary SEMS. Both patients subsequently underwent pancreaticoduodenectomy. A histopathologic review showed a circumferential zone of necrosis of 1.0–1.5 mm in depth. When compared to published animal data, the zone of necrosis was demonstrably reduced. These discrepant findings are likely multifactorial (e.g., heat-sink phenomenon, differences in study protocol, and comparison of dissimilar tissues). Based on our preliminary histopathologic findings, further studies may be necessary to definitively determine the depth of penetration within the human bile duct during endobiliary RFA.

Endoscopic application of a new self-expanding metal stent for palliation of malignant biliary obstruction

Endoscopic application of a new self-expanding metal stent for palliation of malignant biliary obstruction

Metallic stents in malignant biliary obstruction: prospective long-term clinical results.

The purpose of this prospective study was to evaluate the long-term clinical efficacy of metallic stents when used as the initial palliative treatment of patients with inoperable malignant biliary obstruction. From August 1991 through May 1995, 100 consecutive patients with malignant biliary obstruction were treated with percutaneous placement of metallic stents. The causes of obstruction were bile duct carcinoma (n = 50), pancreatic carcinoma (n = 17), gallbladder carcinoma (n = 6), hepatocellular carcinoma (n = 2), and metastatic lymphadenopathy in the hepatoduodenal ligament (n = 25). We used 123 stents: 64 Gianturco Z stents, 39 Hanaro spiral stents, 16 Wallstents, two tantalum Strecker stents, one Endocoil stent, and one Memotherm nitinol stent. Every 3 months we followed up all patients except those who died. The average length of follow-up was 220 days (range, 4-1125 days). Patient survival and stent patency rates were estimated by life-table analysis. The median length of survival for the entire patient group was 246 days: 25-week and 50-week survival rates were 62% and 25%, respectively. We found no statistically significant difference in the median length of survival between patients with hilar obstruction (256 days) and patients with common bile duct (CBD) obstruction (227 days). Patients with bile duct carcinoma had longer median survival (269 days) than did patients with other conditions (197 days). The overall median length of patency for all stents was 360 days; the 25-week and 50-week patency rates were 81% and 53%, respectively. The stent patency rate at the median length of survival was 71%. The median length of stent patency in patients with hilar obstruction (617 days) was nearly double that of patients with CBD obstruction (324 days). However, the median length of stent patency in patients with bile duct carcinoma showed no statistically significant difference from the median length in patients with other disease. Four patients (4%) died within 1 month after stent placement. Twenty-one patients (21%) developed recurrent jaundice or cholangitis. In order of frequency, the causes of recurrent jaundice were tumor overgrowth, incrustation of bile sludge, duodenal obstruction due to tumor invasion, stent impaction into the bile duct wall, stent malposition, and tumor ingrowth. Metallic stents showed a favorable patency rate with regard to patient survival. In patients with hilar obstruction, the clinical efficacy of metallic stents was superior to that in patients with CBD obstruction. We believe that placement of metallic stents is the procedure of choice for palliation of malignant biliary obstruction.

Endoscopic stenting for palliation of malignant biliary obstruction and formation of bacterial biofilm resulting in stent clogging.

Endoscopic stenting for palliation of malignant biliary obstruction and formation of bacterial biofilm resulting in stent clogging.

Endoscopic therapy vs. surgical palliation of malignant biliary obstruction: A decision analysis

Endoscopic therapy vs. surgical palliation of malignant biliary obstruction: A decision analysis

Trans-hepatic proximal migration of percutaneous-endoscopic biliary stent presenting as an abdominal wall abscess

Endoscopically placed biliary prostheses or stents are an established method of relieving obstruction of the common bile duct, whether due to gallstones or stricture, with less morbidity than percutaneous placement 1 Speer AG Cotton PB Russell RCG. Randomised trial of endoscopic versus percutaneous stent insertion in malignant jaundice. Lancet. 1987; 2: 57-62 Abstract PubMed Scopus (590) Google Scholar or surgery. 2 Shepherd HA Royle G Ross AP. Endoscopic biliary endoprosthesis in the palliation of malignant biliary obstruction of the distal common bile duct: a randomised trial. Br J Surg. 1988; 75: 1166-1168 Crossref PubMed Scopus (499) Google Scholar In malignant disease, this procedure affords an improved quality of life by relieving obstructive jaundice, but is often technically difficult to perform because of tightness of the stricture or distortion of the anatomy. This may necessitate a percutaneous transhepatically inserted internal-external stent, with the possibility of converting it into an endoscopically inserted biliary stent. 3 Tan PC Lai ECS Hui WM Chan SCH. Pitfalls of percutaneous-endoscopic biliary stent placement. Am J Gastroenterol. 1990; 85: 207-209 PubMed Google Scholar Complications of both types of stent include stent blockage, sepsis, and migration that is usually distal. We report here a case of proximal migration of a percutaneous-endoscopic biliary stent presenting as an abdominal wall abscess.

INTEGRATING MEDICAL AND SURGICAL TREATMENTS IN GASTROINTESTINAL, GENITOURINARY, AND BILIARY OBSTRUCTION IN PATIENTS WITH CANCER

Although local expertise needs to be considered, the following general guidelines for the palliation of malignant biliary obstruction have been proposed: (1) patients in good general condition with small tumors should undergo laparotomy to assess resectability and undergo surgical bypass; (2) patients with advanced disease and poor general condition are suitable for endoscopic stenting to reduce jaundice, pruritus, and risk of cholangitis; (3) patients with poor cognition and limited life expectancy should be managed pharmacologically as appropriate; and (4) research is required to assess optimal management for patients between these extremes; however, clinicians can use the previously described guidelines to make these difficult management decisions.

Metal stent implantation for palliation of malignant biliary obstruction: A report of 57 cases

Metal stent implantation for palliation of malignant biliary obstruction: A report of 57 cases

Stent or surgery for the palliation of malignant biliary obstruction: Is the choice clear now?: Smith AC, Dowsett JF, Russell RCG, Hatfield ARW, Cotton PB (Department of Gastroenterology, Middlesex Hospital, London, England). Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction. Lancet 1994;344:1655–1660 (December)

Stent or surgery for the palliation of malignant biliary obstruction: Is the choice clear now?: Smith AC, Dowsett JF, Russell RCG, Hatfield ARW, Cotton PB (Department of Gastroenterology, Middlesex Hospital, London, England). Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction. Lancet 1994;344:1655–1660 (December)

Endoscopic Palliation for Unresectable Pancreatic Carcinoma

Endoscopic stenting has revolutionized the palliation of malignant biliary obstruction. Individuals with biliary obstruction due to pancreatic malignancy are best managed by a team approach comprising individuals with expertise in oncology, surgery, endoscopy, and radiology. The clinical value of alleviating jaundice and associated symptoms of anorexia, pruritus, and malaise cannot be overestimated. These quality-of-life factors deserve more attention in future studies to define subgroups of patients most likely to derive benefit from the array of treatment options. Further technical improvements are required to solve the most important clinical problem of late stent occlusion. New developments such as expandable metallic stents and refinements in existing equipment and techniques have already resulted in measurable gains and hold great promise for future expansion of their use in malignant gastric outlet obstruction secondary to tumor infiltration of the duodenum. Corresponding advances are being made in the fields of percutaneous transhepatic intervention and hepatobiliary surgery such that further prospective randomized trials are necessary to define optimal therapy.

Endoscopic stenting for palliation of malignant biliary obstruction. A review of progress in the last 15 years.

Since the late 1970s, endoscopic biliary stenting has become a standard palliative treatment for obstructive jaundice due to malignancies of the pancreas and the hepatobiliary system. Despite the high initial success rate in achieving biliary drainage, endoscopic stenting therapy has been limited by the clogging of biliary stents, usually after four to five months, due to formation of adherent bacterial biofilm and accumulation of biliary sludge. Various methods for the prevention of bacterial adhesion and prolongation of stent patency have been investigated, including prophylactic antimicrobial agents and bile salts, new stent materials, and new stent designs. Recently, the introduction of self-expandable metal stents has significantly improved the duration of stent patency but the cost is considerably higher. Each method has its own merits as well as specific problems. This article reviews the pathogenesis of biofilm formation on the biliary stents and the latest status of research in avoiding stent occlusion.

A three year follow up of self expanding metal stents in the endoscopic palliation of longterm survivors with malignant biliary obstruction.

Effective palliation of malignant biliary obstruction with conventional 10 or 12 French gauge straight polyethylene endoprostheses is limited by stent occlusion, which typically occurs four to five months after insertion. Short term follow up studies of self expanding metal stents (Wallstent, Schneider, UK) in the treatment of patients with malignant biliary obstruction have shown that their use is associated with fewer episodes of stent occlusion compared with plastic stents. There are few data, however, on the longterm patency and durability of metal stents in malignant disease. Between May 1989 and May 1992, metal stents were inserted in 28 patients with malignant bile duct strictures secondary to ampullary tumour (n = 10), pancreatic carcinoma (n = 10), cholangiocarcinoma (n = 7), and porta hepatis nodes from colorectal carcinoma (n = 1). The follow up of these patients until May 1993 is reported with a median follow up of 14.6 months. Twenty two of 28 (78.6%) patients remained free of jaundice or cholangitis. The median period of stent patency was 8.2 months (range 1.0-32.5). Thirteen patients represented with jaundice or cholangitis and endoscopic retrograde cholangiopancreatography showed evidence of stent occlusion due to tumour ingrowth. Successful clearance of metal stents was achieved by balloon trawling, or insertion of a polyethylene stent. In conclusion, metal stents provide improved longterm palliation for patients with malignant biliary strictures with fewer episodes of occlusion compared with conventional stents.

Endoscopic Stenting for Malignant Biliary Obstruction

To evaluate the results of endoscopic stenting in patients with malignant biliary obstruction. Retrospective review. Surgical endoscopy unit at a tertiary referral center. Plastic endoprosthetic stents were inserted for the relief of biliary obstruction in 131 consecutive patients. Among the 104 patients with malignant biliary obstruction, 60 underwent stenting as definitive palliative treatment. Data on the type and size of stents employed, their effectiveness in relieving jaundice, their complications, and the quality of survival were analyzed. Median survival was 1.93 months. The majority of the stents (88.3%) were placed endoscopically, and single straight stents were most frequently used (96.7%). Jaundice was relieved in 35 patients. Early (< or = 14 days) and late acute cholangitis were found in four and 11 patients, respectively. Early and late stent migration was noticed in two and six patients, respectively. Pancreatitis occurred in one patient, and no papillotomy site bleeding was encountered. When compared with the 18 patients with proximal obstruction at or above the common hepatic duct, the 42 patients with distal ductal obstruction had longer median survival (P = .03) and more effective relief of jaundice (P = .005) and required less antibiotic treatment (P = .03). These 42 patients also enjoyed better quality of survival when it was analyzed with reference to six objective parameters (P = .0018). Stenting offers palliation of malignant biliary obstruction, and the results are particularly encouraging in distal obstruction.

Pancreatic Cancer: Stenting versus Surgery

Endoscopic palliation of malignant biliary obstruction due to pancreatic cancer has become an accepted alternative to surgical bilioenteric bypass over the last decade. Clinical experience and randomi