Percutaneous Biliary Stenting Research Articles

Percutaneous Metallic Stents in Malignant Biliary Obstruction: Comparison of Nitinol and Wall Stents.

Palliation of malign biliary obstruction is important which is commonly carried out by percutaneous biliary stenting. Our primary aim with this study was assessment of performance of wall stents, and nitinol stents for the palliation of malign biliary obstruction. The medical records of 157 patients who underwent biliary stenting in our department between January 1, 1995, and December 31, 2005, were retrospectively analyzed. Technical success, treatment success, mortality in the first 30days, minor, and major complications were evaluated and compared among the wall stent, and the nitinol stent groups in all patients which constituted the primary study endpoints. Additionally, stent patency, and mean patient survival times after stent implantation were evaluated in patients for whom follow-up information could be obtained. A total of 213 metallic stents were placed in 157 patients. Wall stent was placed in 83 of the patients with mean age, and SD of 60.4 and 13.5. Nitinol stent was placed in 74 of the patients with mean age of 57.8, and SD of 15.5. Gender ratio was equal in both groups. Biliary stent dysfunction was observed in 13 patients in each of nitinol, and wall stent groups throughout the study period. There was no statistical difference among re-occlusion rates (p = 0.91). For the nitinol stent group median primary patencytime was 119days (90-185days CI 95%), and for the wall stent group median primary patencytime was 81days (60-150days CI 95%). Nitinol stents, and wall stents are safe options that can be safely used in the percutaneous treatment of malignant biliary obstruction with similar treatment and therapeutic success, low complication rates, and patency times that can extend beyond expected survival times.

Placing Plastic Stent via Percutaneous Transhepatic Biliary Drainage following Failure of Endoscopic Retrograde Cholangiopancreatography: Review of Case Series

AbstractThe aim of this study is to describe the technical procedure, patency, and complications of percutaneous biliary plastic stent insertion following failure of the endoscopic approach. The data from 11 patients who underwent percutaneous plastic biliary stent placement following endoscopic approach failure between March 2022 and December 2023 were retrospectively evaluated. Stent placement was successful in all patients. Reduction of the total serum bilirubin level was achieved in all patients. No major complications occurred in all patients. A plastic stent provided enough drainage for patients with patency in our studies for up to 5 months.

Different percutaneous transhepatic biliary stent placements and catheter drainage in the treatment of middle and low malignant biliary obstruction.

For cases of middle and low biliary obstruction with left and right hepatic duct dilatation, the type of approach and whether different approaches affect the difficulty of puncture operation and intraoperative and postoperative complications have not been discussed in detail. To compare the efficacy of different percutaneous transhepatic biliary stent placements and catheter drainage in treating middle and low biliary obstruction. A retrospective analysis was performed on the medical records of 424 patients with middle and low biliary obstruction who underwent percutaneous liver puncture biliary stent placement and catheter drainage at the Department of Interventional Radiology, Shaanxi Provincial People's Hospital between March 2016 and March 2022. Based on the puncture path, patients were categorized into two groups: Subxiphoid left hepatic lobe approach group (Group A, 224 cases) and right intercostal, right hepatic lobe approach group (Group B, 200 cases). Liver function improvement, postoperative biliary bleeding incidence, postoperative pain duration, and abdominal effusion leakage around the drainage tube were compared between the two groups at 3 d and 1 wk after the surgery. Patient survival time was recorded during follow-up. All 424 surgeries were successful without adverse events. Group A comprised 224 cases, and Group B had 200 cases. There was no statistically significant difference in basic data between Group A and Group B (P > 0.05). No significant difference in postoperative biliary bleeding incidence was observed between the groups (P > 0.05). The decreased rates for total bilirubin (Group A: 69.23 ± 4.50, Group B: 63.79 ± 5.65), direct bilirubin (Group A: 79.30 ± 11.19, Group B: 63.62 ± 5.64), and alkaline phosphatase (Group A: 60.51 ± 12.23, Group B: 42.68 ± 23.56) in the 1st wk after surgery were significantly faster in Group A than in Group B. The decreased rate of gamma-glutamyl transpeptidase was also significantly faster in Group A at both 3 d (Group A: 40.56 ± 10.32, Group B: 32.22 ± 5.12) and 1 wk (Group A: 73.19 ± 7.05, Group B: 58.81 ± 18.98) after surgery (P < 0.05). Group A experienced significantly less peritoneal effusion leakage around the drainage tube than Group B (P < 0.05). The patient survival rate was higher in Group A compared to Group B (P < 0.05). In treating jaundice patients with middle and low biliary obstruction, a percutaneous left liver puncture demonstrated better clinical efficacy than a percutaneous right liver puncture.

Prognostic nomogram for acute pancreatitis after percutaneous biliary stent insertion in patients with malignant obstruction

ObjectiveThis study aimed to develop and validate a nomogram to predict the risk of pancreatitis after percutaneous transhepatic biliary stent insertion (PTBS) in patients with malignant biliary obstruction (MBO).Materials and methodsWe enrolled 314 patients who underwent PTBS for MBO from March 2016 to July 2021 in this retrospective study. We used univariate analysis to identify potential risk factors, while a multivariate logistic regression model was employed to establish a nomogram for predicting the risk of pancreatitis. The discrimination and calibration of the nomogram were evaluated by estimating the area under the receiver operator characteristic curve (AUC) and by bootstrap resampling and visual inspection of the calibration curve. The clinical utility of the nomogram was assessed using decision curve analysis (DCA).ResultsAfter the procedure, 41 (13.1%) patients developed pancreatitis. Based on multivariate logistic regression analysis, young age (OR = 2.57, 95% CI 1.16 to 5.69), stent insertion across the papilla (OR = 6.47, 95% CI 2.66 to 15.70), and visualization of the pancreatic duct (OR = 15.40, 95% CI 6.07 to 39.03) were associated with an elevated risk of pancreatitis. Importantly, the performance of the nomogram was satisfactory, with an identical AUC (0.807, 95% CI 0.730 to 0.883) and high-level agreement between predicted and observed probabilities as suggested in calibration curves. The DCA curve subsequently confirmed the clinical utility.ConclusionA predictive nomogram for pancreatitis after PTBS in patients with MBO was successfully established in the present study.

Percutaneous biliary stent combined with brachytherapy for malignant obstructive jaundice: a multicenter retrospective controlled study

Objective: To investigate the efficacy, safety and prognostic factors of percutaneous biliary stent combined with iodine-125 seed chain brachytherapy (radiotherapy) in the treatment of malignant obstructive jaundice. Methods: Data of 107 cases with malignant obstructive jaundice treated with percutaneous biliary stent implantation from January 2017 to December 2020 were retrospectively analyzed. Among them, 58 cases received biliary stent combined with iodne-125 seed chain brachytherapy (study group), and 49 cases received biliary stent implantation (control group). The changes of bilirubin, stent patency time, complications, overall survival (OS) and prognostic factors were analyzed in both groups. Results: The incidence of complications in the study group and the control group were 17.2% and 18.3% respectively, and the difference was not statistically significant (P=0.974). Serum total bilirubin levels were decreased significantly in both groups at one month after surgery (P<0.001). Postoperative stent patency time was significantly better in the study group (10.0±1.6 months) (95% CI: 8.2～12.5) than that in the control group (5.2±0.4 months) (95% CI: 4.1～6.0, P<0.001). The median OS was longer in the study group (11.2±1.8 months) (95% CI: 9.2～12.8) than that in the control group (8.0±1.1 months) (95% CI: 8.0～12.8, P<0.001). Multivariate analysis result showed that stent combined with brachytherapy (HR=0.08, 95% CI:0.04～0.15, P<0.001) and receiving further anti-tumor therapy after surgery (HR=0.27, 95% CI:0.15~0.49, P<0.001) were independent risk factors affecting the patency of biliary stents. Preoperative percutaneous transhepatic biliary drainage (HR=0.46, 95%CI:0.28～0.74, P=0.002), stent combined with brachytherapy (HR=0.23, 95%CI:0.14～0.39, P<0.001) and receiving further anti-tumor therapy after surgery (HR=0.37, 95%CI:0.22～0.61, P<0.001) were independent risk factors affecting OS. Conclusion: Percutaneous biliary stent combined with brachytherapy is safe and effective in the treatment of malignant obstructive jaundice, which can significantly prolong the patency time of biliary stent and the survival time of patients.

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.

Pathogen detection in patients with perihilar cholangiocarcinoma: Implications for targeted perioperative antibiotic therapy

BackgroundCholestasis should be relieved by biliary drainage prior to major liver resection. This condition is often associated with bacterial colonization of the otherwise sterile biliary system. Cholangitis reduces the regenerative capacity of the remaining liver. Therefore, targeted antibiotic therapy is a key feature in perioperative treatment in patients with perihilar cholangiocarcinoma (pCCC). MethodsBetween December 1999 and December 2017, 251 pCCC patients were treated in our center. In total, 115 patients underwent a microbiological analysis. In addition to the characterization of the specific microorganisms and antibiotic resistance, we analyzed subgroups according to preoperative intervention. ResultsEnterococci (87/254, 34%) and Enterobacteria (65/254, 26%) were the most frequently detected genera. In 43% (50/115) of patients, Enterococcus faecalis was found in the bile duct sample. Enterococcus faecium (29/115) and Escherichia coli (29/115) were detected in 25% of patients. In patients with percutaneous transhepatic biliary drainage (3/8, 38%) or stents (24/79, 30%), Enterococcus faecium was diagnosed most frequently (P < 0.05). Enterococcus faecium and Klebsiella oxytoca were significantly more frequently noted in the time period after 2012 (P < 0.05). With regard to fungal colonization, the focus was on various Candida strains, but these strains generally lacked resistance. ConclusionspCCC patients exhibit specific bacterial colonization features depending on the type of preoperative biliary intervention. Specifically, targeted antibiosis should be applied in this patient cohort to minimize the risk of biliary complications after major liver resection. In our cohort, the combination of meropenem and vancomycin represents an effective perioperative medical approach.

Percutaneous Y-shape reconstructive biliary stenting in Klatskin cholangiocarcinoma through a single left-sided entry.

Percutaneous Y-shape reconstructive biliary stenting in the Klatskin tumor is typically performed through bilateral biliary access. Single access from a right-side biliary entry is the more commonly used side for biliary access in general. We present a successful Y-shaped biliary stent reconstruction through a single left-side biliary approach. Unilateral single access Y-shaped biliary stenting can be technically challenging; when performed through a left biliary approach, an additional technical challenge may arise due to the unusual combination of Y-shaped biliary stent reconstruction and the single left-side biliary approach. We concluded that percutaneous Y-shaped biliary reconstruction through a left-sided unilateral approach is a technically feasible, less invasive interventional approach in managing Klatskin tumor.SIMILAR CASES PUBLISHED: None.

Percutaneous biliary stent combined with brachytherapy using 125I seeds for treatment of unresectable malignant obstructive jaundice: A meta-analysis.

BACKGROUNDMalignant obstructive jaundice (MOJ) is a common pathologic manifestation of malignant biliary obstruction. Recently, several clinical trials have explored the clinical effectiveness of intraluminal 125I seed-based brachytherapy for MOJ patients, and various outcomes have been reported.AIMTo assess the efficacy and safety of percutaneous biliary stents with 125I seeds compared to conventional metal stents in patients with unresectable MOJ.METHODSA systematic search of English-language databases (PubMed, Embase, Cochrane Library, and Web of Science) was performed to identify studies published prior to June 2020 that compared stents with or without 125I seeds in the treatment of unresectable MOJ. The outcomes analyzed included primary outcomes (stent patency and overall survival) and secondary outcomes (complications and liver function parameters).RESULTSSix randomized controlled trials and four retrospective studies involving 875 patients were eligible for the analysis. Of the 875 included patients, 404 were treated with 125I seed stents, while 471 were treated with conventional stents. Unadjusted pooled analysis demonstrated that compared to conventional stents, 125I seed stents extended the stent patency time [hazard ratio (HR) = 0.36, 95% confidence interval (CI) = 0.28-0.45, P < 0.0001] and overall survival period (HR = 0.52, 95%CI = 0.42–0.64, P < 0.00001). Subgroup analyses based on the type of 125I seed stent and type of study design showed consistent results. However, there were no significant differences in the occurrence of total complications [odds ratio (OR) = 1.12, 95%CI = 0.75-1.67, P = 0.57], hemobilia (OR = 1.02, 95%CI = 0.45-2.3, P = 0.96), pancreatitis (OR = 1.79, 95%CI = 0.42-7.53, P = 0.43), cholangitis (OR = 1.13, 95%CI = 0.60-2.13, P = 0.71), or pain (OR = 0.67, 95%CI = 0.22-2, P = 0.47). In addition, there were no reductions in the levels of serum indices, including total bilirubin [mean difference (MD) = 10.96, 95%CI = -3.56-25.49, P = 0.14], direct bilirubin (MD = 7.37, 95%CI = -9.76-24.5, P = 0.4), alanine aminotransferase (MD = 7.52, 95%CI = -0.71-15.74, P = 0.07), and aspartate aminotransferase (MD = -4.77, 95%CI = -19.98-10.44, P = 0.54), after treatment. Publication bias was detected regarding the outcome overall survival; however, the conclusions were not changed after the adjustment.CONCLUSIONPlacement of stents combined with brachytherapy using 125I seeds contributes to a longer stent patency and higher overall survival than placement of conventional stents without extra complications or severe liver damage. Thus, it can be considered an effective and safe treatment for unresectable MOJ.

Outcomes of percutaneous biliary stent placement for malignant hilar biliary obstruction

Abstract Introduction: This study aims to evaluate the effectiveness and safety of the percutaneous biliary stent placement for malignant hilar biliary obstruction (MHBO). Patients and Method: Percutaneous biliary stent was placed in 50 patients with MHBO at Viet Duc University Hospital from June 2019 to July 2020. The patients were monitored during their hospitalization, at 1-month and long-term follow-up on clinical symptoms and laboratory results as well as complications. The effect and safety of this technique were evaluated. Results: Successful rate was 98%. The total serum bilirubin decreased from 280.06 ± 164.65 µmol/L before to 165.09±112.90 µmol/L one week later (p&lt;0.001). Additionally, the AST and ALT significantly decreased (p&lt;0.001). Early complication rate was 22.4%, and late complication rate was 2.0% respectively. The stent occlusion rate was 20.4%. The median survival time was 144.2 days. Conclusion: The percutaneous biliary stent placement is a safe and effective palliative therapy for MHBO, helps to improve liver function and quality of life of patients. Keywords: Biliary stent, hilar biliary obstruction, percutaneous trans-hepatic biliary stent, percutaneous trans-hepatic biliary drainage.

A Retrospective Study of Biliary Drainage Strategies for Patients with Malignant Hilar Biliary Strictures.

PurposeThe main aim of this study was to compare the efficacy and safety of different biliary drainage strategies, including percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary stenting (EBS) and unilateral versus bilateral stenting, in patients with unresectable malignant hilar biliary strictures (MHBSs).Patients and MethodsThis was a retrospective review of patients with inoperable MHBSs who underwent biliary drainage by either EBS or PTBD. Efficacy and safety were compared between the two pathways and between unilateral and bilateral stenting in the EBS group. The survival duration was analyzed with K-M curves and Log rank tests.ResultsFrom January 2015 to December 2019, a total of 206 (126: EBS and 80: PTBD) patients with MHBSs were enrolled in our study and underwent 270 procedures (173: EBS and 97: PTBD). Bilateral stenting was superior to unilateral stenting in terms of clinical success (69.6% vs 50.6%, p=0.039), especially for patients with Bismuth type IV (70.0% vs 30.3%, p=0.002). A higher decrease in bilirubin was seen with PTBD in patients with Bismuth types III–IV (66.9 vs 36.7, p=0.006). A survival advantage was seen in successful drainage (227 days vs 82 days, p<0.001), lower tumor-node-metastasis (TNM) scores (I–II) (195 days vs 139 days, p=0.012), and cholangiocarcinoma (184 days vs 84 days, p=0.001).ConclusionFor patients with advanced MHBSs, bilateral stenting may achieve a better drainage effect than unilateral stenting, and PTBD may have a better performance in relieving cholestasis than EBS. Successful drainage and cholangiocarcinoma may provide greater long-term survival benefits.

A preliminary single-center investigation of percutaneous biliary stenting in malignant hilar biliary obstruction: what impacts the clinical success and the long-term outcomes?

The purpose of this study is to investigate the influencing factors that may impact the clinical success, jaundice-free time, and overall survival in patients of malignant hilar biliary obstruction (MHBO) treated with a self-expanding metallic stent (SEMS). Patients diagnosed with MHBO and treated with SEMS through percutaneous access from 1 Jul. 2013 to 1 Jul. 2018 were enrolled in this monocentric study. Demographic information, disease baseline measurements, and interventional strategies were collected and examined. Bilirubin was measured 1-3days before and 3-7days after stenting using the unit of "μmol/L." The bilirubin reduction ratio was compared between different study groups, which were separated by specific characteristics. Univariate and multivariate analyses were performed to evaluate each characteristic's impact on jaundice-free time (JF) and overall survival time (OS). Statistical analyses were conducted using SPSS 14.0, p < 0.05 indicated significance. Eighty patients were enrolled. Direct bilirubin (DB) and indirect bilirubin (IB) both significantly decreased after stenting (U = 1575.0, p < 0.001; U = 1541.0, p < 0.001). The DB reduction ratio of the "nearby lymph metastases" group was significantly higher (U = 566.0, p = 0.037). The IB reduction ratio in the "single stent" group was significantly higher (U = 554.0, p = 0.018). Sixty-six cases reached jaundice recurrence, the median JF was 6months, and the 95% confidence interval was 4.411 ~ 7.589months. Fifty-eight cases ended in death, the median OS was 7months, and the 95% confidence interval was 5.759 ~ 8.241months. "Nearby lymph metastases" and "distant metastases" independently impacted OS (OR = 2.344, p = 0.013; OR = 3.239, p = 0.042). "IB reduction ratio" independently impacted both JF and OS (OR = 0.422, p = 0.021; OR = 0.315, p = 0.001). The goal of treatment in patients with MHBO is to recover liver function. However, the overall survival is greatly impacted by the presence of metastases. Managing to obtain adequate liver function recovery may improve the long-term outcomes in affected patients.

Percutaneous Transhepatic Treatment for Obstructing Retained Surgical Biliary Stents After Pediatric Liver Transplantation Without Placement of Biliary Drain

Percutaneous Transhepatic Treatment for Obstructing Retained Surgical Biliary Stents After Pediatric Liver Transplantation Without Placement of Biliary Drain

Locally advanced pancreatic carcinoma with jaundice: the benefit of a sequential treatment with stenting followed by CT-guided 125I seeds implantation

ObjectivesTo evaluate the role of sequential therapy with percutaneous biliary stenting and CT-guided iodine-125 seed implantation for locally advanced pancreatic carcinoma with concomitant obstructive jaundice.MethodsBetween January 2016 and December 2018, 42 patients diagnosed with locally advanced pancreatic carcinoma with concomitant obstructive jaundice were enrolled retrospectively. All patients received biliary stenting via percutaneous transhepatic biliary drainage (PTBD) to alleviate obstructive jaundice. Thereafter, twenty-two patients underwent CT-guided iodine-125 seed implantation (treatment group), and 20 did not (control group). The prescribed dose in the treatment group was 110–130 Gy. The clinical data, duration of biliary stent patency, and overall survival (OS) were evaluated.ResultsOverall, the total bilirubin level decreased from 275.89 ± 115.44 to 43.08 ± 43.35 μmol/L (p < 0.001) 1 month after percutaneous biliary stenting. In the treatment group, the postoperative median dose covering 90% of the target volume was 129.71 Gy. Compared with the control group, the treatment group had a long mean duration of biliary stent patency and median OS (11.42 vs. 8.57 months, p < 0.01; 11.67 vs. 9.40 months, p < 0.01, respectively). The overall positive response rates 6 months post-treatment in the treatment and control groups were 72.7% (16/22) and 30% (6/20), respectively. Adverse events of more than grade 3 were not observed during the follow-up.ConclusionSequential therapy with percutaneous biliary stenting and CT-guided iodine-125 seed implantation is an effective and safe treatment alternative for locally advanced pancreatic carcinoma with concomitant obstructive jaundice, which is worthy of clinical application.Key Points• Obstructive jaundice was alleviated after biliary stent placement in all patients, and the total bilirubin level decreased.• The overall positive response rates at 6 months post-treatment were higher in the treatment group than in the control group, and adverse events of more than grade 3 were not observed during the follow-up period.• Sequential therapy with percutaneous biliary stenting and CT-guided iodine-125 seed implantation can prolong biliary stent patency and improve survival.

Percutaneous biliary stent with intraluminal brachytherapy versus palliative surgery in the management of extrahepatic cholangiocarcinoma.

To compare the efficacy and outcomes of self-expandable metallic stent combined with catheter-loaded iodine-125 seeds (SEMS-CL-125I) brachytherapy versus conventional palliative surgery (PS) in advanced extrahepatic cholangiocarcinoma (EHCC). The retrospective analysis consisted of 101 advanced EHCC patients who received SEMS-CL-125I (n = 67) or underwent PS (n = 34). The clinical characteristics, postoperative complications and overall survival (OS) were compared between the two groups. Serum levels of bilirubin, transaminase, and albumin (ALB) were significantly improved at 1month, 3months, and 6months postoperatively in both groups (all P < 0.05). At 1month after operation, the level of ALB in SEMS-CL-125I group was significantly higher than that in PS group (39.07 ± 3.83 vs. 36.60 ± 5.58g/L, P = 0.015). No statistically significant difference was found in postoperative overall complications between the two groups (P = 0.052). Length of hospital stay was significantly shorter (P < 0.001), hospital costs were significantly less (P < 0.001), and OS was significantly better (P = 0.029) in SEMS-CL-125I group compared to PS group. Multivariate analysis further identified PS (HR = 2.90, 95% CI 1.71-4.93, P < 0.001) and higher level of carbohydrate antigen 19-9 (HR = 2.67, 95% CI 1.36-3.79, P = 0.002) as independent predictors of worse OS. SEMS-CL-125I significantly improves outcomes compared with PS and could be a safe and effective treatment for advanced EHCC.

Proton Pump Inhibitors Increase the Risk of Early Biliary Infection After Placement of Percutaneous Transhepatic Biliary Stents

PurposeTo investigate the association between the use of proton pump inhibitors (PPIs) and the risk of early biliary infection (EBI) after the placement of percutaneous transhepatic biliary stents (PTBS) in patients with unresectable malignant biliary obstruction (MBO). Materials and MethodsA total of 136 patients with unresectable MBO (82 males and 54 females) treated with PTBS were included in this multicenter retrospective study. PPIs were prescribed to MBO patients with dyspepsia. The risk factors for EBI were identified by univariate and multivariate analyses. The association between the use of PPIs and EBI was assessed by logistic analyses. ResultsA total of 72 (53%) patients were regular users of PPIs, and 33 (24%) patients developed EBI after PTBS. Univariate and multivariate analyses revealed that diabetes (hazard ratio [HR], 20.3; 95% confidence interval [CI], 5.6–72.9; P <.001), biliary stones (HR, 20.3; 95% CI, 5.6–72.9; P <.001) and PPIs (HR, 4.0; 95% CI, 1.2–12.8; P =.020) were risk factors for EBI. Further analyses of the correlation between the duration of PPIs use and EBI demonstrated that a prolonged use of PPIs significantly increased the risk of EBI (PPIs for <15 days vs 15–30 days: HR, 10.2; 95% CI, 3.1–33.3; P <.001; and PPIs <15 days vs ≥30 days; HR, 20.4; 95% CI, 2.2–192.3; P <.001). ConclusionThe use of PPIs increased the risk of EBI after PTBS in patients with unresectable MBO. Furthermore, the risk of EBI increased with a prolonged duration of PPIs use.

Aneurysms of pancreaticoduodenal arcade: Clinical profile and endovascular strategies.

Background and AimPancreaticoduodenal arcade aneurysms (PDAAs) are uncommon lesions associated with a significant risk of rupture and mortality. This study describes the etiology, clinical presentation, and endovascular management strategies of PDAAs across a spectrum of indications.MethodsThe clinical records of patients with PDAAs referred for endovascular management from January 2018 till November 2019 were retrospectively reviewed. Data on presenting symptoms, associated etiologies, and outcomes after endovascular treatment were collected and studied.ResultsWe found 15 patients with false and 1 patient with true aneurysm of pancreatoduodenal arcade (PDA). The associated conditions were coeliac artery stenosis, severe necrotizing pancreatitis, and chronic pancreatitis or iatrogenic (postendoscopic papillotomy and percutaneous metallic biliary stenting). The main presenting feature was gastrointestinal bleed, while 2 patients had abdominal pain and 1 had gastric outlet obstruction. A multiphase computed tomography scan demonstrated the ruptured aneurysm in all patients. Site of origin of PDAA influenced the choice of transarterial endovascular strategy (coiling for aneurysms of main trunk of arteries and glue injection for those arising from small arterial branches). This was carried out in an emergency setting for 12 patients and as an elective procedure in 4 patients. Technical success was demonstrated in all patients and clinical success in 14. The two patients who had rebleed were salvaged by repeat endovascular procedure. Postembolization syndrome was seen in three patients.ConclusionsWith advancing technology, endovascular strategies continue to evolve. Careful attention to ensure hemodynamic resuscitation and stability, correction of pre‐existing coagulopathy and attention to technique can lead to the possibility of endovascular approaches as a dependable option in the management of ruptured PDAAs.

Percutaneous endobiliary radiofrequency ablation and stents in management of hepatocellular carcinoma with bile duct tumor thrombus: Initial single-institution experience.

Hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) is a rare condition, but it can lead to hepatic failure and is associated with poor prognosis. Treatment for HCC with BDTT remains a challenge. This study aimed to retrospectively evaluate the safety and feasibility of percutaneous endobiliary radiofrequency ablation (EB-RFA) and biliary metal stent placement as an alternative treatment for patients with HCC with BDTT. From October 2014 to December 2016, nine patients (all men, mean age 53.2±12.0; range 40-70) who underwent percutaneous EB-RFA and biliary metal stent placement for HCC with BDTT were included. Stent patency, overall survival, technical and clinical success rate and complications were investigated. Median stent patency from the time of the first EB-RFA was 6.0 months (95% CI, 5.4-6.6 months) and survival from the time of diagnosis was 6.0 months (95% CI, 2.2-9.8 months). Two of 9 patients underwent bilateral EB-RFA and stent placement, one underwent unilateral EB-RFA and stent-in-stent procedure, and one EB-RFA as treatment for biliary metal stent occlusion. One patient who presented with stent occlusion underwent repeat ablations 182 days after the first ablation procedure and 53 days after the re-ablation procedure. Combination therapy was administered to five patients. The technical and clinical success rate were 100% and 89% per patient. After treatment, serum direct bilirubin levels were notably decreased in eight patients. No major complications were observed. Minor complications included one bile duct bleeding, three postoperative abdominal pain and two cholangitis. Percutaneous EB-RFA and biliary metal stent placement might be technically safe and feasible therapeutic options for patients with HCC with BDTT.

Percutaneous Biliary Metallic Stent Insertion in Patients with Malignant Duodenobiliary Obstruction: Outcomes and Factors Influencing Biliary Stent Patency.

To investigate the technical and clinical efficacy of the percutaneous insertion of a biliary metallic stent, and to identify the factors associated with biliary stent dysfunction in patients with malignant duodenobiliary obstruction. The medical records of 70 patients (39 men and 31 women; mean age, 63 years; range, 38-90 years) who were treated for malignant duodenobiliary obstruction at our institution between April 2007 and December 2018, were retrospectively reviewed. Variables found significant by univariate log-rank analysis (p < 0.2) were considered as suitable candidates for a multiple Cox's proportional hazard model. The biliary stents were successfully placed in all 70 study patients. Biliary stent insertion with subsequent duodenal stent insertion was performed in 33 patients and duodenal stent insertion with subsequent biliary stent insertion was performed in the other 37 study subjects. The median patient survival and stent patency time were 107 days (95% confidence interval [CI], 78-135 days) and 270 days (95% CI, 95-444 days), respectively. Biliary stent dysfunction was observed in 24 (34.3%) cases. Multiple Cox's proportional hazard analysis revealed that the location of the distal biliary stent was the only independent factor affecting biliary stent patency (hazard ratio, 3.771; 95% CI, 1.157-12.283). The median biliary stent patency was significantly longer in patients in whom the distal end of the biliary stent was beyond the distal end of the duodenal stent (median, 327 days; 95% CI, 249-450 days), rather than within the duodenal stent (median, 170 days; 95% CI, 115-225 days). The percutaneous insertion of the biliary metallic stent appears to be a technically feasible, safe, and effective method of treating malignant duodenobiliary obstruction. In addition, a biliary stent system with a distal end located beyond the distal end of the duodenal stent will contribute towards longer stent patency in these patients.

A rare case of hepatic sub capsular biloma after cholecystectomy treated by percutaneous drainage and endoscopic biliary stenting: A case report

Bilomas are localized collections of bile which usually happen post-operatively from an injured cystic or bile duct and most of the biloma collections are in the sub hepatic space.