Stenting For Biliary Obstruction Research Articles

Managing occluded stents in biliary obstruction using radiofrequency ablation combined with 125I-strand brachytherapy.

We aimed to assess the effectiveness of percutaneous radiofrequency ablation (PRFA) combined with iodine-125 (125I) seed strand brachytherapy (125I-BT) for treatment of occluded biliary stents. From November 2015 to September 2017, 13 consecutive patients with occluded biliary metal stents, implanted for malignant obstruction, underwent PRFA combined with 125I-BT to reopen the bile duct. Data included clinical and technical success, stent patency, complications, and overall survival. The clinical and technical success rates were both 100%. One month after treatment, the total serum bilirubin level had decreased significantly (P < 0.001). Early complications of cholangitis or hemobilia were experienced by one patient each. Three patients (23.1%) had late complications, including two cases of cholangitis and one case of cholecystitis. During the mean follow-up of 233±82.9 days (range, 88-365 days), the stent patency time was 239±26.5 days (95% CI, 187-291 days), and the 6-month stent patency rate was 68.4%. Five patents died; the mean survival time was 298±30.1 days (95% CI, 239-358 days). The 6-month survival rate was 83%. PRFA therapy combined with 125I-BT is feasible and safe for patients with occluded metal stents placed for malignant biliary obstruction. Nevertheless, randomized controlled trails are needed to confirm the effectiveness of this new approach.

Relationship between cholangitis, initial chemotherapy regimen, and overall survival in patients with unresectable pancreatic adenocarcinoma.

e15788 Background: Chemotherapy remains the primary therapy for patients with unresectable pancreatic adenocarcinoma, though response to therapy is variable. Patients with pancreatic adenocarcinoma frequently develop jaundice and cholangitis and require endoscopic biliary stenting. Here, we investigate the association between cholangitis, initial chemotherapy regimen, and one-year survival in patients with unresectable pancreatic adenocarcinoma. Methods: We conducted a retrospective chart review of all patients who received metal stents for biliary obstruction with pancreatic adenocarcinoma over a five-year period at the Massachusetts General Hospital. Only patients with unresectable cancer were included. We compared the association between survival and cholangitis within four subgroups: no chemotherapy, gemcitabine alone or in combination, FOLFOX combination and FOLFIRINOX. The statistical methods used were the chi-squared test for categorical variables, regular ANOVA for continuous variables, and log-rank (Mantel-Cox) test for survival analysis. Results: In total, we identified 74 patients who did not develop cholangitis and 52 patients who developed at least one episode of cholangitis. Among patients undergoing chemotherapy, cholangitis was associated with decreased survival within each subgroup (p-value = &lt; 0.001). At one year from diagnosis, there was an association between cholangitis and decreased survival among patients receiving chemotherapy, independent of the number of episodes of cholangitis. Among those who were not receiving chemotherapy, cholangitis was not associated with survival outcome (p-value = 0.60). Conclusions: In conclusion, the development of cholangitis in patients receiving chemotherapy for metastatic pancreatic cancer is associated with decreased survival. This association is not affected by the number of episodes of cholangitis or by chemotherapy regimen. These data suggest that the development of cholangitis among patients receiving chemotherapy for pancreatic cancer may be a predictor of poor clinical outcomes. Further studies are needed to understand the impact of the local tumor microbial environment and to determine whether cholangitis is a surrogate for a more aggressive disease phenotype.

Functional Self-Expandable Metal Stents in Biliary Obstruction

Biliary stents are widely used not only for palliative treatment of malignant biliary obstruction but also for benign biliary diseases. Each plastic stent or self-expandable metal stent (SEMS) has its own advantages, and a proper stent should be selected carefully for individual condition. To compensate and overcome several drawbacks of SEMS, functional self-expandable metal stent (FSEMS) has been developed with much progress so far. This article looks into the outcomes and defects of each stent type for benign biliary stricture and describes newly introduced FSEMSs according to their functional categories.

Outcomes Trial Demonstrating That Initial Effective Neoadjuvant Chemoradiotherapy for Cure Is a Viable Alternative to Initial Surgery for Cure for Regional Pancreatic Adenocarcinoma

Purpose: To determine through an outcomes trial whether initial laparotomy for possible resection is the only, or even best, chance for cure for regional pancreatic adenocarcinoma (PCa), we compared initial treatment by successful resection to initial treatment with neoadjuvant chemoradiotherapy (CRT) for those found by any reliable staging protocol to have locally invasive unresectable tumor. Methods: 200 reliably staged PCa patients were analyzed as three groups. 159/200 were allocated into two treatment groups based on a staging protocol. CRT-grp1 included 68 with unresectable locally invasive (T3/4) PCa diagnosed initially by only non-operative imaging in 56% and by laparotomy in 44%; all 68 initially received CRT, followed by surgery in selected patients. R-grp2 included 91 with resectable (T1-3) tumor initially resected successfully of all tumor visible; 63/91 (74%) then received postoperative, adjuvant chemo and/or radiotherapy. Due to contraindications/refusal of other treatments, a third group (NoRx-grp3) of 41 with regional PCa diagnosed by EUS received, as initial therapy, only a stent for biliary obstruction. Results: In CRT-grp1 patients, CT scan showed 39/68 tumors downstaged to resectable after CRT. EUS found 24% of these not resectable. 20/68 (29%) had resection after CRT. For R-grp2, accuracy of EUS prediction of vascular invasion was 98% based on pathology. Median survival: 22.8 mo for CRT-grp1 with 8 disease-free 5yr survivors vs. 14.1 mo for R-grp-2 with 2 disease-free 5yr survivors (p=0.005) despite the initially more advanced disease in CRT-grp1 patients. For the 41 NoRx-grp3 patients, median survival was 8.4 mo with no 5yr survivors (p=0.0001); 5.9 mo for the 58% with unresectable T3/4 tumor on EUS, and 11.6 mo for the 42% with resectable T1-3 tumor on EUS (p=0.0002). One yr survival rates for CRT-grp1, R-grp2 and NoRx-grp3 were 78%, 57% and 22%, respectively; 2yr survival rates were 44%, 31%, and 2%, respectively. Mean follow-up for patients alive was >6 yrs. Conclusions: For advanced, unresectable (T:3/4;N:0,1;M:0) PCa treated with initial CRT and later resection of downstaged tumor when possible, the 12% (8/68) cure rate was significantly greater than the 2% (2/91) for earlier stage (T:1-3;N:0,1;M:0) initially resected PCa. Accurate EUS maximizes the benefit of surgery for PCa. When reliable non-operative staging reveals minimal chance of successful tumor resection, survival improves significantly with initial CRT.

A New Self-Expandable and Removable Metal Stent for Biliary Obstruction - A Preliminary Report

We report our experience with a new self expandable metallic stent, a coil spring made from a nickel-titanium alloy. The super elastic characteristic of this metal offers a very strong radial force and previous dilatation of biliary strictures is not necessary. The stent is endoscopically inserted constricted over an introducing catheter, expanding spontaneously after release to its original 8 mm diameter. During the last six months, eleven stents were inserted in nine patients with pancreatic carcinoma to relieve jaundice. Another stent was percutaneously implanted treating a benign stricture in a patient with a choledochojejunostomy after a Whipple operation. Clinical improvement was achieved in all the patients except in one who died from liver metastases 5 weeks later. In two patients, although stents were obstructed after 2 and 4 months from insertion, they were easily removed by pulling their distal end through the endoscopic working channel. After a mean follow up of 4.5 months, patients had no evidence of biliary reobstruction. Although follow-up is short, these results are encouraging, and this new metallic stent seems to have several advantages over the current commercially available ones.

Malignant biliary obstruction complicated by ascites: transjugular insertion of an expandable metallic endoprosthesis.

Although the transjugular approach has long been used to provide safe access to the liver, it has not been used for placement of stents in biliary obstruction. The recent development of an expandable metallic endoprosthesis now makes this method more feasible. The case of a patient with malignant biliary obstruction complicated by ascites is presented herein. Palliation was achieved with an expandable biliary endoprosthesis placed by the transjugular-hepatic vein approach.

Self-expanding biliary stents: preliminary clinical experience.

Nine self-expanding metallic stents were implanted in 7 patients to relieve biliary obstruction. One patient had a benign stricture and 6 patients had malignant stenoses. The stent was inserted percutaneously on a 7 F delivery catheter in 6 patients. Endoscopic transpapillary implantation was performed in one patient. After release the stent expanded to a diameter of 8-10 mm. The correct position was checked by fluoroscopy and cholangiography. In addition, percutaneous cholangioscopy was carried out in 6 patients. No complications were observed within 30 days. Clinical improvement was seen in all patients. After a mean follow-up period of 11 weeks (range: 3-17) 6 of the 7 patients are still alive with no evidence of biliary reobstruction. One patient died of disseminated malignancy. The initial results are promising. The wide-bore diameter, the macroporous configuration and the small surface area of the implanted self-expanding stents would seem to be associated with lower rates of infection, clogging and migration as compared with conventional endoprostheses. Further trials are warranted to determine the future role of self-expanding stents in biliary obstruction.