Transhepatic Biliary Stent Placement Research Articles

Comparison between Suprapapillary and Transpapillary Uncovered Self-Expandable Metallic Stent Placement for Perihilar Cholangiocarcinoma

PurposeTo compare the effectiveness, adverse events (AEs), stent patency, and patient survival with suprapapillary and transpapillary uncovered self-expandable metallic stent placement for perihilar cholangiocarcinoma. Materials and MethodsA single-center retrospective study of 54 patients with inoperable perihilar cholangiocarcinoma who underwent percutaneous transhepatic biliary stent placement between January 1, 2019, and August 31, 2021, was conducted. According to stent location, the patients were classified into 2 groups: suprapapillary (S) and transpapillary (T). Demographic data, Bismuth-Corlette classification, type and location of the stent, laboratory data, postprocedural AEs, procedural success, stent occlusion, reintervention rate, and mortality were compared between the groups. ResultsStent placement was suprapapillary in 13 (24.1%) patients and transpapillary in 41 (75.9%) patients. Mean age was higher in Group T (78 vs 70.5 years; P = .046). Stent occlusion rates were similar in the 2 groups (Group S, 23.8%; Group T, 19.5%), as were AE rates, the most common being cholangitis (Group S, 23.1%; Group T, 24.4%). There were no significant differences in revision rate (Group S, 7.7%; Group T, 12.2%) and 30-day mortality rate (Group S, 15.4%; Group T, 19.5%). Ninety-day mortality rate was statistically significantly higher in Group T (46.3% vs 15.4%; P = .046). Preprocedural bilirubin level was higher in Group T, as were postprocedural leukocyte and C-reactive protein (CRP) levels. ConclusionsSuprapapillary and transpapillary stent placement procedures were similar in terms of procedural success, occlusion rate, revision rate, postprocedural AEs, and 30-day mortality. Ninety-day mortality rate and postprocedural leukocyte and CRP levels were higher in Group T, although these patients were also older and had higher preprocedural bilirubin levels.

Sarcopenia increases the risk of early biliary infection after percutaneous transhepatic biliary stent placement.

To assess the association between sarcopenia and the risk of early biliary infection (EBI) after percutaneous transhepatic biliary stent (PTBS) placement in patients with inoperable biliary tract cancer (BTC). In this single center, retrospective observational study, patients diagnosed with inoperable BTC undergoing PTBS placement between January 2013 and July 2021 were enrolled. Preoperative sarcopenia was defined based on skeletal muscle mass measured by computed tomography images on the level of third lumbar vertebra within one month before PTBS placement. Patients were divided into two groups in accordance with the status of sarcopenia. Univariate and further multivariate logistic analyses were performed to determine predictors for EBI. Stratified and interactive analyses were conducted to investigate the stability of results. Further receiver operating characteristic curve was performed to determine the predictive value of sarcopenia on EBI after PTBS placement. Totally, 134 patients were included in this retrospective study, with 45 (33.6%) patients characterized as sarcopenia. The incidence rate of EBI was 26.9% (36/134). Multivariate analyses demonstrated that sarcopenia [Odds ratio (OR), 2.75; 95%CI: 1.11-6.77; P=0.028], obstruction length (OR, 1.04; 95%CI: 1.00-1.08; P=0.030) and diabetes (OR, 2.46; 95%CI: 1.01-5.96; P=0.047) were significant predictors of EBI. There were no significant interactions in different subgroups (P for interaction > 0.05). Moreover, the areas under the curves (AUC) revealed that the combined index containing sarcopenia, obstruction length, and diabetes showed the better predictive value (AUC= 0.723) than either one alone. Sarcopenia increased the risk of EBI in patients with inoperable BTC after PTBS placement. Preoperative assessment of sarcopenia may aid in risk stratification. Patients with sarcopenia should be given intensive monitoring.

Percutaneous transhepatic biliary stent placement in the palliative management of malignant obstructive jaundice: initial experience in a tertiary center in Ghana.

Introductionone of the mainstays of management of malignant biliary obstruction is the decompression of the biliary system and its associated obstructive symptoms. Non-surgical palliative treatment such as percutaneous transhepatic biliary stenting is desirable in many selected patients. However, this service is often not available in many resource-limited countries. We share our initial experience of percutaneous transhepatic biliary stenting for the management of malignant biliary obstruction in our first set of patients with surgically non resectable malignant biliary obstruction in Ghana.Methodspercutaneous transhepatic biliary stenting was performed on the first 23 consecutive patients at the Korle Bu Teaching Hospital. The procedure served as the first palliation for malignant obstruction through interventional radiology. Medical records as well as serum levels of total bilirubin (TBil), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) were used to assess the efficiency of the intervention. Microsoft Excel 2010 was used to analysis the data.Resultsmost patients had resolution of jaundice with marked improvement in liver function and resolution of the itching associated with obstructive jaundice. During the follow-up of cases, one major complication of hemoperitoneum occurred requiring laparotomy. No other major complications such as bile leakage or death occurred. Four (4) patients had sepsis, which was managed.Conclusionthe introduction of the intervention in Ghana has proven to valuable for palliative drainage and relief of obstructive symptoms, hence contributing to better patient management. It is relatively safe with minor complications among Ghanaians with non-resectable obstructive symptoms.

Early Warning Models to Estimate the 30-Day Mortality Risk After Stent Placement for Patients with Malignant Biliary Obstruction.

To develop, validate, and compare early warning models of the 30-day mortality risk for patients with malignant biliary obstruction (MBO) undergoing percutaneous transhepatic biliary stent placement (PTBS). Between January 2013 and October 2018, this multicenter retrospective study included 299 patients with MBOs who underwent PTBS. The training set consisted of 166 patients from four cohorts, and another two independent cohorts were allocated as external validation sets A and B with 75 patients and 58 patients, respectively. A logistic model and an artificial neural network (ANN) model were developed to predict the risk of 30-day mortality after PTBS. The predictive performance of these two models was validated internally and externally. The ANN model had higher values of area under the curve than the logistic model in the training set (0.819 vs 0.797), especially in the validation sets A (0.802 vs 0.714) and B (0.732 vs 0.568). Both models had high accuracy in the three sets (75.9-83.1%). Along with a high specificity, the ANN model improved the sensitivity. The net reclassification improvement and integrated discrimination improvement also demonstrated that the ANN model led to improvements in predictive ability compared with the logistic model. Early warning models were proposed to predict the risk of 30-day mortality after PTBS in patients with MBO. The ANN model has higher accuracy and better generalizability than the logistic model.

Risk Prediction for Early Biliary Infection after Percutaneous Transhepatic Biliary Stent Placement in Malignant Biliary Obstruction

PurposeTo establish a nomogram for predicting the occurrence of early biliary infection (EBI) after percutaneous transhepatic biliary stent (PTBS) placement in malignant biliary obstruction (MBO). Materials and MethodsIn this multicenter study, patients treated with PTBS for MBO were allocated to a training cohort or a validation cohort. The independent risk factors for EBI selected by multivariate analyses in the training cohort were used to develop a predictive nomogram. An artificial neural network was applied to assess the importance of these factors in predicting EBI. The predictive accuracy of this nomogram was determined by concordance index (c-index) and a calibration plot, both internally and externally. ResultsA total of 243 patients (training cohort: n = 182; validation cohort: n = 61) were included in this study. The independent risk factors were length of obstruction (odds ratio [OR], 1.061; 95% confidence interval [CI], 1.013–1.111; P = .012), diabetes (OR, 5.070; 95% CI, 1.917–13.412; P = .001), location of obstruction (OR, 2.283; 95% CI, 1.012–5.149; P = .047), and previous surgical or endoscopic intervention (OR, 3.968; 95% CI, 1.709–9.217; P = .001), which were selected into the nomogram. The c-index values showed good predictive performance in the training and validation cohorts (0.792 and 0.802, respectively). The optimum cutoff value of risk was 0.25. ConclusionsThe nomogram can facilitate the early and accurate prediction of EBI in patients with MBO who underwent PTBS. Patients with high risk (> 0.25) should be administered more effective prophylactic antibiotics and undergo closer monitoring.

Frequency, Severity, and Risk Factors for Acute Pancreatitis After Percutaneous Transhepatic Biliary Stent Placement Across the Papilla of Vater.

To clarify the frequency, severity, and risk factors for acute pancreatitis after percutaneous biliary stent placement across the papilla of Vater for malignant biliary obstruction. This retrospective study included 95 patients who underwent percutaneous biliary metallic stent placement (64 [67.4%] bare stents and 31 [32.6%] covered stents) across the papilla of Vater for malignant biliary obstruction between January 2010 and December 2012. The incidence of acute pancreatitis (Atlanta classification of acute pancreatitis) and its severity (Common Terminology Criteria for Adverse Events, version 4) were reviewed. Additionally, the characteristics of the patients and biliary stents, and the computed tomography findings of the pancreas were evaluated. Grade 3 acute pancreatitis was observed in 23 patients (24.2%); acute pancreatitis of grade 4 or higher was not observed. The incidence of acute pancreatitis was lower in patients with atrophic pancreas than in those with non-atrophic pancreas (7.5 vs. 36.4%, p=0.004). It was also lower in patients with main pancreatic duct (MPD) obstruction than in those without MPD obstruction (12.5 vs. 36.2%, p=0.026). There was no difference in the incidence of acute pancreatitis between bare and covered stents. Percutaneous biliary stent placement across the papilla of Vater for malignant biliary stricture caused acute pancreatitis requiring medication in 24.2% of patients. Atrophy of the pancreas and the presence of a dilated MPD may be associated with a decreased risk of acute pancreatitis. Level 4, Case Series.

Comparative Study of Percutaneous Transhepatic Biliary Stent Placement with or without Iodine-125 Seeds for Treating Patients with Malignant Biliary Obstruction

PurposeTo prospectively evaluate safety and efficacy of biliary stent placement with iodine-125 (125I) seeds in patients with malignant obstructive jaundice (MOJ). Materials and MethodsFrom July 2011 to June 2014, 55 patients were enrolled (group A, 11 men and 17 women, mean age 70.93 y ± 8.58; group B, 14 men and 13 women, mean age 70.26 y ± 9.71). All patients were randomly assigned to placement of a biliary stent with 125I seeds (group A) or biliary stent only (group B). After stent placement, outcomes were measured regarding relief of MOJ. Clinical success rate, survival time, and safety were recorded. P < .05 was considered to indicate significant difference. ResultsStents were successfully placed in all 55 patients. MOJ was relieved in all patients, and there were no significant differences in complications related to stent insertion between the 2 groups. Mean and median stent patency were 191 days ± 19.8 (95% confidence interval [CI], 152–230 d) and 179 days ± 191.4 (95% CI, 87–267 d) in group A and 88.3 days ± 16.3 (95% CI, 61–114 d) and 77 days ± 88.2 (95% CI, 65–86 d) in group B (P < .001, log-rank test). Mean and median survival time were 222.6 days ± 21.0 (95% CI, 181–263 d) and 241 days ± 18.2 (95% CI, 179–270 d) in group A and 139.1 days ± 14.5 (95% CI, 110–167 d) and 142 days ± 16.3 (95% CI, 83–177 d) in group B (P < .001, log-rank test). Conclusions125I seeds combined with biliary stent placement could significantly improve stent patency. The procedure seems to be safe and to extend survival compared with self-expandable biliary stent placement.

Assistance of CT/MR images to plan for one-stage stent placement in biliary obstructions

This study describes and evaluates a simple method of percutaneous intervention planning in order to treat obstructed biliary systems using computed tomography (CT) or magnetic resonance imaging (MRI). CT (n=18) and MRI (n=31) examinations, which were performed during the imaging work-up of 31 patients with malignant biliary obstruction, were used to plan transhepatic percutaneous biliary intervention. The appropriate intrahepatic duct, the entry point on the skin, and the puncture direction and depth were determined on axial CT or MR images. Under fluoroscopic guidance, a 21-G needle was used for puncture, and the puncture was followed by a percutaneous transhepatic cholangiography, the placement of a stent, and the placement of an external drainage catheter. The biliary system was successfully accessed on the first attempt in 16 patients (51.6%). Second or third attempts were required in eight (25.8%) and two (6.4%) patients, respectively, whereas more than three attempts were necessary for the remaining five (16.3%) patients. One-stage percutaneous transhepatic biliary stent placement was performed in 29 patients (93.5%). Two (n=1) and three (n=1) interventional sessions were required in order to successfully complete stent placement in the remaining two cases. The mean fluoroscopy time for one-stage biliary stent placement was 12.6 min +/- 2.6 min, and no major complications were noted. Thorough CT/MRI-based planning is suggested prior to the interventional treatment of malignant biliary obstruction so as to reduce the number of needle passes, the duration of the procedure, the fluoroscopy time, and the number of complications.

The Role of Sonography in Imaging of the Biliary Tract

Sonography is the recommended initial imaging test in the evaluation of patients presenting with right upper quadrant pain or jaundice. Dependent upon clinical circumstances, the differential diagnosis includes choledocholithiasis, biliary stricture, or tumor. Sonography is very sensitive in detection of mechanical biliary obstruction and stone disease, although less sensitive for detection of obstructing tumors, including pancreatic carcinoma and cholangiocarcinoma. In patients with sonographically documented cholelithiasis and choledocholithiasis, laparoscopic cholecystectomy with operative clearance of the biliary stone disease is usually performed. In patients with clinically suspected biliary stone disease, without initial sonographic documentation of choledocholithiasis, endoscopic ultrasound or magnetic resonance cholangiopancreatography is the next logical imaging step. Endoscopic ultrasound documentation of choledocholithiasis in a postcholecystectomy patient should lead to retrograde cholangiography, sphincterotomy, and clearance of the ductal calculi by endoscopic catheter techniques. In patients with clinical and sonographic findings suggestive of malignant biliary obstruction, a multipass contrast-enhanced computed tomography (CT) examination to detect and stage possible pancreatic carcinoma, cholangiocarcinoma, or periductal neoplasm is usually recommended. Assessment of tumor resectability and staging can be performed by CT or a combination of CT and endoscopic ultrasound, the latter often combined with fine needle aspiration biopsy of suspected periductal tumor. In patients whose CT scan suggests hepatic hilar or central intrahepatic biliary tumor, percutaneous cholangiography and transhepatic biliary stent placement is usually followed by brushing or fluoroscopically directed fine needle aspiration biopsy for tissue diagnosis. Sonography is the imaging procedure of choice for biliary tract intervention, including cholecystostomy, guidance for percutaneous transhepatic cholangiography, and drainage of peribiliary abscesses.