Unresectable Malignant Obstruction Research Articles

The efficacy of temporary placement of nasobiliary drainage following endoscopic metal stenting to prevent post-ERCP cholangitis in patients with cholangiocarcinoma.

Background/Aims:Although endoscopic metal biliary endoprosthesis (EMBE) is widely accepted as the most suitable drainage method for patients with unresectable malignant obstruction, uncontrolled post-procedural cholangitis is still a problem. We aimed to validate a new treatment modality to prevent post-ERCP cholangitis in patients with unresectable cholangiocarcinoma.Patients and Methods:A total of 378 patients who were diagnosed with unresectable malignant biliary obstruction and underwent EMBE or temporary endoscopic nasobiliary drainage (ENBD) following EMBE placement, from January 2010 to July 2016, were enrolled in this retrospective study. Incidence of cholangitis, related infectious indicators, success rate of biliary drainage, and occurrence of complications were evaluated.Results:The risk of overall cholangitis and related infectious indicators was significantly lower in EMBE plus ENBD group than that in EMBE group. The occurrence of cholangitis was 2.4% versus 11.9% (P = 0.004). On further analysis of subgroups, although no difference was detected in nonhilar cholangiocarcinoma subgroup, the incidence of cholangitis and related infectious indicators in hilar cholangiocarcinoma subgroup with EMBE modality were distinctly higher than that with EMBE plus ENBD modality (type I + II was 18.5% vs 0%, P < 0.05; type III + IV was 19.8% vs 3.8%, P < 0.05). No significant difference was found in successful biliary drainage rate and procedure-related complications when all subgroups were compared.Conclusions:The temporary placement of ENBD following EMBE is a simple and effective treatment modality to prevent post-ERCP cholangitis, especially in patients with hilar cholangiocarcinoma.

Endoscopic ultrasound-guided hepaticogastrostomy versus percutaneous transhepatic drainage for malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatography: a retrospective expertise-based study from two centers.

Background:Percutaneous transhepatic biliary drainage (PTBD) is widely performed as a salvage procedure in patients with unresectable malignant obstruction of the common bile duct (CBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) or in case of surgically altered anatomy. Endoscopic ultrasound-guided hepaticogastrostomy (EU-HGS) is a more recently introduced alternative to relieve malignant obstructive jaundice. The aim of this prospective observational study was to compare the outcome, efficacy and adverse events of EU-HGS and PTBD.Methods:From April 2012 to August 2015, consecutive patients with malignant CBD obstruction who underwent EU-HGS or PTBD in two tertiary-care referral centers were included. The primary endpoint was the clinical success rate. Secondary endpoints were technical success, overall survival, procedure-related adverse events, incidence of adverse events, and reintervention rate.Results:A total of 51 patients (EU-HGS, n = 31; PTBD, n = 20) were included. Median survival was 71 days (range 25–75th percentile; 30–95) for the EU-HGS group and 78 days (range 25–75th percentile; 42–108) for the PTBD group (p = 0.99). Technical success was achieved in all patients in both groups. Clinical success was achieved in 25 (86%) of 31 patients in the EU-HGS group and in 15 (83%) of 20 patients in the PTBD group (p = 0.88). There was no difference in adverse events rates between the two groups (EU-HGS: 16%; PTBD: 10%) (p = 0.69). Four deaths within 1 month (two hemorrhagic and two septic) were considered procedure related (two in the EU-HGS group and two in the PTBD group). Overall reintervention rate was significantly lower after EU-HGS (n = 2) than after PTBD (n = 21) (p = 0.0001). Length of hospital stay was shorter after EU-HGS (8 days versus 15 days; p = 0.002).Conclusions:EU-HGS can be an effective and safe mini invasive-procedure alternative to PTBD, with similar success and adverse-event rates, but with lower rates of reintervention and length of hospitalization.

Surgical Palliative Drainage in Un-resectable Malignant Biliary Obstruction

Introduction: Tumor resection is the curative therapy in the patients with malignant obstruction and in nonoperable patients non-surgical palliative therapy, is recommended. These methods may not be successful in some cases because of the various reasons, so the surgical intervention is needed to eliminate biliary obstruction. The aim of this study is to introduce and evaluate a new method for drainage in the patients with un-resectable malignant obstruction in biliary system. Method: This study included 21 patients with un-resectable tumor of biliary tract causing obstruction. After exploring the abdomen, segment II and III of liver will be dissected and then a part of segment III will be removed. In all of cases feeding tube will be put in the duct. Two to three biliary ducts will be specified; thus, feeding tube at least number 5 will be inserted inside the duct and guided through the liver so that it reaches the large ducts inside. A Roux arch will be created afterwards, and will be anastomosed to the liver capsule in parachute procedure. After operation patients will be monitored for the outbreak of cholangitis, anastomosis leakage, pruritus and the decrease of bilirubin level. Results: The new method of surgery in patients with malignant obstruction of the biliary tract was exclusively palliative in all 21 cases. The 30-day mortality in the study group was 14.3% (n=3/21). Pruritus was comparatively cured in the patients (85.7%), and prevalence of cholangitis was decreased after the intervention (19% to 14.3%). Anastomosis was leaked in just one patient. Conclusion: In patients with amalignant obstruction in biliary tract in hilum of liver which non-surgical procedures were not successful, so hepatojejunostomy might be more effective.

Mo1474 Plastic Versus Self-Expanding Metallic Stents for the Management of Malignant Hilar Biliary Strictures

Palliation of jaundice as primary or adjunctive therapy has become the standard approach to patients with unresectable malignant obstruction of the biliary hilum. However, use of plastic or self-expanding metallic stents (SEMS) as preferred management remains controversial. Information on rates of complications are needed before optimal management can be determined.

Dose Biliary Stent Placement Improve the Quality of Life of Patients with Unresectable Malignant Obstruction?

Dose Biliary Stent Placement Improve the Quality of Life of Patients with Unresectable Malignant Obstruction?

SUCCESSFUL TREATMENT USING A SELF‐EXPANDABLE METALLIC STENT IN THE PALLIATION FOR UNRESECTABLE MALIGNANT OBSTRUCTION OF THE COLON AND RECTUM

Background: We attempted the placement of a self‐expandable metallic stent (SEMS) for unresectable malignant obstruction of the proximal colon as well as obstruction of the distal colon and rectum, using a technical device.Patients and methods: Thirty patients were selected to place SEMS. The procedure was performed under endoscopic and fluoroscopic guidance. As a technical device, we used an angiographic introducer to straighten the rectosigmoid region. Moreover, we used a transparent hood to easily obtain a front view of the stricture.Results: Of 30 cases of attempted SEMS placement, SEMS was successfully placed in 26 (87%). The technical success rate was 82% (9/11) in strictures of the proximal colon, while it was 89% (17/19) in those of the distal colon or rectum. According to complications, stent migration occurred in one patient (3%) and restenosis was also observed in one patient (3%).Conclusion: Placement of SEMS is a feasible and effective adjunct and alternative to stoma in malignant large bowel obstruction.

Self-Expanding Nitinol Stent for Malignant Obstructive Dysphagia–Initial Experience

Between July 1992 and December 1994, a total of 31 patients with inoperable or unresctable malignant obstruction of the esophagus or esophagogastric junction were palliated with self-expanding nitinol stents. They were 33 to 86 years old, 55% being 70 years or older. Twenty patients were male. Twenty patients (65%) had squamous cell carcinoma, 10 (32%) had adenocarcinoma and one (3%) had undifferentiated carcinoma. Twenty-five patients (81%) required prestenting dilatation with balloons, bougies or laser. Stent implantation was successful in 30 patients (97%) but failed in one. Two patients had minor complications and one patient with advanced disease died in the hospital one week after the procedure. All stended patients experienced significant short-term relief of dysphagia. Twenty-two patients (73%) were seen at least once after discharge in a follow-up visit. Twenty (66%) were still swallowing satisfactorily when last seen four to 32 weeks after stenting. We conclude that the new nitinol stent represents an important and valuable addition to the treatment options available for palliation of malignant dysphagia.

Percutaneous transhepatic endoprosthesis in malignant obstruction of the bile duct

AbstractThis article reviews our experience with the use of a prosthetic tube, placed percutaneously across unresectable malignant obstructions of the bile duct, in 23 patients. The tube, which is available in various sizes ranging from 8 to 20 Fr., has multiple side holes that allow adequate biliary drainage. A collar at the external end, positioned at skin level, prevents inward migration of the tube. Occlusion of this end by means of a cap allows internal drainage, while external decompression is made possible by connecting it to a closed‐system drainage bottle. This tube is inserted, under fluoroscopic or choledochoscopic guidance, after dilating the sinus tract established by percutaneous transhepatic biliary drainage.Relief of obstructive jaundice was achieved in all patients and the mean survival time of the entire group was 6.8 months. In patients with obstruction at the upper third of the bile duct, survival after placement of the tube ranged from 4 to 38 months, with a mean of 12.4 months. We found this method safe even in the weak and elderly, and tube patency was easy to maintain. We advocate its use particularly in patients with unresectable bile duct cancer, in whom biliary decompression is difficult by other procedures.

Percutaneous-endoscopic biliary stent placement for Billroth II and total gastrectomy with Roux-en-Y enteroenterostomy

Some authors believe the endoscopic placement of large biliary prostheses has become the preferred palliative treatment for unresectable malignant obstruction of the biliary ducts.4 The success rate for inserting these stents endoscopically has approached 90%.3.5.6 In a collected series the mean survival of stented patients has ranged from 13 months for those with ampullary cancers to 5 months for patients with lesions above the midcommon bile duct. However, the presence of prior Billroth II partial gastrectomy with its attendant difficulty in ampullary access has been cited for causing failures of endoscopic approach to prosthetic placement.• Other methods of combined percutaneous-endoscopic biliary stenting (PEBS) that achieve placement of 10-11.5 F internal biliary stents with relative ease have recently been described.4.8·9 Our recently described techniqueS appears to be particularly suited to patients with prior gastric resection. We present two examples, one patient having had prior Billroth II and another with prior total gastrectomy and Roux-en-Y enteroenterostomy.

Palliation of malignant obstruction of the common bile duct by side to side choledochoduodenostomy

A series of forty-eight patients in whom choledochoduodenostomy was performed to relieve malignant obstruction of the common bile duct is reported. A side to side choledochoduodenostomy was performed in forty-six patients, and an end to side in only two in whom it was technically preferable. The operation uniformly cleared the jaundice rapidly, and although the immediate morbidity was high, only 15 per cent of the complications were related to the biliary-duodenal anastomosis. There were no late instances of ascending cholangitis in forty-three survivors of the operation whose progress was followed until they died of the primary disease. The various alternatives to side to side choledochoduodenostomy all appear to be inferior to this operation, for various reasons, and the theoretic objections to its use are refuted by our results. It is our belief that side to side choledochoduodenostomy is the palliative procedure of choice to relieve unresectable malignant obstruction of the distal part of the common bile duct, when the gallbladder is surgically absent or otherwise unsuitable for use. The fashioning of a Roux-Y anastomosis between the common bile duct and the jejunum is needlessly complicated, and should be reserved only for those patients in whom the duodenum cannot be adequately mobilized.