Palliation for Extrahepatic Biliary Obstruction by Metastatic Colorectal Carcinoma

Objectives: Extrahepatic biliary obstruction due to metastatic colorectal carcinoma, though rare, can account for the occurrence of obstructive jaundice even in the presence of hepatic metastases. The present report aims at reviewing our experience with the palliative treatment of these patients. Methods: During a 5-yr period, 11 patients with obstructive jaundice had documented extrahepatic biliary obstruction secondary to metastatic colorectal carcinoma. Their clinical records were retrospectively analyzed. Results: Nonoperative drainage was performed in eight patients by either the endoscopic (n = 5) or percutaneous (n = 3) route. Palliation was achieved in six patients with a mean hospital stay of 24.5 days (14 % of survival). Three patients died of hepatorenai failure before a drainage procedure could be performed. Blocked stent and cholangitis were noted in two patients. The mean survival was 5 months in the drainage group. Conctusions: The occurrence of obstructive jaundice in patients with metastatic colorectal carcinoma deserves routine investigation to exclude extrahepatic biliary obstruction. Endoprosthesis insertion by nonoperative means should be considered for palliation.     

Extrahepatic biliary obstruction caused by metastatic breast carcinoma.

We describe our experience with seven patients who had extrahepatic biliary obstruction caused by metastatic breast cancer. The interval from the original diagnosis of breast cancer to the development of jaundice averaged 40 months, with a range of 9 months to 8 years. All patients were treated with surgical decompression, radiation, transhepatic catheter drainage, chemotherapy, or a combination of these modalities. Resolution of jaundice was achieved in six patients. Prolonged survival was realized in three; one patient lived for more than 6 years after surgical bypass, and two are alive and well at present (greater than 11 months after relief of biliary obstruction). Extrahepatic biliary obstruction by metastatic breast carcinoma should be distinguished from jaundice due to hepatic parenchymal destruction by this tumor; while the latter implies end-stage cancer, the former has the potential for significant palliation and prolonged survival.     

A NEW THIN ENDOSCOPIC METHOD OF TRANSANAL DRAINAGE TUBE INSERTION FOR ACUTE COLONIC OBSTRUCTION DUE TO COLORECTAL CANCER

Aim: Insertion of a transanal drainage tube is effective in the management of obstructing colorectal cancer. We devised a new method of inserting the transanal drainage tube safely and quickly using a thin endoscope. Methods: Sixteen patients (seven men and nine women) with obstructive left‐sided colorectal cancer were treated by inserting a transanal drainage tube using a thin endoscope. We inserted a transanal drainage tube for 32 patients (21 men and 11 women) with left‐sided colorectal cancer using the conventional method. Results: Drainage tube placement by the conventional method was successful in 29 (90.6%) of 32 patients, while via the new method, it was successful in all 16 patients without major complications. Moreover, median insertion time was significantly shortened (34 minutes for the new method compared with 42 minutes for the conventional method). Conclusion: Management of acute colorectal obstruction by transanal drainage tube insertion using the thin endoscope was effective and safe.     

Clinical outcomes of biliary drainage of malignant biliary obstruction due to colorectal cancer metastases: A systematic review

Background and aimsMalignant biliary obstruction is an ominous complication of metastatic colorectal cancer (mCRC). Biliary drainage is frequently performed to relieve symptoms of jaundice or enable palliative systemic therapy, but effective drainage can be difficult to accomplish. The aim of this study is to summarize literature on clinical outcomes of biliary drainage in mCRC patients with malignant biliary obstruction.MethodsWe searched Medline and EMBASE for studies that included patients with malignant biliary obstruction secondary to mCRC, treated with endoscopic and/or percutaneous biliary drainage. We summarized available data on technical success, clinical success, adverse events, systemic therapy administration and survival after biliary drainage.ResultsAfter screening 3584 references and assessing 509 full-text articles, seven cohort studies were included. In these studies, rates of technical success, clinical success and adverse events varied between 63%-94%, 42%-81%, and 19%-39%, respectively. Subsequent chemotherapy was administered in 17%-56% of patients. Overall survival varied between 40 and 122 days across studies (278-365 days in patients who received subsequent chemotherapy, 42-61 days in patients who did not).ConclusionsSuccessful biliary drainage in mCRC patients can be challenging to achieve and is frequently associated with adverse events. Overall survival after biliary drainage is limited, but is significantly longer in patients treated with subsequent systemic therapy. Expected benefits of biliary drainage should be carefully weighed against its risks.     

Stent versus surgery

Following the introduction of percutaneous and endoscopic biliary drainage there has been an ongoing debate about the indications and outcomes of endoscopic versus surgical drainage in a variety of bilio-pancreatic disorders. The evidence-based literature concerning four different areas of pancreatobiliary diseases have been reviewed. Preoperative endoscopic biliary drainage in patients with obstructive jaundice should not be used routinely but only in selected patients. For patients with biliary leakage and bile duct strictures after a laparoscopic cholecystectomy, endoscopic stent therapy might be first choice and surgery should be used for failures of endoscopic treatment. Surgery is the treatment of choice after transection of the bile duct (the major bile duct injuries). The majority of patients with obstructive jaundice due to advanced pancreatic cancer will undergo endoscopic drainage but for relatively fit patients with a prognosis of more than 6 months, surgical drainage or even palliative resection might be considered. For patients with persistent pain due to chronic pancreatitis surgical drainage combined with limited pancreatic head resection might be first choice for pain relief. Most importantly, the management of patients with these pancreatobiliary diseases should be performed by a multidisciplinary HPB approach and teamwork consisting of gastroenterologists, radiologists and surgeons.     

Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction

AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent(PS) or nasobiliary catheter(NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedurerelated adverse events, stent/catheter dysfunction(occlusion or migration of PS/NBC, developmentof cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution(bilirubin level 3.0 mg/d L) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.RESULTS: In total, 419 patients were included in the study(PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients(46%), bile duct cancer in 172(41%), gallbladder cancer in three(1%), and ampullary cancer in 50(12%). The median serum total bilirubin was 7.8 mg/d L and 324 patients(77%) had ≥ 3.0 mg/d L. During the median time to surgery of 29 d [interquartile range(IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio(SHR) = 4.76; 95%CI: 2.44-10.0, P 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method(PS or NBC).CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.     

肝门区转移癌所致梗阻性黄疸的内镜支架引流治疗临床效果分析

目的探讨内镜治疗肝门区转移癌所致梗阻性黄疸的临床应用价值。方法2006年开始随机选择自愿应用内镜治疗的晚期肝门区转移癌所致梗阻性黄疸患者,应用内镜胆道塑料内支架技术解除胆道梗阻,观察操作成功率、生存期等评价指标。共治疗肝门转移癌梗阻性黄疸患者38例,其中肝癌13例,胆囊癌3例,胃癌14例,食管癌2例,回肠腺癌1例,胰腺癌5例。结果所有患者治疗成功且临床黄疸完全消退,随访生存期92～521d,平均（185．42±104．41）d。随访观察5例患者更换胆道支架,更换时间3～14个月,平均（8．6±4．1）个月,其中支架移位1例,胆泥阻塞2例,肿瘤阻塞2例。结论内镜支架引流术是肝门区转移癌所致梗阻性黄疸的一种有效治疗方法,具有较高的治疗成功率,可以一定程度延长患者的生存期。     

Antipyrine elimination as a dynamic test of hepatic functional integrity in obstructive jaundice.

Antipyrine elimination was studied in 29 patients with obstructive jaundice Antipyrine half-lives calculated using plasma concentrations at four and 24 hours ('short antipyrine test') were significantly correlated with those calculated using six time points (p less than 0.001). Mean antipyrine half-life was 28.3 +/- 8 hours (standard error) and was significantly longer than in normal subjects (p less than 0.001). Antipyrine half-life did not correlate with standard biochemical liver function tests, but correlated positively with the postoperative half-time for clearance of endogenous bilirubin (p less than 0.05), and negatively with hepatic cytochrome P-450 content measured in peroperative liver biopsies (p less than 0.05). Of six patients with antipyrine half-life greater than 20 hours, four died, one preoperatively of gastrointestinal haemorrhage and three postoperatively of sepsis. Serial short antipyrine tests were performed in 13 patients before and after biliary drainage. Those with an initial antipyrine half-life greater than 15 hours showed significant changes after drainage, while those with an antipyrine half-life less than 15 hours did not. The test of antipyrine half-life may aid in selecting high risk patients with obstructive jaundice for percutaneous biliary drainage before definitive surgery, and in determining the optimal time for such preliminary biliary decompression.     

Clinical impact of biliary drainage and jaundice resolution in patients with obstructive metastases at the hilum

OBJECTIVES: For patients presenting with progressive liver or lymph node metastases (LM) causing obstructive jaundice, survival without adequate biliary drainage is very brief. The aim of this study was to assess the impact of endoscopic drainage for biliary obstruction secondary to LM at the hilum on subsequent administration of chemotherapy and on patient outcome. METHODS: Thirty-five patients were studied and underwent insertion of plastic and/or metal stents, endoscopically (80%) or percutaneously and endoscopically (20%), to obtain complete resolution of jaundice. LM originated from colon (n = 16), gastric (n = 5), breast (n = 5), pancreatic (n = 3), and miscellaneous cancers (n = 6). Bile duct strictures were Bismuth type I-II in 13 patients and type III in 22. RESULTS: The overall rate of success (i.e., complete resolution of jaundice) was 86% after a median of three procedures per patient (range, 1-7). Pruritus, jaundice, nausea, abdominal pain, and anorexia improved significantly in 88, 86, 75, 66, and 50% of cases, respectively. Overall median survival was 4 months and was 6.5 versus 1.8 months (p < 0.05) in the groups of patients whose jaundice resolved completely versus incompletely. The type of stricture did not affect survival. Patients with colon and breast cancer who were eligible for second line chemotherapy after optimal drainage had the longest survival (12-16 months). CONCLUSIONS: In our patients with obstructive LM, endoscopic biliary drainage completely resolved jaundice in 86% and improved clinical symptoms and survival, thus enabling these patients to have additional chemotherapy.     

Prognostic significance of the serum thymidine phosphorylase levels in venous blood drainage specimens in patients with colorectal cancer

BACKGROUND/AIMS: We investigated whether the serum Thymidine phosphorylase (TP) levels in venous blood drainage specimens were associated with the prognosis and risk of liver metastasis in patients with resectable colorectal cancer. METHODOLOGY: From 88 patients with colorectal cancer, specimens of venous blood drainage were obtained during operation. The serum TP levels were measured by a highly sensitive Enzyme-Linked Immunosorbent Assay (ELISA) method. RESULTS: Subsequently, 88 patients were divided into two groups based on the levels of TP. The dividing line was determined to be 55ng/mL. The TP-high group (> 55ng/mL) had a significantly shorter overall survival than the TP-low group (< 55ng/mL). A multivariate analysis indicated that the serum TP level in venous blood drainage specimens to be a better prognostic factor independent of the traditional pathologic parameters. The serum TP levels of 3 patients with metachronous liver metastasis were high (> 55ng/mL). CONCLUSIONS: These findings suggest that the serum TP levels in venous blood drainage specimens reflect the prognosis of patients with colorectal cancer undergoing curative resection, particularly the risk of liver metastasis.     

Combined percutaneous transhepatic biliary drainage with port implantation for management of patients with malignant biliary obstruction

BACKGROUND: Endoscopic biliary stent insertion has become a standard palliative treatment for patients with obstructive jaundice caused by malignancies of the hepatobiliary system or metastases of other tumors, such as pancreatic or gastric cancer. Unfortunately, bacterial colonization and encrustation frequently leads to occlusion of plastic stents and, consequently, recurrent cholangitis. METHODS: An external-internal Yamakawa-type endoprosthesis was modified and combined with a titanium, subcutaneously implanted port. This technique was evaluated as a new approach to prolongation of stent patency and prevention of cholangitis. Two patients with obstructive jaundice, one with recurrent gastric carcinoma and the other with invasive gallbladder cancer, underwent treatment with this new method. RESULTS: Effective biliary drainage was established and cholangitis was prevented in both patients for 6 and 2 months, respectively. CONCLUSIONS: A new method of percutaneous transhepatic drainage combined with port implantation was effective and safe in two patients. This technique may be a reasonable treatment option for selected patients, but further evaluation in a larger series is required to establish efficacy and safety.     

Biliary Tract Obstruction Secondary to Malignant Lymphoma: Experience at a Referral Center

Lymphoma is a rare cause of biliary obstruction and, on cholangiography, may mimic other causes of obstructive jaundice. The optimum treatment for these patients is unclear. The aim of this study is to evaluate the incidence, clinical and imaging findings, management, and outcome of biliary obstruction caused by lymphoma. Our database was searched retrospectively for patients with biliary obstruction due to lymphoma between 1999 and 2005. Biliary obstruction secondary to lymphoma was found in 7 (0.6%) of 1123 patients with malignant biliary obstruction. One patient had benign biliary obstruction related to lymphoma. Of the eight patients (five male, three female; mean age, 34.50 ± 17.93 years), four had Hodgkin’s disease and four had non-Hodgkin’s lymphoma. Biliary obstruction occurred as part of the initial or early presentation of lymphoma in two patients. The most common cause of obstruction was compression of the biliary tract by enlarged lymph nodes (six patients). Cholangiographic appearances were diverse: narrowing of the common bile duct (six patients), splayed and narrowed common bile duct (one patient), and multiple strictures and dilatations of the intrahepatic bile ducts (one patient). Biliary drainage was performed in all patients including endoscopic stent placement in six patients, nasobiliary drainage in one, and choledochoduodenostomy in one. Hyperbilirubinemia resolved in all but one of the patients with a stent; however, none could be maintained in a stent-free condition. Five patients died within 1 year after onset of jaundice. One of the surviving patients developed a late benign stricture at the site of the earlier lymphoma. We conclude that lymphoma should be considered in the differential diagnosis of obstructive jaundice, particularly in younger patients. We suggest that biliary drainage by the endoscopic or percutaneous route is necessary for the treatment of these patients. Late benign strictures may develop. Biliary obstruction is a sign of poor prognosis in lymphoma.     

Transpapillary bile duct endoprostheses in obstructive jaundice

12 patients were treated with endoscopic transpapillary biliary endoprosthesis. The indication for biliary drainage was malignant obstructive jaundice in 10 and benign obstructive jaundice in 2 cases. The effectiveness of drainage is indicated by the disappearance of jaundice. The lifetime of the endoprosthesis was maximal 4 months and the survival of the tumor patients maximal 6 months. If the endoprosthesis is occluded replacement by a new one is necessary. Nonsurgical biliary drainage is an alternative method to palliative operation and should be preferred in general inoperability and in patients with irresectable tumors.     

Human neutrophil functions in obstructive jaundice

BACKGROUND/AIMS: The effect of obstructive jaundice on neutrophil function has not been extensively studied. Therefore, the present study aimed at evaluating the effect of obstructive jaundice on human neutrophils. METHODOLOGY: Twelve patients with obstructive jaundice due to common bile duct obstruction underwent endoscopic biliary drainage. Neutrophil functions (chemotaxis and superoxide anion generation) were evaluated before and 7 days after drainage. RESULTS: Neutrophil chemotaxis in response to FMLP (formyl-methionyl-leucyl-phenylalanine) or interleukin-8 was abnormally increased before drainage, and was normalized after drainage. Similarly, enhanced superoxide anion generation in response to FMLP or phorbol myristate acetate before drainage was alleviated after drainage. CONCLUSIONS: The results suggest neutrophil overactivity in patients with obstructive jaundice. The ameliorating effect of biliary drainage on neutrophil overactivity might play a role in the prevention of postoperative complications.     

ENDOSONOGRAPHY‐GUIDED BILIARY DRAINAGE IN CASES WITH DIFFICULT TRANSPAPILLARY ENDOSCOPIC BILIARY DRAINAGE

Background: Recently, reports on a new endoscopic biliary drainage technique utilizing endosonographic guidance (endosonography‐guided biliary drainage [ESBD]) have been increasing. The aim of this study was to evaluate the efficacy of ESBD in cases with difficult transpapillary endoscopic biliary drainage (EBD). Patients and Methods: Sixteen patients with obstructive jaundice who underwent ESBD because of difficult EBD between January 2007 and September 2008 were included. The technical success, complications, and clinical efficacy of ESBD were prospectively evaluated. Results: ESBD was performed via the duodenum, stomach, and esophagus in eight, six and two patients, respectively. Stent placement was successful in all cases and excellent biliary decompression was achieved in all but one patient. One patient developed localized peritonitis following guidewire migration and re‐puncture of the bile duct. In another patient, stent migration was observed one week after ESBD and re‐ESBD was carried out. Three patients underwent surgery for their primary diseases, and stent exchange was carried out in 10 patients during the course. Conclusions: ESBD is an effective treatment for obstructive jaundice that will replace percutaneous transhepatic biliary drainage in cases of difficult EBD and is a possible alternative to EBD in selected cases.     

Clinical outcome after biliary drainage for metastatic colorectal cancer: Survival analysis and prognostic factors

IntroductionBiliary obstruction secondary to colorectal cancer liver metastases is associated with a poor prognosis especially when chemotherapy cannot be re-started. The aim of this study was to determine the survival after biliary drainage and the associated prognostic factors.MethodsPatients from two French centers were included retrospectively after first biliary endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography drainage for biliary obstruction secondary to liver metastases of colorectal cancer, occurring during chemotherapy.ResultsThe final analysis included 69 patients. Overall median survival was 115 days. In univariate analysis, a previous liver surgery, technical and functional success of drainage and restarted chemotherapy were significantly associated with an improved survival. Chemotherapy was restarted after a median of 27 days. When drainage was efficient, survival improved from 33 to 262 days (p < 0.001). In multivariate analysis, significant protective factors for survival included previous a hepatectomy (HR 0.41) and functional success of the drainage (HR 0.29). Predictive factors for death included increased lines of chemotherapy (HR 1.68) and fever before drainage (HR 2.97).ConclusionsThis is the first study concerning the benefits of biliary drainage for malignant biliary obstruction during the course of chemotherapy for colorectal cancer. A successful biliary drainage leads to improved survival and allows achievement of chemotherapy for 70% of patients.     

Palliative transhepatic biliary drainage and enteral nutrition

Simultaneous intestinal and biliary obstruction is a rare but agonizing complication of metastatic abdominal cancer. Although endoscopic procedures exist that relieve jaundice or restore enteral nutrition, they can be impossible to perform for technical or anatomical reasons. We propose a palliative approach for these patients that includes transcutaneous common bile duct drainage, progressive dilation of the transhepatic channel over 1 wk, and, finally, insertion of a permanent silicon catheter that drains bile into the duodenum and is combined with an enteral feeding line. We report three patients whose metastatic abdominal tumors had led to simultaneous jaundice and gastric outlet obstruction, neither of which could be treated endoscopically. In all patients, the transcutaneous bile drainage catheter combined with the enteral feeding line was inserted and tumor symptoms resolved rapidly. As a result, the patients chose to return to home care with enteral nutrition and pain medication. The creation of a transhepatic access for simultaneous enteral bile drainage and nutrition is a technically simple procedure that causes little discomfort to a terminally ill patient. It relieves the symptoms of tumor obstruction, and the option of enteral nutrition and medication can obviate the need for intravenous infusions.     

The redox tolerance test as a measure of hepatic function in patients with obstructive jaundice

The redox tolerance test was performed before percutaneous transhepatic biliary drainage, in 15 patients with obstructive jaundice, and repeated 2 weeks after. Four patients without jaundice were evaluated as a control group. No difference was found in the redox tolerance index between the controls and the group with good bilirubin clearance. On the contrary, the redox tolerance index was significantly lower in the group with poor bilirubin clearance. No significant change in the redox tolerance index was revealed after percutaneous drainage. However, of four patients whose indices were smaller than 0.5 before biliary drainage, three died after developing cholangitis. The redox tolerance test is useful for evaluating hepatic function and predicting outcome in patients with obstructive jaundice.     

EUS-guided versus percutaneous biliary access in patients with obstructive jaundice due to gastric cancer

Background

Gastric cancer is sometimes complicated by obstructive jaundice. However, ERCP may be challenging in patients who have advanced gastric cancer, or recurrent gastric cancer after surgical resection that is complicated by obstructive jaundice. In such cases, percutaneous transhepatic biliary drainage (PTBD) is considered. Recently, EUS-guided biliary drainage (EUS-BD) has been developed. We conducted a retrospective study to compare the efficacy of EUS-BD and PTBD in patients with obstructive jaundice due to gastric cancer.

WHICH TYPES OF DRAINAGE TUBE SHOULD WE SELECT FOR ENDOSCOPIC BILIARY DRAINAGE? CURRENT STATUS

Biliary drainage is a standard procedure for cholangitis or obstructive jaundice due to biliary obstruction. However, criterion for the selection of types of drainage tube is not established. The authors analyzed the types of drainage tube used in the University of Tokyo, Tokyo, Japan, during the month of June 2005, and they treated 63 cases. For drainage for cholangitis (31), the authors used endoscopic naso‐biliary drainage (ENBD) tube in 74.1% and plastic stent in 25.9%. In contrast, for the cholestesis cases (16), the authors used ENBD tube in 37.5% and plastic stent in 63.5%. For the unresectable biliary malignancy cases (8) with improved jaundice, the authors used covered metallic stent in seven distally stricture cases and uncovered metallic stent in one proximally stricture case. The remaining eight cases received plastic stent placement. There were six cases of residual common bile duct stones and two cases of prevention of cholangitis after papillectomy. For the patients with unresectable biliary malignancies at distal portion, the authors consider that covered metallic stent is a standard endoprosthesis. For drainage for cholangitis, the authors used ENBD tube because bile juice flow is able to be checked any time. However, the authors used plastic stent rather than ENBD tube for the drainage of cholestesis. A larger study for selection of drainage tube for these aspects is needed in the future.