金属胆道支架治疗恶性梗阻性黄疸的临床疗效

目的 探讨胆道金属支架治疗恶性阻塞性黄疸(MOJ)的临床疗效. 方法 回顾性分析1998年2月至2009年2月的241例MOJ患者临床资料,所有患者均接受经皮肝穿刺胆道金属支架置入术.评价预后以死亡为研究终点,随访时间截至2010年2月,统计学分析比较患者生存期及治疗前后各实验室指标改变,评价疗效.计数资料采用x2检验,计量资料用t检验;生存率比较采用Kaplan-Meier法;Cox回归模型评估各危险因素对生存时间的影响. 结果 支架置入技术成功率为100％.支架置入术后4周内血清胆红素下降明显(P＜ 0.05),术后院内死亡11例,失访28例,202例获得完整随访资料;随访时间为8～ 193周,其13周、26周、39周、52周的生存率分别为87％、66％、56％、41％,中位生存期为43.55周.同期支架通畅率分别为70％、46％、36％和24％,平均通畅时间为27.57周.Cox回归分析示:术前胆红素＜ 221 μmol/L(P=0.01)及术后胆红素下降比例超过50％(P=0.002)者预后较好.结论 胆道金属支架置入术治疗MOJ技术安全、可行,可有效缓解黄疸症状,延长生存期.高胆红素血症及胆红素下降程度低于50％是影响MOJ患者生存率的因素.     

Endobiliary stents for palliation in patients with malignant obstructive jaundice

BACKGROUND: Endobiliary drainage for malignant obstructive jaundice presents a viable palliative alternative. Its role and efficacy depend on factors related to the stent, procedure, and patient. GOALS: To review the evidence in the literature in which settings plastic or metal stents are cost-effective, and whether adjuvant measures or patient-related factors affect duration of stent patency. STUDY: Using databases a literature search was performed for papers published from 1979 to April 2004. All retrieved papers reporting experimental or clinical observations were rated according to strength of evidence, and carefully analyzed. RESULTS AND CONCLUSIONS: Metal stents (Wallstent) stay patent longer than plastic stents (large-bore polyethylene with side-holes), overall median 250 and 110 days, respectively, and seem cost-effective in patients with longer than about 6 months survival, which cannot be accurately predicted. Antibiotics or choleretic agents do not prolong stent patency in clinical settings. In case of stent occlusion, indicated stent exchanges and insertion of a plastic stent, respectively, seem cost-effective in patients initially treated with plastic and metal stents.     

胆道支架引流术对恶性梗阻性黄疸患者肝功能的影响

目的探讨恶性梗阻性黄疸行内镜下胆道金属支架引流术(EBMSD)的临床疗效。方法选取北京军区总医院2012年1月-2014年4月接受EBMSD治疗的48例恶性梗阻性黄疸患者为研究对象,比较患者手术前后血清ALT、AST、ALP、TBil、DBil及GGT等肝功能指标的变化情况。计量资料组间比较采用t检验。结果 48例患者中,成功置入金属支架44例,手术成功率为91.67%,其中单支引流34例,双支引流10例。患者术后肝功能各项指标较术前均有所改善,TBil、DBil、ALT、AST、ALP及GGT均显著下降,差异具有统计学意义(P值均0.01);双支引流患者肝功能指标改善情况优于单支引流患者,差异具有统计学意义(P值均0.01);术后成功随访38例,随访患者3个月存活率为94.25%,6个月存活率为73.39%。结论采用EBMSD治疗恶性阻塞性黄疸疗效明显,可有效缓解临床症状,提高患者的生活质量,且左右双支引流效果优于单支引流。     

Management of occluded uncovered metallic stents in patients with malignant distal biliary obstructions using covered metallic stents

BACKGROUND: Self-expandable metallic stents (EMSs) have been widely used for the palliative treatment of unresectable malignant biliary obstructions, but EMSs are often occluded owing to tumor ingrowth via the wire mesh. Currently, there is no consensus on the management of occluded EMSs. We evaluated the efficacy of a covered EMS as a second endoprosthesis in patients with an occluded EMS. METHODS: Forty patients with an occluded uncovered EMS (14 men, 26 women; mean age 72 y, range 41 to 89 y) were studied. The patients suffered from the following: pancreatic cancer in 18, bile duct cancer in 11, gallbladder cancer in 5, lymph node metastasis in 4, and papillary cancer in 2. Of these, 26, 7, and 7 were treated with a covered EMS, an uncovered EMS, and a plastic stent (PS), respectively. The second stent was inserted as a stent-in-stent. RESULTS: The mean patent period for the covered EMS was 220 days, whereas the mean patent periods for the uncovered EMS and plastic stent were 141 and 58 days, respectively. The cumulative patency of the covered EMS group was significantly higher (P=0.0404) than that of the uncovered EMS group. No significant differences in survival were observed between the covered and uncovered groups. No serious complications occurred. CONCLUSION: Insertion of a covered EMS is an effective and safe treatment for an occluded uncovered EMS.     

Self-expandable metallic stents for malignant duodenal obstruction caused by biliary tract cancer

BACKGROUND: Malignant duodenal obstruction is a common event in patients with advanced biliary tract cancer. Because bypass surgery is accompanied by significant morbidity, self-expandable metallic stents have emerged as a possible alternative for palliation. METHODS: Twenty patients with biliary tract cancer (7 gallbladder, 13 Klatskin tumors) and duodenal obstruction were treated with metallic stents at a single institution between 1999 and 2001. Survival, morbidity, and stent function were studied prospectively. The ability to eat was assessed by using a scoring system. RESULTS: Stent placement was technically successful in all patients. An additional stent was required in 6 cases (4 occlusions, 2 dislocations). Median survival was 20.5 weeks; there was no treatment-related death. Twenty-eight biliary stent exchanges were performed in 13 (65%) patients. Erosive reflux esophagitis improved in 11 of 12 (92%) cases. After 4 weeks, all 17 surviving patients tolerated soft or solid food, whereas 13 of 17 (77%) tolerated a more solid diet (p < 0.001, gastric outlet obstruction scoring system). Twelve of 17 (71%) patients gained a median of 1.5 kg of body weight (p = 0.001). The median Karnofsky scale increased from 50% to 60% in 13 of 17 (77%) patients. CONCLUSIONS: Self-expandable metallic stents are a safe, efficacious, and minimally invasive treatment option for palliation of patients with duodenal obstruction from biliary tract cancer. Technical complications can be managed endoscopically and the bile duct remains accessible for endoluminal treatment.     

Endoscopic biliary drainage for patients with unresectable pancreatic cancer with obstructive jaundice who are to undergo gemcitabine chemotherapy

INTRODUCTION Pancreatic cancer is one of the most intractable mali- gnancies of the digestive tract and has a dismal prognosis. Such cancer in most patients is in an advanced stage when they first visit medical facilities, and management of obstructive ja…     

Endoscopic removal of malfunctioning biliary self-expandable metallic stents

BACKGROUND: Endoscopic removal of malfunctioning self-expandable metallic biliary stents (SEMS) is difficult and not well described. The aim of this study is to review the indications, the techniques, and the results of SEMS removal in a cohort of patients with malfunctioning stents. METHODS: All patients who underwent an attempt at endoscopic removal of biliary SEMS over a 5-year period were retrospectively identified. The main indications for SEMS removal were the following: distal migration of the stent or impaction to the duodenum, impaction into the bile-duct wall, tissue ingrowth, and inappropriate length of the stent causing occlusion of intrahepatic ducts. SEMS were removed by using foreign-body forceps or polypectomy snares. RESULTS: Endoscopic removal of 39 SEMS (13 uncovered and 26 covered) was attempted in 29 patients (17 men; mean age, 66 years). SEMS extraction was attempted after a mean of 7.5 months (8.75 months standard deviation) post-SEMS insertion. Removal was successful in 20 patients (68.9%) and in 29 SEMS (74.3%). Covered SEMS were effectively removed more frequently than uncovered ones: 24 of 26 (92.3%) and 5 of 13 (38.4%), respectively (p < 0.05). No major complications were recorded. Multivariate analysis showed that the time interval between insertion and removal, SEMS length, stent-mesh design (zigzag vs. interlaced), and indication for removal were not predictive of success at stent removal. CONCLUSIONS: Endoscopic removal of biliary SEMS is feasible and safe in more than 70% of cases. Because only 38% of uncovered SEMS were removable, the presence of a stent covering is the only factor predictive of successful stent extraction. The presence of diffuse and severe ingrowth was the main feature limiting SEMS removal.     

Management of dysfunctional covered self-expandable metallic stents in patients with malignant distal biliary obstruction

Background

Endoscopic placement of covered self-expandable metallic stents (CSEMSs) is effective for distal malignant biliary obstruction. However, management of dysfunctional CSEMSs has not been established.

Methods

Between March 1998 and July 2007, a total of 74 patients who underwent endoscopic re-interventions for CSEMS dysfunction were analyzed. Second stent insertion (CSEMS or plastic stent) or mechanical cleaning of the occluded CSEMS was performed endoscopically. The period between second stent insertion and stent dysfunction or patient death (time to dysfunction; TTD) was calculated. The cleaned initial CSEMSs were analyzed as second stents.

Results

Dysfunction of the second stent occurred in 17 of 37 patients (45.9 %) in the CSEMS group, 16 of 20 (80.0 %) in the plastic stent group, and 13 of 17 (76.5 %) in the cleaning group. The median TTD of each group was 176, 57, and 46 days, respectively. The cumulative TTD was significantly higher in the CSEMS group than in the plastic stent and cleaning groups (P = 0.08). From the multivariate analysis, sludge occlusion of the first CSEMS was identified as a significant risk factor for second stent dysfunction (HR, 2.51; 95 % CI, 1.19–5.46), and placement of the second CSEMS significantly reduced the risk of dysfunction (HR, 0.39; 95 % CI, 0.18–0.79).

Conclusions

Insertion of a new CSEMS should be considered as the treatment of choice for the management of dysfunctional CSEMSs.     

Primary patency of percutaneously inserted self-expanding metallic stents in patients with malignant biliary obstruction

Background:

Effective bile duct drainage is crucial to the health-related quality of life of patients with jaundice caused by obstruction of the bile duct by inoperable malignant tumours.

Methods:

All patients who were treated at Uppsala University Hospital, Sweden with percutaneous stenting between 2000 and 2005 were identified retrospectively. Data on the location of the obstruction and type of stent used, date and cause of death and date of stent failure were abstracted from the patients'' notes. Stent patency was defined as the duration from the insertion of the stent to the date of failure. In cases in which the cause of death was directly related to failure of the stent, the date of death was defined as the patency endpoint.

Results:

A total of 64 patients (34 women, 30 men) were identified. Their mean age was 71 years (standard deviation 11 years). The median length of patency was 11.4 months. Stent diameter >10 mm and distal stricture were found to be associated with significantly longer patency time in univariate Cox proportional hazard analysis. In multivariate Cox proportional hazard analysis, only location of the stricture was found to be independently and significantly associated with patency time.

Discussion:

Percutaneous stenting is a good alternative for patients with obstructive jaundice and a life expectancy ≤1 year. It may give instant relief from the symptoms associated with jaundice. Patency time may be prolonged by using stents with a diameter ≥10 mm. However, patency time was found to be lower for hilar tumours.     

Malignant obstructive jaundice: the role of percutaneous metallic stents

OBJECTIVES: Efficiency evaluation of percutaneous metallic stents in palliative treatment of malignant biliary obstruction. METHODS: One hundred sixteen percutaneous metallic stents were implanted in 80 patients with malignant biliary obstruction. Thirty-five patients had hilar obstruction, 32 patients obstruction of the common bile duct and 12 patients obstruction of a bilioenteric anastomosis. RESULTS: Adequate biliary drainage was achieved in 79 patients. Early complications occurred in 23.75% of patients; 12.5% of patients died within 30 days. The procedure-related mortality rate was 5%; 18.75% of patients showed recurrent jaundice after an average of 175 days. CONCLUSION: Percutaneous metallic stents are an efficient means of treating malignant biliary strictures, particularly of upper biliary obstructions. However, this treatment has risks and limits that require careful patient recruitment.     

Endoscopic biliary stent insertion through specialized duodenal stent for combined malignant biliary and duodenal obstruction facilitated by stent or PTBD guidance

Objectives: Endoscopic stenting for combined malignant biliary and duodenal obstruction is technically demanding. However, this procedure can be facilitated when there is guidance from previously inserted stent or PTBD tube. This study aimed to evaluate the feasibility and clinical success rate of endoscopic placement of biliary self-expandable metal stent (SEMS) through duodenal SEMS in patients with combined biliary and duodenal obstruction due to inoperable or metastatic periampullary malignancy.

Materials and methods: A total of 12 patients with combined malignant biliary and duodenal stricture underwent insertion of biliary SEMS through the mesh of specialized duodenal SEMS from July 2012 to October 2016. Technical and clinical success rate, adverse events and survival after completion of SEMS insertion were evaluated.

Results: The duodenal strictures were located in the first portion of the duodenum in four patients (Type I), in the second portion in three patients (Type II), and in the third portion in five patients (Type III). Technical success rate of combined metallic stenting was 91.7%. Insertion of biliary SEMS was guided by previously inserted biliary SEMS in nine patients, plastic stent in one patient, and PTBD in two patients. Clinical success rate was 90.9%. There were no early adverse events after the procedure. Mean survival period after combined metallic stenting was 91.9 days (range: 15–245 days).

Conclusions: Endoscopic placement of biliary SEMS through duodenal SEMS is feasible with high success rates and relatively easy when there is guidance. This method can be a good alternative for palliation in patients with combined biliary and duodenal obstruction.     

Endoscopic removal and trimming of distal self-expandable metallic biliary stents

AIM:To evaluate the efficacy and safety of endoscopic removal and trimming of self-expandable metallic stents(SEMS).METHODS:All SEMS had been placed for distal biliary strictures.Twenty-seven endoscopic procedures were performed in 19 patients in whom SEMS(one uncovered and 18 covered) removal had been attempted,and 8 patients in whom stent trimming using argon plasma coagulation(APC) had been attempted at Tokyo Medical University Hospital.The APC settings were:voltage 60-80 W and gas flow at 1.5 L/min.RESU...     

Percutaneous biliary metal wall stenting in malignant obstructive jaundice

BACKGROUND: Most patients with advanced stage malignant obstructive jaundice will be suitable for palliation only. Metallic stents are safe, effective and minimally invasive. DESIGN: A review of case notes of patients who had Wallstents inserted percutaneously from January 1996 to December 2000. RESULTS: Eighty-nine patients with a median age of 72 years underwent percutaneous insertion of biliary metal stents. The diagnoses were cholangiocarcinoma (41.5%), pancreatic carcinoma (40.5%), nodal metastases at the porta hepatis (14.6%) and gall bladder cancer (3.4%). Ninety-six per cent of patients improved their hyperbilirubinaemia to normal levels by 1 month. The median post-procedure hospital stay was 16 days. Early overall complications (within 30 days of stenting) occurred in 30% of patients (70% of these were disease related). The 30 day mortality rate was 20% (n = 18). Fifty (70%) patients were readmitted to hospital, most commonly because of carcinomatosis (16) or stent obstruction (12). The symptom-free period ranged from 2 weeks to 13 months. Median survival for all patients was 3.5 months. Survival correlated inversely with serum bilirubin at presentation (r = -0.34, P = 0.001), but not with other liver function tests. DISCUSSION: Metal wall stenting for malignant obstructive jaundice provides good palliation with low, procedure-related morbidity and mortality, but poor overall survival from disease-related morbidity. Survival significantly correlates with pre-stenting serum bilirubin levels. There is a need to identify the subgroup of patients in whom stenting has no beneficial effect.     

Intrahepatic cholangiojejunostomy for unresectable malignant biliary tumors with obstructive jaundice

We reviewed our experience with intrahepatic cholangiojejunostomy as a palliative therapy for patients with unresectable malignant diseases involving the ductal confluence or the common hepatic duct. Fifteen patients with malignant biliary obstruction were treated by cholangiojejunostomy at our hospital. Two patients had intrahepatic cholangiocarcinoma, 7 had gallbladder carcinoma, 5 had bile duct carcionoma, and 1 had pancreatic carcinoma. Segment III cholangiojejunostomies were performed in 14 patients and segment V cholangiojejunostomy in 1. Contraindications for surgical resection were locoregional invasion of tumors involving the proper and/or common hepatic artery and portal vein in 15 patients and the presence of hepatic metastases in 6 patients. Liver metastases were detected in 5 of the 7 patients with gallbladder carcinoma. Postoperative complications occurred in 2 patients (13%), but there was no leakage of the cholangioenteric anastomosis in our series. There was no operative mortality after cholangiojejunostomy. Of the 9 patients who survived for more than 6 months after surgery, 7 showed a significant improvement in performance status (PS) (82 ± 10%) 3 months after the surgery compared with the preoperative PS (70 ± 7%). Four of the 9 patients had recurrent cholangitis as a late complication, but 4 were completely free from jaundice. Median survival after cholangioenteric bypass was 9 months (range, 2–25 months). With respect to tumor location, the median survival time was 4 months (range, 2–25 months) in patients with gallbladder carcinoma and 15.5 months (range, 12–22 months) in those with bile duct carcinoma. While the median survival period after surgery was only 3 months (range, 2 to 8 months) in the 5 patients with hepatic metastases from gallbladder carcinoma, 2 patients without liver metastasis survived for 9 and 25 months after segment III cholangioenteric bypass. In conclusion, cholangiojejunostomy can provide useful palliation for malignant biliary obstruction when combined with careful patient selection.