Long-term follow-up of patients with hilar malignant stricture treated by endoscopic internal biliary drainage

Seventy patients with biliary obstruction secondary to hilar tumors underwent attempted endoscopic internal biliary drainage using large transpapillary stents between December 1981 and March 1986. Placement of one or more stents was successful in 68. The type of stricture and mode of treatment were more important in determining subsequent survival than the type of tumor. In type II and III malignant strictures of the bifurcation of the common hepatic duct and the main hepatic duct, use of two or more stents to achieve complete drainage of the biliary system improves survival compared to incomplete drainage (176 vs. 119 days) and reduces procedure-related mortality and the incidence of early and late cholangitis. Patients with hilar tumors causing type II and III strictures treated with placement of multiple stents have at least as good a prognosis as patients with tumor involving only the common hepatic duct treated with use of a single stent. Once ERCP is performed and palliative endoscopic management of bifurcation tumors is begun, it must completed as soon as possible.     

Treatment of unresectable hepatic hilar malignancies with self-expanding metallic stents

BACKGROUND/AIMS: This study assesses the treatment of biliary obstruction in patients with hilar malignancies by metallic stents. METHODOLOGY: Twenty-one consecutive patients with unresectable malignant biliary obstruction at the hepatic hilum (Bismuth type II, III and IV) were treated with percutaneous transhepatic placement of self-expandable metallic endoprostheses. The endoprostheses were successfully inserted in all patients. In 12 patients all segments of the liver were drained and in 9 patients partial segments of the liver were drained. RESULTS: Seventeen patients (81%) showed relief from jaundice and could be freed of external drainage tubes. Ten patients (48%) showed no recurrent symptoms due to stent obstruction until death. Overall survival was 4.86+/-4.15 (mean+/-SD) months, stent patency was 3.76+/-3.64 months and comfort index representing a ratio of well-being was 70.5+/-38.3%. There was no significant difference in survival rate, stent patency or comfort index between the groups with complete and those with partial drainage. CONCLUSIONS: Even in patients with complicated hepatic hilar biliary occlusions, internal drainage using metallic stents can relieve jaundice and leave patients free of external tubes with a comfortable quality of life.     

Management of hilar biliary strictures

Biliary strictures at the liver hilum are caused by a heterogeneous group of benign and malignant conditions. In the absence of a clear-cut benign etiology, i.e. bile duct damage during surgery, hilar biliary strictures remain a diagnostic and therapeutic challenge for which a multidisciplinary approach is often necessary. A definitive diagnosis can be achieved in only 40–60% of the patients, while in all the other cases strictures are treated as though they are malignant until surgical pathology determines otherwise. Surgical resection is the only treatment that prolongs survival in patients with malignant strictures. Because these tumors frequently extend longitudinally via the hepatic ducts into the liver parenchyma, partial hepatic resection has been gradually added to biliary resection to ensure tumor-free surgical margins. For unresectable cases, endoscopic stenting of biliary obstruction is considered the preferred palliation modality to relieve pruritus, cholangitis, pain and jaundice, while the percutaneous approach has been reserved for cases of failure. Other modalities of treatment such as radiotherapy, chemotherapy, and photodynamic therapy currently remain investigational. For benign post surgical hilar strictures, surgical repair can be difficult and requires specific skills and experience. As an alternative, a multi-stent technique with endoscopic placement of an increasing number of stents over time until complete resolution of the stricture has been proposed.     

Result of endoscopic biliary drainage in hilar cholangiocarcinoma

Patients with hilar obstruction usually require bilateral biliary drainage. The prognosis of patients who fail bilateral biliary drainage after contrast injection into both intrahepatic ducts is poor due to a high infection rate in the undrained segments. The incidence of post-endoscopic retrograde cholangiopancreatography cholangitis in those with successful bilateral biliary drainage was less, but still significant. Incomplete subsegmental intrahepatic duct drainage is suggested to be responsible for post-biliary drainage cholangitis in cases of advanced hilar tumors. This study was undertaken to determine the incidence of post-endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and stent clogging in different types of malignant biliary obstruction after biliary drainage. From our endoscopic retrograde cholangiopancreatography database, there were 63 patients who underwent endoscopic biliary drainage between September 2000 and November 2001, for malignant biliary obstruction. Sixty-one endoscopic retrograde cholangiopancreatographies had biliary drainage performed (2 patients who failed biliary drainage were excluded). We divided our patients into 3 groups: Group 1 = Bismuth I, Group 2 = Bismuth II, and Group 3 = Bismuth III and IV. All but 2 Group 1 patients had successful biliary endoprosthesis (plastic [n = 13], metallic [n = 12], failed [n = 2]) placement into an extrahepatic duct. All patients from Group 2 (n = 10) and 20 patients from Group 3 (n = 26) had successful bilateral biliary drainage. Unilateral biliary drainage was performed in 6 patients from Group 3, each with a plastic endoprosthesis. The incidence of post-biliary drainage cholangitis (new onset of fever >38.5 degrees C with leukocytosis), jaundice resolution (normal bilirubin level), and the duration of endoprosthesis patency were compared among the 3 groups. The incidences of post-endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and the duration of endoprosthesis patency were: Group 1 (4%, 96%, and 87.2 days, respectively), Group 2 (10%, 100%, and 69.1 days, respectively) and Group 3 (57.7%, 73.1%, and 41.3 days, respectively). Of those patients who did not undergo surgery, patients from Group 3 required endoprosthesis exchange sooner than others. The outcome of biliary drainage in patients with advanced hilar tumors (Bismuth III or IV) was poorer than hilar tumor at earlier stages (Bismuth I or II).     

Successful diagnosis and resection of icteric type hepatocellular carcinoma

We report a rare case of icteric type hepatocellular carcinoma with successful preoperative diagnosis and curative resection. A 50-year-old man was admitted to our hospital with fever elevation and jaundice. Endoscopic retrograde cholangiography revealed a tumor at the hepatic hilum, which caused obstruction of the right and left hepatic duct. The tumor was suspected of being a hilar cholangiocarcinoma, but it was diagnosed as being a hepatocellular carcinoma by endoscopic retrograde bile duct biopsy. After percutaneous transhepatic biliary drainage a right hemihepatectomy was performed. Subsequent pathological finding showed the tumor to be moderately-differentiated hepatocellular carcinoma (Edmondson III) which invaded into the right hepatic duct. The patient survived for three years without recurrence. Although patients with icteric type hepatocellular carcinoma have been reported to have a poor prognosis, earlier diagnosis and curative resection may occasionally bring them an improved prognosis.     

Does aggressive surgical resection improve the outcome in advanced gallbladder carcinoma?

BACKGROUND/AIMS: Patients with advanced gallbladder carcinoma have usually been considered nonresectable, leading to a very poor outcome. This study was aimed to evaluate the results of our aggressive surgical approaches in certain cases of advanced gallbladder carcinoma. METHODOLOGY: Ninety-one patients with advanced gallbladder carcinoma of stages pT3 and pT4 who underwent surgery at our institution were the subjects of this study. Fifty-eight of 91 patients had surgical excision; 44 by hepatic resection and 14 by hilar resection. Post-operative outcome was evaluated. Advanced gallbladder carcinomas were classified according to our previously reported classification: type I hepatic; type II biliary; type III hepatobiliary; type IV others. RESULTS: Curative resection was obtained at a more increased rate in type I tumor patients than in types II and III (91% vs. 29%, p < 0.01). The surgical mortality rate was 17%. Survival rates of resected patients were significantly higher that those of nonresected patients: 45%, 31%, 22%, 17%, 13% at 1, 2, 3, 4, 5 years vs. 9%, 9%, 0% at 1, 2, 3 years (p < 0.01). Survival rates of type I tumor patients after curative resection were remarkably higher than those of type II and III tumor patients, (69%, 64%, 56%, 48%, 39% at 1, 2, 3, 4, 5 years vs. 17%, 17%, 0% at 1, 2, 3 years). CONCLUSIONS: Aggressive surgical approaches might bring about improved prognosis in advanced gallbladder carcinoma, especially for patients with type I tumors.     

Hilar tumours.

Tumours that involve the confluence of the bile ducts in the liver hilum provide a major therapeutic challenge. Adequate palliation requires relief of jaundice. Even though jaundice can be relieved if only 30% of the liver is drained, the presence of undrained bile ducts may result in pruritus and a continued risk of cholangitis and hepatic abscess. The biliary anatomy is defined by cholangiography, which today can be performed by magnetic resonance; the stricture is dilated, and plastic or metallic stents are endoscopically inserted over a guidewire. Patients with complex hilar strictures may benefit from the insertion of one or more stents, although there is debate about how many are necessary. The present article provides specific technical details, describes comparative trials of unilateral versus bilateral biliary drainage and explores new techniques that warrant further investigation.     

Post-cholecystectomy biliary strictures: Not always benign

Background:  Post-cholecystectomy malignant biliary obstruction masquerading as benign biliary stricture (BBS) has not been reported in the literature; it presents a diagnostic and management challenge.
Methods:  Of the 349 post-cholecystectomy BBS managed at a tertiary care hospital in northern India between 1989 and 2004, 11 patients were found to have biliary malignancy. Records of these 11 patients were analyzed retrospectively for the purpose of this study.
Results:  Mean age of patients with malignant biliary strictures was significantly higher (52 vs 38 years, P  = 0.000); they were more likely to have jaundice (100% vs 78%, P  = 0.008) and pruritus (82% vs 48%, P  = 0.03). Unlike most patients with BBS referred from elsewhere to us, they had had a smooth postoperative course uncomplicated by bile leak, had a longer cholecystectomy-presentation interval, and were more likely to have high strictures ((Bismuth type III/IV) 91% vs 49%, P  = 0.008).
Conclusions:  Post-cholecystectomy biliary obstruction is not always benign. High bilirubin levels and hilar strictures, especially after an uneventful cholecystectomy, in a middle-aged patient should raise a suspicion of underlying missed malignancy.     

Segment VI cholangiocholecystostomy for unresectable malignant obstruction at the hepatic hilum

Anastomosis between the segment VI intrahepatic bile duct and the stump of the cystic duct was done to relieve obstructive jaundice caused by high biliary malignant obstruction. This procedure is considered to be a safe and easy method to provide good palliation in patients with unresectable hepatic hilar carcinoma.     

Comparative analysis of postoperative morbidity according to type and extent of hepatectomy

BACKGROUND/AIMS: The aim of our retrospective study was to compare the factors contributing to postoperative complications according to the extent of hepatectomy. METHODOLOGY: We examined 166 patients with hepatobiliary carcinoma who underwent hepatectomy. Patients were divided into three groups according to the type and extent of hepatectomy: 1) left lobectomy (n=27), 2) right lobectomy or posterior segmentectomy (n=55) and 3) other hepatectomies (n=84). Patient demographics, major complications (infection, ascites, pleural effusion, atelectasis, static symptoms of the stomach, biliary leakage and hepatic failure) after hepatectomy were analyzed. RESULTS: In patients with obstructive jaundice, lobectomy was the most commonly performed operation due to the extent of tumor along the main hepatic duct. Prolonged ascites or massive pleural effusion was frequently observed after right lobectomy (p=0.001) and posterior segmentectomy (p=0.002). However, the incidences of these complications were similar in patients with chronic viral hepatitis. Symptoms related to gastric stasis and biliary leakage were significantly more common after left lobectomy than other surgeries. The incidence of hepatic failure was higher (p<0.05) after major hepatectomy, particularly right lobectomy, than other surgeries. CONCLUSIONS: Our results emphasize the need to understand characteristics of specific complications occurring after different types of hepatic resection surgery to prevent post-hepatectomy complications.     

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.     

Results of endoscopic retrograde cholangiopancreatography in the treatment of biliary tract complications after orthotopic liver transplantation: our experience

BACKGROUND/AIMS: Biliary tract complications are a common cause of morbidity and mortality after orthotopic liver transplantation. We report our experience in the use of ERCP in the treatment of post liver transplantation biliary complications. METHODOLOGY: Retrospectively we evaluated 34 patients who had undergone ERCP out of 460 who received a liver transplantation between January 1999 and December 2004. Eighteen patients presented biliary strictures, anastomotic in 12 cases and hilar in 6 cases; seven patients presented a biliary fistula and fifteen presented biliary stones in 8 cases associated to stricture and in 1 case to a fistula. Finally three patients underwent ERCP do to jaundice. The 18 patients with biliary strictures underwent sphincterotomy, dilation and stenting; the seven cases with fistulas were treated with a plastic biliary stent without sphincterotomy and the patients with biliary stones underwent sphincterotomy and endoscopic toilette of the common bile duct. RESULTS: An ERCP success rate of 97.7% was achieved without any significant complications. We obtained the resolution of all the biliary anastomotic strictures; resolution of hilar strictures was obtained in 66.6%. Biliary leak healed in 85.7% of patients. Complete endoscopic toilette was achieved in all the patients with biliary stones. CONCLUSIONS: In our experience ERCP has proved to be safe and effective in the treatment of post liver transplant biliary complications.     

Performance characteristics of magnetic resonance cholangiography in the staging of malignant hilar strictures

BACKGROUND: Magnetic resonance cholangiography (MRC) is currently under investigation for non-invasive biliary tract imaging. AIM: To compare MRC with endoscopic retrograde cholangiography (ERC) for pretreatment evaluation of malignant hilar obstruction. METHODS: Twenty patients (11 men, nine women; median age 74 years) referred for endoscopic palliation of a hilar obstruction were included. The cause of the hilar obstruction was a cholangiocarcinoma in 15 patients and a hilar compression in five (one hepatocarcinoma, one metastatic breast cancer, one metastatic leiomyoblastoma, two metastatic colon cancers). MRC (T2 turbo spin echo sequences; Siemens Magnetomvision 1.5 T) was performed within 12 hours before ERC, which is considered to be the ideal imaging technique. Tumour location, extension, and type according to Bismuth's classification were determined by the radiologist and endoscopist. RESULTS: MRC was of diagnostic quality in all but two patients (90%). At ERC, four patients (20%) had type I, seven (35%) had type II, seven (35%) had type III, and two (10%) had type IV strictures. MRC correctly classified 14/18 (78%) patients and underestimated tumour extension in four (22%). Successful endoscopic biliary drainage was achieved in 11/17 attempted stentings (65%), one of which was a combined procedure (endoscopic + percutaneous). One patient had a percutaneous external drain, one had a surgical bypass, and in a third a curative resection was attempted. Effective drainage was not achieved in six patients (30%). If management options had been based only on MRC, treatment choices would have been modified in a more appropriate way in 5/18 (28%) patients with satisfactory MRC. CONCLUSION: MRC should be considered for planning treatment of malignant hilar strictures. Accurate depiction of high grade strictures for which endoscopic drainage is not the option of choice can preclude unnecessary invasive imaging.     

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.     

Endoscopic palliation of patients with biliary obstruction caused by nonresectable hilar cholangiocarcinoma: efficacy of self-expandable metallic Wallstents

BACKGROUND: The aim of this study was to evaluate the efficacy of an endoscopically inserted self-expandable metal stent for treatment of biliary obstruction caused by nonresectable hilar cholangiocarcinoma. METHODS: Data on all patients with nonresectable hilar cholangiocarcinoma receiving self-expandable metal stents between January 1990 and April 2000 were retrospectively reviewed. Patients with pseudo Klatskin tumors (metastases in the liver hilum) and gallbladder carcinoma were excluded. Early complications (within 30 days of stent placement), early and late stent occlusion, stent patency, and biliary reintervention rates were recorded. RESULTS: Fifty-two Wallstents were inserted in 36 patients, with 7, 13, and 16 having, respectively, Bismuth type I/II, III, and IV lesions. Insertion was successful in 35 of 36 (97%) patients. Complications occurred within the first 30 days after insertion in 5 patients (14%) but did not require biliary reintervention. Thirty-day mortality was 6% (2 deaths). There were 3 early (9%) and 8 late (23%) stent occlusions, bringing the total to 11 patients (31%) who required biliary reintervention after Wallstent insertion. Median Wallstent patency and patient survival were, respectively, 169 days (95% CI [154, 184]) and 147 days (95% CI [106, 188]), with no difference between patients with Bismuth I/II, III, IV type tumors. CONCLUSIONS: Wallstent insertion is safe and feasible, and achieves successful palliation without the need for further biliary reintervention in the majority (69%) of patients with nonresectable hilar cholangiocarcinoma.     

Eosinophilic Cholangitis—A Challenging Diagnosis of Benign Biliary Stricture: A Case Report

When confronting a biliary stricture, both benign and malignant etiologies must be carefully considered as a variety of benign biliary strictures can masquerade as hilar cholangiocarcinoma (CCA). Therefore, patients could undergo a major surgery despite the possibility of a benign biliary disease. Approximately 15% to 24% of patients undergoing surgical resection for suspected biliary malignancy will have benign pathology. Eosinophilic cholangitis (EC) is a rare benign disorder of the biliary tract, which can cause obstructive jaundice and can pose a difficult diagnostic task.We present a rare case of a young woman who was referred to our hospital with obstructive painless jaundice due to a biliary stricture at the confluence of the hepatic bile ducts, with a provisional diagnosis of cholangiocarcinoma.Though, during her work up she was found to have EC, an extremely rare benign cause of biliary stricture, which is characterized by a dense eosinophilic infiltration of the biliary tree causing stricturing, fibrosis, and obstruction and which is reversible with short-term high-dose steroids.Despite its rarity, EC should be taken into consideration when imaging modalities demonstrate a biliary stricture, especially if preoperative diagnosis of malignancy cannot be made, in the setting of peripheral eosinophilia and the absence of cardinal symptoms of malignancy.     

Partial stent-in-stent placement of biliary metallic stents using a short double-balloon enteroscopy

Endoscopic intervention is less invasive than percutaneous or surgical approaches and should be considered the primary drainage procedure in most cases with obstructive jaundice. Recently, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) using double-balloon enteroscopy (DBE) has been shown to be feasible and effective, even in patients with surgically altered anatomies. On the other hand, endoscopic partial stent-in-stent (PSIS) placement of self-expandable metallic stents (SEMSs) for malignant hilar biliary obstruction in conventional ERCP has also been shown to be feasible, safe and effective. We performed PSIS placement of SEMSs for malignant hilar biliary obstruction due to liver metastasis using a short DBE in a patient with Roux-en-Y anastomosis and achieved technical and clinical success. This procedure can result in quick relief from obstructive jaundice in a single session and with short-term hospitalization, even in patients with surgically altered anatomies.     

Vascular reconstruction of the hepatic artery using the gastroepiploic artery: a case report.

A 59 year-old woman with obstructive jaundice secondary to proximal bile duct carcinoma underwent percutaneous transhepatic biliary drainage (PTDB). This revealed complete obstruction of the bifurcation of the hilar hepatic duct and encasement of the right hepatic artery. Wedged hilar hepatectomy with combined resection of the extrahepatic bile duct, gallbladder, and the encased right hepatic artery was performed. The hepatic artery was reconstructed using an in situ right gastroepiploic artery (GEA) pedicle graft. The anastomosis was protected with fatty tissue from the greater omentum. This technique can be used to reconstruct the hepatic artery after radical surgery for malignant hepatobiliary and pancreatic disease.     

Contrast-free unilateral endoscopic palliation in malignant hilar biliary obstruction: new method

BACKGROUND: Bilateral endoscopic drainage is difficult in malignant hilar biliary obstruction. Recently, unilateral drainage in malignant hilar biliary obstruction has been shown to be equally effective. However, contrast injection leads to cholangitis. There have been no reported studies on contrast-free metal stenting in malignant hilar biliary obstruction. The present study was undertaken to evaluate the results of contrast-free unilateral metal stenting in type II malignant hilar biliary obstruction. METHODS: We prospectively studied the results of unilateral metal stenting in type II malignant hilar biliary obstruction without contrast injection in 18 patients. RESULTS: A successful endoscopic drainage was achieved in 100% (18/18) of patients with hilar strictures. Cholangitis and 30-day mortality occurred in none. CONCLUSIONS: Unilateral endoscopic metal stenting without contrast in type II malignant hilar biliary obstruction is a safe and effective method of palliation.     

Perioperative hepatic functional risk assessed with technetium-99m diethylenetriamine pentaacetic acid-galactosyl human serum albumin liver scintigraphy in patients undergoing pancreaticoduodenectomy complicated by obstructive jaundice.

CONCLUSION: Liver scintigraphy with technetium-99m diethylenetriamine pentaacetic acid-galactosyl human serum albumin (Tc-GSA) can be used to predict outcome of biliary drainage and hepatic function after pancreaticoduodenectomy in patients with pancreatic, biliary, and ampullary carcinomas complicated by obstructive jaundice. BACKGROUND: Preoperative obstructive jaundice has been reported as a crucial risk factor for serious postoperative complications in patients undergoing pancreaticoduodenectomy. The aim of the present study was to investigate whether Tc-GSA liver scintigraphy can assess hepatic functional risk in patients with pancreatic, biliary, and ampullary carcinomas complicated by obstructive jaundice. METHODS: Liver scintigraphy was performed before biliary drainage in 18 patients with obstructive jaundice. The maximum removal rate of Tc-GSA (GSA-Rmax; standard normal value > or = 0.60) was calculated. These patients underwent pancreaticoduodenectomy with wide lymphadenectomy. The efficacy of preoperative biliary drainage was assessed with the decrease in serum bilirubin concentration in the first week after biliary drainage. Postoperative liver function was assessed with the increase in serum bilirubin concentration, which was the difference between the immediate preoperative and maximal postoperative bilirubin concentrations. RESULTS: Serum bilirubin decreased more in the first week after biliary drainage in patients with GSA-Rmax > or = 0.60 (7.64 +/- 1.09 mg/Dl/wk) than in patients with GSA-Rmax < 0.60 (3.56 +/- 1.25 mg/DL/wk, p = 0.042). Postoperative bilirubin increased less in patients with GSA-Rmax > or = 0.60 (0.81 +/- 0.30 mg/dL) than in patients with GSA-Rmax < 0.60 (4.00 +/- 0.69 mg/DL, p = 0.0012). Multivariate analysis showed that GSA-Rmax significantly predicted the postoperative bilirubin increase (p = 0.020).