Extrahepatic biliary obstruction caused by small-cell lung cancer

Twelve patients with small-cell lung cancer seen during a 30-month period had jaundice at diagnosis. Five patients had a pancreatic metastasis resulting in extrahepatic biliary obstruction, and seven had diffuse hepatic metastases without extrahepatic obstruction. All patients with pancreatic masses had complete (or nearly complete) resolution of jaundice and abdominal pain within 3 weeks of starting chemotherapy. Patients with extensive liver metastases usually remained icteric in spite of intensive treatment. Three patients with pancreatic metastases survived more than 12 months after the institution of therapy. No patient presenting with jaundice caused solely by hepatic metastases survived beyond 8 months. Small-cell lung cancer can present with jaundice due to diffuse hepatic parenchymal involvement, which is associated with a poor prognosis, or as a result of extrahepatic biliary obstruction, which has potential for rapid palliation and prolonged survival.     

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.     

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。     

Palliation of gastric outlet obstruction and proximal small bowel obstruction with self-expandable metal stents: a single center series

BACKGROUND: Self-expandable metal stents (SEMS) are being increasingly used to palliate malignant stenoses of the gastric outlet and proximal small bowel. Accordingly, we reviewed our experience in this setting. METHODS: Patients with gastric outlet or proximal small bowel stents were identified by reviewing hospital charts. Outcome criteria included survival data, need for reintervention, and clinical improvement. RESULTS: A total of 52 SEMS were placed in 36 patients with nonesophageal upper GI stenosis. Initial stent placement was successful in 92% and clinical improvement documented in 75%. Mean survival of patients who eventually died was 3.5 months. Seven patients are alive (mean follow-up, 5.0 months). Stent dysfunction occurred in 36% and required subsequent interventions. Biliary obstruction was documented in 50% of patients, 12 of whom had previously undergone biliary stenting and 5 who needed subsequent biliary decompression. CONCLUSIONS: Enteral stent placement has been reported to be an effective alternative for palliation of high-risk surgical patients with malignant gastric outlet and small bowel obstruction. Considering the short life expectancy of these patients and significant complications including stent migration, perforation, biliary obstruction, and need for subsequent endoscopic, radiologic and surgical interventions, the authors suggest that this procedure be performed in experienced centers on selected patients only and that biliary decompression be ensured early.     

Obstructive icterus in patients with hepatic tumor. Result of non-surgical biliary drainage

Seventeen patients with biliary obstruction and hepatic tumors were treated by endoscopic or percutaneous transhepatic drainage with an endoprothesis. There were 9 men and 8 women (mean age = 61 +/- 13 years). Four patients had primary hepatic carcinoma and 13 had hepatic metastases. Decrease of serum bilirubin of more than 75 percent was achieved in 12 of the patients (71 percent). The success rate was related to the level of the biliary obstacle and not to the importance of hepatic parenchymal involvement. Failure was significantly more frequent (p = 0.003) in patients with type III hilar strictures compared to the other patients with pedicular or type I and II hilar strictures. Cholangitis was the major complication (29 percent) and occurred only in the patients with type III hilar strictures. Mortality was 24 percent at 30 days. This rate was 57 percent in the group of patients with type III hilar strictures and significantly higher (p = 0.015) than other patients. Cumulative survival was better in patients with relief of jaundice than that observed in the other patients (p less than 0.01). Two patients with metastatic carcinoma of the breast treated by chemotherapy survived more than 20 months without jaundice. Analysis of these data indicates that in patients with hepatic tumors and obstructive jaundice, palliative treatment with endoprothesis can provide relief of jaundice and that prolonged survival may be observed in patients with chemosensible tumors.     

Extrahepatic biliary stenoses after hepatic arterial infusion (HAI) of floxuridine (FUdR) for liver metastases from colorectal cancer.

Hepatic arterial infusion of floxuridine is an effective treatment for unresectable hepatic metastases from colorectal cancer. Despite its pharmacological advantage of higher tumor drug concentration with minimal systemic toxicity, hepatic arterial infusion of floxuridine is characterized by regional toxicity, including hepatobiliary damage resembling idiopathic sclerosing cholangitis (5-29% of treated cases). Unlike previous reports describing biliary damage of both intrahepatic and extrahepatic ducts, a case series of extrahepatic biliary stenosis after hepatic arterial infusion with floxuridine is herein described. Between September 1993 and February 1999, 54 patients received intraarterial hepatic chemotherapy based on continuous infusion of floxuridine (dose escalation 0.15-0.30 mg/kg/day for 14 days every 28 days) plus dexamethasone 28 mg. Twenty-seven patients underwent laparotomy to implant the catheter into the hepatic artery, the other 27 patients receiving a percutaneous catheter into the hepatic artery through a transaxillary access. Five patients (9.2%) developed biliary toxicity with jaundice and cholangitis (3 cases), alterations of liver function tests and radiological features of biliary tract abnormalities. They received from 9 to 19 cycles (mean 14.5 +/- 6.3 cycles) of floxuridine infusion with a total drug delivered dose ranging from 20.3 to 41.02 mg/kg (mean: 31.4 +/- 13.5 mg/kg). Extrahepatic biliary sclerosis was discovered by computed tomography scan and ultrasound, followed by endoscopic retrograde cholangiopancreatography and/or percutaneous cholangiography in 3 cases. Radiological findings included common hepatic duct complete obstruction in 1 case, common hepatic duct stenosis in 2 cases, common bile duct obstruction in 1 case, and intrahepatic bile ducts dilation without a well-recognized obstruction in 1 case. Two patients were treated by sequentially percutaneous biliary drainage and balloon dilation while 1 patient had an endoscopic transpapillary biliary prosthesis placed. Percutaneous or endoscopic procedures obtained the improvement of hepatic function and cholestatic indexes without subsequent jaundice or cholangitis. In two patients suppression of floxuridine infusion allowed the improvement of hepatic function. The present series suggests that in some patients receiving hepatic arterial infusion of floxuridine extrahepatic biliary stenosis may represent the primary event leading to a secondary intrahepatic biliary damage that does not correlate with specific floxuridine toxicity but results from bile stasis and infection, recurrent cholangitis and eventually biliary sclerosis. Aggressive research for extrahepatic biliary sclerosis is advised, since an early nonsurgical treatment of extrahepatic biliary stenosis may prevent an irreversible intrahepatic biliary sclerosis worsening the prognosis of metastatic liver disease.     

Management of cholangitis

Acute cholangitis remains a life-threatening complication of biliary obstruction, particularly in the elderly with comorbid disease or when there is a delay in diagnosis and treatment. The initial management consists of fluid resuscitation, correction of coagulopathy, and administration of broadspectrum antibiotics. The choice of antibiotics should cover both gram-negative and gram-positive organisms associated with cholangitis until the results of a blood culture are available. The timing and choice of biliary decompression varies depending on the response to antibiotic therapy, the presence of comorbid disease, and the underlying cause. Biliary sepsis resolves in most patients with conservative treatment, thus allowing time to perform more detailed noninterventional imaging (e.g., spiral computed tomography [CT], magnetic resonance cholangiopancreatography [MRCP]) to determine the underlying cause and level of biliary obstruction. Those with cholangitits who do not respond to conservative therapy will require urgent biliary decompression. In patients with choledocholithiasis, endoscopic drainage is now the treatment of choice or, if this fails, transhepatic biliary decompression is a useful alternative. Various endoscopic options are available for managing choledocholithiasis, ranging from endoscopic papillotomy (EP) and extraction of stones, to the placement of a biliary drainage system. In patients who respond to antibiotic therapy, EP with stone extraction is preferred, while in those with ongoing sepsis and multiple large stones, the placement of a stent with or without an EP is the safest option. Transhepatic biliary drainage is now reserved for failure of endoscopic drainage and for patients with suspected hilar cholangiocarcinoma or intrahepatic stones. Surgical biliary decompression is seldom required in the emergency setting, but still plays an important role in the definitive treatment of the underlying cause.     

Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study

BACKGROUND: The systematic use of metal stents to treat biliary obstruction is restricted by high cost compared with plastic stents. The aims of this study were to compare cost and efficacy of plastic stents and metal stents in the treatment of patients with malignant common bile duct strictures and to define factors that predict survival of these patients. METHODS: One hundred eighteen patients (mean age 75 years) with malignant strictures of the common bile duct were randomized to placement of a plastic stent or metal stent. Comparisons were made with the Mann-Whitney or chi-square test as indicated; survival rates were compared with a Cox proportional hazards model. RESULTS: There was no significant difference in survival between the two groups. Time to first obstruction was longer for patients in the metal stent group (metal stent, median not reached vs. plastic stent, 5 months; p = 0.007). The number of additional days of hospitalization, days of antibiotic therapy, and the numbers of ERCPs and transabdominal US procedures was significantly higher in the plastic stent group. After multivariate analysis, only the presence of liver metastases was independently related to survival (p < 0.0005; OR = 2.25). This variable defined a group with a shorter survival. Median survival of patients with hepatic metastasis at diagnosis was 2.7 months compared with 5.3 months for patients without liver metastasis; in the latter group, the overall cost associated with metal stents was lower than for plastic stents. CONCLUSIONS: Metal stent placement is the most effective treatment of inoperable malignant common bile duct stricture. Placement of a metal stent is cost effective in patients without hepatic metastases, whereas a plastic stent should be placed in patients with spread of the tumor to the liver.     

A case of choledochoduodenal fistula as a delayed complication after biliary metallic stent placement in distal cholangiocarcinoma]

Biliary drainage in patients with malignant biliary obstruction relieves jaundice and prevents the development of cholangitis or hepatic failure from biliary obstruction. Therefore, this may result in better quality of life along with survival prolongation. Biliary stent placement is an effective and safe measure for biliary decompression and is preferred than bypass surgery in high risk patients. Entero-biliary perforation-communication is one of the rare complications of biliary stent. We herein report a case of duodeno-biliary perforation-communication in patient with distal cholangiocarcinoma who presented with duodenal ulcer and obstruction, occurring 4 years later from the metallic biliary stent insertion. Patient was managed with a pyloric metal stent and conservative care.     

Cost analysis of magnetic resonance cholangiography in the management of inoperable hilar biliary obstruction

OBJECTIVE: Palliation of patients with Klatskin tumors involving both hepatic ducts is usually performed with bilateral biliary stent placement. Magnetic resonance cholangiopancreatography (MRCP) offers the ability to visualize the hepatic ducts without injection of contrast, thereby reducing the patient's risk of developing postprocedure bacterial cholangitis. We used decision analysis techniques to quantitate the cost-effectiveness of MRCP before stent placement versus routine placement of bilateral biliary stents in the setting of inoperable malignant hilar obstruction. In addition to determining which strategy was most economical, we used sensitivity analysis to identify the critical factors defining relative costs. METHODS: A decision analysis model was designed comparing MRCP with subsequent unilateral biliary stent placement and double biliary stent placement approaches for palliation of jaundice in a patient with inoperable malignant hilar obstruction, as viewed from the societal perspective. Baseline probabilities, obtained from the published literature, were varied through plausible ranges using sensitivity analysis. Charges were based on Medicare professional plus facility fees or diagnosis-related group rates for out- and inpatients, respectively. RESULTS: MRCP with subsequent directed unilateral stent placement was the least costly approach ($3806) compared with bilateral stent placement ($4275), provided the bilateral biliary stent complication rate was >3%. Bilateral stent placement needed to confer a survival advantage of at least 7 days over unilateral stent placement to become the more cost-effective approach. CONCLUSIONS: The use of MRCP to guide biliary stent placement in a patient with inoperable hilar obstruction reduces the overall cost of treatment. The uncertainty of any survival advantage that bilateral biliary stent placement confers over unilateral stent placement makes cost-effectiveness difficult to assess.     

ENDOSCOPIC ULTRASOUND‐GUIDED CHOLEDOCHODUODENOSTOMY

Endoscopic biliary drainage (EBD) may be unsuccessful in some patients, because of failed biliary cannulation or tumor infiltration, limiting endoscopic access to major papilla. The alternative method of percutaneous transhepatic biliary drainage carries a risk of complications, such as bleeding, portal vein thrombus, portal vein occlusion and intra‐ or extra‐abdominal bile leakage. Recently, endoscopic ultrasonography (EUS)‐guided biliary stent placement has been described in patients with malignant biliary obstruction. Technically, EUS‐guided biliary drainage is possible via transgastric or transduodenal routes or through the small intestine using a direct access or rendezvous technique. We describe herein a technique for direct stent insertion from the duodenal bulb for the management of patients with jaundice caused by malignant obstruction of the lower extrahepatic bile duct. We think transduodenal direct access is the best treatment in patients with jaundice caused by inoperable malignant obstruction of the lower extrahepatic bile duct when EBD fails.     

Percutaneous-endoscopic biliary stent placement. A preliminary report

The placement of large-bore endoprostheses for relief of biliary obstruction by the percutaneous-transhepatic route is painful, requires a large hepatic parenchymal tract, and has a fairly high complication rate. The alternative technique of endoscopically placing similar-sized stents requires special instruments and skills, and may fail in passing very tight stenoses. We report a simpler combined percutaneous-endoscopic biliary stent (PEBS) placement technique with a high placement rate used in 11 patients with advanced malignant obstruction. In all 11 patients, 10 and 11.5 French stents were easily placed. Three patients developed sepsis but responded to antibiotics. One clogged stent required replacement. Two stents needed later endoscopic adjustment. Results of liver function test improved in 10 patients, and 8 patients showed improved quality of life.     

Polyurethane-covered metal stent for management of distal malignant biliary obstruction

BACKGROUND: The efficacy of polyurethane-covered metal expandable stents for treatment of neoplastic distal biliary obstruction was analyzed. METHODS: Twenty-one patients with unresectable malignant tumors involving the mid to distal bile duct who were seen with obstructive jaundice were consecutively enrolled. Eighteen patients underwent endoscopic implantation of a polyurethane-covered metal stent and 3 patients underwent transhepatic insertion because of duodenal obstruction. The stent patency, complications, and patient survival were analyzed. RESULTS: Effective biliary decompression was achieved in all patients. Adverse events were minor: mild pancreatitis (1) and cholecystitis (2) occurred within 7 days of stent insertion. Mean survival and stent patency were 233 days and 206 days, respectively. Stent occlusion occurred in 3 patients (14%) after a mean of 188 days. Tumor ingrowth through the stent mesh was not observed. However, 2 stents were occluded by tumor overgrowth and 1 by compacted alimentary debris. CONCLUSIONS: A polyurethane membrane may prevent tumor ingrowth and reduce the occlusion rate for expandable metal stents implanted in patients with malignant obstruction of the distal bile duct.     

SINGLE‐SESSION ENDOSCOPIC BILATERAL Y‐CONFIGURED PLACEMENT OF METAL STENTS FOR HILAR MALIGNANT BILIARY OBSTRUCTION

Background: The aim of this study was to evaluate the efficacy and safety of endoscopic bilateral biliary metal stent placement for hilar malignant obstruction. Patients and Methods: Twenty patients with unresectable malignant hilar biliary obstruction who had undergone endoscopic bilateral Y‐configured biliary drainage with metal stents were enrolled as a study group (YMS group). Thirty‐seven patients who had undergone bilateral drainage with plastic stents were selected as a historical control (PS group). Two newly designed metal stents for bilateral Y‐configured placement were endoscopically deployed in a partial stent‐in‐stent manner in one session. Technical success, early complications, and stent patency were evaluated. Results: The technical success rate in the YMS group was 100%. Mild post‐endoscopic retrograde cholangiopancreatography pancreatitis occurred in one patient in the YMS group and in two in the PS group. The success rate of biliary decompression was 95% in the YMS group and 89% in the PS group (P = 0.65). During a median follow‐up period of 7.3 months, the incidence of stent occlusion in the YMS group was significantly lower than that in the PS group (30% vs 62%, P = 0.028). Mean stent patency in the YMS group was 250 days and that in the PS group was 115 days (P = 0.0061). Risk factors for stent occlusion were bile duct cancer (P = 0.035) and the PS group (P = 0.07) by multivariate analysis. Conclusion: Single‐session endoscopic bilateral biliary placement of newly designed metal stents for hilar malignant obstruction is safe and useful with a high technical success rate and a long patency period.     

The Tannenbaum Stent: A New Plastic Biliary Stent without Side Holes

Objective: Clogging of plastic biliary stents used in malignant biliary obstruction remains a major problem. In vitro studies have shown that side holes, a standard feature of commercially available stents, may contribute to stent clogging. In a pilot study, we designed and prospectively evaluated a new biliary stent without side holes (Tannenbaum stent).
Methods: Over a 12-month period, 55 consecutive patients (mean age 75 yr) with malignant distal common bile duct obstruction and without papillary or duodenal tumor infiltration underwent endoscopic placement of the Tannenbaum stent for the palliative treatment of jaundice.
Results: Tannenbaum stent insertion was technically successful on the first attempt in all patients and was accompanied by a significant reduction in mean serum bilirubin levels (10.1–1.6 mg%). Fifty-one patients were followed until death (median survival of 130 days); the symptomatic occlusion rate was 16%, the dislocation rate was 8%, and the median stent patency was 64 wk. Aside from stent clogging, there were no complications.
Conclusion: The Tannenbaum stent provided effective palliative biliary decompression in all patients. The patency rate was longer than that reported in the literature for conventional plastic stents with side holes and compared favorably with patency rates that have been reported for the metallic expandable biliary stents. The results of this pilot study are encouraging and warrant further studies.     

Endoscopic biliary stent placement for bile duct stricture after hepatic artery infusion of 5-FUDR

Three patients with metastatic colorectal adenocarcinoma developed bile duct strictures after treatment of liver metastases by hepatic artery infusion of 5-fluorodeoxyuridine (5-FUDR). All underwent decompression and drainage via endoscopically placed biliary stents, a treatment approach not previously reported in this setting. One patient with recurrent hepatic metastases did not benefit, but two patients with bile duct strictures and tumor regression profited from stent placement and died of nonbiliary tumor-related complications. Stent placement may be helpful in treating patients with persistent and unremitting cholestasis and bile duct strictures in whom tumor regression has followed regional chemotherapy.     

CONTRAST‐FREE BALLOON‐ASSISTED UNILATERAL PLASTIC STENTING IN MALIGNANT HILAR BILIARY OBSTRUCTION: A NEW METHOD

Background: Unilateral endoscopic drainage in unresectable type II malignant hilar biliary obstruction is effective. Contrast injection leads to cholangitis. Recently, contrast‐free unilateral metal stenting in malignant hilar biliary obstruction has shown encouraging results, however, it is costly. Methods: We prospectively studied the outcome of unilateral balloon‐assisted plastic stenting in 15 patients with type II malignant hilar biliary obstruction without contrast. Results: A successful endoscopic drainage was achieved in 100% (15/15) patients. Cholangitis occurred in none and no patient died within 30 days. Mean patency of stent was 104.8 ± 18.3 days. Mean (±SD) survival of these patients was 129.5 ± 39.2 days. No major complications were observed. Conclusions: Unilateral endoscopic contrast‐free balloon‐assisted plastic stenting in type II malignant hilar biliary obstruction is a safe and effective method of palliation. However, a larger study is needed to validate the findings.     

Managing malignant biliary obstruction in pancreas cancer: Choosing the appropriate strategy

Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) has shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depends on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, percutaneous or surgical treatments are appropriate. Endoscopic therapy or surgical approach can be used to treat concomitant duodenal and biliary obstruction.     

Endoscopic biliary stenting for treatment of persistent biliary fistula after blunt hepatic injury

BACKGROUND: Surgical treatment for persistent biliary fistula after blunt hepatic injury is often technically difficult. Endoscopic treatment for such fistulas has been described only infrequently. METHODS: We reviewed 6 patients who underwent endoscopic biliary stent placement with (n = 1) or without (n = 5) sphincterotomy for persistent (12 to 138 days; mean 48 days) biliary fistula after blunt hepatic injury. RESULTS: ERCP showed bile leakage from a second-order or more peripheral branch of the intrahepatic bile ducts in 5 patients but failed to reveal the fistula in 1. Stent placement was successful without complications in all patients. Bile leakage resolved within 1 to 3 days in 5 patients. After 36 to 86 days, the stent was removed and ERCP confirmed disappearance of the fistula. These patients have remained asymptomatic for a mean of 2.6 years since stent removal. In the patient in whom ERCP had not shown a fistula, bile leakage continued despite successful stent placement. CONCLUSIONS: Endoscopic biliary stent placement is a rapid, safe and effective treatment for persistent post-traumatic biliary fistula demonstrated by ERCP.