经内镜胆管内引流治疗恶性胆道梗阻的探讨

为缓解胆道梗阻，对２８例恶性胆道梗阻（ＭＢＯ）患者行经内镜胆管内引流术（ＥＢＤ）。结果２５例（８９％）插管成功，共插管４４次，７Ｆ管３次，１０Ｆ２５次，１２Ｆ１６次。２３例（９２％）减黄有效，ＥＢＤ后第３天胆红素平均下降４６．３％，肝外胆管径平均回缩５８．６％，减黄有效者腹胀迅速消失或减轻。首次插管维持有效引流时间１４１．５±１５１．２天，早、中期并发胆管炎４０％，１年以上生存１７％。结果表明ＥＢＤ减黄效果和症状改善是显著的，胆红素下降与胆管径回缩相平行。认为胆管是否屈曲及乳头括约肌切开术的好坏是ＥＢＤ成败的关键；腹胀再现，有胆道感染症状及Ｂ超见肝外胆管扩张为通管的指征。ＥＢＤ适合高龄或高危人群的ＭＢＯ患者，对延长生存期有重要的价值。     

经内镜胆管内引流治疗恶性胆道梗阻的探讨

为缓解胆道梗阻，对２８例恶性胆道梗阻（ＭＢＯ）患者行经内镜胆管内引流术（ＥＢＤ）。结果２５例（８９％）插管成功，共插管４４次，７Ｆ管３次，１０Ｆ２５次，１２Ｆ１６次。２３例（９２％）减黄有效，ＥＢＤ后第３天胆红素平均下降４６．３％，肝外胆管径平均回缩５８．６％，减黄有效者腹胀迅速消失或减轻。首次插管维持有效引流时间１４１．５±１５１．２天，早、中期并发胆管炎４０％，１年以上生存１７％。结果表明ＥＢＤ减黄效果和症状改善是显著的，胆红素下降与胆管径回缩相平行。认为胆管是否屈曲及乳头括约肌切开术的好坏是ＥＢＤ成败的关键；腹胀再现，有胆道感染症状及Ｂ超见肝外胆管扩张为通管的指征。ＥＢＤ适合高龄或高危人群的ＭＢＯ患者，对延长生存期有重要的价值。     

ENDOSCOPIC STENT DRAINAGE FOR MALIGNANT BILIARY OBSTRUCTION: THE KOREAN EXPERIENCE

Endoscopic biliary drainage (EBD) is the treatment of choice for biliary obstruction caused by unresectable pancreaticobiliary malignancies. Clogging is an unsolved problem of the plastic stent. A self‐expanding metal stent (SEMS) was developed to overcome this limitation. Total resource utilization was reported to be lower with SEMS compared with plastic stents in the West. However, in Korea, the average total cost is estimated to be higher in the metal stent group. The use of SEMS should be indicated if the survival is expected to be more than 3 months. Covered SEMS was introduced to overcome the problem of tumor ingrowth into the uncovered stent. Patency rates for covered SEMS tended to be greater than uncovered SEMS, but the complication rate in covered SEMS was higher than uncovered SEMS due to migration, occlusion of the cystic duct, of a contralateral hepatic duct, or of pancreatic duct. Stents without clogging or migration, with antitumor or biodegradable properties are being investigated. For unresectable hilar cholangiocarcinoma (HC) of Bismuth type III or IV, unilateral percutaneous transhepatic biliary drainage (PTBD) and subsequent internal stent causes less cholangitis and longer patency than EBD or PTBD alone. However, the result with EBD is good if the Bismuth type of biliary obstruction is I or II. Photodynamic therapy may improve survival of patients with unresectable cholangiocarcinoma. Preoperative biliary drainage is not usually necessary except for HC. Procedure‐related complication and inflammation of the operative field resulting from endoscopic nasobiliary drainage or endoscopic retrograde biliary drainage are expected to cause surgical difficulties and to affect postoperative complications.     

MALIGNANT BILIARY OBSTRUCTION: A COMPARISON OF COST FOR A USE OF METAL OR PLASTIC STENT FOR PALLIATION IN JAPANESE HEALTH CARE SYSTEM

Endoscopic treatment with endoprosthesis for obstructive jaundice is a well‐accepted method for palliation of obstructive jaundice and its associated symptoms. Yet, there is no consensus whether a plastic stent or metal stent to be used. The longer patency period with metal stent is a definite advantage but its high cost limits its routine use. The best use of metal stent is accomplished with consideration of patients’ predicted prognosis and a medical cost in Japan. We used a simulated case scenario to calculate a cost for metal stent and non‐metallic stent. Metal stent use would cost about 437 000 yen per patient at 6 months compared with 276 000–329 000 for non‐metallic stents, and thus metal stent use appears to be more costly in current Japanese medical system. Longer patency rate with covered metal stent would make metal stent more favorable, and less frequent procedure would be beneficial for patients who are at their terminal stage of diseases. Alternatively, many patients would not need stent replacement after first biliary stent placement due to the nature of underlying diseases. In addition to a development of an ideal stent and an appropriate technique, our research should also aim at determining who would benefit most for each stent in our own practice, preferably in prospective randomized trial.     

Biliary obstruction due to pancreatic insulinoma

Summary Pancreatic insulinomas are rare tumors and their association with polycystic disease of the liver is uncommon. We report here a patient with pancreatic insulinoma with hepatic metastasis and biliary obstruction presenting with neuroglycopenic symptoms and cholestasis on a background of polycystic liver disease.     

Endoscopic ultrasound-guided choledochoduodenostomy for treatment of ampullary cancer

We describe the case of a patient for whom choledochoduodenostomy was performed under endoscopic ultrasound (EUS) guidance as an alternative to percutaneous transhepatic biliary drainage (PTBD) for the treatment of obstructive jaundice. An 82-year-old man with ampullary cancer was considered operable, but he refused surgery. Endoscopic biliary drainage (EBD) with an 8.5-French plastic stent was performed 2 months later because of the development of obstructive jaundice. The EBD stent was occluded 5 months after the stent insertion, and EUS choledochoduodenostomy (EUS-CDS) was performed. Pneumoperitoneum occurred 1 day after the procedure, which resolved with conservative treatment. Six months later, multiple lymph node metastases occurred, and the patient was effectively treated by chemotherapy (S-1). The patient is still alive with a good quality of life more than 2 years after EUS-CDS. We conclude that EUS-CDS is an effective alternative to PTBD or EBD for patients with malignant biliary obstruction, especially due to ampullary cancer.     

Evaluation of new plastic stents for malignant biliary obstruction

Background: A new plastic stent was designed for endoscopic biliary stenting to achieve a long and effective drainage period. Method: The Double layer stent is composed of Teflon as the inner layer and nylon as the outer layer divided with metallic mesh. This structure gives the stent several side‐flaps without side‐holes. Double layer stents were applied in 24 patients with inoperable malignant biliary obstruction. Results: The Double layer stents were successfully placed in all cases, and the effective drainage rate of these stents was 96%. The mean patency period evaluated by the Kaplan–Meier method without ineffective cases was 207 days, which was longer than the ordinary plastic stent of the same diameter. Concerning the complications related to inserting, we experienced dislocation was experienced in three patients. Conclusions: The authors regard this new device as an useful stent, which users can expect long patency period, easy exchange management, and reduced cost for the patients with inoperable obstruction in the biliary tract.     

Clinical signiifcance of isolated biliary candi-diasis in patients with unresectable cholangio-carcinoma

BACKGROUND: The frequency of isolated biliary candidiasis is increasing in cancer patients. The clinical signiifcance of isolated biliary candidiasis remains unclear. We analyzed the risk factors of biliary candidiasis and outcomes of the patients with unresectable cholangiocarcinoma after percutaneous transhepatic biliary drainage (PTBD).
METHODS: Among 430 patients who underwent PTBD between January 2012 and March 2015, 121 patients had unresectable cholangiocarcinoma. Bile and blood samples were collected for consecutive fungal culture.
RESULTS: The study cohort included 49 women and 72 men with a median age of 71 years. Multivariate analysis showed that cancer progression (P=0.013), concurrent presence of another microorganism (P=0.010), and previous long-term (>7 days) antibiotic use (P=0.011) were potential risk factors of biliary candidiasis. Chemotherapy was not associated with overall biliary candidiasis (P=0.196), but was signiifcantly related to repeated biliary candidiasis (P=0.011). Patients with isolated biliary candidiasis showed remarkably reduced survival compared with those without [median overall sur-vival (OS): 32 vs 62 days,P=0.011]. Subgroup analysis was also performed. Patients with repeated candidiasis had markedly decreased survival compared with those with transient candi-diasis (median OS: 30 vs 49 days,P=0.046). Biliary candidiasis was identiifed as a poor prognostic factor by univariate and multivariate analyses (P=0.033). Four cases of repeated can-didiasis (4/19, 21%) showedCandida species in consecutive blood culture until the end of the study, but others showed no candidemia.
CONCLUSIONS: Isolated biliary candidiasis may be associ-ated with poor prognosis in patients with unresectable chol-angiocarcinoma. Especially, repeated biliary candidiasis may have the possibility of progression to candidemia. We suggest that biliary dilatation treatment or antifungal agents might be helpful for patients with biliary candidiasis.     

Endoscopic management of combined malignant biliary and gastric outlet obstruction

Patients with periampullary cancer or gastric cancer often develop malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), and combined MBO and GOO is not rare in these patients. Combined MBO and GOO is classified by its location and sequence, and treatment strategy can be affected by this classification. Historically, palliative surgery, hepaticojejunostomy and gastrojejunostomy were carried out, but the current standard treatment is combined transpapillary stent and duodenal stent placement. Although a high technical success rate is reported, the procedure can be technically difficult and duodenobiliary reflux with subsequent cholangitis is common after double stenting. Recent development of endoscopic ultrasound (EUS)‐guided procedures enables the management of MBO as well as GOO under EUS guidance. EUS‐guided biliary drainage is now increasingly reported as an alternative to percutaneous transhepatic biliary drainage in failed endoscopic retrograde cholangiopancreatography (ERCP), and GOO is one of the major reasons for failed ERCP. In addition to EUS‐guided biliary drainage, the feasibility of EUS‐guided double‐balloon‐occluded gastrojejunostomy bypass for MBO was recently reported, and EUS‐guided double stenting can potentially become the treatment of choice in the future. However, as each procedure has its advantages and disadvantages, treatment strategy should be selected based on the type of obstruction and the prognosis and performance status of the patient.     

An audit of metal stent palliation for malignant biliary obstruction

BACKGROUND AND AIMS: Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction. Metal stents have several advantages over the polyethylene alternatives, but are significantly more expensive. It has been reported that patients need to survive beyond 6 months to make metal stents more cost-effective. The aim of this study was to audit the performance of expanding metal biliary stents in our endoscopy unit, and to identify factors that might help with patient selection. METHODS: The records of all patients who were selected for endoscopic metal stent insertion at the Royal Perth Hospital for malignant biliary obstruction between September 1994 and November 1998 were reviewed. RESULTS: Thirty-two patients (16 males, mean age 71 years (range 34-88 years) were identified and followed up for a mean 201 days (range 3-810 days). Fifteen (47%) had cholangiocarcinoma, 13 (41%) had pancreatic cancer, and four had metastatic disease as the cause of obstruction. Mortality rates after metal stent insertion were 16, 41 and 55% at 30, 90 and 180 days, respectively. In total, 24 (75%) patients died during the follow-up period. Eleven (34%) stents became obstructed during follow up with a median time to occlusion of 125 days (range 44-729 days). Patients with cholangiocarcinoma had significantly longer survival than pancreatic cancer cases (median 286 vs 58 days, P = 0.04). No other factors were found to correlate with the survival or stent complications. CONCLUSIONS: Less than half of this mixed cohort survived beyond 6 months. Metal stent palliation of malignant biliary obstruction should probably be targeted at those with cholangiocarcinoma, as these patients tend to survive longer.     

One-step percutaneous transhepatic insertion of a balloon-expanding metallic stent for obstructive jaundice

Background and Aim: The aim of this study was to evaluate the efficacy and safety of one‐step percutaneous transhepatic insertion of the Express LD stent, a balloon‐expanding stainless steel stent used for the management of distal artery stenosis in the treatment of obstructive jaundice caused by various inoperable malignancies. Methods: Seventy‐one consecutive patients with unresectable malignant biliary obstruction who underwent Express LD stent placement between 2007 and 2010 at our institute were reviewed. Results: Mean stent patency was 165 ± 144 days and mean patient survival was 180 ± 156 days, while the cumulative stent patency rate and patient survival rate at 6 and 12 months were 79% and 65%, and 38% and 16%, respectively. Stents were successfully placed in all cases without any stent migration or misplacement. Stent failure occurred in 14 patients (20%), and 16 complications were observed, including 12 cholangitis (17%), two cholecysitis (3%), and two pancreatitis (3%). Y‐configuration stenting for hilar bile duct obstruction was the only independent prognostic factor for stent failure. Conclusions: One‐step percutaneous transhepatic insertion of the Express LD stent is effective and safe for the management of obstructive jaundice caused by inoperable malignancies.     

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.     

恶性胆管梗阻内支架置入后再梗阻的研究现状

通过内镜置入胆道内支架引流是目前治疗恶性胆管梗阻的首选措施,然而内支架再梗阻却是当前困扰临床的主要问题.近年来,国内外在探讨支架阻塞的机制,通过多种方法防治以延长引流时间等方面进行了广泛而深入的研究,此文就此作一综述.     

Laparoscopic choledochojejunostomy via PTFE-covered stent successfully achieves internal drainage of common bile duct obstruction

The purpose of this study was to develop a method of laparoscopic biliary bypass utilizing a PTFE-covered biliary stent. An animal model of common bile duct obstruction was developed. Three days before the planned choledochojejunostomy, the common duct in 10 female pigs was ligated using mini-laparoscopy instrumentation (2 mm) to create an obstruction model. A laparoscopic choledochojejunostomy was then performed using intracorporal suturing (n=5) or stented (n=5) techniques. In the sutured group, a side-to-side two-layer anastomosis was performed. In the stented group, a Seldinger technique was used to deliver the stent into the abdomen through the small bowel and into the anterior wall of the common bile duct for deployment across both the duct and bowel to create an anastomosis (under fluoroscopic guidance). After the surgery, the animals were followed for 7 days, and then sacrificed to examine the anastomosis grossly and histologically. Statistical analysis was used to compare the two groups. Although the difference was not statistically significant, the mean anastomosis time in minutes was shorter for the stented group (37.8; range 15-74 minutes) than in the sutured group (52.8; range 28-70 minutes). All animals survived for 7 days after the procedure with no detectable biliary leaks or biliary obstruction at autopsy. These gross findings were confirmed by pathologic examination of the anastomoses. Laparoscopic choledochojejunostomy using a PTFE-covered metallic biliary stent can be performed to relieve common bile duct obstruction. In addition, the stent method was as safe and effective as sutured laparoscopic choledochojejunostomy.     

Management of malignant hilar biliary obstruction by endoscopy results and prognostic factors

Between January 1983 and December 1987, 103 patients who had hilar biliary obstruction (59 men, 44 women, median age 73 years) were referred to our institution. The causes of hilar biliary obstruction were carcinoma of the bile ducts (55), hepatic metastases or hepatocellular carcinoma (30), and carcinoma of the gallbladder (18). When endoscopic retrograde cholangiography was performed, the stricture was classified as type I in 28%, type II in 41%, and type III in 31% of the patients. In 92 patients, we tried to insert endoscopically a 10, 11, or 12 F Amsterdam type prosthesis; it proved possible in 66 (74%), and the prosthesis proved functional without further procedure in 49 cases (53%); no combined percutaneous and endoscopic method was used. At death or discharge, 45 patients (49%) had a successful drainage. Cholangitis was the main procedure-related complication and occurred in 25 patients. The 30-day mortality was 43%. Results varied according to type of stenosis: successful drainage was performed in 15% of the patients with type III stenosis, compared with 86% when the stenosis was of type I. Under a multivariate analysis the independent prognostic factors of 30-day mortality were: (1) development of infectious complications after endoscopic attempt at drainage (P<0.0001), and (2) absence of successful drainage (P<0.0001). In conclusion, endoscopic endoprosthesis placement allows a sufficient drainage in 53% of the cases. In type III stenosis, the high rate of 30-day mortality leads us the conclusion that endoscopic drainage must be avoided.     

Stent-in-stent through a side hole to prevent biliary metallicstent migration

The covered self-expandable metallic stent(SEMS) has been developed to overcome the problem of tissue ingrowth,However,stent migration is a well-known complication of covered SEMS placement.Use of a double pigtail stent to lock the movement of the SEMS and prevent migration has been advised by many experts.Unfortunately,in our case this technique led to an incidental upward migration of the SEMS.We used APC to create a side hole in the SEMS for plastic stent insertion as stent-in-stent.This led to a successful prevention of stent migration.     

Hilar Malignant Biliary Obstruction Treated with Four Metallic Stents Involving a New Slim Device

Endoscopic hilar multiple stenting is challenging. A 68-year-old patient had self-expandable metallic stents (SEMSs) inserted for unresectable hilar malignant biliary obstruction. After the SEMSs were inserted into the left hepatic duct and bile duct branch of segment (B) 6, a new SEMS with a wide mesh and slim delivery system was inserted into the right anterior hepatic duct. However, liver abscess and dilated B7 were observed on computed tomography; therefore, an additional new SEMS was quickly and easily inserted into B7. After the placement of these four SEMSs, the liver abscess improved. The new SEMS was effective for hilar multiple biliary drainage.     

UNILATERAL VERSUS BILATERAL DRAINAGE USING SELF‐EXPANDABLE METALLIC STENT FOR UNRESECTABLE HILAR BILIARY OBSTRUCTION

Background: There is no consensus on the choice of either unilateral or bilateral drainage in stent placement for patients with unresectable hilar biliary obstruction. The aim of the present study was to clarify which drainage method is superior. Methods: We retrospectively reviewed 82 patients with hilar biliary obstruction who underwent metallic stenting. These patients were divided into a unilateral drainage group (Uni group) and a bilateral drainage group (Bi group). Results: There was no significant difference between the groups in median survival time, median stent patency period, and median complication‐free survival time. The most frequent complication was stent obstruction, followed by cholangitis. Liver abscess was found at a higher frequency in the Bi group (17.6%) than in the Uni group (1.5%) (P = 0.0266). There was no significant difference between the groups in the occurrence of two or more complications (P = 0.247), life‐threatening severe complications (P = 0.0577), and stent obstruction by sludge (P = 0.0912). Conclusion: When compared with bilateral biliary drainage, unilateral biliary drainage is associated with a lower incidence of liver abscess as well as a comparable outcome of stent patency time and complication‐free survival. We therefore propose that hilar biliary obstruction can be treated first by unilateral drainage with a metallic stent and by bilateral drainage only in patients who develop cholangitis in the contralateral biliary tree.