Management of malignant biliary stricture with self-expanding metallic stent

Background: Self-expanding metallic mesh stents are designed to remain patent longer than polyethylene (PE) stents, which generally clog in 3 to 4 months. Though more expensive, metal stents may therefore be a better choice for malignant strictures. Methods: From January 1991 to October 1995, we performed ERCP in 212 patients with malignant or benign strictures, and 34 ultimately had insertion of a metallic stent. These stents were placed by the percutaneous transhepatic route in 17 patients and endoscopically in 17. Results: Metallic stent insertion was successful in each case and relieved the preoperative jaundice and cholangitis. There were no procedure-related deaths; complications were pancreatitis (one) and hemorrhage (one). Overall stent patency was 6.2 months. Three of 34 stents occluded due to tumor ingrowth at 3, 4.5, and 8 months and were treated by placing a new PE stent through the blocked metal stent. The remaining 31 stents remained patent until patient death (n= 15, mean survival = 4.9 months) or are still open (n= 16, mean patency = 12.2 months). Conclusions: Self-expanding metal stents provide effective palliation of malignant biliary strictures and should be considered an alternative to open surgery. Metal stents remain patent much longer than PE stents and usually a single session of metal stenting can palliate biliary obstruction for life. Received: 20 March 1996/Accepted: 9 May 1996     

经皮胆道支架植入术联合放疗治疗不可手术切除的肝门部胆管癌

目的 描述肝门部胆管癌患者经皮胆道裸支架植入术的操作方法,评估操作的安全性;分析胆道裸支架植入术联合放疗是否延长不可手术切除的肝门部胆管癌患者支架通畅时间和生存时间。方法 回顾性分析海军总医院和粤北人民医院肝胆外科2007年2月至2013年9月间不能手术切除肝门部胆管癌行经皮胆道裸支架植入术者38例临床资料,均在超声以及透视下行支架植入术。25例接受支架联合放疗（UMS+RT组）,13例接受单纯支架治疗（UMS组）。收集患者支架植入术并发症发生情况;分析比较两组间支架通畅时间和生存时间的差异。结果 经皮胆道裸支架植入术技术成功率为100%,胆道引流成功率为86.8%,早期并发症发生率为15.8%,手术相关病死率为2.6%。支架联合放疗组的中位支架通畅时间为326 d,单纯支架组中位支架通畅时间为196 d（P=0.022）;支架联合放疗组生存时间明显长于单纯支架组（中位生存时间：367 d vs 267 d,P=0.025）。结论 本研究结果显示经皮胆道裸支架植入术为不可手术切除肝门部胆管癌提供一种安全、有效的姑息治疗方法,支架联合放疗有助于延长支架通畅时间以及生存时间。     

Endoscopic biliary stenting: Plastic stent or expandable metallic stent?

Since its introduction 1979, endoscopic biliary stenting has become the method of first choice to treat cholestasis in malignant or benign biliary obstuction or leakage of biliary fistulas. The success rate of endoscopic biliary stenting generally exceeds 90% and procedure-related complications are rare. Although metal stents are becoming more popular, plastic stents are still the first choice. Their major drawback is occlusion with sludge mediated by bacteria. Pharmaco-chemical measures failed to prevent occlusion. With Teflon material and a 10-French stent, stent exchange rates were reduced to 15% in patients with malignant biliary obstruction, the shape without sideholes showing the best results. Stent exchange is easily feasable. Metal stents are expensive and more difficult to handle. Occlusion with sludge is rare, but patency is limited by tumor ingrowth. Metal stents may be indicated in selected patients, such as those with recurrent stent occlusion causing cholangitis. If only a small-caliber prosthesis (7-Fr) can be placed (e.g. in Klatskin tumor) metal stents may have a longer patency than plastic stents. Metal stents should not be used in benign biliary obstruction because these stents are not removable.     

EXPANDABLE METALLIC BILIARY STENTS

Eighteen expandable metallic biliary stents were inserted in patients with malignant (16 patients) or benign (two patients) biliary strictures. Four were the Gianturco-Rosch biliary Z-stents and the remaining 14 were the Wallstent. The stents were delivered through either the endoscopic transpapillary (10 patients), percutaneous transhepatic (five patients) or combined percutaneous-endoscopic (three patients) route. No failure in implantation was encountered. Bile drainage was successful in all patients. Stent occlusions were observed in four patients with hilar obstruction due to tumour overgrowth above the stents at 30–67 days (mean 47.75 days) after insertion. The occlusions were drained percutaneously (two patients) or endoscopically (two patients). Migration of stent did not occur. After a median follow-up period of 170.5 days (range 57–731 days), 11 patients were still alive and free of jaundice. The median patency period of the stents for common bile duct and hilar obstruction was 288.5 days (range 117–731 days) and 61.5 days (range 30–188 days), respectively. The overall median patency period was 165 days. It is concluded that expandable metallic biliary stent is a useful adjunct to the treatment of malignant biliary obstructions with a better result in distal obstruction.     

Interventional treatment of biliary stricture

Biliary stenting is a well-established intervention in pancreatic-biliary disease. Although interventional therapy is an excellent less-invasive method that can improve the quality of life of patients with stricture of the bile duct, inappropriate application can be harmful. The procedure includes the endoscopic as well as percutaneous transhepatic approach. The indications for each procedure depend upon the characteristics of the lesion, and technical feasibility must also be considered. Two types of prosthesis, the plastic tube stent (TS) and expandable metallic stent(EMS), are available. Since the former costs less and has the advantage of removability compared with the latter, it can be used in the treatment of benign strictures and for temporary stenting of resectable malignant strictures. However, the TS has a short patency period because it is likely to become occluded by clogging. In contrast, the EMS has a long patency period due to its large diameter, and multiple stents can be placed in hepatic hilar strictures. Tumor ingrowth is a major late complication of EMS. To maintain patency, other procedures such as radiation, microwave coagulation therapy, and hyperthermia can be considered in combination with EMS, which may contribute to further improvement in survival and quality of life in patients with unresectable malignant biliary strictures. Those procedures should not be performed in patients with benign biliary strictures since the EMS cannot be removed, and the long-term outcome after placement remains to be clarified.     

可膨式金属胆道支架解除恶性胆管梗阻的临床应用及其疗效分析

目的 探讨可膨式金属胆道支架支解除恶性胆管梗阻的中远期疗效及初步分析影响疗效的因素,方法 １３４例各类恶性肿瘤导致胆管梗阻的患者接受金属支架放置术,其中内镜下经乳头放置１２８例,经皮经肝放置６例,随访引流效果并与同期９７例内镜下放置塑料支架的患者进行对比。结果 操作成功率９５．７％,并发症６．４％,黄疸消除率８５．６％,金属支架的平均通畅期为３００天,明显高于塑料支轲的８０天（Ｐ〈０．０１）;平均     

射频消融联合支架植入术治疗恶性胆道梗阻

目的探讨射频消融联合支架植入术治疗恶性胆道梗阻的临床应用价值。方法选取恶性胆道梗阻的患者34例,对其中19例行射频消融联合胆道金属支架植入术(射频组),15例行单纯胆道金属支架植入引流术(引流组)。记录术前、术后5天和7天的血清总胆红素(TBIL),及术后胆瘘、胆道穿孔、胰腺炎及胆管炎的发生率。分别于术后3、6、12个月进行电话随访,记录支架通畅率、生存率及生存时间,并进行统计学分析。结果对两组患者均顺利完成手术,无胆瘘、胆道穿孔、胆道出血、胰腺炎发生。两组术前、术后5天和7天TBIL水平差异均无统计学意义(P均0.05)。10例出现胆管炎(射频组6例,引流组4例),两组差异无统计学意义(P0.05)。术后3、12个月支架通畅率及术后3、6、12个月生存率差异均无统计学意义(P均0.05)。射频组术后6个月支架通畅率高于引流组(P0.05)。射频组生存时间长于引流组(P0.05)。结论射频消融联合支架植入术可提高术后6个月支架通畅率并延长患者生存时间,可作为治疗胆道恶性梗阻的重要方法之一。     

Pancreaticoduodenectomy after placement of endobiliary metal stents

Contemporary treatment programs for patients with potentially resectable pancreatic cancer often involve preoperative therapy. When the duration of preoperative therapy exceeds 2 months, the risk of plastic endobiliary stent occlusion increases. Metal stents have much better patency but may complicate subsequent pancreaticoduodenectomy (PD). We evaluated rates of perioperative morbidity, mortality, and stent complications in 272 consecutive patients who underwent PD at our institution from May 2001 to November 2004. Of these 272 patients, 29 (11%) underwent PD after placement of a metal stent, 141 underwent PD after placement of a plastic stent, 10 had PD after biliary bypass without stenting, and 92 had PD without any form of biliary decompression. No differences were found between the Metal Stent group and all other patients in median operative time, intraoperative blood loss, or length of hospital stay. No perioperative deaths occurred in the Metal Stent group versus 3 (1.2%) deaths in the other 243 patients. The incidence of major perioperative complications was similar between the two groups, including the rates of pancreatic fistula, intra-abdominal abscess, and wound infection. Furthermore, there were no differences in the perioperative morbidity or mortality rates between patients who underwent preoperative biliary decompression with a stent of any kind (metal or plastic) and those patients who underwent no biliary decompression at all. Metal stent-related complications occurred in 2 (7%) of 29 patients during a median preoperative interval of 4.1 months; in contrast, 75 (45%) of the 166 patients who had had plastic stents experienced complications, including 98 stent occlusions, during a median preoperative interval of 3.9 months (P < 0.001). We conclude that the use of expandable metal stents does not increase PD-associated perioperative morbidity or mortality, and as such an expandable metal stent is our preferred method of biliary decompression in patients with symptomatic malignant distal bile duct obstruction in whom surgery is not anticipated, or in whom there is a significant delay in the time to surgery. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation). Supported by the Lockton Fund for Pancreatic Cancer Research, The University of Texas M. D. Anderson Cancer Center, Houston, Texas.     

Are expandable metallic stents better than conventional methods for treating difficult intrahepatic biliary strictures with recurrent hepatolithiasis?

BACKGROUND: Conventional methods for treating patients with recurrent hepatolithiasis associated with complicated intrahepatic biliary strictures include balloon dilatation of the intrahepatic biliary strictures, lithotripsy, and the clearance of difficult stones as completely as possible, with the placement of an external-internal stent for at least 6 months. After these modalities are used, symptomatic refractory strictures remain. Recently we used internal Gianturco-Rosch metallic Z stents to treat patients who had refractory strictures. OBJECTIVE: To compare therapeutic results and complications of an internal expandable metallic Z stent with those of repeated external-internal stent placement. STUDY DESIGN: Case-control study. SETTING: A referral center. PATIENTS: From January 1992 to December 1996, 18 patients with recurrent hepatolithiasis and complicated intrahepatic biliary strictures underwent percutaneous dilatation of stricture and transhepatic percutaneous cholangioscopic lithotomy for recurrent stones. After their stones were completely cleared, their biliary strictures failed to dilate satisfactorily. The patients were randomly enrolled into 2 groups: group A (7 patients), who received an expandable metallic Z stent, and group B (11 patients), who had repeated placement of external-internal stents. INTERVENTIONS: Percutaneous stricture dilatation, electrohydraulic lithotripsy, balloon dilatation, percutaneous transhepatic cholangioscopic lithotomy, and biliary stenting by a Silastic external-internal catheter or a modified Gianturco-Rosch expandable metallic Z stent (for an internal stent). MAIN OUTCOME MEASURES: The number of procedures, days in hospital, procedure-related complications, incidents of stone recurrence and recurrence of cholangitis, readmissions to the hospital, treatment sessions required, and mortality rate. Patients' limitations in ordinary activities were also compared. RESULTS: The follow-up period ranged from 28 to 60 (40.7+/-12.7 [mean +/- SD]) months in group A and from 28 to 49 (36.0+/-7.2) months in group B. Fewer group A patients (3 [43%]) than group B patients (8 [73%]) tended to have recurrent cholangitis and to require readmission to the hospital, but this was not statistically significant (P = .33). When their cumulative probability of a first episode of cholangitis during follow-up was compared, however, it was significantly lower in patients treated with a metallic stent (P = .04). Compared with group B patients, group A patients had less frequent recurrence of stones (0% vs 64%; P = .01), fewer procedures for the clearance of biliary stones or sludge (1.7+/-2.2 vs 6.4+/-4.3; P = .03), and shorter hospital stays (8.0+/-11.5 days vs 17.0+/-12.0 days; P = .07). No patients in group A experienced limitation in ordinary activities, whereas 7 patients in group B did (P<.02). CONCLUSIONS: Compared with the repeated placement of external-internal stents, the use of a metallic internal stent effectively decreases stone recurrence, simplifies further procedures, and is more convenient. Its use is suggested as an alternative choice in the treatment of recurrent hepatolithiasis with refractory intrahepatic biliary strictures.     

Tannenbaum and metal stents in the palliative treatment of malignant distal bile duct obstruction: a comparative study of patency and cost effectiveness

Background Stent clogging is the major limitation of palliative treatment for malignant biliary obstruction. Metal stents have much better patency than plastic stents, but are more expensive. Preliminary data suggest that the recently designed plastic (Tannenbaum) stent has better duration of patency than the polyethylene stent. This study aimed to compare the efficacy and cost effectiveness between the Tannenbaum stent without side holes and the uncovered metal stent for patients with malignant distal common bile duct obstruction. Methods In this study, 47 patients (median age, 73 years, range, 56–86 years) with inoperable malignant distal common bile duct strictures were prospectively randomized to receive either a Tannenbaum stent (n = 24) or an uncovered self-expandable metal stent (n = 23). The patients were clinically evaluated, and biochemical tests were analyzed if necessary until their death or surgery for gastric outlet obstruction. Cumulative first stent patency and patient survival were compared between the two groups. Cost-effectiveness analysis also was performed for the two study groups. Results The two groups were comparable in terms of age, gender, and diagnosis. The median first stent patency was longer in the metal group than in the Tannenbaum stent group (255 vs 123.5 days; p = 0.002). There was no significant difference in survival between the two groups. The total cost associated with the Tannenbaum stents was lower than for the metal stents (17,700 vs 30,100 euros; p = 0.001), especially for patients with liver metastases (3,000 vs 6,900 euros; p < 0.001). Conclusions Metal stent placement is an effective treatment for inoperable malignant distal common bile duct obstruction, but Tannenbaum stent placement is a cost-saving strategy, as compared with metal stent placement, especially for patients with liver metastases and expected short survival time.     

Unresectable Malignant Biliary Obstruction: Treatment by Self-Expandable Biliary Endoprostheses

The primary goal in the treatment of malignant obstruction is the relief of jaundice. Although operative biliary bypass is a reliable method of palliation, nonoperative palliation may be desirable in selected patients.We report our experience with forty-eight self expandable metallic biliary endoprostheses (Wallstent) percutaneously placed in 35 patients with irresectable malignant biliary obstruction. In twelve patients more than one stent was necessary to bridge the entire length of the biliary stenosis. The obstruction was due to primary tumors in 14 and to lymph node metastases in 12. In nine patients transanastomotic stents were placed after previous bilioenteric anastomosis because of malignant obstruction. Complications occurred in 11 patients (31.4%), and five patients died within 30 days of stent placement (14.3%). The mean stent patency to date of patients discharged is 6.1 months, and the mean survival 7.2 months. Follow up data is available for 29 patients, and excellent palliation was achieved for more than 75% of the survival time in 22 (76%). Seven patients have had documented stent occlusion requiring further intervention (24%).In this selected group of patients, the results of percutaneous self-expandable stents are encouraging. However, our data does not support the initial reports of self-expandable endoprostheses that suggest an improved result compared to conventional plastic stents. A randomized study using either expandable stents as compared to operative biliary enteric bypass is necessary.     

Covered expandable tracheal stents in the management of benign tracheal granulation tissue formation

BACKGROUND: Tracheal obstruction secondary to benign proliferation of granulation tissue is a difficult problem to address if tracheal resection is contraindicated. Some patients may benefit from Nd:YAG (neodymium: yttritium-aluminum garnet) laser fulguration or tracheal stenting. If uncovered expandable metallic stents are employed granulation tissue can regrow and proliferate through the mesh, thereby obstructing the lumen once again. Covered metallic stents confer the advantage of preventing granulation tissue proliferation and therefore maintain patency of the tracheal lumen. METHODS: Two patients who developed tracheal obstruction secondary to proliferating granulation tissue formation after tracheostomy and who were medically unfit for prolonged general anesthesia were successfully treated using covered expandable metallic tracheal stents. RESULTS: Each patient demonstrated a significant improvement in respiratory status, and in both patients, at 6 and 9 months' follow-up, stent position has not changed, tracheal lumen remains patent, and there has been no proliferation of granulation tissue through the stent. CONCLUSIONS: Covered expandable metallic stents should be considered in the management of patients with proliferating tracheal granulation tissue when tracheal resection is contraindicated.     

Newly designed large cell Niti-S stent for malignant hilar biliary obstruction: a pilot study

Background

Whether uni- or bilateral drainage should be performed for malignant hilar biliary obstruction remains a matter of debate. Moreover, endoscopic placement of bilateral metallic stents has been considered difficult and complicated. Although the Y-stent with a central wide-open mesh facilitates bilateral stent placement, it has limitations. This study evaluated the feasibility and efficacy of the Niti-S large cell D-type biliary stent (LCD) with a uniform large cell for both uni- and bilateral drainage of malignant hilar biliary obstruction.

Methods

From April 2008 to March 2009, a total of 12 consecutive patients with unresectable malignant hilar biliary obstruction of Bismuth type 2 or greater underwent placement of LCD. Before LCD placement, all the patients underwent endoscopic unilateral biliary drainage using a plastic stent or a nasobiliary drainage tube. If jaundice improved after the procedure, the plastic stent or nasobiliary drainage tube was replaced with the unilateral LCD. If jaundice did not resolve or contralateral cholangitis occurred, bilateral LCD placement was performed.

Results

Seven patients had unilateral and five patients had bilateral LCD placement. Technical success was achieved for all 12 patients. An early complication occurred for one patient (8%), and stent occlusion occurred for six patients (50%) because of tumor ingrowth (n?=?4) or sludge (n?=?2). These patients were managed by insertion of plastic stents (n?=?4) or percutaneous transhepatic biliary drainage (n?=?2). The median stent patency period was 202?days.

Conclusions

The newly designed endoscopic metallic stent may be feasible and effective for malignant hilar biliary obstruction, and endoscopic reintervention is relatively simple.     

Palliation of anastomotic obstructions in recurrent gastric carcinoma with the use of covered metallic stents: clinical results in 25 patients

BACKGROUND: The purpose of this study was to investigate the technical feasibility and the clinical effectiveness of the placement of covered self-expandable metallic stents for the treatment of anastomotic obstructions in recurrent gastric carcinoma. METHODS: With fluoroscopic guidance, covered stents were placed in 25 patients with recurrent gastric carcinoma for the palliation of obstructions at anastomotic sites (14 gastrojejunostomy, 11 esophagojejunostomy). All patients had severe nausea and recurrent vomiting before the stent placement. RESULTS: Stent placement was technically successful in 24 patients (96%). After stent placement, symptoms improved in all 24 patients. During the follow-up of 2 to 65 weeks (mean, 13.7 weeks), stent migration occurred in 1 patient 16 days after the procedure. He needed percutaneous catheter drainage because of an abscess, which was followed by esophagojejunostomy site rupture during a second stent trial. Stricture recurred in 4 patients because of tumor overgrowth 10 to 55 weeks after the procedure; all patients underwent coaxial placement of a second stent and had good oral intake. CONCLUSIONS: The placement of covered expandable metallic stents seems to be both technically feasible and an effective means for the palliation of anastomotic obstructions in recurrent gastric carcinoma. This procedure can be considered to be the primary choice for the palliation in those patients.     

Do preoperative biliary stents increase postpancreaticoduodenectomy complications?

It has been suggested that the placement of endoscopic or percutaneous biliary stents prior to pancreaticoduodenectomy increases postoperative morbidity. A retrospective review of a prospectively collected database was performed. Patients undergoing preoperative biliary stenting were compared with patients who did not undergo stenting. In addition, outcomes after endoscopic and percutaneous stenting were compared. Patients who had undergone operative biliary bypass prior to pancreaticoduodenectomy were excluded from the analysis. Between January 1994 and December 1997,567 patients underwent pancreaticoduodenectomy without prior operative biliaty bypass. Preoperative biliary stenting was performed in 408 patients (72%), whereas the remaining 159 patients (28%) did not undergo biliary stenting. In the stented group, 64% had stents placed via a percutaneous approach and 36% had stents placed endoscopically. The stented patients were older (mean 63.1 years vs. 61.4 years; P = 0.05) and were more likely to be white (92% vs. 82%; P = 0.005). Those who had stents placed were more likely to have jaundice (67% vs. 38%; P < 0.0001) and fever (5% vs. 1%; P = 0.03) as presenting symptoms. There were no differences in multiple intraoperative parameters when the two groups were compared. Patients who had stems placed had a perioperative mortality rate of 1.7% compared to 2.5% in those who did not (P = 0.3). Although the overall complication rates were 3 5% in those who had stents placed and 30% in those who did not (P = NS), patients with stems experienced a significantly increased incidence of pancreatic fistula (10% vs. 4%; P = 0.02) and wound infection (10% vs. 4%; P = 0.02). The incidences of other postoperative complications were similar between the stented and unstented groups. Eight patients (3 %) in the percutaneously stented group developed significant hemobilia after stent placement, whereas none of the patients undergoing endoscopic stent placement developed hemobilia (P = 0.03). There were no statistical differences in other complications between the percutaneously and endoscopically stented groups. Preoperative biliary stenting did not increase the overall complication rate or mortality rate in patients undergoing pancreaticoduodenectomy. Stenting does appear to increase the rate of pancreatic fismla formation, possibly as a result of pancreatic inflammation related to the stenting procedure. Stenting also increases the rate of wound infection, likely secondary to contaminated bile (bactibilia) after instrumentation of the biliary tree. Preoperative biliary stenting is safe but should be used selectively because of the above-mentioned risks. The method of stenting should be based on local expertise. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, May 16–19, 1999, Orlando, Fla.     

Migration of biliary plastic stents: experience of a tertiary center

Background and study aims  Stent migration occurs in about 5–10% of patients undergoing biliary stenting. The aim of this study was to analyze the risk factors for stent migration in patients with benign and malignant strictures. Patients and methods  We retrospectively analyzed records of 524 biliary plastic stent placement procedures. Details noted included the cause and localization of stricture, characteristics and number of stents, direction of stent migration, presentation of patient with migrated stent, and the methods used for retrieval of migrated stents. Results  Two hundred and four (38.9%) of the procedures were performed for benign biliary strictures (BBS) and 320 (61.1%) for malignant biliary strictures (MBS). Thirty-four patients had 45 migrated biliary stents. The rate of migration was 8.58% (proximal 4.58% and distal 4.00%). Migration frequency was higher in BBS compared with MBS (13.7% versus 5.3%, p = 0.001). In BBS, the rate of stent migration was higher in cases with one (19.3%) and two stents (20.9%) when compared with cases with multiple stents (2.7%) (p = 0.001; p = 0.001, respectively). Migration occurred more frequently (10.9%) in cases with two stents when compared both to cases with one stent (3.0%) and those with multiple stents (0%) in MBS (p = 0.008; p = 0.020, respectively). In BBS, short stents migrated more frequently proximally (77%) and long stents more frequently distally (73%) (p = 0.008). In BBS, migration in cases with proximal stricture occurred more frequently distally (76.9%), while in those with distal stricture, migration was more frequently proximal (73.3%) (p = 0.008). All of the proximally migrated stents could be successfully retrieved endoscopically. Conclusions  The risk of stent migration is higher in BBS compared with in MBS. The cases with multiple stents had significantly lower stent migration. In BBS, long stent, proximal and postcholecystectomy strictures were associated with distal migration, while short stent, distal and non-postcholecystectomy strictures were associated with proximal migration.     

Prevention of clogging of biliary stents by administration of levofloxacin and ursodeoxycholic acid

One of the main advances in biliopancreatic endoscopic therapy has been the ability to palliate patients with biliary obstruction by placement of a stent during ERCP, but this is often complicated by clogging of the stent with subsequent jaundice and/or cholangitis. Stent clogging may be caused by microbiological adhesion and biliary stasis. Therefore, the use of antibiotics and choleretic agents such as levofloxacin and ursodeoxycholic acid has been investigated to see whether they prolong stent patency. Ninety patients with strictures of the biliary tract and untreatable macrolithiasis with endoscopically inserted stents were randomized into two groups: 49 subjects in group 1 (levofloxacin + ursodeoxycholic acid) and 41 in group 2 (ursodeoxycholic acid alone). In the patients in group 1 "stent patency in situ" was 50% longer than in group 2, with a lower incidence of cholangitis and hospital admittance. No adverse pharmacological effects were registered. Treatment with ursodeoxycholic acid and levofloxacin to prevent clogging of biliary stents is recommended as routine practice on the basis of our brief experience. Further trials are needed with rigorous methodology and adequate statistical power, because the perfect biliary stent (inexpensive, easy to insert, and with prolonged patency) does not exist. Prophylactic stent replacement is probably the most prudent strategy to avoid cholangitis, but the optimal time interval is unknown.     

Endoscopic biliary stenting facilitates safe and early removal of T-tube in liver transplant patients

AIM: Duct to duct anastomosis in orthotopic liver transplant (OLT) patients have been traditionally performed with a t-tube in place for 3 to 6 months. Following removal of the t-tube a high incidence of biliary leakage has been reported. METHODS: Prospective study to evaluate the role of endoscopic biliary stenting to facilitate early and uncomplicated t-tube removal. All patients with duct to duct biliary anastomosis who had a t-tube in situ, from January 1998 to December 2002 were included in this study. RESULTS: There were 29 patients eligible for the study. Eight patients were not included due to early death. A protocol t-tube cholangiogram was performed in all patients, (median 12 days; range 4-47 days) followed by an endoscopic stent insertion (median 37 days; range 20-55 days). The stent was removed later (median 84 days; range 45-133 days). All complications related to the procedure were noted. Stent insertion was successful in all cases. In 2 patients a second endoscopic retrograde cholangiopancreatography (ERCP) was necessary, either because of failure to cannulate the papilla or to reposition the stent. There was a patient who presented a biliary leak due to stent displacement requiring a laparotomy. There were two further biliary leaks, one of them in an asymptomatic patient, which were managed conservatively. In addition 1 patient developed a mild case of postERCP pancreatitis. CONCLUSIONS: In liver transplants patients with an end-to-end choledochostomy with a t-tube, endoscopic biliary stenting allows an early removal of the T tube, with few complications.     

经皮胆道射频消融术在治疗恶性胆道梗阻中的应用

目的分析经皮肝穿刺射频消融联合支架植入治疗恶性胆道梗阻的有效性、安全性。方法 33例恶性胆道梗阻患者接受胆道射频消融联合胆道金属支架植入治疗,评价术后1、2、3个月支架通畅率和患者的生存率。结果对33例患者均完成胆道射频消融联合胆道金属支架植入治疗。术后患者肝功能均得到不同程度的恢复。随访期内,中位支架通畅时间103天(9~578天)。术后1、2、3个月支架通畅率分别为78.79%(26/33)、66.67%(22/33)、54.55%(18/33)。随访期内,28例患者死亡,中位生存时间193天(19~578天)。患者术后1、2、3个月生存率分别为96.97%(32/33)、81.82%(27/33)、75.76%(25/33)。9例患者术后出现胆道感染,其中1例严重肝病患者死于胆道感染引起的感染性休克,8例患者恢复;13例患者出现无症状淀粉酶升高。所有患者均未出现胆道出血、穿孔等严重并发症。结论经皮肝穿刺射频消融联合金属支架植入治疗恶性胆道梗阻具有较高的安全性和有效性。     

胆道梗阻经内镜引流术的体会

目的探讨经内镜胆道引流治疗胆道梗阻的可行性和疗效。方法回顾性分析我院2003年3月~2004年10月对96例胆道梗阻病例进行103例次内镜下胆道引流的诊治经过,分析其黄疸改善情况、支架通畅率及生存期。结果操作成功率为93.6%。良性胆道梗阻者总有效率为86.7%,恶性梗阻者为88.0%。ERBD组3、6、12月生存率分别为45.8%、33.3%、0;EMBE组分别为100%、76.9%、30.7%。EMBE支架通畅率与平均引流时间均优于ERBD者(P<0.01)。结论经内镜胆道引流治疗老年人良、恶性胆道梗阻疗效确切,可达到减黄、减压、延长生存期的目的。