Endoscopic Biliary Sphincterotomy Is Not Required for Transpapillary SEMS Placement for Biliary Obstruction

Background  

Endoscopic retrograde cholangiopancreatography with biliary self-expanding metal stent placement is the preferred method of providing biliary drainage for pancreaticobiliary malignancies. Some endoscopists routinely perform biliary sphincterotomy to facilitate biliary stent placement and potentially minimize pancreatitis with transpapillary self-expanding metal stent placement.     

Optimum Palliation of Inoperable Hilar Cholangiocarcinoma: Comparative Assessment of the Efficacy of Plastic and Self-Expanding Metal Stents

Background  

Endoscopic retrograde biliary drainage (ERBD) with plastic or self-expanding metal stents (SEMS) is often performed for palliative care for cholangiocarcinoma.     

Management of occluded self-expanding biliary metal stents in malignant biliary disease

Background: Occlusion of self-expanding metal stents(SEMS) in malignant biliary obstruction occurs in up to 40% of patients. This study aimed to compare the different techniques to resolve stent occlusion in our collective of patients.Methods: Patients with malignant biliary obstruction and occlusion of biliary metal stent at a tertiary referral endoscopic center were retrospectively identified between April 1, 1994 and May 31, 2014. The clinical records were further analyzed regarding the characteristics of patients, malignant strictures, SEMS,management strategies, stent patency, subsequent interventions, survival time and case charges.Results: A total of 108 patients with biliary metal stent occlusion were identified. Seventy-nine of these patients were eligible for further analysis. Favored management was plastic stent insertion in 73.4% patients. Second SEMS were inserted in 12.7% patients. Percutaneous transhepatic biliary drainage and mechanical cleansing were conducted in a minority of patients. Further analysis showed no statistically significant difference in median overall secondary stent patency(88 vs. 143 days, P = 0.069), median survival time(95 vs. 192 days, P = 0.116), median subsequent intervention rate(53.4% vs. 40.0%, P = 0.501)and median case charge(€5145 vs. €3473, P = 0.803) for the treatment with a second metal stent insertion compared to plastic stent insertion. In patients with survival time of more than three months,significantly more patients treated with plastic stents needed re-interventions than patients treated with second SEMS(93.3% vs. 57.1%, P = 0.037).Conclusions: In malignant biliary strictures, both plastic and metal stent insertions are feasible strategies for the treatment of occluded SEMS. Our data suggest that in palliative biliary stenting, patients especially those with longer expected survival might benefit from second SEMS insertion. Careful patient selection is important to ensure a proper decision for either management strategy.     

Preoperative biliary stents in pancreatic cancer

Background

Pancreatic cancer is a common digestive cancer with high mortality, and surgical resection is the only potential curative treatment option. Pancreatic head cancer is usually accompanied by biliary obstruction, which potentially increases surgical complications following pancreaticoduodenectomy. Thus, preoperative biliary drainage has long been advocated.

Methods

A review of the literature using Medline, Embase and Cochrane databases was undertaken.

Results

Endoscopic or percutaneous biliary stent placement is technically successful in most patients. The use of routine preoperative biliary drainage in the setting of pancreatic cancer with biliary obstruction is controversial. Prospective studies have shown that complications related to preoperative biliary drainage using endoscopic placement of traditional plastic endoprostheses increase the overall morbidity compared to pancreaticoduodenectomy alone. Placement of self-expandable metal stents could reduce stent-related complication rates such as early occlusion because of prolonged patency, especially when surgery is delayed.

Conclusion

Pancreatic cancer patients with deep jaundice and expected delay prior to curative intent surgery are potential candidates for temporary biliary drainage. Cholangitis remains a formal indication for early, urgent preoperative biliary decompression for patients with pancreatic cancer.     

Analysis of Biliary Epithelial-Mesenchymal Transition in Portal Tract Fibrogenesis in Biliary Atresia

Background  

The cellular origin of myofibroblast in the liver fibrosis remains unclear. This study was designed to investigate whether biliary epithelial cells (BECs) undergoing epithelial–mesenchymal transition (EMT) might be found in patients with biliary atresia, thereby serving as a source of fibrotic myofibroblasts.     

Precut Papillotomy: A Risky Technique Not Only for Experts but Also for Average Endoscopists Skilled in ERCP

Purpose  

To evaluate the success and complication rates of early precut papillotomy in difficult biliary cannulations performed by an average endoscopist skilled in ERCP.     

Long-Term Risk of Cholangitis in Patients with Metal Stents for Malignant Biliary Obstruction

Background

Patients with malignant biliary obstruction are commonly living longer than previously due to improved oncologic therapies, often exceeding expected times of self-expanding metal stent patency.

Aims

The purpose of this study was to assess the long-term risk and impact of cholangitis in these patients.

Methods

Retrospective review of electronic medical records at an academic medical center.

Results

One hundred and one patients had a self-expanding metal stent placed for malignant biliary obstruction. The median survival after SEMS was 214 days. Of these patients, 22 % developed at least one episode of cholangitis requiring inpatient admission, 20 % (9/45) of patients were hospitalized for cholangitis at 6 months, 40 % (8/20) at 1 year, and 75 % (3/4) at 2 years. All of the (8/8) patients receiving chemotherapy prior to hospitalization for cholangitis experienced delays in subsequent chemotherapy. Follow-up of 36 episodes of cholangitis revealed a 14 % 30-day mortality.

Conclusions

Cholangitis develops commonly in long-term survivors with self-expanding metal stents for malignant biliary obstruction, and is associated with delays in chemotherapy and a 14 % 30-day mortality.     

Metallic or plastic stent for bile duct obstruction in ampullary cancer?

Background and Aims  

Although ampullary cancer is a relatively uncommon malignancy, it is frequently associated with biliary obstruction. Endoscopic biliary drainage is regarded as a palliative treatment of choice for patients with inoperable ampullary cancer. However, there are no data concerning choice of stent in this patient population. The objective of this study was to compare the efficacy of metallic and plastic stents for biliary obstruction in patients with ampullary cancer.     

Familial Clustering and Genetic Background of Primary Biliary Cirrhosis in Japan

Background  

Primary biliary cirrhosis (PBC) is regarded as an autoimmune liver disease and familial clustering of PBC could represent some genetic predisposition to the disease.     

Cholecystectomy and sphincterotomy in patients with mild acute biliary pancreatitis in Sweden 1988 - 2003: a nationwide register study

Background  

Gallstones represent the most common cause of acute pancreatitis in Sweden. Epidemiological data concerning timing of cholecystectomy and sphincterotomy in patients with first attack of mild acute biliary pancreatitis (MABP) are scarce. Our aim was to analyse readmissions for biliary disease, cholecystectomy within one year, and mortality within 90 days of index admission for MABP.     

Long-Term Biliary Endoscopic Sphincterotomy Restenosis: Incidence,Endoscopic Management,and Complications of Retreatment

Background  

Ampullary restenosis is a late complication of biliary endoscopic sphincterotomy. Long-term data are limited regarding both the rate of restenosis and complications resulting from repeat therapy.     

Endoscopic double-metallic stenting for malignant biliary and duodenal obstructions

Background

Endoscopic metallic stenting is a safe, effective treatment for malignant biliary obstructions, but can be technically difficult when combined malignant biliary and duodenal obstructions exist. Available duodenal metallic stents feature a tight mesh unsuitable for transpapillary biliary stenting. We evaluated the feasibility and usefulness of new endoscopic procedures for endoscopic double-stent placement in managing such obstructions.

Methods

The through-the-scope duodenal metallic stent has a central cross-wired, unfixed structure that allows insertion of the biliary stent through the mesh wall of a duodenal stent. Transpapillary endoscopic placement of a biliary stent was performed through the lumen of this duodenal stent. Endoscopic ultrasound (EUS)-guided biliary drainage was performed successfully through the duodenal bulb after puncturing with a 19G needle. Biliary metallic stenting through the choledochoduodenal tract and effective drainage were achieved.

Conclusions

Use of a combined endoscopic biliary and duodenal stent inserted through the mesh of the new duodenal metallic stent is feasible and effective in managing the aforementioned obstructions. EUS-guided biliary metal stenting is a therapeutic option for endoscopic management when a failed transpapillary approach through the lumen of the duodenal stent occurs. The continued development of endoscopic procedures and devices should resolve issues associated with complicated strictures.     

Prevalence of Autoimmune Liver Disease Related Autoantibodies in Chinese Patients with Primary Biliary Cirrhosis

Background  

The prevalence of autoimmune liver disease (AiLD)-related autoantibodies has not been defined in Chinese patients with primary biliary cirrhosis (PBC) and therefore needs to be characterized.     

Role of Radial Endosonography in the Diagnosis of Acute Cholangitis

Background and Study Aim  

We aimed to assess radial endoscopic ultrasound (EUS) features of the bile duct wall as well as biliary luminal liquid characteristics in cases with acute cholangitis.     

Early Use of Needle-Knife Fistulotomy Is Safe in Situations Where Difficult Biliary Cannulation Is Expected

Background and Aims  

Difficult cannulation is a well known risk for post-ERCP pancreatitis. This study evaluated the outcomes of needle-knife fistulotomy (NKF) used prior to being faced with difficult biliary cannulation.     

Management of patients with biliary sphincter of Oddi disorder without sphincter of Oddi manometry

Background  

The paucity of controlled data for the treatment of most biliary sphincter of Oddi disorder (SOD) types and the incomplete response to therapy seen in clinical practice and several trials has generated controversy as to the best course of management of these patients. In this observational study we aimed to assess the outcome of patients with biliary SOD managed without sphincter of Oddi manometry.     

Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment

Background  

Anomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases.     

Impact of hospital volume on clinical outcomes of endoscopic biliary drainage for acute cholangitis based on the Japanese administrative database associated with the diagnosis procedure combination system

Background  

We aimed to determine the relationship between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis, using the Japanese administrative database associated with the diagnosis procedure combination (DPC) system.     

Preoperative Biliary Drainage Before Resection for Hilar Cholangiocarcinoma: Whether or Not? A Systematic Review

Background  

The value of preoperative biliary drainage (PBD) before resection for hilar cholangiocarcinoma (HCCA) is still controversial nowadays. The objective of this review is to summarize quantitatively the evidence related to this issue.     

Comparison between emergency and elective endoscopic sphincterotomy in patients with acute cholangitis due to choledocholithiasis: is emergency endoscopic sphincterotomy safe?

Purpose  

We retrospectively assessed post-EST complications and examined whether combination therapy comprising endoscopic biliary drainage (EBD) plus endoscopic sphincterotomy (EST) as the initial treatment is safe in patients with acute cholangitis due to choledocholithiasis.