Rate of bilirubin regression after stenting in malignant biliary obstruction for the initiation of chemotherapy

BACKGROUND.

This study was conducted to evaluate the rate of regression of bilirubin after stent placement for malignant biliary obstruction.

METHODS.

Records were reviewed from October 2002 to September 2005 for patients who underwent endoscopic retrograde cholangiopancreatography with stent placement. The time to achieve a bilirubin level ≤2 mg/dL was the primary endpoint because this is the level required by most chemotherapy protocols. Patient variables included type of cancer, liver metastasis, recent chemotherapy, baseline creatinine, and international normalized ratio (INR). Stent variables included type, dimension, stricture location, and sphincterotomy.

RESULTS.

In total, 156 patients were included in the analysis: Ninety‐three patients achieved a poststent bilirubin level ≤2 mg/dL, 29 patients failed because of stent failure, and 34 patients failed because of inadequate follow‐up. The time required for 80% of patients to achieve normalization was more than doubled in those who had prestent bilirubin levels ≥10 mg/dL (6 weeks) compared with those who had prestent bilirubin levels <10 mg/dL (3 weeks). The following variables were identified as statistically significant: prestent bilirubin level, stricture location, liver metastasis, and INR. The cancer type, recent chemotherapy, stent type and diameter, and sphincterotomy were not statistically significant variables.

CONCLUSIONS.

The rate of bilirubin normalization after biliary stenting was highly dependent on the prestent bilirubin level. Endoscopic intervention should be considered in patients who fail to achieve adequate normalization of serum bilirubin in 6 weeks if prestent bilirubin level was ≥10 mg/dL and in 3 weeks if their prestent bilirubin level was <10 mg/dL. Independent variables, such as diffuse liver metastases, stricture outside the common bile duct, and elevated INR had predictive value for bilirubin normalization. Cancer 2008. © 2008 American Cancer Society.     

恶性高位梗阻性黄疸的介入治疗

背景与目的:侵犯或压迫肝门部胆管的恶性肿瘤造成的胆道高位梗阻,因梗阻部位多位于胆总管上段、肝总管,左右叶肝管甚至互不相通,单侧PTBD引流只能局限于引流管头端所放置的单一分支肝管,部分病例PTBD术后黄疸没有明显减退,甚至短期内加重,导致病情进一步恶化。本研究探讨左右叶双侧PTBD结合内支架术治疗恶性高位梗阻性黄疸的疗效。方法:17例高位恶性梗阻性黄疸的患者(男性11例,女性6例,平均年龄63.4岁),行左、右叶双侧PTBD结合内支架治疗。置入2枚支架的15例;2例为一侧肝管至胆总管置入支架,另一侧留置引流管。15例PTBD术后行TAI/TACE或放疗。结果:全部患者PTBD手术成功。治疗后总胆红素明显下降,由(357.7±142.5)μmol/L降至(174.7±87.6)μmol/L。引流通畅中位时间8.9个月,全组生存中位时间11.2个月。结论:左右叶双侧PTBD结合内支架治疗高位恶性梗阻性黄疸近期疗效肯定,早期引流与多支引流同样重要。     

胆管内双极射频消融联合支架植入术治疗恶性胆管梗阻的研究

目的探讨经皮肝穿刺胆管腔内双极射频消融联合支架植入术治疗恶性胆管梗阻的可行性、安全性及临床疗效。方法分析江苏省肿瘤医院2012年3月至2016年1月27例经皮肝穿刺治疗恶性胆管梗阻患者临床资料,其中9例行经皮肝穿刺胆管内射频消融联合内支架置入术(胆管射频消融组),18例行单纯内支架置入术(单纯胆管支架组)。观察手术安全性、并发症及近期疗效情况。采用Kaplan-Meier方法比较两组患者的支架通畅率及患者生存时间。结果 27例患者均顺利完成手术。胆管射频消融组手术操作时间平均58.6 min(42.0~70.0 min),较单纯胆管支架组平均手术操作时间45.0 min(35.0~60.0 min)有所增加(P=0.003)。两组患者术中均无并发症发生。术后两组患者的胆管感染、腹痛、恶心呕吐等并发症发生率比较,差异无统计学意义。两组患者术后血清胆红素、转氨酶均明显改善。治疗后3个月胆管射频消融组胆管支架通畅率为100%(8/8),单纯胆管支架组为50%(7/14),P=0.022;6个月时分别为100%(6/6)和0,两组比较,P=0.036。胆管支架中位通畅时间,胆管射频消融组为189 d(Q1,92 d;Q3,279 d),单纯胆管支架组为87 d(Q1,82 d;Q3,161 d),两组比较,P=0.001。在治疗后6个月,胆管射频消融组生存率为66.7%(6/9),单纯胆管支架组为11.1%(2/18),两组比较,P=0.006。9个月生存率分别为33.3%(3/9)和0,两组比较,P=0.029。患者中位生存时间胆管射频消融组189 d(Q1,100 d;Q3,279 d),单纯胆管支架组118 d(Q1,96 d;Q3,171 d),两组比较,P=0.028。结论经皮肝穿刺胆管腔内射频消融联合支架植入治疗恶性胆管梗阻安全可行,临床疗效优于单纯支架置入术,可延长支架的通畅期和患者的生存期。     

Endoscopic therapy in the management of malignant biliary obstruction

Malignant biliary obstruction is often caused by tumour within the biliary tree, or extrinsic compression. This often results in patients becoming jaundiced causing a significant associated morbidity.     

胆道恶性肿瘤辅助治疗的研究现状及展望

胆道恶性肿瘤侵袭性强,恶性程度高,预后差。早期根治性切除是目前首选的治疗方法,也是唯一可能获得长期生存的方法。但大多数患者初诊时已为晚期,只有约20%的患者有手术机会。不仅如此,即使行根治性手术,复发率依然极高。为了降低术后复发率,多年来人们一直致力于探索辅助治疗策略,包括放疗、化疗和放化疗结合。但大多数数据来源于Ⅱ期临床试验和回顾性研究,缺乏高质量的数据来证实辅助治疗的效果。近年来随着几项大型随机临床试验的发布以及精准治疗的发展,越来越多的研究聚焦于该领域,结果令人期待。本综述总结并分析了近年来胆道恶性肿瘤辅助治疗领域的研究数据,并探讨了未来的研究方向。     

Intraluminal radiation therapy in the management of malignant biliary obstruction

Fifteen patients with malignant biliary obstruction from carcinoma of the bile ducts, gallbladder, and pancreas (Group I) or metastatic disease (Group II) were treated with intraluminal radiation therapy (ILRT) at Memorial Sloan-Kettering Cancer Center. In 11 cases ILRT was used as a central boost in combination with 3000 cGy external beam radiation therapy (ERT). No significant treatment toxicity was observed. Cholangiographic response was observed in 2 of 12 evaluable patients. In no patient was long-term relief of jaundice without indwelling biliary stent achieved. Survival from treatment in eight Group I patients treated with ILRT +/- ERT was 3 to 13 months (median, 4.5). Survival in seven similarly treated Group II patients was 0.5 to 8 months (median, 4.0). Additional data for ten similar patients referred for ILRT but treated with ERT alone are presented. Analysis of this and other reports indicate the need for prospective controlled trials of the role of this regimen in the management of malignant biliary obstruction before wider application can be recommended.     

食管恶性狭窄的治疗

目的 探讨食管癌恶性狭窄支架置入的方法及其临床疗效。方法 所有患先行钡餐或口服泛影葡胺检查，了解食管狭窄的部位、程度，经扩张后，在内镜或X线下按常规方法置入食管支架。术后应用抗菌素、抑酸、粘膜保护剂、促胃肠动力药物治疗。结果31例食管恶性狭窄和合并瘘的患均一次操作成功，术后恶性狭窄再通率100％。术后有80．6％患胸痛、异物感，返流性食管炎发生率22．6％。结论 食管支架置入术是治疗食管癌恶性狭窄的一种微创姑息治疗术，可达到缓解梗阻，延长生存期目的。     

内镜下胆道金属支架治疗肝门部胆管恶性梗阻的临床研究

为了探讨经内镜放置胆道金属支架治疗肝门部胆管恶性梗阻的可行性及安全性,回顾分析我院接受胆道金属支架治疗的67例肝门部恶性梗阻患者临床资料.所有患者术前行B超、CT、MRCP或ERCP检查.常规ERCP检查,置入导丝越过狭窄段,经胆道扩张管扩张后,在X线监视下置入胆道金属支架,支架近端超过狭窄1.5 cm.67例患者中置入支架62例,成功率91.9%,术后出现胆道感染15例,全部经抗感染治疗后控制.放置支架1周后血清胆红素由术前(349.32±62.39)μmol/L降至(67.43±12.56)μmol/L,平均通畅时间145 d.对其中支架堵塞后的26例患者,再次行内镜检查及治疗,分别置入塑料支架8例,放置鼻胆引流管11例,治疗失败7例.初步研究结果提示,胆道金属支架置入对难以手术切除的肝门部胆管恶性梗阻有较明显治疗效果,是一种操作简单、经济有效、并发症少的方法,具有安全性和可行性.     

Outcomes in percutaneous stenting of non‐hepato‐biliary/pancreatic malignant jaundice

MELLER M.T., ARTS G.R.J. & DEAN J.R. (2010) European Journal of Cancer Care 19 , 664–668 Outcomes in percutaneous stenting of non‐hepato‐biliary/pancreatic malignant jaundice The aim of this study is to review the practice and outcomes at our institution of percutaneous transhepatic placement of metallic biliary stents for non‐hepato‐biliary/pancreatic (non‐HBP) malignant obstructive jaundice. A retrospective review was performed of the records of all patients undergoing transhepatic stenting for non‐HBP malignant obstructive jaundice over a 7‐year period. A total of 25 patients were successfully stented and linear regression analysis of a variety of demographic, clinical and laboratory markers against survival was performed. Survival after stenting varied from 1 to 1354 days (median 58, mean 152). An initial bilirubin level less than 300 µmol/L (P= 0.01) and a reduction of greater than 50% in bilirubin post stenting (P= 0.02) were strong predictors of improved survival. Older patients survived longer than younger ones (P < 0.01). There was a weak association of survival with an albumin >30 g/L (P= 0.06), but no statistically significant correlation with creatinine or haemoglobin levels or active tumour treatment after stenting. There were few major complications from the procedures. Transhepatic metallic biliary stenting for non‐HBP malignant biliary obstruction is a safe and effective procedure, and with careful patient selection, significant periods of survival and palliation of jaundice can be achieved.     

Esophageal stenting for the palliation of malignant dysphagia

Self-expanding metal stents (SEMS) are currently the standard for palliation of malignant dysphagia. Innovations in stent technology, including the advent of retrievable stents and the development of self-expanding plastic stents (SEPS), show promise to increase the possible applications for esophageal stents. This article reviews the indications and usage of both SEMS and SEPS in patients with malignant dysphagia as well as the potential complications of their use.     

胆道支架放置术治疗恶性胆道梗阻的临床应用

目的：探讨胆道支架放置术治疗恶性胆道梗阻性黄疸的疗效和安全性。方法：恶性梗阻性黄疸病人24例，均采用胆道支架放置术的治疗方法，分别观察血清胆红素下降程度，手术并发症，并随访病人生存期和胆道支架维持通畅时间。结果：所有病人在治疗过程中均安全，胆道支架放置术疗效显著，黄疸消除率为70．8％，平均支架维持通畅时间为8．6个月，半年和一年生存率为62．5％和16．7％。结论：胆道支架放置术在治疗恶性梗阻性黄疸有较好疗效，使用安全。     

Evaluation of the endoprosthesis by metallic stent and tube stent for malignant biliary stenosis

We evaluated the effect of biliary endoprotheses for 20 malignant stenosis patients by an expandable metallic stent and hydrophilic heparinized tube (H-PSD) connected to an implantable port (IP), which reduces bacterial adherence. Group A consisted of 6 patients of cholangiocarcinoma who underwent hepatic arterial infusion chemotherapy associated with radiotherapy. Groups B and C consisted of 8 and 6 patients of stage IVa and IVb pancreatic carcinoma, respectively, who underwent hepatic and splenic arterial infusion chemotherapy following transcatheter peripancreatic arterial embolization. The 50% patent time was 12 months, 6 months and 7 months in groups A, B and C and the 50% overall survival time was 16 months, 23 months and 13 months, respectively. There were two complications, 1 case of infection around the IP in which the IP was withdrawn, and 3 cases of cholangitis in which we had easy access to the bile duct via IP. This technique appears to offer significant benefit in selecting patients with this type of biliary obstruction.     

Colonic stenting for malignant disease: review of literature

Colonic stents potentially offer effective palliation for patients with bowel obstruction attributable to incurable malignancy, and a "bridge to surgery" for those in whom emergency surgery would necessitate a stoma. Literature search of the Medline, Scopus and Cochrane Library was performed to identify comparative studies reporting outcomes on colonic stenting and surgery for large bowel obstruction; and to identify the use of stents as a "bridge to the elective surgery". Colorectal stenting can be considered a safe and effective procedure with a low mortality and morbidity for both preoperative and palliative decompression of colonic obstruction.     

恶性高位胆道梗阻经皮经肝胆道引流方式的疗效分析

目的：探讨恶性高位胆道梗阻患者经皮经肝胆道引流方式对术后近远期疗效影响,为临床选择适当的治疗方式提供依据。方法-回顾性分析我院108例恶性高位胆道梗阻患者,比较单侧引流（68例）和双侧引流（40例）,左右肝管是否相通,引流材料对近期胆红素下降值和生存情况的影响。结果：三组术后3—5天胆红素的下降值明显,但无统计学差异（P〉0．05）。随访1—36个月,单侧组和双侧组、单枚引流管与单枚支架生存率没有显著差异（P〉0．05）。结论：恶性高位胆道梗阻以右侧入路单侧引流为主,生存期预计大于3个月,放置胆道支架,否则置入胆道引流管。     

恶性高位胆道梗阻经皮经肝胆道引流方式的疗效分析

目的:探讨恶性高位胆道梗阻患者经皮经肝胆道引流方式对术后近远期疗效影响,为临床选择适当的治疗方式提供依据.方法:回顾性分析我院108例恶性高位胆道梗阻患者,比较单侧引流(68例)和双侧引流(40例),左右肝管是否相通,引流材料对近期胆红素下降值和生存情况的影响.结果:三组术后3-5天胆红素的下降值明显,但无统计学差异(P＞0.05).随访1-36个月,单侧组和双侧组、单枚引流管与单枚支架生存率没有显著差异(P＞0.05).结论:恶性高位胆道梗阻以右侧入路单侧引流为主,生存期预计大于3个月,放置胆道支架,否则置入胆道引流管.     

Endoscopic radiofrequency ablation for malignant biliary obstruction

Cholangiocarcinoma and pancreatic cancer are the most common causes of malignant biliary obstruction. The majority of patients are diagnosed at a late stage when surgical resection is rarely possible. In these cases, palliative chemotherapy and radiotherapy provide only limited benefit and are associated with poor survival. Radiofrequency ablation (RFA) is a procedure for locoregional control of tumours, whereby a high-frequency alternating current turned into thermal energy causes coagulative necrosis of the tissue surrounding the catheter. The subsequent release of debris and tumour antigens by necrotic cells can stimulate local and systemic immunity. The development of endoluminal RFA catheters has led to the emergence of endoscopically delivered RFA, a treatment mainly used for malignant biliary strictures to prolong survival and/or stent patency. Other indications include recanalisation of occluded biliary stents and treatment of intraductal ampullary adenoma or benign biliary strictures. This article presents a comprehensive review of endobiliary RFA, mainly focusing on its use in patients with malignant biliary obstruction. The available data suggest that biliary RFA may be a promising modality, having positive impacts on survival and stent patency and boasting a reasonable safety profile. However, further studies with better characterised and stratified patient populations are needed before the method becomes accepted within routine clinical practice.     

Airway stenting for malignant respiratory complications in esophageal cancer

Airway stenting is required for the palliative treatment of advanced esophageal cancer. This study retrospectively analyzes the outcomes of airway stenting for esophageal cancer at our institution. Data from nine patients who underwent airway stenting were reviewed. All patients had poor respiratory status due to esophagorespiratory fistula and/or respiratory stenosis. We retrospectively assessed the results of airway stenting as five grades of respiratory symptoms, regarding stent-related complications and clinical course and survival. Six silicone and six covered self-expandable metallic stents were deployed in five and six patients, respectively. Two types of airway stents were deployed in two patients, and double stents were positioned in the airway and in the esophagus of three other patients. The grade of respiratory symptoms improved in seven patients. The mean dyspnea grade was 3.0±0.9 and 1.3±1.3 before and after airway stenting, respectively. Stent-related complications comprised of chest pain, incomplete closure of the ERF, sputum retention and stent migration. The mean±SD survival of all patients was 103±108 (range, 0 to 325) days, and the survival of patients without relapsed cancer at the time of stenting, who underwent cancer-specific therapy after stenting, was prolonged. Although the airway should be stented according to the status and the prognosis of each patient individually stenting can relieve symptoms and improve the prognosis even when esophageal cancer is at very advanced stages. Airway stenting could play a role in the multidisciplinary management of advanced esophageal cancer.     

恶性胆道梗阻内镜介入治疗的临床应用价值

目的 探讨恶性胆道梗阻采用内镜介入治疗方法 的有效性和临床应用价值.方法 对78例恶性胆道梗阻患者采用内镜逆行胰胆管造影术(ERCP)进行内镜下介入治疗,置入单根塑料支架42例,双根塑料支架10例,金属支架26例,15例于金属支架内置入125I粒子行腔内近距离照射治疗.结果 77例患者一次性支架置入成功,1例经皮经肝胆道造影(PTC)联合ERCP支架置入成功,术后2周塑料支架组平均总胆红素降至68.92 μmol/L,金属支架组降至64.15 μmol/L,125I粒子组降至61.13 μmol/L.术后随访,1年后125I粒子置入患者86.7%引流有效,内镜与超声复查,肿瘤病灶无扩大,未见周围淋巴结转移;另外两组引流通畅率分别为1.9%、27.3%.结论 内镜介入治疗恶性胆道梗阻方法 有效,疗效满意,合并症少,值得推广.     

经皮胆道内支架置入术姑息性治疗恶性梗阻性黄疸临床观察

目的研究经皮胆道内支架置入术姑息性治疗恶性梗阻性黄疸的临床价值。方法28例恶性梗阻性黄疸接受经皮经肝胆道内支架置入术,男18例,女10例。胆管癌13例,胰头癌4例,胆囊癌3例,肝门区转移癌8例。共置入胆道内28枚金属内支架。结果28例采用经皮经肝穿刺置入胆道内支架均获得成功。结论经皮胆道内支架置入术是姑息治疗手术不能切除的恶性梗阻性黄疸的有效方法,配合动脉内灌注化疗可提高恶性阻塞患者的生存率。