Treatment of common bile duct obstruction by pancreatic cancer using various stents: single-center experience

PURPOSE: To compare the effectiveness of various means of stenting in patients with biliary obstruction caused by pancreatic cancer in a retrospective analysis. METHODS: Sixty-two patients with biliary obstruction due to unresectable pancreatic cancer underwent biliary stenting. On the basis of the findings obtained by percutaneous transhepatic cholangiography (10 patients) and endoscopic retrograde cholangiography (52 patients), the site of obstruction was distal to the hilar confluence, predominantly especially in the middle to lower third of the common bile duct. Polyurethane-covered Wallstents (9 mm in diameter) were inserted in 13 patients, while uncovered Wallstents (10 mm in diameter) were used in 10 patients and plastic stents (10 Fr and 12 Fr) were used in 39 patients. RESULTS: Stenting was successful in 34 patients (87.2%) treated with plastic stents and in 22 patients (95.7%) treated with Wallstents. Effective biliary drainage was achieved in 32 out of 34 patients (94.1%) treated with plastic stents and in 21 out of 22 patients (95.5%) treated with Wallstents. The cumulative patency rate was significantly higher for the uncovered and covered Wallstents compared to plastic stents, but was not significantly higher for covered than for uncovered Wallstents. Stent occlusion occurred in 23 patients (70%; all by clogging) from the plastic stent group, in two patients (22%; by tumor ingrowth) from the uncovered Wallstent group, and in one patient (9%; by clogging) from the covered Wallstent group. The survival rate showed no significant difference among the three stent groups. CONCLUSION: The Wallstent is effective for long-term palliation in patients with obstruction caused by pancreatic cancer invading the middle to lower part of the common bile duct. The covered Wallstent can prevent tumor ingrowth, a problem with the uncovered Wallstent. However, it may be necessary to take measures to prevent the migration or clogging of covered Wallstents.     

Malignant melanoma presenting as a mass obstructing the common bile duct

Pathologic and computed tomographic correlation of an obstructing common bile duct mass, found to be malignant melanoma, is presented. No tumour was demonstrated elsewhere. Such a pattern of presentation has not previously been described in this condition. Malignant melanoma, even in the absence of disease elsewhere, should be considered in the differential diagnosis of such lesions seen on computed tomography.     

The treatment of bile duct stenoses using metal mesh endoprostheses (stents)]

Transhepatic biliary drainage is an established therapy for the palliative treatment of biliary stenosis. Long-term biliary drainage may be accomplished by the introduction of an endoprosthesis. Plastic endoprostheses are, however, prone to clogging and dislocation. A new type of endoprosthesis consisting of an expandable metallic mesh has, therefore, been developed. Results in 51 patients using two different types of metallic stents demonstrated that the technical success rate is higher with self-expanding stents than with balloon-expandable stents. Symptoms of obstructive jaundice were effectively palliated in the vast majority of patients (80%). Reobstruction during the first 4 weeks occurred in only 1 patient. Malfunction was related to the inappropriate length of the stent. At follow-up, 25% of patients with malignant biliary strictures developed recurrent jaundice, which was controlled by a single additional placement of a stent or a plastic endoprosthesis. In conclusion, although recurrent biliary stenosis is still a problem, the frequency of reinterventions can be considerably reduced by the use of metallic instead of plastic endoprostheses (20% vs. 45%).     

Malignant biliary obstruction: treatment with self-expandable metallic stents

In a 3-year period, 57 self-expandable metallic biliary stents (Wallstent) were successfully placed in 49 patients with malignant biliary obstruction. Thirty-three of our patients have died. In this group follow-up was 1–12 months with a mean of 4.5 months and stent patency was 1–12 months with a mean of 4.3 months. Sixteen patients are still alive. In this group, follow-up was 2–26 months with a mean of 8.4 months and stent patency was 1–18 months with a mean of 6.8 months. In 4 patients a secondary stent was used due to malpositioning during deployment. In 1 patient bilateral drainage was achieved with two stents. Four patients required 5 reinterventions due to reocclusion, with a reocclusion rate of 9.4 %; 3 of them were treated with secondary metallic stents, 1 with a conventional stent and the remaining 1 with balloon dilatation. Thirty-day mortality rate was 8.1 % and procedure-related mortality was 2 %. Major and minor complication rates were 10 % and 22 %, respectively. Self-expandable metallic stents provide good palliation in patients with malignant biliary obstruction. Correspondence to: M. N. Özmen     

Transient obstruction of the common bile duct following its exploration.

Failure of the contrast medium to enter the duodenum during the operative cholangiography following the common bile duct exploration and instrumentation may be caused by transient obstruction of the common bile duct. It is attributed to spasm and oedema of the sphincter choledochus of Boyden and not of the sphincter of Oddi. The knowledge of the possibility of the pseudo-obstruction of the common bile duct following its exploration may save the surgeon from unnecessary re-exploration and performing sphincterotomy or choledochoduodenostomy. The exploration is unnecessary if, during the common duct exploration, the dilators and the catheter passes easily into the duodenum and on the cholangiogram the obstructed area is smooth and there is no filling defect. A normal cholangiogram performed 8-10 days following the operation proves that the obstruction was transient and not caused by calculus stricture or tumour.     

Positive predictive value of cholescintigraphy in common bile duct obstruction

Technetium-99m DISIDA imaging was employed in 400 patients to differentiate obstruction of the common bile duct from medical and other surgical causes of hyperbilirubinemia. Sequential anterior images demonstrated variable degrees of liver uptake, yet there was no evidence of intrabiliary or extrabiliary radioactivity for at least 4 hr after injection in 25 patients. Twenty-three patients were surgically documented to have complete obstruction of the common bile duct. One patient had hepatitis, and another had sickle cell crisis without bile duct obstruction. The remaining patients had either partial or no obstruction of the common bile duct. We conclude that the presence of liver uptake without evident biliary excretion by 4 hr on cholescintigraphy is highly sensitive and predictive of total obstruction of the common bile duct.     

术中胆道造影胆总管阻塞征象的研究

目的探索术中胆道造影中出现的假性胆总管阻塞征(简称假性阻塞)X线征象,减少误诊。材料与方法搜集整理200例术中胆道造影,其中男性72例女性128例,年龄为23～84岁,手术时胆囊切除经胆囊管注入造影剂,造影剂为60％胆影葡胺或12．5％碘化钠溶液10～20ml。结果本组出现假性阻塞55例占27．5％。X线表现常能鉴别假性阻塞与真性阻塞,假性阻塞表现为阻塞远端钝圆、有柔软感,而不象真性阻塞的远端有僵直感。如胆总管括约肌痉挛时,可向胆总管内注入1％普鲁卡因5ml,使痉挛缓解。结论熟悉术中胆道造影胆总管假性阻塞与真性阻塞X线征象十分重要否则会误诊。     

Nasolacrimal stents in the treatment of epiphora: long-term results.

PURPOSE: Assessment of the long-term results achieved with use of nasolacrimal stents in the treatment of epiphora caused by obstruction of the lacrimal apparatus. The role of stents in treating this condition is evaluated. MATERIALS AND METHODS: From February 1997 to April 1999, a total of 89 procedures to insert nasolacrimal stents were performed in 77 patients (20 men, 57 women; mean age, 53 years). A total of 79 stents were successfully implanted, with 10 failures (11.2%). Postprocedural course was followed for 16-38 months (mean, 27 mo) by means of clinical examinations and/or periodic dacryocystography, with removal of occluded stents. On conclusion of the study in September 2000, dacryocystography was performed in all patients in whom stents were still in place. RESULTS: Of the 79 stents deployed, two were lost, two had to be excluded from the study, 45 (60%) ceased to function, and 30 (40%) remained patent. Median duration of stent patency of these 79 stents was 20 months. Mean time to occlusion was 9.2 months for all obstructed stents; 4.4 months for improperly placed stents (via a trajectory outside the normal lacrimal drainage apparatus) and 12.2 months for stents that appeared to have been inserted properly. Of the 45 occluded stents, 40 were removed and five were left in place. Upon removal, adherence of the stents to the lacrimal apparatus was frequently observed. CONCLUSIONS: The low patency rate and the difficulties encountered in removing nasolacrimal stents during the course of long-term placement calls into question the efficacy of this method as a definitive treatment for epiphora caused by obstruction of the lacrimal drainage system, although studies comparing this and other treatment modalities are needed. Assessment of temporary stent placement may be in order.     

恶性胆管梗阻内照射支架植入术的护理体会

目的 探讨恶性胆管梗阻内照射支架植入术后相关护理的辅助价值.方法 12例临床诊断明确的恶性胆管梗阻患者,在进行内照射支架植入术前及术后实施心理护理、饮食护理、穿刺点护理、并发症的观察与护理等方法,确保手术顺利进行及术后患者尽早康复.结果 所有患者术前心态平和;对6例由于缺乏疾病认知而存在紧张焦虑心理的患者采取相应的护理方案,确保了手术顺利进行.对于术后出现的呕吐、发热的患者采取呕吐姿势指导、心理护理,所有患者均未出现感染、胆管穿孔等严重并发症.结论 对于行胆管内照射支架置入的患者,细致的术前心理护理,有效的术后护理对减少并发症、保证手术成功及缩短住院时间具有重要的作用.     

Metallic stents for treatment of benign biliary obstruction: a long-term study comparing different stents

PURPOSE: To investigate the role of metallic stents in the treatment of benign biliary strictures and analyze the differences in primary patency associated with the various types of stents deployed. MATERIALS AND METHODS: Between 1990 and 1997, 21 patients with benign obstructive jaundice were treated with transhepatic placement of metallic stents (11 Wallstents in 10 patients, nine Palmaz stents in seven patients, and four tantalum Strecker stents in four patients). Nineteen patients presented with strictures not responding to balloon angioplasty (postsurgical, n = 13; cholangitis, n = 5; unknown, n = 1). Estimates for cumulative patency, patency rate in the different stent groups, and survival were calculated with use of life-table analysis; the log-rank test was used to compare the different stent groups. The prognostic relevance of the selected variables-stent type, stent length, etiology, and location-were modeled with respect to patency according to Weibull distribution. RESULTS: The median follow-up time was 80.5 months (range, 2-116 months). The median survival time was 91 months. One patient was lost to follow-up after 3 months. Repeat intervention for recurrent obstructive jaundice was necessary in 11 patients (55%), and the median patency rate was 26 months (range, 2-96 months). The Palmaz stent was the most effective in achieving long-term patency, with a median patency duration of 36 months (range, 22-96 months), versus 9 months (range, 3-67 months) for the Wallstent and 6 months (range, 2-15 months) for the tantalum Strecker stent. The cumulative patency rate with the Palmaz stent was significantly higher than for the tantalum Strecker stent (log-rank test, P = .017) and nonsignificantly higher compared with the Wallstent (log-rank test, P = .07). Multivariate analysis showed that the type of stent (Wald test, P = .003) and stent length (Wald test, P < .0001) influenced the patency rate. CONCLUSIONS: These results suggest that the type of stent and the stent length have a significant influence on the patency rate. In this series, the Palmaz stent was most effective in achieving long-term patency in benign biliary strictures.