Endoscopic therapy in the management of malignant biliary obstruction

doi:10.1016/j.ejso.2007.07.210

European Journal of Surgical Oncology (EJSO)

Volume 34, Issue 3, March 2008, Pages 313-317

https://doi.org/10.1016/j.ejso.2007.07.210 Get rights and content

Abstract

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.

The majority of malignant biliary obstruction is due to inoperable disease, and therefore the mainstay of palliating jaundice is stent placement at endoscopic retrograde cholangiopancreatography (ERCP).

Cross-sectional imaging is necessary to determine if stenting is appropriate and to guide stent placement. This is especially important in patients with hilar cholangiocarcinoma, where drainage should be undertaken in specialist centres.

Self-expanding metal stents are preferable to plastic stents and are cost effective if survival is likely to be more than 6 months.

With the exception of pancreatic carcinoma, traditional non-operative disease modifying treatments for biliary malignancies have shown only limited benefit. This particularly relates to radio and chemotherapy. Photodynamic therapy is a relatively new modality of treatment that appears to be effective in patients with local but inoperable cholangiocarcinoma and is capable of prolonging survival.

Introduction

Common causes of malignant biliary obstruction include pancreatic carcinoma, cholangiocarcinoma and metastatic disease, either intrahepatic or lymphadenopathy, usually portal but occasionally distal biliary. The greater majority of patients with such will not undergo surgical resection of the obstructing tumour due to either the advanced nature of the disease or the significant co-morbidity precluding surgery. These patients will therefore require a non-surgical approach to the relief of resulting biliary obstruction usually in the form of endoscopic therapy. This will often be purely palliative but in some cases survival-enhancing therapy may be possible. This review will discuss both technical aspects and outcomes of endoscopic therapy in the management of malignant biliary obstruction. The technique of intrabiliary photodynamic therapy will be considered in detail.

Section snippets

Early studies

Restoring biliary flow with relief of jaundice and pruritus is the primary goal in the palliation of obstructive biliary malignancy. Several studies conducted in the late 1980s confirmed the value of endoscopic retrograde cholangiopancreatography (ERCP) in this situation. Randomised trials comparing surgical bypass to ERCP placement of plastic drainage tubes (“stents”) demonstrated equivalent success rates in terms of survival and relief of obstruction but lower morbidity and mortality for the

Technique of endoscopic stenting

Careful consideration of prior imaging allows detailed planning and successful execution of the procedure. Whatever stent is to be used, the initial placement of a 0.035-inch wire across the stricture to be stented is a prerequisite. Precut sphincterotomy may be required for access, but sphincterotomy is only necessary for the placement of multiple stents or to guarantee future access where it has been initially difficult. Dilatation is not usually required for distal strictures but is usually

Types of stent

Plastic stents are usually gently curved polyethylene tubes of relatively low cost. A variety of side holes and flanges are formed to aid drainage and prevent migration. Stents of 10–11.5 Fr have patency rates of approximately 3 months but narrower diameter stents have significantly lower patency rates and should not be routinely placed for palliative drainage.⁴ The major problem with plastic stents is occlusion from bacterial biofilm comprising protein, bilirubin, bacteria and amorphous debris.

Biliary drainage in patients with colorectal liver metastases

Limited data exist about the role of palliation of jaundice in metastatic disease. Benefit has been shown in the successful placement of stents compared to those patients who had unsuccessful attempts in terms of survival, 5 months compared to 1 month, p < 0.01. The control group in this study, however, was the patients in who the stents had been unsuccessful rather than a matched untreated control group, randomised or otherwise.¹⁹

Liver metastases due to colorectal cancer seem to have better

Photodynamic therapy for cholangiocarcinoma

The greater majority of patients with cholangiocarcinoma do not undergo resection. The disease has a particularly poor prognosis, especially if the disease is advanced with a median survival time of 62 days if there is bilateral intrahepatic disease.¹⁶ Photodynamic therapy (PDT) has emerged as the most promising new modality of treatment for patients who do not undergo resection.

PDT uses the combination of two non-toxic moieties; light and a photosensitising chemical which when combined

Summary

Endoscopic therapy is a cornerstone in the management of the majority of patients who suffer malignant biliary obstruction. For a significant number of patients it will appropriately be the only disease specific therapy used. It is safe and effective, in the overall context of the background disease. Stenting with a plastic stent is appropriate in patients with a short life expectancy and with a metal stent in those with a longer life expectancy.

The role of stenting metastatic disease seems to

Conflict of interest

The author has no conflicts of interest.

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Palliative biliary brachytherapy is used in the management of malignant biliary tract obstruction (MBTO), a common complication of both primary and metastatic gastrointestinal malignancies (33,34) . The first step in the management of cancers presenting with an MBTO is typically decompression of the biliary tree with endoscopic (ERCP) and/or percutaneous transhepatic (PTC) stent insertion, with their own risks and benefits (35–39). Stents can be bare metal, covered metal, or plastic, with varied indications and benefits (35,40); metal stents tend to reocclude while plastic and covered stents tend to migrate, frequently requiring retrieval procedures (41,42).
While brachytherapy applications are not widely used for cancer diagnoses in the upper GI tract (including the esophagus, liver, stomach, and pancreas), they have a clear role in palliation and symptom management and occasionally definitive locoregional treatment. With the increasing use of image-guided techniques, the incidence of side effects and complications has shown to be lower than many other alternative treatment modalities, making brachytherapy approaches a preferred treatment option. This review examines procedural complications and acute and chronic adverse effects from radiation associated with esophageal, hepatobiliary, and pancreatic brachytherapy and their management.
Feasibility and safety of percutaneous transhepatic endobiliary radiofrequency ablation as an adjunct to biliary stenting in malignant biliary obstruction
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The purpose of this study was to investigate the feasibility and safety of percutaneous transhepatic endobiliary radiofrequency ablation (RFA) combined with biliary stenting in palliative treatment of malignant biliary obstructions.
Twenty-one patients who had undergone percutaneous transhepatic endobiliary RFA as an adjunct to biliary stenting were included. There were 12 men and nine women with a mean age of 67 ± 13.6 (SD) years (range: 34–86 years). Demographic data, procedure details and follow-up data including complications, survival time and stent patency time were documented. The median stent patency time and survival time, as well as the 30- day and 180-day cumulative survival and stent patency rates were estimated using the Kaplan-Meier method.
Twenty-four percutaneous transhepatic endobiliary RFA procedures were performed. There were no procedure-related major complications or death. Three patients who had developed stent reocclusion underwent a second endobiliary RFA, without insertion of a new stent. The most common complications were post-procedural pain and cholangitis. Overall survival and stent patency times ranged between 5–542 days and 5–251 days, respectively. The median survival time was 76 days (95%CI: 0–233 days) and stent patency time was 133 days (95% CI: 25–240 days). The 30- and 180- day cumulative stent patency rates were 75% and 34%, respectively.
Percutaneous transhepatic endobiliary RFA is a feasible, safe and cost-effective method in restoration of biliary drainage in patients with malignant biliary obstruction.
Endoscopic Evaluation in the Workup of Pancreatic Cancer
2016, Surgical Clinics of North America
Citation Excerpt :
Published data have shown that self-expanding biliary metal stents have a longer patency, have a lower incidence of occlusion and cholangitis, are associated with a shorter duration of hospital stay, and are more cost effective, especially in patients with an expected of survival more than 3 to 6 months without any difference in overall short-term mortality.55,57–59 The average patency of metal biliary stents approaches 1 year compared with 3 to 4 months for the plastic bile duct stents.60 The superiority and cost effectiveness of metal stents have been confirmed by metaanalyses as well.61,62
A comparison of uncovered metal stents for the palliation of patients with malignant biliary obstruction: Nitinol vs. stainless steel
2012, Digestive and Liver Disease
Citation Excerpt :
The endoscopic insertion of self-expandable metal stents (SEMSs) is widely recognised as the best option for the palliative treatment of patients with unresectable malignant biliary obstructions with an expected survival of more than 4 months [1–4].
Various types of self-expandable metal stents have been introduced for the palliation of malignant biliary obstruction.
To compare the outcomes of WallFlex™ and Wallstent™ uncovered biliary self-expandable metal stents (SEMSs) for the palliation of patients with malignant biliary obstruction.
Between October 2008 and December 2009, all SEMSs placed for malignant biliary obstruction were WallFlex™: all patients palliated were included in the study. Before October 2008, all the SEMSs placed for malignant biliary obstruction were Wallstent™, and the patients palliated from July 2007 to September 2008 were the comparative group.
A total of 58 WallFlex™ and 54 Wallstent™ SEMSs were placed, and efficacious biliary decompression was achieved in all patients. Early complications occurred in 5 patients in the WallFlex™ group and in 3 in the Wallstent™ group (p = ns). Late complications occurred in 6 patients in the WallFlex™ group and in 16 in the Wallstent™ group (p < 0.01). The overall patency of the self-expandable metal stent in the WallFlex™ and the Wallstent™ groups was similar (227 days vs. 215 days, p = ns). Mean patient survival was 242 days in the WallFlex™ group and 257 days in the Wallstent™ group (p = ns).
We found no difference in terms of overall patency between the two types of SEMSs, but there was an increased rate of late adverse events in the Wallstent™ group.
Effect of percutaneous stenting strategy of unresectable malignant hilar biliary obstruction by three-dimensional reconstruction volumetry
2023, Cancer Medicine

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ReviewEndoscopic therapy in the management of malignant biliary obstruction

Abstract

Introduction

Section snippets

Early studies

Technique of endoscopic stenting

Types of stent

Biliary drainage in patients with colorectal liver metastases

Photodynamic therapy for cholangiocarcinoma

Summary

Conflict of interest

Lancet

Lancet

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Lancet

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Surg Oncol

Surg Oncol

Gastrointest Endosc

Review
Endoscopic therapy in the management of malignant biliary obstruction