One-stage percutaneous triple procedure for treatment of endoscopically unmanageable patients with malignant biliary obstruction and marked ascites

Background and study aims: To assess the feasibility, safety and efficacy of one-stage percutaneous triple procedure including; ascites drainage, primary metallic biliary stenting, and tract embolisation with N-butyl 2-cyanoacrylate [NBCA], in treatment of patients with malignant biliary obstruction and marked ascites

Patients and methods: This study involved 25 patients with malignant biliary obstruction and marked ascites [age range, 46-78 y; mean age +/- SD, 65 y +/- 5] for whom endoscopic treatment failed or was unsuitable. Ascites drainage, percutaneous primary metallic biliary stenting, and tract embolisation with lipiodol/NBCA mixture were performed in a one-stage procedure. The mean +/- SD follow up period was 26 +/- 2 weeks

Results: The technical and clinical success rates were 96% and 88% respectively. No procedure related deaths or major complications were observed. The reported minor complications included; moderate pain and vomiting during and after balloon dilation, postprocedural cholangitis, and bile leakage in 44%, 16%, and 8% of the patients respectively. Primary stent patency was achieved in 96%. The 30-days mortality was 8%. The stent obstruction occurred in 3 [13%] of the 23 patients who survived more than 30-days

Conclusions: Percutaneous drainage of ascites followed immediately by primary biliary stenting, together with tract embolisation with NBCA is technically feasible, safe, and effective alternative palliative treatment for endoscopically unmanageable patients with malignant biliary obstruction and marked ascites

Combined transcatheter embolisation and medical treatment as a replacement therapy for surgery, in low-operative risk patients with endoscopically unmanageable massive bleeding from gastric-duodenal ulcers

There is a concept that embolization does not change the underlying pathophysiology of peptic ulcer disease, so endovascular therapy is still used as an alternative treatment to surgery, only in high-risk patients. In this study, we assess the usefulness of endovascular therapy as an alternative to operation in low risk patients with massive bleeding from a peptic ulcer. A retrospective study of 22 consecutive embolization procedures in endoscopically unmanageable, hemodynamically unstable patients, referred from 2004 to 2010. Different techniques and embolization materials were used. Mean follow-up was 7 months. Endoscopy was performed for 12 patients 5 to 9 months after embolization to assess healing of the ulcer. Gastric ulcer was noted in 7 patients, bulbar duodenal ulcer in 13 patients and postbulbar duodenal ulcer in 2 patient. The technical success rate was 100%. The rebleeding rate was 9%, and 30-days mortality rate was 4%. No major complications were reported. Follow up endoscopy revealed healing of the ulcer in 10 of the 12 patients [83%]. Angio-embolization is safe and effective for controlling life-threatening endoscopically unmanageable, bleeding from gastroduodenal ulcers especially in low risk patients. Whenever combined with proper medical therapy it allows ulcer healing without the need for higher risk laparotomy

Prophylactic embolisation of the left gastric artery in cases with massive upper gastrointestinal haemorrhage with normal angiographic findings

The management of massive upper gastrointestinal haemorrhage [UGIH] is problem ridden, especially if the arteriorgraphy shows no pathological findings. Percutaneous embolotherapy of the apparently normal gastric artery could provide a safe haemostatic effect. Our study is a descriptive one aimed to highlight the efficacy and safety of trans-arterial embolisation of the left gastric artery in six cases with massive UGIH and normal angiographic findings. From January 2004 to December 2008, we performed 24 embolisation procedures for treatment of patients with massive UGIH. All patients had significant bleeding and were referred for arteriography. The outcomes for nine patients having massive UGIH with normal angiographic findings were studied retrospectively. Six of these patients had undergone embolisation of the left gastric artery, whereas the remaining three exsanguinated before embolisation. Nine patients with massive UGIH, who had normal findings on arteriography, were selected to represent the study group. Three patients who did not undergo embolisation exsanguinated after arteriography and two of them died from massive haematemesis. All the six embolised cases showed cessation or marked decrease of bleeding. No major complications were reported during or after embolisation. Left gastric artery embolisation may be a safe and effective method in controlling UGIH with normal angiographic findings, for which both, a large number of patients and a multi-centre study, are recommended