Clinical value of preferred endoscopic ultrasound-guided antegrade surgery in the treatment of extrahepatic bile duct malignant obstruction

ABSTRACT Objectives: To explore the clinical value of preferred ultrasound endoscopic guided biliary drainage in patients with extrahepatic biliary obstruction with intrahepatic biliary ectasis. Methods: A total of 58 patients with malignant obstruction and intrahepatic bile duct expansion, including 32 males, 26 females and median age 65 (58-81) were selected. A prospective randomized controlled study was randomized into EUS-AG and ERCP-BD, with 28 patients in EUS-AG and 30 in ERCP-BD. The efficacy of the two treatments, operation success rate, operation time, the incidence of complications, hospitalization days, cost, unimpeded stent duration, and survival time were compared. Results: 1) The surgical success rate in group EUS-AG was 100%, and in group, ERCP-BD was 96.67%. There was no statistical difference in surgical success rate in the two groups (p>0.05). 2) Average operating time in EUS-AG was (23.69±11.57) min, and in ERCP-BD was (36.75±17.69) min. The difference between the two groups has statistical significance (p<0.05). 3) The clinical symptoms of successful patients were significantly relieved. Compared with the preoperative procedure, the differences in group levels had statistical significance (p<0.05); TBIL, ALP, WBC and CRP levels, no statistical significance difference in groups (p>0.05). Conclusion: EUS-AG operation has short time, low incidence of complications, safe, effective, and can be used as the preferred treatment plan for patients with extrahepatic biliary duct malignant obstruction associated with intrahepatic biliary duct expansion; EUS-AG operation has more unique clinical advantages for patients with altered gastrointestinal anatomy or upper gastrointestinal obstruction.

Comparison of clinical curative effect between ERCP and PTCD in treatment of malignant obstructive jaundice / 中国内镜杂志

Objective To compare the clinical curative effect of endoscopic retrograde cholangio-pancreatography (ERCP) and percutaneous transhepatic cholangial drainage (PTCD) in treatment of malignant obstructive jaundice. Methods Clinical data of 97 patients with malignant obstructive jaundice were collected and analyzed retrospectively, includs 54 patients in ERCP group and 43 patients in PTCD group. The clinical curative effect, postoperative complications, comfort score and hospitalization time and costs were compared between the two groups. Results The symptoms improved compared with preoperative. The total remission rate of jaundice in ERCP group and PTCD group was 77.78％ vs 79.07％, and the remission rate of high obstructive jaundice was 55.00％, vs 89.29％, and the remission rate of low obstruction jaundice was 91.18％, vs 60.00％.There was significant difference between the two groups (P < 0.05); The incidence of postoperative complications in ERCP group and PTCD group was 37.04％ vs 16.28％. There was significant difference between the two groups (P < 0.05); The comfort scale of ERCP group and PTCD group was (15.13 ± 3.89) points vs (16.60 ± 3.15) points. There was significant difference between the two groups (P < 0.05); The hospitalization time of ERCP group and PTCD group were (8.74 ± 4.94) days vs (11.12 ± 4.82) days, and the hospitalization costs were (22.70 ± 6.30) thousand yuan vs (21.90 ± 3.40) thousand yuan. Conclusion Satisfactory clinical curative effect for patients with malignant obstructive jaundice can be derived from both ERCP and PTCD. The treatment of ERCP has more advantages than PTCD in patients with low obstruction, while PTCD is better than ERCP in patients with high obstruction. But ERCP group is better than PTCD in comfort score and shorter in hospitalization time. There is no obvious difference on hospitalization costs.

Use of esophageal small balloon or papillary sphincter knife in the treatment of stent implantation for colorectal malignant obstruction / 中南大学学报(医学版)

Objective:To explore the function of esophageal small balloon or papillary sphincter knife in the treatment of stent implantation for colorectal malignant obstruction,and to improve the success rate of colonic stent placement in such patients.Methods:A total of 49 patients with colorectal cancer complicated with almost complete obstruction or colorectal cancer were enrolled for this study.The esophageal small balloon or papillary sphincter knife was used in the guide wires.The guide wires gradually crossed the tumor gap and they were placed in the contralateral intestinal cavity with balloon progression.X-ray was then used to confirm whether the guide wire was inserted in the lesion intestinal cavity,and then the metal bare stent was inserted.Results:The guide wires was successfully inserted with conventional methods in these 49 cases,while they were also successfully placed the guide wire and the stent in the new way.Conclusion:For the patients with colorectal cancer complicated with complete obstruction or colorectal cancer located in obviously angled location,the use of esophageal small balloon or papillary sphincter knife can help the guide wire insert.They greatly improve the success rate of stent implantation.

The impact and the risk factors of different preoperative biliary drainage procedures for patients with malignant obstruction jaundice on overall survival : a Meta-analysis / 中华肝胆外科杂志

Objective To determine the impact and the risk factors of different methods of preoperative biliary drainage (PBD) for malignant obstruction jaundice (MOJ) on overall survival (OS).Methods Databases including the PubMed,Medline,Web of Knowledge,and other databases were searched up to 30th April,2018 for clinical studies which compared the OS rates between percutaneous transhepatic biliary drainage (PTBD) and endoscopic biliary drainage (EBD) for MOJ.Hazard ratio (HR) and Odds Ratio (OR) with 95％ confidence interval (CI) were performed using the Review Manager 5.3 software to synthesize the results.Results Nine studies were enrolled in this meta-analysis,which included 818 patients in the PTBD group and 1253 patients in the EBD group.EBD was shown to be superior to PTBD in OS (HR=0.63,95％ CI:0.51～0.77,P＜0.05).Risk factors analysis showed that patients in the EBD group had a higher rate of early tumor stage (P＜0.05) and a lower rate of lymphatic metastasis (P＜0.05).When compared with the PTBD group,the EBD group had a lower rate of intraoperative bleeding (P＜0.05),and a higher rate of adjuvant therapy (P＜0.05).Conclusion In PBD for patients with resectable MOJ,there was insufficient evidence to support EBD to be superior to PTBD in OS.

Outcomes of metallic ureteral stents for malignant ureteral obstruction and chronic benign ureteral obstruction / 局解手术学杂志

Objective To evaluate the curative effect of metallic stent placed for malignant and chronic benign ureteral obstruction. Methods From October 2013 to April 2014, 10 patients were given placement of the metallic stents for treatment of malignant ureteral ob-struction and chronic benign ureteral obstruction in our institutionl. ECT was performed to test split kidney function after metallic stents placement. Results After the mean follow-up time of 4 months ( ranged from 1 to 7 months) , unilateral renal function improved in 11 cases. And there was no decrease of kidney function among all the patients who were given placement of the metallic stents. Conclusion Metallic stent is a valuable treatment for releasing the malignant and chronic benign ureteral obstruction.

Endoscopic parallel placement of biliary double metal stents for advanced malignant hilar obstruction / 中华消化内镜杂志

Objective To explore the effects and safety of endoscopic parallel placement of double metal stents on unresectable hilar malignant obstruction.Methods The clinical data of 11 patients with malignant hilar obstructive jaundice due to advanced carcinoma who were treated with parallel placement of double biliary stents from January 2011 to September 2012 were retrospectively analyzed.Results Out of 11 patients,10(90.9％) were successfully embedded with double biliary stents and 4 were dead during the follow-up.There was no sign of stent occlusion during the follow-up period.The survival time ranges from 128 to 185 days.One case was lost during the follow-up and 5 others are still alive.Conclusion The endoscopic parallel placement of double biliary stents is effective and safe for patients with unresectable malignant hilar obstruction.

Percutaneous Placement of Self-Expandable Metallic Stents in Patients with Obstructive Jaundice Secondary to Metastatic Gastric Cancer after Gastrectomy

OBJECTIVE: To evaluate the outcomes of patients undergoing percutaneous placements of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy. MATERIALS AND METHODS: Fifty patients (mean age, 62.4 years; range, 27-86 years) who underwent percutaneous placements of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy were included. The technical success rate, clinical success rate, complication rate, stent patency, patient survival and factors associated with stent patency were being evaluated. RESULTS: The median interval between the gastrectomy and stent placement was 23.1 months (range, 3.9-94.6 months). The 50 patients received a total of 65 stents without any major procedure-related complications. Technical success was achieved in all patients. The mean total serum bilirubin level, which had been 7.19 mg/dL +/- 6.8 before stent insertion, decreased to 4.58 mg/dL +/- 5.4 during the first week of follow-up (p < 0.001). Clinical success was achieved in 42 patients (84%). Percutaneous transhepatic biliary drainage catheters were removed from 45 patients (90%). Infectious complications were noted in two patients (4%), and stent malfunction occurred in seven patients (14%). The median stent patency was 233 +/- 99 days, and the median patient survival was 179 +/- 83 days. Total serum bilirubin level after stenting was an independent factor for stent patency (p = 0.009). CONCLUSION: Percutaneous transhepatic placement of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy is a technically feasible and clinically effective palliative procedure.

Palliation of Malignant Upper Gastrointestinal Obstruction with Self-Expandable Metal Stent

OBJECTIVE: To assess the technical success, ability to eat, complications and clinical outcomes of patients with self-expandable metal stent (SEMS) placed for malignant upper gastrointestinal (GI) obstruction. MATERIALS AND METHODS: Data was collected retrospectively on patients who underwent SEMS placement for palliation of malignant upper GI obstruction by reviewing hospital charts from June 1998 to May 2011. Main outcome measurements were technical success, gastric outlet obstruction scoring system (GOOSS) score before and after treatment, complications, and survival. RESULTS: A total of 82 patients underwent SEMS placement with malignant upper GI obstruction. The initial SEMS placement was successful in 77 patients (93.9%). The mean GOOSS score was 0.56 before stenting and 1.92 (p < 0.001) after treatment. Complications arose in 12 patients (14.6%): stent migration in 1 patient (1.2%), perforation in 1 (1.2%), and obstruction of stent due to tumor ingrowth in 10 (12.2%). The median survival time after stenting was 52 days (6-445). CONCLUSION: SEMS placement is an effective and safe treatment for palliation of malignant upper GI obstruction. It provides lasting relief in dysphagia and improves the QOL of patients.

Colonic Stent Insertion Through a Colostomy in a Patient with Recurred Malignant Obstruction / 대한소화기내시경학회지

Colorectal self-expanding metal stents have been used for palliation or preoperative decompression as a bridge-to-surgery in patients with malignant obstruction due to primary or recurred colorectal cancer. The usual attempt to implant of the stent is through the anus under endoscopic guidance, but that is difficult or impossible in patient who have undergone laparoscopic abdominoperineal resection (APR) and who have a colostomy. Especially, to advance and position the stent in the target lesion through the colostomy is very difficult because of the tortuosity and anatomical alteration of the proximal bowel caused by surgery. We herein report on a case of recurred malignant colonic obstruction with stent placement through a preformed colostomy. To date, this approach through a colostomy for the deployment of a stent has not been described in the Korean literature.

Biliary tract prosthesis combined with pancreatic duct stents in patients with periampullary carcinoma / 中华消化内镜杂志

Objective To evaluate the efficacy of biliary tract prosthesis and pancreatic duct stents for advanced periampullary carcinoma. Methods A total of 36 patients were diagnosed as advanced periampullary carcinoma pathologically or clinically, with strictures both in pancreatic and biliary ducts confirmed by imaging. Teflon stents were firstly implanted through endoscopy to the narrowed pancreatic ducts, expansible metal prosthesis were then implanted to the biliary tract. If failed, the metal stents were given through percutaneous transhepatic biliary drainage (PTCD) pathway. Serum levels of liver enzymes, amylase and clinical manifestations were observed before and after operation. Results Teflon stents were successfully implanted into pancreatic ducts in all patients. Metal prostheses into bile ducts were endoscopically implanted in 29 cases, and via PTCD in 7, including 2 cases of Billroth Ⅱ gastrectomy. The levels of liver enzymes significantly decreased (P<0.01) after stents implacement. The levels of amylase (plasma and urine) and lipase increased in 15 cases, but they were corrected to normal levels after adequate treatments. Rates of abdominal pain relieving and diahhrea improvement were 82.4% (28/34) and 88.2% (15/17), respectively. Conclusion The combined implacement of biliary tract prosthesis and pancreatic duct stents is safe and effective in relieving malignant obstruction in periampullary carcinoma.

The Effect of Self-Expanding Metallic Stent Insertion for the Treatment ofMalignant Colorectal Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: The aim of this study was to evaluate the clinical and cost effectiveness of the use of stent insertion for malignant colorectal obstruction as compared with performing emergency surgery. METHODS: We retrospectively reviewed the medical records of 201 patients. Malignant colorectal obstructions caused by a resectable tumor were treated with preoperative stenting followed by surgery (group A, n=55) or emergency surgery (group B, n=59). Malignant obstructions caused by an unresectable cancer were treated with palliative stenting (group C, n=58) or palliative emergency surgery (group D, n=29). RESULTS: The one-staged radical resection rate was significantly higher in group A patients than in group B patients (87.3% vs. 52.5%, p<0.05). Post-operative complications were more frequent in group A patients than in group B patients (9.1% vs. 32.2%, p<0.05). The admission period was significantly shorter for group A patients than for group B patients (25.0 days vs. 33.7 days, p<0.05). The medical cost was not different for group A and group B patients. Life-long stoma formation was necessary for 15.5% of group C patients and 69% of group D patients, respectively. The admission period was significantly shorter for group C patients than group D patients (10.5 days vs. 22.7 days, p<0.05). The medical cost was not different for group C and D patients. CONCLUSIONS: Stent insertion was an effective treatment modality for malignant colorectal obstruction.

Treatment of Malignant Biliary Obstruction with a PTFE-Covered Self-Expandable Nitinol Stent

OBJECTIVE: We wanted to determine the technical and clinical efficacy of using a PTFE-covered self-expandable nitinol stent for the palliative treatment of malignant biliary obstruction. MATERIALS AND METHODS: Thirty-seven patients with common bile duct strictures caused by malignant disease were treated by placing a total of 37 nitinol PTFE stents. These stents were covered with PTFE with the exception of the last 5 mm at each end; the stent had an unconstrained diameter of 10 mm and a total length of 50-80 mm. The patient survival rate and stent patency rate were calculated by performing Kaplan-Meier survival analysis. The bilirubin, serum amylase and lipase levels before and after stent placement were measured and then compared using a Wilcoxon signed-rank test. The average follow-up duration was 27.9 weeks (range: 2-81 weeks). RESULTS: Placement was successful in all cases. Seventy-six percent of the patients (28/37) experienced adequate palliative drainage for the remainder of their lives. There were no immediate complications. Three patients demonstrated stent sludge occlusion that required PTBD (percutaneous transhepatic biliary drainage) irrigation. Two patients experienced delayed stent migration with stone formation at 7 and 27 weeks of follow-up, respectively. Stent insertion resulted in acute elevations of the amylase and lipase levels one day after stent insertion in 11 patients in spite of performing endoscopic sphincterotomy (4/6). The bilirubin levels were significantly reduced one week after stent insertion (p < 0.01). The 30-day mortality rate was 8% (3/37), and the survival rates were 49% and 27% at 20 and 50 weeks, respectively. The primary stent patency rates were 85%, and 78% at 20 and 50 weeks, respectively. CONCLUSION: The PTFE-covered self-expandable nitinol stent is safe to use with acceptable complication rates. This study is similar to the previous studies with regard to comparing the patency rates and survival rates.

Interventional therapy of cervical esophageal malignant obstruction / 介入放射学杂志

Objective To explore the feasibility of microinvasive technique in high level malignantesophageal obstruction and to provide the palliative therapy that can't be dredged by traditional methods. Methods There were 39 patients suffered from high level esophageal obstruction,involving the segments from esophageal circular pharynx to 12mm below. Tube-reticular nitinol metal stents woven by single thread were placed in orally to dredge the esophagus under fluoroscopic guidance after repeated tolerant expanding performance through expandable catheter. Interventional chemical therapy were administrated through blood-supply vessels. Results Thirty nine patients were grafted with 46 high level esophageal stents. 34 patients accepted 156 times of interventional chemical therapy. All patients restored with fine residue diet without showing side-effects except slight pain and tolerant uncomfortable feeling. The survival rate of the patients with both interventional chemical therapy and stents was longer than those with stent therapy alone. Conclusion Cervical high level segment of esophagus shouldn't be the restricted zone in the management of inner-stents. Interventional chemical therapy showed tumor-inhibiting effect in the cervical malignant diseases.

The Clinical investigation of Percutaneous Placement of Stent for Relieving Malignant Biliary Obstruction / 实用放射学杂志

Objective To evaluate the approaches of percutaneous trans-hepatic stent for relieving malignant biliary obstruction and its clinical effect. Methods 20 stents were set up in bile duct to treat malignant biliary obstruction in 18 cases using two steps under x-ray fluoroscopy. After the stents set up successfully, the contrast agent was injected through the long sheath in order to find out the expansion and expedition of the stent. The stents were provided by Micro-Tech co.1td.(Nanjing). The patient’s jaundice, liver function and amylase (AMY)levels were observed after the procedure and all the patients were followed up for three to eleven months. Results Twenty stents were placed in 18 patients successfully in one time.STB , ALT, AST, r-GT and ALP decreased 66.27%, 57.83%, 62.21%, 44.74% and 47.57% respectively one week after the procedure. Early complications included hyperamylasemia , acute pancreatitis,hernobilia, bile leakage,ect.Late complications were displacement and restenosis of the stent . A patient died due to failure of heart and lung. Conclusion The percutaneous transhepatic insertion of biliary stent is an effective method in relieving malignant obstructive jaundice.

The Cause and Treatment of Restenosis after Percutaneous Transhepatic Biliary Stent Placement / 实用放射学杂志

Objective To explore the cause and the interventional treatment of restenosis after percutaneous transhepatic biliary stent.Methods 20 patients with biliary restenosis after percutaneous transhepatic biliary stent placement were collected.According to drainage volume from biliary tract and degree of amelioration of jaundice,post-operation hepatic function,blood,urine and stool routines,ultrasound,CT scan and cholangiography were performed to determine the nature and location of biliary restenosis,and then all cases underwent recanalization with intervention method by the exteriorized drainage tube approach.The China-made nickel-titanium alloy stents with diameter of 10 mm and length ranged from 40 mm to 80 mm were used.Results The biliary restenosis occurred in mid-inferior segment of common bile duct in 9 patients, common hepatic duct in 7 patients and hepatic porta in 4 patients. As regarding the causes of restenosis included tumor compression in 9 cases, angulation in upper segment of stent in 3 cases, obstruction in stent by bile, food or clot in 4 cases, cholangitic stenosis in 2 cases and granulation proliferation in 2 cases.The obstruction in all cases was relived by extraction through drainage tube, drug irrigation,dredging by wire, balloon dialtion or stent replacement, so that the total survival rate was beyond 6 months.Conclusion After percutaneous transhepatic biliary stent placement in treating the malignant biliary obstruction,the rate of biliary restenosis is still high,which should be attached importance to.

Comparison of One Stage Operation with Staged Operation in Malignant Obstruction of the Left Colon and Rectum

BACKGROUND: The optimal management of malignant obstruction of the left colon and rectum is controversial. METHODS: A retrospective study was performed of 33 patients who underwent one-stage operation(n=11), staged operation(n=20), and palliative colostomy(n=2) at Kwangju Christian Hospital between January 1992 and December 1996. RESULTS: Eleven patients underwent one-stage operations(7 cases with anterior resection, 3 cases with left hemicolectomy, 1 case with Miles' operation). In this group, postoperative morbidity was 36.3% including 1 wound infection(9.0%), 1 anastomotic leakage (9.0%), 1 postoperative intestinal obstruction and 1 pulmonary complication, but there was no postoperative death. The average of hospital stay in this group was 18.1 days and the first day of normal diet was 6.0 days. Twenty patients underwent staged operations including 12 cases of Hartmann's procedure. In this group, postoperative morbidity was 35.0% including 3 wound infections(15.0%), 2 pulmonary complications(10.0%), 1 parastomal hernia and 1 fistula. There were two postoperative deaths as a result of sepsis. The average of hospital stay in this group was 34.9 days and the first day of normal diet was 6.8 days. CONCLUSION: We believe that one-stage operation was of value in management of malignant obstruction of the left colon and rectum in selected patients.

MRCP for Diagnosis of Malignant Biliary Obstructive Disease / 实用放射学杂志

Objective To evaluated the diagnostic value of malignant biliary obstrutive disease magnetic resonance cholangiopancreatography(MRCP).Methods 21 cases with malignant biliary obstructive disease diagnosed by clinic and CT were examined by MRCP,the results of MRCP and operation-pathology were analysed.Results The accuracy of MRCP for evaluating the cause of obstructive were 90.5%(19/21),dilated biliary duct appeared "soft canes-like"and "sausage-like",obstructive ends of biliary duct exhibited "cut-off form","down cup mouth-form"and "mouse tail-form".Conclusion Malignant biliary obstruction can accurately diagnosed by MRCP,it may provide an efficient method for the patients who can not accept ERCP provide an efficient alternative to direct cholangiopancreatography.

Common complications and treatments in the malignant obstruction of upper alimentary tract with stent insertion / 介入放射学杂志

Objective To explore the common complications and methods of treatment in the malignant obstruction of upper alimentary tract with stent insertion. Methods With interventional procedure under fluoroscopic guidance fourteen self expanding stents were implanted in twelve patients, including nine with strictures or obstructions of esophagus, three with obstructions of gastroduodenum. Of the fourteen, nine were coated stents and five were uncoated stents. Results All stents were implanted successfully, but complications after the procedure occurred sometimes. There complications included: 1. Food bolus obstructed in three patients. 2. Chest pain occurred in four patients. 3. Tumour overgrowth or hyperplasia of granulation tissue in three patients caused restenosis of gastrointestinal tract. 4. Stent replacement in three patients. 5. Hemorrhage occurred in two patients (over 300 ml) causing threat to life. Conclusions The implantation of self expanding stent is a simple and effective method offering good palliation for upper alimentary tract obstructions. The complications shoud be treated correctly.