Result of Endoscopic Biliary Drainage in Hilar Cholangiocarcinoma

Abstract

Patients with hilar obstruction usually require bilateral biliary drainage. The prognosis of patients who fail bilateral biliary drainage after contrast injection into both intrahepatic ducts is poor due to a high infection rate in the undrained segments. The incidence of post-endoscopic retrograde cholangiopancreatography cholangitis in those with successful bilateral biliary drainage was less, but still significant. Incomplete subsegmental intrahepatic duct drainage is suggested to be responsible for post-biliary drainage cholangitis in cases of advanced hilar tumors. This study was undertaken to determine the incidence of post-endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and stent clogging in different types of malignant biliary obstruction after biliary drainage. From our endoscopic retrograde cholangiopancreatography database, there were 63 patients who underwent endoscopic biliary drainage between September 2000 and November 2001, for malignant biliary obstruction. Sixty-one endoscopic retrograde cholangiopancreatographies had biliary drainage performed (2 patients who failed biliary drainage were excluded). We divided our patients into 3 groups: Group 1 = Bismuth I, Group 2 = Bismuth II, and Group 3 = Bismuth III and IV. All but 2 Group 1 patients had successful biliary endoprosthesis (plastic [n = 13], metallic [n = 12], failed [n = 2]) placement into an extrahepatic duct. All patients from Group 2 (n = 10) and 20 patients from Group 3 (n = 26) had successful bilateral biliary drainage. Unilateral biliary drainage was performed in 6 patients from Group 3, each with a plastic endoprosthesis. The incidence of post-biliary drainage cholangitis (new onset of fever >38.5 degrees C with leukocytosis), jaundice resolution (normal bilirubin level), and the duration of endoprosthesis patency were compared among the 3 groups. The incidences of post-endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and the duration of endoprosthesis patency were: Group 1 (4%, 96%, and 87.2 days, respectively), Group 2 (10%, 100%, and 69.1 days, respectively) and Group 3 (57.7%, 73.1%, and 41.3 days, respectively). Of those patients who did not undergo surgery, patients from Group 3 required endoprosthesis exchange sooner than others. The outcome of biliary drainage in patients with advanced hilar tumors (Bismuth III or IV) was poorer than hilar tumor at earlier stages (Bismuth I or II).

Crisscross-Configured Dual Stent Placement for Trisectoral Drainage in Patients with Advanced Biliary Hilar Malignancies

“…Concerns related to performing only unilateral drainage include the inability to relieve jaundice as well as the potential for bacterial contamination of undrained ducts, particularly when a contrast medium is introduced into them (2-6). Supporters of unilateral drainage emphasize the lower complication rate, but caution that overfilling of contrast medium into undrained ducts should be avoided (7)(8)(9)(10). However, preventing overfilling with any certainty seems to be unrealistic.…”

“…PERCUTANEOUS palliation with metallic endoprostheses is the accepted method to relieve malignant biliary hilar obstruction (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11). Although the necessity of complete biliary drainage remains controversial, it seems certain that drainage of as much of the liver as possible is prudent (3)(4)(5)(6)(7)(8).…”

Biliary drainage strategy of unresectable malignant hilar strictures by computed tomography volumetry

“…In biliary obstruction in the hepatic hilum, effective drainage is difficult to achieve because of the anatomical complexity of the bile ducts. Various procedures of biliary drainage of hilar biliary obstruction have been performed: percutaneous or endoscopic routes [1][2][3][4][5] , plastic or metallic stents [6][7][8][9][10][11] , and unilateral or bilateral hepatic duct drainage [11][12][13][14][15][16][17][18][19][20][21] . However, no consensus has been reached on the optimal drainage strategy for treating biliary obstruction.…”

Role of Preoperative Biliary Drainage in Resectable Hilar Cholangiocarcinoma

“…It has been reported that the post-procedural morbidity rate of percutaneous techniques is lower compared to the endoscopic technique [9]. PTBD is a direct approach for bile duct decompression in patient with HC and it is usually the procedure of choice in most groups due to effectiveness in decreasing serum bilirubin with low rates of cholangitis [9,10]. In particular, success rate of bile duct decompression is significantly higher by percutaneous approach than EBD in locally advanced HC [11].…”

“…Moreover, after the procedure, evaluation of tumor length and extension may be less accurate in the presence of one or more stents and for local inflammation and fibrosis [8,9]. EBD is affected by an higher rate of postprocedural complications compared to other techniques, with an overall 25-50% morbidity and 3-5% mortality rate [9,10].…”