Endoscopic or Percutaneous Biliary Drainage for Klatskin Tumors?
Controversy exists regarding the preferred biliary drainage technique in patients with Klatskin tumors because few comparative studies exist. This study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD).
Materials and methods:
Consecutive patients (N = 129) with Klatskin tumors treated with initial EBD or PTBD were identified, and their clinical histories were retrospectively reviewed. The primary endpoint was the time to therapeutic success (TTS), defined as the time between the first drainage and a total bilirubin measurement of 40 μmol/L or lower.
EBD was the first biliary decompression procedure performed in 87 patients; PTBD was performed first in 42. Technical success rates (78% with EBD vs 98% with PTBD; P = .004) and therapeutic success rates (49% vs 79%, respectively; P = .002) were significantly lower in the EBD group than in the PTBD group. Forty-four patients in the EBD group (51%) subsequently underwent PTBD before therapeutic success was achieved or antitumoral treatment was started. Median TTSs were 61 days in the EBD group and 44 days in the PTBD group, and multivariate analysis showed a hazard ratio of 0.63 (95% confidence interval, 0.41-0.99; P = .045). In patients treated with surgery or chemotherapy with or without radiation therapy, median times to treatment were 76 and 68 days in the EBD and PTBD groups, respectively (P = .76). Cholangitis occurred in 25% and 21% of patients in the EBD and PTBD groups, respectively (P = .34).
PTBD should be seriously considered for biliary decompression when treating patients with Klatskin tumor.
Available from: pubs.rsna.org
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ABSTRACT: Various biliary pathologic conditions can lead to acute abdominal pain. Specific diagnosis is not always possible clinically because many biliary diseases have overlapping signs and symptoms. Imaging can help narrow the differential diagnosis and lead to a specific diagnosis. Although ultrasonography (US) is the most useful imaging modality for initial evaluation of the biliary system, multidetector computed tomography (CT) is helpful when US findings are equivocal or when biliary disease is suspected. Diagnostic accuracy can be increased by optimizing the CT protocol and using multiplanar reformations to localize biliary obstruction. CT can be used to diagnose and stage acute cholecystitis, including complications such as emphysematous, gangrenous, and hemorrhagic cholecystitis; gallbladder perforation; gallstone pancreatitis; gallstone ileus; and Mirizzi syndrome. CT also can be used to evaluate acute biliary diseases such as biliary stone disease, benign and malignant biliary obstruction, acute cholangitis, pyogenic hepatic abscess, hemobilia, and biliary necrosis and iatrogenic complications such as biliary leaks and malfunctioning biliary drains and stents. Treatment includes radiologic, endoscopic, or surgical intervention. Familiarity with CT imaging appearances of emergent biliary pathologic conditions is important for prompt diagnosis and appropriate clinical referral and treatment. © RSNA, 2013.
Radiographics 11/2013; 33(7):1867-88. DOI:10.1148/rg.337125038 · 2.60 Impact Factor
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ABSTRACT: To describe the technique and report on the clinical benefit of percutaneous transhepatic metal biliary endoprosthesis (TMBE) placement for the palliation of malignant biliary obstruction (MBO).
This is a retrospective single-center case series of 31 TMBE placements between October 2007 and October 2011 in 29 patients with inoperable MBO who failed endoscopic drainage and were not candidates for surgical resection. The mean age was 66.4 years. Eastern Cooperative Oncology Group performance scores were ≤2 in all patients. Data on procedural success, clinical and radiologic markers of stent patency, procedure-related complications, return to medically treatable status, benefit from chemotherapy, and survival were recorded.
All TMBE procedures were successful with no major procedure-related complications, and all patients improved clinically. Mean preprocedural and postprocedural bilirubin concentrations were 228.9±138.4 and 39.9.0±33.6 μmol/L, respectively (P<0.0001). Mean overall survival and occlusion-free survival were 9.355±2.425 months (95% confidence interval [4.60-14.12]) and 4.678±0.720 months (95% confidence interval [3.27-6.09]), respectively. Chemotherapy was initiated or reinstated in 16 patients (55%), 7 of whom (44%) demonstrated stable disease or partial response. Three patients were lost to follow-up.
TMBE provides acceptable palliation for patients with inoperable MBO who have failed endoscopic drainage. Stents appear to remain patent for the remainder of the patient's life in most cases and may facilitate the first induction or reinstatement of chemotherapy with further clinical response in some patients.
American journal of clinical oncology 09/2013; 38(5). DOI:10.1097/COC.0b013e3182a5341a · 3.06 Impact Factor
Available from: Fatih Aslan
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ABSTRACT: Objective. We aimed to determine the effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) in patients with inoperable perihilar cholangiocarcinoma and establish the incidence of cholangitis development following ERCP. Material and Method. This retrospective study enrolled patients diagnosed with inoperable perihilar cholangiocarcinoma who underwent endoscopic drainage (stenting) with ERCP. Patients were evaluated for development of cholangitis and the effectiveness of ERCP. The procedure was considered successful if bilirubin level fell more than 50% within 7 days after ERCP. Results. Post-ERCP cholangitis developed in 40.7% of patients. Cholangitis development was observed among 39.4% of patients with effective ERCP and in 60.6% of patients with ineffective ERCP. Development of cholangitis was significantly more common in the group with ineffective ERCP compared to the effective ERCP group (P = 0.001). The average number of ERCP procedures was 2.33 ± 0.89 among patients developing cholangitis and 1.79 ± 0.97 in patients without cholangitis. The number of ERCP procedures was found to be significantly higher among patients developing cholangitis compared to those without cholangitis (P = 0.012). Conclusion. ERCP may not provide adequate biliary drainage in some of the patients with perihilar cholangiocarcinoma and also it is a procedure associated an increased risk of cholangitis.
Gastroenterology Research and Practice 05/2014; 2014(29):508286. DOI:10.1155/2014/508286 · 1.75 Impact Factor
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