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Endoscopic radiofrequency ablation of cholangiocarcinoma: New palliative treatment modality (with videos)

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... Since 2011, an endoscopic catheter is available that allows ID-RFA in biliary or pancreatic ducts. Biliary RFA is performed after biliary tract cannulation with ERCP [21]. A sphincterotomy is generally performed but not mandatory [4]. ...
... The probe is then inserted over the guidewire across the stricture and energy is applied for the desired period, according to the different RFA probe manufacturer's indications. By applying thermal energy to the tissue through high-frequency alternating current, RFA induces coagulative necrosis and causes local destruction of the tumor [20,21]. Usually, multiple radiofrequency applications are completed during the same session [4,20,21]. ...
... By applying thermal energy to the tissue through high-frequency alternating current, RFA induces coagulative necrosis and causes local destruction of the tumor [20,21]. Usually, multiple radiofrequency applications are completed during the same session [4,20,21]. Before with-drawing the probe, a pause of about 60 s is necessary to prevent tissue from adhering to the electrodes. After removing the probe, coagulated tissue debris is extracted with an extraction balloon, and a PS or metal stent is positioned to guarantee biliary drainage [22]. ...
Article
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Hilar cholangiocellular carcinoma (CCC) is a malignant neoplasm of epithelial origin occurring at the confluence of the right and left hepatic bile ducts. Typically, these tumors are small, poorly differentiated, exhibit aggressive biologic behavior with non-specific symptoms and tend to obstruct the intrahepatic bile ducts. Surgery is the only available curative option. Unfortunately, in less than half of the patients a complete resection is possible with poor survival rate in unresectable cases. In this report, we present the case of a 58-year-old woman with a history of unresectable hilar cholangiocarcinoma. Initially she was treated with intraductal dilatation of malignancy and placement of a plastic stent and chemotherapy (Gemcitabin® and Platinol®). Two years later she underwent a second-line chemotherapy with Gemcitabin® and Oxyplatin® because of tumor progression. Despite a second line chemotherapy and placement of an uncovered self-expandible metal stent (ucSEMS) that was extended later on by stent-in stent technique, there was tumor progression which led to a complex course with relapsing obstructive cholangiosepsis and cholestasis. Because of tumor ingrowth, endobiliary radiofrequency ablation of the malignant stenosis was performed in repeated sessions. This case illustrates that radiofrequency ablation of solitary malignant biliary obstruction is feasible, safe and allows an improvement of quality of life in non-operable patients.
... An open-label pilot study involving 22 patients with malignant biliary strictures confirmed the safety and feasibility of this radiofrequency ablation (RFA) technique for clinical use [12]. The technique has shown promising results in the palliative treatment of malignant biliary strictures, preventing stent occlusion [13][14][15][16][17][18], clearing blocked metal stents [7], prolonging stent patency [19], and improving patient survival [20]. We previously reported our early experience in managing patients with unresectable Bismuth types III and IV hilar cholangiocarcinoma using biliary RFA, and demonstrated that the long-term efficacy and safety is promising [21]. ...
... Foremost, the local thermal effect can destroy the malignant biliary stricture, resulting in a local coagulation necrosis that has the potential to delay tumor growth and, therefore, prolong the duration of stent patency [16]. This local effect on tumor tissue was confirmed by Monga et al. [13], who reported the disappearance of tumor blood vessels and enlargement of the lumen following RFA. Moreover, RFA can be used to clear the occlusion of a previously deployed metal stent, and restore the biliary flow without the need to insert a new stent inside the obstructed stent [7]. ...
Article
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Background Patients with unresectable malignant biliary obstruction have limited life expectancy because of limited stent patency and tumor progression. The aim of our study was to retrospectively evaluate the safety and efficacy of combining intraductal RFA with biliary metal stent placement for patients with malignant biliary obstruction. Methods Patients who received percutaneous intraductal RFA and biliary stent placement for malignant biliary obstruction between 2013 and 2015 were identified. Outcomes were stent patency, technique and clinical success rate, overall survival (OS) and complication rates. Kaplan-Meier and Cox regression analyses were used to examine the association of various factors with stent patency and OS. Complications and laboratory abnormalities were recorded. Results Fifty patients were treated with percutaneous RFA and stent placement. The rates of technical success and clinical success were 98% and 92%, respectively. The median stent patency was 7.0 (95% confidence interval [CI]: 5.3, 8.7) months and OS was 5.0 (95% CI: 4.0, 6.0) months. On univariable analysis, previously cholangitis was an independent poor prognosis factor for recurrent biliary obstruction. OS was improved in patients who received more than one intervention compared to those who received only one intervention (log-rank P = 0.007), and in those treated without versus those treated with sequential chemotherapy (log-rank P = 0.017). On multivariable analysis, the occurrence of more than one intervention (P = 0.019) had independent prognostic significance for OS. Conclusion Percutaneous RFA and stent placement is a technically safe and feasible therapeutic option for the palliative treatment of malignant biliary obstruction. The long-term efficacy and safety of the procedure is promising, but further study is required via randomized and prospective trials.
... Recently, intraductal RFA has shown to confer satisfactory therapeutic effects. Additionally, the safety and efficacy of RFA catheter deployment combined stent placement has been demonstrated in patients with unresectable malignant obstructive jaundice [14,[19][20][21].The RFA procedure can be performed either through an endoscopic or percutaneous route with the use of a special RFA catheter (Habib TM EndoHPB, EMcision Ltd, London, UK). In this study, we performed clinical study to select a percutaneous approach for RFA combined with non-covered self-expanding metal stent placement (SEMS) (WallFlex, Boston Scientific, Natick, MA) because RFA can be applied following PTCD with minimal discomfort to the patient, and metal stent placement is considered to relieve obstructive symptoms and improve quality of life [13]. ...
... One previous report asserted that ablation treatment should be performed cautiously because of excessive charring leading to perforation [31]. We agree that intraductal RFA can destroy the tumor tissue to some extent to enlarge the lumen for stent placement, leading to blood vessel loss; this is in agreement with the findings of Monga et al. [21]. Median stent patency and overall survival compare favorably with those of prior reports [14]. ...
Article
Purpose: To assess the feasibility and safety of percutaneous intraductal radiofrequency ablation (RFA) for unresectable Bismuth types III and IV hilar cholangiocarcinoma. Results: Percutaneous intraductal RFA combined with metal stent placement was successful in all patients without any technical problems; the technical success rate was 100%. Chemotherapy was administered to two patients. After treatment, serum direct bilirubin levels were notably decreased. Six patients died during the follow-up period. Median stent patency from the time of the first RFA and survival from the time of diagnosis were 100 days (95% confidence interval (CI), 85-115 days) and 5.3 months (95% CI, 2.5-8.1 months), respectively. No acute pancreatitis, bile duct bleeding and perforation, bile leakage, or other severe complications occurred. Four cases of procedure-related cholangitis, three cases of postoperative abdominal pain, and five cases of asymptomatic transient increase in serum amylase were observed. One patient who presented with stent blockage 252 days' post-procedure underwent repeat ablation. Materials and methods: Between September 2013 and May 2015, nine patients with unresectable Bismuth types III and IV hilar cholangiocarcinoma who were treated with percutaneous intraductal RFA combined with metal stent placement after the percutaneous transhepatic cholangial drainage were included in the retrospective analysis. Procedure-related complications, stent patency, and survival after treatment were investigated. Conclusion: Percutaneous intraductal RFA combined with metal stent placement is a technically safe and feasible therapeutic option for the palliative treatment of unresectable Bismuth types III and IV hilar cholangiocarcinoma. Its long-term efficacy and safety is promising, but needs further study via randomized and prospective trials that include a greater number of patients.
... Only one study reported patients with benign non-tumoural strictures and included four postsurgical strictures, three after liver transplant and two chronic inflammatory strictures [55] . The RF Monga et al [40] , 2011 ...
... However, stent patency and survival have not been uniformly described. Only five studies have detailed data about stent patency in patients with malignant strictures treated with RF before placing a self-expanding metal stent (SEMS) [40,50,51,58,62] . In two studies, the mean lengths of stent patency in 10 and 58 patients with malignant strictures were 270 and 170 d (range 180-450 and 63-277) [51,58] . ...
Article
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Most pancreatic cancers and extrahepatic cholangiocarcinomas are unresectable at the time of diagnosis, and even in case of a resectable cancer, for elderly or patients with coexistent comorbidities, surgery is not an option. Current treatment alternatives in these scenarios are very limited. Biliary stenting with self-expanding metal stents (SEMS) is the mainstay palliative treatment of biliary obstruction due to unresectable pancreatic cancer or cholangiocarcinoma. Nevertheless, more than 50% of SEMS become occluded after 6 mo due to tumour over- and ingrowth, leading to hospital readmissions and reinterventions that significantly impair quality of life. Regimes of chemotherapy or chemoradiotherapy also provide minimal survival benefits. Therefore, novel therapies are eagerly awaited. Radiofrequency (RF) energy causes coagulative necrosis leading to local destruction of the accessed malignant tissue and has an established role in the treatment of malignancies in several solid organs, especially liver cancers. However, pancreatic and extrahepatic biliary cancers are not easily accessed by a percutaneous route, making the procedure dangerous. Over the past five years, the development of dedicated devices compatible with endoscopic instruments has offered a minimally invasive option for RF energy delivery in biliopancreatic cancers. Emerging experience with endoscopic RF ablation (RFA) in this setting has been reported in the literature, but little is known about its feasibility, efficacy and safety. A literature review makes it clear that RFA in biliopancreatic tumours is feasible with high rates of technical success and acceptable safety profile. Although available data suggest a benefit of survival with RFA, there is not enough evidence to draw a firm conclusion about its efficacy. For this reason, prospective randomized trials comparing RFA with standard palliative treatments with quality-of-life and survival endpoints are required. Anecdotal reports have also highlighted a potential curative role of RFA in small pancreatic tumours and benign conditions, such as ductal extension of ampullomas, intrahepatic adenomas or non-tumoural biliary strictures. These newest indications also deserve further examination in larger series of studies.
... The technical feasibility, cholangioscopic video recording and fluoroscopic images of the procedure were described in a concise manner in a pilot study conducted by Monga et al. 18 Subsequent studies described by Dolak et al., 14 Steel et al., 15 Alis et al., 19 Figueroa-Barojas et al., 20 Mizandari et al., 21 and Tal et al. 22 confirmed that RFA is generally a safe and feasible procedure with 100% technical success rate in most of the studies (Table 1). Several mild procedure-related complications were described by the above studies with mild postprocedure pain being the commonest. ...
Article
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Biliopancreatic malignancies such as cholangiocarcinoma (CCA) has notoriously been diagnosed late. As such most therapy have been palliative in nature. Cholangioscopy allows for an earlier diagnosis to be made. Brachytherapy with the insertion of catheter with iridium-132 seeds, percutaneously or through endoscopic retrograde cholangiopancreatography (ERCP) was the earliest ablative techniques used. It has been shown to have a beneficial effect only in prolonging survival. Photodynamic therapy (PDT) has also been used for several years. stenting with PDT versus stenting alone for unresectable CCA showed a marked survival benefit with the addition of PDT. However the most exciting endoscopic ablative modality appears to be intraductal radiofrequency ablation using the Habib catheter and device. Several case series have shown the effectiveness of this technique in ablating tumors. This technique is evolving and coupled with early diagnosis of CCA through cholangioscopy will allow for a curative therapy. The crux to the effective treatment of early cancerous lesions in the bile or pancreatic duct is the early diagnosis of such lesions. Effective endoscopic ablative therapy is now available with the advent of radiofrequency ablation probes that can be passed through the duodenoscope via ERCP.
... Only a handful of data exists regarding intraductal RFA for hilar CCA. Monga et al. [58] reported a clinical case report of successful therapy of intraductal CCA, while Steel et al. [59] reported the feasibility of using intraductal therapy for malignancy, of which only six of 21 cases were diagnosed as CCA. Therefore, more information regarded the efficacy and safety of this particular therapy is still needed; however, it was considered a potential "new tool" for the endobiliary treatment of hilar CCA. ...
Article
Cholangiocarcinoma is a high-mortality primary hepatic malignancy. A higher incidence of cholangiocarcinoma was reported in Asia, especially Southeast Asia, than in Western countries. Hilar cholangiocarcinoma is a specific type of extrahepatic cholangiocarcinoma that involves the hepatic hilum and has a worse prognosis. More than half of the patients with jaundice are inoperable at the time of first diagnosis. Therefore, biliary drainage is the mainstay of palliative treatment in these patients. Endoscopic biliary drainage via endoscopic retrograde cholangiopancreatography, the modality of choice, for the advanced hilar type is more difficult and complex than those in distal cholangiocarcinoma. Endoscopists should consider many factors before selecting the most appropriate treatment for each patient. Here we discuss the factors systematically. In cases of transpapillary approach failure, other therapeutic modalities should be considered. Percutaneous transhepatic biliary drainage is the most popular method in such cases. At the present, endoscopic ultrasound-guided biliary drainage, especially hepaticogastrostomy, is an alternative procedure with the same efficacy and low complications when it was carried out in the expert hands. Furthermore, recent locoregional therapies for tumor control including trans-luminal photodynamic therapy and radiofrequency ablation also benefit these patients.
... Monga et al. [19] reported a case of common bile duct carcinoma treated with intraductal RFA. Two weeks after the procedure, choledochoscopy indicated that RFA was able to induce some destruction of local tumor tissue. ...
Article
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To determine the safety and feasibility of intraductal radiofrequency ablation (RFA) followed by locoregional tumor treatments in patients with non-resectable malignant biliary obstruction and stent re-occlusion. Fourteen patients with malignant biliary obstruction and blocked metal stents were studied retrospectively. All had intraductal RFA followed by locoregional tumor treatments and were monitored clinically and radiologically. The practicality, safety, postoperative complications, jaundice remission, stent patency and survival time were analyzed. Combination treatment was successful for all patients. There were no severe complications during RFA or local treatments. All patients had stent patency restored, with a decline in serum bilirubin. Three patients had recurrent jaundice by 195, 237 and 357 days; two patients underwent repeat intraductal RFA; and one required an internal-external biliary drain. The average stent patency time was 234 days (range 187-544 days). With a median follow-up of 384 days (range 187-544 days), six patients were alive, while eight had died. There was no mortality at 30 days. The 3, 6, 12 and 18 month survival rates were 100%, 100%, 64.3% and 42.9%, respectively. Intraductal RFA followed by locoregional tumor treatments for occluded metal stents is safe and practically feasible and potential increase stent patency and survival times.
... With the introduction of an endoscopic probe for RFA Ortner et al [56] 2003 39 3 16 < 0.0001 Cheon et al [57] 2004 47 10 18 0.0143 Zoepf et al [58] 2005 32 7 21 0.0109 Table 5 Photodynamic therapy as an adjunct to biliary stenting: Improved survival PDT: Photodynamic therapy. and the use of a lower power setting with the existing generators, it is now possible to treat pancreatico-biliary cancers with this modality [63] . Within the bile duct, it has the potential of improving stent patency by decreasing tumor ingrowth and benign epithelial hyperplasias. ...
Article
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Hilar cholangiocarcinomas are common tumors of the bile duct that are often unresectable at presentation. Palliation, therefore, remains the goal in the majority of these patients. Palliative treatment is particularly indicated in the presence of cholangitis and pruritus but is often also offered for high-grade jaundice and abdominal pain. Endoscopic drainage by placing stents at endoscopic retrograde cholangio-pancreatography (ERCP) is usually the preferred modality of palliation. However, for advanced disease, percutaneous stenting has been shown to be superior to endoscopic stenting. Endosonography-guided biliary drainage is emerging as an alternative technique, particularly when ERCP is not possible or fails. Metal stents are usually preferred over plastic stents, both for ERCP and for percutaneous biliary drainage. There is no consensus as to whether it is necessary to place multiple stents within advanced hilar blocks or whether unilateral stenting would suffice. However, recent data have suggested that, contrary to previous belief, it is useful to drain more than 50% of the liver volume for favorable long-term results. In the presence of cholangitis, it is beneficial to drain all of the obstructed biliary segments. Surgical bypass plays a limited role in palliation and is offered primarily as a segment III bypass if, during a laparotomy for resection, the tumor is found to be unresectable. Photodynamic therapy and, more recently, radiofrequency ablation have been used as adjuvant therapies to improve the results of biliary stenting. The exact technique to be used for palliation is guided by the extent of the biliary involvement (Bismuth class) and the availability of local expertise.
... In published clinical reports, endobiliary RF has been associated with a 10%-20% morbidity rate [5,8,11,12] , including cases of cholangiosepsis, liver infarction, hepatic coma, cholecystitis, and pancreatitis, all of which can be explained at least in part by excessive tissue damage to the distal bile duct or to the hepatic parenchyma. Moreover, generator settings reported in clinical studies have been heterogeneous, ranging from 5 W and 120 s [13] to 10 W and 120 s [4] , and frequent use of intermediate power values or ablation times [5,8,11,12] . Only one publication reported the use of endobiliary RF ablation on a periampullary tumor, 1227 November 10, 2015|Volume 7|Issue 16| WJGE|www.wjgnet.com ...
Article
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Aim: To determine the optimal generator settings for endobiliary radiofrequency ablation. Methods: Endobiliary radiofrequency ablation was performed in live swine on the ampulla of Vater, the common bile duct and in the hepatic parenchyma. Radiofrequency ablation time, "effect", and power were allowed to vary. The animals were sacrificed two hours after the procedure. Histopathological assessment of the depth of the thermal lesions was performed. Results: Twenty-five radiofrequency bursts were applied in three swine. In the ampulla of Vater (n = 3), necrosis of the duodenal wall was observed starting with an effect set at 8, power output set at 10 W, and a 30 s shot duration, whereas superficial mucosal damage of up to 350 μm in depth was recorded for an effect set at 8, power output set at 6 W and a 30 s shot duration. In the common bile duct (n = 4), a 1070 μm, safe and efficient ablation was obtained for an effect set at 8, a power output of 8 W, and an ablation time of 30 s. Within the hepatic parenchyma (n = 18), the depth of tissue damage varied from 1620 μm (effect = 8, power = 10 W, ablation time = 15 s) to 4480 μm (effect = 8, power = 8 W, ablation time = 90 s). Conclusion: The duration of the catheter application appeared to be the most important parameter influencing the depth of the thermal injury during endobiliary radiofrequency ablation. In healthy swine, the currently recommended settings of the generator may induce severe, supratherapeutic tissue damage in the biliary tree, especially in the high-risk area of the ampulla of Vater.
... Most studies using ERCP-guided RFA in the treatment of HC assessed improvements in stent patency duration and luminal diameter. In the treatment of malignant tumors, RFA can induce high temperatures locally, which leads to coagulation necrosis of tumor cells and controls tumor re-growth [23,24]. ...
Article
Full-text available
Cancer of the biliary confluence also known as hilar cholangiocarcinoma (HC) or Klatskin tumor, is a rare type of neoplastic disease constituting approximately 40%-60% of intrahepatic malignancies, and 2% of all cancers. The prognosis is extremely poor and the majority of Klatskin tumors are deemed unresectable upon diagnosis. Most patients with unresectable bile duct cancer die within the first year after diagnosis, due to hepatic failure, and/or infectious complications secondary to biliary obstruction. Curative treatments include surgical resection and liver transplantation in highly selected patients. Nevertheless, very few patients are eligible for surgery or transplant at the time of diagnosis. For patients with unresectable HC, radiotherapy, chemotherapy, photodynamic therapy, and liver-directed minimally invasive procedures such as percutaneous image-guided ablation and intra-arterial chemoembolization are recommended treatment options. This review focuses on currently available treatment options for unresectable HC and discusses future perspectives that could optimize outcomes.
... In conclusion, ERCP may not provide adequate biliary drainage in patients with perihilar cholangiocarcinoma and it is associated with an increased risk of cholangitis. Therefore, in patients with perihilar cholangiocarcinoma to provide adequate biliary drainage and to reduce the risk of cholangitis such as photodynamic therapy and radiofrequency ablation therapy for local tumor control should be considered [4,23]. Based on previous studies, we suggest that it would be more appropriate to prefer percutaneous drainage for tumors with more proximal localization and to use air in lieu of contrast agent. ...
Article
Full-text available
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.
... Kahaleh et al. have also recently reported their interim results from using RFA in a multicenter registry ( Figure 8); the 25 patients with unresectable cholangiocarcinoma had an increase in stricture diameter after RFA treatment (mean diameter before treatment: 2.21 mm, mean diameter after RFA: 5.26 mm; p < 0.0001) [76]. Cholangioscopydirected RFA has also been used to confirm tissue necrosis and abalation [73,77]. ...
Article
Cholangiocarcinomas are often locally advanced or have metastasized, and at the time of diagnosis individuals often have a poor prognosis. Endoscopic treatment options traditionally include biliary decompression via stenting to allow for systemic chemotherapy and radiotherapy, with self-expanding metal biliary stents being preferred. Recent developments in locoregional therapy delivered endoscopically, such as photodynamic therapy and radiofrequency abalation, have shown promising results in improving patient survival.
... The current management approaches for occluded SEMSs include mechanical cleaning and the insertion of a second stent (a covered SEMS, uncovered SEMS or plastic stent) via an endoscopic or percutaneous approach [2] . Recently, numerous clinical reports have demonstrated the safety and efficacy of using a novel radiofrequency (RF) ablation (RFA) catheter for endoscopic palliative procedures [3,4] . There is a clinical need for an effective method of re-opening biliary stents that accounts for the limitations of an endoscope, particularly in cases involving hepatic hilar tumors or after gastrointestinal operations. ...
Article
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AIM To assess the feasibility and effectiveness of a novel application of percutaneous intraductal radiofrequency (RF) for the treatment of biliary stent obstruction. METHODS We specifically report a retrospective study presenting the results of percutaneous intraductal RF in patients with biliary stent occlusion. A total of 43 cases involving biliary stent obstruction were treated by placing an EndoHPB catheter and percutaneous intraductal RF was performed to clean stents. The stent patency was evaluated by cholangiography and follow-up by contrast enhanced computed tomography or ultrasound after the removal of the drainage catheter. RESULTS Following the procedures, of the 43 patients, 40 survived and 3 died with a median survival of 80.5 (range: 30-243) d. One patient was lost to follow-up. One patient had the stent patent at the time of last follow-up. Two patients with stent blockage at 35 d and 44 d after procedure underwent percutaneous transhepatic drain insertion only. The levels of bilirubin before and after the procedure were 128 ? 65 ?mol/L and 63 ? 29 ?mol/L, respectively. There were no related complications (haemorrhage, bile duct perforation, bile leak or pancreatitis) and all patients? stent patency was confirmed by cholangiography after the procedure, with a median patency time of 107 (range: 12-180) d. CONCLUSION This preliminary clinical study demonstrated that percutaneous intraductal RF is safe and effective for the treatment of biliary stent obstruction, increasing the duration of stent patency, although randomized controlled trials are needed to confirm the effectiveness of this approach.
... Within the bile duct, RFA uses specific endobiliary probes that enable increased precision in the delivery of thermal energy in the biliary tree and pancreas, which appears to be safe and may result in decreased epithelial hyperplasia and tumour ingrowth [12]. Several studies have confirmed the safety and feasibility of this radiofrequency technique for clinical use [12][13][14], with promising results reported for the palliative treatment of malignant biliary strictures; to prevent stent occlusion [15][16][17][18][19][20], clear blocked metal stents [21] and prolong stent patency [22]; as well as to improve patient survival [23]. However, due to limited clinical experience using intraductal RFA and the small number of reports regarding this technique, the beneficial effect of a treatment combining intraluminal RFA and stent placement compared to stent placement alone remains to be evaluated [22][23][24]. ...
Article
PURPOSE: To retrospectively evaluate the added benefit of adding intraluminal radiofrequency ablation (RFA) to biliary metal stent placement for patients with malignant biliary obstruction (MBO). METHODS: From November 2013 to December 2015, 89 patients with MBO who had undergone percutaneous intraluminal RFA and stent placement (RFA-Stent group, n = 50) or stent placement only (Stent group, n = 39) were included. Outcomes were compared according to the type of tumor: cholangiocarcinoma or non- cholangiocarcinoma. RESULTS: Primary and secondary stent patency (PSP, SSP) were significantly higher for the RFA-stent group than the Stent group (PSP: 7.0 months vs. 5.0 months, P = 0.006; SSP: 10.0 months vs. 5.6 months, P < 0.001), with overall survival being comparable (5.0 months vs. 4.7 months, P = 0.068). In subgroup analysis, RFA-stent showed significant PSP benefits compared to Stent alone in patients with cholangiocarcinoma (7.4 months vs 4.3 months; P = 0.009), but with comparable outcomes in patients with non-cholangiocarcinoma (6.3 months vs 5.2 months; P = 0.266). The SSP was improved in both subgroups (cholangiocarcinoma, 12.6 months vs 5.0 months, P < 0.001; non-cholangiocarcinoma, 10.3 months vs 5.5 months, P = 0013). Technical success and clinical success were not significantly different between the two groups. The rate of complication was higher for the RFA-stent group, but tolerable when compared to the Stent group. CONCLUSIONS: Although survival was comparable between the groups, RFA-stent confers therapeutic benefits to patients with MBO in terms of stent patency compared to stent placement alone, especially in those with cholangiocarcinoma.
... The close temporal relationship of RFA to pseudoaneurysm formation, and the absence of other apparent etiologies, implicate intraductal RFA as the likely cause. RFA may be used to treat cholangiocarcinoma [1,2] and intraductal extension of ampullary polyp [3]. The cross-sectional diameter of the RFA tissue ablation zone varies from 4.3 to 11.3 mm depending on the power and duration of treatment [4]. ...
... Over the last 3 years, four studies including over 100 patients, most presenting with cholangiocarcinoma (>75%), have been published, documenting the technical feasibility and short-term success of RFA. 7,9,10,51 Most of the data consist of retrospective case series with a limited number of patients, and with malignant biliary strictures of various etiologies. A recently published study attempted to overcome some of these limitations. ...
Article
Radiofrequency ablation (RFA) is a well-validated treatment of dysplastic Barrett's esophagus. Other indications of endoscopic RFA are under evaluation. Four prospective studies (total 69 patients) have shown that RFA achieved complete remission of early esophageal squamous intra-epithelial neoplasia at a rate of 80%, but with a substantial risk of stricture. In the setting of gastric antral vascular ectasia, two prospective monocenter studies, and a retrospective multicenter study, (total 51 patients), suggest that RFA is efficacious in terms of reducing transfusion dependency. In the setting of chronic hemorrhagic radiation proctopathy, a prospective monocenter study and a retrospective multicenter study (total 56 patients) suggest that RFA is an efficient treatment. A retrospective comparative study (64 patients) suggests that RFA improves stents patency in malignant biliary strictures. Endoscopic RFA is an upcoming treatment modality in early esophageal squamous intra-epithelial neoplasia, as well as in gastric, rectal, and biliary diseases.
... Palliative treatment with biliary drainage by endoscopic or percutaneous placement of self-expandable metal stents (SEMSs) currently represents the best option available to improve the quality of life of these patients. In the last 30 years, endoluminal complementary treatments, including brachytherapy, photodynamic therapy (PDT) and radiofrequency ablation (RFA), have been investigated as possible adjuncts to biliary drainage with the aim of obtaining control of local tumour growth [3][4][5][6][7][8][9][10]; however, strong evidence for any beneficial effect is lacking. ...
Article
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Adequate biliary drainage with endoscopic or percutaneous placement of self-expandable metal stents represents the goal of palliation in patients with inoperable malignant obstruction of the biliary tree. As an adjunct to stenting, various tissue ablation treatments have been proposed with conflicting results. The aim of this study was to test the effect on biliary tissue of a new ablation technique based on Nd:YAG laser light delivery. The study was conducted on ex vivo specimens of 18 healthy farm pigs, using cystic ducts that are the simplest biliary structures to isolate and cannulate ex vivo. A 22G cannula was positioned into the cystic duct and a quartz optical fibre, with a prototypal cooling system, was inserted into the cannula. Nd:YAG laser output powers of 10, 12, and 15 W were tested, with a total delivered energy of 1000 J in continuous mode in each case. After laser treatment, histological analysis was performed. At macroscopical examination, no lesions of the external wall of the cystic ducts were detected. At histopathological examination, a coagulative necrosis involving the entire mucosa up to the muscolaris propria without significant changes of periductal tissues was observed in all specimens. This study shows the possibility of using Nd:YAG laser on ex vivo porcine biliary ducts with the effect of obtaining a coagulative necrosis involving the whole mucosa.
... p < 0.001) without causing serious adverse events [9]. RFA may play a role as a rescue therapy for stent obstruction by tumor ingrowth; however, its efficacy and safety still lack evidence [18][19][20][21]. ...
Article
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Background. Radiofrequency ablation (RFA) is a palliative method known for its application in the endoscopic treatment of malignant bile duct obstruction. It may be a useful rescue method for metal stent malfunction caused by tumor ingrowth. This study aimed to examine the feasibility and safety of endoluminal RFA for occluded bilateral hilar metal stents due to tumor ingrowth in patients with malignant hilar bile duct obstruction. Methods: From March 2016 to June 2018, 11 patients with unresectable malignant hilar bile duct stricture with occluded bilateral hilar metal stents due to tumor ingrowth were enrolled. Endoluminal RFA was performed through a novel temperature-controlled catheter at a setting of 7 W power for 120 s with a target temperature of 80 °C via endoscopic retrograde cholangiopancreatography (ERCP). The patients’ demographics, clinical outcomes, and adverse events were investigated. Results: The median age was 64 (interquartile range, 54–72) years. All RFA procedures were successful. Clinical success was achieved in eight patients (72.7%). During the follow-up, eight patients (72.7%) showed stent dysfunction, and the median patency after RFA was 50 days (95% confidence interval (CI): 34–not available (NA)). All stent dysfunctions were successfully managed with ERCP. Ten patients died, and the median overall survival was 289 days (95% CI, 107–NA) from RFA to death. There was one case of mild abdominal pain after the procedure without serious adverse events. Conclusions: As a rescue therapy for occluded bilateral hilar metal stents due to tumor ingrowth, endoluminal RFA seemed to be safe and useful in selected patients.
... In order to increase the duration of stent patency and exert local tumour destruction, the Habib TM Percutaneous Endobiliary Radiofrequency (Habib TM PERF) catheter (EMcision Ltd, London, UK), has been developed for malignant biliary obstruction. Previous clinical studies have shown the safety and efficacy of this novel radiofrequency (RF) ablation catheter when used for endoscopic palliative procedures [2,3]. Kahaleh and colleagues [4] showed that endoscopic RF ablation increased significantly the diameter of malignant biliary strictures. ...
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Purpose: Previous clinical studies have shown the safety and efficacy of this novel radiofrequency ablation catheter when used for endoscopic palliative procedures. We report a retrospective study with the results of first in man percutaneous intraductal radiofrequency ablation in patients with malignant biliary obstruction. Methods: Thirty-nine patients with inoperable malignant biliary obstruction were included. These patients underwent intraductal biliary radiofrequency ablation of their malignant biliary strictures following external biliary decompression with an internal-external biliary drainage. Following ablation, they had a metal stent inserted. Results: Following this intervention, there were no 30-day mortality, hemorrhage, bile duct perforation, bile leak, or pancreatitis. Of the 39 patients, 28 are alive and 10 patients are dead with a median survival of 89.5 (range 14-260) days and median stent patency of 84.5 (range 14-260) days. One patient was lost to follow-up. All but one patient had their stent patent at the time of last follow-up or death. One patient with stent blockage at 42 days postprocedure underwent percutaneous transhepatic drain insertion and restenting. Among the patients who are alive (n = 28) the median stent patency was 92 (range 14-260) days, whereas the patients who died (n = 10) had a median stent patency of 62.5 (range 38-210) days. Conclusions: In this group of patients, it appears that this new approach is feasible and safe. Efficacy remains to be proven in future, randomized, prospective studies.
... Pancreatic resection improves survival, but only a minority of patients are eligible due to locally advanced disease, distant metastasis or comorbidities. Up to 70% of patients with PC manifestation exhibit malignant biliary obstruction [22]. ...
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Cholangiocarcinoma and pancreatic cancer are the most common causes of malignant biliary obstruction. The majority of patients are diagnosed at a late stage when surgical resection is rarely possible. In these cases, palliative chemotherapy and radiotherapy provide only limited benefit and are associated with poor survival. Radiofrequency ablation (RFA) is a procedure for locoregional control of tumours, whereby a high-frequency alternating current turned into thermal energy causes coagulative necrosis of the tissue surrounding the catheter. The subsequent release of debris and tumour antigens by necrotic cells can stimulate local and systemic immunity. The development of endoluminal RFA catheters has led to the emergence of endoscopically delivered RFA, a treatment mainly used for malignant biliary strictures to prolong survival and/or stent patency. Other indications include recanalisation of occluded biliary stents and treatment of intraductal ampullary adenoma or benign biliary strictures. This article presents a comprehensive review of endobiliary RFA, mainly focusing on its use in patients with malignant biliary obstruction. The available data suggest that biliary RFA may be a promising modality, having positive impacts on survival and stent patency and boasting a reasonable safety profile. However, further studies with better characterised and stratified patient populations are needed before the method becomes accepted within routine clinical practice.
... In order to increase the duration of stent patency and exert local tumour destruction, the Habib TM Percutaneous Endobiliary Radiofrequency (Habib TM PERF) catheter (EMcision Ltd, London, UK), has been developed for malignant biliary obstruction. Previous clinical studies have shown the safety and efficacy of this novel radiofrequency (RF) ablation catheter when used for endoscopic palliative procedures [2,3]. Kahaleh and colleagues [4] showed that endoscopic RF ablation increased significantly the diameter of malignant biliary strictures. ...
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The major complication occurring with biliary stents is stent occlusion, frequently seen because of tumour in-growth, epithelial hyperplasia, and sludge deposits, resulting in recurrent jaundice and cholangitis. We report a prospective study with the results of first in man percutaneous intraductal radiofrequency (RF) ablation to clear the blocked metal stents in patients with malignant biliary obstruction using a novel bipolar RF catheter. Nine patients with malignant biliary obstruction and blocked metal stents were included. These patients underwent intraductal biliary RF ablation through the blocked metal stent following external biliary decompression with an internal-external biliary drainage. All nine patients had their stent patency restored successfully without the use of secondary stents. Following this intervention, there was no 30-day mortality, haemorrhage, bile duct perforation, bile leak, or pancreatitis. Of the nine patients, six are alive and three patients are dead with a median follow-up of 122 (range 50-488) days and a median stent patency of 102.5 (range 50-321) days. Six patients had their stent patent at the time of last follow-up or death. Three patients with stent blockage at 321, 290, and 65 days postprocedure underwent percutaneous transhepatic drain insertion and repeat ablation. In this selective group of patients, it appears that this new approach is safe and feasible. Efficacy remains to be proven in future, randomized, prospective studies.
... The technique of endobiliary RFA is as follows [4]. Initial imaging (e.g., MRCP) is reviewed to determine the length and the location of the biliary stricture. ...
... 3,4 An additional open-labeled study in humans demonstrated clinical safety, leading to subsequent device approval. 5,6 Since the availability of this probe, retrospective series have evaluated its efficacy in biliary neoplasms not amenable to surgery. These retrospective data have alluded to the benefit of RFA in improving stenosis, the duration of stent patency, and survival. ...
... The ablation electrode can generate high thermal energy, which induces coagulative necrosis of tumour cells in the bile duct cavity. Monga confirmed the disappearance of tumour blood vessels and lumen enlargement after intra-RFA [25]. Several studies have reported the clinical efficacy, safety, and survival benefit of intra-RFA for MBO [13,15,26]. ...
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Objective: To evaluate the efficacy and safety of stent placement combined with intraluminal radiofrequency ablation (intra-RFA) and hepatic arterial infusion chemotherapy (HAIC) for patients with advanced biliary tract cancers (Ad-BTCs) and biliary obstruction (BO). Methods: We retrospectively reviewed data for patients with Ad-BTCs and BO who underwent stent placement with or without intra-RFA and HAIC in three centres between November 2013 and November 2018. The stent patency time (SPT), overall survival (OS), and adverse events (AEs) were analysed. Results: Of the 135 enrolled patients, 64 underwent stent placement combined with intra-RFA and HAIC, while 71 underwent only stent placement. The median SPT was significantly longer in the combination group (8.2 months, 95% confidence interval [CI]: 7.1-9.3) than in the control group (4.3 months, 95% CI: 3.6-5.0; p < 0.001). A similar result was observed for OS (combination: 13.2 months, 95% CI: 11.1-16.5; control: 8.5 months, 95% CI: 7.6-9.6; p < 0.001). The incidence of AEs related to biliary tract operation was not significantly different between the two groups (p > 0.05). The most common AE and serious AE related to HAIC were alanine aminotransferase elevation (24/64; 37.5%) and thrombocytopenia (8/64; 12.5%), respectively. All AEs were tolerable, and there was no death from AEs. Conclusions: Stent placement combined with intra-RFA and HAIC may be a safe, potential treatment strategy for patients with Ad-BTCs and BO. Key points: • Advanced biliary cancers (Ad-BTCs) with biliary obstruction (BO) can rapidly result in liver failure and cachexia with an extremely poor prognosis. • Stent placement combined with intraluminal radiofrequency ablation and hepatic arterial infusion chemotherapy may be safe and effective for patients with Ad-BTCs and BO. • The long-term efficacy and safety of the combined treatment is promising.
Article
To determine the safety and feasibility of percutaneous transhepatic cholangiography (PTC) and intraductal radiofrequency (RF) ablation combined with biliary stent placement for malignant biliary obstruction. Data from patients with unresectable malignant biliary obstruction who underwent PTC, intraductal RF ablation, and biliary stent placement (n = 12) or PTC and biliary stent placement only (control group; n = 14) were reviewed. Postoperative complications, jaundice remission, and stent patency were assessed. All procedures were successful. No severe complications (eg, biliary bleeding, perforation) occurred. Two experimental group patients developed cholangitis, which resolved with conservative treatment. The 1-week jaundice remission and 3-month stent patency rates were similar in both groups, but the 6-month stent patency rate was higher in the experimental group (P < .05). In the experimental group, one death occurred as a result of gastrointestinal hemorrhage (unrelated to stent placement) by 3 months, and there were two cases of recurrent jaundice by 6 months. The latter two patients underwent repeat PTC, ablation, and stent placement. In the control group, one death occurred as a result of hepatic failure caused by progressive jaundice at 3 months, and another death resulted from disseminated intravascular coagulation caused by jaundice recurrence at 138 days after stent placement. In addition, seven patients developed jaundice recurrence (50-151 d after stent placement). PTC and repeat stent placement were performed in these patients. PTC and intraductal RF ablation combined with biliary stent placement for malignant biliary obstruction is safe and feasible and effectively prolongs stent patency time. Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.
Article
Purpose of review: To describe the use of endobiliary radiofrequency ablation (RFA) in the treatment of malignant disease of the bile duct and offer a comprehensive review of the emerging evidence on the safety and effectiveness of this new technique. Recent findings: Ex-vivo and in-vivo porcine studies have been reported, confirming the feasibility of the technique, gathering preliminary safety data and defining appropriate power settings for human studies. Moderate-sized case series have now reported the use of RFA in mixed cohorts of human individuals with pancreatic cancer, cholangiocarcinoma and other malignant diseases of the bile duct. Endoscopic and percutaneous approaches have both been investigated. Small case series of blocked self-expanding metal stent clearance using RFA have been published. Summary: Intraductal RFA, via both endoscopic and percutaneous approaches, is feasible. Complication rates appear to be comparable with the current standard endoscopic and percutaneous approaches to palliation of malignant strictures of the bile duct. The current body of literature is germinal, but warrants the further investigation of planned clinical trials.
Article
New technological developments in endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and treatment have been slow to progress. However, several informative study results were presented during the 2014 Digestive Disease Week (DDW; 3 - 6 May; Chicago, Illinois, USA) in specific ERCP areas, such as prevention of post-ERCP pancreatitis using nonsteroidal anti-inflammatory drugs and pancreatic duct stenting. Novel and interesting study results regarding preoperative stent selection for periampullary tumors, metal stents for hilar stricture or for prevention of duodenal reflux, and intraductal biliary tumor ablation using photodynamic therapy or radiofrequency ablation were discussed. Study results presented at the meeting regarding single-operator cholangioscopy using the SpyGlass system or direct peroral cholangioscopy have indicated the possibility of future development. Results using peroral pancreatoscopy and confocal laser endomicroscopy for biliary lesions, including strictures, were also presented.
Article
Malignant biliary obstruction can arise from intrahepatic, extrahepatic, and hilar locations from either primary or metastatic disease. Biliary-enteric surgical bypass has been surpassed in the last 20 years by endoscopic balloon dilation and stenting. The goal of stenting for biliary decompression is to palliate obstructive symptoms; it has not been shown that survival is affected by stenting alone. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have been evaluated and show promise. Both therapies seem to be safe and effective in the treatment of malignant bile duct strictures but are in need of prospective studies of longer duration.
Article
Self-expandable metal stents (SEMS) are the current standard of care for the palliative management of malignant biliary strictures. Recently, endoscopic ablative techniques with direct affect to local tumor have been developed to improve SEMS patency. Several reports have demonstrated the technical feasibility and safety of intraductal radiofrequency ablation (RFA), by both endoscopic and percutaneous approaches, in palliation of malignant strictures of the bile duct. Intraductal RFA has also been used in the treatment of occlusion of both covered and uncovered SEMS occlusion from tumor ingrowth or overgrowth. This article provides a comprehensive review of intraductal RFA in the management of malignant biliary obstruction.
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The cornerstone of palliative treatment for inoperable extrahepatic cholangiocarcinoma is the relief of malignant biliary obstruction. The most commonly applied method is endoscopic stenting. However, the procedure can be complicated with stent obstruction. In this respect, endobiliary radiofrequency ablation may serve as an adjunctive tool for prolonging the stent patency. Patients who underwent endoscopic retrograde cholangiopancreatography for differential diagnosis and/or palliative treatment after the diagnosis of inoperable extrahepatic cholangiocarcinoma between March 2011 and January 2012 were analyzed. Those in whom endobiliary radiofrequency ablation and endoscopic stenting was successfully performed were included in the study. Technical details of the procedure, duration of stent patency, length of hospital stay, short-term morbidity and mortality rate were documented. Seventeen patients were analyzed, and 10 patients were included in the study. The morbidity and mortality rate within the first 30 days after the procedure was 20% and 0%, respectively. In 2 patients, mild pancreatitis occurred because of the endobiliary procedure. In 1 patient, endobiliary decompression could not be achieved, and therefore, percutaneous transhepatic biliary drainage was carried out. The median duration of stent patency in 9 patients with successful biliary decompression was 9 months (range 6-15). Endobiliary radiofrequency ablation seems to be safe and feasible as a palliative measure and may prolong the stent patency and overall survival in patients with malignant biliary obstruction due to inoperable extrahepatic cholangiocarcinoma.
Article
Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by progressive inflammation affecting the entire biliary tree and leading to biliary symptoms and complications. It is of unclear etiology and is usually associated with inflammatory bowel diseases. Despite advances in modern medicine, treatment options remain very limited, and without liver transplantation, survival rates are reduced. We aim in this review to highlight available endoscopic methods to evaluate, diagnose, and manage symptoms and complications associated with this disease, including diagnosis of cholangiocarcinoma and endoscopic palliative treatment for advanced cholangiocarcinoma not amenable to surgical resection.
Article
Endoscopic management of benign biliary stricture (BBS) remains challenging. There is no reported method for the amelioration of biliary fibroplasia endoscopically. We report our initial experience of radiofrequency ablation (RFA) for the management of BBS. Nine patients with BBS (postoperation stricture four, liver transplant three, and chronic inflammation two), seven of whom had previously unsuccessful endoscopic or percutaneous interventions, were enrolled. Intraductal bipolar RFA was delivered at power of 10 W for 90 s per stricture segment, followed by balloon dilatation with/without stent placement. All patients had immediate stricture improvements after RFA. No severe adverse event occurred except for one patient with mild post-endoscopic retrograde cholangiopancreatography pancreatitis. During median (SD) follow-up duration of 12.6 (3.9) months, BBS resolution without the need for further stenting was achieved in four patients whereas two patients had stent(s) in situ waiting scheduled removal. However, one patient had stricture relapse after initial resolution, one underwent surgery, and another patient died of other cause. Endobiliary RFA appears to be safe and effective for the treatment of BBS, especially for refractory cases. Further studies are warranted.
Article
Cholangiocellular carcinoma (CCC) is a very aggressive tumor, which remains highly resistant to current chemoradiation therapies. Death is usually caused by the tumor burden. However, biliary obstruction, which leads to cholangitis and liver failure, is also a cause of death. Therefore, relief of biliary obstruction is one of the key palliative treatment options for patients with hilar or distal CCC. Radiologic or endoscopic insertions of stents (plastic or self-expanding metal) are definite biliary drainage options. Whereas stents alone can help achieve relief of bile duct obstruction, endoscopic ablative interventions with photodynamic therapy or radiofrequency ablation are also useful in destroying intraluminal tumor. Destroying the tumor leads to an increase in the luminal diameter of the obstructed bile duct, allowing for placement of more or larger diameter stents, and thus improving bile flow. Besides decreasing morbidity associated with obstruction, ablative therapies such as photodynamic therapy have also been associated with improved survival in a sub-group of patients with CCC and should therefore be incorporated into the treatment algorithm of any center treating patients with CCC.
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OBJECTIVE: To evaluate the treatment of biliary stent restentnosis with duodenal endoscopy radiofrequency ablation.
Article
Introduction La radiofréquence (RF) est un traitement validé de l’endobrachyoesophage dysplasique. Cette revue de la littérature a pour objectif d’évaluer les techniques, l’efficacité et les effets indésirables de la RF endoscopique dans d’autres indications, émergentes. Résultats Quatre études prospectives (total 69 patients) ont montré que la RF permettait d’obtenir une rémission complète de néoplasies intraépithéliales oesophagiennes malpighiennes en dysplasie de haut grade ou avec carcinome épidermoïde in situ dans 80 % des cas, avec cependant un risque substantiel de sténoses oesophagiennes proximales. Dans l’indication des ectasies vasculaires antrales de l’estomac, une étude pilote prospective (six patients), une étude prospective monocentrique ouverte (21 patients) et une étude rétrospective multicentrique (24 patients) montrent que la RF semble un traitement efficace en termes de diminution du recours aux transfusions. Une étude prospective ouverte monocentrique (39 patients) et une étude rétrospective multicentrique (17 patients) suggèrent que la RF est un traitement efficace de la rectopathie radique hémorragique chronique. Une étude rétrospective comparative (64 patients) montre que la radiofréquence améliore la durée de perméabilité des prothèses dans les situations de sténoses biliaires malignes. Une étude pilote suggère que la RF endobiliaire peut également être une option intéressante dans les sténoses biliaires bénignes réfractaires. Les données sont encore limitées concernant la radiofréquence lors de ponction sous échoendoscopie pour des cancers du pancréas localement avancés non réséquables et pour les traitements des adénopathies médiastinales. Conclusion La radiofréquence endoscopique est une modalité thérapeutique qui ouvre de nouvelles perspectives dans la destruction des néoplasies intraépithéliales oesophagiennes malpighiennes à un stade précoce, dans le traitement hémostatique de lésions vasculaires digestives (ectasies vasculaires antrales de l’estomac et rectopathie radique hémorragique) et dans les maladies biliaires.
Chapter
Pancreatoscopy and cholangioscopy can be achieved perorally by several methods. The early “mother/baby” systems were effective but cumbersome and fragile, and are being superseded with small visual catheters passed through standard endoscopes, and even by passing small scopes directly into the ducts (after sphincterotomy). Techniques are still evolving.Whilst other modalities (CT, magnetic resonance cholangiopancreatography (MRCP), EUS) have largely taken over the diagnostic role in biliary/pancreatic diseases, there are circumstances where direct visualization of the ductal systems is of clinical value. Examples include unusual filling defects, indeterminate strictures, and assessing the extent of IPMN in the pancreas. However, the main roles for cholangioscopy and pancreatography are therapeutic. They can facilitate direct electrohydraulic or laser lithotripsy, and be the vehicles for PDT RFA, and brachytherapy.The methods are often technically challenging, and not without potential hazard.
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The palliative therapy of advanced pancreato-biliary cancers is focused primarily on biliary stenting in majority of patients. However, biliary stent occlusion or dysfunction is a main concern. Several types of stents have bleed designed and studied to improve stent function, but with limited success. The local ablative therapy, such as photodynamic therapy (PDT) and radiofrequency ablation (RFA) in combination with biliary stenting is a paradigm shift in the management of advanced pancreato-biliary malignancies. The current review analyses the data on the role of combining either PDT or RFA with biliary stenting in inoperable pancreato-biliary malignancies.
Article
Cholangiocarcinoma (bile duct cancer) is the most common malignant tumor of the biliary tree. This devastating malignancy presents late, and is notoriously difficult to diagnose, thus resulting a high mortality. The majority of cholangiocarcinoma patients present with an unresectable disease, and survive less than 12 mo following diagnosis. Biliary stent placement is an effective palliative therapy for malignant biliary obstruction, which can significantly improve the quality of life, and extend the survival time of patients. Different biliary stent placement methods would closely affect the prognosis of patients. The purpose of this article is to review the treatment efficacy, insertion paths and types of biliary stents. This paper also covers emerging Cholangiocarcinoma (bile duct cancer) is the most common malignant tumor of the biliary tree. This devastating malignancy presents late, and is notoriously difficult to diagnose, thus resulting a high mortality. The majority of cholangiocarcinoma patients present with an unresectable disease, and survive less than 12 mo following diagnosis. Biliary stent placement is an effective palliative therapy for malignant biliary obstruction, which can significantly improve the quality of life, and extend the survival time of patients. Different biliary stent placement methods would closely affect the prognosis of patients. The purpose of this article is to review the treatment efficacy, insertion paths and types of biliary stents. This paper also covers emerging biliary stents including drug stents, and biliary stent combination local therapy. © 2014 Baishideng Publishing Group Co., Limited. Allrights reserved.
Article
Objective: To evaluate the safety and efficacy of percutaneous endobiliary radioffequency ablation combined with biliary stenting in treating malignant obstructive jaundice. Methods: Percutaneous endobiliary radiofrequency ablation combined with biliary stenting was carried out in 2 patients with malignant obstructive jaundice after they received percutaneous transhepatic biliary drainage. The curative effect, complications and stent patency at 50 days after the treatment were recorded. The results were analyzed. Results: Successful endobiliary radiofrequency ablation and intraluminal stent implantation was accomplished in both patients, with a technical success rate of 100%. Segmental radioffequency ablation procedure was employed. After the treatment the serum total bilirubin level was significantly decreased. No bile duct bleeding, perforation of bile duct, bile leakage or other serious complications occurred. The stent remained unobstructed during the follow-up period of 50 days. Conclusion: As a new treatment for malignant obstructive jaundice, percutaneous endobiliary radiofrequency ablation combined with biliary stenting is clinically safe and effective, although its long-term efficacy needs to be further proved with randomized controlled trials.
Article
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Background and study aims: Catheter-based radiofrequency ablation (RFA) delivered during endoscopic retrograde cholangiopancreatography (ERCP) may represent a viable treatment option for intraductal extension of ampullary neoplasms, however, clinical experience with this modality is limited. After ampullary resection, 4 patients with intraductal extension underwent adjunctive RFA of the distal bile duct. All patients received a temporary pancreatic stent to reduce the risk of pancreatitis, as well as a plastic biliary stent to prevent biliary obstruction. Three patients were treated for adenoma and 1 for adenoma with a focus of adenocarcinoma. During a short follow-up period, 3 patients experienced complete eradication of the target lesion, whereas the patient with a focus of adenocarcinoma had progression to overt invasive cancer. There were no immediate adverse events. One patient developed a post-RFA bile duct stricture, which has required additional endoscopic therapy. Catheter-based RFA of ampullary lesions that extend up the bile duct is technically feasible. Additional research is necessary to understand the risks and long-term benefits of this technique.
Article
The aim of this report is to discuss the results of percutaneous endobiliary radiofrequency ablation (RFA) combined with balloon-sweep technique in restoring the patency of occluded self-expandable metallic stents (SEMS) secondary to tumor infiltration. A total of eight patients underwent endobiliary RFA for reopening of occluded SEMS at our institute. Post RFA, all patients showed restoration of stent patency. After a median follow-up of 6.5 months, four patients had succumbed to the underlying disease at three, four, six, and seven months. Two of these required reinterventions at two and five months. One patient died of sepsis and aspiration pneumonia at three months. Of the remaining three patients, two required re-intervention after two months, while the other remained asymptomatic. The mean duration of stent patency after the first session of RFA was 4 ± 2.1 months, which was comparable to the primary patency of these stents (4.2 months). Our experience suggests that endobiliary RFA with balloon sweep is a safe and useful technique for re-establishing the patency of occluded SEMS.
Introduction: Radiofrequency ablation (RFA) causes coagulative necrosis of tissue and may be beneficial prior to biliary stenting. We report our experience using RFA for malignant biliary obstruction and review the literature. Patients and methods: Retrospectively analysis of all patients undergoing RFA for malignant biliary obstruction over the last two years. Success, complications and re-intervention following RFA were assessed. Controls were age, sex and disease matched who had stenting alone. Results: 31 patients were included and 15 patients underwent biliary RFA prior to stenting (median age 78 years, 8 females). 14 patients had pancreatic cancer, 13 cholangiocarcinoma (6 hilar lesions) and 4 malignant disease invading the bile duct. Adverse events included acute pancreatitis (n=2) and bacteremia in (n=1). Median duration of intervention free survival was 220 days in the RFA group compared to 106.5 days in controls (hazard ratio 2.4, 95% CI 1.1 - 5.3, p=0.025). Multivariable Cox proportional hazard analysis showed survival was associated with RFA (hazard ratio 2.55, 95% CI 1.09 - 5.96, p=0.026) but not age, site or type of malignancy. Conclusions: Biliary RFA is a technically feasible with a low adverse event rate and is associated with increased survival. Multi-centre randomized controlled trials are required.
Article
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Purpose: To evaluate the safety and clinical efficacy of percutaneous intraductal radiofrequency ablation (RFA) followed by dual stent placement in advanced malignant biliary hilar duct obstruction. Materials and Methods: Between September 2013 and August 2015, ten patients with malignant biliary hilar duct obstruction who underwent percutaneous intraductal RFA followed by dual stent placement were included in this retrospective study. Technical success, clinical success, procedure-related complications, stent patency, and patient’s survival durations after treatment were investigated. Results: Percutaneous intraductal RFA followed by dual stent placement was successful in all patients; the technical success rate was 100%. No major complications were identified. After the procedure, serum total bilirubin levels were notably normalized, and therefore, percutaneous transhepatic biliary drainage (PTBD) catheter was successfully removed in 8 patients; the clinical success rate was 80%. Four patients with stent dysfunction associated with tumor ingrowth/overgrowth underwent a repeat PTBD procedure or secondary stent insertion. Mean stent patency and survival durations were 233.8 ± 35.6 days [95% confidence interval (CI), 164.0–303.5 days] and 387.2 ± 114.6 days (95% CI, 162.6–611.8 days), respectively. Conclusion: Percutaneous intraductal RFA combined with dual stent placement in advanced malignant biliary hilar duct obstruction is a safe and feasible palliative treatment option.
Article
Aim: We evaluated feasibility, safety and efficacy of Electrochemotherapy (ECT) in a prospective series of patients with unresectable Perihilar-Cholangiocarcinoma (PHCCA). Patients and methods: Five patients with PHCCA underwent ECT. Three patients underwent percutaneous ECT of a single PHCCA nodule. One patient underwent resection of a nodule in the IV segment and intraoperative ECT of a large PHCCA in the VIII segment. Another patient underwent percutaneous ECT of a large PHCCA recurrence after left lobectomy and RF ablation of a synchronous metastasis in the VI segment. ECT was performed under US guidance. Efficacy was evaluated by contrast-enhanced multiple-detector-computed-tomography (MDCT) 4 weeks after treatment. Follow-up entailed MDCT every 6 months thereafter. Results: No major complication occurred. Follow-up ranges from 10 to 30 months. Four weeks post-treatment CT showed complete response in 3 cases. These patients are still alive, and follow-up CT controls demonstrated no local or distant intrahepatic recurrences and no biliary duct dilation in 2 cases and local recurrence at 18 months follow-up control in 1 patient. In the remaining 2 cases, 4-weeks-post-treatment CT showed incomplete response (>90%). In these patients follow-up CT demonstrated local progression of the disease at 6 months. One of them had bilateral external biliary drainages and died because of tumor progression at 16-months-follow-up. The other patient, died at 10 months follow-up for cardiovascular failure not related to the hepatobiliary disease. Conclusions: ECT is feasible, safe and effective therapy to improve prognosis and quality of life of patients with unresectable PHCCA.
Chapter
When it comes to endoscopic management, a malignant stricture at the biliary confluence poses a significant challenge to the therapeutic endoscopist both diagnostically and therapeutically. The diagnostic goal is to determine malignant or benign etiology of a biliary stricture and to determine resectability. In addition to proper imaging of the biliary hilum with computed tomography (CT) and magnetic resonance (MR), endoscopic tissue acquisition is an extremely important component to determining the etiology of a biliary stricture, specifically to differentiate between malignant and benign process. Brushings for cytology, intraductal biopsies, and even endoluminal fine-needle aspiration can all be performed at the time of endoscopic retrograde cholangiography (ERC), while endoscopic ultrasound (EUS) offers additional opportunity for fine-needle aspiration. Peroral cholangioscopy is an emerging technique that can directly visualize a malignant hilar stricture and allow for directed biopsies. Therapeutically, the ultimate goal is palliative biliary drainage to relieve biliary obstruction. This can be accomplished endoscopically with the placement of plastic or metal biliary stents to drain the most obstructed lobe of the liver, with uncovered self-expanding metal stents (SEMS) being preferred. Photodynamic therapy and radiofrequency ablation are emerging endoscopic techniques that allow for localized destruction of tumor cells, potentially improving biliary drainage, quality of life, and survival in most patients, but require further randomized, controlled studies.
Article
Most extrahepatic cholangiocarcinomas are unresectable at the time of diagnosis and even in case of a resectable cancer, surgery is not an option for the elderly or patients with comorbidities (1). Current treatment alternatives in these scenarios are very limited. Biliary stenting with self-expanding metal stents (SEMS) is the mainstay palliative treatment for biliary obstruction (2). However, emerging experience with endoscopic RF ablation (RFA) in this setting has been reported in the literature.
Article
Aim Hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) is a rare condition, but it can lead to hepatic failure and is associated with poor prognosis. Treatment for HCC with BDTT remains a challenge. This study aimed to retrospectively evaluate the safety and feasibility of percutaneous endobiliary radiofrequency ablation (EB‐RFA) and biliary metal stent placement as an alternative treatment for patients with HCC with BDTT. Methods From October 2014 to December 2016, nine patients (all men, mean age 53.2 ± 12.0; range 40–70) who underwent percutaneous EB‐RFA and biliary metal stent placement for HCC with BDTT were included. Stent patency, overall survival, technical and clinical success rate and complications were investigated. Results Median stent patency from the time of the first EB‐RFA was 6.0 months (95% CI, 5.4–6.6 months) and survival from the time of diagnosis was 6.0 months (95% CI, 2.2–9.8 months). Two of 9 patients underwent bilateral EB‐RFA and stent placement, one underwent unilateral EB‐RFA and stent‐in‐stent procedure, and one EB‐RFA as treatment for biliary metal stent occlusion. One patient who presented with stent occlusion underwent repeat ablations 182 days after the first ablation procedure and 53 days after the re‐ablation procedure. Combination therapy was administered to five patients. The technical and clinical success rate were 100% and 89% per patient. After treatment, serum direct bilirubin levels were notably decreased in eight patients. No major complications were observed. Minor complications included one bile duct bleeding, three postoperative abdominal pain and two cholangitis. Conclusion Percutaneous EB‐RFA and biliary metal stent placement might be technically safe and feasible therapeutic options for patients with HCC with BDTT.
Chapter
Cholangiocarcinoma (CCA) is the most frequent and aggressive malignant tumor of the biliary tract. Endoscopic management has evolved in recent years and has come to hold a vital role in the management of CCA. Classically, the endoscopic approach was limited to palliative procedures for draining the biliary tract. With the development and use of new techniques such as cholangioscopy, endoscopy can not only facilitate early detection of CCA but also offers the possibility of novel therapies such as radiofrequency and photodynamic therapy that can improve quality of life and mortality. In this chapter we describe old and new endoscopic techniques with some perspectives regarding future developments in the field and the enduring need to help improve survival associated with this aggressive malignancy.
Article
This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. This guideline is an update of a previous ASGE guideline published in 2005.(1) In preparing this guideline, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When few or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1). 2 The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as "We suggest," whereas stronger recommendations are typically stated as " We recommend." This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.
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