Current Status of Endoscopic Biliary Drainage in Patients with Distal Malignant Biliary Obstruction

Distal malignant biliary obstruction is caused by various malignant diseases that require biliary drainage. In patients with operable situations, preoperative biliary drainage is required to control jaundice and cholangitis until surgery. In view of tract seeding, endoscopic biliary drainage is the first choice. Since neoadjuvant therapies are being developed, the time to surgery is increasing, especially in pancreatic cancer cases. Therefore, it requires long stent patency. Recently, preoperative biliary drainage using self-expandable metal stents has been reported as a useful modality to secure long stent patency. In patients with unresectable distal malignant biliary obstruction, self-expandable metal stent is the first choice for maintaining long stent patency. Although there are many comparison studies between a covered and an uncovered self-expandable metal stent, their use is still controversial. Recently, endoscopic ultrasound-guided biliary drainage has been performed as an alternative treatment. The clinical success and stent patency are favorable. We should take into consideration that both endoscopic retrograde cholangiopancreatography-guided biliary drainage and endoscopic ultrasound-guided biliary drainage have advantages and disadvantages and chose the drainage method depending on the patient’s situation or the expertise of the endoscopist. Here, we discuss the current status of endoscopic biliary drainage in patients with distal malignant biliary obstruction.

ENDOSCOPIC BILIARY DRAINAGE AS PALLIATIVE TREATMENT FOR MALIGNANT BILIARY OBSTRUCTION: FINDINGS AND FACTORS ASSOCIATED WITH THE SUCCESSOR FAILURE

Introduction: Le drainage biliaire endoscopique connait des progres incessants et prend une large place dans le traitement palliatif des stenoses malignes des voies biliaires. Notre objectif est dexposer les resultats de cette technique dans notre formation, ainsi que les differents facteurs associes a son echec ou son succes. Methodes:Il sagit dune etude retrospective entre Janvier 2008 et novembre 2020, a propos de 204 patientsayant beneficie dun drainage endoscopique pour stenose biliaire dorigine neoplasique, et qui sont repartis en 3 groupes: les patients atteints dun cholongiocarcinome dans le groupe A , dun cancer du pancreas dans groupe B , et dun calculocancer dans le groupe C . Lanalyse statistique a ete realisee par le logiciel SPSS20.0. Resultats:Lage moyen etait de 63,5±11,4 ans avec un sex ratio a 1,4. Le succes global etait de 82,4% et letude comparative des resultats dans les 3 groupes a montre un taux de succes a 86,6% du groupe B, suivi du groupe C a 80,8% et du groupe A a 76,4%. En analyse multivariee et en ajustant les parametres etudies, a savoir le sexe, lage, limagerie, la presence de metastases et la dilatation endoscopique de la stenose, seule la presence de metastases et la dilatation endoscopique de la stenose modifient le taux de succes. La dilatation endoscopique de la stenose avant la mise en place de prothese multiplie par 8 le taux de succes [OR=9,177p<0,001], alors que la presence de metastases diminue ce taux de 88% et augmente le risque dechec [OR=0,117 p<0,001]. Conclusion:Notre etude a demontre que la presence de metastases semble etre significativement associee a lechec du drainage biliaire endoscopique et la dilatation endoscopique avant la mise en place de la prothese semble etre associee a son succes.

Hepaticogastrostomia guíada por ecoendoscopia en pacientes con estenosis biliares malignas proximales. Serie de casos

Endoscopic retrograde cholangiopancreatography is the method of choice for draining both benign and malignant biliary obstruction. Given the failure or impossibility of this procedure, the options for draining the biliary tree are limited to percutaneous drainage, surgical biliary diversion, or endoscopic ultrasound-guided bile duct drainage. Echo-endoscopic biliary drainage is an effective alternative to endoscopic retrograde cholangiopancreatography failure and in recent years, it has been taking an increasingly important place because it is less invasive and has a lower rate of complications. Our aim is to report a series of cases of patients with proximal malignant biliary strictures, treated by means of an endoscopic ultrasound-guided liver-gastrostomy, as palliative treatment.

Biosafety of a novel covered self-expandable metal stent coated with poly(2-methoxyethyl acrylate) in vivo

Covered self-expandable metal stents (CSEMS) are often used for palliative endoscopic biliary drainage; however, the unobstructed period is limited because of sludge occlusion. The present study aimed to evaluate the biosafety of a novel poly(2-methoxyethyl acrylate)-coated CSEMS (PMEA-CSEMS) for sludge resistance and examine its biosafety in vivo. Using endoscopic retrograde cholangiopancreatography, we placed the PMEA-CSEMS into six normal porcine bile ducts and conventional CSEMS into three normal porcine bile ducts. We performed serological examination and undecalcified histological analysis at 1, 3, and 6 months during follow-up. In the bile ducts with PMEA-CSEMS or conventional CSEMS, we observed no increase in liver enzyme or inflammatory marker levels in the serological investigations and mild fibrosis but no inflammatory response in the histopathological analyses. Thus, we demonstrated the biosafety of PMEA-CSEMS in vivo.

Feasibility study of endoscopic biliary drainage under direct peroral cholangioscopy by using an ultra-slim upper endoscope (with videos)

The therapeutic utility of peroral cholangioscopy (POC) is limited. Direct POC using an ultra‑slim upper endoscope expands the therapeutic indications because of its larger working channel, of up to 2.2 mm. We evaluated the feasibility of selective biliary drainage using a plastic stent under direct POC. From April 2015 to March 2019, biliary drainage under endoscopic visualization was performed in the same endoscopic session as direct POC without exchanging the duodenoscope. After guidewire insertion through the stricture or stone, a 5 Fr plastic stent and/or nasobiliary drainage catheter was used for biliary drainage. Selective biliary drainage under direct POC was performed in 32 patients, including 17 with difficult bile duct stones. Biliary drainage was performed with a plastic stent in 29 patients, nasobiliary drainage in one, and combined drainage in two patients. The technical success rate for biliary drainage placement under direct POC was 100 % (32/32). No significant procedure-related complications occurred. In conclusion, biliary drainage with a plastic stent or catheter under direct POC using an ultra-slim upper endoscope is feasible and may be useful for lesions obstructing the bile duct.