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Endoscopic biliary drainage
van Berkel, A.M.
Publication date
2003
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Citation for published version (APA):
van Berkel, A. M. (2003). Endoscopic biliary drainage.
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WallstentsWallstents for metastatic
biliarybiliary obstruction
A.M.. van Berkel', JJ.G.H.M. Bergman', I. Waxman\ P.. Andres^.K. Huibregtse'
Departmentt of Gastroenterology and Hepatology
Academicc Medical Center1, Amsterdam, The Netherlands andd Beth Israel Hospital*, Boston, USA
-WALLSTENTSS FOR METASTATIC BILIARY OBSTRUCTION 89
ABSTRACT T
BackgroundBackground and Study Aims: In patients with obstruction of the common bile duct
causedd by primary pancreaticobiliary tumors, Wallstents have been shown to remainn patent for a median duration of 273 days (range:i4-363). However, in one studyy that included both patients with primary pancreaticobiliary malignancies and patientss with metastatic malignant disease, the reported median Wallstent patency wass found to be significantly shorter. We have studied the patency of Wallstents in patientss with metastatic biliary obstruction.
PatientsPatients and Methods: All patients who had received a Wallstent for metastatic biliary
obstructionn between January 1990 and August 1994 were analyzed retrospectively. Follow-upp was achieved by contacting referring physicians and general practitio-ners,, and lasted up to the end of the study period (November 1994) or death of the patient.. Follow-up was discontinued if a polyethylene stent was inserted through the Wallstentt for treatment of stent dysfunction.
Results:Results: 28 patients were identified, 14 men and 14 women, with a mean age 61.3 years
(rangee 24-87). Long-term follow-up was possible in 27 patients (96%), for a median durationn of 140 days {range 29-561). Eleven patients died during the study period, and theree were three deaths related to Wallstent dysfunction. The median duration of Wallstentt patency was 265 days (range 11-519)- Wallstent obstruction occurred in 13 patients;; seven patients presented with cholangitis, six patients had jaundice. The causee of obstruction was established at endoscopic retrograde cholangiopancreatogra-phyy in ten patients: seven had tumor ingrowth and three had tumor overgrowth. Treatmentt consisted of insertion of a polyethylene stent in seven and placement of a secondd Wallstent in three patients.
Conclusion:Conclusion: In patients with metastatic obstruction of the common bile duct, duration
off patency of Wallstents is comparable to that reported in series of Wallstents for pri-maryy pancreaticobiliary malignancies.
I N T R O D U C T I O N N
Patientss suffering from metastatic malignant biliary obstruction are known to have a poorr survival rate (1-5). However, it has been shown that the biliary obstruction can effec-tivelyy be palliated by endoscopic or percutaneous insertion of endoprostheses (1,2,5). Recently,, Wallstents have been introduced for malignant biliary obstruction (6-10). InIn patients with obstruction of the common bile duct caused by primary pancrea-ticobiliaryy tumors, Wallstents have been shown to remain patent for a median dura-tionn of 273 days (range:i4-363) (6). However, in one study that included both patients withh primary pancreaticobiliary malignancies and patients with metastatic malig-nantt disease (19%), the reported median Wallstent patency was found to be significantlyy shorter (9).
Wee therefore studied the patency of Wallstents in patients with biliary obstruction duee to metastatic malignant disease.
goo ENDOSCOPIC BILIARY DRAINAGE
PATIENTSS EN M E T H O D S
Alll patients who had received a Wallstent {Schneider, Switzerland) for metastatic bil-iaryy obstruction between January 1990 and August 1994 were analyzed retrospec-tively.. Patients were included in the trial if they had a stenosis of the extrahepatic bil-iaryy system and proved malignancy of nonbiliary and nonpancreatic origin, or metastasiss of a malignancy at another nonbiliary location.
AA total of 28 patients were identified. There were 14 women and 14 men ranging in agee from 24 to 87 years (mean age 61.3 years). The location of the primary tumor was thee colon in nine patients (32%), the breast in six (21%), gastroesophageal in five (18%),, bronchus in two, (7%) and miscellaneous in six patients {lymph-node metas-tasiss with an unknown primary tumor, apudoma, multiple myeloma, larynx carcino-ma,, melanoma, cutaneous T-cell lymphoma).
Thee time from the diagnosis of the primary tumor until the insertion of the Wallstentt varied from o to 163 months (median 29 months). Thirteen patients had hadd polyethylene stents inserted previously, and seven had had a polyethylene stent exchangee before the placement of a Wallstent (median number of stent exchanges two,, range 1-6).
Thee indication for endoscopic retrograde cholangiopancreatography was jaundice in 166 patients, cholangitis in seven patients, and cholestasis in five patients. Cholangi-tiss was defined as jaundice, fever, and abnormal liver function tests; cholestasis was definedd as a three times elevated gamma-glutamyl transferase level, or alkaline phos-phatasee level, or both. The location of the stricture of the common bile duct was dis-tall in 20 patients, middle in seven patients, and proximal in one patient.
Endoscopicc retrograde cholangiopancreatography and Wallstent insertion were car-riedd out according to the standard guidelines (11) (Figure I). Wallstents could be placedd in all patients without problems. Successful biliary drainage was defined as resolutionn of jaundice and fever and a drop of more than 20% in the pre-procedure gamma-glutamyll transferase or alkaline phosphatase levels.
Follow-upp was achieved by contacting the referring physician and the general practitioner,, and lasted up to the end of the study period (November 1994), or up to thee death of the patient. If a patient had a polyethylene stent inserted through the Wallstentt for treatment of stent dysfunction, follow-up was discontinued.
Thee stent patency rate was calculated according to the Kaplan-Meier method.
RESULTS S
EarlyEarly results
Alll patients underwent uneventful placement of a Wallstent. Successful biliary drainage,, as defined above, was achieved in all 28 patients. No early complications (earlierr than 15 days) of the endoscopic procedure were observed.
Long-termm follow-up was established in 27 patients (96%) for a median duration of 1400 days (range 29-561). One patient moved abroad, and could not be contacted.
WALLSTENTSS FOR METASTATIC BILIARY OBSTRUCTION 91
Long-termLong-term follow-up
Elevenn patients died during the study period (41%). Three patients died of cholangi-tiss or jaundice, or both, secondary to Wallstent dysfunction, and the remaining eight patientss died of extrabiliary causes.
Thee cumulative patency of the Wallstent in patients with metastatic malignant bil-iaryy obstruction is shown in Figure 2. The median duration of Wallstent patency was 2655 days {range n-519).
Wallstentt dysfunction occurred in 13 patients (48%), with a median time to obstruc-tionn of 203 days (range n-519). Seven patients presented with cholangitis whereas six hadd jaundice. ERCP was carried out in ten patients, and demonstrated tumor ingrowthh in seven patients and tumor overgrowth at the distal or proximal end in three.. No ERCP was performed in three patients with terminal disease.
Inn addition to these 13 patients with Wallstent dysfunction, two patients presented withh jaundice, but were found to have a patent Wallstent at ERCP or HIDA scanning. Jaundicee was considered to be due to intrahepatic metastasis, and no further treat-mentt was instituted. These two patients died from liver failure during the same admission. .
TreatmentTreatment for late complications
Tenn of the thirteen patients with Wallstent dysfunction underwent an ERCP for treat-mentt of biliary obstruction. A polyethylene stent was inserted through the Wallstent inn seven patients. Three patients had a second Wallstent inserted through the Wallstentt in situ. Of the latter three patients, one is alive at follow-up to date, 6.5 monthss after insertion of the second Wallstent. Another patient died ten months afterr insertion of the second Wallstent, from a nonbiliary cause. The third patient hadd persistence of jaundice after insertion of the second Wallstent, due to extensive intrahepaticc metastasis, and died three weeks later.
DISCUSSION N
Inn this study of 28 patients with metastatic biliary obstruction, we found that Wallstentss remained patent for a median duration of 265 days. This is comparable too the median stent patency of patients with primary pancreaticobiliary tumors (6). Wee therefore conclude that there is no evidence suggesting shorter Wallstent paten-cyy in patients with metastatic malignant biliary obstruction compared to patients withh primary pancreaticobiliary tumors.
Stentt dysfunction is caused by tumor ingrowth through the meshes of the stent, or tumorr overgrowth at the proximal or distal end of the endoprosthesis. Optimum treatmentt of an occluded Wallstent is established by insertion of a polyethylene stent orr a second Wallstent (12,13). We insert polyethylene stents in these patients, main-lyy because of the costs involved in inserting a second Wallstent. In patients respond-ingg to treatment of their primary tumor, however, we sometimes insert a second
922 ENDOSCOPIC BILIARY DRAINAGE
Wallstent,, since they have a much longer life expectancy.
Otherr techniques for treating occluded Wallstents include tumor ablation by diathermyy or laser coagulation (14,15). We no longer use these techniques, because off the risks of hemorrhage, perforation, and stent breakage (16). Coating the Wallstentt with an impermeable membrane ought to prevent tumor ingrowth. However,, in a recent study we were not able to show any difference in the patency ratee between non-covered and covered Wallstents, because an increased number of patientss was observed to have overgrowth proximally or distally in the group of patientss with covered Wallstents (17).
Shouldd Wallstents be used in all patients with biliary obstruction due to metastasis? Thee high costs of the Wallstent ($ 1000) compared to the polyethylene stent ($ 35) precludee its use in all patients. In our opinion, the choice between insertion of a polyethylenee stent or a Wallstent is mainly based on the patient's life expectancy, whichh is determined by the primary tumor, the histological tumor type, the presence off multiple tumor spread, response to systematic anticancer therapy, and the patient'ss general condition.
Inn patients with a short life expectancy (e.g. less than three months), we prefer to insert polyethylenee stents, since comparative studies did not show any benefit of Wallstents comparedd to polyethylene stents in the first three months after insertion (6).
InIn patients with a longer life expectancy (e.g. over six months), placement of a Wallstentt has to be considered. This group of patients will really benefit from the advantagess of a Wallstent.
Patientss who present with early clogging of a polyethylene stent (within one month afterr insertion) should receive a Wallstent, irrespective of their life expectancy, because repeatedd clogging of a second polyethylene stent can be expected very quickly. Wallstentss provide successful biliary drainage and acceptable patency rates in patientss with bile duct obstruction due to metastatic malignant disease. Drawbacks includee tumor ingrowth through the meshes of the stent, and the costs involved. Furtherr developments should be aimed at reducing these disadvantages.
WALLSTENTSS FOR METASTATIC BILIARY OBSTRUCTION 93
Figuree l. Left: Distal common bile duct stenosis with proximal dilatation due to mul-tiplee myeloma. Right: Wallstent inserted through the common bile duct stenosis. Theree is still a relative compression of the stent immediately after insertion.
Figuree 2. Kaplan Meier plot for stent patency in patients with metastatic malignant biliaryy obstruction. Related deaths are marked with an asterisk.
. . --'' . " " T T i i ' ' . .
944 ENDOSCOPIC BILIARY DRAINAGE
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