• Journal of Digestive Cancer Research
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• v.11 no.2
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• pp.99-103
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• 2023

Malignant tumors located near the papilla of the duodenum can cause concomitant biliary and duodenal obstruction, which reduces the quality of life and increases the morbidity and mortality. Apart from traditional surgical treatment methods, various treatment methods such as endoscopic treatment and radiological interventions are used for the treatment. This study aimed to explore treatment methods according to the situation of patients with malignant biliary obstruction combined with duodenal obstruction.

• Asian Pacific Journal of Cancer Prevention
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• v.17 no.8
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• pp.4155-4161
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• 2016

Biliary obstruction is a common clinical manifestation of various conditions, including extrahepatic cholangiocarcinoma. However, a screening test for diagnosis of extrahepatic cholangiocarcinoma in patients with biliary obstruction is not yet available. According to the rationale that the biliary system plays a major role in lipid metabolism, biliary obstruction may interfere with lipid profiles in the body. Therefore, plasma lipidomics may help indicate the presence or status of disease in biliary obstruction suspected extrahepatic cholangiocarcinoma. This study aimed to use plasma lipidomics for diagnosis of extrahepatic cholangiocarcinoma in patients with biliary obstruction. Plasma from healthy volunteers, patients with benign biliary obstruction extrahepatic cholangiocarcinoma, and other related cancers were used in this study. Plasma lipids were extracted and lipidomic analysis was performed using matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Lipid profiles from extrahepatic cholangiocarcinoma patients showed significant differences from both normal and benign biliary obstruction conditions, with no distinction between the latter two. Relative intensity of the selected lipid mass was able to successfully differentiate all extrahepatic cholangiocarcinoma samples from patient samples taken from healthy volunteers, patients with benign biliary obstruction, and patients with other related cancers. In conclusion, lipidomics is a non-invasive method with high sensitivity and specificity for identification of extrahepatic cholangiocarcinoma in patients with biliary obstruction.

• Clinical Endoscopy
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• v.56 no.2
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• pp.155-163
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• 2023

Malignant hilar biliary obstruction (MHO), an aggressive perihilar biliary obstruction caused by cholangiocarcinoma, gallbladder cancer, or other metastatic malignancies, has a poor prognosis. Surgical resection is the only curative treatment for biliary malignancies. However, the majority of patients with MHO cannot undergo surgery on presentation because of an advanced inoperable state or a poor performance state due to old age or comorbid diseases. Therefore, palliative biliary drainage is mandatory to improve symptomatic jaundice and the quality of life. Among the drainage methods, endoscopic biliary drainage is the current standard for palliation of unresectable advanced MHO. In addition, combined with endoscopic drainage, additional local ablation therapies, such as photodynamic therapy or radiofrequency ablation (RFA), have been introduced to prolong stent patency and survival. Currently, RFA is commonly used as palliative therapy, even for advanced MHO. This literature review summarizes recent studies on RFA for advanced MHO.

• Clinical Endoscopy
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• v.56 no.2
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• pp.135-142
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• 2023

Endoscopic biliary drainage strategies for managing unresectable malignant hilar biliary obstruction differ in terms of stent type, drainage area, and deployment method. However, the optimal endoscopic drainage strategy remains unclear. Uncovered self-expandable metal stents (SEMS) are the preferred type because of their higher functional success rate, longer time to recurrent biliary obstruction (RBO), and fewer cases of reintervention than plastic stents (PS). Other PS subtypes and covered SEMS, which feature a longer time to RBO than PS, can be removed during reintervention for RBO. Bilateral SEMS placement is associated with a longer time to RBO and a longer survival time than unilateral SEMS placement. Unilateral drainage is acceptable if a drainage volume of greater than 50% of the total liver volume can be achieved. In terms of deployment method, no differences were observed in clinical outcomes between side-by-side (SBS) and stent-in-stent deployment. Simultaneous SBS boasts a shorter procedure time and higher technical success rate than sequential SBS. This review of previous studies aimed to clarify the optimal endoscopic biliary drainage strategy for unresectable malignant hilar biliary obstruction.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.26 no.4
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• pp.298-307
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• 2022

Portal cavernoma cholangiopathy is defined as an obstruction of the biliary system due to distended veins surrounding bile ducts that mainly occur in patients with extrahepatic portal venous obstruction. The periductal venous plexuses encircling the ducts can cause morphological changes which may or may not become symptomatic. Currently, non-invasive techniques such as ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, and dynamic contrast enhanced magnetic resonance images are being used to diagnose this disorder. Only a few patients who have symptoms of biliary obstruction require drainage which might be accomplished using endoscopic stenting, decompression of the portal venous system usually via a lienorenal shunt, a difficult direct hepaticojejunostomy, and rarely a liver transplant.

• The Korean Journal of Medicine
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• v.99 no.1
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• pp.4-10
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• 2024

Malignant hilar biliary obstruction (MHO), an aggressive type of perihilar biliary obstruction caused by cholangiocarcinoma, gallbladder cancer, or other metastatic malignancies, has a poor prognosis. Surgical resection is the only curative treatment for biliary malignancies. However, most patients with MHO cannot undergo surgery upon presentation because of their advanced inoperable state or poor performance resulting from old age or comorbid diseases. Therefore, palliative biliary drainage is required to improve symptomatic jaundice and quality of life. Preoperative biliary drainage is controversial in resectable cases of MHO. Preoperative biliary drainage should be considered according to specific selection criteria. Palliative drainage is currently the mainstay of symptomatic treatment. Compared with percutaneous access, primary endoscopic palliation using plastic or metal stents has recently shown higher technical feasibility and clinical success without increasing the frequency of adverse events, even in high-degree MHO. However, the use of stents still has numerous limitations, including challenges in determining the optimal type of stent, number of stents, deployment method, and additional local therapies. Therefore, this report presents the current optimal endoscopic drainage status for MHO based on recent guidelines and published literature.

• Korean Journal of Radiology
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• v.21 no.6
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• pp.695-706
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• 2020

Objective: To investigate the technical and clinical efficacy of the percutaneous insertion of a biliary metallic stent, and to identify the factors associated with biliary stent dysfunction in patients with malignant duodenobiliary obstruction. Materials and Methods: The medical records of 70 patients (39 men and 31 women; mean age, 63 years; range, 38-90 years) who were treated for malignant duodenobiliary obstruction at our institution between April 2007 and December 2018, were retrospectively reviewed. Variables found significant by univariate log-rank analysis (p < 0.2) were considered as suitable candidates for a multiple Cox's proportional hazard model. Results: The biliary stents were successfully placed in all 70 study patients. Biliary stent insertion with subsequent duodenal stent insertion was performed in 33 patients and duodenal stent insertion with subsequent biliary stent insertion was performed in the other 37 study subjects. The median patient survival and stent patency time were 107 days (95% confidence interval [CI], 78-135 days) and 270 days (95% CI, 95-444 days), respectively. Biliary stent dysfunction was observed in 24 (34.3%) cases. Multiple Cox's proportional hazard analysis revealed that the location of the distal biliary stent was the only independent factor affecting biliary stent patency (hazard ratio, 3.771; 95% CI, 1.157-12.283). The median biliary stent patency was significantly longer in patients in whom the distal end of the biliary stent was beyond the distal end of the duodenal stent (median, 327 days; 95% CI, 249-450 days), rather than within the duodenal stent (median, 170 days; 95% CI, 115-225 days). Conclusion: The percutaneous insertion of the biliary metallic stent appears to be a technically feasible, safe, and effective method of treating malignant duodenobiliary obstruction. In addition, a biliary stent system with a distal end located beyond the distal end of the duodenal stent will contribute towards longer stent patency in these patients.

• Journal of Digestive Cancer Research
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• v.6 no.1
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• pp.32-35
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• 2018

Non-Hodgkin's lymphoma is known to be a rare and unusual cause of biliary obstruction. We report a case of biliary obstruction that a 25-year-old male showed icteric sclera and yellow discoloration of his skin caused by metastasis of non-Hodgkin lymphoma. Initial imaging & endoscopic work-up led us to an impression of either cholangiocarcinoma or IgG4-related disease, yet the pathological results weren't diagnostic. Through our thorough re-examination, we found a 5cm sized round, fixed, non-tender sternal mass, and additional imaging studies were suggestive of lymphoma, which was also consistent with the results of incisional chest wall biopsy. Biliary obstruction by lymphoma was successfully treated by endoscopic plastic stent insertion procedure and chemotherapy. Although it is widely accepted that lymphoma accounts for very few portion of malignant biliary obstruction, due to the fact that lymphoma and cholangiocarcinoma are often indistinguishable, careful diagnostic approach should be done.

• Clinical Endoscopy
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• v.56 no.6
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• pp.802-811
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• 2023

Background/Aims: Covered self-expandable metallic stents (cSEMS) have become popular for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting (EUS-HGS). We compared the time to recurrent biliary obstruction (TRBO), complications, and reintervention rates between EUS-HGS using plastic stent (PS) and cSEMS in patients with unresectable malignancies at multicenter institutions in Japan. Methods: Patients with unresectable malignant biliary obstruction who underwent EUS-HGS between April 2015 and July 2020 at any of the six participating facilities were enrolled. Primary endpoint: TRBO; secondary endpoints: rate of complications other than recurrent biliary obstruction and technical success rate of reintervention were evaluated. Results: PS and cSEMS were used for EUS-HGS in 109 and 43 patients, respectively. The TRBO was significantly longer in the cSEMS group than in the PS group (646 vs. 202 days). Multivariate analysis identified two independent factors associated with a favorable TRBO: combined EUS-guided antegrade stenting with EUS-HGS and the use of cSEMS. No significant difference was observed in the rate of complications other than recurrent biliary obstruction between the two groups. The technical success rate of reintervention was 85.7% for PS and 100% for cSEMS (p=0.309). Conclusions: cSEMS might be a better option for EUS-HGS in patients with unresectable malignancies, given the longer TRBO.

• Clinical Endoscopy
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• v.56 no.2
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• pp.143-154
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• 2023

Advanced malignant hilar biliary obstruction (MHBO) with inaccessible papilla poses a significant challenge to endoscopists, as drainage of multiple liver segments may be warranted. Transpapillary drainage may not be feasible in patients with surgically altered anatomy, duodenal stenosis, prior duodenal self-expanding metal stent, and after initial transpapillary drainage, but require re-intervention for draining separated liver segments. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous trans-hepatic biliary drainage are the feasible options in this scenario. The major advantages of EUS-BD over percutaneous trans-hepatic biliary drainage include a reduction in patient discomfort and internal drainage away from the tumor, thus reducing the possibility of tissue or tumor ingrowth. With innovations, EUS-BD is helpful not only for bilateral communicating MHBO but also for non-communicating systems with bridging hilar stents or isolated right intra-hepatic duct drainage by hepatico-duodenostomy. EUS-guided multi-stent drainage with specially designed cannulas and guidewires has become a reality. A combined approach with endoscopic retrograde cholangiopancreatography for re-intervention, interventional radiology, and intraductal tumor ablative therapies has been reported. Stent migration and bile leakage can be minimized with proper stent selection and technique, and stent blocks can be managed with EUS-guided interventions in a majority of cases. Future comparative studies are required to establish the role of EUS-guided interventions in MHBO as rescue or primary therapy.