Malignant distal biliary obstruction: A systematic review and meta-analysis of endoscopic and surgical bypass results

doi:10.1016/j.ctrv.2006.10.006

Cancer Treatment Reviews

Volume 33, Issue 2, April 2007, Pages 213-221

https://doi.org/10.1016/j.ctrv.2006.10.006 Get rights and content

Summary

Background

Surgical bypass and endoscopic stents are available for palliative bypass of malignant distal biliary obstruction.

Aim

Comparison of reported outcomes in randomized controlled trials (RCTs) which included surgery, endoscopic plastic stents or endoscopic metal stents in palliative relief of malignant distal biliary obstruction.

Methods

Systematic review and meta-analysis of published literature and conference proceedings review to June 2006.

Results

We found 24 studies, containing 2436 patients, which met our inclusion criteria. Endoscopic stenting with plastic stents (three studies) is associated with a lower risk of complications (RR 0.60, 95% CI 0.45–0.81), but a higher risk of recurrent biliary obstruction (RR 18.59, 95% CI 5.33 –64.86) than traditional surgical bypass. Self-expanding metal stents (seven studies) are associated with a significantly reduced risk of recurrent biliary obstruction at 4 months (RR 0.44, 95% CI 0.3, 0.63), or prior to death or end of study (RR 0.52, 95% CI 0.39–0.69), but are not superior to plastic stents in terms of technical success, therapeutic success, mortality or complications. Cost-effectiveness outcomes were not suitable for meta-analysis. No other plastic stent designs have been demonstrated to be superior to polyethylene stents (12 studies).

Conclusions

Endoscopic metal stents are the intervention of choice in patients with malignant distal biliary obstruction, producing similar outcomes to plastic stents, but with improved patency rates.

Section snippets

Background

Obstruction of the biliary tree due to pancreatic carcinoma, cholangiocarcinoma or lymph node metastases is a common cause of jaundice in the elderly. In general, these malignancies present at late stage, making most inoperable when diagnosed.¹ Despite technological advances, the five year survival for pancreatic and cholangiocarcinomas remains less than 5%.² Biliary tree obstruction and consequent jaundice occur in 70–90% of patients with pancreatic neoplasms and has important consequences for

Search strategy

We conducted a literature search for RCTs that compared surgery to endoscopic stents, metal to plastic stents or different stent types inserted endoscopically for malignant biliary obstruction. Eligible studies had to enroll patients with obstruction of the common bile duct due to malignancy based on radiological and clinical assessment or confirmed histologically. We only considered data on patients deemed unsuitable for curative resection on the basis of advanced stage of disease or poor

Results

A total of 90 studies were reviewed for consideration of inclusion in this review and 24 met inclusion criteria. The 24 included studies involved 2436 participants, and consisted of 19 published papers and five abstracts from conference proceedings. The total numbers of patients randomized were 306 in the surgery/plastic stent studies, 724 in the metal/plastic stent studies, 963 in the plastic/plastic stent studies, and 443 in the metal/metal studies. There was no statistically significant

Discussion

In patients with malignant distal biliary tree obstruction due to advanced carcinoma, endoscopic stenting with plastic stents is associated with fewer complications and shorter total hospital stay, but with a higher risk of recurrent biliary obstruction than surgery. These results are not particular to endoscopic stents, as the one randomized trial published comparing percutaneous stents and surgery also reported a higher rate of recurrent jaundice in percutaneous stent recipients.⁴⁰ The

Acknowledgements

Jan Lilleyman, Gemma Sutherington, Iris Gordon – Upper Gastrointestinal and Pancreatic Review Group, Cochrane Collaboration, Leeds. Funded by a Cochrane Fellowship, Health Research Board of Ireland (AM).

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Obstructive jaundice is the most common symptom of malignant diseases of the extrahepatic biliary system and necessitates either non-operative or operative biliary bypass. Because of percutaneous and endoscopic approaches, the use of palliative surgical procedures has decreased in recent years. However, in resource-limited situations, open biliary bypasses remain a viable option. This study aimed to identify factors associated with adverse perioperative outcomes following open biliary bypass.
From June 2022 to May 2023, 69 patients underwent open biliary bypass for malignant biliary obstruction. Postoperative morbidity and mortality within 30 days of surgery were assessed. A Kaplan-Meier was used for categorical variables, and a log-rank test was used to determine the statistically significant difference between variables. A Cox regression analysis was conducted to identify factors associated to time to develop complications.
The hazard of developing complications among those with preoperative cholangitis was 2.49 times higher than those without preoperative cholangitis (HR 2.49, 95% CI [1.06, 5.84]). For every hour increment in the length of surgery, the hazard of getting complications increased by 2.47 times (HR 2.47, 95% CI [1.28, 4.77]). As serum bilirubin increased by 1 mg/dl, the hazard of developing complications increased by 14% (HR 1.14, 95% CI [1.03, 1.17]).
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Treatment of malignant biliary strictures with endoscopic retrograde cholangiopancreatography (ERCP) guided stent placement is highly effective. Our objective was to compare the efficacy and adverse outcomes between plastic stents (PS) and self-expandable metallic stents (SEMS).
A cohort study was performed of all consecutive patients who underwent ERCP with stent placement for the management of malignant biliary stricture. Comparisons on clinical success, patency duration, stent dysfunction, unplanned reintervention and adverse outcomes were performed. Univariate and multivariable analyses were performed to identify factors associated with clinical success, need for reintervention, and stent dysfunction.
From 2012 to 2019, 1139 patients underwent ERCP with PS placement while 1008 patients received SEMS for the management of malignant biliary stricture. In distal strictures, SEMS reported a significantly higher rate of clinical success compared with PS (94.1% vs 87.4%, P < 0.001) and a lower rate of unplanned reintervention (17.1% vs 27.4%, P < 0.001). In hilar strictures, the rates of clinical success and unplanned intervention were comparable. The patency duration and time to unplanned reintervention were significantly longer with SEMS than PS, irrespective of stricture location. In distal stricture, PS was associated with a significantly higher rate of cholangitis than SEMS (6.9% vs 2.4%; P < .001) but a lower rate of pancreatitis (3.6% vs 6%; P = 0.021).
Given superior efficacy, durability and lower rates of cholangitis, SEMS should be offered as the first line endoscopic treatment option for malignant distal biliary stricture. For malignant hilar stricture, SEMS is an attractive alternative to PS in some cases by offering a comparable efficacy with a superior durability.
The diagnostic value of exosomal miRNAs in human bile of malignant biliary obstructions
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Diagnosis of malignant biliary obstruction is complicated and lacks accuracy. Exosomes may be secreted by malignant tumors; intact miRNAs from exosomes might serve as potential biomarkers for the disease.
To identify exosomal microRNAs in human bile among benign and malignant biliary obstructions.
Bile samples were collected from patients undergoing therapeutic endoscopic retrograde cholangiopancreatography for biliary obstruction. Exosome microRNAs were determined by RNA-sequencing in the discovery cohort, which comprising benign (n = 5) cases and malignant biliary obstruction (n = 5) cases. Then, the diagnostic performance of the two up-regulated microRNAs (mir-483-5p and mir-126-3p) of bile exosomes was verified by analysis of 82 patients with a diagnosis of malignant (n=37) or nonmalignant (n=45) biliary obstruction.
In both cohorts, the expressions of mir-483-5p and mir-126-3p were significantly higher in bile exosomes samples from patients with malignant biliary obstructions than controls. In the verification cohort, the two miRNAs can distinguished the benign and malignant groups with high diagnostic accuracy and specificity; the diagnostic values of the two microRNAs were better than serum carbohydrate antigen 19-9 (CA19-9), area under the curve (AUC) were 0.81 and 0.74.
The expression of exosomal mir-483-5p and mir-126-3p in the bile samples discriminates between patients with malignant and nonmalignant biliary obstructions.
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Management problems in patients with pancreatic cancer from a surgeon's perspective
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Pancreatic cancer is one of the most lethal gastrointestinal tumor entities. Surgery is the only chance for cure; however, only a minority of patients can be offered this option. Due to the anatomic location of the gland, tumor-related problems and complications affecting the surrounding structures are common, leading to biliary and gastric outlet obstruction as well as portal vein thrombosis. This review article summarizes the management of pancreatic cancer-related problems from a surgical point of view. We further describe surgical treatment options in unresectable, metastasized and recurring pancreatic cancer, highlighting potential resection of oligometastatic disease in selected settings.
Long-term outcomes of a long, partially covered metal stent for EUS-guided hepaticogastrostomy in patients with malignant biliary obstruction (with video)
2020, Gastrointestinal Endoscopy
We previously reported safety and effectiveness of EUS-guided hepaticogastrostomy (EUS-HGS) using a long, partially covered metal stent (LP-CMS) for malignant biliary obstruction (MBO). In this study, we aimed to evaluate long-term outcomes of EUS-HGS in an expanded cohort.
One hundred ten patients undergoing EUS-HGS using an LP-CMS in 2 centers were retrospectively studied. Technical and functional success, adverse events, recurrent biliary obstruction (RBO), and reinterventions were evaluated.
The cause of MBO was pancreatic cancer in 50%, and the location of MBO was distal in 68%. The stent length was 8 cm in 2%, 10 cm in 84%, and 12 cm in 15%, with a median intragastric stent length of 54 mm. Technical and functional success rates were 100% and 94%, respectively. The adverse event rate was 25% (mild 15%, moderate 7%, severe 3%), but about one-half of adverse events were mild transient fever and abdominal pain. RBO developed in 33%, with a median cumulative time to RBO of 6.3 months. The major cause of RBO was hyperplasia at an uncovered portion. The presence of prior biliary drainage and short intragastric stent length were significantly associated with RBO. Reintervention for RBO was successfully achieved through the EUS-HGS route in 92%. The remaining reintervention procedures were 1 EUS-HGS and 2 percutaneous transhepatic biliary drainage all in cases with hilar MBO.
EUS-HGS using an LP-CMS for unresectable MBO was safe and effective. RBO was not uncommon, but reintervention through the EUS-HGS route was technically possible in most cases.
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Standard of care guidelines endorse self-expanding metal stents (SEMS) rather than open surgical biliary bypass (OSBB) for biliary palliation in the setting of unresectable pancreatic ductal adenocarcinoma (PDAC). This study used competing risk analysis to compare short- and long-term morbidity and overall survival among patients undergoing SEMS or OSBB after unresectable or metastatic disease is identified at the time of exploration.
Single institution retrospective cohort study (n = 127) evaluating outcomes after OSBB and SEMS for biliary palliation in patients found to have unresectable PDAC at exploration. Short-term, long-term, and lifetime risk of biliary occlusion and survival were compared after adjustment for stage and comprehensive complication index (CCI).
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GENERAL AND SUPPORTIVE CAREMalignant distal biliary obstruction: A systematic review and meta-analysis of endoscopic and surgical bypass results

Summary

Background

Aim

Methods

Results

Conclusions

Section snippets

Background

Search strategy

Results

Discussion

Acknowledgements

Lancet

J Gastrointest Surg

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Am J Gastroenterol

Gastrointest Endosc

Control Clin Trials

J Clin Epidemiol

Lancet

Lancet

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Lancet

Am J Gastroenterol

The National Cancer Data Base report on pancreatic cancer

Cancer

SEER Cancer Statistics Review, 1975–2003

Guidelines for the application of surgery and endoprostheses in the palliation of obstructive jaundice in advanced cancer of the pancreas

Ann Surg

Randomised trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice

Gut

Endoscopic biliary endoprosthesis in the palliation of malignant obstruction of the distal common bile duct: a randomized trial

Br J Surg

GENERAL AND SUPPORTIVE CARE
Malignant distal biliary obstruction: A systematic review and meta-analysis of endoscopic and surgical bypass results