Response letter to “Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the outcomes?” with imaging aspects

Radiological imaging findings may contribute to the differentiation of malignant biliary obstruction from choledocholithiasis in the etiology of acute cholangitis.

Imaging features of malignant vs stone-induced biliary obstruction:Aspects to consider

Radiological studies play a crucial role in the evaluation of patients with biliary duct obstruction,allowing for the guidance of clinical diagnosis towards a malignant or stone-induced etiology through the recognition of relevant imaging features,which must be continuously revisited given their prognostic significance.This article aims to emphasize the importance of recognizing crucial imaging aspects of malignant and stone-induced biliary obstruction.

Role of endoscopic-ultrasound-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent for palliation of malignant biliary obstruction

In this editorial,we discuss the article by Peng et al in the recent issue of the World Journal of Gastrointestinal Surgery,focusing on the evolving role of endoscopicultrasound-guided biliary drainage(EUS-BD)with electrocautery lumen apposing metal stent(LAMS)for distal malignant biliary obstruction.Therapeutic endoscopy has rapidly advanced in decompression techniques,with growing evidence of its safety and efficacy surpassing percutaneous and surgical approaches.While endoscopic retrograde cholangiopancreatography(ERCP)has been the gold standard for biliary decompression,its failure rate approaches 10.0%,prompting the exploration of alternatives like EUS-BD.This random-effects meta-analysis demonstrated high technical and clinical success of over 90.0% and an adverse event rate of 17.5%,mainly in the form of stent dysfunction.Outcomes based on stent size were not reported but the majority used 6 mm and 8 mm stents.As the body of literature continues to demonstrate the effectiveness of this technique,the challenges of stent dysfunction need to be addressed in future studies.One strategy that has shown promise is placement of double-pigtail stents,only 18% received the prophylactic intervention in this study.We expect this to improve with time as the technique continues to be refined and standardized.The results above establish EUS-BD with LAMS as a reliable alternative after failed ERCP and considering EUS to ERCP upfront in the same session is an effective strategy.Given the promising results,studies must explore the role of EUS-BD as first-line therapy for biliary decompression.

Endoscopic ultrasound-guided biliary drainage using electrocauteryenhanced lumen-apposing metal stent for malignant biliary obstruction:A promising procedure

In this editorial,we comment on the article by Peng et al.Palliative drainage for biliary obstruction resulting from unresectable malignant lesions includes internal and external drainage.The procedures of biliary drainage are usually guided by fluoroscopy or transcutaneous ultrasound,endoscopic ultrasound(EUS),or both.Endoscopic retrograde cholangiopancreatography(ERCP)has been primarily recommended for the management of biliary obstruction,while EUS-guided biliary drainage and percutaneous transhepatic biliary drainage(PTBD)are alternative choices for cases where ERCP has failed or is impossible.PTBD is limited by shortcomings of a higher rate of adverse events,more reinterventions,and severe complications.EUS-guided biliary drainage has a lower rate of adverse events than PTBD.EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent(ECE-LAMS)enables EUS-guided biliaryenteric anastomosis to be performed in a single step and does not require prior bile duct puncture or a guidewire.The present meta-analysis showed that ECELAMS has a high efficacy and safety in relieving biliary obstruction in general,although the results of LAMS depending on the site of biliary obstruction.This study has highlighted the latest advances with a larger sample-based comprehensive analysis.

Unveiling the potential of electrocautery-enhanced lumen-apposing metal stents in endoscopic ultrasound-guided biliary drainage

This editorial delves into Peng et al's article,published in the World Journal of Gastrointestinal Surgery.Peng et al's meta-analysis investigates the effectiveness of electrocautery-enhanced lumen-apposing metal stents(ECE-LAMS)in ultrasound-guided biliary drainage for alleviating malignant biliary obstruction.Examining 14 studies encompassing 620 participants,the research underscores a robust technical success rate of 96.7%,highlighting the efficacy of ECE-LAMS,particularly in challenging cases which have failed endoscopic retrograde cholangio pancreatography.A clinical success rate of 91.0% underscores its impact on symptom alleviation,while a reasonably tolerable adverse event rate of 17.5% is observed.However,the 7.3% re-intervention rate stresses the need for post-procedural monitoring.Subgroup analyses validate consistent outcomes,bolstering the applicability of ECE-LAMS.These findings advocate for the adoption of ECELAMS as an appropriate approach for biliary palliation,urging further exploration in real-world clinical contexts.They offer valuable insights for optimizing interventions targeting malignant biliary obstruction management.

Endoscopic ultrasound-guided biliary drainage vs percutaneous transhepatic biliary drainage for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography failure

In a recent issue of the World Journal of Gastrointestinal Surgery,a meta-analysis investigated the safety and efficacy of electrocautery-enhanced lumen-apposing metal stent(ECE-LAMS)implantation for managing malignant biliary obstruction following failed endoscopic retrograde cholangiopancreatography.This manusc-ript endeavors to offer a comprehensive look at the progression of endoscopic ultrasound-guided biliary drainage(EUS-BD)technologies,weighing their merits and drawbacks against traditional percutaneous methods.Several meta-analyses and randomized controlled trials have compared the performance of EUS-BD and percutaneous transhepatic cholangiodrainage(PTCD).These studies revealed that the technical success rate,clinical success rate,and adverse events were similar between EUS-BD and PTCD.Nevertheless,given that most of these studies preda-te 2015,the safety and effectiveness of novel EUS-BD techniques,including ECE-LAMS,compared with those of percutaneous biliary drainage remain elusive.Further investigation is imperative to ascertain whether these novel EUS-BD techniques can safely and efficaciously replace conventional percutaneous thera-peutic approaches.

Still elusive: Developments in the accurate diagnosis of indeterminate biliary strictures

Indeterminate biliary strictures pose a significant diagnostic dilemma for gastroenterologists.Despite advances in endoscopic techniques and instruments,it is difficult to differentiate between benign and malignant pathology.A positive histological diagnosis is always preferred prior to high risk hepatobiliary surgery,or to inform other types of therapy.Endoscopic retrograde cholangiopancreato-graphy with brushings has low sensitivity and despite significant improvements in instruments there is still an unacceptably high false negative rate.Other methods such as endoscopic ultrasound and cholangioscopy have improved diagnostic quality.In this review we explore the techniques available to aid accurate diagnosis of indeterminate biliary strictures and obtain accurate histology to facilitate clinical management.

Self-expandable metallic stents for malignant biliary obstruction:Efficacy on proximal and distal tumors

AIM： To compare the efficacy of self-expandable metallic stents （EMS） in the treatment of distal and proximal stricture of malignant biliary tumors. METHODS： From March 1995 to June 2004, 61 patients （40 males, 21 females） with malignant biliary obstruction who received self-expandable metallic stent implantation were reviewed retrospectively. The stents were inserted by an endoscopic or percutaneous transhepatic method. We tried to place two stents in the biliary system in T or Y configuration in cases of hilar tumors with bilateral hepatic duct obstruction. The end points of the study were stent occlusion or patient death. RESULTS： The mean time of stent patency was 421 ± 67 d in the group of proximal stricture（ group Ⅰ） and 168 ± 18 d in the group of distal stricture （group Ⅱ）. The difference was significant in borderline between the two groups （P = 0.0567）. The mean survival time was 574 ± 76 d in group I and 182 ± 25 d in group II. There was a significant difference between the two groups （P = 0.0005）. CONCLUSION： EMS implantation is a feasible, palliative method for unresectable malignant biliary obstruction. The clinical efficacy of EMS in patients with proximal hilar tumors is better than that in patients with distal tumors.

Catheter tract implantation metastases associated with percutaneous biliary drainage for extrahepatic cholangiocarcinoma

AIM： To estimate the incidence of catheter tract implantation metastasis among patients undergoing percutaneous transhepatic biliary drainage （PTBD） for extrahepatic cholangiocarcinoma, and to provide data regarding the management of this unusual complication of PTBD by reviewing cases reported in the literature. METHODS： A retrospective analysis of 67 consecutive patients who underwent PTBD before the resection of extrahepatic cholangiocarcinoma was conducted. The median follow-up period after PTBD was 106 too. The English language literature （PubMed, National Library of Medicine, Bethesda, MD, USA）, from .lanuary 1966 through December 2004, was reviewed. RESULTS： Catheter tract implantation metastasis developed in three patients. The cumulative incidence of implantation metastasis reached a plateau （6%） at 20 mo after PTBD. All of the three patients with implantation metastasis died of tumor progression at 3, 9, and 20 mo after the detection of this complication. Among the 10 reported patients with catheter tract implantation metastasis from extrahepatic cholangiocarcinoma （including our three patients）, two survived for more than 5 years after the excision of isolated catheter tract metastases. CONCLUSION： Catheter tract implantation metastasis is not a rare complication following PTBD for extrahepatic cholangiocarcinoma. Although the prognosis for patients with this complication is generally poor, the excision of the catheter tract may enable survival in selected patients with isolated metastases along the catheter tract.

Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction

AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent (PS) or nasobiliary catheter (NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedure-related adverse events, stent/catheter dysfunction (occlusion or migration of PS/NBC, development of cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution (bilirubin level < 3.0 mg/dL) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.RESULTS: In total, 419 patients were included in the study (PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients (46%), bile duct cancer in 172 (41%), gallbladder cancer in three (1%), and ampullary cancer in 50 (12%). The median serum total bilirubin was 7.8 mg/dL and 324 patients (77%) had ≥ 3.0 mg/dL. During the median time to surgery of 29 d [interquartile range (IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio (SHR) = 4.76; 95%CI: 2.44-10.0, P < 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method (PS or NBC).CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.

Biliary stenting with or without sphincterotomy for malignant biliary obstruction:A meta-analysis

AIM: To investigate the benefits of endoscopic sphincterotomy (EST) before stent placement by meta-analysis of randomized controlled trials (RCTs).

outcomes of preoperative endoscopic nasobiliary drainage and endoscopic retrograde biliary drainage for malignant distal biliary obstruction prior to pancreaticoduodenectomy

AIM to compare the outcomes of preoperative endoscopic nasobiliary drainage (ENBD) and endoscopic retrograde biliary drainage (ERBD) in patients with malignant distal biliary obstruction prior to pancreaticoduodenectomy (PD). METHODS Data from 153 consecutive patients who underwent preoperative endoscopic biliary drainage prior to PD between January 2009 and July 2016 were analyzed. We compared the clinical data, procedure-related complications of endoscopic biliary drainage (EBD) and postoperative complications of PD between the ENBD and ERBD groups. Univariate and multivariate analyses with odds ratios (ORs) and 95% confidence intervals (95% CIs) were used to identify the risk factors for deep abdominal infection after PD. RESULTS One hundred and two (66.7%) patients underwent ENBD, and 51 (33.3%) patients underwent ERBD. Endoscopic sphincterotomy was less frequently performed in the ENBD group than in the ERBD group (P = 0.039); the EBD duration in the ENBD group was shorter than that in the ERBD group (P = 0.036). After EBD, the levels of total bilirubin (TB) and alanine aminotransferase (ALT) were obviously decreased in both groups, and the decreases of TB and ALT in the ERBD group were greater than those in the ENBD group (P = 0.004 and P = 0.000, respectively). However, the rate of EBD procedure-related cholangitis was significantly higher in the ERBD group than in the ENBD group (P = 0.007). The postoperative complications of PD as graded by the Clavien-Dindo classification system were not significantly different between the two groups (P = 0.864). However, the incidence of deep abdominal infection after PD was significantly lower in the ENBD group than in the ERBD group (P = 0.019). Male gender (OR = 3.92; 95% CI: 1.63-9.47; P = 0.002), soft pancreas texture (OR = 3.60; 95% CI: 1.37-9.49; P = 0.009), length of biliary stricture (= 1.5 cm) (OR = 5.20; 95% CI: 2.23-12.16; P = 0.000) and ERBD method (OR = 4.08; 95% CI: 1.69-9.87; P = 0.002) were independent risk factors for deep abdominal infection after PD. CONCLUSION ENBD is an optimal method for patients with malignant distal biliary obstruction prior to PD. ERBD is superior to ENBD in terms of patient tolerance and the effect of biliary drainage but is associated with an increased risk of EBD procedure-related cholangitis and deep abdominal infection after PD. (C) The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.

Prognostic relevance of circulating CK19 mRNA in advanced malignant biliary tract diseases

AIM: To determine the role of circulating tumor cells (CTCs) in prediction of the overall survival of patients with advanced malignant biliary tract obstruction. METHODS: We investigated the prognostic value of CTCs by examining two markers, cytokeratin (CK) 19 and human telomerase reverse transcriptase (hTERT) mRNA, in 40 patients diagnosed with advanced malig- nant biliary tract diseases. Quantitative real-time re- verse transcription polymerase chain reaction was used to detect CK19 and hTERT mRNA in the peripheral blood of these patients. Overall survival was analyzed using the Kaplan-Meier method and Cox regression modeling.RESULTS: Positive CK19 and hTERT mRNA expression was detected in 45% and 60%, respectively, of the 40 patients. Univariable analysis indicated that positive CK19 mRNA expression was significantly associated with worse overall survival (P = 0.009). Multivariable analysis determined that positive CK19 mRNA expres- sion, patient's age and serum bilirubin were each inde- pendently associated with overall survival. CONCLUSION: CK19 mRNA expression levels in pe- ripheral blood appear to provide a valuable marker to predict the overall survival of patients with advanced malignant biliary tract obstruction.

Folfirinox chemotherapy prolongs stent patency in patients with malignant biliary obstruction due to unresectable pancreatic cancer

Background:Stent insertion for biliary decompression to relieve jaundice and subsequent biliary infection is necessary for patients with biliary obstruction caused by pancreatic cancer,and it is important to keep the stent patent as long as possible.However,few studies have compared stent patency in terms of chemotherapy in patients with pancreatic cancer.This study aimed to evaluate the differences in stent patency in terms of recently evolving chemotherapy.Methods:Between January 2015 and May 2017,161 patients with pancreatic cancer who had undergone biliary stent insertion with a metal stent were retrospectively analyzed.The relationship between chemotherapy and stent patency was assessed.Additionally,overall survival according to the treatment,risk factors for stent patency,and long-term adverse events were evaluated.Results:Median stent patency was 42 days for patients with the best supportive care and 217 days for patients with chemotherapy(conventional gemcitabine-based chemotherapy and folfirinox)(P<0.001).Furthermore,the folfirinox group showed the longest median stent patency and overall survival,with 283 days and 466 days,respectively(P<0.001)despite higher adverse events rate.Patients who underwent folfirinox chemotherapy after stent insertion had better stent patency in multivariate analysis(HR=0.26;95%CI:0.12–0.60;P=0.001).Conclusions:Compared with patients who received best supportive care only,patients who underwent chemotherapy after stent insertion had better stent patency.More prolonged stent patency can be expected for patients with folfirinox than conventional gemcitabine-based chemotherapy.

Partial stent-in-stent placement of biliary metallic stents using a short double-balloon enteroscopy

Endoscopic intervention is less invasive than percutaneous or surgical approaches and should be considered the primary drainage procedure in most cases with obstructive jaundice.Recently,therapeutic endoscopic retrograde cholangiopancreatography(ERCP) using double-balloon enteroscopy(DBE) has been shown to be feasible and effective,even in patients with surgically altered anatomies.On the other hand,endoscopic partial stent-in-stent(PSIS) placement of selfexpandable metallic stents(SEMSs) for malignant hilar biliary obstruction in conventional ERCP has also been shown to be feasible,safe and effective.We performed PSIS placement of SEMSs for malignant hilar biliary obstruction due to liver metastasis using a short DBE in a patient with Roux-en-Y anastomosis and achieved technical and clinical success.This procedure can result in quick relief from obstructive jaundice in a single session and with short-term hospitalization,even in patients with surgically altered anatomies.

Predictive factors for the failure of endoscopic stent-instent self-expandable metallic stent placement to treat malignant hilar biliary obstruction

AIM To investigate the factors predictive of failure when placing a second biliary self-expandable metallic stents(SEMSs). METHODS This study evaluated 65 patients with an unresectable malignant hilar biliary obstruction who were examined in our hospital. Sixty-two of these patients were recruited to the study and divided into two groups: the success group, which consisted of patients in whom a stent-in-stent SEMS had been placed successfully, and the failure group, which consisted of patients in whom the stent-in-stent SEMS had not been placed successfully. We compared the characteristics of the patients, the stricture state of their biliary ducts, and the implemented endoscopic retrograde cholangiopancreatography(ERCP) procedures between the two groups.RESULTS The angle between the target biliary duct stricture and the first implanted SEMS was significantly larger in the failure group than in the success group. There were significantly fewer wire or dilation devices(ERCP catheter, dilator, or balloon catheter) passing the first SEMS cell in the failure group than in the success group. The cut-off value of the angle predicting stent-in-stent SEMS placement failure was 49.7 degrees according to the ROC curve(sensitivity 91.7%, specificity 61.2%). Furthermore, the angle was significantly smaller in patients with wire or dilation devices passing the first SEMS cell than in patients without wire or dilation devices passing the first SEMS cell. CONCLUSION A large angle was identified as a predictive factor for failure of stent-in-stent SEMS placement.

Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the clinical presentation and outcomes?

BACKGROUND Whether clinical outcomes of acute cholangitis(AC)vary by etiology is unclear.AIM To compare outcomes in AC caused by malignant biliary obstruction(MBO)and common bile duct stones(CBDS).METHODS This retrospective study included 516 patients undergoing endoscopic retrograde cholangiopancreatography(ERCP)due to AC caused by MBO(MBO group,n=56)and CBDS(CBDS group,n=460).Clinical and laboratory parameters were compared between the groups.Propensity score matching(PSM)created 55 matched pairs.Confounders used in the PSM analysis were age,sex,time to ERCP,and technical success of ERCP.The primary outcome comparison was 30-d mortality.The secondary outcome comparisons were intensive care unit(ICU)admission rate,length of hospital stay(LOHS),and 30-d readmission rate.RESULTS Compared with the CBDS group,the MBO group had significantly lower body temperature,percentage of abnormal white blood cell counts,and serum levels of aspartate aminotransferase,alanine aminotransferase,and creatinine.Body temperature,percent abnormal white blood cell count,and serum aspartate aminotransferase levels remained significantly lower in the MBO group in the PSM analysis.Platelet count,prothrombin time/international normalized ratio,and serum levels of alkaline phosphatase and total bilirubin were significantly higher in the MBO group.The MBO group had a significantly higher percentage of severe AC(33.9%vs 22.0%,P=0.045)and received ERCP later(median,92.5 h vs 47.4 h,P<0.001).However,the two differences were not found in the PSM analysis.The 30-d mortality(5.4%vs 0.7%,P=0.019),ICU admission rates(12.5%vs 4.8%,P=0.028),30-d readmission rates(23.2%vs 8.0%,P<0.001),and LOHS(median,16.5 d vs 7.0 d,P<0.001)were significantly higher or longer in the MBO group.However,only LOHS remained significant in the PSM analysis.Multivariate analysis revealed that time to ERCP and multiple organ dysfunction were independent factors associated with 30-d mortality.CONCLUSION MBO patients underwent ERCP later and thus had a worse prognosis than CBDS patients.Therefore,clinicians should remain vigilant in MBO patients with clinically suspected AC,and perform ERCP for biliary drainage as soon as possible.

Revision of bilateral self-expandable metallic stents placed using the stent-in-stent technique for malignant hilar biliary obstruction

Background: Endoscopic biliary decompression using bilateral self-expandable metallic stent(SEMS) placed using the stent-in-stent(SIS) technique is considered favorable for unresectable malignant hilar biliary obstruction(MHBO). However, occlusion of the bilateral SIS placement is frequent and revision can be challenging. This study was performed to investigate the efficacy, the long-term patency and the appropriate approach for revision of occluded bilateral SIS placement in unresectable MHBO. Methods: From January 2011 to July 2016, thirty-eight patients with unresectable MHBO underwent revision of occluded bilateral SIS placement. Clinical data including success rates and patency of revision, were retrospectively analyzed. Results: The technical success rate of revision was 76.3%. The clinical success rate of revision was 51.7% and mean patency of revision was 49.1 days. No significant predictive factor for clinical failure of revision was observed. The cell size of SEMS was not found to have significant effects on clinical success rates or revision patency. Conclusions: Revision of occluded bilateral SIS placement for MHBO showed fair patency and clinical success rate. Revision method and cell size of SEMS were not found to influence clinical outcomes.

Improvedendoscopicretrogradecholangiopancreatographybrushincreases diagnosticyieldofmalignantbiliarystrictures

AIM: To determine if a new brush design could im-prove the diagnostic yield of biliary stricture brushings. METHODS: Retrospective chart review was performed of all endoscopic retrograde cholangiopancreatography procedures with malignant biliary stricture brushing between January 2008 and October 2012. A standard wire-guided cytology brush was used prior to proto-col implementation in July 2011, after which, a new 9 French wire-guided cytology brush(Infinity sampling device, US Endoscopy, Mentor, OH) was used for all cases. All specimens were reviewed by blinded pa-thologists who determined whether the sample waspositive or negative for malignancy. Cellular yield was quantified by describing the number of cell clusters seen. RESULTS: Thirty-two new brush cases were compared to 46 historical controls. Twenty-five of 32 (78%) cases in the new brush group showed abnormal cellular find-ings consistent with malignancy as compared to 17 of 46(37%) in the historical control group(P = 0.0003). There was also a significant increase in the average number of cell clusters of all sizes(21.1 vs 9.9 clusters, P = 0.0007) in the new brush group compared to his-torical controls. CONCLUSION: The use of a new brush design for brush cytology of biliary strictures shows increased di-agnostic accuracy, likely due to improved cellular yield, as evidenced by an increase in number of cellular clus-ters obtained.

Safety and efficacy of transpapillary bridged bilateral side-by-side stenting for unresectable malignant hilar biliary obstruction

To the Editor:Biliary drainage is most frequently performed among endoscopic procedures using pancreatobiliary endoscopy.A large-diameter metallic stent can significantly extend the patency period rather than a plastic stent for extrahepatic biliary stricture.;However,the optimal drainage for the hilar biliary obstruction is still controversial.