Korean J Radiol.  2012 Feb;13(Suppl 1):S56-S61. 10.3348/kjr.2012.13.S1.S56.

Evidence-Based Decompression in Malignant Biliary Obstruction

• Ho CS
• Warkentin

• KMID: 1372868
• DOI: http://doi.org/10.3348/kjr.2012.13.S1.S56

Abstract

As recent advances in chemotherapy and surgical treatment have improved outcomes in patients with biliary cancers, the search for an optimal strategy for relief of their obstructive jaundice has become even more important. Without satisfactory relief of biliary obstruction, many patients would be ineligible for treatment. We review all prospective randomized trials and recent retrospective non-randomized studies for evidence that would support such a strategy. For distal malignant biliary obstruction, an optimal strategy would be insertion of metallic stents either endoscopically or percutaneously. Evidence shows that a metallic stent inserted percutaneously has better outcomes than plastic stents inserted endoscopically. For malignant hilar obstruction, percutaneous biliary drainage with or without metallic stents is preferred.

Keyword

Malignant biliary obstruction; Percutaneous, endoscopic, biliary drainage; Evidence-based medicine; Cholangiocarcinoma, Klatskin tumor

MeSH Terms

Bile Duct Neoplasms/pathology/surgery
Biliary Tract Diseases/pathology/*surgery
Cholangiocarcinoma/pathology/surgery
Decompression, Surgical
Drainage/methods
Endoscopy
*Evidence-Based Medicine
Hepatic Duct, Common
Humans
Jaundice, Obstructive/pathology/*surgery
Klatskin's Tumor/pathology/surgery
Stents

Figure

• 

  Fig. 1 Low profile fixation device for transfixing internal / external biliary drainage catheter at skin surface.

• 

  Fig. 2 Patient with internal/external biliary drainage for palliation of obstructive jaundice. External portion of catheter has been transfixed by low profile device and cut short to 3 mm above skin level. Photo showing device covered by dressings and transparent adhesive tape (Reproduced with permission from AJR).

Reference

1. Andersen JR, Sørensen SM, Kruse A, Rokkjaer M, Matzen P. Randomised trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice. Gut. 1989. 30:1132–1135.

2. Shepherd HA, Royle G, Ross AP, Diba A, Arthur M, Colin-Jones D. Endoscopic biliary endoprosthesis in the palliation of malignant obstruction of the distal common bile duct: a randomized trial. Br J Surg. 1988. 75:1166–1168.

3. Smith AC, Dowsett JF, Russell RC, Hatfield AR, Cotton PB. Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction. Lancet. 1994. 344:1655–1660.

4. Dinant S, Gerhards MF, Rauws EA, Busch OR, Gouma DJ, van Gulik TM. Improved outcome of resection of hilar cholangiocarcinoma (Klatskin tumor). Ann Surg Oncol. 2006. 13:872–880.

5. Nakeeb A, Tran KQ, Black MJ, Erickson BA, Ritch PS, Quebbeman EJ, et al. Improved survival in resected biliary malignancies. Surgery. 2002. 132:555–563. discussion 563-564.

6. Seyama Y, Makuuchi M. Current surgical treatment for bile duct cancer. World J Gastroenterol. 2007. 13:1505–1515.

7. Valle J, Wasan H, Palmer DH, Cunningham D, Anthoney A, Maraveyas A, et al. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Engl J Med. 2010. 362:1273–1281.

8. Speer AG, Cotton PB, Russell RC, Mason RR, Hatfield AR, Leung JW, et al. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet. 1987. 2:57–62.

9. Piñol V, Castells A, Bordas JM, Real MI, Llach J, Montañà X, et al. Percutaneous self-expanding metal stents versus endoscopic polyethylene endoprostheses for treating malignant biliary obstruction: randomized clinical trial. Radiology. 2002. 225:27–34.

10. Saluja SS, Gulati M, Garg PK, Pal H, Pal S, Sahni P, et al. Endoscopic or percutaneous biliary drainage for gallbladder cancer: a randomized trial and quality of life assessment. Clin Gastroenterol Hepatol. 2008. 6:944–950.e3.

11. Lee SH, Park JK, Yoon WJ, Lee JK, Ryu JK, Yoon YB, et al. Optimal biliary drainage for inoperable Klatskin's tumor based on Bismuth type. World J Gastroenterol. 2007. 13:3948–3955.

12. Paik WH, Park YS, Hwang JH, Lee SH, Yoon CJ, Kang SG, et al. Palliative treatment with self-expandable metallic stents in patients with advanced type III or IV hilar cholangiocarcinoma: a percutaneous versus endoscopic approach. Gastrointest Endosc. 2009. 69:55–62.

13. Kloek JJ, van der Gaag NA, Aziz Y, Rauws EA, van Delden OM, Lameris JS, et al. Endoscopic and percutaneous preoperative biliary drainage in patients with suspected hilar cholangiocarcinoma. J Gastrointest Surg. 2010. 14:119–125.

14. Laméris JS, Obertop H, Jeekel J. Biliary drainage by ultrasound-guided puncture of the left hepatic duct. Clin Radiol. 1985. 36:269–274.

15. Lammer J, Hausegger KA, Flückiger F, Winkelbauer FW, Wildling R, Klein GE, et al. Common bile duct obstruction due to malignancy: treatment with plastic versus metal stents. Radiology. 1996. 201:167–172.

16. Davids PH, Groen AK, Rauws EA, Tytgat GN, Huibregtse K. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet. 1992. 340:1488–1492.

17. Knyrim K, Wagner HJ, Pausch J, Vakil N. A prospective, randomized, controlled trial of metal stents for malignant obstruction of the common bile duct. Endoscopy. 1993. 25:207–212.

18. Raju RP, Jaganmohan SR, Ross WA, Davila ML, Javle M, Raju GS, et al. Optimum palliation of inoperable hilar cholangiocarcinoma: comparative assessment of the efficacy of plastic and self-expanding metal stents. Dig Dis Sci. 2011. 56:1557–1564.

19. Deviere J, Baize M, de Toeuf J, Cremer M. Long-term follow-up of patients with hilar malignant stricture treated by endoscopic internal biliary drainage. Gastrointest Endosc. 1988. 34:95–101.

20. Silva MA, Tekin K, Aytekin F, Bramhall SR, Buckels JA, Mirza DF. Surgery for hilar cholangiocarcinoma; a 10 year experience of a tertiary referral centre in the UK. Eur J Surg Oncol. 2005. 31:533–539.

21. Mansfield SD, Barakat O, Charnley RM, Jaques BC, O'Suilleabhain CB, Atherton PJ, et al. Management of hilar cholangiocarcinoma in the North of England: pathology, treatment, and outcome. World J Gastroenterol. 2005. 11:7625–7630.

22. Ho CS, Hatrick AG. Innovative catheter fixation using a low-profile device. AJR Am J Roentgenol. 2000. 174:823–825.