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Commentary (Raijman/Wallace): Management of Malignant Biliary Obstruction: Nonoperative and Palliative Techniques

Commentary (Raijman/Wallace): Management of Malignant Biliary Obstruction: Nonoperative and Palliative Techniques

The first description of percutaneous biliary drainage in the United States appeared in 1965 [1]. The percutaneously placed catheters were left in the obstructed biliary tract for drainage for up to 5 days. Since then, biliary drainage techniques have advanced substantially, and options have proliferated. Now, the nonsurgical palliation of malignant biliary obstruction, accomplished either endoscopically or percutaneously, is a well-established therapeutic modality.

The aim of palliative therapy is to provide relief of jaundice and pruritus, as well as associated cholangitis, but most importantly to prepare patients for anticancer therapy. Neither the endoscopic nor the percutaneous approach has an advantage with regard to influencing patient survival, and the choice of technique is often a team decision based on the available local expertise.

If skilled therapeutic endoscopists and therapeutic radiologists are both available, other factors, such as associated morbidity and mortality, patient comfort, associated postprocedural care, and costs, must be considered when choosing a primary approach. Based on currently available knowledge, and on a growing consensus among units that have experience with both endoscopic and percutaneous stenting techniques [2-5], it could be argued that all patients with malignant obstructive jaundice should be offered palliation by therapeutic endoscopy as the primary approach and that the percutaneous approach should be considered a secondary therapy. Surgery solely for the purpose of accomplishing biliary drainage in patients with malignancy is not recommended.

Endoscopic vs Percutaneous Approaches

A direct comparison between the percutaneous and endoscopic approaches is difficult because of variations in techniques, patient selection, and definition of complications [2]. In addition, the rapid advancement in endoscopic techniques makes previous comparisons invalid. Speer et al [2] described 70 patients with malignant biliary obstruction who were randomized to undergo drainage by either the percutaneous method (33 patients) or endoscopic stenting (37 patients). The success rate of endoscopic stents in relieving jaundice (81%, vs 61% for the percutaneous method) and the complication rate (19% vs 67%) were significantly different in favor of the endoscopic approach. In addition, 30-day mortality in the two groups (15% and 33%, respectively), although very high, also favored patients who were palliated endoscopically.

When either percutaneous or endoscopic stent placement is compared to surgical bypass, the success in relieving jaundice is similar, around 90%; however, the incidence of major complications, 30-day mortality, and the number of hospital days are all lower for the nonsurgical group [6]. In addition, costs are significantly lower with the nonoperative approaches [7].

Endoscopically placed stents are well accepted by patients and can usually be placed in a single session. These stents have a low rate of significant complications during the postprocedural period and require no maintenance care on the part of the patient. When compared to percutaneously placed stents, endoscopically placed prostheses provide greater comfort and quality of life [5,8]. With external catheters, there is a need to adjust to a post-stent placement routine, including periodic maintenance, regular catheter exchanges, and skin care.

Virtually 100% of externally placed catheters are eventually colonized when left in for a prolonged period, and this often results in cholangitis, requiring removal or exchange of the catheter. These complications add substantially to patient care costs. The possible complications of stent occlusion and the need to change the stent periodically occur with stents placed by either approach. For endoscopically placed stents, the mean event-free time using large-bore plastic endoprostheses (12 French) is 190 days (range, 9 to 450 days) [9], and stent exchange every 6 months may be appropriate [10]. In addition, loss of electrolytes and fluids and pH imbalance may occur with external, but not internal, drainage [11].

Occlusion

Stent occlusion remains a significant problem [12]. The advent of expandable metallic stents, placed either endoscopically or transhepatically, has reduced the rate of occlusion of the stent, although occlusion secondary to tumor ingrowth or overgrowth remains a problem. Prospective, randomized studies comparing endoscopically placed expandable metallic stents vs their plastic counterparts have shown an increased patency rate for the metallic stents [12-15]. Placement of similar stents through the percutaneous route has had encouraging results, although the occlusion and early complications rates may be higher compared to rates reported in endoscopic series [16-18].

Some experts advocate that low-lying biliary strictures, such as those produced by pancreatic or ampullary cancers, are best treated by peroral endoscopic stent placement, and those in a more proximal location, such as a Klatskin tumor, are best treated by the percutaneous approach, because the access to the lesion, including placement of bilateral stents, is much more difficult for the endoscopist. The combined endoscopic-percutaneous route has been used successfully by others [14,15,19]. While proximally located strictures undeniably pose more difficulty for the endoscopist, a peroral approach should be tried first, since, in expert hands, successful placement of a stent should be achievable in the majority of patients.

According to the Bismuth classification of biliary strictures [20], type I lesions are easier to treat than type IV lesions, and achieve complete drainage. While complete drainage is favored by some [21] in order to prevent possible cholangitis, others suggest that drainage of one segment of the liver parenchyma is enough in the majority of patients [19,22]. In our experience, placement of a single large-bore endoprosthesis (plastic or metallic) is usually sufficient. For metastatic disease to the liver, we place the stent in the less affected lobe. For bifurcation tumors, we place the stent(s) in the duct that shows the least involvement of more peripheral branches.

In this issue, Dr. Shapiro reports on the interventional management of malignant biliary obstruction. Although an overview on currently available techniques for the nonoperative management of malignant biliary strictures, the article mostly emphasizes the percutaneous approach. In addition, the author summarizes her group's unpublished data on the use of brachytherapy for selected malignant strictures.

Dr. Shapiro states that "high obstruction at the ductal confluence...is beyond the reach of most endoscopists," and adds that "although biliary obstructions are usually complete, it is almost always possible for a trained interventional radiologist to negotiate through a stricture...." Conceptually, the distance between the proximal stricture and the tip of the endoscope adds to the distance the endoscopist needs to negotiate, but adds little when compared to the distance from the stricture to the mouth. A skilled interventional endoscopist should be able to negotiate such proximal obstructions in the majority of patients.

Not All Patients Require Drainage

Not all patients with jaundice as a result of advancing regional malignancy qualify for biliary drainage. Only those patients in whom further local, regional, or systemic therapies are planned should be subjected to a drainage procedure. In selecting this approach, the patient's expected survival must be taken into account.

At M.D. Anderson Cancer Center, where we have expert interventional radiologists as well as therapeutic endoscopists, our primary approach is to attempt an endoscopic biliary drainage. This approach is successful in > 90% of patients (unpublished data). If the initial endoscopic drainage fails, a second endoscopic attempt is often tried. If the second attempt also proves unsuccessful, percutaneous palliation is undertaken. This approach has proved to be effective, well tolerated, and well accepted by the overwhelming majority of patients (and their families). We have also been able to endoscopically place internalized stents that had been previously placed percutaneously.

In summary, in the relief of jaundice, pruritus, associated cholangitis, and planning of anticancer therapy, an endoscopic approach to biliary drainage may have advantages. However, the percutaneous approach should also be available in instances where the endoscopic method proves unsuccessful.

References

1. Dodd GD, Greening RR, Wallace S: The radiologic diagnosis of cancer, in Nealon T (ed): Management of Patients with Cancer, vol. 3, pp 72-113. Philadelphia, WB Saunders Co, 1965.

2. Speer ERG, Cotton PBS, Russell RCA, et al: Randomized trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 2:57-62, 1987.

3. Summerfield JA: Biliary obstruction is best managed by endoscopists. Gut 29:741-745, 1988.

4. Deviere J, Cremer M: Endoscopic approach to malignant biliary obstruction. Cardiovasc
Intervent Radiol 13:223-230, 1990.

5. Soehendra N, Binmoeller KF, Grimm H: Endoscopic therapy for biliary obstruction. World J Surg 16:1066-1073, 1992.

6. Dowsett JF, Russell RCG, Hatfield ARW, et al: Malignant obstructive jaundice: What is the best management? Gut 29:1493, 1988.

7. Brandabur JJ, Kozarek RA, Ball TJ, et al: Nonoperative versus operative treatment of obstructive jaundice in pancreatic cancer: Cost and survival analysis. Am J Gastroenterol 83:1132-1139, 1988.

8. McLean GK, Burke DR: Role of endoprostheses in the management of malignant biliary obstruction. Radiology 170:961-967, 1989.

9. Siegel JH, Pullano W, Kodsi B, et al: Optimal palliation of malignant bile duct obstruction: Experience with endoscopic 12 french prosthesis. Endoscopy 20:137-141, 1988.

10. Frakes JT, Johanson JF, Stake JJ: Optimal timing for stent replacement in malignant biliary tract obstruction. Gastrointest Endosc 39:164-167, 1993.

11. Sandborn WJ, Gros JB, Larson DE, et al: High-volume postobstructive choleresis after transhepatic external biliary drainage resolves with conversion to internal drainage. J Clin Gastroenterol 17:42-45, 1993.

12. Huibregtse K, Carr-Locke DL, Cremer M, et al: Biliary stent occlusion: A problem solved with self-expanding metal stents? Endoscopy 24:391-394, 1992.

13. Davids PHP, Groen AK, Rauwsa EAJ, et al: Randomized trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 340:1488-1489, 1992.

14. Knyrim K, Wagner HJ, Pausch J, et al: A prospective, randomized, controlled trial of metal stents for malignant obstruction of the common bile duct. Endoscopy 25:207-212, 1993.

15. Wagner HJ, Knyrim K, Vakil N, et al: Plastic endoprostheses versus metal stents in the palliative treatment of malignant hilar biliary obstruction: A prospective and randomized trial. Endoscopy 25:213-218, 1993.

16. Stoker J, Lameris JS, Blankenstein MV: Percutaneous metallic self-expandable endoprostheses in malignant hilar biliary obstruction. Gastrointest Endosc 39:43-49, 1993.

17. Lee MJ, Dawson SL, Mueller PR, et al: Percutaneous management of hilar biliary malignancies with metallic endoprostheses: Results, technical problems, and causes of failures. Radiographics 13:1249-1263, 1993.

18. Stoker J, Lameris JS: Complications of percutaneously inserted biliary wallstents. J Vasc Intervent Radiol 4:767-772, 1993.

19. Polydorou AA, Cairns SR, Dowsett JF, et al: Palliation of proximal malignant biliary obstruction by endoscopic endoprosthesis insertion. Gut 32:685-689, 1991.

20. Bismuth H, Castaing D, Traynor O: Resection or palliation: Priority of surgery in the treatment of hilar cancer. World J Surg 12:39-47, 1988.

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

22. Polydorou AA, Chisholm EM, Romanos AA, et al: A comparison of right vs left hepatic duct endoprosthesis insertion in malignant hilar biliary obstruction. Endoscopy 21:266-271, 1989.


 
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