Biliary Decompression in Perihilar Cholangiocarcinoma Improves Survival: A Single-Center Retrospective Analysis

Cassani, Lisa S.; Chouhan, Jay; Chan, Christopher; Lanke, Gandhi; Chen, Hsiang Chun; Wang, Xuemei; Weston, Brian; Ross, William A.; Raju, Gottumukkala S.; Lee, Jeffrey H.

doi:10.1007/s10620-018-5277-z

Cited by 29 publications

(21 citation statements)

References 12 publications

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“…The relief of jaundice enhances quality of life in the palliative care setting and can facilitate the use of palliative chemotherapy [7]. Results remain conflicting regarding the necessity of placing unilateral versus bilateral stents, despite 2 randomized prospective studies [8][9][10]. One randomized controlled trial of 57 patients concluded that single stent insertion is effective and has a lower risk of complications, similar to our findings [11].…”

Section: Discussionsupporting

confidence: 78%

Unilateral versus bilateral hilar stents for the treatment of cholangiocarcinoma: a multicenter international study

Staub

Siddiqui

Murphy

et al. 2020

aog

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Background Endoscopic placement of hilar stents is an accepted palliative therapy for patients with advanced, unresectable cholangiocarcinoma. However, whether unilateral versus bilateral stent placement provides optimal relief continues to be a subject of debate. The aim of this study was to compare the technical and clinical outcomes in patients with inoperable cholangiocarcinoma who received unilateral or bilateral self-expanding metal stents (SEMS). MethodsWe conducted a multicenter, international retrospective study of 187 patients with cholangiocarcinoma who received unilateral or bilateral SEMS. Outcomes included, but were not limited to, technical success, clinical success, adverse events, stent occlusion, and survival time.Results were further stratified based on the Bismuth classification.Results Fifty patients received unilateral stents and 137 patients received bilateral stents. All patients achieved technical success. The clinical success rates were 86% for unilateral stents and 82.5% for bilateral stents (P>0.99). Clinical success was not statistically different for either group when stratified by the Bismuth classification (P=0.62 and P=0.72 respectively). There were significantly more adverse events in the bilateral stents group (11.7% vs. 0%, P=0.007). There was no greater risk of stent occlusion when bilateral stents were used (unadjusted P=0.71, adjusted P=0.81). There was a greater risk of death for patients who received bilateral SEMS (hazard ratio 1.78, 95% confidence interval 1.09-2.89; P=0.02).Conclusions Unilateral and bilateral drainage had similar technical and clinical success rates. However, bilateral stents had a higher risk of death and more adverse events. Therefore, unilateral SEMS placement is sufficient for relief of biliary obstruction secondary to cholangiocarcinoma.

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Section: Discussionsupporting

confidence: 78%

Unilateral versus bilateral hilar stents for the treatment of cholangiocarcinoma: a multicenter international study

Staub

Siddiqui

Murphy

et al. 2020

aog

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“…1,2 Most patients with PHC are inoperable at the time of diagnosis. 3,4 Under these circumstances, effective biliary drainage for patients with PHC has been a challenge, because of the anatomical complexity involved. 5,6 As chemotherapy for IUPHC should be carried out for a minimum of 3 months with minimal interruption, suitable and effective biliary drainage is a prerequisite.…”

Section: Introductionmentioning

confidence: 99%

The placement of multiple plastic stents still has important roles in candidates for chemotherapy for unresectable perihilar cholangiocarcinoma

Iwasaki

Kubota

Kurita

et al. 2020

J Hepato Biliary Pancreat

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Background/Purpose: Placement of uncovered self-expandable metallic stents (U-SEMSs) of patients with unresectable perihilar cholangiocarcinoma (UPHC) is recommended as the treatment of first choice to address bile stasis. The aim of this study was to determine which of the following two endoscopic stents might be the stent of first choice for the treatment of biliary stasis in patients with UPHC: plastic stents (PSs) or U-SEMSs. Methods: U-SEMSs, deployed as a stent-in-stent, were selected as the stents of first choice from 2013 and 2014, while PSs began to be selected as the stents of first choice from 2015 onward. Results: The median time to recurrent biliary obstruction were 66 days in the PS group (N = 38) and 105 days in the U-SEMS group (N = 37; P = .04). Emergency endoscopy was necessitated in 76.3% (29/38) of patients of the PS group and 54.1% (20/37) of patients of the U-SEMS group (P = .0434). The success rate of the first reintervention was 96.5% (27/29) in the PS group and 55% (11/20) in the U-SEMS group (P = .0002). Sustainable chemotherapy could be carried out in 55.2% of patients in the PS group and 32.4% of patients in the U-SEMS group (P = .0472). Multivariate analysis identified selection of U-SEMS as the stent of first choice as the only independent factor predictive of successful reintervention (P = .0016, odds ratio = 0.058). However, the stent selection was not an independent factor for feasible chemotherapy. Conclusions: Plastic stent placement could enhance the success rate of reintervention in patients with UPHC and might be facilitated by sustainable chemotherapy. However, stent selection might not have an influence on the prognosis.

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“…Therapeutic ERCP often produces dramatic cures of life-threatening conditions, and is less invasive and safer than surgical options for various disorders, such as ascending cholangitis from choledocholithiasis[11]. ERCP therapies have largely obviated surgery for choledocholithiasis and choledochal strictures, and can improve survival in patients with cholangiocarcinoma[12,13]. The relatively recent change of ERCP to become a predominantly therapeutic modality has also been fostered by development of less invasive and safer pancreatico-biliary diagnostic tests than ERCP, including EUS and magnetic resonance cholangiopancreatography (MRCP).…”

Section: Resultsmentioning

confidence: 99%

Stricter national standards are required for credentialing of endoscopic-retrograde-cholangiopancreatography in the United States

Cappell

Friedel

2019

WJG

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Endoscopic-retrograde-cholangiopancreatography (ERCP) is now a vital modality with primarily therapeutic and occasionally solely diagnostic utility for numerous biliary/pancreatic disorders. It has a significantly steeper learning curve than that for other standard gastrointestinal (GI) endoscopies, such as esophagogastroduodenoscopy or colonoscopy, due to greater technical difficulty and higher risk of complications. Yet, GI fellows have limited exposure to ERCP during standard-three-year-GI-fellowships because ERCP is much less frequently performed than esophagogastroduodenoscopy/colonoscopy. This led to adding an optional year of training in therapeutic endoscopy. Yet many graduates from standard three-year-fellowships without advanced training intensely pursue independent/unsupervised ERCP privileges despite inadequate numbers of performed ERCPs and unacceptably low rates of successful selective cannulation of desired (biliary or pancreatic) duct. Hospital credentialing committees have traditionally performed ERCP credentialing, but this practice has led to widespread flouting of recommended guidelines ( e.g ., planned privileging of applicant with 20% successful cannulation rate, or after performing only 7 ERCPs); and intense politicking of committee members by applicants, their practice groups, and potential competitors. Consequently, some gastroenterologists upon completing standard fellowships train and learn ERCP “on the job” during independent/unsupervised practice, which can result in bad outcomes: high rates of failed bile duct cannulation. This severe clinical problem is indicated by publication of ≥ 12 ERCP competency studies/guidelines during last 5 years. However, lack of mandatory, quantitative, ERCP credentialing criteria has permitted neglect of recommended guidelines. This work comprehensively reviews literature on ERCP credentialing; reviews rationales for proposed guidelines; reports problems with current system; and proposes novel criteria for competency. This work advocates for mandatory, national, written, minimum, quantitative, standards, including cognitive skills (possibly assessed by a nationwide examination), and technical skills, assessed by number performed (≥ 200-250 ERCPs), types of ERCPs, success rate (approximately ≥ 90% cannulation of desired duct), and letters of recommendation by program director/ERCP mentor. Mandatory criteria should ideally not be monitored by a hospital committee subjected to intense politicking by applicants, their employers, and sometimes even competitors, but an independent national entity, like the National Board of Medical Examiners/American Board of Internal Medicine.

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Biliary Decompression in Perihilar Cholangiocarcinoma Improves Survival: A Single-Center Retrospective Analysis

Cited by 29 publications

References 12 publications

Unilateral versus bilateral hilar stents for the treatment of cholangiocarcinoma: a multicenter international study

Unilateral versus bilateral hilar stents for the treatment of cholangiocarcinoma: a multicenter international study

The placement of multiple plastic stents still has important roles in candidates for chemotherapy for unresectable perihilar cholangiocarcinoma

Stricter national standards are required for credentialing of endoscopic-retrograde-cholangiopancreatography in the United States

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