Biliary drainage strategy of unresectable malignant hilar strictures by computed tomography volumetry

Abstract

AIM:To identify criteria for predicting successful drainage of unresectable malignant hilar biliary strictures (UMHBS) because no ideal strategy currently exists. METHODS:We examined 78 patients with UMHBS who underwent biliary drainage. Drainage was considered effective when the serum bilirubin level decreased by ≥ 50% from the value before stent placement within 2 wk after drainage, without additional intervention. Complications that occurred within 7 d after stent placement were considered as early complications. Before drainage, the liver volume of each section (lateral and medial sections of the left liver and anterior and posterior sections of the right liver) was measured using computed tomography (CT) volumetry. Drained liver volume was calculated based on the volume of each liver section and the type of bile duct stricture (according to the Bismuth classification). Tumor volume, which was calculated by using CT volumetry, was excluded from the volume of each section. Receiver operating characteristic (ROC) analysis was performed to identify the optimal cutoff values for drained liver volume. In addition, factors associated with the effectiveness of drainage and early complications were evaluated. cirrhosis) and 50% for patients with impaired liver function (with decompensated liver cirrhosis). The sensitivity and specificity of these cutoff values were 82% and 80% for preserved liver function, and 100% and 67% for impaired liver function, respectively. Among patients who met these criteria, the rate of effective drainage among those with preserved liver function and impaired liver function was 90% and 80%, respectively. The rates of effective drainage in both groups were significantly higher than in those who did not fulfill these criteria (P < 0.001 and P = 0.02, respectively). Drainage-associated cholangitis occurred in 9 patients (12%). A smaller drained liver volume was associated with drainage-associated cholangitis (P < 0.01). RESULTS: CONCLUSION:Liver volume drainage ≥ 33% in patients with preserved liver function and ≥ 50% in patients with impaired liver function correlates with effective biliary drainage in UMHBS. Core tip: An ideal biliary drainage strategy for unresectable malignant hilar biliary strictures (UMHBS) has not been defined. The aim of our study was to identify useful criteria for predicting successful drainage of UMHBS. In the present study, multivariate analysis revealed that liver function and drained liver volume calculated by computed tomography volumetry (CTV) are independent factors of drainage effectiveness for UMHBS. Receiver operating characteristic analysis showed cutoff values of 33% of liver volume for patients with preserved liver function and 50% for patients with impaired liver function. Before attempting biliary drainage procedures, establishing an appropriate drainage strategy using CTV is important.Takahashi E, Fukasawa M, Sato T, Takano S, Kadokura M, Shindo H, Yokota Y, Enomoto N. Biliary drainage strategy of unresectable malignant hilar strictures by...

Evaluation of endoscopic reintervention for self‐expandable metallic stent obstruction after stent‐in‐stent placement for malignant hilar biliary obstruction

“…Management of jaundice and cholangitis caused by MHBO is highly important. However, a consensus regarding the optimal method of drainage for MHBO has not been reached with regard to the drainage area , most suitable type of stent , and stent placement method . In our study, we found that ABBS > 104º and overgrowth were both risk factors for ERI failure after SIS placement.…”

“…However, there is still no consensus as to the optimal drainage strategy for treating UMHBO . Generally, bilateral drainage is required when adequate/necessary drainage amounts to >50% of the liver volume . Stent‐in‐stent (SIS) placement or side‐by‐side (SBS) placement are two deployment methods for placement of bilateral SEMSs.…”

Recommendations for Invasive Procedures in Patients With Diseases of the Liver and Biliary Tract: Report of a Joint Meeting of the Brazilian Society of Hepatology (Sbh), Brazilian Society of Digestive Endoscopy (Sobed) and Brazilian Society of Interventional Radiology and Endovascular Surgery (Sobrice)

“…However, this goal usually requires bilateral stenting, increasing the complexity of the procedure. More recently, Takahashi et al showed that a liver volume drainage ≥33% in patients with preserved liver function and ≥50% in patients with impaired liver function correlates with effective biliary drainage in malignant hilar obstruction (130) . Simi larly to distal malignant obstruction, drainage of unresectable hilar tumors should be performed preferably with SEMS, as these stents are associated with prolonged patency.…”

Endoscopic biliary stenting for unresectable malignant hilar obstruction

“…They suggested that draining ≥50% of the liver volume, which frequently required bilateral stenting, was a significant predictor of drainage effectiveness in MHBO and a pre-endoscopic retrograde cholangio-pancreatography (ERCP) assessment of hepatic volume distribution of a computed tomography imaging optimized endoscopic procedure. Recently, Takahashi et al [14] examined the liver volume and preserved liver function for effective biliary drainage in UMHBO. They revealed that drainage volume required for effective drainage in UMHBO was ≥33% in patients with normal liver function and ≥50% in patients with impaired liver function (decompensated liver cirrhosis).…”