Introduction

Hilar malignant biliary stricture, caused by malignant tumors, often leads to late diagnosis due to subtle initial symptoms, resulting in poor outcomes. Effective endoscopic interventions significantly improve quality of life and survival, yet often lead to post-operative complications like cholangitis.

Aims & Methods

This study aims to assess the effectiveness and safety of utilizing sequential nasobiliary tube cutting as an alternative to stent placement post-nasobiliary drainage in patients, specifically in mitigating post-operative cholangitis. Additionally, to identify risk factors associated with the development of post-operative cholangitis.
Patients diagnosed at Hangzhou First People's Hospital from January 2015 to January 2023 were divided into nasobiliary tube cutting group and conventional stent group. The former underwent nasobiliary drainage followed by tube cutting when stable, transitioning from external to internal drainage, while the latter received standard stent placement. Statistical analyses compared postoperative cholangitis incidence, drainage success, interventions, complications, and hospital stay, further examining risk factors for postoperative cholangitis.

Results

1. This study encompassed a total of 208 patients, with 103 in the nasobiliary tube cutting group and 105 in the conventional stent group. Postoperative cholangitis occurred in 40 patients, with 12 cases (11.7%) in the nasobiliary tube cutting group and 28 cases (26.7%) in the conventional stent group, showing a statistically significant difference between the two groups (P=0.006). The number of patients whose total bilirubin levels decreased by more than 50% within 7 days postoperatively was 50 (48.5%) in the nasobiliary tube cutting group and 29 (27.6%) in the conventional stent group, a statistically significant difference favoring the nasobiliary tube cutting group (P=0.002). There was no statistically significant difference in the overall drainage success rate between the two groups (P=0.207). Besides postoperative cholangitis, there were no statistically significant differences in other postoperative complications between the two groups (P>0.05). The postoperative hospital stay was longer for patients in the nasobiliary tube cutting group than those in the conventional stent group, with median durations of 10.0 (7.0, 14.0) days versus 7.0 (5.5, 12.5) days, respectively, a difference that was statistically significant (P=0.024).
2. Based on whether postoperative cholangitis occurred, the patients were further categorized into a postoperative cholangitis group (n=40) and a non-postoperative cholangitis group (n=168). Univariate analysis revealed significant differences between the postoperative cholangitis group and the non-postoperative cholangitis group in terms of gender (male), Bismuth-Corlette classification (Type IV), number of ERCP procedures (≥2 times), and re-intervention (P<0.05). Multivariate logistic regression analysis identified Bismuth-Corlette classification (Type IV) (OR=3.207, 95%CI: 1.253-8.210, P=0.015) as an independent risk factor for developing postoperative cholangitis.

Conclusion

For patients with hilar malignant biliary stricture, sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage can reduce the incidence of postoperative cholangitis and achieve early successful drainage, but it results in a prolonged postoperative hospital stay. Bismuth-Corlette classification (Type IV) is an independent risk factor for the development of postoperative cholangitis.

References

[1] VALLE J W, KELLEY R K, NERVI B, et al. Biliary tract cancer [J]. Lancet (London, England), 2021, 397(10272): 428-444.
[2] KHALAF N, EL-SERAG H B, ABRAMS H R, et al. Burden of Pancreatic Cancer: From Epidemiology to Practice [J]. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 2021, 19(5): 876-884.
[3] ELMUNZER B J, MARANKI J L, GóMEZ V, et al. ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures [J]. Am J Gastroenterol, 2023, 118(3): 405-426.
[4] PIMPINELLI M, MAKAR M, KAHALEH M. Endoscopic management of benign and malignant hilar stricture [J]. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society, 2023, 35(4): 443-452.
[5] BANG J Y, HAWES R, VARADARAJULU S. Endoscopic biliary drainage for malignant distal biliary obstruction: Which is better - endoscopic retrograde cholangiopancreatography or endoscopic ultrasound? [J]. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society, 2022, 34(2): 317-324.
[6] IRISAWA A, MIYOSHI H, ITOI T, et al. Recent innovations in therapeutic endoscopy for pancreatobiliary diseases [J]. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society, 2020, 32(3): 309-315.

Disclosure

The authors declare that there are no conflicts of interest.

Introduction

The management of malignant hilar biliary obstruction can be done by endoscopic biliary stenting, which is a well-established palliative treatment, improving the quality of life by relieving symptoms.

Aims & Methods

This systematic review and meta-analysis aimed to compare the use of stents placed above and across the sphincter of Oddi in patients with malignant hilar biliary obstruction. We performed a systematic search of the PubMed, Embase, and Cochrane Library databases in April 2025. Article screening was conducted independently by two authors using Rayyan software. Inclusion criteria were randomized controlled trials (RCTs) comparing stent placement above and across the sphincter of Oddi for malignant hilar biliary obstruction, evaluating at least one of the outcomes of interest. The outcomes were stent migration, stent patency, cholangitis, stent occlusion, and successful placement of the stent. RStudio software was used for statistical analysis, applying a random-effects model to calculate the risk ratio (RR) in binary outcomes and mean differences (MD) in continuous outcomes.

Results

We included three RCTs comprising 161 patients. There was no significant difference between the transpapillary and suprapapillary stents regarding the rates of stent migration (RR 2.03; 95% CI 0.41–10.16; p=0.39; I²=55%), cholangitis (RR 0.65; 95% CI 0.08–5.07; p=0.68; I²=0%), technical success (RR 0.99; 95% CI 0.95–1.04; p=0.80; I²=0%), and stent occlusion (MD 89.20; 95% CI 16.30–162.10; p=0.02; I²=78%). However, the mean number of patent stents was significantly lower in the suprapapillary stent group.

Conclusion

The two types of stent seem similar in terms of technique, efficacy, and safety, although the suprapapillary stent seems superior in terms of stent patency.

References

Ko SW, Joo HD, Song TJ, Kim S, Choi SJ, Oh CH, Oh D, Park JS, Yoon SB, Yoon JH, Seo DW, Lee SK. Impact of the suprapapillary method on patency in distal malignant biliary obstruction: a multicenter randomized controlled trial. Gastrointest Endosc. 2024 Oct;100(4):679-687.e1. doi: 10.1016/j.gie.2024.03.024. Epub 2024 Mar 21. PMID: 38521477.
Kurita A, Uza N, Asada M, Yoshimura K, Takemura T, Yazumi S, Kodama Y, Seno H. Stent placement above the sphincter of Oddi is a useful option for patients with inoperable malignant hilar biliary obstruction. Surg Endosc. 2022 May;36(5):2869-2878. doi: 10.1007/s00464-021-08576-x. Epub 2021 Jun 2. PMID: 34076770.
Finn Møller Pedersen, MD, Annmarie Touborg Lassen, Ove B. Schaffalitzky de Muckadell. Finn Møller Pedersen, MD, Annmarie Touborg Lassen, Ove B. Schaffalitzky de Muckadell. Gastroint Endosc. 1998;48(6):574-579.

Introduction

Endoscopic nasobiliary drainage is accompanied by a risk of accidental removal of the nasobiliary drainage (NBD) tube, especially through self-removal in elderly patients. UMIDAS NB stent (Olympus, Tokyo, Japan), hereafter referred to as UMIDAS, is an integrated plastic stent (PS) and NBD catheter system. In UMIDAS, the PS stays in the same place to maintain biliary drainage when the NBD tube is removed. Thus, UMIDAS has been developed to reduce endoscopic procedures following biliary drainage. We speculated that UMIDAS can be a safety net in accidental NBD tube deviation for acute cholangitis and obstructive jaundice. Therefore, we prospectively observed and reported the efficacy and disadvantages of UMIDAS (UMIN000047515).

Aims & Methods

From April to November 2022, we placed a UMIDAS NB stent in 30 patients with acute cholangitis or obstructive jaundice. We evaluated the plastic stent (PS) position at the time of accidental stent removal and before the planned endoscopic procedure. In addition, we studied the ratio of successful biliary drainage and complications based on the usage of UMIDAS.

Results

In this study, 19 planned NBD tube removals and 11 accidental removals were included. Among the 11 accidental removals, 4 were self-removal, 2 were accidental deviation to the intestine, and 5 were long period to next procedure. All 11 patients with accidental NBD tube removal showed a correct PS position after NBD tube removal. Of the 19 patients with planned NBD tube removal, 15 had a correct PS position, 2 had complete migrations into the common bile duct (Figure 5a), and 2 had incomplete migrations (the migration of the duodenal side flap only) before NBD tube removal. After removal, 13 patients had a correct PS position, 3 had complete migration of PS, and 3 had incomplete migration of PS. Of the 30 patients with UMIDAS, 24 (80%) had a correct PS position after NBD tube removal (27 (90%) if including incomplete migration). All patients with UMIDAS had successful biliary drainage, including patients with accidental removal of NBD, and had no complications.

Conclusion

The UMIDAS NB stent might be useful for biliary drainage in patients with a high risk of NBD tube self-removal.

Introduction

ERCP is effective for common bile duct stone treatment but carries post-op risks like pancreatitis and cholangitis. Biliary drainage post-surgery is vital, with methods like ENBD and ERBD being common. ENBD allows monitoring but has drawbacks like infection and inconvenience. ERBD mitigates these but can cause complications. A new solution, Detachable biliary plastic stents without flanges, uses soft materials for self-expulsion, reducing the need for further procedures and patient burden.

Aims & Methods

This study aimed to investigate the efficacy and safety of using detachable biliary plastic stents without flanges for the prevention of cholangitis following endoscopic retrograde cholangiopancreatography (ERCP) in patients with common bile duct stones.
The study cohort comprised patients diagnosed with common bile duct stones and treated at the First People's Hospital affiliated with West Lake University School of Medicine between January 2019 and January 2024. Participants were randomly assigned to either the group receiving detachable biliary plastic stents without flanges or the nasobiliary drainage group. In the former group, the stents were deployed for biliary drainage following the clearance of stones during ERCP. The latter group received nasobiliary drains for similar purposes. Comprehensive clinical data were gathered, encompassing preoperative and postoperative details, including laboratory investigations, endoscopic procedures, complications, hospital stay, and comfort levels assessed using the Visual Analogue Scale (VAS). Additionally, the incidence of cholangitis, the rate of spontaneous drain removal, and stent detachment were compared between the two groups.

Results

1. The study included 820 patients who underwent ERCP for common bile duct stones. After accounting for 10 patients lost to follow-up, a total of 810 patients were analyzed, with equal distribution across both study groups. The incidence of postoperative cholangitis was 2.0% in the stent group and 3.0% in the nasobiliary drainage group, showing no significant difference (P=0.365). Pancreatitis occurred in 2.7% of patients in the stent group and 4.2% in the drainage group, also not statistically significant (P=0.248). No instances of perforation or bleeding were reported in either group.
2. The median postoperative hospital stay was significantly shorter in the stent group at 2.0 days (range: 1.0 to 4.0d) compared to 3.0 days (range: 2.0 to 5.0d) in the nasobiliary drainage group (P＜0.001).
3. The VAS scores for postoperative comfort were significantly lower in the stent group with a mean of 2.86±1.08 versus 5.13±2.19 in the nasobiliary drainage group (P＜0.001).
4. All 405 patients in the stent group returned for follow-up one month postoperatively. Stent detachment was confirmed in 373 patients (92.1%). Among the 32 patients with retained stents, two developed cholangitis, and two reported recurrent abdominal pain, resulting in a complication rate of 1.0%. In the nasobiliary drainage group, 10 patients (2.5%) spontaneously removed their drains, with an average age of 72.2±8.3 years.

Conclusion

The deployment of detachable biliary plastic stents without flanges following ERCP for common bile duct stones is as effective as traditional nasobiliary drainage in preventing postoperative cholangitis. This approach offers enhanced patient comfort, reduced hospital stay, and a high rate of spontaneous stent detachment, demonstrating its safety and efficacy in clinical practice.

Disclosure

The authors declare that there are no conflicts of interest.

Introduction

With the increase in the incidence of hilar cholangiocarcinoma, resection centres have seen an increase in the incidence of operable hilar malignancies. Biliary drainage of the future liver remnant (FLR) prior to resection has been demonstrated to improve surgical outcomes. Traditionally, preoperative biliary drainage has been achieved using either percutaneous (PTBD) or endoscopic (ERCP) techniques, with PTBD being favoured in many centres. Single operator cholangioscopy (SOC) via ERCP or PTBD, can enhance diagnostic yield and may optimise drainage. We sought to compare current drainage modalities incorporating SOC techniques in a cost effectiveness model.

Aims & Methods

A cost effectiveness model was developed using Markov healthcare states. PTBD cholangioscopy assisted drainage was compared to ERCP-cholangioscopy assisted drainage, ‘standard’ fluoroscopy assisted ERCP drainage with brush cytology and PTBD drainage with fluoroscopy guided endobiliary biopsy and drainage. Patients could cycle through each clinical drainage modality with crossover modalities in case of failure of a technique (e.g PTBD drainage for ERCP failure and PTBD external drainage for failure of PTBD cholangioscopy and internal-external drainage). Healthcare associated quality of life data were extracted from the literature to develop utilities used in the model. Procedure related complications were incorporated. Deterministic and Probabilistic sensitivity analysis (PSA) were performed over 1000 patient runs. Incremental cost effectiveness ratios (ICER) were calculated for a willingness to pay (WTP) threshold of £30,000 and net monetary benefits (NMB) for each strategy were derived.

Results

Base-case cost benefit analysis demonstrated that a strategy of ERCP-cholangioscopy assisted drainage (strategy 2, Table 1) was the most cost-effective strategy (Cost £1,895, effectiveness 0.51) and absolutely dominated the PTBD drainage strategies with an ICER of 8,630. The NMB for the ERCP and cholangioscopy strategy was the highest amongst the comparative strategies.

Table 1: Base case analysis

Strategy	Dominance	Cost (£)	Effectiveness (QALY)	ICER	NMB at £30K
1. ERCP, brushings, stent	Undominated	1,072	0.41	reference	11,303
2. ERCP, SOC and biopsies, stenting	Undominated	1,895	0.51	8,630	13,341
3. PTBD drainage + endobiliary biopsy	Absolutely dominated	2,887	0.27	-4180	5,231
4. PTBD drainage + percutaneous SOC	Absolutely dominated	3,616	0.25	-6678	3,889

On PSA, ERCP, SOC and stenting was the most cost-effective intervention with a mean cost of £ 1,895 (97.5% CIs (1,894-1,896)) / 0.51 QALYs, in comparison to ERCP, brushings, stent (£ 1,072 (1,048-1,098) / 0.41, PTBD drainage + endobiliary biopsy (£ 2,887 (2,855-2,927) / 0.27 and PTBD drainage + percutaneous SOC £ 3,618 (3,604-3,625) / 0.25. The ERCP-SOC strategy also delivered the greatest NMB at £ 13,340 in comparison to the other strategies. 1-way sensitivity analysis and threshold analysis did not identify any variable that impacted on the overall model.

Conclusion

A strategy of ERCP and SOC assisted sampling and biliary drainage seems to be the most cost-effective pre-operative biliary drainage option for resectable hilar biliary obstruction.

Disclosure

The authors have no disclosures to make.

Introduction

The success rate of endoscopic retrograde cholangiopancreatography (ERCP) is suboptimal in patients with complex surgically altered anatomy (e.g. Roux-en-Y anastomosis, pancreaticoduodenectomy) due to difficulty in advancement of scope to the target site and selective biliopancreatic duct cannulation. Although balloon-assisted enteroscopy can achieve a higher rate of intubation, its clinical application is limited by its small working channel and few compatible accessories.

Aims & Methods

We aimed to explore the feasibility and effectiveness of a novel endoscopic approach in patients with complex surgically altered anatomy.
This is a retrospective study of patients who underwent ERCP with complex surgically altered anatomy at our center with an annual ERCP volume of approximately 3000, between January 2018 and November 2022. The endoscopic procedures were performed by three senior endoscopists who had ERCP experience for at least 5 years. Long colonoscopy (measuring 168cm)-assisted ERCP was adopted as a first-line intervention, and selective biliopancreatic duct cannulation was performed after the target site (native papilla or the surgical anastomosis) was reached. For patients with failed cannulation, a plastic guide tube measuring 250 cm was inserted via the working channel of the colonoscope and its distal end was placed near the target site. The colonoscope was then withdrawn while the guide tube was left in-situ. By following the guide tube, a conventional side-viewing duodenoscope was cautiously advanced to the target site and biliopancreatic duct cannulation re-attempted.

Results

A total of 58 patients were recruited (mean age:56.7 years [standard deviation [SD]:14.4; male:36 [62.1%]]. The reconstruction methods were as follows – Roux-en-Y hepaticojejunostomy:32 (55.2%), Billroth-II gastrectomy with Braun anastomosis:11 (19.0%), pancreaticoduodenectomy:10 (17.2%) and Roux-en Y gastrectomy:5 (8.6%). Common bile duct stone was the most common indication for ERCP (n=30; 51.7%), followed by bilioenteric anastomotic stenosis (n=15; 25.9%), pancreaticojejunal anastomotic stenosis (n=7; 12.1%) and chronic pancreatitis (n=6; 10.3%). 55 (94.8%) of 58 had successful intubation by long colonoscope with a mean procedure time of 57.7minutes (SD:23.4). The mean time to reach target site was 19.1minutes (SD:9.0). The target site could not be identified in two patients and intestinal perforation occurred during endoscopic intubation in one patient. Among those with successful endoscopic intubation, biliopancreatic duct cannulation was achieved in 35 (63.6%) patients. For the remaining 20 patients with initial failure of biliopancreatic duct cannulation, intubation rate by duodenoscope was 100% by tracing the guide tube to target site. The success rate of biliopancreatic duct cannulation by duodenoscope was 85% (17/20) with a mean procedure time of 83.5 minutes (SD:21.1). The mean time to reach target site was 17.0minutes (SD:6.1). Notably, 90% (18/20) had either native papilla or pancreaticojejunostomy, in which selective biliopancreatic duct cannulation is known to be technically difficult with any type of forward-viewing scope due to unfavorable cannulation trajectory. For those with failed cannulation, two had anatomical stricture and one had impacted pancreatic stone.

Conclusion

ERCP by conventional duodenoscope with colonoscopy-assisted pre-placement of guide tube is a feasible, effective and safe alternative for patients with complex surgically altered anatomy in experienced endoscopists.

Introduction

Among the diagnostic methods for EHCC, cell brush is the conventional method for EHCC diagnosis, but the sensitivity of cell brush and routine biopsy is low. The sensitivity and accuracy of EHCC diagnosis can be improved by single oral choledochoscopy. Radiofrequency ablation is a common and effective treatment for unresectable EHCC, providing local tumor control. Single oral choledochoscopy combined with radiofrequency ablation can improve the positive rate of pathological diagnosis.

Aims & Methods

To investigate the feasibility and safety of treating nonresectable extrahepatic cholangiocarcinoma (EHCC) with single resection combined with radiofrequency ablation (RFA).
A total of 149 patients with suspected extrahepatic cholangiocarcinoma treated in Hangzhou First People's Hospital from January 2013 to January 2023 were reviewed. According to the treatment process, 114 patients were eventually included and divided into two groups (n=48 cases) : Single oral choledochoscopy was performed by ERCP and the lesion tissue was biopsied under direct vision. Intraoperative rapid pathologic examination was performed on the same stage RFA for the patients who were pathologically identified as malignant tumors. Regular times group (n = 66) : first by endoscopic retrograde pancreatic angiography (endoscopic retrograde cholangiopancreatography, ERCP) + cells brush or a single biopsy samples by mouth choledochoscope examination, pathological results to obtain positive line of ERCP + RFA again; The operation success rate, postoperative liver function recovery, average ERCP number, postoperative adverse event incidence, length of hospitalization and cost were compared between the two groups.

Results

1. Patients in both groups successfully completed the RFA, the operation success rate was 100% (114/114).
2. There was no significant difference in the overall incidence of postoperative adverse events between the two groups [39.58% (19/48) vs. 39.40% (26/66),χ2=0.00, P=0.984].
3. There was no significant difference in the proportion of patients with total bilirubin improvement between the two groups [41.67% (20/48) vs. 42.42% (28/66), χ2= 0.32, P=0.750].
4. The average number of ERCP in the same group was significantly lower than that in the conventional group, and the difference was statistically significant (1.00±0.00 times/person vs. 2.64±0.49 times/person, t=0.77, P<0.001).
5. The average length of hospital stay in the same group was significantly longer than that in the conventional group, with statistical significance (8.40±3.63 days vs. 17.47±9.82 days, t=6.21, P<0.001).
6. The average hospitalization cost in the same group was significantly higher than that in the conventional group, and the difference was statistically significant (27718.31±9142.02 yuan versus 49112.76±16153.14 yuan, t=7.38, P<0.001).

Conclusion

Single oral choledochoscopy combined with biopsy and RFA in the diagnosis and treatment of unresectable EHCC can reduce the number of operations and does not increase the incidence of postoperative adverse events, which is a safe and effective method with a high cost-benefit ratio.

References

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Disclosure

The authors declare that there are no conflicts of interest.