Introduction

Malignant biliary obstruction is the cause of numerous complications affecting nutritional status. Biliary drainage with stenting is the recommended palliative treatment for these patients. This study assesses the impact of biliary drainage on nutritional status by comparing patients before and after the procedure.

Aims & Methods

The aim of this study was to evaluate, through a retrospective analysis, the variation in patients nutritional status before and after biliary drainage wether in perihilar or periampullary strictures.
We studied 200 patients with malignant biliary stenosis who underwent endoscopic biliary drainage. Demographic, anthropometric and clinical data were collected before and after drainage in two stages (1 month and 3 months). Statistical analysis was performed using SPSS26 software.

Results

The results showed a significant increase in mean weight, reaching 59.27kg after 3 months (p<0.05). Mean BMI also increased significantly, (20.39kg/m² after 3 months (p<0.05)). NRI (Nutritional risk index) decreased significantly after drainage. 35.17% still had severe undernutrition after 3 months (p<0.05). Mean ALB (Albumin) increased significantly, (34.52g/l after 3 months (p<0.05)). Mean TB (Total Bilirubin) also decreased significantly, (15.03mg/l after 3 months (p<0.05)). However, the decrease in CRP was not statistically significant. The WHO performance score showed significant improvement, with 25% of patients presenting with Stage 0 after 3 months. Pruritus and jaundice were absent in 100% of patients after 3 months, and vomiting absent in 90% of patients after 3 months (p<0.05). When comparing the perihilar and periampullary stenosis groups, no significant differences were observed for any of the parameters studied.

Conclusion

The study suggest that endoscopic biliary drainage significantly improves the nutritional and clinical status of patients with malignant biliary strictures, independently of the location of the obstruction.

Disclosure

No conflict of interest.

Introduction

Malignant biliary strictures are mainly secondary to biliopancreatic cancer, and inevitably affect the nutritional status of these icteric patients. Deterioration of this nutritional status conditions therapeutic management, particularly surgery.
The aim of this study is to assess the nutritional status of patients with biliary stenosis.

Aims & Methods

All patients with non-operable malignant biliary stenosis who underwent endoscopic biliary drainage were included from 2015 to 2022 in a single-center descriptive and analytical study. Patients with advanced WHO 3/4 impairment of general condition were excluded. Nutritional status was assessed before and after the procedure (3-6 months) on the basis of weight, BMI, weight change, nutritional risk index (NRI), albumin and CRP levels. The various data collected were analyzed using SPSS software.

Results

200 patients were included: mean age 59 years (18-96 years) with no clear gender predominance (sex ratio=1.04). The etiology of malignant biliary stenosis was dominated by cholangiocarcinoma in 112 cases (56%), followed by pancreatic cancer in 64 cases (34%), extrinsic compression in 16 cases (8%) and ampulloma in 8 cases (4%). Endoscopic biliary drainage was performed in 192 cases (96%), bilio-digestive anastomosis in 6 cases (3%) and trans-hepatic drainage in 2 cases (1%). Pre-therapeutic nutritional assessment showed that: 100% of patients had significant weight loss with a mean of 21.91%, 71.5% had anorexia and 47% were underweight (BMI < 18.5 kg/m2), 83.5% had hypoalbuminemia and 84% had elevated CRP. An improvement in nutritional status was noted 3 to 6 months after biliary drainage, with an improvement in: underweight from 47% to 17%, severe undernutrition from 61.5% to 22.06%, anorexia from 71.5% to 18.61% and an increase in mean albumin level from 29g/l to 34.52g/l and a decrease in mean CRP level from 61.73 mg/l to 26 mg/l. The 6-month survival rate was 72.5% (n=145).

Conclusion

Malignant biliary strictures are essentially linked to cholangiocarcinomas, with a clear impact on nutritional status, represented by weight loss in all cases, anorexia in around ¾ of cases and underweight in around 50%. The impact of biliary drainage on nutritional status is clear, since there is an improvement in the various clinical and biological factors assessing the latter.

Introduction

Endoscopic drainage is standard of care in malignant biliary obstruction (MBO).

Aims & Methods

The aim of this study was to investigate efficacy of biliary stenting in providing access to systemic chemotherapy. Patients with biliary obstruction (bilirubin >2.5 mg/dl) caused by unresectable biliary or pancreatic cancer were retrospectively analyzed with respect to use of chemotherapy and survival. Laboratory data were analyzed at baseline, 7-10 and 28-35 days following biliary stenting.

Results

Patients with MBO (n=78) were allocated into one of three groups according to bilirubin level [mg/dl] 2.5 – 5.99 (group 1), 6.0 - 15.0 (group 2) and >15 (group 3). On first blood testing mean bilirubin declines from baseline in respective groups were: 1.19 (29.5%), 3.77 (38.5%) and 7.1 (27.3%), and on second measurement 1.61 (40%), 5.69 (58.2%) and 13.0 (50%). Chemotherapy was applied in 28 (35.8%) patients, less frequently in group 3 than in group 1 (31.2% vs 44.0%; p =0.07) and group 2 (vs 38.1%; p =0.06). Mean survival time was 4.8 ±2.8 months and was significantly shorter in group 3 as compared to group 2 (3.8 ±2.0 vs 6.2 ±3.9 months; p =0.02) and to group 1 (vs 5.4 ±2.7 months; p =0.03).

Conclusion

In two-thirds of patients with MBO endoscopic biliary drainage does not grant access to chemotherapy. Use of chemotherapy and survival time are significantly higher in patients with bilirubin level below 15 mg/dl as compared to those with greater bilirubinemia, but in patients with bilirubin level below 6 mg/dl the biliary drainage is minimally effective.

Disclosure

No.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is an effective therapeutic option for biliopancreatic cancers, which generally have a good prognosis. However, endoscopic drainage remains a challenge for endoscopists. The aim of our study was to report the outcomes of endoscopic biliary drainage in biliopancreatic tumors and to analyze the factors associated with its success or failure.

Aims & Methods

This was a retrospective, descriptive, comparative, and analytical single-center study conducted in a gastroenterology department over a 5-year period (2019–2024). It included patients with biliopancreatic tumors who underwent ERCP for biliary drainage. Data were collected from medical records and patient follow-up. Factors associated with overall success of endoscopic biliary drainage were analyzed using univariate and multivariate binary logistic regression models.

Results

A total of 206 patients were included. The mean age at diagnosis was 63.2 ± 11.8 years. The female-to-male ratio was 1. Smoking was reported in 31 (15%) patients, alcohol consumption in 17 (8.2%), and a history of biliary surgery in 11 (5.8%).
Pancreatic tumors accounted for 116 (58%) cases, cholangiocarcinomas for 68 (34%), and ampullary tumors for 16 (8%).
Cholestatic jaundice was present in 170 (82.5%) patients, general health deterioration in 133 (64.56%), biliary colic in 48 (23.3%), and pancreatic-type pain in 50 (24.2%). The median bilirubin level was 225 [131–279] mg/L, with 95 patients (46.1%) having levels above 150 mg/L.
During the endoscopic procedure, an abnormal appearance or position of the papilla was noted in 13 (6.3%) patients. A precut or Burdick technique was used in 29 (14%) cases. The double-guidewire technique was used in 33 (16%) patients. Cholangiography showed distal bile duct stenosis in 170 (82.5%) cases. A stent was placed in 168 (81.5%) patients: 120 (58.2%) had uncovered metal stents, 40 (19.4%) had plastic stents, and 8 (3.8%) had covered metal stents.
The overall success rate of biliary drainage was 192 (93.2%).
In univariate analysis, factors associated with drainage failure were the presence of cholangitis (OR = 3.35, 95%CI [1.62–6.9], p = 0.001), bilirubin level >150 mg µmol/L (OR = 3.88, 95%CI [1.6–9.39], p = 0.003), and abnormal papilla appearance or position (OR = 8.73, 95%CI [4.86–32.22], p < 0.001). In contrast, distal bile duct stenosis was associated with successful drainage (OR = 0.56, 95%CI [0.42–0.17], p = 0.045).
In multivariate analysis, after adjusting for the studied variables, predictors of drainage failure were a bilirubin level >150 mg/L (OR = 3.13, 95%CI [2.28–23.15], p = 0.01), and abnormal papilla appearance or position (OR = 4.21, 95%CI [3.18–14.23], p = 0.002). Conversely, predictors of successful drainage included the presence of distal bile duct stenosis (OR = 0.3, 95%CI [0.09–1.03], p = 0.05), and the use of a precut or Burdick technique (OR = 0.44, 95%CI [0.03–0.7], p = 0.047).

Conclusion

Despite the emergence of new techniques, ERCP remains the most commonly used method for biliary drainage in biliopancreatic tumors. Our study identified two main factors predicting failure: a bilirubin level above 150 mg/L and an abnormal papilla. On the other hand, factors associated with success were the presence of distal bile duct stenosis and the use of a precut or Burdick technique.

Introduction

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a minimally invasive and promising alternative to percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) in managing malignant biliary obstruction. Different techniques are available such as choledocoduodenostomy (CDS), gallbladder drainage (GBD) and hepaticogastrostomy HGS). All have been shown to be safe and effective techniques, but which is the most suitable and effective approach is still unknown.

Aims & Methods

We aim to compare the three techniques available in terms of technical success and clinical success, and to assess the adverse events related to the different procedures. Single center retrospective analysis of all consecutive cases of CDS, GBD and HGS acceding to the Therapeutic Endoscopy Unit of Fondazione Policlinico Universitario Campus Bio-Medico of Rome. Data about patients and procedures were collected. Technical success was defined as successful biliary drainage with stent placement. Clinical success was defined as a decrease in total bilirubin level by ⩾30% within 7 days of EUS-BD.

Results

From April 2016 to December 2024 101 patients were included (47.5% male, mean age 74.6 years old), all with malignant biliary obstruction. 52,5% of the subjects (53/101) underwent EUS-CDS, 22,7 % (23/101) underwent EUS-GBD and 24,75% (25/101) underwent EUS-HGS. In 35/101 (34,65%) duodenal stenosis was observed. A total of 7 patients had altered anatomy. The mean procedure time was 26 ± 15,7 minutes. Overall technical success was 93%, 48/53 (90,5%) in the CDS group, 23/23 (100%) in the GBD group and 23/25 (92%) in the HGS group. Overall clinical success was achieved in 57/79 (72%), 29/38 (76,3%) in the CDS group, 12/20 (60%) in the GBD group and 16/21 (76,1%) in the HGS group. When considering a reduction in bilirubin level ⩾50%, the overall clinical success was lower (55%). Adverse events occurred in 6/101 (5,9%) of the patients, 3/53 (5,6%) in the CDS group, 0/23 in the GBD group and 3/25 (12%) in the HGS group. There was no difference in terms of sex, age, altered anatomy, presence of duodenal stenosis and the EUS technique performed. The mean time of the procedure was higher in the HGS group, with a difference statistically significant (CDS=22,87±14,78 min, GBD=26±15,73 min, HGS=41±16,09 min, p=0,005). No difference was observed in terms of technical and clinical success, and adverse events between the three procedures. However, if the reduction in bilirubin level ⩾50% cut-off was used, the HGS was the procedure with the highest rate of clinical success (CDS 59,5% vs GBD 25% vs HGS 76%, p=0,003).

Conclusion

EUS-BD is a safe procedure with high technical and clinical success rate and it s a valid alternative for managing malignant biliary obstruction in high volumes centers. No differences are described between the three approaches. However HGS seems to reduce bilirubin levels more quickly, with longer procedure time.

Introduction

Hilar cholangiocarcinoma patients often require biliary drainage, but objective tools for assessing the effectiveness of endoscopic biliary drainage are unsatisfactory. Studies have shown that biliary obstruction can reduce hepatic blood flow.

Aims & Methods

The aim of this study was to analyze changes in portal vein flow after endoscopic biliary drainage and evaluate the correlation between portal vein flow and liver function.
​A prospective study enrolled 14 patients who underwent endoscopic stenting for hilar cholangiocarcinoma between September 2021 and June 2022. Portal vein velocity (Vmax) by Doppler ultrasonography and bilirubin level were assessed on all patients before and on the 1st, 3rd, and 14th days after endoscopic drainage. The patients were divided into two groups based on the success of drainage, with 11 patients in Group A (successful) and 3 in Group B (unsuccessful).

Results

​The mean Vmax was 14.3 ± 2.5 cm/s before endoscopic drainage and 16.4 ± 3.3 cm/s, 18.0 ± 3.6 cm/s, and 20.8 ± 5.5 cm/s on the 1st, 3rd, and 14th day after drainage, respectively. The Vmax was significantly higher on each day following drainage compared to before (p<0.001). The rate of increase in Vmax was significantly higher in Group A than Group B on the 14th day (1.6 ± 0.48 vs 1.1 ± 0.13, P=0.03). The rate of increased Vmax correlated significantly with the rate of decreased serum bilirubin levels (r² = 0.407, P < 0.001).

Conclusion

​Successful endoscopic biliary drainage in hilar cholangiocarcinoma significantly increased portal vein velocity (Vmax). Vmax assessment by Doppler ultrasonography may be a useful tool for evaluating the effectiveness of endoscopic biliary drainage in malignant hilar biliary obstruction.

Introduction

Endoscopic biliary drainage (BD) in patients with altered anatomy is a challenging scenario reducing the chance of clinical success compared to standard anatomy. The choice between different BD approaches is still not standardized and relies on local availability and expertise.

Aims & Methods

Aim of this study was to explore the type and the number of endoscopic BD approach in patients with altered anatomy in different Italian centers. This was a retrospective multicenter cohort study within the i-EUS network of biliopancreatic endoscopy. All adult patients with upper GI surgical altered anatomy who underwent endoscopic BD for any indication in the last 5 years were enrolled. Patients with Billroth-I or sleeve gastrectomy were excluded. Patients with duodenopancreasectomy were grouped with patients with BillrothII reconstruction for the statistical analysis. Fisher’s exact test and Mann-Whitney test were used when appropriate.

Results

21 centers participated in the study. All centers were equipped for interventional endoscopic ultrasound (EUS) whereas only 7 centers had also the availability of device-assisted enteroscopy (DAE). 428 patients were enrolled. Clinical and BD techniques characteristics of patients are described in table 1. Indication to BD was not different between patients with Billroth-II (B-II, N=263) or Roux-en-Y (RY, N=165) reconstructions. 16% of patients had at least one previous failed BD attempt. B-II anatomies were more frequently managed transpapillary with a duodenoscope or a forward viewing scope (85%), whereas in case of RY reconstruction BD approach was more heterogeneous. In 68% of RY cases endoscopic BD was performed with a luminal approach (in 43% of cases with standard scopes). In patients who underwent to EUS-BD, hepaticogastrostomy or antegrade stenting were performed in 74% of cases mostly for malignant indications (90%). Type of surgical reconstruction did not affect the clinical success (84% in BII and 79% in RY, p=ns). Interventional EUS demonstrated a higher clinical success compared to DAE (94% vs 73%, p=0.004). The total number of procedures to achieve clinical success was similar between B-II and RY patients. Patients who failed endoscopic BD for whom follow-up was available were managed by PTBD or surgery in 71% and 15% of cases respectively.

Conclusion

Endoscopic BD in altered anatomy has a sub-optimal clinical success compared to standard anatomy. A relevant proportion of patients requires more than one endoscopic attempt to achieve the clinical success. Despite the recent advent, interventional EUS is optioned in a significant proportion of patients and demonstrated a high efficacy in patients with surgically altered anatomy.