flffh international course on therapeutic...

FlFfH INTERNATIONAL COURSE ON THERAPEUTIC ENDOSCOPY

Endoscopic stenting of the biliary tract and pancreatic duct

K l l LliRREGTSE, MD, $ RI VERA-M ACMURRA Y, MD

K H UIBREGTSE, S RIVERA-MACM URRAY. Endoscopic st cnt ing o f th e biliary tract and pancreatic duct . Can J Gastroen terol 1993;7( 1 ): 15-22. Biliary and pancreatic drainage by endoscopic insertion of endoprostheses has become wutinc treatment for patients with ma lignant obstructions. This method is particularly indicated for pa tients with irreseccable tumour o r contra in<licat ions for surgery. However, accumula ting data suggest this methoJ is supe rior even to surgical pallia tive procedures. Endoscopic trea tment of ben ign bilia ry and p,mcreatic strictures is more controve rsial a nd further studies a rc needed to estahlish its place a mong t he o ther n on surgical and surgica l treatme nt mod alit ies. A survey of possible ind ication s, success ra tes and complication rates are <liscusseJ and compared with o ther treatment optio ns.

Key Words: Bile duct strictures, Biliary drainage, Endoscopic retrograde cholangiopancreawgrapliy, Obstructive jaundice

Moulage endoscopique des voies biliaires et du canal pancreatique

RESUME: Le <lrainage bilia irc c t panc rcatique par insertion endoscopique d'cndoprothcscs est dcven u un traitemcn t de routine ch ez lcs pat ients attc ints d'obstruct ion malign c. Cet tc mc thodc est partic ulic re ment in<l iquee c hez les patients porceurs <le cumeurs impossibles a rcsequer ou chez qui il est contre ind1quc d'in tcrvcnir ch irurgicalcment. Cepcndanc, les do nnccs recucillies suggcrent que cettc me thode serait meme superie ure aux interventions chirurgicalespalliacives. Le traitc mcn tendoscopique des retrecissements beninsdes voics hiliaireset pancreatiques est plus controverse e t d'autres etu<les sont requises pour evaluer son role pa rmi les autres modali tcs thcrapeutiqucs chirurgica les et non chirurgicales. O n proccde a un survo l des indications possibles, des caux de reussitc ct des caux de complicat ion proprcs a d ifferences optio ns cherapeutiqucs.

SINCE Tl IE INITIAL DESCRIPTION IW

SochcnJ rn in 1980 of endoscopic in,t'rt1on of a transpapil lary stem (I), tht procedu re h,1s gained wide ,1ecept.1nceanJ multiple applica t ion~ ( 2). lnJiG1tinn~, complicatiom a nd success r,1tt·, have been studied. Endoscopic ,tmt placement in benign and mal ig-

na nt bd ia ry lesions, and managcmc n t of pancreatic disorders arc d iscussed .

TECHNIQUE OF STENT INSERT ION

T he aut hur~ use an e ndoscope with a large 4.2 mm instrumen tat ion channel to ~tan rhe procedure, a lth ough

Academic Medical Cemer, Amstenlmn , Tht> Ner/1erlamh l :orr~i(>ondence and reprints: Dr K 1-/ 11iln·eg1se. Unit•crnzy of AmsrerJmn , Academic Medical

c~mcr, M~ihcrgdreef 9, 11 05 AZ A1mcerJam , Th~ N<!chcrland.,

C,\\J l, \ ~TROENTEROI Vl )I 7 Nu J jANUJ\RY/FEBRLJAR) 1991

others prefer to use a d iagnostic endoscope with a 2.7 or 3.2 mm channel ini t ia lly. C a nnulat ion may he d ifficul t because of tumour compress ion , Jbplnccmen t or fixation. On occasion a precll[ papilloromy may he needed to

unroof the papilla and en gain access to the bile d uct. After routine endoscop ic retrograde cho la ngiopancreacography (ERC P) n 6 co 8 mm sph incterotomy is performed to fac ilita te stent insertion a nd subsequent exchanges. Cyto logy bru~hi ngs arc don e at th is poin t. Then a Teflon catheter con rn in ing a n atraumatic nex ihlc rip guidewirc is inserted into the co mmon bile duct up w the structure. The gu idewire is man ipulated across it by move me nts of the wire , the catheter and the cndmcope as needed under tl uornscopy. Forcctul pushing should be avoided so that false passages arc not c reated.

O nce the rigid rart of the guidewi rc is we ll above the stcnosis, the Tenon catheter is pushed above the stric ture a lso. T he stem is loaded nn to the T ct1un cathe ter a nd wi re assembly and advanced tt) t he t ir of the endnscopc \\'i th the pusher tuhe. T he e levator bridge is opene<l whe n the sten t b fe lt to he adjacent to it. The whole assembly (guide wi re , Teflon cmhcte r, scent nnd pusher tuhc) is then moved forward hy advanc ing chc pushe r rube. T he assistant sec ures and withdraws the guiding catheter/wire slightly as rhc c ndnscopist advances the pushe r tuhc. T he endnprosthcsis is moved up the duc t in a stepwise fash ion as the endoscopist opens and clmes the e leva tor hridgc in coord ination with elevat ion of the e n-

15

I IUIHRE< ,T:,I 1\NI l RI\ Ht·\ M •\l 'Ml 'RR:\ Y

Figure I) Enduprmrlie~i, m d11od<?n11rn 11,ir/i /!OOd /iii<' j1ow

Figure 2) Parrem u,rr/1 pose c/10/ccv.-rccwrnv hi/<· b1kc1.~e tl11<' w ,1 cli.,wl hilc J11.:1 ohsrrncrion c,wwd h,• 11 />(111c1eari, ,llltrcr. Left Srri,11tr<! rn 11,mcr<?c111c cl11c1 tl11e ltJ />lllllT<'(l(IC CclllCl'l Right Jl,/<' /c(l/-<1.Qc /i'om c,•,11r ~11m1J1 w1el /,i/i,irv c11do1>rnsr/i,·,i,

doscope tip towards the p;ipilla. Tho.?

right/left knnh is in the locked pusll iPn.

Cnre should he takl'n to keer t hL· dis

tance h<.?t ween the l'"ri ll;i :ind the L'n doscnre slwrt . Howing pf the ste1H in

the dll\idcnum m,1kcs successful in,er

tinn unlikely. When the d 1swl flap re,iche, the papilh1, th l' assist.mt pulb

the Tdlon catheter and wi re ,1ut as thl'

16

end,iscopist h u kb the stL·n t 111 111:KL'

with the pusher tuhe. 0 1K,· the stcnt i,

frl'L'd from the endnsuipe ,1h1lut I un

should be pnitruding frnm the papilla

(Figure l ). Aftcrdr:1mage isestahlished

<.?ndoscnp1cally or undn fl uc ,n ,scopy

the cnd,iscPpe i, withdrnwn.

Most stenh are ,tnlight ll1 Fg. Nine

centimet re ~tent , ;ire often us,·d for dis -

w l comnwn hile duct strictures, 11 cm

stcnt s for mid comm,m hill' duct stric

ture,, 14 cm stents fm h1 furca1 ion <1ml

19 cm stents fiir 111rrnhcpmic strictures.

INDICATIONS IN BENIGN BILIARY LESIONS

Postoperative bile leakage: I nad\'crtenr damage t,1 1 he hill' duct during

surgery can rc~ult in hiliary-L utaneou,

or biliary-peritoneal fistuln~. nr high output from T-tuhes 1f present. Inade

quate c losure o l the L)",llc stum1~ can

have the same efkct. Trnditinrrnlly

patients have undcrgunc ,urgic,11 repair.

hut in the past few yc,irs several groups

have ohw incd .£!11od re.,uli , w ith endo

sc,1pic treatment (3.4 ). The authors' experience w1rh 55

p<1tients w,1s recent!) re,·1ewed (4). Patients presented with htli,iry-cutan

eous fistulae, perttlmitis, 1ntrac1hdnm

inal abscess, increasing J<lundice, Lhol

angitis <'r pat1Lreatitis. At ERCP,

cxtravasnrcd cnntrast flowed from the

cystic duct stump ( 3 I pa11ents), rhc

common hep,1tic duct (six patients),

the common hile dull (six patients). a h <.?patiL rad ical (four pmiem,) and from

a surgical anast,1mnsi~ (one p,ll1en1 ).

ERCP foiled in one patient with a Rillrnth 11. Eventual closure of the b1ks or fistul.1e was achieved in 4 3 of the 4tl patients (90'}b) tre,1ted rndo,rnpically.

Most c losed wit hm I to IO days. Fi\'L' patients died n( persistent ,cpsis ( l 0%). Ohtruc ti,,n distal to t hL· sit~· nf hik

leakage due rn 1Ts1dual swne, m ,t r it.:

tu res was seen m I 0",, llf tlw pat 1ent,

(Figure 2). The purpose I if trt:nt ment b tu

facilitate hile flnw 1ntll the duodenum

by c liminilting re'iistance m t h.: sphinc

ter nf Oddi. P:11 il'nt' were treated in tlw follnwing W,l\' . If the cys1 iL stump ,,r hep,ll!C rad1Clc kabge w,1, ,ecn \\'ith

out dist,1' ohstruct1<m lm ly a sphinL·

teromy wa, dlu1e. If ,wne, \\'ere seen 111

the Cl>mnHm hik duu, rhey \VL'IT cx

trnued after ,phmcrer<1tl1111y. If there was ,1 his1ory ,,( upentrive hiliar)

traum,1, nr ,1 ,t n c ture wa, , 1hservl'd, nr 11

,di ,wncs could n11t he exrrncted, ,1 10 Fg ,tent wa, plaled . The pn1'1hes1s 1,

hclp(ul m dil,1ting a narnnwd area

during the healing ph:i,,e, thereh)

dL'Cl'L'a, i ng t h t risk nf Lite , t ri c t ure for ·

marion. In pan e m , 111 whrnn a stncture

wa~ found l ln C or t Wl 1 sce nts we re placed for about one year. T hen: were no earl y complacauo ns. Lite compliG1tio m 111-cluded chn langH 1, 1n two patit·nts (despite trimonthly stcnt excha nge:..)

and recurrent stnLturc aft er scent removal 111 one p;n1cn t.

Endoscopic cv.1lua tio n ,111J mter

\'Cntion 1s a valua hlc tolll 111 the diagnm,is and management o f pllstoperall\ 'C

bile leakage a nd should he perfo rmed a, \\Xm as 1t ,, suspeued.

Postoperative and benign bil iary strictures: Pllst opera ti vc hiliary strictures

occur 111 2 to S°'o of paucnts afte r h il,ary tract surgery ( 5 ). The choice nf drainage procedures inc ludes hiliary enten c bypass surgery a nd pcrc ur.rncllu, u r

tndoscnpK stenrmg and ba llolm dilatation. There arc no rand(l111i:cd contro lled studies companng the three upn llm.

Scnc, from maim cent re, rc\'eal

good results with e11Joscop1c stents. Gccncn ct al (6) repllrted excelle n t or good rc,pome m 2 5 pa tien t, ( 88'1-i,) who underwent balloon di lat io n and/\1r

, tent placement over a mean fo llo w-up of 48 months. T he re wa, no , ,gnifiLant

morb1d1ty or morta lity assrn.: mtcd with the procedu re. In rc,·1c,,·111g the present authors' expericnLL' with 70 pau cnt ,,

8'3% had a good or excelle nt respo nse (7). Se\'entccn pe rcent h.id recurrence ot the stric ture afte r , tent remo\'al over

a mean fo llow-up of 42 months. T he re was 2.5% 30-day morta li ty.

These n umhcr, cumpare \'l'ry

favorably with thme from a rcccn1 study (8) which showed that cxpcrr ,urgery achieved result, 111 80 w 90'\, \if ca~c~ over a fi ve-year fo llow-up. A no n surg1Cal approach may he tlw hcst 1111 -nal procedu re wnh surgery reserved (or

those wnh recurrence,.

These paticn b a rc usuall y managed ~\ plac ing one stt·n t fo r ,,x wecb ( F,gurc3 ), after whid1 two IO rg stem s nrc

,mcrtcd. T hey arc left in place lor o ne

year, replaced every three mnmhs (or carl,cr) if c ho langit ,.., cn~ucs. T hey arc

kept Ill place for o ne year. A nrihiuu cs .ire adm1111stcrcJ ,f c ho l,mgn,, ,,

present or 1f successful d ramagc ,.., not

llbtaincd. Bccau,c o f the t 1ght fi brnt IL nature of the stric tu re:-., 21 "o 111 pau cm s rcqu1rc dilm ion hcforc , ren t placement.

Endoscopic stenting

Figure 3) P<Hr.:nr U'lth li1·a crrrho.si, d11<' co 11 />ml o/1cr,ui1.: hi/1<11)' ,rncllfh' Left Pmro(',•r<111t·c ,cnc11irc ar rh,• h1f11rcarron Right / "ndo/>rc,rhl',i., r, 1mcrrd for ,rrrco,r,• dilmion

Ball1111n L,ll ht·tc·rs (4 tu ti mm l\Uts1dc dia meter ) or meta l t ippeJ d ilm mg Lathe rer, L,tn be u,cd . Ball\l11n d1bt1on a l11nc ( w1th\lut sten t mg) ha, 11\lt been fo und to he henc fic1.1 I, hy rhe,c author,,

a lthough o ther, h,I\ c rcp11n cd gnod rc,ul ts with J,brnm \in ly.

hna lly, afte r rc muva l o f t he stcnts.

the ,mcturc· " cnnsidcrcd ,uff1ucnt h d 1L1tl'd ,f ,1 I cm ha ll11on can he pulled th n1ugh c.1sily or If rap id Jr.image i,

,t'l'n under flt ll 1rosc"I'\ llther hc111gn ,rr1L turcs l,lll he

t reatl·d 111 t ht· same manner hu t La!"l' 111u,t he taken t11 c•n,urc th,ll the\' ,ire· mJ\'l'd hl·n1gn . A laLk 1,f .1 rumour 'sh l·lf' or L'\'L'n ncgau vc cyto logy hru~h

111gs du ll\ll rule o ut mal ignant\. Endnscol'iL hili.H\ dramagc 1, also

u,cJ fo r pau cnr, w1th ch rornL J'ancrcatll ts who ha,·c in trapancrcallL h il, an st n uurc, La using Jaund ice. T hc·,e ,tnl

turc, arc usuall y lunger, Sl11\lllt her and eas ier to m tuhatc t h .111 rhnsc c.uiscd h, panncatl( lancer. Thl' natt11 ,1 I h1't111·, nl these ,tnl tu rcs 1, unc le,1r. Ril, ary

dram.1ge prm 1dt•.., an .1dequmc tcmJ'nr

ar\ mc:isurc while the pnt1en t undergoc, further e\'aluatton. h abo ,cr\'l'' n, an .1 lt crnat l\T Ill , u rjc!cry 111 high nsk pau c n r,.

Primary scle rosing cholangitis: P rimary sdcm,mg d 1(ilang1 t1, i., a chn,n1L

(ibmsm g m t1:1mmatory J 1scast• uf the mtr,l - ,rnd l'Xtr.1hcp,1t 1L h,k d11Lt, rcstilt mg 111 arl•as nf ,rrll t urcs ,md Jilat1\m, form inl,! the cla,,1c 'head mg' pattern Its pathogl'nc,1, ,, unkn1l\\n but

c, ,,knee ,ucgcsh an ,wtrnmmunl' pmcess. Evaluat 1<ll1 ,ii c ndtiscPptc t rcnt·

mcnt "hamJ't·rcd h t lw ,111,111 numhcr, , ,f J',ll ll'n ts rcportc·J .md th<? , ,m ,1hil1t,

n f 111ten11J1v1dua l disc',hL' ('.l tl l'r1's.

T he di,ea,l' ca n aflelf 111tr,1hl'J'atic, cxt rahcpatiL 1,r h,ith Juu,il ,,,tc·m, to vary mg ,kgn:,·,. Nonctl1L' le,,, t re,11 -mcn t 111 1~,ll ient, \\'llh d1ol.111}.!it1, ,mJ

,a1m,l1cl' "hn h,1\·l' dnmmanr ,tnuurc:, (dass1 ficJ a, 111,1Jnr d ur t,11 smcturt·, m pn m,iry hrand1c ... 111 large 111tra- nr

cxrralwpat1c Juu-.) 1s .1dnic,ncd (2,9). StonL', and dl'hn, arc rcmll\ ,·d and the

17

Figure 4) Parrenc u•uh r..>curr<?m />ancreatrm and /U1ncr<?<1.1 dit•is1nn Top H,Rhh dilcu,•d dona/ Ji,mcr<?,wc J11L1 Bottom Fmlo/mMh<'"' (IO F~) ,, imerc<?J t•ia minor pa/>illa

striuures l'ither Jil,HeJ with ballonm m ,tented. Follow-up nf 35 p.u,enb rrl'atl·J with coml,inat 1011, of ,1cnh ,md di lari<lns shrnwJ sign ifk,mr 1mpr, 1vement m r,Hcs nf hnsp1t ,1 li:,1t ion for chulang1us and Ill lahur.itt>r) data (9) Antih1uLics should he giwn ht•fnrl' and l!lr se\'eral days ,1ttcr Lrl'atmt·nt. Nasobtli,H) dramagt· should hl' LN'd if dila rion llr stcnr placement 1s not immcd1atdy poss1hk. Follow-up attl·mpb tan tl1l'n hl• performl·J ,aid) .1 few days later. One ,1udy found that if adequatl' d1l,ll1 lll1 could hl· llht,11ned \\ uh Crum : ,g halkions ur Sodwndra dilaung cathl'ters, stenb shuuld prnhahly n11t be phlLl'J ,1, they appt·,1r r11 111treasl' the risk of suhsl'qul'nt thlllangitb (9) Biliary endoprostheses in gallstone disease· Ol.c,1s11mallv ,ery dJerl) ur very high risk parit·nt, ha\'l' common hde duct swnes that .,re l'lthl'r toll l.,rge or t<lll numl'r<lus fnr end1istop1t dearance. Despite the many treatment mmlal 1tics ,l\',lllal,k•, .,l'\ era[ st uJ,e,

have shown that scenting is a reasonable hmg term alternanve m this suhgmup of patients ( I O, l I). One study of 63 pat1enb treated with permanenr cnJoprosthcsb rep1irted good resulh m a Ol1l'· t\l five-year follow-up with only 14 p,1t1ents requiring scent exdrnnge ( 12). The exdrnnge is not rout me, ,111d should he performed only if pauent, hcu,me symptomattc. The ~tent, ,f possihlc, should he 19cm hmg,norderthat 1t can he positioned high in the biliary tree Ml It docs not migrate out. It~ purpo,e ts tn pre,·e1,r :-cone 1mpact1on and thus l hl1langit1s. Pancreatic drainage: flccaw,e therapeutic end11scopy ot the pancrt·as ts rechn1c,1l ly d,ffiuilt and chronic panul'atllis 1s uncommon, llllbt studies ha\C heen tnnducted at the few Lentres with the necessary l'XPl'rt1se. Treatment t,m cnns1st uf panueauc sphtnctcrowmy, stone extr,kt inn, stnuure dilation, nasoparn.: reat ic dramagl' or stcnt pl,1eemen1 ( I 3-16) (Figure 4 ). Srndies 111-

volving a total of 54 patients wnh chronic pancreat1t1s m whom a stent was placed m the main duct across a dominant st ricture showed unproved pain tomrol 111 9 L 0«, ( 17). Several other studies have shown decreased signs and symptoms in panents with pancreas J"·bum who had a stent placed 111 the dorsal duu. Although the results of srenc placement arc encouragmg there arc potential mks, such as tnducmg further duccal changes, that must be studied ( 18). Because M> many questions remam as m optimal duraunn of therapy anJ pauent sclecuon, general clinical use of pancreat1L stems is nm recommended at present

MALIGNANT BILIARY STRICTURES

Malignant hde duct obst rtll tion 1s ,t discasl' mainly of the elderly ( 19). B~ the time clinical signs and symptom, occur and patients present l\l physi c1ans, spread to the liver, nodal hed anJ adjacent vascular ,tructures ha~ frequently Otturred (20). Because of thl· late presentamin of the mal,gnanq and the concomitant physiologic dy,functHm of the elderly, kw can undergo lurat1ve re,ecuon. Pall1at1\·e surgical intervention has an overall npcratl\'C mortality llf 20 w 30'l'o (2 1,22). Surgical mcervenrion, howe,·er, l>ffers tht: nnlv chance nf a cure. Therefore, carcfu I tonsidernnnn for surgical 1nterven t1on is warranted on an ind1v1dual hasi,, taking into cons1dcrat1nn the type an,I cxtenr ut the tumour, ,md a patient\ physmlogital status. For the majortt; of patients endoscopic therapy nffcrs dw hest llll'thod of pall1at1nn. Thl.· ratttin· a le for pall,atl\'e mtnvent1on is the rt:licf of prunrus, malaise, onas1onal cholangitis, multtpll' mgan dysfunction anJ phy,wlog,cal impact of jaun<li<.:c. I

Because of I ts ddeten ous effects llll mulnple mgan ~ystems, ob,tructi,·c jaundi<.:l' ,, thought tll tnuease surgi<.:al murhid1ty anJ mon,,lity. Thrt·e random1:ed ,tudie, \\'llh percutaneous dramage have not ,hown l,enclu (23-25). Whether enJoscop1t dramage with ,rlower risk of compl1catiom will shim anv benefits remains to he studied.

Suctessful dn11nage rates and cornplicatinm, ary w1th the Sill' of nl:istruc-

11> C,\N J G,\~lRl)l'NTERt1L Vt11 7 Nt1 l ]ANUARY/FHRUAR\ 199l

TABLE 1 Results of biliary endoprosthesis in 1153 patients (38)

Bifurcation Gallbladder c arc inoma

(biopsy proven) Pancreatic

carcinoma Papillary carcinoma

Mad/on survival/sin days (range)

Success rate

85% 86%

92%

97%

tion (Table l ). The management of distal, mid common duct and proximal biliary tree lesions is described. Distal lesions: Papillary carcinoma is the cause of malignant jaundice in 8% of cases. The tumour can be seen as a fleshy, friable, exophytic growth, as ulcerated tumours around the papilla, or as a mass behind the papillary opening covered with normal-looking mucosa (26).

Because the tumour has a better prognosis then other biliary tree malignancies ( with five-year survival after surgery in some 30 to 50% of cases) and because almost 25% will develop duodenal obstruction (27), surgery is the optimal treatment for these patients. Endoscopic drainage is reserved for patients with contraindications to surgery such as extensive mernstases or high surgical risk. Because the tumour is frequently very friable, it is preferable co msert a stent without a sphincteroromy although smaller firmer tumours can initially be treared effectively with sphincteroromy only.

30-day mortality Cholangitis

23 25°/., 16 11%

11 ]O,,;

5%

Endoscopic stenting

Bilirubin Duodenal Median decrease Stent clogging stenosis survival

86°/c 28°A: 2% 95 (1 to 2319) 93°/c 40% 6% 123 (3 to 1255)

97% 29"/c 9% 149 (0 to 934)

98% 53% 23% 409 (12 to 2365)

A sphinctcrotnmy may be needed ro access tissue for biopsy diagnosis. Successful drainage can be achieved in over 95% of cases with no procedure related mortality and little morbidity. Late complications, such as stent clogging, which result in jaundice, pain or cholangitis arc resolved by stent exchange.

Figure 5) Patient with adenocarcinoma of the pancreas. Left Pancreatic d11cr obscruction and /11/e J11cr obstrnction. Right EnJo/)rosrhe.1is m common lnle duct imh fluw of ccmtra1t w the cluodt!n11m

Cancer of the pancreatic head is the most frequent cause of malignant distal bile duce obstruction, accounting for more than 50% of cases (Figure 5) (28). The median age of onset is 70 years. Less then 30% of tumours are rescctable and five-year survival is a dismal 1%. The mortality of pall iative bypass surgery has been reported as high as 43 to 59% in patients with extensive

metastatic disease (29). Three randnmi:ed prospecnve tnah. o( cndnscop1<.. versus surgical bypass imervent1un have been reported (Table 2) 00-3 2). Patients who had unresectable distal bile duct malignancy hut were otherwise nperau vc candidates were ran domized to either endoscopic sten t placement or surgical hypass. Endoscopic therapy was equally cffccnvc in relieving jaundice with less complicat ium and lower 30-day mortality. Survival in both groups was the same, indicatmg that che ,Kh·anragl' lies in

CAN J GASTROENTEROL VOL 7 No l jANUARY/FrnRUAR, 1991

the , horcer initial 11llspital ,tay (twu to five Jays versus the reported rhree weeb of postoperative hnsp1ral1:at1on) and the lower mortality. On the other hand, re-admissions fnr srcnt exchange or duodenal obstruction may he 111-

rolernhle for soml: patients and qualit} ,if li fe studies uf the rrcarmenr <1rms have nnt been reported.

Tumour growth near the papilla may distort the u1mmon hdc duct and make cannulation and ,phincterotomy difficult. Nonetheless, srent plncemcnr 1s successful in over 901

'.1 of p,111ent~

19

TABLE 2 Results of three prospective randomized trials comparing endoscopic stenting with surgical bypass for obstructive jaundice (30-32)

-- --- ---Shepherd et al (30) Andersen et al (31) Dowsett et al (32)

Stent Surgery Stent Surgery Stent Surgery Number of patients 23 25 25 19 101 103 Successful drainage 91% 92',o 96% 84 Yo 94-Yo 91% Complications 22% 40i'o NA NA lOYo 28%1

30-day mortality 9'K 20% NA NA ] JI: 17%1

Duodenal bypass 0 )(, OYo 0 OYo 60' ]'f I

Recurrent 1aundice 17% 2'Yo 28',c 16·,,, 18% 3 t

Median survival (range) 152 days 125 days 84 days 100 days 5 months• 5 monlhs· (39-411) (52-354) (3-498)

·Mean surv,vo/ 1Stot,sticolly sign,t,cont NA Not ovoiloble

\\'1th prnn·dun: rl'Llll'd m11n:iln) ,it 2.5"o, ~\) d,1) m,,11.d11y 11! 10''., .ind ,I\ L'ragc hl ,,p11 al ,ta\ , 11 t \\'l l l II t i\'l' day,. A lt h11ugh L,hl', must hL' 1udi.:L·d 111dl\ 1du.ill) '" r11 tht· hL·nd11 ,1l ,urt,:1t,d hV(':tss n:r,u, L'nd11,u>p1L drain,tgl', t hL· l,lltl'r 1, kit t11 hl' thl' hl',t lllL'tl1lld 111 p.1llL'l1b ,,·11hnuc 1mpL·111.l111g dundL'n,tl ,1h,trull11H1.

MiJ common duct ob~truction· c;,111 hbdder L.trL 111t11n,1 ,md Ll1ol,mg1, 1L.11 unllma HrL' thl' tl1lll'L' lrequl'nt cau,es 111°

1111,I duLt ,,h,truLtllm; 15 tll 2()% nf

p,l!tt·nr,. "1th malignant Jaund1t:e will h,1\'L ,t ks1on ,ll chb lL'\l'I. Ry thl' t11nl' pund1CL' lwt 11t11L'' man1fe,t, ll\l'r I 5l\, , ,t p,ll tL'llh h·tn: lt\'L·r .ind nnd,tl hl',I im,,hl'ment, wh1k· kss thl'n 15 to 25'\, h,l\'L' rL·,ect,1hk d1sea,l'. Pall1a1 l\'L' surg1, cal pn>cl',lun.::-. h,1,·L· pn1dt1CL'd m,1rtal11y r.lll', ot 15 ll l 20'!b and du not pnilnng sun t\ ·ii hl·y,111d a 111L',111 llf 111111 t,1 st, 11111111 hs. Nl',trl\' 2 5°(, l >t pat ll'l1h under _going ,urt,:tL,d ('alli:trilll1' dtl' \\1th111 3L~

(10-642)

days of surgcn ( 31 ). lndl'l'd, rumour l'Xtensttlll hL•y1111d thl' suhmucnsa prL'· d icts ;1 poor ('rllgnt 1s1,.

1 n t hL' author,' ,l'rtL'' end, isCll('iC dramagl' was SllCLl',,ful 111 H4"n llf patients. PmccdurL' n.:latl'd mortalll) \\'as 3. 1 ''., ,md 30-d.iy mor1.d11y wa, 14 5''n ( B). O,ernll nw.1n ,un t\'al nt 2 ~ wc.:l'b wa~ comparable 1, > that :1d1 ll'Vl'd with surgtLal pal11.111un of ad, .mcl'd d1sea,L'. G1\'l't1 thl' dism,tl 11tHL1lllll' ,,f the d1,L'asl', l'ndnscoptL managl'ml'nt ('rovidl's pall tat 11111 at a lo\\'l'r mllrtalll y, morh1,I tt) and uist rh,m ,urg1L,tl hyp,1,,.

Bifurcation tumour~: Malignant growl hs 11woh 111g thl' h1(un.:.att()n m,1\ arbL from adiacl'nt L1rga11s, h m('lwma nr tnl't,btasl', front thl' uilnn or hrc.:ast. They· ,IC<.ount for 20 rn 2 5'fo l1I case, wtth malignant 1,1undtLl' Th i, l)'J'l' Ill' mnl1gn,111t nhstruct 1Pn 1, d1ff1Lult tn rrc.H hy ,lll\ 1111l'rvenuon ,md ,,ftcn rL'· quire, u>·nperau,111 hL'l\\'L'L'l1 the rad10-log1st, ,urgl'tll1 and gastrol'n t..:rohigtst.

Pat ll'nt, with pnm,tr\ htlar hill' duct canCL'T should hL· L'\ aluatL·d for ,urgcry 111 hopl' for a curL'. ::-.urg1L;1l scriL·, nmc resl'llahtltty ratl', 11f 2011

0 ( H), 22''., ( 3 5) .md l',·en 4 7'\, ( 36). A. rL'LL'nr rl'\'lt:\\ of 499 pat tL'nts wh,, undL·1went rL'Sl'L I ion, ,howcd ,lll "l'l'rati,·L· 1rn1rtaltt) lll I 2l\, .md ,I fl\l'-)'L'ar SLIT\ I\ .1l t1f I 3%. T hL· mcd1.m ,urv1\'al w,1s 14 t1> I~ months. Pall 1,ll t\'L' ,urgtl ,ti hypass ha, an PJ'L'r,llL\L' murtaltt\ pf B 0 o 04). Ch11Lmg111, 1, ,t l1L'qt1L'nt clllnpltL,1t1,1n , ,f hL'Pill iL < ljL·j lll1l lSI llll11l''>.

Endo,u1p1L ,tL'nt placl'ml'nt aero,, rhesL' ultl' l1 tnrtuuu, and .isymmetn,

,trict urcs 1, tl'd111ic.11iy dl'mand111g {F1gurl' 6). ThL· u,ual L.llt,l' pf fotlurt· 1, 111.1htl11y ttl pa,, ,1 gt11dl'w trl' nr dtl,1ting

TABLE 3 Results of endoscopic treatment of hilar lesions by Bismuth classification

Number of Successful Early patients drainage complications

Polydorou et al (39) Type I 58 9l'X 7% Type II 54 83'h 15% Type Ill 78 73'1, 31°ft, Total 190 82'X, 19/o Coene (38) Type I 63 94'X, no Type II 72 93'Yr 17% Type Ill 62 85'Y, 29 Type IV 60 53°, 40°1c Total 257 85', 25',

Figure 7) Left The wm1rcunec.l w<1llm.'11L 1.1111s.:r11?d 1hro11gh a d111a//,i/t! t/11(1 s1r1,11iri:. Middle Thi! tl'allscent is wm/ilecdy deplowd. Right ( )f>tmwlj)uw nfro1111w1 rlm>11gh 1h<! stl'TH

catheter rhmugh a sl ricturl'. O\'erall

succeslul Jrninagl' rate, arc 80 to 85'\, (37, 39). The fbmuth cla,sificauon i,

u,cful in reporri ng re,u It s of 111 tcrvcn

tion. Type I tunwur, invo lve the u1111-

mon hepatic Juel withan 2 cm of the

bifurcation, hut ntll rlw right and ldr duct. Type JI lc:,ion:, extend lo in \'l)lvc

hnth main hepacic duct:,. In T ype Ill tumours, the right, left and intrnhcpat1c

ducts arc involved. The mo re cxtcm1vc thnliscn:,c (ie, Tyre III) the h igher the

morbiJity and mortality rare, (Table J). All rate:, arc 11·mse 111 ca:,e, uf meras,

tascs frnm di:,tant mal1gnan1..ics. Tyre

Ill les1on:, from meu1,u1tic d1,L'asc had

,ucccs,ful drainage in 71 "{, (l[ cases,

complicatiom in 7 1%, 30-day mortal -

1ty in 42'\, and median surn val of 1.5

nH,nth, in 1lnc report (40). In p,1t1en b

with cxtcn,ive mtraherauc srriuure, the hcncfir nf any intcn'l'nt inn 1, quc,, t 1unahlc.

The maior c,1rly c, >mpl 1cat ion ts

chol,mgiti, whic.h ha, been reported in

7 u 1 19% nf case,. A It hough a II ca,c,

arc pcrl1mned ll'lth a nt1h11ll ll ul\'erngl'.

adcqu,lll' drn111agc 1s the critical cle

ml'nt. T hi, ma, entail more than one

at tempt at ,rent pl,iccm1..·nt or ,1 com

bined pcrcut,111enu,/cndnscnp1t ;q1-

prnad1. Con1 rm l'rsy l'XJsts ,is t11 t hl'

nL'L'd t11 dram .111 nhstructcd li,'l'r s1..·g

rnents. Srnne d1l so aggress1\'L·lv ( 3 7) hut

other, h,l\e ,1ht ,11nt:d g11od rc,ult, \\'1th

Just one stcnt dr,llnillg ,lt lc,1'1 25",, nl

CAN J G-\~TR1.)ENHR, ll \ \ ll 7 N, 1 I J.\Nt \"Y/hBRl •\RY l 91,))

Endoscopic stenting

30-day Median survival mortality (weeks)

14'){ 21 15" 12 32'1 10 22% 12

l4Vo 20 16110 17 32', 11 33% 6 23% 13

the liver parcnchyma (39). A ,cwnd

slenl 1s placed on ly Ill thn,e ll'llh

ch,1langn1, tnim , uspccted undnllned ,cgmcnh ( 38). Early and late complications of endo, prosthe~is: Early rnmpliG1tion, occur

les, 1 hrn, 1 ll1L' wel'k .1fte1 t hl' prnLcdure

while latl' u 11npl1L,1t11111s c.m 01..c ur

from eight days t1l 15 111,mth, aftn insert llll1 ( 38). The m.1111 cnmplicauon b

dogg111g wh11..h 01..1.. ur, 111 2 l w 36'\1 nt

1..,i...c,. Par1i:nr- prc,e111 with a 'flu- like

s1ndrome, mah11,c, l1i11· grade fc,er 11r

illcrl',tsin,g lil'er en:ymes. II ,ympt,JJns

arc nor rccogn1: ed prnmptly, frank

jaundice and Lholangit1, \\'Ill en,uc.

Symp1onh respond prorn,,tlv to st<:nt

exchange. Studies on the me1..han1,m,

ol c.logg111g ,md possihle "1luti1ll1s arc

,1nguing. Self expandmg ll'lre-me,h 30 Fg ,tent, a rc hc1nl! L'\',il uarcd wnh promi,1ng mitial rl',ults (F1[!urc 7) (41 ).

CONCLUSIONS Endo,c\1p11.. L'ndopw,these, olkr ,1

good altcrnauve rn surgical int c rven

t1<ll1, 1'rodt1L ing l,111· mnrtalit) and rnor

h1d1t) rate, 111 many ,11 uat1uns. There

torl', .in me rc,1smg need tnr these

procedure, can he expected. In ,1 rcCl'nl report ol the Bnti,h So1.. ic1y of Castro,

cntcrol,1gy thi, nl'ed was calculated as

50 ER( 'P pro1..cdures p<:r I 00,000 in

hahit ,mt, rcr year, uf whom 16 l'L' r

W0,000 need .i hd1ary drainage proLL'· dure (42). Cnod training 11f end1isui,

p1st, ,md u1opL'r,H1<1n hct1Vcen inter

\'L' nt1<11rnl rad1ok1gisb, ,urgcurn, and

gasrruenterl1 lug1~t, .trc prerl'l]Uhites lor

upumal tre,lln1ent ot the p:1t1ent ll'1th ,1h,1ruLt1,·1.: Jaundice.

21

I IUIHRWTSf' AND RIVIRA-MACMURR,\ Y

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22 CAN J CiA'-TR1)ENTEROL VOL 7 Nol JANUARY/FEBRUARY 1993

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