Reduced complication rates of percutaneous transhepatic biliary drainage with ultrasound guidance.

BACKGROUND: We aimed to analyze the benefits of adding ultrasound (US) guidance to the standard fluoroscopically assisted percutaneous transhepatic biliary drainage (F-PTBD). We also performed a systematic literature review of success and complication rates of US-PTBD in a wide field of indications. METHODS: We evaluated a total of 81 US-PTBDs carried out in our institution, 74% of which were part of the management of malignancy. In addition, we compared our results with those of a total of 5,272 procedures (3,779 F-PTBD and 1,493 US-PTBD) reported in the literature. RESULTS: US-PTBD was technically successful in 94% of attempts with a mean of 2.2 needle passes. Procedural success was achieved in 86% of cases. There were no procedure-related deaths or severe complications. Minor complications were catheter dislodgement (15%) as well as one case each of a porto-biliary fistula, hematoma, and biloma. A systematic review of the literature also showed that US-PTBD has a similar technical success rate to F-PTBD but lower median rates of severe early complications (0% versus 8%) and procedural death (0% versus 1%). CONCLUSIONS: Given our results and our review of the literature, US-PTBD is as effective as F-PTBD and has significantly lower complication rates. US-PTBD should be preferred to F-PTBD. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:400-407, 2017.

Untutored learning curve to establish endoscopic submucosal dissection on competence level.

BACKGROUNDS/AIMS: Endoscopic submucosal dissection (ESD) of early cancer allows precise staging and avoids recurrence or surgery. Tutored by experts, ESD has rapidly spread in Japan, but still demands untutored learning in Western countries. A step-up approach starts with easiest gastric neoplasias, but fails on their low prevalence in Western countries. A prevalence-based approach includes challenging colonic neoplasias. METHODS: We analyzed an untutored series of initial 50 ESD procedures by an experienced endoscopist on consecutive lesions referred according to prevalence. RESULTS: Overall, 48 lesions (20% upper gastrointestinal, 80% colorectal; 2 hyperplastic (inflammatory) lesions, 46 neoplasms) were completely resected intention-to-treat with ESD, 2 required a second ESD. Neoplasias were resected 76% en-bloc (46% ESD, 30% ESD with snaring), 17% by ESD with snaring in 2-3 pieces, and 6.5% as ESD with snaring in multiple pieces. None of 15 neoplasias with high-grade intraepithelial neoplasia or an early esophageal cancer (R0) had recurred. Complications were 2 bleedings (4%) and 7 perforations (14%), 5 clipped and 2 (4%) operated. All patients were discharged within 9 days without long-term morbidity. CONCLUSION: Untutored learning of ESD is feasible on colonic lesions. We propose to establish ESD in Europe with structured training and a prevalence-of-lesions-based approach.

Photodynamic therapy for hilar bile duct cancer: clinical evidence for improved tumoricidal tissue penetration by temoporfin.

Photodynamic therapy (PDT) has been established for palliation of non-resectable hilar bile duct cancer (hBDC). Ablation of hBDC using porfimer (P-PDT) improves cholestasis and survival. However, the tumoricidal effect is confined to the inner 4 mm of the tumor wall. Here, we have studied whether temoporfin PDT (T-PDT) shows an efficient local response and an increased tumoricidal penetration depth. In the first stage of a phase-II trial (NCT01016002), eleven patients with hBDC (Bismuth III-IV) were treated with T-PDT plus stenting and 10 could be analyzed for local tumor response. T-PDT resulted in complete local response in n = 1 of 10 patients, partial response in n = 8 and no response in one patient (occluded right hepatic duct re-opened but positive for residual tumor cells) - indicating a tumoricidal efficacy of 90%. Four patients showed a tumoricidal depth of ≥7.5 mm. Cholestasis and palliation improved in 8 patients with an overall median survival of 18 (4.4-32.0) months after the first T-PDT. Adverse events were phototoxic skin reaction (n = 4), cholangitis (n = 3), and liver abscess (n = 3). T-PDT doubles the depth of the local tumor-ablative effect of P-PDT, is highly tumoricidal and is associated with similar rates of infectious complications and grade I and II skin phototoxicity.