Efficacy and safety assessment of ERCP in patients with malignant biliary obstruction.

BACKGROUND: To assess the efficacy and safety of Endoscopic retrograde cholangiopancreatography (ERCP) for malignant biliary obstruction (MBO). MATERIAL AND METHODS: A review of all ERCP-procedures performed at Akershus University Hospital during the six year period between 2009-2014 was analysed. Data for the period 2009- 2013 were obtained retrospectively and prospectively for 2014. Patients with jaundice due to MBO were selected for the present study. RESULTS: A total of 210 patients (51% females), median age of 70 years (range 33-96) were included. The total number of procedures were 314, whereof 218 (69%) were successful and 96 (31%) were failures. 292 procedures were palliative and 22 procedures were intended as 'bridge to surgery' whereof 15 patients underwent surgery. Pancreatic carcinoma occurred in 105 (50%) patients and was the most common reason for MBO. Straight plastic stents (I-stents) were applied in 145 (74%), double-pigtail stents (JJ-stents) in 29 (15%), self-expanding metal stent (SEMS) in 18 (9%) procedures and in 3 procedures (1.5%) an I-stent was inserted through an indwelling SEMS. Median duration of stentpatency in months was 2 (range 0-74) for I-stent, 1 (range 0-29) for JJ-stent and 4 (range 0-29) for SEMS. The rates of complication and mortality due to complication were 8.9% and 1.3% per procedure. CONCLUSION: Adequate drainage of MBO by ERCP was obtained in 69%. The rates of complication and procedure related mortality were at acceptable levels.

Influence of gender and socioeconomic background on the decision to perform gallstone surgery: a population-based register study.

BACKGROUND: In the absence of unequivocal standardized indications for surgery, socioeconomic background and gender may have a major impact on the decision to perform surgery for cholecystolithiasis. The purpose was to assess how decisions to perform surgery in Sweden are influenced by patient-related factors and how this affects the epidemiology of gallstone disease. MATERIALS AND METHODS: This study is based on the Swedish Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks), which covers >90% of surgical units, including 98% of all procedures performed. All procedures performed during 2005-2009 were included. Data on socioeconomic background were obtained from Statistics Sweden. The influence of gender and age on decision to perform surgery was tested in multivariate linear regression analysis. RESULTS: Up to the age of 40 years, women were 6 times more likely than men to undergo surgery for biliary colic. On the other hand, there was a relative preponderance of men undergoing cholecystectomy for jaundice, cholecystitis, bile duct stone or pancreatitis in the elderly population (p < 0.001). Socioeconomic background did not have any significant impact on the decision to operate. CONCLUSION: Presentations of gallstone disease differ between men and women, as does the decision to perform surgery. The higher incidence of surgery for secondary complications in older men could be explained by a higher prevalence of gallstones resulting from a lower incidence of surgery at a younger age. Whether or not wider indications for surgery in young patients reduce the risk for gallstone complications requiring surgery should be explored in future studies.

A comparison of metal and plastic stents for the relief of jaundice in unresectable malignant biliary obstruction in Korea: an emphasis on cost-effectiveness in a country with a low ERCP cost.

BACKGROUND: In countries where ERCP costs are low relative to those of metal stents (eg, Korea), initial endoscopic retrograde biliary drainage (ERBD) with a plastic stent is thought to be more economical. OBJECTIVE: We conducted this study to compare metal and plastic stent-based ERBD in efficacy, complications, and total cost of biliary drainage. DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS: A total of 112 patients who had not undergone previous biliary drainage procedures and who underwent ERBD for unresectable malignant biliary obstruction. INTERVENTIONS: Endoscopic sphincterotomy was performed, and covered or uncovered Wallstents were used in 56 patients and plastic stents in 56 patients. RESULTS: Stent occlusion occurred in 31 patients after a mean of 278 days in the metal stent group and in 39 patients after a mean of 133 days in the plastic stent group (P = .0004). The incidence of and length of hospitalization for cholangitis were significantly lower in the metal stent group. There was no difference in the total number of drainage procedures between the 2 groups. There was no statistical difference in the mean cost of the relief of jaundice between the 2 groups ($1488.77 in the metal stent group vs $1319.26 in the plastic stent group, P = .422). LIMITATIONS: Nonrandomized, retrospective study. CONCLUSION: Even in countries where ERCP costs are lower than those of metal stents, ERBD with metal biliary stents as the first-line treatment may offer better palliation without a significant increased cost in patients with unresectable malignant biliary obstruction.

Biliary and gastric bypass or stenting in nonresectable periampullary cancer: analysis on the basis of controlled trials.

BACKGROUND: The median survival rate of patients with nonresectable periampullary cancer is not much longer than 6-12 mo. Nevertheless, in most incurable patients palliative treatment is necessary, which has to focus on jaundice, pain, and prevention of gastric outlet obstruction. Up to now, debate remains about how to best provide palliative treatment. METHOD: The results of controlled clinical trials and large multicenter studies comparing operative biliary bypass and biliary stent insertion in nonresectable pancreatic tumors are discussed in this review. RESULTS: The initial success rate in palliation of jaundice is similar after endoscopic stent insertion and biliary bypass operation (range: 90-95 %). Morbidity (range: 1 1-36% vs 26-40%) and 30-d mortality (range: 8-20% vs 15-31%) is higher after bypass operation, whereas stent insertion is accompanied by a higher rate of hospital readmission and reintervention because of recurrent jaundice (range: 28-43%) and a later gastric outlet obstruction (up to 17%). CONCLUSION: Endoscopic biliary stent insertion should be performed if there is evidence of hepatic, peritoneal, or pulmonary metastasis formation, in old patients with a high comorbidity, or if the patient has had several laparotomies. Combined biliary and gastric operative bypass procedures should be performed in nonresectable periampullary carcinomas with accompanying gastric outlet obstruction, in the absence of metastatic spread, if a locally advanced tumor is the only reason for incurability, if exploratory laparotomy demonstrates an unresectable tumor, or if endoscopic treatment fails.

[The economical use of methods employed in the diagnosis of jaundice: decisional attitude as opposed to diagnostic attitude (author's transl)]. / Economie de moyens dans le diagnostic des ictères: attitude décisionnelle contre attitude diagnostique.

For the diagnosis of jaundice, a comparison is established between a classical diagnostic attitude and a decisional attitude which consists in guiding and restricting the investigations according to the therapeutic possibilities. It appears from the comparative study of the two groups of patients that the decisional attitude is better, resulting in a treatment which occurs earlier, is less expensive and probably of a better quality.