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Endoscopic biliary stents and obstructive jaundice
Endoscopic Biliaty Stents and Obstructive Jaundice
Douglas C. Walta, MD, Craig S Fausel, MD, and Bolek Brant, MD, FACS, Portland, Oregon
Obstruction of the common bile duct has been tradltlonally treated by surgical mterventlon Recent advances m endoscopy have allowed an alternative approach to this problem This report describes our experience with endoscoplcally placed plastic endoprostheses (stents) for the dramage of bile ducts of 84 patients over the past 3 years Matenal and Methods
Between November 1983 and October 1986,84 patients had endoscoplcally placed plastic stents used for the treatment of obstructive Jaundice due to varying causes There were 72 patients with malignant obstructive dlsease, 5 with common bile duct stones, 4 with bile duct uqurles, and 3 patients with inflammatory obstructive disease There were 39 men and 45 women who ranged m age from 30 to 93,47 of whom were over the age of 70 and 18 of whom were past the age of 80 A total of 135 stents were placed overall Standard endoscoplc retrograde cholanglopancreatography was performed along with a small paplllotomy if the obstructive process did not involve the pancreatic duct A guide wire was then advanced through the segment of the bile duct where the stent was to be placed Balloon dilatation of the obstructing lesions was used when necessary The guide wire position was stabilized by a supporting catheter Plastic stents ranging from 9 to 12 F m diameter were then inserted by a pusher tube to bridge the involved segment of the bile duct, allowing the distal end of the stent to protrude mto the duodenal lumen The stablhzmg catheter and the guide wire were then removed, leaving the stent m place The stent length measured 5 to 15 cm, depending on the anatomy of the area Intravenous mldazolam and fentanyl citrate were used for sedation The maJorlty of the procedures were accomplished on an outpatient basis, with occasional overnight observation All procedures were carried out m the radlologlc suite with the partlclpatlon of a radlologlst and two endoscopy nurses We used the Olympus model TJAF-10, 3 7 mm or 4 2 mm duodenoscope and straight as well as double-pigtail stents produced by various manufacturers Requests for reprmts should be addressed to Douglas C Walta, MD, 5 10 NE 49th Street Swte 611. Portland Oreoon 97213 Presented at the 73rd’Annual Meetlig of the North Paclflc Surgvzal Assoclatlon, Tacoma Washington, November 14 and 15, 1986
444
Results This series was comprised of 84 patients, 72 with malignant obstructive disease, 5 mth common bile duct stones, 4 with bile duct inJuries, and 3 with inflammatory obstructive disease Restentmg was employed only m patients with mahgnancy The longest time over which a single stent dramage was successfully maintained was 406 days (average 132 days) Table I shows the types of mahgnancy encountered m our patients Three patients required mandatory operation preclpltated by the development of duodenal obstruction due to growing mahgnancy after stent apphcatlon Eight patients with malignancy, and 5 with other diseases had surgery before endoscoplc retrograde cholanglopancreatography and stentmg, whereas 14 patients had elective surgery after endoscoplc stentmg (Table I) The length of survival after stentmg m patients with malignancy 1sshown m Table II and the incidence of restentmg m these patients 1s depicted m Table III There were four patients with bile duct inJury One occurred after an auto accident and three were related to operation The patient with motor vehicle trauma had primary liver mvolvement Hepatlc duct repair was accomphshed mtraoperatlvely, but a bile leak at the blfurcatlon of the common bile duct was not apparent Two weeks later, the lesion was identified by endoscoplc retrograde cholanglopancreatography and an endoscoplc stent was placed, ehmmatmg the bile leak The stent passed spontaneously 3 weeks later The second instance occurred when the lower hmb of the T tube became displaced outside the common bile duct The source of persistent bile leakage was ldentlfled 10 days later at the time of T-tube cholanglography Stent placement permitted the T tube to be removed without comphcatlon The stent was removed 2 months later without obstruction of the blhary tree The two other cases included mishaps at the time of cholecystectomy Jaundice with common bile duct stricture developed m the first patient 2% weeks after surgery A figure-of-eight tie hgature had been placed through the common bile duct Dllatatlon of the stricture and stent placement were achieved Stent removal 2 months later revealed no
The American Journal of Surgery
EndoscopicSiliatyStentsandObstructiveJaundice
TABLE I
Indlcatlone for Stent Placement lndrcation
Carcrnoma Prtmary Ampullary Pancreatic Common bile duct Gallbladder & common bile duct Bifurcation
n
%
72 59 7 34 9 6
65 7 70 2 83 40 5 107 71
Common bile duct stones Trauma Benign disease
5 11 5 4 3
6 13 1 59 46 36
Total
84
Metastatlc
100
evidence of obstruction Abdominal pam and vile ascites occurred in the second patient 2 weeks after an uneventful cholecystectomy At endoscopic retrograde cholangropancreatography, a cystic duct bile leak was identified and a common bile duct stent was placed When elective operation was subsequently carried out, the stent greatly facrhtated localization and correction of the cystic duct bile leak. In the patients with mflammatory blhary obstructive disease, one patient had chronic pancreatltls. Endoscoplc retrograde cholanglopancreatography showed common bile duct stricture over a 2 5 cm segment which successfully resolved after 3 months of stentmg The stent was then removed The second patient m this group was treated for sclerosmg cholangltls The stent was removed after 1 month when no obvious improvement was noted A third patient was semicomatose and had clrrhosls wrth ascltes and chronic pancreatltls Cholangltls subsequently developed m this patient Stentmg was attempted for treatment of the cholangltls, which promptly resolved, however, the multisystem disease progressed, and the patient died within the next 2 weeks In the group of patients wrth obstructive common bile duct stones one was a 53 year old woman with end-stage chronic obstructive pulmonary disease that represented a prohlbltlve surgical risk The other four ranged from 36 to 93 years of age and had other comphcatmg surgical risk factors In all five patients, endoscoplc removal of the stones was attempted but the stones were too large. In all five, the stent application was successful and without comphcatrons The stents contmued to be fun&or& at last follow-up There was one procedure-related death which occurred in a woman wrth adenocarcmoma of the pancreas One year earlier she had undergone exploration with biopsy followed by radiotherapy and chemotherapy She was stented for exacerbation of
Volume 153,May 1987
Prevrous
Operatron Mandatory
Elective
1 2
2 2
1 6 3
1 3
1 2
4 1
1
13
TABLE II
3
IA
Mean Survlval After Stentlng Tumor Location
No of Patients
Duration (d)
Ampulla Pancreas Common bile duct Gallbladder 8 common bile duct Bifurcation Metastatic
1 15 3 4
210 268 133 96
3 3
34 277
TABLE Ill
Restentlng Employed for Malignant Obetructlon
No of Stents per Patients
n
One Two Three or more
39 10 9
Total
58
Patients % 67 2 17 2 155 100
pam and obstructive Jaundice The stent was madvertently placed m the cystic duct remnant, and drainage was inadequate Cholangrtrs developed and the patient died 11 days later There were 14 other comphcatlons (Table IV) A nonfatal myocardml mfarctlon occurred m one patient which mamfested Itself on the day of the procedure There were three cases of displacement of the stent mto the common bile duct, all of which occurred m patients with obstructive mahgnant dlsease The first occurred at the time of the nutml procedure when the stent moved totally mto the proximal common bile duct It could not be removed, but another stent was successfully placed along side the first The other two displacements occurred late as a result of tumor growth where the stents were pushed up into the proximal common
445
Walta et
al
TABLE IV
Complications in the Series (84 patients, 135 stents)
Comphcations Death (due to cholangltls) Myocardlal InfarctIon (nonfatal) Stent displacement Into common bile duct Stent passage Liver abscess Cholecystltls Early occlusion Restent failure Total
lncldence
lncldence
per Stent (“/)
per Pabent (%)
1
07
12
1
07
12
3
22
36
4 2 1 2 1
3 15 07 15 07
48 24 12 24 12
No of Patients
15
11
18
bile duct In one of these patients, the original stent was removed and replaced with a new one, m the other, the second stent was placed alongside the original one since it could not be removed There were four mcldents of spontaneous passage of the stents through the gastromtestmal tract The first occurred m a patient with radlographlcally apparent malignancy who vomited his stent approxlmately 3 weeks after the original placement For reasons unrelated to the incident it was elected not to treat that patient further The second incident occurred m a trauma patient who had a stent placed postsurglcally to treat a bile leak m the common duct blfurcatlon area Two weeks after its successful apphcatlon the stent was recovered m the stool The other two incidents occurred m a single patlent He received a stent after unsuccessful blhary decompression One year previously this patient had undergone operation followed by radiotherapy The stent passed m the stool on two occasions and no further procedures were attempted Liver abscesses occurred m two patients One of them was the trauma patient m whom a liver abscess was discovered 6 months after total resolution of the problem The relationship between the stentmg and liver abscess 1s difficult to analyze m this case The other liver abscess was found m a complicated patient with malignancy where multiple stents were used The abscess was surgically dramed Acute cholecystltls developed m one patient 3 months after successful stentmg for obstructive malignancy of the common bile duct At the time of cholecystectomy, the tumor had involved the cystic duct and the gallbladder, but the common bile duct was still being adequately decompressed with normal liver function, and the stent was left m place In addition, there were two cases of early stent occlusion (one at 8 days and the other at 18 days) Attempted restentmg failed and each patient underwent operation m another faclh-
446
ty No perforations or significant bleedmg occurred m any of the patients m this series Comments The development of endoscoplc mterventlonal techniques has been truly spectacular Yesterday’s advances of endoscoplc sphmcterotomy m treatment of retained bile duct stones have been further augmented by today’s ability to endoscoplcally stent a stricture of the common bile duct Endoscoplc placement of blhary endoprostheses was first reported by Soehendra and ReiJnders-Frederlx [I] m 1981 Imtlally, small-caliber stents (6 to 7 F ) were employed With the avallablhty of newer endoscopes with larger channels, apphcatlon of larger stents of 9 to 12 F became possible, dlmmlshmg the incidence of early clogging and associated cholangltls Hulgbretse and associates [2] reported a 90 percent successful apphcatlon of this technique m the palliative treatment of 221 Jaundiced patients with carcinoma of the head of the pancreas Their procedure-related mortality rate was 2 percent Our report extends the apphcatlon of this new technique to other disease entitles The optimal treatment of pancreatic carcinoma causing obstructive Jaundice may be open for dlscusslon depending on such factors as the age of the patient, size and location of the lesion, the patient’s general health, and other possible risk factors In unresectable cases, however, palhatlve operation surgery 1s associated with a 30 day operative mortahty rate of 20 percent and survival 1s essentially the same regardless of treatment used This was confirmed by a recent review of over 8,000 patients m the English literature from 1965 to 1980 [3] In such cases, endoscoplc stentmg has to be considered as a reasonable alternative In patients with failed surgical drainage and previous radiotherapy, for unresectable pancreatic carcinoma many surgeons would consider endo‘scoplc stentmg as the procedure of choice Metastatic malignancy m the porta hepatls area causing obstructive Jaundice, as seen m 11 patients m our series, would probably also be considered by many to be best treated by this new modality There 1s a well-recogmzed problem of timing m operating on patients m whom postoperative Jaundice related to surgical trauma develops 3 to 6 weeks after their original procedure In such clrcumstances, endoscoplc stentmg can be used to buy time while Jaundice is resolved until elective surgery can safely be performed The advantages of preoperative relief of infection and Jaundice are well documented [4] In some instances, such as m the three cases of the bile duct inJury reported m this series, secondary operation may be totally avoided Endoscoplc stentmg m treatment of blhary obstructive disease caused by an inflammatory condltlon 1s controversial In our series, acute cholangltls and obstructive Jaundice secondary to chronic pan-
The American Journal of Surgery
Endoscopic Bilm-y Stents and Obstructive Jaundice
creatltls were successfully resolved by thusmethod Appropriate patient selectron m this setting 1srecommended On the other hand, scleroamg cholangltls 1sa disease where the surgeon’s role is generally considered open for drscussron, perhaps with the exception of liver transplantatron In our third patient m that group, the stent did not contrlbute any slgmfrcant relief, but reports m literature indicate that m some patrents the techmque can be of benefit Our group of five patients with obstructive common duct stones represented a special problem where the stones were too big to be removed endoscoplcally and the surgical risks were prohlbltlve Under such unusual circumstances, rt 1sgratifying to have a reasonable alternative where the stent can provide resolution of stasis and Jaundice The most frequent and troublesome comphcatlon of endoscoplc stentmg 1scholangltls, which has occurred m approximately 8 percent of cases reported m the literature The only mortahty m our series of patients was caused by this comphcatlon. We have not noticed any obvious difference m stent longevlty based on the different stents we have used, but further studies comparing different tubmg matenala, tubing srxe,antrblotlc prophylaxis, and possrble use of oral bile salts should be carried out Duodenal obstructron may develop as part of the natural history of the malignancy of pancreas and the blhary tree Surgical drainage with gastroenterostomy should be a procedure of choice m patients who can tolerate rt rf the tumor compressron or mfrltratlon of the duodenum 1sobserved durmg endoscoprc retrograde cholanglopancreatography Endoscoplc stentmg does not commit or hmlt any patient to that particular form of therapy It 1s reasonable to view this procedure as an extension of dlagnostrc endoscoplc retrograde cholanglopancreatography, as rt can be applied to accelerate the
Volume153, May 1997
resolution of infection and stasis m appropriate patients with obstructive Jaundice Summary Eighty-four patients with obstructive Jaundice due to various causes were treated with endoscoprtally placed plastic stents Seventy-two patients had malignant obstructive disease, 5 patients had common bile duct stones, 4 patients had bile duct mJunes, and 3 patients had mflammatory processes resultmg m common bile duct obstructron Straight as well as double pigtail stents ranging from 9 to 12 F were used Restentmg was employed only m patients with malignancy, and the longest perlod of a single stent drainage was 406 days with the average of 132 days There was one procedure-related mortality m a patient with pancreatic cancer m whom the stent was misplaced Inadequate dramage resulted m cholangrtls and death There were 14 nonfatal comphcatlons which included 1 myocardml mfarctlon, 2 liver abscesses, 2 early closures (at 8 and 18 days), 1 episode of cholecystltls, 3 dlsplacements of the stent which required restentmg, and 4 spontaneous passages of the stent through the gastromtestmal tract There were no perforations and no slgmfrcant bleeding was encountered References 1 Soehendra M. Relfnders-Frederlx V Palllatlve bile duct drainage A new endoscoplc method of introducing a transpaplllary drain Endoscopy 1980, 12 8-l 1 2 Huibregtse K. Katon RM, Coene PP, Tytgat GNJ Endoscoplc palliative treatment In pancreatic cancer Gastrolntest Endose 1986,32 334-8 3 Sarr GM, Cameron JL Surgical management of unresectable carcinoma of the pancreas ClInIcal review Surgery 1982, 91 123-33 4 Denning DS, Elltson EC, Carey LC Preoperative percutaneous transhepatlc biliary decompression lowers operative morbidity in pabents with obstructive jaundice Am J Surg 198 1, 141 61-5
447
Douglas C. Walta, MD, Craig S Fausel, MD, and Bolek Brant, MD, FACS, Portland, Oregon
Obstruction of the common bile duct has been tradltlonally treated by surgical mterventlon Recent advances m endoscopy have allowed an alternative approach to this problem This report describes our experience with endoscoplcally placed plastic endoprostheses (stents) for the dramage of bile ducts of 84 patients over the past 3 years Matenal and Methods
Between November 1983 and October 1986,84 patients had endoscoplcally placed plastic stents used for the treatment of obstructive Jaundice due to varying causes There were 72 patients with malignant obstructive dlsease, 5 with common bile duct stones, 4 with bile duct uqurles, and 3 patients with inflammatory obstructive disease There were 39 men and 45 women who ranged m age from 30 to 93,47 of whom were over the age of 70 and 18 of whom were past the age of 80 A total of 135 stents were placed overall Standard endoscoplc retrograde cholanglopancreatography was performed along with a small paplllotomy if the obstructive process did not involve the pancreatic duct A guide wire was then advanced through the segment of the bile duct where the stent was to be placed Balloon dilatation of the obstructing lesions was used when necessary The guide wire position was stabilized by a supporting catheter Plastic stents ranging from 9 to 12 F m diameter were then inserted by a pusher tube to bridge the involved segment of the bile duct, allowing the distal end of the stent to protrude mto the duodenal lumen The stablhzmg catheter and the guide wire were then removed, leaving the stent m place The stent length measured 5 to 15 cm, depending on the anatomy of the area Intravenous mldazolam and fentanyl citrate were used for sedation The maJorlty of the procedures were accomplished on an outpatient basis, with occasional overnight observation All procedures were carried out m the radlologlc suite with the partlclpatlon of a radlologlst and two endoscopy nurses We used the Olympus model TJAF-10, 3 7 mm or 4 2 mm duodenoscope and straight as well as double-pigtail stents produced by various manufacturers Requests for reprmts should be addressed to Douglas C Walta, MD, 5 10 NE 49th Street Swte 611. Portland Oreoon 97213 Presented at the 73rd’Annual Meetlig of the North Paclflc Surgvzal Assoclatlon, Tacoma Washington, November 14 and 15, 1986
444
Results This series was comprised of 84 patients, 72 with malignant obstructive disease, 5 mth common bile duct stones, 4 with bile duct inJuries, and 3 with inflammatory obstructive disease Restentmg was employed only m patients with mahgnancy The longest time over which a single stent dramage was successfully maintained was 406 days (average 132 days) Table I shows the types of mahgnancy encountered m our patients Three patients required mandatory operation preclpltated by the development of duodenal obstruction due to growing mahgnancy after stent apphcatlon Eight patients with malignancy, and 5 with other diseases had surgery before endoscoplc retrograde cholanglopancreatography and stentmg, whereas 14 patients had elective surgery after endoscoplc stentmg (Table I) The length of survival after stentmg m patients with malignancy 1sshown m Table II and the incidence of restentmg m these patients 1s depicted m Table III There were four patients with bile duct inJury One occurred after an auto accident and three were related to operation The patient with motor vehicle trauma had primary liver mvolvement Hepatlc duct repair was accomphshed mtraoperatlvely, but a bile leak at the blfurcatlon of the common bile duct was not apparent Two weeks later, the lesion was identified by endoscoplc retrograde cholanglopancreatography and an endoscoplc stent was placed, ehmmatmg the bile leak The stent passed spontaneously 3 weeks later The second instance occurred when the lower hmb of the T tube became displaced outside the common bile duct The source of persistent bile leakage was ldentlfled 10 days later at the time of T-tube cholanglography Stent placement permitted the T tube to be removed without comphcatlon The stent was removed 2 months later without obstruction of the blhary tree The two other cases included mishaps at the time of cholecystectomy Jaundice with common bile duct stricture developed m the first patient 2% weeks after surgery A figure-of-eight tie hgature had been placed through the common bile duct Dllatatlon of the stricture and stent placement were achieved Stent removal 2 months later revealed no
The American Journal of Surgery
EndoscopicSiliatyStentsandObstructiveJaundice
TABLE I
Indlcatlone for Stent Placement lndrcation
Carcrnoma Prtmary Ampullary Pancreatic Common bile duct Gallbladder & common bile duct Bifurcation
n
%
72 59 7 34 9 6
65 7 70 2 83 40 5 107 71
Common bile duct stones Trauma Benign disease
5 11 5 4 3
6 13 1 59 46 36
Total
84
Metastatlc
100
evidence of obstruction Abdominal pam and vile ascites occurred in the second patient 2 weeks after an uneventful cholecystectomy At endoscopic retrograde cholangropancreatography, a cystic duct bile leak was identified and a common bile duct stent was placed When elective operation was subsequently carried out, the stent greatly facrhtated localization and correction of the cystic duct bile leak. In the patients with mflammatory blhary obstructive disease, one patient had chronic pancreatltls. Endoscoplc retrograde cholanglopancreatography showed common bile duct stricture over a 2 5 cm segment which successfully resolved after 3 months of stentmg The stent was then removed The second patient m this group was treated for sclerosmg cholangltls The stent was removed after 1 month when no obvious improvement was noted A third patient was semicomatose and had clrrhosls wrth ascltes and chronic pancreatltls Cholangltls subsequently developed m this patient Stentmg was attempted for treatment of the cholangltls, which promptly resolved, however, the multisystem disease progressed, and the patient died within the next 2 weeks In the group of patients wrth obstructive common bile duct stones one was a 53 year old woman with end-stage chronic obstructive pulmonary disease that represented a prohlbltlve surgical risk The other four ranged from 36 to 93 years of age and had other comphcatmg surgical risk factors In all five patients, endoscoplc removal of the stones was attempted but the stones were too large. In all five, the stent application was successful and without comphcatrons The stents contmued to be fun&or& at last follow-up There was one procedure-related death which occurred in a woman wrth adenocarcmoma of the pancreas One year earlier she had undergone exploration with biopsy followed by radiotherapy and chemotherapy She was stented for exacerbation of
Volume 153,May 1987
Prevrous
Operatron Mandatory
Elective
1 2
2 2
1 6 3
1 3
1 2
4 1
1
13
TABLE II
3
IA
Mean Survlval After Stentlng Tumor Location
No of Patients
Duration (d)
Ampulla Pancreas Common bile duct Gallbladder 8 common bile duct Bifurcation Metastatic
1 15 3 4
210 268 133 96
3 3
34 277
TABLE Ill
Restentlng Employed for Malignant Obetructlon
No of Stents per Patients
n
One Two Three or more
39 10 9
Total
58
Patients % 67 2 17 2 155 100
pam and obstructive Jaundice The stent was madvertently placed m the cystic duct remnant, and drainage was inadequate Cholangrtrs developed and the patient died 11 days later There were 14 other comphcatlons (Table IV) A nonfatal myocardml mfarctlon occurred m one patient which mamfested Itself on the day of the procedure There were three cases of displacement of the stent mto the common bile duct, all of which occurred m patients with obstructive mahgnant dlsease The first occurred at the time of the nutml procedure when the stent moved totally mto the proximal common bile duct It could not be removed, but another stent was successfully placed along side the first The other two displacements occurred late as a result of tumor growth where the stents were pushed up into the proximal common
445
Walta et
al
TABLE IV
Complications in the Series (84 patients, 135 stents)
Comphcations Death (due to cholangltls) Myocardlal InfarctIon (nonfatal) Stent displacement Into common bile duct Stent passage Liver abscess Cholecystltls Early occlusion Restent failure Total
lncldence
lncldence
per Stent (“/)
per Pabent (%)
1
07
12
1
07
12
3
22
36
4 2 1 2 1
3 15 07 15 07
48 24 12 24 12
No of Patients
15
11
18
bile duct In one of these patients, the original stent was removed and replaced with a new one, m the other, the second stent was placed alongside the original one since it could not be removed There were four mcldents of spontaneous passage of the stents through the gastromtestmal tract The first occurred m a patient with radlographlcally apparent malignancy who vomited his stent approxlmately 3 weeks after the original placement For reasons unrelated to the incident it was elected not to treat that patient further The second incident occurred m a trauma patient who had a stent placed postsurglcally to treat a bile leak m the common duct blfurcatlon area Two weeks after its successful apphcatlon the stent was recovered m the stool The other two incidents occurred m a single patlent He received a stent after unsuccessful blhary decompression One year previously this patient had undergone operation followed by radiotherapy The stent passed m the stool on two occasions and no further procedures were attempted Liver abscesses occurred m two patients One of them was the trauma patient m whom a liver abscess was discovered 6 months after total resolution of the problem The relationship between the stentmg and liver abscess 1s difficult to analyze m this case The other liver abscess was found m a complicated patient with malignancy where multiple stents were used The abscess was surgically dramed Acute cholecystltls developed m one patient 3 months after successful stentmg for obstructive malignancy of the common bile duct At the time of cholecystectomy, the tumor had involved the cystic duct and the gallbladder, but the common bile duct was still being adequately decompressed with normal liver function, and the stent was left m place In addition, there were two cases of early stent occlusion (one at 8 days and the other at 18 days) Attempted restentmg failed and each patient underwent operation m another faclh-
446
ty No perforations or significant bleedmg occurred m any of the patients m this series Comments The development of endoscoplc mterventlonal techniques has been truly spectacular Yesterday’s advances of endoscoplc sphmcterotomy m treatment of retained bile duct stones have been further augmented by today’s ability to endoscoplcally stent a stricture of the common bile duct Endoscoplc placement of blhary endoprostheses was first reported by Soehendra and ReiJnders-Frederlx [I] m 1981 Imtlally, small-caliber stents (6 to 7 F ) were employed With the avallablhty of newer endoscopes with larger channels, apphcatlon of larger stents of 9 to 12 F became possible, dlmmlshmg the incidence of early clogging and associated cholangltls Hulgbretse and associates [2] reported a 90 percent successful apphcatlon of this technique m the palliative treatment of 221 Jaundiced patients with carcinoma of the head of the pancreas Their procedure-related mortality rate was 2 percent Our report extends the apphcatlon of this new technique to other disease entitles The optimal treatment of pancreatic carcinoma causing obstructive Jaundice may be open for dlscusslon depending on such factors as the age of the patient, size and location of the lesion, the patient’s general health, and other possible risk factors In unresectable cases, however, palhatlve operation surgery 1s associated with a 30 day operative mortahty rate of 20 percent and survival 1s essentially the same regardless of treatment used This was confirmed by a recent review of over 8,000 patients m the English literature from 1965 to 1980 [3] In such cases, endoscoplc stentmg has to be considered as a reasonable alternative In patients with failed surgical drainage and previous radiotherapy, for unresectable pancreatic carcinoma many surgeons would consider endo‘scoplc stentmg as the procedure of choice Metastatic malignancy m the porta hepatls area causing obstructive Jaundice, as seen m 11 patients m our series, would probably also be considered by many to be best treated by this new modality There 1s a well-recogmzed problem of timing m operating on patients m whom postoperative Jaundice related to surgical trauma develops 3 to 6 weeks after their original procedure In such clrcumstances, endoscoplc stentmg can be used to buy time while Jaundice is resolved until elective surgery can safely be performed The advantages of preoperative relief of infection and Jaundice are well documented [4] In some instances, such as m the three cases of the bile duct inJury reported m this series, secondary operation may be totally avoided Endoscoplc stentmg m treatment of blhary obstructive disease caused by an inflammatory condltlon 1s controversial In our series, acute cholangltls and obstructive Jaundice secondary to chronic pan-
The American Journal of Surgery
Endoscopic Bilm-y Stents and Obstructive Jaundice
creatltls were successfully resolved by thusmethod Appropriate patient selectron m this setting 1srecommended On the other hand, scleroamg cholangltls 1sa disease where the surgeon’s role is generally considered open for drscussron, perhaps with the exception of liver transplantatron In our third patient m that group, the stent did not contrlbute any slgmfrcant relief, but reports m literature indicate that m some patrents the techmque can be of benefit Our group of five patients with obstructive common duct stones represented a special problem where the stones were too big to be removed endoscoplcally and the surgical risks were prohlbltlve Under such unusual circumstances, rt 1sgratifying to have a reasonable alternative where the stent can provide resolution of stasis and Jaundice The most frequent and troublesome comphcatlon of endoscoplc stentmg 1scholangltls, which has occurred m approximately 8 percent of cases reported m the literature The only mortahty m our series of patients was caused by this comphcatlon. We have not noticed any obvious difference m stent longevlty based on the different stents we have used, but further studies comparing different tubmg matenala, tubing srxe,antrblotlc prophylaxis, and possrble use of oral bile salts should be carried out Duodenal obstructron may develop as part of the natural history of the malignancy of pancreas and the blhary tree Surgical drainage with gastroenterostomy should be a procedure of choice m patients who can tolerate rt rf the tumor compressron or mfrltratlon of the duodenum 1sobserved durmg endoscoprc retrograde cholanglopancreatography Endoscoplc stentmg does not commit or hmlt any patient to that particular form of therapy It 1s reasonable to view this procedure as an extension of dlagnostrc endoscoplc retrograde cholanglopancreatography, as rt can be applied to accelerate the
Volume153, May 1997
resolution of infection and stasis m appropriate patients with obstructive Jaundice Summary Eighty-four patients with obstructive Jaundice due to various causes were treated with endoscoprtally placed plastic stents Seventy-two patients had malignant obstructive disease, 5 patients had common bile duct stones, 4 patients had bile duct mJunes, and 3 patients had mflammatory processes resultmg m common bile duct obstructron Straight as well as double pigtail stents ranging from 9 to 12 F were used Restentmg was employed only m patients with malignancy, and the longest perlod of a single stent drainage was 406 days with the average of 132 days There was one procedure-related mortality m a patient with pancreatic cancer m whom the stent was misplaced Inadequate dramage resulted m cholangrtls and death There were 14 nonfatal comphcatlons which included 1 myocardml mfarctlon, 2 liver abscesses, 2 early closures (at 8 and 18 days), 1 episode of cholecystltls, 3 dlsplacements of the stent which required restentmg, and 4 spontaneous passages of the stent through the gastromtestmal tract There were no perforations and no slgmfrcant bleeding was encountered References 1 Soehendra M. Relfnders-Frederlx V Palllatlve bile duct drainage A new endoscoplc method of introducing a transpaplllary drain Endoscopy 1980, 12 8-l 1 2 Huibregtse K. Katon RM, Coene PP, Tytgat GNJ Endoscoplc palliative treatment In pancreatic cancer Gastrolntest Endose 1986,32 334-8 3 Sarr GM, Cameron JL Surgical management of unresectable carcinoma of the pancreas ClInIcal review Surgery 1982, 91 123-33 4 Denning DS, Elltson EC, Carey LC Preoperative percutaneous transhepatlc biliary decompression lowers operative morbidity in pabents with obstructive jaundice Am J Surg 198 1, 141 61-5
447