Metallic biliary stenting versus surgery for palliation of inoperable distal malignant obstructive jaundice :Mohammad H El-Shafey, Muhammad Ramadan, Al-Azhar Assiut Medical Journal

ORIGINAL ARTICLE
Year : 2020 | Volume : 18 | Issue : 3 | Page : 261--265

Metallic biliary stenting versus surgery for palliation of inoperable distal malignant obstructive jaundice

Mohammad H El-Shafey, Muhammad Ramadan
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Correspondence Address:
Muhammad Ramadan
Sanhur, Damanhur, Al-Buhaira, 22742
Egypt

Abstract

Background Pancreatic and biliary malignancies are rarely operable. The role of intervention is to palliate jaundice. Biliary drainage can be done by surgical bypass or biliary stenting either percutaneously or by endoscopic retrograde cholangiopancreatography. Plastic and expandable metal stents (EMS) are available. Aim To compare metallic biliary stenting versus surgery for palliation of inoperable malignant obstructive jaundice due to unresectable pancreatobiliary cancer. Patients and methods This retrospective, cohort study included 43 patients, presented by malignant obstructive jaundice due to unresectable pancreatobiliary cancer. They were divided into two groups: group I (20 patients) underwent palliative biliary-enteric surgical bypass; group II (23 patients) underwent endoscopic retrograde cholangiopancreatography and metal stent drainage. Results This study showed that both surgical bypass and EMS insertion have similar short-term satisfactory results in the control of jaundice. Surgical bypass had low incidence rate as regards late complications, although gastric outlet obstruction may occur for patients without gastric bypass. Despite EMS resulted in a shorter hospital stay, the higher late complications rate raised the cost, especially stent occlusion. Conclusion Endoscopic EMS and surgical bypass had similar results according to the efficacy of biliary drainage and mean survival period. EMS had a shorter hospital stay and fewer early complications. But, in the long run, surgical bypass results in less recurrent jaundice than the EMS but higher morbidity and mortality.

How to cite this article:
El-Shafey MH, Ramadan M. Metallic biliary stenting versus surgery for palliation of inoperable distal malignant obstructive jaundice.Al-Azhar Assiut Med J 2020;18:261-265

How to cite this URL:
El-Shafey MH, Ramadan M. Metallic biliary stenting versus surgery for palliation of inoperable distal malignant obstructive jaundice. Al-Azhar Assiut Med J [serial online] 2020 [cited 2023 Mar 23 ];18:261-265
Available from: http://www.azmj.eg.net/text.asp?2020/18/3/261/299567

Full Text

Introduction

Pancreatic and biliary malignancies are rarely operable. The role of intervention is to palliate jaundice [1]. Biliary drainage can be done by surgical bypass or biliary stenting, either percutaneously or by endoscopic retrograde cholangiopancreatography (ERCP). Plastic and expandable metal stents (EMS) are available.

Occlusion is a common complication of all plastic biliary stents due to deposition of bacteria [2]. Diameter of plastic stents ranges between 7 and 10 Fr, with patency periods of approximately between 30 and 120 days [3].

Palliation of malignant obstructive jaundice with EMS started in 1990s. EMSs have wider diameters than plastic stents and longer median patency of up to 8 months [3],[4],[5],[6],[7],[8]. However, the EMS is expensive and may be revised due to obstruction in 5–20% of cases [9].

Many studies have compared surgical intervention and plastic stenting for palliation of malignant obstructive jaundice [3],[10],[11],[12],[13],[14],[15],[16]. Fewer studies have compared between EMS and surgery [17],[18].

The present study aimed to compare metallic biliary stenting versus surgery for palliation of inoperable malignant obstructive jaundice due to unresectable pancreatobiliary cancer according to hospital stay, survival of patients, effectiveness, complications, reinterventions, and mortality.

Patients and methods

This retrospective, cohort study included 43 patients, presented to Al-Hussain University Hospital, in Cairo, Egypt, by malignant obstructive jaundice due to unresectable pancreatobiliary cancer, during the period from February 2017 to January 2019. After obtaining the local ethics committee approval, all patients admitted to the surgery department signed a written informed consent. They were divided into two groups:

Group I: 20 patients underwent palliative biliary-enteric surgical bypass.

Group II: 23 patients underwent ERCP and metal stent drainage.

For all patients: clinical assessment, computed tomography (CT) scan or MRI, and histopathology (brush cytology, percutaneous biopsy) were used for diagnosis.

Surgical techniques

Surgical bypass

One of the following cholecystoenterostomy, choledochoduodenostomy, or hepaticojejunostomy was performed according to intraoperative findings and surgeon preferences, with or without the addition of a retrocolic gastrojejunostomy for palliation or prophylactic measure for gastric outlet obstruction.

Biliary stenting

In group II, covered metallic stents of 10 mm diameter (WallFlex Biliary RX; Boston Scientific, Marlborough, Massachusetts, USA) was inserted by means of ERCP. Adequate placement was confirmed fluoroscopically.

Statistical analysis

Data were analyzed using IBM SPSS software package, version 20.0. Quantitative data were presented as mean and SD. Qualitative data were presented as number and percentage. Logistic regression analysis was used to calculate odds ratio and P value. A P value less than 0.05 was considered significant.

Results

There was no statistically significant difference between both groups as regards preoperative patient characteristics including age, sex, hemoglobin, bilirubin, leukocytes, albumin levels, location of the tumor, presence of liver metastasis, previous biliary stenting, or American Society of Anesthesiologists score, between the two groups, as shown in [Table 1].{Table 1}

As regards tumor site in both groups (43 patients), it was pancreatic (23 patients, 53%), distal common bile duct (11 patients, 26%), gallbladder (seven patients, 16%), and the ampulla of Vater (two patients, 5%). The surgical procedures performed were cholecystojejunostomy for seven (35%) patients, hepaticojejunostomy for seven (35%) patients, choledochoduodenostomy for two (10%) patients, cholecystojejunostomy with gastrojejunostomy for three (15%) patients, and hepaticojejunostomy with gastrojejunostomy for one (5%) patient.

As regards postoperative outcomes the mean hospital stay for the surgery group was 13.5±4 days and for the stent group it was 6.5±7 days (P<0.01). The mean survival time (days) was 162.2±64 for the surgery group and 178.1±58 for the stent group (P=0.87). Therapeutic success (defined by a decrease in serum bilirubin to less than 50% of the initial value within 2 weeks) was achieved in 19 (95%) of the 20 patients in group I. Therapeutic success was obtained in 21 (92%) of the 23 patients in group II ([Table 2]).{Table 2}

Early complications occurred in nine of group I patients and three of group II patients, while late complications occurred in four of group I patients and seven of group II patients (P=0.21) ([Table 3]).{Table 3}

As regards recurrent postoperative jaundice due to stent blockage in four patients, only two patients had recurrent jaundice in the surgery group due to anastomotic stenosis (P=0.2).

Four patients underwent prophylactic gastrojejunostomy due to higher risk for gastric outlet obstruction in the surgery group. One of them had gastrojejunostomy obstruction (early complication). Another two patients in the surgical group, who had not undergone prophylactic gastrojejunostomy, have had postoperative gastric outlet obstruction due to duodenal invasion (late complication). One of them underwent palliation by gastroduodenal metal stenting. In group II, three patients developed duodenal obstruction during the follow-up period (P=0.736).

Mortality after 1 month was two patients in the surgery group and one patient in the stent group (P=0.6).

Discussion

Most patients with malignant obstructive jaundice are not fit for curative surgery. Endoscopic metal stent drainage, surgical bypass, or percutaneous drainage are the main palliative options. Despite few, different studies comparing endoscopic metal stenting and surgical bypass have shown similar survival rates. However, stenting patients usually have had shorter hospital stays and higher readmission rates [19],[20].

This study showed that both surgical bypass and EMS insertion have similar short-term satisfactory results in the control of jaundice. Surgical bypass had low incidence rate as regards late complications, although gastric outlet obstruction may occur for patients without gastric bypass. Despite EMS resulting in a shorter hospital stay, the higher late complications rate raised the cost, especially stent occlusion.

There were no statistically significant differences between the two groups as regards the efficacy of control of jaundice or survival rates. Two patients in the surgical group, who had not undergone prophylactic gastrojejunostomy, have had postoperative gastric outlet obstruction due to duodenal invasion. One of them underwent palliation by gastroduodenal metal stenting.

There is a controversy as regards the necessity of prophylactic gastrojejunostomy for unresectable pancreatobiliary cancer. According to Holbrook et al. [21], adding gastrojejunostomy doubled the mortality rate without showing any advantage in survival rate, so biliary bypass alone is recommended except for the patients with gastric outlet obstruction. But according to Singh et al. [22] and Lillemoe et al. [23], adding gastrojejunostomy did not differ in the mortality rate or survival time over biliary bypass alone, so gastrojejunostomy is recommended routinely for all patients undergoing palliative biliary bypass.

In this study, despite that EMS had shorter hospital stay and had a lower cost than biliary bypass, there was no statistically significant differences between the two groups as regards the rate of recurrent jaundice. Tumor in-growth was the main problem with the EMS as regards jaundice recurrence.

Recurrent jaundice, due to tumor ingrowth, is not exclusive to ERCP-placed EMS. In a study by Bornman et al. [24], comparing percutaneous stenting and surgical bypass, they reported a higher rate of recurrent jaundice among the percutaneous stent group. Moss et al. [25] confirmed the superiority of palliative endoscopic EMS over surgical bypass in the management of inoperable malignant biliary obstruction.

According to Isayama et al. [26], a covered EMS (like the one used in our study) may cause cholangitis, cholecystitis, or pancreatitis by occluding the orifice of the duodenal papilla. However, Artifon et al. [27] suggested that a covered EMS would not increase the incidence of pancreatitis, because the main pancreatic duct is already occluded by tumor invasion in most patients. In their study, no pancreatitis was reported in the stent group. And, the addition of sphincterotomy may prevent obstructive pancreatitis but may increase stent migration.Artifon et al. [18] reported that surgical bypass had a higher average cost (US $8321) than endoscopic EMS (US $4271) but with longer mean survival period (202 vs. 162 days).

In the present study, our results were similar to the results obtained by Maosheng et al. [17] and Artifon et al. [18], who compared metal stents versus surgery for malignant distal biliary obstruction.

Our study had some limitations: the retrospective design which has its risk of selection bias. Although, no significant differences in both groups as regard patients’ characteristics, that could potentially influence results. Also, no exclusion to patients with previous biliary decompression was done. However, there was no significant difference between the two groups regarding the number of patients with prior biliary decompression.

Conclusion

Endoscopic EMS and surgical bypass had similar results according to the efficacy of biliary drainage and mean survival period. EMS had a shorter hospital stay and fewer early complications. But, in the long run, the surgical bypass results in less recurrent jaundice than the EMS but with higher morbidity and mortality.

Recommendation

Management of inoperable distal malignant obstructive jaundice should be done at large-volume centers with a multidisciplinary approach and to minimize morbidity and mortality with balanced choice between the two methods.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1	Venkatesh B, Anand L, Padamavathi VK, Balachandar V. Review on clinical and molecular diagnosis of periampullary carcinoma. Int J Adv Res Biol Sci 2016; 3:210–216.
2	Sung JY, Leung JW, Shaffer EA, Lam K, Costerton JW. Bacterial biofilm, brown pigment stone, and blockage of biliary stents. J Gastroenterol Hepatol 1993; 8:28–34.
3	Smith AC, Dowsett JF, Russell RC, Hatfield AR, Cotton PB. Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction. Lancet 1994; 344:1655–1660.
4	Blero D, Huberty V, Devière J. Novel biliary self-expanding metal stents: indications and applications. Expert Rev Gastroenterol Hepatol. 2015; 9:359–367.
5	Weng H, Wang XF. Endoscopic retrograde biliary drainage for unresectable pancreatic cancer. In: Liu Y. (eds) Surgical atlas of pancreatic cancer. Vol 19. Singapore: Springer 2020 155–159.
6	Mao XN, Lu ZM, Wen F, Liang HY, Guo QY. Bare-metal stents across the Vater’s ampulla is a safe method for patients with lower bile duct obstruction. Medicine (Baltimore). 2017; 96:e7475.
7	Tringali A, Hassan C, Rota M, Rossi M, Mutignani M, Aabakken L. Covered vs. uncovered self-expandable metal stents for malignant distal biliary strictures: a systematic review and meta-analysis. Endoscopy 2018; 50:631–641.
8	Prat F, Chapat O, Ducot B, Ponchon T, Pelletier G, Fritsch J. et al... A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct. Gastrointest Endosc 1998; 47:1–7.
9	Perdue DG, Freeman ML, DiSario JA, Nelson DB, Fennerty MB, Lee JG et al. Plastic versus self-expanding metallic stents for malignant hilar biliary obstruction: a prospective multicenter observational cohort study. J Clin Gastroenterol 2008; 42:1040–1046.
10	Raikar GV, Melin MM, Ress A, Lettieri SZ, Poterucha JJ, Nagorney DM, Donohue JH. Cost-effective analysis of surgical palliation versus endoscopic stenting in the management of unresectable pancreatic cancer. Ann Surg Oncol 1996; 3:470–475.
11	Shepherd HA, Royle G, Ross AP, Diba A, Arthur M, Colin-Jones D. Endoscopic biliary endoprosthesis in the palliation of malignant obstruction of the distal common bile duct: a randomized trial. Br J Surg 1988; 75:1166–1168.
12	Andersen JR, Sorensen SM, Kruse A, Rokkjaer M, Matzen P. Randomised trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice. Gut 1989; 30:1132–1135.
13	Martin RC, Vitale GC, Reed DN, Larson GM, Edwards MJ, McMasters KM. Cost comparison of endoscopic stenting vs surgical treatment for unresectable cholangiocarcinoma. Surg Endosc 2002; 16:667–670.
14	Schwarz A, Beger HG. Biliary and gastric bypass or stenting in nonresectable periampullary cancer: analysis on the basis of controlled trials. Int J Pancreatol 2000; 27:51–58.
15	Santagati A, Ceci V, Donatelli G, Pasqualini MJ, Silvestri F, Pitasi F et al. Palliative treatment for malignant jaundice: endoscopic vs surgical approach. Eur Rev Med Pharmacol Sci 2003; 7:175–180.
16	Brandabur JJ, Kozarek RA, Ball TJ, Hofer BO, Ryan JA Jr, Traverso LW et al. Nonoperative versus operative treatment of obstructive jaundice in pancreatic cancer: cost and survival analysis. Am J Gastroenterol 1988; 83:1132–1139.
17	Maosheng D, Ohtsuka T, Ohuchida J, Inoue K, Yokohata K, Yamaguchi K et al. Surgical bypass versus metallic stent for unresectable pancreatic cancer. J Hepatobiliary Pancreat Surg 2001; 8:367–373.
18	Artifon EL, Sakai P, Cunha JE, Dupont A, Filho FM, Hondo FY et al. Surgery or endoscopy for palliation of biliary obstruction due to metastatic pancreatic cancer. Am J Gastroenterol 2006; 101:2031–2037.
19	Weber A, Mittermeyer T, Wagenpfeil S, Schmid RM, Prinz C. Selfexpanding metal stents versus polyethylene stents for palliative treatment in patients with advanced pancreatic cancer. Pancreas 2009; 38:e7–e 12.
20	Hwang SI, Kim HO, Son BH, Yoo CH, Kim H, Shin JH. Surgical palliation of unresectable pancreatic head cancer in elderly patients. World J Gastroenterol 2009; 15:978–982.
21	Holbrook AG, Chester JF, Britton DC. Surgical palliation for pancreatic cancer: will biliary bypass alone suffice? J R Soc Med 1990; 83:12–14.
22	Singh SM, Longmire WP Jr, Reber HA, Surgical palliation for pancreatic cancer. The UCLA experience. Ann Surg 1990; 212:132–139.
23	Lillemoe KD, Cameron JL, Hardacre JM, Sohn TA, Sauter PK, Coleman J et al. Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial. Ann Surg 1999; 230:322–328; discussion 328–330.
24	Bornman PC, Harries-Jones EP, Tobias R, Van Steigmann G, Terblanche J. Prospective controlled trial of transhepatic biliary endoprosthesis versus bypass surgery for incurable carcinoma of head of pancreas. Lancet 1986; 1:69–71.
25	Moss AC, Morris E, Leyden J, MacMathuna P. Malignant distal biliary obstruction: a systematic review and meta-analysis of endoscopic and surgical bypass results. Cancer Treat Rev 2007; 33:213–221.
26	Isayama H, Komatsu Y, Tsujino T, Sasahira N, Hirano K, Toda N et al. A prospective randomised study of ‘covered‘ versus ‘uncovered’ diamond stents for the management of distal malignant biliary obstruction. Gut 2004; 53:729–734.
27	Artifon EL, Sakai P, Ishioka S, Marques SB, Lino AS, Cunha JE et al. Endoscopic sphincterotomy before deployment of covered metal stent is associated with greater complication rate: a prospective randomized control trial. J Clin Gastroenterol 2008; 42:815–819.