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How I it : Biliary Drainage and Stenting Angus CW Chan Director, Endoscopy Centre Assistant Director, Surgery Centre Hong Kong Sanatorium & Hospital Honorary Associate Professor, CUHK & HKU Biliary Drainage • Benign biliary obstruction - acute cholangitis - CBD stones - Bile duct leakage • Malignant biliary obstruction - cholangiocarciona - Ca head of pancreas - LN compression Indications for emergency ERCP • Acute suppurative cholangitis - bile duct stones ( CBD / IHD ) • Acute biliary pancreatitis - ass bile duct stones Acute suppurative cholangitis Charcot’s triad • • • Right upper quadrant pain / epigastrium Fever, chills & rigors Jaundice Reynold’s Pentad • • Septicaemic shock Confusion Acute suppurative cholangitis Pathophysiology • • • • obstructed biliary system impacted stone bacteria in bile stone harbors the raise intra-biliary pressure cholangio-venous reflux systemic sepsis septicemic shock Urgent biliary decompression to relieve the pressure ? Surgical exploration Vs ? Endoscopic drainage bacteria Endoscopic biliary drainage • Safe and effective • Less morbidity and mortality rate • Later removal of stones when sepsis controlled Bile duct decompression with NB drain Urgent endo drainage for acute cholangitis Leung (1989) Lai (1992) Surgery Patients 105 41 Endo drain 41 Success rate102 (97%) Complications 27 (66%) 14 (34%) Mortality 13 (32%) (10%) (4.7%) Leung et al Lancet Lai ECS et al NEJM Patient • • • • • Critically ill Haemodynamically unstable Confused Desaturation / Hypoxia Increase the risks of ERCP Preparation • • • • • • Consult ICU if necessary May need intubation before ERCP No sedation Intensive monitoring during the procedure Prepare all accessories before start Aim for a short procedure time Technical points: • Shortening 2cm margins • Length • Inside CBD or outside papilla Metal stenting procedure Metal stenting for hilar obstruction SEMS of biliary stricture Advantages Drawbacks • Easy insertion - Permanent • Longer patency - In- & over growth • Less re-admission - Expensive ($1200) • Better quality of life Cost-benefit of SEMS • Hoepffner (Endoscopy 1994) “Long term experience in Wallstent therapy for malignant choledochal stenosis” n=51, survive > mo, 86% at mo, 72% at 12, 41% at 18 mo • Prat (Gastro Endo 2000) “ A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the CBD” n=101, 11.5F on prn Vs 11.45F on mo Vs SEMS Similar survival, more complications in gp Cost-analysis: SEMS for patients > mo Plastic for patients < mo Tumor ingrowth & overgrowth Covered biliary metal stent Shim CS (Endoscopy 1998) Retrospective series PolyurethaneSEMS Patients 21 26 Success rate (%) Drainage (%) 90.4 88.5 100 95.6 Patency rate (d) In-growth SEMS 267 233 (10.5%) (26.1%) SEMS for benign biliary strictures • Cannot be removed • Mucosal hyperplasia into the mesh • 4-15 months patency rate Dumonceau et al 1998 GI Endo Stenting for biliary stricture Which stents : Plastic vs Metal • • • • Nature of stricture Level of stricture Life expectancy and quality of life Cost Indications for SEMS of biliary strictures • Inoperable malignant biliary obstruction • Survival > months • Percutneous or ERCP • Good financial support • Selected cases for benign strictures Pancreatic duct leakage Pancreatic duct disruption • • • • Severe pancreatic necrosis 75% associated with PD disruption Extremely ill patient Role of pancreatic duct stent or naso-pancreatic drainage ?? Pancreatic duct disruption Thank you ... (n) (%) (%) (days) Metal 49 96 33 273 Plastic 56 95 54 Metal 86 98 13 111 Plastic 78 95 13 Metal 31 100 22 FU mos Plastic 31 100 43 Davids (1992) 1 26 Carr-Locke (1993) 62 Knyrim (1993) Technical... Retrospective series PolyurethaneSEMS Patients 21 26 Success rate (%) Drainage (%) 90.4 88.5 100 95 .6 Patency rate (d) In-growth SEMS 267 233 (10.5%) ( 26. 1%) SEMS for benign biliary strictures • Cannot... relieve the pressure ? Surgical exploration Vs ? Endoscopic drainage bacteria Endoscopic biliary drainage • Safe and effective • Less morbidity and mortality rate • Later removal of stones when sepsis