Endoscopic stenting in bile duct cancer increases liver volume

Transcription

1 Endoscopic stenting in bile duct cancer increases liver volume Chang Hun Lee 1,3, Seung Young Seo 1,3, Seong Hun Kim 1,3, In Hee Kim 1,3, Sang Wook Kim 1,3, Soo Teik Lee 1,3, Dae Ghon Kim 1,3, Jae Do Yang 2,3, Hee Chul Yu 2,3, Baik Hwan Cho 2,3, and Seung Ok Lee 1,3 Division of Gastroenterology, Department of Internal Medicine (1), Department of Surgery, Chonbuk National University Medical School and Hospital (2), Biomedical Research Institute, Chonbuk National University Hospital (3), Jeonju, South Korea.

2 Introduction Bile duct cancers Commonly cause biliary obstruction Endoscopic biliary stenting Decompress obstructive lesions An alternative to surgery For palliative treatment Not determined issues Optimal stent type and number for biliary stenting Relative merits of unilateral and bilateral stenting in hilar cholangiocarcinoma still under debate

3 Effective biliary stenting Ameliorate jaundice Reduce cholangitis Extend survival Effects of biliary stenting on liver regeneration Liver growth related to hepatic regeneration Major concept of liver resection and transplantation Biochemical and Clinical Aspects. Philadelphia: W. B. Saunders, 1992

4 Aim of the study To evaluate liver regeneration after endoscopic biliary stenting for bile duct cancer by volumetry To compare liver volume changes according to stent location. To compare the type of stenting (unilateral and bilateral) in hilar bile duct cancer.

5 Patient enrollment Assessed for eligibility (n=421) Selection of the patients Underwent SEMS placement Histologically confirmed malignancy Diagnosed bile duct cancer 2 consecutive sets of CT images Hilar bile duct stricture (n=40) Distal bile duct stricture (n=68) Hilar bile duct cancer Bilateral stent (n=13) Unilateral stent (n=18) Distal bile duct cancer (n=29)

6 Liver volume measurement

7 Baseline clinical characteristics `

8 Changes in liver volume

9 Case 1. Hilar bilateral stenting 72/M C.C) Jaundice o : 1MA v : spon PHx) No underlying disease R.O.S) non-specific PEx) Mild icteric sclera No abdominal DT/RT Hilar cholangiocarcinoma (Klatskin tumor, Bismuth type IV) Biliary stent (Y-stent) insertion -- 1 st Lt lobe : 10mm diameter, 80mm length -- 2 nd Rt ant seg : 10mm diameter, 60mm length

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11 Case 1. Hilar bilateral stenting 72/M Follow-up duration : 7.0 weeks Volume increase : 874mL (94.9%) Pre-stenting ( ) Post-stenting ( ) Hilar cholangiocarcinoma (Klatskin tumor, Bismuth type IV) Biliary stent (Y-stent) insertion -- 1 st Lt lobe : 10mm diameter, 80mm length -- 2 nd Rt ant seg : 10mm diameter, 60mm length

12 Case 2. Hilar unilateral stenting for left duct 77/F C.C) Jaundice o : 10DA v : spon Ass Sx : pruritis, G.weakness PHx) No underlying disease R.O.S) fever (-), chills (+) PEx) Icteric sclera No abdominal DT/RT Hilar cholangiocarcinoma (Klatskin tumor, Bismuth type IV) Biliary stent insertion -- 12cm in lengh -- uncovered stent -- into the Lt. IHBD

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14 Case 2. Hilar unilateral stenting for left duct 77/F Follow-up duration : 7.9 weeks Volume increase : 865mL (77.4%) Pre-stenting ( ) Post-stenting ( ) Hilar cholangiocarcinoma (Klatskin tumor, Bismuth type IV) Biliary stent insertion -- 12cm in lengh, uncovered into the Lt. IHBD

15 Case 3. Hilar unilateral stenting for right duct 69/M C.C) Jaundice For evaluation of incidentally detected abnormal findings PHx) No underlying disease R.O.S) non-specific PEx) Mild icteric sclera No abdominal DT/RT Hilar cholangiocarcinoma (Klatskin tumor, Bismuth type IIIa) Biliary stent insertion -- 12cm in lengh -- uncovered stent -- into the Rt. ant segment

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17 Case 3. Hilar unilateral stenting for right duct 69/M Follow-up duration : 6.1 weeks Volume increase : 765mL (53.2%) Pre-stenting ( ) Post-stenting ( ) Hilar cholangiocarcinoma (Klatskin tumor, Bismuth type IIIa) Biliary stent insertion -- 12cm in lengh, uncovered into the Rt. ant segment

18 Rate of Liver growth (ml/wk) Change in the rate of liver volume increase Rate: 44.4 ml/week Average rate: 22.0 ml/week Days after biliary stenting (weeks)

19 Comparison of liver volume changes according to stent location (hilar vs distal) and number (hilar unilateral vs hilar bilateral)

20 Comparison of liver volume changes according to stent location (hilar vs distal) and number (hilar unilateral vs hilar bilateral)

21 Discussion Biliary stenting resulted in a liver volume increase Relieving biliary obstruction Promotes liver regeneration Liver volumetry as an effective tool for evaluating stent efficacy Location and number of stents Hilar biliary stenting showed a greater increase High baseline bilirubin and AST levels Unilateral stenting vs Bilateral stenting Depend upon difference of coverage of a drained liver section Regeneration process time Early rapid compensation by the damaged liver

22 Limitations Different reasons for a second CT scan Different baseline bilirubin and AST/ALT levels Clinical parameters reflecting the patients condition not stated No additional objective testing such as liver biopsy Not consider the effect of stent patency and additional biliary procedures such as external drainage Not consider segmental liver volume changes.

23 Conclusions In bile duct cancer, metal stent placement increased liver volume significantly regardless of the location, especially within 4 to 8 weeks. In hilar bile duct cancer, liver volume increases by bilateral stenting were similar to those by unilateral stenting. Liver volume assessment should be considered as a useful tool for evaluating stent efficacy in patients or for large studies on new stent types or techniques.

24 Thank You For Your Attention