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Huang XH, Wu SH, Li P, Ke Q, Weng XT, Li L, Liu DX, Zhuang SW, Sun JH, Guo WH. [Percutaneous biliary stent combined with brachytherapy for malignant obstructive jaundice: a multicenter retrospective controlled study]. ZHONGHUA GAN ZANG BING ZA ZHI = ZHONGHUA GANZANGBING ZAZHI = CHINESE JOURNAL OF HEPATOLOGY 2022; 30:702-709. [PMID: 36038338 DOI: 10.3760/cma.j.cn501113-20220728-00399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Objective: To investigate the efficacy, safety and prognostic factors of percutaneous biliary stent combined with iodine-125 seed chain brachytherapy (radiotherapy) in the treatment of malignant obstructive jaundice. Methods: Data of 107 cases with malignant obstructive jaundice treated with percutaneous biliary stent implantation from January 2017 to December 2020 were retrospectively analyzed. Among them, 58 cases received biliary stent combined with iodne-125 seed chain brachytherapy (study group), and 49 cases received biliary stent implantation (control group). The changes of bilirubin, stent patency time, complications, overall survival (OS) and prognostic factors were analyzed in both groups. Results: The incidence of complications in the study group and the control group were 17.2% and 18.3% respectively, and the difference was not statistically significant (P=0.974). Serum total bilirubin levels were decreased significantly in both groups at one month after surgery (P<0.001). Postoperative stent patency time was significantly better in the study group (10.0±1.6 months) (95% CI: 8.2~12.5) than that in the control group (5.2±0.4 months) (95% CI: 4.1~6.0, P<0.001). The median OS was longer in the study group (11.2±1.8 months) (95% CI: 9.2~12.8) than that in the control group (8.0±1.1 months) (95% CI: 8.0~12.8, P<0.001). Multivariate analysis result showed that stent combined with brachytherapy (HR=0.08, 95% CI:0.04~0.15, P<0.001) and receiving further anti-tumor therapy after surgery (HR=0.27, 95% CI:0.15~0.49, P<0.001) were independent risk factors affecting the patency of biliary stents. Preoperative percutaneous transhepatic biliary drainage (HR=0.46, 95%CI:0.28~0.74, P=0.002), stent combined with brachytherapy (HR=0.23, 95%CI:0.14~0.39, P<0.001) and receiving further anti-tumor therapy after surgery (HR=0.37, 95%CI:0.22~0.61, P<0.001) were independent risk factors affecting OS. Conclusion: Percutaneous biliary stent combined with brachytherapy is safe and effective in the treatment of malignant obstructive jaundice, which can significantly prolong the patency time of biliary stent and the survival time of patients.
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Kazami Y, Arita J, Nishioka Y, Kawaguchi Y, Ichida A, Ishizawa T, Akamatsu N, Kaneko J, Nakai Y, Koike K, Hasegawa K. Preoperative Predictive Features of Invasive Carcinoma Among Intraductal Papillary Mucinous Neoplasm of the Pancreas. Pancreas 2022; 51:642-648. [PMID: 35835103 DOI: 10.1097/mpa.0000000000002078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Noninvasive intraductal papillary mucinous neoplasms (IPMNs) theoretically do not metastasize. The purpose of this study is to preoperatively distinguish invasive carcinomas associated with IPMN from noninvasive IPMN. METHODS A total of 131 patients who underwent surgical resection for IPMN were retrospectively analyzed to identify the predictors of invasive carcinoma, based on the International Association of Pancreatology Consensus Guidelines. RESULTS Of the 131 patients, 29 (22%) had invasive carcinomas and 102 (78%) had noninvasive IPMN. An enhancing mural nodule (MN) greater than or equal to 5 mm, obstructive jaundice, an abrupt change in the caliber of the pancreatic duct (PD) with distal pancreatic atrophy, and lymphadenopathy were the significant predictors of invasive carcinoma in univariate analysis. The optimal cutoff value for the size of the enhancing MN to differentiate invasive carcinoma was 13 mm. In multivariate analysis, enhancing MN greater than or equal to 13 mm, obstructive jaundice, and an abrupt change in the PD caliber were the independent predictors. When all these factors were absent, only 17% were invasive carcinomas. CONCLUSIONS Enhancing MN greater than or equal to 13 mm, obstructive jaundice, and an abrupt change in the PD caliber were predictive factors for invasive carcinoma. Systematic lymph node dissection may be omitted when a high-risk patient has none of these factors.
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Subasi O, Ercan M, Aziret M, Biricik A, Kahraman YS, Altıntoprak F, Celebi F, Karaman K. Effects of preoperative biliary drainage methods and time to postoperative complications after biliary drainage in periampullary tumors. Ann Ital Chir 2022; 93:403-409. [PMID: 35758240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To compare postoperative morbidity and mortality results in patients with and without endoscopic and percutaneous transhepatic biliary drainage due to obstructive jaundice caused by a periampullary tumor and to examine the effect of intervals until surgery on postoperative morbidity and mortality in patients who underwent preoperative biliary drainage (BD). METHODS Patients were divided into 3 groups according to their BD status. Group1, no biliary drainage (NBD), Group2, Endoscopic biliary drainage (EBD), Group3, Percutaneous transhepatic biliary drainage (PBD). Patients who underwent biliary drainage before pancreaticoduodenectomy (PD) were divided into 3 intervals according to the time interval between drainage and surgery: Short interval; patients undergoing surgery in 21 days and <, Medium interval; between 22-42 days, Long interval; 43 days and >. Groups and intervals were compared in terms of postoperative morbidity and mortality. RESULTS Of the 122 patients who underwent PD, 76 (62.3%) were male, and 46 (37.7%) were female. Within these patients, 47 (38.52%) had NPD, 42 (34.42%) had EBD, and 33 (27.05%) had PBD. The rate of postoperative Grade B and C fistula was higher in the groups that underwent preoperative drainage compared to the group without preoperative drainage (p = 0.007). CONCLUSION It was determined that the postoperative complication rate was lower in patients who did not undergo BD compared to patients who underwent biliary drainage. Besides, the endoscopic drainage method was observed to be associated with fewer complications than the percutaneous transhepatic drainage method. KEY WORDS Preoperative biliary drainage, Pancreaticoduodenectomy, Periampullary tumors, Post procedure complication, Timing.
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Yartsev PA, Teterin YS, Mironova KA, Askerov AC. [Oral cholangioscopy for biliary system diseases]. Khirurgiia (Mosk) 2022:28-34. [PMID: 36223147 DOI: 10.17116/hirurgia202210128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To improve the results of treatment of obstructive jaundice by using of oral cholangioscopy. MATERIAL AND METHODS There were 321 patients with obstructive jaundice between October 2020 and November 2021. Of these, cholangioscopy (SpyGlass video system) was used in 18 patients. Patients were divided into two groups: group 1 (n=9) - malignant biliary strictures; group 2 (n=9) - choledocholithiasis with large calculi (≥1.2 cm). At admission, all patients underwent laboratory and instrumental examination. In the first group, bilioduodenal stenting with plastic stents 7 and 10 Fr in diameter, 7 to 12 cm long or self-expanding nitinol stents 0.8-1.0 cm in diameter, 6 to 10 cm long was carried out. Patients with large calculi underwent targeted laser lithotripsy under endoscopic control until formation of 1-cm fragments. These fragments were removed using a lithoextraction balloon and Dormia basket. RESULTS Cholangioscopy (SpyGlass system) was performed within 2 days after admission. In group 1, tumor tissue overgrowths were found during cholangioscopy. Five out of 9 (55.6%) patients underwent bilioduodenal stenting for adequate biliary drainage. Of these, 4 (44.5%) patients developed acute edematous pancreatitis on the first postoperative day. This complication regressed after 3-4 days under therapy. Four (44.5%) patients died from cancer-related multiple organ failure. In group 2, cholangioscopy effectively visualized the calculus and ensured its destruction by laser contact lithotripsy. Intraoperative and postoperative complications were not revealed in both groups. CONCLUSION SpyGlass system is effective and safe for diagnosis and treatment in 100% of patients with extrahepatic biliary strictures and/or large calculi.
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Mie T, Sasaki T, Takeda T, Furukawa T, Yamada Y, Kasuga A, Matsuyama M, Ozaka M, Sasahira N. A case of endoscopic ultrasound-guided hepaticogastrostomy for obstructive jaundice caused by intraductal papillary mucinous neoplasm-associated pancreatobiliary fistula. Clin J Gastroenterol 2021; 14:893-898. [PMID: 33590462 DOI: 10.1007/s12328-021-01355-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/30/2021] [Indexed: 11/27/2022]
Abstract
Intraductal papillary mucinous neoplasm (IPMN) sometimes forms fistulas with other organs due to high pressure of pancreatic duct filled with huge amount of mucus. Pancreatobiliary fistula may cause obstructive jaundice due to the mucus and it is hard to manage the jaundice by endoscopic biliary stenting because of high viscosity of the bile. We report a case of IPMN with pancreatobiliary fistula managed by endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS). The patient was 87 years old and presented with obstructive jaundice. As a transpapillary biliary stent was considered to have a risk of migration due to the absence of bile duct stenosis, a nasobiliary catheter was placed as an initial drainage. However, the catheter was frequently obstructed by mucus. The patient was intolerable for surgery because of his age. Considering the intrahepatic bile was serous, EUS-HGS was performed and jaundice improved successfully. This case study revealed that EUS-HGS might be a therapeutic option for obstructive jaundice caused by an IPMN-associated pancreatobiliary fistula.
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Angelescu M, Enciu O, Florescu V, Miron A. Obstructive Jaundice Secondary to Clip Migration in the Common Bile Duct 9 Years after Laparoscopic Cholecystectomy. Chirurgia (Bucur) 2020; 115:526-529. [PMID: 32876027 DOI: 10.21614/chirurgia.115.4.526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2020] [Indexed: 11/23/2022]
Abstract
Surgical clip migration in the common bile duct with consecutive stone formation is a rare occurrence after laparoscopic cholecystectomy, less than 100 cases being reported so far. We report a case of a 55-year-old woman with obstructive jaundice due to bile duct stone formed around a migrated surgical clip 9 years after laparoscopic cholecystectomy. The patient presented with pain in the upper abdomen and jaundice. Abdominal ultrasound diagnosed dilation of the common bile duct and intrahepatic bile ducts. The diagnosis was confirmed by computed tomography which revealed a metal clip in the distal part of the common bile duct. The patient was managed successfully by endoscopic retrograde cholangiopancreatography (ERCP) and the surgical clip was retrieved using the Dormia basket. The exact mechanism of clip migration is not fully understood but may be explained by local inflammation and ineffective clipping. Although a rare occurrence, clip migration should not be excluded when considering the differential diagnosis of patients presenting with obstructive jaundice or cholangitis after laparoscopic cholecystectomy. Minimally invasive management by ERCP is the procedure of choice for migrated clips related complications but surgical common bile duct exploration may be necessary.
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Castiglione D, Gozzo C, Mammino L, Failla G, Palmucci S, Basile A. Health-Related Quality of Life evaluation in "left" versus "right" access for percutaneous transhepatic biliary drainage using EORTC QLQBIL-21 questionnaire: a randomized controlled trial. Abdom Radiol (NY) 2020; 45:1162-1173. [PMID: 31327040 DOI: 10.1007/s00261-019-02136-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate the impact of the different access for percutaneous transhepatic biliary drainage (PTBD) in terms of "Quality of Life" (QoL) in the management of malignant obstructive jaundice. METHODS In this IRB-approved study, 64 consecutive patients with malignant obstructive jaundice were prospectively randomized to the right (group A) or left access (group B) for PTBD between February 2017 and December 2018. In order to demonstrate differences in terms of QoL between these groups, patients were asked to complete the "EORTC QLQ-BIL21" questionnaire the week after the treatment. Continuous variables were summarized by mean ± SD and compared using a Mann-Whitney U test. RESULTS Percutaneous transhepatic biliary drainages were performed through right access in 31 cases and 33 cases through left access. Technical success was achieved in all cases (100%). During 1 week's follow-up, there was a significant difference between group A and B in terms of pain (p < 0.001). Group A showed higher intercostal pain and respiratory difficulties compared to group B. Moreover, patients of group A showed a higher level of tiredness, anxiety, and more difficult tubes drainage and bags management than group B patients. CONCLUSION In our experience, the use of the questionnaires showed the right access is associated with intercostal pain and respiratory difficulties. Left access for PTBD provides a better Quality of Life for patients who underwent PTBD as palliative treatment for the management of malignant obstructive jaundice and could be considered as the approach of choice in case of distal obstruction.
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Chen MX, Zhang RL, Xu XN, Yu Q, Huang DN, Liu W, Chen SH, Song P, Lu L, Cai YC, Ai L, Chen JX. Parasitological and molecular detection of human fascioliasis in a young man from Guizhou, China. Trop Biomed 2020; 37:50-57. [PMID: 33612717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A 24-year-old man born in Guizhou province was diagnosed with obstructive jaundice and bile duct stones in 2013. Four living trematodes were found during laparotomy and cholecystectomy. Based on the morphology and molecular genetics analysis of internal transcribed spacer and pcox1 genes of the flatworm specimens, the trematodes from the patient were confirmed to be Fasciola hepatica. This report provided the clinical and molecular diagnosis information on human fascioliasis, which is an emerging sanitary problem still ignored in China. Human fascioliasis constantly occurs due to climatic changes and frequency of human travel. Therefore, it deserves more attention from physicians working in both developing and developed countries.
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Verma R, Saha A, Saha K. Inflammatory Myofibroblastic Tumor of the Mid Common Bile Duct Masquerading as Cholangiocarcinoma. J Gastrointest Cancer 2020; 50:613-616. [PMID: 29453762 DOI: 10.1007/s12029-018-0074-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Rees J, Mytton J, Evison F, Mangat KS, Patel P, Trudgill N. The outcomes of biliary drainage by percutaneous transhepatic cholangiography for the palliation of malignant biliary obstruction in England between 2001 and 2014: a retrospective cohort study. BMJ Open 2020; 10:e033576. [PMID: 31980509 PMCID: PMC7045186 DOI: 10.1136/bmjopen-2019-033576] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Relieving obstructive jaundice in inoperable pancreato-biliary cancers improves quality of life and permits chemotherapy. Percutaneous transhepatic cholangiography with drainage and/or stenting relieves jaundice but can be associated with significant morbidity and mortality. Percutaneous transhepatic biliary drainage (PTBD) in malignant biliary obstruction was therefore examined in a national cohort to establish risk factors for poor outcomes. METHODS Retrospective study of adult patients undergoing PTBD for palliation of pancreato-biliary cancer in England between 2001 and 2014 identified from Hospital Episode Statistics. Multivariate logistic regression analysis was used to examine associations with mortality and the need for a repeat PTBD within 2 months. RESULTS 16 822 patients analysed (median age 72 (range 19-104) years, 50.3% men). 58% pancreatic and 30% biliary tract cancer. In-hospital and 30-day mortality were 15.3% (95% CI 14.7% to 15.9%) and 23.1% (22.4%-23.8%), respectively. 20.2% suffered a coded complication within 3 months. Factors associated with 30-day mortality: age (≥81 years OR 2.68 (95% CI 2.37 to 3.03), p<0.001), increasing comorbidity (Charlson score 20+, 3.10 (2.64-3.65), p<0.001), pre-existing renal dysfunction (2.37 (2.12-2.65), p<0.001) and non-pancreatic cancer (unspecified biliary tract 1.28 (1.08-1.52), p=0.004). Women had lower mortality (0.91 (0.84-0.98), p=0.011), as did patients undergoing PTBD in a 'higher volume' provider (84-180 PTBDs per year 0.68 (0.58-0.79), p<0.001). CONCLUSIONS In patients undergoing PTBD for the palliation of malignant biliary obstruction, 30-day mortality was high at 23.1%. Mortality was higher in older patients, men, those with increasing comorbidity, a cancer site other than pancreas and at 'lower-volume' PTBD providers.
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Sochnieva AL. OPTIMUM DURATION OF PERCUTANEOUS TRANSHEPATIC CHOLANGIODRAINAGE IN COMMON BILE DUCT DISEASES COMPLICATED BY OBSTRUCTIVE JAUNDICE. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2020; 73:1915-1925. [PMID: 33148834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE The aim: Is to determine the optimum duration of percutaneous transhepatic cholangiodrainage depending on the duration of obstructive jaundice and the baseline total bilirubin level in patients with benign and malignant common bile duct diseases complicated by obstructive jaundice. PATIENTS AND METHODS Materials and methods: The experience of applying percutaneous transhepatic cholangiodrainage was combined for 88 patients with common bile duct diseases complicated by obstructive jaundice. The patients were divided into three groups: the Group 1 included 15 patients (17.1%) with benign common bile duct diseases, the Group 2 included 11 patients (12.5%) with resectable cholangiocarcinomas, and the Group 3 included 62 patients (70.4%) with unresectable cholangiocarcinomas. To determine optimal terms of biliary decompression using percutaneous transhepatic cholangiodrainage, the Poisson process was applied, and, to be more precise, the quasi-Poisson distribution. RESULTS Results: It was found that the reduction of total bilirubin was the fastest in Group 3 patients. It took these patients an average of 7-8 days to reduce total bilirubin to 50 μmole/l. In Group 1 patients, the process is somewhat slower. The duration of biliary decompression in this category of patients averages 10-12 days. For Group 2 patients, biliary decompression requires at least 12 days. CONCLUSION Conclusions: Using the Poisson process, or, to be more precise, the quasi-Poisson distribution, we managed to determine the optimum duration of biliary decompression using percutaneous transhepatic cholangiodrainage depending on the obstructive jaundice duration and the baseline total serum bilirubin.
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Li W, Wang X, Wang Z, Zhang T, Cai F, Tang P, Meng J, Du H, Wang H, Li M, Li S. The role of seed implantation in patients with unresectable pancreatic carcinoma after relief of obstructive jaundice using ERCP. Brachytherapy 2020; 19:97-103. [PMID: 31564517 DOI: 10.1016/j.brachy.2019.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/27/2019] [Accepted: 08/21/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose of the study was to investigate the role of iodine-125 seed implantation, guided by endoscopic ultrasound (EUS) and/or percutanous ultrasound, in patients with unresectable pancreatic carcinoma after relief of obstructive jaundice using endoscopic retrograde cholangiopancreatography (ERCP). METHODS AND MATERIALS A total of 101 patients with obstructive jaundice due to unresectable pancreatic carcinoma were enrolled between January 2010 and December 2017 in this retrospective study. Of these patients, 50 underwent implantation of iodine-125 seeds under EUS and/or percutaneous ultrasound guidance after receiving a stent via ERCP (treatment group), and 51 received a stent via ERCP without undergoing seed implantation (control group). The clinical data and therapeutic outcomes of these patients were analyzed. RESULTS Compared with the control group, the treatment group obtained significant relief of abdominal pain at the 1-week, 1-month, and 3-month followup (p < 0.05), with a significantly lower visual analog scale pain score (p < 0.05). The treatment group obtained a longer median survival (8.8 vs. 6.5 months, p = 0.02), longer median duration of stent patency (10.8 ± 1.4 vs. 6.9 ± 0.8 months, p = 0.02), and prolonged average time to gastric outlet obstruction (6.8 ± 1.6 vs. 5.3 ± 1.3 months, p = 0.02). Differences between liver function and appetite for the two groups were not significant (p > 0.05 and p = 0.59, respectively). CONCLUSIONS Iodine-125 seed implantation after relief of obstructive jaundice via ERCP prolongs survival, biliary stent patency, and time to gastric outlet obstruction and improves patient quality of life by relieving pancreatic pain in patients with unresectable pancreatic carcinoma.
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Soares PFDC, Gestic MA, Utrini MP, Callejas-Neto F, Chaim EA, Cazzo E. Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study. SAO PAULO MED J 2019; 137:491-497. [PMID: 32159634 PMCID: PMC9754274 DOI: 10.1590/1516-3180.2019.0109170919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 09/17/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING Cross-sectional study at a tertiary-level university hospital. METHODS Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.
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Mann K, Gilbert T, Cicconi S, Jackson R, Whelan P, Campbell F, Halloran C, Neoptolemos J, Ghaneh P. Tumour stage and resection margin status are independent survival factors following partial pancreatoduodenectomy for duodenal adenocarcinoma. Langenbecks Arch Surg 2019; 404:439-449. [PMID: 30972486 PMCID: PMC6614162 DOI: 10.1007/s00423-019-01779-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 03/20/2019] [Indexed: 01/14/2023]
Abstract
INTRODUCTION There is limited published evidence on duodenal carcinoma due to its rarity. This study aimed to evaluate gastric outlet obstruction and obstructive jaundice along with pathological variables as survival factors in patients with duodenal adenocarcinoma following resection. METHODS Survival factor analysis was undertaken in patients undergoing duodenal cancer surgery from 1997 to 2015 in a single centre. RESULTS There were 57 patients of whom 18 had gastric outlet obstruction and 14 had obstructive jaundice. Fifty-three had a partial pancreatoduodenectomy and four had palliative bypass. Perioperative mortality and morbidity were 4% (2/53) and 47% (25/53) respectively in resected patients. With a median (95% confidence interval, CI) follow-up of 72 (57-86) months, median overall and recurrence-free survival was 38 months (95% CI 28-113) and 27 months (95% CI 18-83) respectively. The 1 and 3-year overall survival rates were 84% (95% CI 74-95) and 52% (95% CI 39-69) respectively. Median overall survival was 19 months in patients with gastric outlet obstruction vs 53 months in those without (p = 0.026) and 28 months in patients with obstructive jaundice vs 38 months in those without (p = 0.611). Univariate analysis revealed that tumour stage, resection margin status, pre-operative albumin status, gastric outlet obstruction and age were associated with poorer overall and recurrence-free survival but multivariate analysis confirmed only tumour stage and resection margin status to be significant. CONCLUSION Whereas gastric outlet obstruction in duodenal cancer appeared to be an important survival factor following partial pancreatoduodenectomy, multivariate analysis showed that only tumour stage and resection margin status were the key independent survival factors. Further multicentre studies are required to elucidate further characteristics of duodenal carcinoma and develop neoadjuvant/adjuvant management strategies.
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Morita S, Suda T, Terai S. Submucosal painting for gastroduodenal stent placement. Dig Endosc 2019; 31:e64-e65. [PMID: 30664261 DOI: 10.1111/den.13349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 01/15/2019] [Indexed: 02/08/2023]
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Sha J, Dong Y, Niu H. A prospective study of risk factors for in-hospital mortality in patients with malignant obstructive jaundice undergoing percutaneous biliary drainage. Medicine (Baltimore) 2019; 98:e15131. [PMID: 30985679 PMCID: PMC6485810 DOI: 10.1097/md.0000000000015131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The in-hospital mortality rate in patients undergoing percutaneous transhepatic biliary drainage (PTBD) for malignant obstructive jaundice (MOJ) is high. There are few reports on the risk factors associated with hospital death after MOJ, with most of them being retrospective analyses of single factors. Therefore, this study aimed to assess pre-, intra-, and post-procedure risk factors that were independently associated with increased in-hospital mortality in MOJ patients who underwent PTBD. METHODS One-hundred fifty-five patients with MOJ who underwent initial PTBD were included in this study. A total of 25 pre-, 4 intra-, and 6 post-procedure factors potentially related to in-hospital mortality were assessed by univariate and multivariate analyses. RESULTS The in-hospital mortality rate was 16.8% (26/155). Of 25 pre-procedure variables analyzed, Child-Pugh classification C, creatinine level ≥6.93 μmol/L, and quality-of-life score (≤30) were found to be significant in univariate and multivariate analyses. Increased mortality was observed in patients with 2 or more risk factors, which was significantly different from patients with no risk factors or one risk factor (P < .01). None of the intra-procedure factors were important in identifying patients at risk of death. Multivariate analysis indicated post-PTBD cholangitis and unsuccessful drainage as post-procedure risk factors that correlated with in-hospital death. CONCLUSION It was identified that in-hospital mortality was associated with 3 pre-procedure and 2 post-procedure risk factors, such as the liver function classification, quality-of-life score of cancer patients, creatinine level, PTBD-associated biliary duct infection, and unsuccessful drainage.
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Liu XM, Yan XP, Zhang HK, Ma F, Guo YG, Fan C, Wang SP, Shi AH, Wang B, Wang HH, Li JH, Zhang XG, Wu R, Zhang XF, Lv Y. Magnetic Anastomosis for Biliojejunostomy: First Prospective Clinical Trial. World J Surg 2019; 42:4039-4045. [PMID: 29947988 DOI: 10.1007/s00268-018-4710-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Magnetic compression anastomosis (magnamosis, MCA) has been verified safe and effective by us and others in animal bilioenteric anastomosis (BEA). The objective of the present study was to introduce clinical application of magnetic compression bilioenteric anastomosis (MC-BEA) with a unique device in series of patients. METHODS Patients with obstructive jaundice with an indication of BEA were prospectively enrolled from 2012 to 2015. After dissection of bile ducts, the mother ring and drainage tube were placed in the proximal bile duct and the purse-string suture was tightened over the drainage tube. The drainage tube was introduced into the jejunal lumen at the anastomotic site and used to guide the daughter ring to assemble with the mother ring. All the patients were routinely followed up for magnets discharge or any complications associated. RESULTS Forty-one patients were included. Thirty-four (82.9%) patients had a malignant primary disease, while seven (17.1%) had benign disease. The median time for MC-BEA was 10.5 min (interquartile range [IQR] 8.3-13.0 min). No perioperative morbidity or mortality associated with MC-BEA was observed. The median time for a patent bilioenteric anastomosis formation was 19.0 days (IQR 14.5-23.0 days), and the magnets were discharged with a median postoperative duration of 35.0 days (IQR 28.0-43.0 days). With a median follow-up of 547.5 days (range 223-1042 days), no patients had biliary fistula, while two (4.9%) developed anastomotic stricture at 4 months and 14 months after surgery, and underwent reoperation for reconstruction of BEA. CONCLUSIONS MCA is a safe, effective, and time-saving modality for biliojejunostomy.
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Eso Y, Uza N, Shirakawa K, Sawada K, Katsuragi K, Matsuura M, Seno H. Choledochoduodenal Fistula during Chemotherapy with Brentuximab Vedotin for Methotrexate-associated Lymphoproliferative Disorder. Intern Med 2018; 57. [PMID: 29526961 PMCID: PMC6120836 DOI: 10.2169/internalmedicine.0557-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report a patient with a history of rheumatoid arthritis treated with methotrexate, which caused methotrexate-associated lymphoproliferative disorder and obstructive jaundice due to an enlarged lymph node. The obstructive jaundice was treated with endoscopic biliary stenting. A histopathological examination revealed features of Hodgkin's lymphoma, and chemotherapy with brentuximab vedotin was administered. Cholangiography and duodenoscopy after four rounds of chemotherapy revealed a choledochoduodenal fistula that developed in response to chemotherapy. It should be noted that, in cases of lymphoma infiltrating the gastrointestinal wall, fistulae can occur because of rapid regression due to regimens comprising monoclonal antibodies, such as rituximab and brentuximab vedotin.
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Shen Z, Tian L, Wang X. Treatment of pancreatic head cancer with obstructive jaundice by endoscopy ultrasonography-guided gastrojejunostomy: A case report and literature review. Medicine (Baltimore) 2018; 97:e11476. [PMID: 29995808 PMCID: PMC6076102 DOI: 10.1097/md.0000000000011476] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Ultrasonography-guided gastrojejunostomy (EUS-GJ) might be a safe, innovative and minimally invasive interventional treatment for patients with gastric outlet obstruction (GOO) as an alternative to the surgical approach. To date, few cases have been reported in the literature. PATIENT CONCERNS A case of pancreatic head carcinoma with obstructive jaundice occurred in a 78-year-old man with a prior history of pancreatic head cancer. Biliary stent placement was conducted 1 year earlier. DIAGNOSES The patient was diagnosed with pancreatic cancer, pulmonary infection, pyloric obstruction, and biliary stent implantation. INTERVENTIONS EUS-GJ was performed. The wire and a double-balloon catheter reached the position of stenosis, then a double mushroom head bracket was released under EUS. The position was confirmed via X-ray. OUTCOMES The symptoms of obstruction were alleviated. No recurrence of obstruction, bleeding, perforation, and other complications occurred for the following 1.5 months while he died because of whole body spread of pancreatic cancer. LESSONS EUS-GJ may be reliable and effective for patients with GOO.
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Manuel-Vázquez A, Latorre-Fragua R, Ramiro-Pérez C, López-Marcano A, De la Plaza-Llamas R, Ramia JM. Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature. World J Gastroenterol 2018; 24:1978-1988. [PMID: 29760541 PMCID: PMC5949711 DOI: 10.3748/wjg.v24.i18.1978] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 04/26/2018] [Accepted: 05/06/2018] [Indexed: 02/06/2023] Open
Abstract
The major symptoms of advanced hepatopancreatic-biliary cancer are biliary obstruction, pain and gastric outlet obstruction (GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decision-making must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation of the patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.
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Liu YS, Lin CY, Chuang MT, Tsai YS, Wang CK, Ou MC. Success and complications of percutaneous transhepatic biliary drainage are influenced by liver entry segment and level of catheter placement. Abdom Radiol (NY) 2018; 43:713-722. [PMID: 28741168 DOI: 10.1007/s00261-017-1258-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE To examine outcomes and complications of percutaneous transhepatic biliary drainage (PTBD) performed via the right or left lobe and different entry levels (lobar, segmental, subsegmental, sub-subsegmental). METHODS The records of patients who underwent PTBD for obstructive jaundice from 2008 to 2015 were retrospectively reviewed. Logistic regression analysis was performed to determine factors associated with outcomes and complications based on entry side and entry level. PTBD success was defined as a total bilirubin decrease after catheter placement. RESULTS The data of 446 patients (mean age 68.4 years) were included. Multivariate logistic regression revealed a decrease of bilirubin level was associated with left lobe (vs. right) entry [adjusted odds ratio (aOR) = 2.657, 95% confidence interval (CI) 1.160, 6.087], external drainage (aOR = 2.908, 95% CI 1.226, 6.897), and liver volume undrained <50% (aOR = 2.623, 95% CI 1.045, 6.581). PTBD success was increased with left lobe entry (aOR = 1.853, 95% CI 1.167, 2.940) and associated with entry level (subsegmental vs. lobar, aOR = 2.992, 95% CI 1.258, 7.114; sub-subsegmental vs. lobar, aOR = 3.711, 95% CI 1.383, 9.956). Complications were significantly decreased with left lobe entry (aOR = 0.450, 95% CI 0.263, 0.769) and associated with entry level (segmental vs. lobar, aOR = 0.359, 95% CI 0.148, 0.873; subsegmental vs. lobar, aOR = 0.248, 95% CI 0.10, 0.615; sub-subsegmental vs. lobar, aOR = 0.129, 95% CI 0.041, 0.411). CONCLUSIONS The success and complications of PTBD vary with entry side and level.
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Fan C, Zhang H, Yan X, Ma J, Wang C, Lv Y. Advanced Roux-en-Y hepaticojejunostomy with magnetic compressive anastomats in obstructive jaundice dog models. Surg Endosc 2018; 32:779-789. [PMID: 28779259 PMCID: PMC5772124 DOI: 10.1007/s00464-017-5740-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 07/14/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Although commonly used procedure, Roux-en-Y hepaticojejunostomy (RYHJ) remains to be complicated, time consuming, and has a relatively poor prognosis. We designed the magnetic compressive anastomats (MCAs) to perform RYHJ more efficiently and safely. MATERIALS AND METHODS 36 dogs were divided into two groups randomly. After obstructive jaundice model construction, RYHJ was performed with MCAs in study group or by hand-sewn in control group. Both groups were followed for 1, 3, and 6 months after RYHJ. The liver function and postoperative complications were recorded throughout the follow-up. At the end of each time point, dogs were sent for magnetic resonance imaging (MRI) and sacrificed. Anastomotic samples were taken for anastomotic narrowing rate calculation, histological analyses, tensile strength testing, and hydroxyproline content testing. RESULTS The anastomotic construction times were 44.20 ± 23.02 min in study group, compared of 60.53 ± 11.89 min in control group (p < 0.05). The liver function recovered gradually after RYHJ in both groups (p > 0.05). All anastomats were expelled out of the body in 8.81 ± 2.01 days. The gross incidence of morbidity and mortality was 33.3% (6/18) and 16.7% (3/18) in study group compared with 38.9% (7/18) and 22.2% (4/18) in control group (p > 0.05), and there is no single case of anastomotic-specific complications happened in study group. The narrowing rates of anastomosis were 14.6, 18.5, and 18.7% in study group compared with 35.4, 36.9, and 34% in control group at 1st, 3rd, and 6th month after RYHJ (p < 0.05). In study group, preciser alignment of tissue layers and milder inflammatory reaction contributed to the fast and better wound healing process. CONCLUSION Perform RYHJ with MCAs is safer, more efficient than by hand-sewn method in obstructive jaundice dog models.
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Nishiwaki M, Mizuno C, Yano K, Oya H, Amano I, Matsumoto J, Tanaka I, Sawai N, Mizuno M, Shima T, Miyamoto Y, Okanoue T. Retroperitoneal Perforation Caused by Migration of a Pancreatic Spontaneous Dislodgement Stent into Periampullary Diverticula. Intern Med 2018; 57:351-355. [PMID: 29093393 PMCID: PMC5827315 DOI: 10.2169/internalmedicine.9054-17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
An 85-year-old woman underwent endoscopic retrograde cholangiopancreatography (ERCP) for obstructive jaundice. Selective bile duct cannulation was unsuccessful because of periampullary diverticula (PAD). A pancreatic spontaneous dislodgement stent (PSDS) (5F diameter, 3 cm, straight type) was inserted to prevent post-ERCP pancreatitis. Three days after ERCP, she complained of abdominal pain, and computed tomography revealed retroperitoneal perforation because of PSDS migration to the PAD. If the papillary orifice is observed at the diverticular rim or in the diverticula, a pigtailed PSDS on the duodenal side or flanged stent on the pancreatic ductal side should be inserted in order to prevent this rare adverse event.
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Gholami S, Brennan MF. Preoperative Stenting for Benign and Malignant Periampullary Diseases: Unnecessary if Not Harmful. Surg Clin North Am 2018; 98:37-47. [PMID: 29191276 PMCID: PMC6643266 DOI: 10.1016/j.suc.2017.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Preoperative biliary drainage (PBD) is often performed in patients with jaundice with the presumption that it will decrease the risk of postoperative complications. PBD carries its own risk of complications and, therefore, has been controversial. Multiple randomized controlled trials and metaanalyses have shown that PBD has significantly increased overall complications compared with surgery alone. As such, the routine application of PBD should be avoided except in a subset of clinical situations. This is discussed in detail in this article.
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Pavlidis ET, Pavlidis TE. Pathophysiological consequences of obstructive jaundice and perioperative management. Hepatobiliary Pancreat Dis Int 2018; 17:17-21. [PMID: 29428098 DOI: 10.1016/j.hbpd.2018.01.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 01/25/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Obstructive jaundice is a common problem in daily clinical practice. Understanding completely the pathophysiological changes in obstructive jaundice remains a challenge for planning current and future management. DATA SOURCES A PubMed was searched for relevant articles published up to August 2016. The effect of obstructive jaundice on proinflammatory cytokines, coagulation status, hemodynamics and organ functions were evaluated. RESULTS The effects of obstructive jaundice included biliary tree, the hepatic cell and liver function as well as systemic complications. The lack of bile in the gut, the disruption of the intestinal mucosal barrier, the increased absorption of endotoxin and the subsequent endotoxemia cause proinflammatory cytokine production (TNF-α, IL-6). Bilirubin induces systemic inflammatory response syndrome which may lead to multiple organ dysfunction syndrome. The principal clinical manifestations include hemodynamic instability and acute renal failure, cardiovascular suppression, immune compromise, coagulation disorders, nutritional impairment, and wound healing defect. The proper management includes full replacement of water and electrolyte deficiency, prophylactic antibiotics, lactulose, vitamin K and fresh frozen plasma, albumin and dopamine. The preoperative biliary drainage has not been indicated in overall, but only in a few selected cases. CONCLUSION The perioperative management is an essential measure in improving the outcome after the appropriate surgical operation in jaundiced patients especially those with malignancy.
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