[Oral cholangioscopy for biliary system diseases]

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.

A case of endoscopic ultrasound-guided hepaticogastrostomy for obstructive jaundice caused by intraductal papillary mucinous neoplasm-associated pancreatobiliary fistula

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.

Obstructive Jaundice Secondary to Clip Migration in the Common Bile Duct 9 Years after Laparoscopic Cholecystectomy

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.

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

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.

Parasitological and molecular detection of human fascioliasis in a young man from Guizhou, China

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.

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

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.

OPTIMUM DURATION OF PERCUTANEOUS TRANSHEPATIC CHOLANGIODRAINAGE IN COMMON BILE DUCT DISEASES COMPLICATED BY OBSTRUCTIVE JAUNDICE

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.

The role of seed implantation in patients with unresectable pancreatic carcinoma after relief of obstructive jaundice using ERCP

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.

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

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.

Tumour stage and resection margin status are independent survival factors following partial pancreatoduodenectomy for duodenal adenocarcinoma

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.

A prospective study of risk factors for in-hospital mortality in patients with malignant obstructive jaundice undergoing percutaneous biliary drainage

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.

Magnetic Anastomosis for Biliojejunostomy: First Prospective Clinical Trial

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.

Choledochoduodenal Fistula during Chemotherapy with Brentuximab Vedotin for Methotrexate-associated Lymphoproliferative Disorder

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.

Treatment of pancreatic head cancer with obstructive jaundice by endoscopy ultrasonography-guided gastrojejunostomy: A case report and literature review

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.

Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature

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.

Success and complications of percutaneous transhepatic biliary drainage are influenced by liver entry segment and level of catheter placement

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.

Advanced Roux-en-Y hepaticojejunostomy with magnetic compressive anastomats in obstructive jaundice dog models

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.

Retroperitoneal Perforation Caused by Migration of a Pancreatic Spontaneous Dislodgement Stent into Periampullary Diverticula

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.

Preoperative Stenting for Benign and Malignant Periampullary Diseases: Unnecessary if Not Harmful

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.

Pathophysiological consequences of obstructive jaundice and perioperative management

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.

Comparison Of Biliary Stenting And Surgical Bypass In Palliative Management Of Irresectable Periampullary Carcinoma

BACKGROUND

Some 20-40% of the periampullary carcinoma is irresectable at the time of diagnosis. Biliary stenting and surgical bypass are commonly used palliative procedure. There is no consensus favouring one procedure over the other. This study compares the both procedures.

METHODS

This Randomized Controlled Trial included 47 patients who presented with diagnosis of obstructive jaundice due to periampullary carcinoma to the Department of Surgery, Federal General Hospital, Islamabad from July 2012 to December 2014.

RESULTS

Out of total 47 patients 27 (57.44%) were males and 20 (42.55%) were females. Group-A included 25 (53.19%) patients while group-B included 22 (46.81%) patients. The mean age in both groups was 62.34 years (SD=±5.01). All patients died during the study. The mean survival time for the stent patients was 7.5 months while the mean survival time for surgical bypass patients was 8.3 months. The jaundice was relived in all surgical (22, 100%) of the patients as compared to (18, 72%) of the patients in stent group.

CONCLUSIONS

We concluded that surgical bypass as a primary procedure in selected patients provided better jaundice relieve as compared to biliary stenting..

Selection of biliary decompression method for treatment of obstructive jaundice in patients of older age groups

OBJECTIVE

Introduction: The development of minimally invasive techniques allowed to expand the indications and possibility of performing surgeries in patients of elderly and old age with obstructive jaundice (OJ). However, the criteria for the selection of minimally invasive and open surgeries in patients with OJ remain undefined. The aim: To study the efficacy of single or multiple-stage methods of biliary decompression for treatment of OJ in patients of older age groups.

PATIENTS AND METHODS

Materials and methods: We have analyzed the results of surgical treatment in 140 patients with OJ of benign origin. The patients were divided in two groups: group I (n = 70) where two-stage minimally invasive methods were used and group II (n = 70) where single-stage minimally invasive and open surgeries were used. The average age was 75 ± 6.0 years. The average duration of OJ was 22 ± 3.7 days.

RESULTS

Results: The patients in group I were subjected to two-stage minimally invasive surgeries in 70 (50.0%) cases. The patients in group II were subjected to single-stage minimally invasive surgeries in 16 (11.4%) cases and to open surgeries in 54 (38.6%) cases. The average duration of hospital stay in patients of group I made 7.1 ± 1.5 days, and 11.2 ± 1.2 days in patients of group II. The patients of group I experienced complications in 5 (7.1%) cases and patients of group II experienced complications in 10 (14.3%) cases. 1 (1.4%) patient died.

CONCLUSION

Conclusions: Stepwise approach to minimally invasive surgeries in patients of elderly and old age with bile duct obstructions allows to reduce the frequency of postoperative complications down to 7.2% (p< 0.05). Single-stage correction is recommended for patients with hyperbilirubinemia of less than 100 mcmol/l and the duration of OJ of less than 14 days, with presence of compensated or subcompensated co-occurring pathology as well as in the absence of purulent cholangitis and biliary pancreatitis.

Bare-metal stents across the Vater's ampulla is a safe method for patients with lower bile duct obstruction

This study explored the effect of the implant position of stents across the Vater's ampulla on treatment outcomes in patients with lower bile duct obstruction.In the retrospective study, 41 patients with malignant obstruction of the lower bile duct and obstructive jaundice received percutaneous transhepatic biliary placement of bare-metal stents. Basic demographic data on patients, such as sex, age, and primary diseases, and follow-up data, including postoperative complications and jaundice-free survival, were recorded. The follow-up data on patients with an involved ampulla, patients with an uninvolved ampulla, patients with a stent across the ampulla, and patients with a stent at a site other than the ampulla were compared. Furthermore, prognostic factors for jaundice- free survival were investigated using Cox proportional hazards regression analysis.Among the 41 patients, 38 patients experienced subsiding of jaundice, whereas 3 cases had unsuccessful stent patency. Whether or not the ampulla was involved did not influence the incidence rates of postoperative complications and the jaundice-free survival time. Notably, when stents were placed across the ampulla, the jaundice-free survival time was significantly longer than when stents were placed at sites other than across the ampulla (P < .05). Furthermore, placement of the stent across the ampulla or at other sites was an independent prognostic factor (hazard ratio = 0.154, 95% confidence interval 0.042-0.560, P = .005) for jaundice-free survival of patients.The current study revealed that the implant position of a stent across the ampulla resulted in maintenance of stent patency and prolongation of the jaundice-free survival time.