Repeated rendezvous treatment of PTBD and ERCP in patients with recurrent obstructive jaundice

BACKGROUND/AIMS

Repeated applications of rendezvous technique combining percutaneous transhepatic biliary drainage (PTBD) with endoscopic retrograde cholangiopancreatography (ERCP) (PE) in patients with recurrent obstructive jaundice have not been reported. The present study aimed to evaluate treatment effects of this technique in patients who previously received the same rendezvous treatment.

METHODOLOGY

Repeated PE rendezvous procedure was performed in 27 patients who received the same procedure previously and had recurrent obstructive jaundice. Twenty-two patients were treated by second-time rendezvous procedure and five patients by third-time. The clinical characteristics and therapeutic effects were retrospectively analyzed.

RESULTS

By means of repeated rendezvous technique, 26 patients gained access to the bile duct and were successfully implanted new stents, only one failed with stent implantation. Total serum bilirubin level decreased within one week from 221.89 +/- 64.70 micromol/L to 156.0 +/- 32.2 micromol/L in patients with second-time treatment and from 297.07 +/- 109.12 micromol/L to 238.77 +/- 36.81 micromol/L in patients with third-time treatment. There was no severe complications observed that are associated with repeated PE procedure.

CONCLUSIONS

Rendezvous procedure of PTBD and ERCP could be used repeatedly and effectively for patients who present recurrent obstructive jaundice after ERCP failure.

[Study of integral hematological indices in patients with mechanical jaundice of benign genesis]

The retrospective analysis of 105 case records of patients with mechanical jaundice of benign genesis in the period 2000 to 2008 revealed the specific features of changes in integral hematological indices. In all the patients, the admission hematological indices were found to significantly differ from those in the control group. All the patients underwent surgical interventions by one of two modes: laparotomy or endoscopic surgery. Integral hematological indices decreased more rapidly and the patients' status stabilized more early after endoscopic versus laparatomic surgery.

Endoscopic ultrasound-guided transduodenal placement of a fully covered metal stent for palliative biliary drainage in patients with malignant biliary obstruction

BACKGROUND

Endoscopic ultrasound (EUS)-guided biliary drainage (EUSBD) has been described as a viable alternative to percutaneous transhepatic cholangiography (PTC) in patients in whom ERCP has been unsuccessful. The purpose of our study was to assess the utility of EUSBD using a newly released, fully covered, self-expanding, biliary metal stent (SEMS) for palliation in patients with an obstructing malignant biliary stricture.

METHODS

We collected data on all patients who presented with obstructive jaundice and who underwent transduodenal EUSBD after a failed ERCP. Eight patients presented with biliary obstruction from inoperable pancreatic cancer or cholangiocarcinoma. Reasons for failed ERCP were duodenum stenosis, high-grade malignant stenosis of the common bile duct, periampullary tumor infiltration, failure to access the common bile duct, and periampullary diverticulum. EUS was used to access the common bile duct from the duodenum after which a guidewire was advanced upwards toward the liver hilum. The metal stent was then advanced into the biliary tree. Technical success was defined as correct stent deployment across the duodenum. Clinical success was defined as serum bilirubin level decreased by 50% or more within 2 weeks after the stent placement.

RESULTS

Technical and clinical success was achieved in all eight patients. No stent malfunction or occlusion was observed. Complications included one case of duodenal perforation, which required surgery, and one case of self-limiting abdominal pain.

CONCLUSIONS

EUSBD with a fully covered SEMS in whom ERCP is unsuccessful is effective for palliation of biliary obstruction. The limitations of our study are that we had a small number of patients and a limited follow-up time.

[Criteria of differential assignment of drugs with sorptive and disintoxication properties to patients with obturative icterus of non-tumoral genesis]

The article defines criteria of differential assignment of drugs with sorptive and disintoxication properties according an analysis of clinical signs of a mechanical icterus, results of biochemical, immunologic, biophysical, crystal optics methods. The results were assessed by points (high--a score 98-65; average--64-32 a point; low--not higher 31 points) that allowed to judge severity level of a patient condition with obturative icterus not tumoral genesis. Positive efficiency of treatment was defined by point estimation which was not lower than 10 times (severe and moderate degrees; moderate and mild degrees). The study has shown that consideration both clinical and laboratory characteristics of the course of obturative icterus allows raising results of the treatment due to individual therapy and to predict its efficiency based on dynamic definition of point assessment of severity level.

Successful endoscopic ultrasound-guided transduodenal biliary drainage through a pre-existing duodenal stent

CONTEXT

When ERCP fails in the setting of combined biliary and duodenal obstruction, EUS-guided biliary drainage has emerged as an alternate method of biliary decompression.

CASE REPORT

We present a case of a 40-year-old man with advanced pancreatic cancer and a pre-existing duodenal wall stent who subsequently develops jaundice due to biliary obstruction. An ERCP was technically unsuccessful as the papilla was inaccessible despite probing within the duodenal stent. Transduodenal biliary drainage was achieved using EUS guidance to create a choledochoduodenostomy tract. A fully covered metal biliary stent was then deployed through the mesh of the duodenal wall stent. The patient's jaundice and pruritus subsequently resolved.

CONCLUSION

This is the first report of successful transduodenal EUS-guided biliary drainage performed through an existing enteral wall stent and can still be considered as an alternate mode of biliary drainage in this setting.

[Changes of micellarity and lithogenicity of bile under conditions of transcutaneous electrostimulation and enterosorption in patients with obturation jaundice of nontumoral genesis]

The conduction of pathogenetically substantiated treatment--enterosorption together with procedures of electrostimulation--in patients, suffering obturation jaundice of nontumoral genesis, secures favorable course of postoperative period, the hepatorenal insufficiency prophylaxis, and postcholecystectomy syndrome occurrence as well.

[Palliative treatment of nonresectable pancreatic cancer complicated by obturation jaundice]

There are presented the results of palliative treatment of 411 patients, suffering pancreatic cancer, complicated by obturation jaundice. To all the patients the four-staged treatment, including preoperative preparation, draining operation, chemoradiation and subsequent symptomatic operation, was applied. While performing draining operation there were applied the methods of choledochoduodenoanastomosis formation, elaborated in the clinic. Postoperative complications rate and lethality after application of elaborated method of choledochoduodenoanastomosis formation is lesser than after formation of cholecystojejunoanastomosis and external drainage.

[Dynamics of changes of the blood biochemical indices in patients with obturation jaundice caused by choledocholithiasis, effect of plasmapheresis]

In choledocholithiasis the obturation jaundice and its complication hepatic insufficiency are accompanied by accumulation of significant quantity of water-soluble and protein-associated toxins in the blood. Application of plasmapheresis promotes the patients state improvement and intoxication severity reduction. The levels in the blood lowering of bilirubin, the average-mass peptides concentration, activity of transaminases, alkaline phosphatase were noted.

[Change of humoral immunity under influence of enterosorption in presurgery period in the treatment of patients with mechanical jaundice of non-neoplastic genesis]

The authors have studied indices of the humoral immunity with mechanical jaundice of nonneoplastic genesis. Disorders of immune status of patients with bilious ways obturation, which were characterized by concentration increase IgG in 1,6 times, IgA--in 1,3 times and IgM--in 1,7 times of the level of circulating immune complexes--in 1,6 times and decrease in fractional index and fractional number in 2 and 1,7 times accordingly. The study has shown principle efficiency of enterosorption in patients with mechanical jaundice in restoration of indices of the humoral immunity. It was seen more considerably with application of chitin-contained active substance, mycotin. It has allowed improving functional ability of the liver, especially its synthesizing function and hydroxylation processes in hepatic cells.

Preoperative biliary drainage for cancer of the head of the pancreas

BACKGROUND

The benefits of preoperative biliary drainage, which was introduced to improve the postoperative outcome in patients with obstructive jaundice caused by a tumor of the pancreatic head, are unclear.

METHODS

In this multicenter, randomized trial, we compared preoperative biliary drainage with surgery alone for patients with cancer of the pancreatic head. Patients with obstructive jaundice and a bilirubin level of 40 to 250 micromol per liter (2.3 to 14.6 mg per deciliter) were randomly assigned to undergo either preoperative biliary drainage for 4 to 6 weeks, followed by surgery, or surgery alone within 1 week after diagnosis. Preoperative biliary drainage was attempted primarily with the placement of an endoprosthesis by means of endoscopic retrograde cholangiopancreatography. The primary outcome was the rate of serious complications within 120 days after randomization.

RESULTS

We enrolled 202 patients; 96 were assigned to undergo early surgery and 106 to undergo preoperative biliary drainage; 6 patients were excluded from the analysis. The rates of serious complications were 39% (37 patients) in the early-surgery group and 74% (75 patients) in the biliary-drainage group (relative risk in the early-surgery group, 0.54; 95% confidence interval [CI], 0.41 to 0.71; P<0.001). Preoperative biliary drainage was successful in 96 patients (94%) after one or more attempts, with complications in 47 patients (46%). Surgery-related complications occurred in 35 patients (37%) in the early-surgery group and in 48 patients (47%) in the biliary-drainage group (relative risk, 0.79; 95% CI, 0.57 to 1.11; P=0.14). Mortality and the length of hospital stay did not differ significantly between the two groups.

CONCLUSIONS

Routine preoperative biliary drainage in patients undergoing surgery for cancer of the pancreatic head increases the rate of complications. (Current Controlled Trials number, ISRCTN31939699.)

[The use of self-expanding metal stents in tumors of biliopancreatoduodenal zone]

Nitinol self-expanding stents were used in treatment of 15 patients with blastomatous lesions of biliopancreatoduodenal zone. Stenting was successful in all cases, long-term results were obtained in all patients. Death occurred in 8 patients within 5,5-11 month after stent insertion. 7 patients remain under observation. In 6 patients nitinol stents remain open with no signs of occlusion from 2,5 to 15 months' observation period. Jaundice recurred in one patient after 11 month after the insertion due to stent occlusion. Thus, stenting proved to be an effective and safe method of bile flow restoration by tumor biliary tract obstruction.

[Treatment of calculous cholecystitis, complicated by obturational jaundice]

Results of surgical treatment of 52 patients for chronic calculous cholecystitis, complicated by cholelithiasis, were studied. In 26 (50%) patients as a first stage of treatment there was applied endoscopic papillosphincterotomy (EPST) and transpapillary endobiliary manipulations and then--laparoscopic cholecystectomy (CHE). In 13 (25%) patients as the first stage of treatment EPST and transpapillary endobiliary manipulations were performed, and as the second one--CHE through laparotomy. In 13 (25%) patients there were performed an open CHE. choledocholithotomy and one of variants of the biliary ducts drainage. In chronic calculous cholecystitis, complicated by cholelithiasis, the optimal treatment consists of complex endoscopic treatment. The combined and standard surgical tactic are indicated when application of endoscopic technologies is impossible.

[Carcinoma of the head of the pancreas: indication for emergency surgery]

In a recent multicentre randomized clinical trial, Van der Gaag et al. randomly assigned 220 patients to early surgery or preoperative biliary drainage ('Preoperative drainage for cancer of the head of the pancreas'). The rate of serious complications was significantly higher in the preoperative drainage group (p < 0.001), mainly because of drainage-related complications. There was no difference in surgical complications or mortality. Data on costs and impact on quality of life were not presented, but it can be predicted that the preoperative drainage strategy would be more expensive and would have greater negative impact on quality of life. If forthcoming publications by this research group confirm this suggestion, the current paradigm - obstructive jaundice, endoscopic retrograde cholangiopancreatography with stenting, delayed surgery for carcinoma of the head of the pancreas - should be changed to: obstructive jaundice due to peri-ampullary carcinoma should be considered an indication for emergency surgery.

[Assessment of severity of obstructive jaundice of tumoral genesis for predicting of endoscopic retrograde cholangiopancreatography and endoscopic retrograde biliary decompression complications]

Mechanical jaundice is a vital indication for performing biliary decompression. Mechanical jaundice is one of the important reasons of serious and frequent complications after ERCP. It is required to assess patient's conditions, to determinate the potential risk of biliary decompretion with the aim of prognosis possible complications. AIM OF THE INVESTIGATION: Assessment of severity patient's conditions to prognosticate risk of complications and mortality development after ERCP in the group of patients who suffered from mechanical jaundice. TASKS: Preoperative analysis of complications severity and frequency after ERCP in dependence of patients'conditions.

METHODS

Before performing ERCP severity of mechanical jaundice was assessed concerning V.D. Fedorov's scale (2000); cholangitis was detected by blood analysis, symptoms and bile investigations; coagulative disorders were revealed by blood checking. Effectiveness and complication's possibilities were controlled after each ERCP. Relations between ERCP and complications, severity of complications and patient's conditions were analyzed.

MATERIALS

Prospective nonrandomized study was held, based on the investigation and treatment of 133 patients who have been performed 214 diagnostic and therapeutic ERCP.

RESULTS

There were 13 (9.8%) complications of 133, of which fatal--6 (4.5%) and there were 7 cases (6.5%) in a jaundice group. In 11 cases (85%) mechanical jaundice was severe, including 6 fatal cases (100%). Cholangitis was diagnosed in 7 (53%) of 13, including 4 (67%) of 6 in the fatal group. Coagulopathy was diagnosed in 6 (46%) of 13, including 3 (50%) in the fatal group.

CONCLUSION

Preoperative assessment of severity patient's condition is a very important element of clinical patient's study. It optimizes the choice of method and its particularities. It is necessary to inform the doctors, the patients or their representatives about possible complications. That is why the informed consent must be obligatory signed.

Endoscopic retrograde cholangiopancreaticography prior to explorative laparotomy avoids unnecessary surgery in patients suspected for biliary atresia

BACKGROUND/AIMS

Timely diagnosis of biliary atresia (BA) requires key investigations that are less invasive but as accurate as possible. Non-invasive imaging preselects patients before explorative laparotomy is performed. The purpose of this prospective study was to evaluate the accuracy of endoscopic retrograde cholangiopancreaticography (ERCP) in these patients and to discuss its relevance to future diagnostic guidelines in neonatal jaundice.

METHODS

Over a 7-year period, ERCP was routinely performed in cholestatic patients less than 6 months of age suspected for an extrahepatic origin of cholestasis, most likely BA. Endoscopic diagnosis was correlated with intraoperative findings.

RESULTS

In 140 consecutive patients (mean age: 60 days; weight: 4 kg), ERCP excluded BA in 34 (25%) but failed in 18 newborns (13%) for technical reasons. The average procedure time was 23 min, and no severe complications occurred. Explorative laparotomy was performed in 106 patients and revealed BA in 80 cases. In this series, the sensitivity of ERCP for diagnosing biliary atresia was 92% and specificity was 73%.

CONCLUSIONS

In preselected patients, ERCP is not an alternative to non-invasive imaging, but it avoids unnecessary surgical procedures in almost 25% of the cases. Hence, ERCP is recommended prior to explorative laparotomy in all patients suspected for BA.