Biliary drainage in obstructive jaundice: experimental and clinical aspects

Outcomes of endoscopic retrograde cholangiopancreatography-guided gallbladder drainage compared to percutaneous cholecystostomy in acute cholecystitis

Backgrounds/Aims

Endoscopic retrograde cholangiopancreatography-guided gallbladder drainage (ERGD) is an alternative to percutaneous cholecystostomy (PTC) for hospitalized acute cholecystitis (AC) patients.

Methods

We retrospectively analyzed propensity score matched (PSM) AC hospitalizations using the National Inpatient Sample database between 2016 and 2019 to compare the outcomes of ERGD and PTC.

Results

After PSM, there were 3,360 AC hospitalizations, with 48.8% undergoing PTC and 51.2% undergoing ERGD. There was no difference in median length of stay between the PTC and ERGD cohorts (p = 0.110). There was a higher median hospitalization cost in the ERGD cohort, $62,562 (interquartile range [IQR] $40,707-97,978) compared to PTC, $40,413 (IQR $25,244-65,608; p < 0.001). The 30-day inpatient mortality was significantly lower in hospitalizations with ERGD compared to PTC (adjusted hazard ratio 0.16, 95% confidence interval [CI]: 0.1-0.41; p < 0.001). There was no difference in association with blood transfusions, acute renal failure, ileus, small bowel obstruction, and open cholecystectomy conversion (p > 0.05) between hospitalizations with ERGD and PTC. There was lower association of acute hypoxic respiratory failure (adjusted ratio [AOR] 0.46, 95% CI: 0.29-0.72; p = 0.001), hypovolemia (AOR 0.66, 95% CI: 0.49-0.82; p = 0.009) and higher association of lower gastrointestinal bleed (AOR 1.94, 95% CI: 1.48-2.54; p < 0.001) with ERGD compared to PTC.

Conclusions

ERGD is a safer alternative to PTC in patients with AC. The risk complications are lower in ERGD compared to PTC but no difference exists based on mortality or conversion to open cholecystectomy.

Percutaneous transhepatic biliary stent placement in the palliative management of malignant obstructive jaundice: initial experience in a tertiary center in Ghana

Introduction

one of the mainstays of management of malignant biliary obstruction is the decompression of the biliary system and its associated obstructive symptoms. Non-surgical palliative treatment such as percutaneous transhepatic biliary stenting is desirable in many selected patients. However, this service is often not available in many resource-limited countries. We share our initial experience of percutaneous transhepatic biliary stenting for the management of malignant biliary obstruction in our first set of patients with surgically non resectable malignant biliary obstruction in Ghana.

Methods

percutaneous transhepatic biliary stenting was performed on the first 23 consecutive patients at the Korle Bu Teaching Hospital. The procedure served as the first palliation for malignant obstruction through interventional radiology. Medical records as well as serum levels of total bilirubin (TBil), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) were used to assess the efficiency of the intervention. Microsoft Excel 2010 was used to analysis the data.

Results

most patients had resolution of jaundice with marked improvement in liver function and resolution of the itching associated with obstructive jaundice. During the follow-up of cases, one major complication of hemoperitoneum occurred requiring laparotomy. No other major complications such as bile leakage or death occurred. Four (4) patients had sepsis, which was managed.

Conclusion

the introduction of the intervention in Ghana has proven to valuable for palliative drainage and relief of obstructive symptoms, hence contributing to better patient management. It is relatively safe with minor complications among Ghanaians with non-resectable obstructive symptoms.

Influence of bile contamination for patients who undergo pancreaticoduodenectomy after biliary drainage

BACKGROUND

The influence of bile contamination on the infectious complications of patients undergoing pancreaticoduodenectomy (PD) has not been thoroughly evaluated.

AIM

To evaluate the effect of preoperative biliary drainage and bile contamination on the outcomes of patients who undergo PD.

METHODS

The database of 4101 patients who underwent PD was reviewed. Preoperative biliary drainage was performed in 1964 patients (47.9%), and bile contamination was confirmed in 606 patients (14.8%).

RESULTS

The incidence of postoperative infectious complications was 37.9% in patients with preoperative biliary drainage and 42.4% in patients with biliary contamination, respectively. Patients with extrahepatic bile duct carcinoma, ampulla of Vater carcinoma, and pancreatic carcinoma had a high frequency of preoperative biliary drainage (82.9%, 54.6%, and 50.8%) and bile contamination (34.3%, 26.2%, and 20.2%). Bile contamination was associated with postoperative pancreatic fistula (POPF) Grade B/C, wound infection, and catheter infection. A multivariate logistic regression analysis revealed that biliary contamination (odds ratio 1.33, P = 0.027) was the independent risk factor for POPF Grade B/C. The three most commonly cultured microorganisms from bile (Enterococcus, Klebsiella, and Enterobacter) were identical to those isolated from organ spaces.

CONCLUSION

In patients undergoing PD, bile contamination is related to postoperative infectious complication including POPF Grade B/C. The management of biliary contamination should be standardised for patients who require preoperative biliary drainage for PD, as the main microorganisms are identical in both organ spaces and bile.

Risk prediction of post-hepatectomy liver failure in patients with perihilar cholangiocarcinoma

BACKGROUND AND AIM

In most patients with perihilar cholangiocarcinoma (PHCC), major hepatectomy and extrahepatic bile duct resection are needed for surgical radicality, and a high risk of hepatic insufficiency exists. This study aims to develop a prediction model for post-hepatectomy liver failure (PHLF) in patients with PHCC.

METHODS

A total of 143 patients who underwent major liver resection and extrahepatic bile duct resection for PHCC between October 2001 and December 2013 were included. Clinically relevant PHLF was defined as liver failure corresponding to grade B or C of the International Study Group of Liver Surgery criteria. Multivariate logistic regression was used to develop the PHLF risk model. Model performance was evaluated internally using the area under the curve analysis (discrimination) after 1000 bootstrap resampling and the Hosmer-Lemeshow goodness-of-fit test (calibration).

RESULTS

Post-hepatectomy liver failure occurred in 43.4% of patients (n = 62). In multivariate analysis, PHLF was significantly associated with future liver remnant ratio (odds ratio [OR] per 10% = 0.68, 95% confidence interval [CI] 0.51-0.88), intraoperative blood loss (OR per 1 L = 1.82, 95% CI 1.11-3.17), and preoperative prothrombin time > 1.20 (OR = 3.22, 95% CI 1.15-9.97). The PHLF risk score model showed good discrimination (area under the curve = 0.708, 95% CI 0.623-0.793) and calibration (P = 0.227).

CONCLUSIONS

The risk model proposed in this study accurately predicted PHLF in patients with PHCC. This offers surgeons a practical guide to quantitative risk assessment of hepatic insufficiency and aids decision-making in surgical treatment and perioperative management.

Preoperative biliary drainage in hilar cholangiocarcinoma: Systematic review and meta-analysis

BACKGROUND

The role of preoperative biliary drainage (PBD) for hilar cholangiocarcinoma (HCC) remains unclear. The aim of this meta-analysis is to investigate the role of PBD in the treatment of potentially resectable HCC.

METHODS

All studies reporting outcomes on patients with PBD vs without PBD were included. A systematic literature search was performed in PubMed, Embase, and the Cochrane Library for studies published between 1980 and 2016.

RESULTS

Initial search identified 667 articles. Only 9 studies met the inclusion criteria and were included in this analysis. No significant differences in mortality were observed between the two groups (RR = 0,935; 95% CI = 0,612 to 1429; p = 0,463). Overall morbidity was significantly higher in PBD group (RR = 1266; 95% CI = 1039 to 1543; p = 0,011). No significant differences in transfusion rate, hospital stay, anastomotic leaks, abdominal collections and operative time, were found. Wound infections were significantly higher in PBD group.

CONCLUSIONS

PBD seems to be associated with higher postoperative morbidity and increases the risk of wound infections. Further prospective studies are needed to better define the impact of PBD in outcomes after surgery for hilar cholangiocarcinoma.

Postoperative Outcome after Major Liver Resection in Jaundiced Patients with Proximal Bile Duct Cancer without Preoperative Biliary Drainage

BACKGROUND/AIMS

The need for routine use of preoperative biliary drainage (PBD) before major liver resection in jaundiced patients has recently been questioned. Our aim was to present our experience of patients with proximal bile duct cancer who undergo major liver resection without PBD and compare these results with patients without biliary obstruction who underwent major liver resection.

METHODS

Eighty six consecutive jaundiced patients underwent major liver resection without PBD. The postoperative outcome was compared to the control group, which was the same size and matched.

DESIGN

A case-comparison study.

RESULTS

Fifty nine jaundiced patients (69%) and 22 non-jaundiced patients (25%) received blood transfusion (p = 0.04). Fifty-three patients (62%) in the jaundiced group and 17 (19%) in the non-jaundiced patients experienced postoperative complications (p = 0.003). A statistically significant difference could not be detected for mortality (6 vs. 2%) and transient liver failure (10 vs. 3%). Those patients who underwent extended right hemihepatectomy (with future liver remnant <50%) express high morbidity (55 vs. 24%; p = 0.04) and mortality (23 vs. 8%; p = 0.001) compared to the non-jaundiced patients.

CONCLUSIONS

Major liver resection without PBD leaving a liver remnant of more than 50% is safe in jaundiced patients. However, transfusion requirement and morbidity are higher in jaundiced patients than in non-jaundiced patients.

Preoperative biliary drainage

The role of preoperative biliary drainage (PBD) in patients with distal or proximal biliary obstruction secondary to resectable tumors has been a matter for debate. A review of the literature using Medline, Embase and Cochrane databases was undertaken for studies evaluating routes of drainage (endoscopic or percutaneous) and stent types (plastic or metal) in patients with resectable disease. Preoperative biliary drainage is indicated for relief of symptomatic jaundice, cholangitis, patients undergoing neoadjuvant therapy or those patients where surgery may be delayed. Endoscopic methods are preferred over percutaneous methods because of lower complication rates. In patients with proximal biliary obstruction, PBD should be guided by imaging studies to aid in selective biliary cannulation for unilateral drainage in order to reduce the risk of cholangitis in undrained liver segments.

The prognostic importance of jaundice in surgical resection with curative intent for gallbladder cancer

BACKGROUND

Preoperative jaundice is frequent in gallbladder cancer (GBC) and indicates advanced disease. Resection is rarely recommended to treat advanced GBC. An aggressive surgical approach for advanced GBC remains lacking because of the association of this disease with serious postoperative complications and poor prognosis. This study aims to re-assess the prognostic value of jaundice for the morbidity, mortality, and survival of GBC patients who underwent surgical resection with curative intent.

METHODS

GBC patients who underwent surgical resection with curative intent at a single institution between January 2003 and December 2012 were identified from a prospectively maintained database.

RESULTS

A total of 192 patients underwent surgical resection with curative intent, of whom 47 had preoperative jaundice and 145 had none. Compared with the non-jaundiced patients, the jaundiced patients had significantly longer operative time (p < 0.001) and more intra-operative bleeding (p = 0.001), frequent combined resections of adjacent organs (23.4% vs. 2.8%, p = 0.001), and postoperative complications (12.4% vs. 34%, p = 0.001). Multivariate analysis showed that preoperative jaundice was the only independent predictor of postoperative complications. The jaundiced patients had lower survival rates than the non-jaundiced patients (p < 0.001). However, lymph node metastasis and gallbladder neck tumors were the only significant risk factors of poor prognosis. Non-curative resection was the only independent predictor of poor prognosis among the jaundiced patients. The survival rates of the jaundiced patients with preoperative biliary drainage (PBD) were similar to those of the jaundiced patients without PBD (p = 0.968). No significant differences in the rate of postoperative intra-abdominal abscesses were found between the jaundiced patients with and without PBD (n = 4, 21.1% vs. n = 5, 17.9%, p = 0.787).

CONCLUSIONS

Preoperative jaundice indicates poor prognosis and high postoperative morbidity but is not a surgical contraindication. Gallbladder neck tumors significantly increase the surgical difficulty and reduce the opportunities for radical resection. Gallbladder neck tumors can independently predict poor outcome. PBD correlates with neither a low rate of postoperative intra-abdominal abscesses nor a high survival rate.

Multimodal treatment strategies for advanced hilar cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common primary malignancy of the liver arising from malignant transformation and growth of biliary ductal epithelium. Approximately 50-70 % of CCAs arise at the hilar plate of the biliary tree, which are termed hilar cholangiocarcinoma (HC). Various staging systems are currently employed to classify HCs and determine resectability. Depending on the pre-operative staging, the mainstays of treatment include surgery, chemotherapy, radiation therapy, and photodynamic therapy. Surgical resection offers the only chance for cure of HC and achieving an R0 resection has demonstrated improved overall survival. However, obtaining longitudinal and radial surgical margins that are free of tumor can be difficult and frequently requires extensive resections, particularly for advanced HCs. Pre-operative interventions may be necessary to prepare patients for major hepatic resections, including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and portal vein embolization. Multimodal therapy that combines chemotherapy with external beam radiation, stereotactic body radiation therapy, bile duct brachytherapy, and/or photodynamic therapy are all possible strategies for advanced HC prior to resection. Orthotopic liver transplantation is another therapeutic option that can achieve complete extirpation of locally advanced HC in judiciously selected patients following standardized neoadjuvant protocols.

Hilar cholangiocarcinoma: diagnosis, treatment options, and management

Hilar cholangiocarcinoma (HC) is a rare disease with a poor prognosis which typically presents in the 6(th) decade of life. Of the 3,000 cases seen annually in the United States, less than one half of these tumors are resectable. A variety of risk factors have been associated with HC, most notably primary sclerosing cholangitis (PSC), biliary stone disease and parasitic liver disease. Patients typically present with abdominal pain, pruritis, weight loss, and jaundice. Computed topography (CT), magnetic resonance imaging (MRI), and ultrasound (US) are used to characterize biliary lesions. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) assess local ductal extent of the tumor while allowing for therapeutic biliary drainage. MRCP has demonstrated similar efficacies to PTC and ERCP in identifying anatomic extension of tumors with less complications. Treatment consists of surgery, radiation, chemotherapy and photodynamic therapy. Biliary drainage of the future liver remnant should be performed to decrease bilirubin levels thereby facilitating future liver hypertrophy. Standard therapy consists of surgical margin-negative (R0) resection with extrahepatic bile duct resection, hepatectomy and en bloc lymphadenectomy. Local resection should not be undertaken. Lymph node invasion, tumor grade and negative margins are important prognostic indicators. In instances where curative resection is not possible, liver transplantation has demonstrated acceptable outcomes in highly selected patients. Despite the limited data, chemotherapy is indicated for patients with unresectable tumors and adequate functional status. Five-year survival after surgical resection of HC ranges from 10% to 40% however, recurrence can be as high as 50-70% even after R0 resection. Due to the complexity of this disease, a multi-disciplinary approach with multimodal treatment is recommended for this complex disease.

MRI-guided percutaneous transhepatic cholangiodrainage: feasibility study in a porcine model

BACKGROUND AND STUDY AIMS

MRI-guided procedures combine high-quality imaging with lack of radiation. Percutaneous transhepatic cholangiodrainage under real-time MRI guidance (MRI-PTCD) seems promising, allowing targeted puncture and avoiding multiple blind passes and use of contrast, which are associated with standard PTCD's heaviest complications.

PATIENTS AND METHODS

Aim of this study was to investigate the feasibility of MRI-PTCD in three outbred piglets. Obstructive cholestasis was induced by common bile duct ligation. Two days later, MRI-PTCD was performed (open MRI, 1.0 Tesla) with prototype MRI-compatible accessories. Visualization was achieved with a balanced steady-state free precession real-time sequence (bSSFP: 0.75 frames/s, TR/TE [ms]: 7.2/3.6; flip angle: 45°; 200 × 200 matrix size; resolution: 1.3 × 1.3 mm(2), slice thickness: 7 mm). Cannulation of the bile ducts was followed by placement of Yamakawa drainages.

RESULTS

Twelve punctures were performed (four per animal, 10/12 successful); in 2/10 the bile ducts could not be cannulated. Animal survival was 100% and no significant complications occurred.

CONCLUSIONS

Initial data show that MRI-PTCD can be successfully performed. This may lead to establishment of a new optimized PTCD technique compared to the standard approach under fluoroscopy.

Preoperative cholangitis during biliary drainage increases the incidence of postoperative severe complications after pancreaticoduodenectomy

BACKGROUND

It remains controversial how preoperative biliary drainage affects occurrence of severe complications after pancreaticoduodenectomy (PD).

METHODS

One hundred twenty-seven patients (60 external drainage and 67 internal drainage) required biliary drainage before PD were retrospectively reviewed.

RESULTS

Preoperative cholangitis in internal drainage group (22.4%) occurred significantly more often than in external drainage group (1.7%; P < .001). The incidence of severe complications (grade III or more) was significantly higher in patients with cholangitis (62.5%) than in those without it (25.2%; P = .002). The incidence of delayed gastric emptying was significantly higher in patients with cholangitis (31.2%) than in those without it (5.4%; P = .001). A multivariate logistic regression analysis revealed that preoperative cholangitis (odds ratio 4.61, 95% confidence interval 1.3 to 16.5; P = .019) was the independent risk factor for severe complications after PD.

CONCLUSIONS

Preoperative cholangitis during biliary drainage significantly increases incidence of severe complications after PD.

Role of preoperative biliary drainage in jaundiced patients who are candidates for pancreatoduodenectomy or hepatic resection: highlights and drawbacks

INTRODUCTION

In this review of the literature, we analyze the indications for preoperative drainage in jaundiced patients who are candidates for pancreaticoduodenectomy (PD) or major hepatectomy due to periampullary or proximal bile duct neoplasms.

OBJECTIVE

The aim of this study is to review the literature and to report on the current management of jaundiced patients with periampullary or proximal bile duct neoplasms who are candidates for PD or major liver resection.

BACKGROUND

Jaundiced patients represent a major challenge for surgeons. Alterations and functional impairment caused by jaundice increase the risk of surgery; therefore, preoperative biliary decompression has been suggested.

METHODS

A literature review was performed in the MEDLINE database to identify studies on the management of jaundice in patients undergoing PD or liver resection. Papers considering palliative drainage in jaundiced patients were excluded.

RESULTS

The first group of papers considered patients affected by middle-distal obstruction from periampullary neoplasms, in which preoperative drainage was applied selectively. The second group of papers evaluated patients with biliary obstructions from proximal biliary neoplasms. In these cases, Asian authors and a few European authors considered it mandatory to drain the future liver remnant (FLR) in all patients, while American and most European authors indicated preoperative drainage only in selected cases (in malnourished patients and in those with hypoalbuminemia, cholangitis or long-term jaundice; with an FLR < 30% or 40%) given the high risk of complications of drainage (choleperitoneum, cholangitis, bleeding, and seeding). The optimal type of biliary drainage is still a matter of debate; recent studies have indicated that endoscopy is preferable to percutaneous drainage. Although the type of endoscopic biliary drainage has not been clearly established, the choice is made between plastic stents and short, covered, metallic stents, while other authors suggest the use of nasobiliary drainage.

CONCLUSIONS

: A multidisciplinary evaluation (made by a surgeon, biliary endoscopist, gastroenterologist, and radiologist) of jaundiced neoplastic patients should be performed before deciding to perform biliary drainage. Middle-distal obstruction in patients who are candidates for PD does not usually require routine biliary drainage. Proximal obstruction in patients who are candidates for major hepatic resection in the majority of cases requires a drain; however, the type, site, number, and approach must be defined and tailored according to the planned hepatic resection. Recently, the use of preoperative biliary drainage limited to the FLR has been a suggested strategy. However, multicenter, randomized, controlled trials should be conducted to clarify this issue.

Hepatic cytokine response can be modulated using the Kupffer cell blocker gadolinium chloride in obstructive jaundice

INTRODUCTION

Depletion of Kupffer cells by gadolinium chloride (GdCl(3)) reduces the systemic response during sepsis. The study aim was to investigate the effect of this depletion on hepatic proinflammatory cytokine response to portal endotoxaemia.

METHODS

Sixteen Wistar rats were randomised to receive either saline IV (n = 8) or GdCl(3) (10 mg/kg IV, n = 8) six days after bile duct ligation (BDL). 24 h later the animals were perfused for 2 h, using isolated hepatic perfusion. Aliquots of effluent perfusate were collected at 20-min intervals for cytokine analysis. Sections of liver were sampled and the hepatic Kupffer cell number of each group was measured using ED1 immunohistochemistry.

RESULTS

Pre-treatment with GdCl(3) resulted in significantly reduced serum bilirubin concentrations but significantly elevated serum ALP and AST levels compared to the control group. It was also associated with a significant reduction in Kupffer cell numbers and a corresponding significant reduction in hepatic TNFα and IL-6 production in response to portal endotoxaemia.

CONCLUSIONS

Pre-treatment with GdCl(3) in jaundiced animals reduced Kupffer cell numbers, attenuated liver enzyme abnormalities and reduced TNFα and IL-6 in response to portal endotoxaemia. Hepatic Kupffer cells, therefore, play a significant role in the development of an exaggerated inflammatory response in obstructive jaundice.

Percutaneous transhepatic cholangiodrainage under real-time MRI guidance: initial experience in an animal model

AIMS

To assess percutaneous transhepatic cholangiodrainage (PTCD) under real-time MRI-guidance and compare it to procedures performed under fluoroscopy.

METHODS

We developed an in vitro model for MRI-guided and conventional PTCD, using an animal organ set including liver and bile ducts placed in an MRI-compatible box and tested it in a 1.0-Tesla open MRI-scanner. Prototype 18G needles and guide wires, standard guide wires, dilatation bougies, and drainages were used (MRI-compatible). MRI-visualization was by means of a bFFE real-time sequence using a surface coil (Flex-L). Outcome measurements were success rates and time needed for bile duct puncture using real-time MRI-guidance versus conventional radiologic methods in the model. Cannulation and drainage placement were also analysed.

RESULTS

Fifty MRI-guided experiments were performed, leading to rapid (mean: 43s, range: 15-72s) and successful puncture and cannulation in 96% of procedures. Median drainage placement time was 321.5s (range: 241-411s). In 35 control experiments under fluoroscopy, puncture success was 69%, whereas times were significantly longer (mean 273s, range 45-631s).

CONCLUSIONS

Initial in vitro experience shows that PTCD can be successfully and rapidly performed under real-time MRI-guidance and demonstrates improved performance compared to the conventional radiologic approach.

Preoperative biliary drainage before resection for hilar cholangiocarcinoma: whether or not? A systematic review

BACKGROUND

The value of preoperative biliary drainage (PBD) before resection for hilar cholangiocarcinoma (HCCA) is still controversial nowadays. The objective of this review is to summarize quantitatively the evidence related to this issue.

METHODS

Two investigators independently searched the Medline, Embase, Academic Search Premier (EBSCO), Chinese BioMedical Literature on disc (CBMdisc), and Chinese Medical Current Contents (CMCC) databases. Eleven studies with a total number of 711 HCCA cases were included. Comparison was made of PBD versus no PBD in HCCA patients undergoing surgical resection. Outcome measures were postoperative complications, in-hospital death rate, postoperative infectious complications, and postoperative hospital stay.

RESULTS

There was no difference in death rate or postoperative hospital stay between the two treatment modalities. However, the overall postoperative complication rate and postoperative infectious complication rate were significantly adversely affected by PBD compared with surgery without PBD. In postoperative complications analysis, ten studies including 442 patients who underwent PBD and 233 patients who had no PBD were estimated. The odds ratio (OR) for postoperative morbidity was 1.67: 95% confidence interval (CI) [1.17, 2.39]. In postoperative mortality analysis, ten studies including 422 patients who underwent PBD and 238 patients who had no PBD were estimated. The OR for postoperative mortality was 0.70: 95% CI [0.41, 1.19]. In postoperative infectious complications analysis, five studies including 134 patients who underwent PBD and 122 patients who had no PBD were estimated. The OR for infectious morbidity was 2.17: 95% CI [1.24, 3.80]. In postoperative hospital stay analysis, only three studies with 84 patients who underwent PBD and 65 patients who had no PBD were estimated; the weighted mean difference (WMD) for postoperative hospital stay was 5.37 days: 95% CI [-1.78, 12.52 days].

CONCLUSIONS

This systematic review could not provide evidence for a clinical benefit of using PBD in jaundiced patients with HCCA planned for surgery. Preoperative drainage should not routinely be performed in patients with proximal bile duct cancer scheduled for surgical resection. Because of the lack of uniformity of this analysis, randomized controlled trials (RCTs) with large sample size and improved PBD techniques should be carried out to confirm our results.

Preoperative risk assessment for patients with liver disease

Patients with underlying liver disease often present for non-liver-related surgery and are at risk for postoperative decompensation. Several predictive models exist to determine the risk of morbidity and mortality after surgery in such patients, but the risk depends on the severity of liver disease and also the type and urgency of the surgery. Clinicians should be cognizant of the various risk assessment tools and incorporate them into their practice when encountering patients with liver disease undergoing surgery.

Primary patency of Wallstents in malignant bile duct obstruction: single vs. two or more noncoaxial stents

The purpose of this study was to determine the primary patency of two or more noncoaxial self-expanding metallic Wallstents (Boston Scientific, Natick, MA) and to compare this with the primary patency of a single stent in malignant bile duct obstruction. From August 2002 to August 2004, 127 patients had stents placed for malignant bile duct obstruction. Forty-five patients were treated with more than one noncoaxial self-expanding metallic stents and 82 patients had a single stent placed. Two patients in the multiple-stent group were lost to follow-up. The primary patency period was calculated from the date of stenting until the first poststenting intervention for stent occlusion, death, or the time of last documented follow-up. The patency of a single stent was significantly different from that of multiple stents (P = 0.0004). In the subset of patients with high bile duct obstruction, the patency of a single stent remained significantly different from that of multiple stents (P = 0.02). In the single-stent group, there was no difference in patency between patients with high vs. those with low bile duct obstruction (P = 0.43). The overall median patency for the multistent group and the single-stent group was 201 and 261 days, respectively. In conclusion, the patency of a single stent placed for malignant low or high bile duct obstruction is similar, and significantly longer than, that of multiple stents placed for malignant high bile duct obstruction. Given the median patency of 201 days, when indicated, percutaneous stenting of multiple bile ducts is an effective palliative measure for patients with malignant high bile duct obstruction.

Preoperative biliary drainage increases infectious complications after hepatectomy for proximal bile duct tumor obstruction

BACKGROUND

The role of preoperative biliary drainage before liver resection in jaundiced patients remains controversial. The objective of this study is to compare the perioperative outcome of liver resection for carcinoma involving the proximal bile duct in jaundiced patients with and without preoperative biliary drainage.

METHODS

Seventy-four consecutive jaundiced patients underwent hepatectomy for carcinoma involving the proximal bile duct from January 1989 to June 2006 and their data were retrospectively analyzed. Fourteen patients underwent biliary drainage before portal vein embolization and were excluded from the study. Thirty patients underwent biliary drainage before hepatectomy and 30 underwent liver resection without preoperative biliary drainage. All patients underwent resection of the extrahepatic bile duct.

RESULTS

Overall mortality and operative morbidity were similar in the two groups (3% vs. 10%, p = 0.612 and 70% vs. 63%, p = 0.583, respectively). The incidence of noninfectious complications was similar in the two groups. There was no difference in hospital stay between the two groups. Patients with preoperative biliary drainage had a significantly higher rate of infectious complications (40% vs. 17%, p = 0.044). At multivariate analysis, preoperative biliary drainage was the only independent risk factor for infectious complication in the postoperative course (RR = 4.411, 95%CI = 1.216-16.002, p = 0.024). Even considering patients with preoperative biliary drainage in whom the bilirubin level went below 5 mg/dl, the risk of infectious complications was higher compared with patients without biliary drainage (47.6% vs. 16.6%, p = 0.017).

CONCLUSIONS

Overall mortality and morbidity after liver resection are not improved by preoperative biliary drainage in jaundiced patients. Prehepatectomy biliary drainage increases the incidence of infectious complications.

Obstructive jaundice induces early depression of mitochondrial respiration in rat hepatocytes

INTRODUCTION

Oxidative phosphorylation dysfunction of hepatocyte mitochondria is involved in the pathophysiology of organ dysfunction following obstructive jaundice (OJ). However the time period from biliary occlusion to the occurrence of the dysfunction has not been determined decisively.

PURPOSE

To evaluate the early effects (1 d and 7 d) of OJ on liver mitochondria respiratory function in rats.

METHODS

Male Wistar rats (200-250 g) were randomly divided into the following 3 groups: laparotomy plus OJ for 24 h (1d group) (n = 10); laparotomy plus OJ for 7 d (7d group) (n = 10); sham control procedure (CTR group) (n = 12). At the end of OJ periods, total serum bilirubin level, hepatic enzyme activity levels (GOT, GTP, Gama-GT, ALP), mitochondrial respiration phases S3 and S4, as well as the respiratory control ratio (RC = S3/S4), and ADP consumption/oxygen consumption (ADP/O) ratio, were determined.

RESULTS

Total serum bilirubin, activity of most hepatic enzymes, and O2 consumption during basal (S4) respiration were increased in the 1d and 7d groups (ANOVA, p = 0.05 vs. CTR). After ADP addition, the O2 consumption rate (S3) in the 1d group remained similar to the CTR rate (ANOVA p > .05), while the RC rate was reduced (ANOVA, p = 0.001) vs. CTR. The effects observed on mitochondrial respiration in the 1d group were exacerbated in the 7d group.

CONCLUSION

These results indicate that OJ induces early (24 h) depression of liver mitochondria respiration, and thus may lead to early reduction in the production of high energy bonds.

Pancreaticoduodenectomy for periampullary malignancies: the effect of bile colonization on the postoperative outcome

OBJECTIVES

The presence of bacteria in the bile of patients undergoing biliary tract surgery has been proposed as associated to an increased incidence of postoperative complications. The present study was designed to determine whether colonization of the bile has an adverse effect in terms of postoperative infectious or noninfectious complications and mortality in a homogenous population of patients suffering from periampullary region malignancies, who all underwent resectional (curative) procedures.

MATERIALS AND METHODS

Between January 1997 and December 2002, 115 patients (n = 115) suffering from periampullary region malignancies underwent resectional procedures. Fifty-two of the above patients were referred having undergone preoperative internal biliary drainage. During the operation, bile was routinely isolated from the common bile duct and was sent for culture and sensitivity. Based on the bile culture results, the patients were divided in sterile and colonized group and were retrospectively compared in terms of postoperative outcome and mortality.

RESULTS

Of the 115 bile cultures, 67 were colonized with bacteria and 48 were sterile. Postoperatively, 40 patients developed 35 noninfectious and 21 infectious complications. Univariate analysis did not disclose statistically significant differences in overall, noninfectious or infectious morbidity and mortality between the two groups of patients. Although not statistically significant, a higher incidence (22 vs 10%) of postoperative leaks in the colonized group of patients was noticed. Multiple regression analysis disclosed that colonized bile was independently related to the advanced age, preoperative biliary drainage presence, elevated preoperative serum bilirubin levels and low preoperative serum albumin levels but did not predispose to an increased postoperative morbidity, mortality, or reoperation rate.

CONCLUSION

The present study did not conclude in any statistically significant differences in the postoperative infectious and noninfectious morbidity as well as mortality, between colonized and sterile groups of patients who underwent resectional procedures for malignancies of the periampullary region. Although internal biliary drainage introduces microorganisms into the biliary tree, this colonization does not increase the risk of either infectious or noninfectious complications or postoperative death. Thus, the likelihood of bacterobilia should not contraindicate the procedure in selected cases.

Preoperative assessment of liver function: a comparison of 99mTc-Mebrofenin scintigraphy with indocyanine green clearance test

BACKGROUND/AIMS

The indocyanine green (ICG) clearance test is the most frequently used test for preoperative assessment of liver parenchymal function but has its limitations. The aim of this study was to investigate the correlation between ICG clearance test and the liver uptake of 99-Technetium-labelled (99mTc)-Mebrofenin (99mTc-Mebrofenin) as measured with hepatobiliary scintigraphy.

METHODS

Fifty-four patients were diagnosed as hepatocellular carcinoma (n=9), hilar tumours (n=20) and 25 patients with non-parenchymal tumours including colorectal metastasis (n=15) and miscellaneous tumours (n=10). One day prior to operation, hepatobiliary 99mTc-Mebrofenin scintigraphy was performed after intravenous injection of 85 MBq and the 15-min clearance rate of ICG (ICG-C15) was measured.

RESULTS

The mean ICG-C15 was 86.86+/-1.19% (SEM). The mean 99mTc-Mebrofenin uptake rate was 12.87+/-0.52%/min. A significant correlation was obtained between 99mTc-Mebrofenin uptake rate by scintigraphy and ICG-C15 (r=0.73, P<0.0001). The mean clearance capacity of the right liver segments (79.83+/-1.63, range 47.75-95.97%) was larger than that of the left segments (20.24+/-1.55, range 6.51-52.51%).

CONCLUSION

99mTc-Mebrofenin uptake rate as assessed by scintigraphy is an efficient method for determining liver function and correlates well with ICG clearance. At the same time, 99mTc-Mebrofenin scintigraphy provides information of segmental functional liver tissue, which is of additional use when planning liver resection.

Effect of 5-lipoxygenase inhibition on Kupffer cell clearance capacity in obstructive jaundiced rats

BACKGROUND

Obstructive jaundice is a common surgical problem. It may cause hepatic and Kupffer cell dysfunction. Previous studies demonstrated that 5-lipoxygenase inhibition prevents hepatic injury. However, its effect on Kupffer cell clearance capacity has not been determined yet.

MATERIALS AND METHODS

Rats were divided into four groups. In group 1 (sham control group), only bile duct dissection was performed. In other groups bile ducts were ligated and divided. In groups 1 and 2 saline, in group 3 ethanol, and in group 4 a 5-lipoxygenase inhibitor AA-861 was given intraperitoneally to the animals. Rats were sacrificed 14 days after the operations. Serum alkaline phosphatase, total bilirubin, and alanine aminotransferase levels were determined. Kupffer cell clearance capacity was measured using an in situ isolated hepatic perfusion technique. Hematoxylin-eosin-stained liver samples were evaluated under light microscope for histopathologic scoring.

RESULTS

Rats in the sham control group had significantly lower serum ALP and bilirubin values than those in the experimental groups with biliary obstruction. AA-861 administration significantly decreased serum ALT levels and histopathologic scores. There was no significant difference in ALT levels and histopathologic scores between the sham control and AA-861 groups. Kupffer cell clearance capacity was found to be significantly increased in the AA-861 group compared to other experimental groups with obstructive jaundice.

CONCLUSIONS

This study shows that leukotriene synthesis inhibition using AA-861 prevents hepatic damage and improves Kupffer cell clearance capacity in obstructive jaundiced rats. This may have significant implications for the management of patients with obstructive jaundice.

The abnormal lipid spectrum in malignant obstructive jaundice in relation to endotoxin sensitivity and the result of preoperative biliary drainage

BACKGROUND

Biliary obstruction changes the spectrum of lipoproteins, which are now known to bind and neutralize endotoxin. Postoperative septic complications related to an increased susceptibility to endotoxin occur frequently in patients with obstructive jaundice. The effect of preoperative biliary drainage on changes in the lipoprotein spectrum and its relation to endotoxin sensitivity was studied.

METHODS

Abnormalities in the lipoprotein spectrum were assessed in 15 patients with malignant obstructive jaundice before and 3 weeks after endoscopic biliary drainage. Changes in endotoxin responsiveness were assessed by using endotoxin-neutralizing reagents (anti-CD14 monoclonal antibody, polymyxin B, and recombinant bactericidal permeability increasing protein) to block cytokine production in whole blood cell cultures that were stimulated by cholestatic plasma taken before and after drainage.

RESULTS

Drainage normalized very-low-density, low-density, and high-density lipoprotein cholesterol fractions from, respectively, 43% to 19%, 50% to 65%, and 6% to 16% (P <.01). Ex vivo stimulation of whole blood with predrainage cholestatic plasma was 20-fold higher (P <.001) than with postdrainage plasma. Blocking the endotoxin response during the stimulation with predrainage cholestatic plasma with anti-CD14 monoclonal antibody, polymyxin B or recombinant bactericidal permeability increasing protein resulted in attenuation of the inflammatory response, reducing tumor necrosis factor-alpha levels at least 5-fold.

CONCLUSIONS

Preoperative biliary drainage normalizes the changed lipid profile and the endotoxin-stimulating capacity of cholestatic plasma, and this signifies a change in sensitivity to endotoxin.

[Proximal bile duct cholangiocarcinomas]

AIM

The aim of this retrospective study was to report a series of 12 patients with hilar cholangiocarcinoma treated by curative resection.

PATIENTS AND METHODS

Between 1980 and 1998, curative resection was performed in 12 patients out of 33 patients with a Klatskin's tumor. Preoperative biliary drainage was performed in 6 cases. Resection was limited to the extrahepatic bile duct in one case only. Resection was extended to the liver in 11 cases including segmentectomy I (n = 9), left hepatectomy (n = 7), right hepatectomy (n = 3) and segmentectomy IV (n = 1). Postoperative brachytherapy was performed in 3 patients combined with conventional radiotherapy. Conventional radiotherapy irradiation was performed in 2 patients and was associated with chemotherapy in 1 patient.

RESULTS

There was no postoperative mortality. Postoperative follow-up was uneventful in 5 patients. Actuarial survival rate at 1, 2, 3, and 5 years was 81, 57, 28 and 28%, respectively. Prolonged survivals (88 and 114 months) were observed.

CONCLUSION

Hilar cholangiocarcinomas have a poor prognosis. Curative resections are usually performed with major liver resections. RM cholangiography is now the most efficient examination for selection of surgical indications and choice of the best strategy. Long-term survival can be obtained with curative surgery. Adjuvant treatment has to be assessed by controlled trials.

The management of patients with advanced cancer (II)

In this second article in the series, obstruction of hollow viscera in patients with advanced malignant disease is discussed. The obstruction of such structures can be associated with the development of painful and incapacitating symptoms, often in patients who have a limited life expectancy. This obstruction may be caused by the primary tumour, compression from adjacent tumour-draining lymph nodes, the presence of metastases distant from the site of the primary tumour or to adhesions within the abdominal compartment (usually as a result of previous surgery). The organs most often affected are the oesophagus, the intestine (small and large), the biliary tree and the genito-urinary tract. Obstruction of each of these organs and its management is discussed in more detail below.

Renal dysfunction in obstructive jaundice

The association between renal dysfunction and obstructive jaundice is well established. Despite a substantial number of clinical reviews and prospective studies, the exact incidence and extent of the problem has not been determined accurately. Various pathogenic mechanisms and therapeutic strategies have been proposed but renal dysfunction remains a persistent problem in hepatobiliary practice. The intention of this review is to determine the current extent of the problem, outline the proposed pathophysiological mechanisms and assess the current therapeutic options.

Hepatic functional reserve in patients with obstructive jaundice: an assessment by the redox tolerance test

PURPOSE

Hepatic mitochondrial response to oral glucose load (redox tolerance test) was evaluated as an indicator of hepatic functional reserve of patients with obstructive jaundice.

PATIENTS AND METHODS

The redox tolerance test was performed in 29 patients with obstructive jaundice before percutaneous transhepatic biliary drainage and 2 weeks after the procedure.

RESULTS

The redox tolerance index (RTI) before drainage was not related to conventional parameters other than albumin, but was significantly associated with bilirubin half-life (P < 0.01). Of 19 patients with an RTI > or = 0.5 before drainage, all maintained similar values after drainage and experienced satisfactory clinical courses, even after major surgery. Of 10 patients with an RTI < 0.5 before drainage, 5 showed improvement and 5 deteriorated after drainage. Four of the latter 5 died within 60 days after drainage. The hospital mortality was significantly greater in patients with initial RTI < 0.5 than in patients with RTI > or = 0.5 (P < 0.01).

CONCLUSION

The redox tolerance test is useful for evaluating hepatic functional reserve and prognosis in patients with obstructive jaundice.