Endoscopic Biliary Darinage (EBD) versus Percutaneous Transhepatic Biliary Drainage (PTBD) for biliary drainage in patients with Perihilar Cholangiocarcinoma (PCCA): A systematic review and meta-analysis

EASL Clinical Practice Guidelines on the management of extrahepatic cholangiocarcinoma

Recent years have witnessed significant advances in the imaging, molecular profiling, and systemic treatment of cholangiocarcinoma (CCA). Despite this progress, the early detection, precise classification, and effective management of CCA remain challenging. Owing to recent developments and the significant differences in CCA subtypes, EASL commissioned a panel of experts to draft evidence-based recommendations on the management of extrahepatic CCA, comprising distal and perihilar CCA. Particular attention is given to the need for accurate classification systems, the integration of emerging molecular insights, and practical strategies for diagnosis and treatment that reflect real-world clinical scenarios.

Primary percutaneous metal stenting above the ampulla in resectable perihilar cholangiocarcinoma

INTRODUCTION

We present a case of a patient with resectable perihilar cholangiocarcinoma (pCCA) who underwent primary metal stenting above the ampulla, followed by a successful surgical resection. Biliary drainage is a crucial step in the preoperative management of pCCA, yet there is no consensus on the optimal approach. Traditional drainage methods involve passing through the ampulla and/or the skin barrier, thereby increasing the risk of bacterial contamination of the biliary tree and secondary cholangitis.

METHOD

A novel drainage technique was utilised in this case. A metal stent was percutaneously placed across the malignant hilar stenosis without external biliary drainage. During the procedure, both guidewires and stents were meticulously prevented from passing through the ampulla. Additionally, percutaneous access to the biliary tree was removed during the index procedure to minimise the risk of biliary colonisation and cholangitis.

RESULTS

Following the drainage, bilirubin levels rapidly normalised, and no clinical or biochemical signs of cholangitis were observed. This allowed for rapid and uncomplicated surgical resection.

CONCLUSION

This case illustrates the potential of a novel biliary drainage technique in patients with pCCA. By minimising the risk of biliary colonisation and cholangitis, this approach could potentially improve surgical outcomes.

Advances in minimally invasive treatment of malignant obstructive jaundice

Malignant obstructive jaundice (MOJ) encompasses a range of diseases stemming from malignant tumors such as cholangiocarcinoma, pancreatic cancer, and primary liver cancer, among others, which cause obstruction in both intra- and extra-hepatic bile ducts. This obstruction may lead to elevated bilirubin levels, hepatic function impairment, and a low rate of successful surgical resection in clinical settings. There are various minimally invasive treatment options for MOJ, including endoscopic biliary drainage, ultrasound-guided procedures, and percutaneous biliary tract puncture drainage.

An Approach to and Treatment of Indeterminate Biliary Strictures: A Comprehensive Review of the Literature

This review aims to focus on what we know about the management of biliary strictures of unknown etiology, especially exploring our diagnostic armamentarium in the setting of indeterminate biliary strictures. Presently, this is a current issue that has a relevant impact both on patient prognosis, often delaying diagnosis, and on overall costs associated with repeating diagnostic procedures, sometimes performed with very expensive devices. We also focus on current biliary drainage approaches, providing an overview of therapeutic options, endoscopic or not.

Chinese national clinical practice guideline on diagnosis and treatment of biliary tract cancers

BACKGROUND

Biliary tract carcinoma (BTC) is relatively rare and comprises a spectrum of invasive tumors arising from the biliary tree. The prognosis is extremely poor. The incidence of BTC is relatively high in Asian countries, and a high number of cases are diagnosed annually in China owing to the large population. Therefore, it is necessary to clarify the epidemiology and high-risk factors for BTC in China. The signs associated with BTC are complex, often require collaborative treatment from surgeons, endoscopists, oncologists, and radiation therapists. Thus, it is necessary to develop a comprehensive Chinese guideline for BTC.

METHODS

This clinical practice guideline (CPG) was developed following the process recommended by the World Health Organization. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess the certainty of evidence and make recommendations. The full CPG report was reviewed by external guideline methodologists and clinicians with no direct involvement in the development of this CPG. Two guideline reporting checklists have been adhered to: Appraisal of Guidelines for Research and Evaluation (AGREE) and Reporting Items for practice Guidelines in Healthcare (RIGHT).

RESULTS

The guideline development group, which comprised 85 multidisciplinary clinical experts across China. After a controversies conference, 17 clinical questions concerning the prevention, diagnosis, and treatment of BTC were proposed. Additionally, detailed descriptions of the surgical principles, perioperative management, chemotherapy, immunotherapy, targeted therapy, radiotherapy, and endoscopic management were proposed.

CONCLUSIONS

The guideline development group created a comprehensive Chinese guideline for the diagnosis and treatment of BTC, covering various aspects of epidemiology, diagnosis, and treatment. The 17 clinical questions have important reference value for the management of BTC.

Unilateral and bilateral radioactive stent insertion in patients diagnosed with inoperable hilar cholangiocarcinoma: a comparative analysis

Background

While hilar cholangiocarcinoma (HCCA) patients commonly undergo radioactive stent (RS) insertion treatment, the relative benefits of unilateral versus bilateral RS insertion procedures remain to be established. Accordingly, this study was designed to evaluate the relative safety and efficacy of percutaneous bilateral and unilateral RS insertion for patients with HCCA.

Methods

In total, 126 HCCA patients who underwent unilateral (n=64) or bilateral (n=62) RS insertion from January 2017 - December 2021 were included in this analysis. Treatment efficacy and long-term outcomes were compared between groups. The primary endpoint was stent patency, and the secondary endpoints included technical success rate, clinical success rate, local control rate, overall survival (OS), and complications.

Results

The respective technical success rates in the unilateral and bilateral groups were 90.6% (58/64) and 93.5% (58/62) (P = 0.782). The clinical success rates were 82.8% and 86.2% in unilateral and bilateral groups, respectively (P = 0.608). Both groups exhibited comparable medial post-intervention bilirubin levels (100 vs. 99 μmol/L; P = 0.501), and restenosis occurred in 12 (20.7%) and 15 (25.9%) patients over the follow-up interval (P = 0.510). The stent reintervention rate was significantly higher in the unilateral group than bilateral group (66.7% vs. 0.0%, P < 0.001). The median stent patency in the unilateral and bilateral groups was 189 and 210 days, respectively (P = 0.796), while the median OS interval was 222 and 229 days, respectively (P = 0.969). Comparable cholangitis (17.2% vs. 22.4%, P = 0.485) and cholecystitis (3.4% vs. 3.4%, P = 1.000) rates were also detected in these two groups.

Conclusions

In summary, HCCA patients exhibit comparable efficacy when undergoing unilateral and bilateral radioactive stenting, suggesting that unilateral RS can be routinely performed owing to the simpler nature of this procedure.

Pancreatic fistula and bleeding following choledochal cyst excision: Experience of two decades

OBJECTIVES

Choledochal cyst excision (CDCE) with hepaticojejunostomy is standard of care in choledochal cysts. Complications related to inadequate healing of distal stump like post-operative pancreatic fistula (POPF) and bleeds have not been addressed in literature. We report two decade experience with these complications following CDCE.

MATERIAL AND METHODS

Retrospective analysis of demographics, operative details and post-operative course of patients who developed POPF (according to International Study group of Pancreas surgery classification) and bleeds following CDCE were compared with those who did not develop these complications.

RESULTS

POPF was seen in in 34 out of 377 operated patients (incidence of 9%). In those with POPF, 24/34 (70%) had biochemical leak and 10/34 (30%) had clinically relevant POPF (B and C). All grade B POPF 6/34, required additional percutaneous drains while all grade C 4/34 required operative intervention to control sepsis. There was no mortality in the POPF group while two patients in control died from non-surgical causes. A difficult distal stump precluding closure was the only factor found associated with subsequent development of POPF (5.9% in POPF group vs. 0.5% in control group, p= 0.03). Post-operative bleeding was seen in 2 (6%) patients with POPF and in 5/343 (1.4%) in control group.

CONCLUSION

It is possible to anticipate development of POPF intraoperatively, during CDCE. Most of these POPFs can be managed conservatively with adequate drainage. Surgery is required only in grade C fistula and bleeds. Since these are isolated pancreatic fistulas, unlike those seen after pancreaticoduodenectomy, they are associated with more favourable outcomes.

Endoscopic management of malignant biliary obstructions

Malignant biliary obstruction (MBO), both distal and hilar, represents an ensemble of different clinical conditions frequently encountered in everyday practice. Given the frequent unresectability of the disease at presentation and the increasing indications for neoadjuvant chemotherapy, endoscopic biliary drainage is generally required during the course of the disease. With the widespread use of interventional endoscopic ultrasound (EUS) and the introduction of dedicated devices, EUS-guided biliary drainage has rapidly gained acceptance, together with transpapillary endoscopic biliary drainage and the percutaneous approach. This comprehensive review describes the current role of endoscopy for distal and hilar MBO supported by evidence, with a focus on the current hot topics in this field.

Ultrasound-Guided Interventions in the Biliary System

Ultrasound guidance in biliary interventions has become the standard tool to facilitate percutaneous biliary drainage as well as percutaneous gall bladder drainage. Monitoring of the needle tip whilst penetrating the tissue in real time using ultrasound allows precise manoeuvres and exact targeting without radiation exposure. Without the need for fluoroscopy, ultrasound-guided drainage procedures can be performed bedside as a sometimes life-saving procedure in patients with severe cholangitis/cholecystitis when they are critically ill in intensive care units and cannot be transported to a fluoroscopy suite. This article describes the current data background and guidelines and focuses on specific sonographic aspects of both the procedures of percutaneous biliary drainage and gallbladder drainage.

Clinical observation of gastrointestinal function recovery in patients after hepatobiliary surgery

BACKGROUND

The liver is an important metabolic and digestive organ in the human body, capable of producing bile, clotting factors, and vitamins.

AIM

To investigate the recovery of gastrointestinal function in patients after hepatobiliary surgery and identify effective rehabilitation measures.

METHODS

A total of 200 patients who underwent hepatobiliary surgery in our hospital in 2022 were selected as the study subjects. They were divided into a control group and a study group based on the extent of the surgery, with 100 patients in each group. The control group received routine treatment, while the study group received targeted interventions, including early enteral nutrition support, drinking water before gas discharge, and large bowel enema, to promote postoperative gastrointestinal function recovery. The recovery of gastrointestinal function was compared between the two groups.

RESULTS

Compared with the control group, patients in the study group had better recovery of bowel sounds and less accumulation of fluids in the liver bed and gallbladder fossa (P < 0.05). They also had shorter time to gas discharge and first meal (P < 0.05), higher overall effective rate of gastrointestinal function recovery (P < 0.05), and lower incidence of postoperative complications (P < 0.05).

CONCLUSION

Targeted nursing interventions (early nutritional support, drinking water before gas discharge, and enema) can effectively promote gastrointestinal function recovery in patients undergoing hepatobiliary surgery and reduce the incidence of complications, which is worthy of promotion.