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Zhu Z, Hu K, Zhao F, Liu W, Zhou H, Zhu Z, Li H. Machine learning-based nomogram for 30-day mortality prediction for patients with unresectable malignant biliary obstruction after ERCP with metal stent: a retrospective observational cohort study. BMC Surg 2023; 23:260. [PMID: 37649027 PMCID: PMC10470194 DOI: 10.1186/s12893-023-02158-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND This study aimed to investigate the risk factors for 30-day mortality in patients with malignant biliary obstruction (MBO) after endoscopic retrograde cholangiopancreatography (ERCP) with endobiliary metal stent placement. Furthermore, we aimed to construct and visualize a prediction model based on LASSO-logistic regression. METHODS Data were collected from 245 patients who underwent their first ERCP with endobiliary metal stent placement for unresectable MBO between June 1, 2013, and August 31, 2021. Univariable and multivariable logistic regression analyses were conducted to identify the risk factors for 30-day mortality. We subsequently developed a logistic regression model that incorporated multiple parameters identified by LASSO regression. The model was visualized and the nomogram was plotted. Risk stratification was performed based on nomogram-derived scores. RESULTS The 30-day mortality rate was 10.7% (23/245 patients). Distant metastasis, total bilirubin, post-ERCP complications, and successful drainage were independent risk factors of 30-day mortality. The variables screened by LASSO regression, including distant metastasis, total bilirubin, post-ERCP complications, and successful drainage, were incorporated into the logistic model. The results were visualized through a nomogram based on the model. To assess the model's performance, discrimination was evaluated using the area-under-the-curve values obtained from receiver operating characteristic analyses with 10-fold cross-validation in the training group and validated in the testing group. The calibration curve showed the good predictive ability of the model. Decision curve analysis is used to evaluate the clinical application of nomogram. Finally, we performed risk stratification based on the risk calculated using the nomogram. Patients were assigned to the low-, moderate-, and high-risk groups based on their probability scores. The Kaplan-Meier survival curves for the different nomogram-based groups were significantly different (p < 0.001). CONCLUSIONS We developed a nomogram using the LASSO-logistic regression model to forecast the 30-day mortality rate in patients who had undergone ERCP with endobiliary metal stent placement due to MBO. This nomogram can assist in identifying individuals at high-risk of 30-day mortality following ERCP.
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Affiliation(s)
- Zongdong Zhu
- Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Jiaxing, Zhejiang, China
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Kaixin Hu
- Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Jiaxing, Zhejiang, China
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Fengqing Zhao
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Wen Liu
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Hongkun Zhou
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Zongliang Zhu
- Henan University of Science and Technology, Luoyang, Henan, China
| | - Huangbao Li
- Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Jiaxing, Zhejiang, China.
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China.
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Sarkodie BD, Botwe BO, Brakohiapa EKK. Percutaneous transhepatic biliary stent placement in the palliative management of malignant obstructive jaundice: initial experience in a tertiary center in Ghana. Pan Afr Med J 2020; 37:96. [PMID: 33425129 PMCID: PMC7757328 DOI: 10.11604/pamj.2020.37.96.20050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 08/31/2020] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Benjamin Dabo Sarkodie
- Department of Radiology, School of Medicine and Dentistry, University of Ghana, Accra, Ghana
| | - Benard Ohene Botwe
- Department of Radiography, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Accra, Ghana
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Oliveira MBD, Santos BDN, Moricz AD, Pacheco-Junior AM, Silva RA, Peixoto RD, Campos TD. TWELVE YEARS OF EXPERIENCE USING CHOLECYSTOJEJUNAL BY-PASS FOR PALLIATIVE TREATMENT OF ADVANCED PANCREATIC CANCER. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 30:201-204. [PMID: 29019562 PMCID: PMC5630214 DOI: 10.1590/0102-6720201700030009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 06/06/2017] [Indexed: 11/22/2022]
Abstract
Background: The cholecistojejunal bypass is an important resource to treat obstructive jaundice due to advanced pancreatic cancer. Aim: To assess the early morbidity and mortality of patients with pancreatic cancer who underwent cholecystojejunal derivation, and to assess the success of this procedure in relieving jaundice. Method: This retrospective study examined the medical records of patients who underwent surgery. They were categorized into early death and non-early death groups according to case outcome. Results: 51.8% of the patients were male and 48.2% were female. The mean age was 62.3 years. Early mortality was 14.5%, and 10.9% of them experienced surgical complications. The cholecystojejunostomy procedure was effective in 97% of cases. There was a tendency of increased survival in women and patients with preoperative serum total bilirubin levels below 15 mg/dl. Conclusion: Cholecystojejunal derivation is a good therapeutic option for relieving jaundice in patients with advanced pancreatic cancer, with acceptable rates of morbidity and mortality.
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Affiliation(s)
| | | | - André de Moricz
- Department of Pancreatic and Bile Duct Surgery, Santa Casa de São Paulo
| | | | | | - Renata D'Alpino Peixoto
- Department of Clinical Oncology, Antônio Ermírio de Moraes Oncology Center.,Nove de Julho University, São Paulo, Brazil
| | - Tércio De Campos
- Department of Pancreatic and Bile Duct Surgery, Santa Casa de São Paulo
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Mukherjee S, Kocher HM, Hutchins RR, Bhattacharya S, Abraham AT. Palliative surgical bypass for pancreatic and peri-ampullary cancers. J Gastrointest Cancer 2009; 38:102-7. [PMID: 18810668 DOI: 10.1007/s12029-008-9020-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The optimal method of palliation for patients with unresectable pancreatic and peri-ampullary cancer (PAC) is controversial with surgical bypass or endoscopic stenting, each having advantages and disadvantages. AIMS We analysed short term outcomes and survival for all patients undergoing surgical palliative bypass procedures. MATERIALS AND METHODS All patients undergoing palliative surgical bypass for unresectable PAC from Aug 1999 to July 2007 were identified from our database. Outcomes analysed were peri-operative morbidity, mortality, and overall survival with comparisons from contemporaneous literature. RESULTS One hundred eight patients (median age 65 (range 36-86) years; male = 61) had palliative surgical bypass procedures for unresectable PAC. Patients underwent combined biliary and gastric bypass (n = 81, 75%), gastric bypass alone (n = 24, 22.2%) or biliary bypass alone (n = 3, 2.8%). Overall mortality was 6.5% and the morbidity was 15.7%. Median hospital stay was 11 (range 4-54) days. Median survival was 6 (95% confidence interval (CI) = 4.3-7.6) months. No re-explorations for recurrent biliary or gastric obstruction were required. Contemporaneous literature review showed similar results. CONCLUSION Surgical bypass performed in a specialist pancreatic center can offer effective palliation for unresectable PAC, with satisfactory outcomes.
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Affiliation(s)
- Samrat Mukherjee
- Barts and the London NHS Trust, Barts and the London HPB Centre, The Royal London Hospital Whitechapel, London, E1 1BB, UK.
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Connor S, Wigmore SJ, Madhavan KK, Parks RW, Garden OJ. Surgical palliation for unresectable hilar cholangiocarcinoma. HPB (Oxford) 2005; 7:273-7. [PMID: 18333206 PMCID: PMC2043105 DOI: 10.1080/13651820500372442] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The majority of patients who present with hilar cholangiocarcinoma will have incurable disease and require only palliation. Efficient relief of disabling symptoms is required with minimal morbidity and mortality and can be achieved by either surgical or non-operative options. A review of the indications, anatomical considerations and surgical techniques is presented. Segment III cholangio-jejunostomy is the most frequently used surgical bypass procedure and in those patients with an expected survival of more than 6 months, surgical palliation offers good quality and long-lasting palliation. There is a need for randomized controlled data to define the optimal role of surgical palliation in this difficult disease.
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Affiliation(s)
- S. Connor
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
| | - S. J. Wigmore
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
| | - K. K. Madhavan
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
| | - R. W. Parks
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
| | - O. J. Garden
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
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Karamarković A, Milić N, Djukić V, Radenković D, Jeremić V, Bumbasirević V, Popović N, Kojić Z, Bajec D. Intrahepatic segmental bile duct B3 cholangiojejunostomy in the palliative management of high unresectable malignant biliary obstruction. ACTA ACUST UNITED AC 2004; 51:85-91. [PMID: 16018372 DOI: 10.2298/aci0403085k] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Palliating the effects of biliary obstruction is a major goal of therapy in patients with unresectable cancer at the hepatic duct confluence. We reviewed our expirience with intrahepatic holangioenteric bypass to the segmental bile duct B3 as a palliative therapy in patients with unresectable malignant diseases involving the ductal confluence or the common hepatic duct. Since March 2001, we have performed intrahepatic segmental bile duct B3 cholangiojejunostomy by Roux-en-Y fashion utilizing a round ligament approach in 13 patients with malignant obstructive jaundice due to unresectable hilar holangiocarcinoma (8 cases) and gallbladder cancer (5 cases). Mean hospital stay was123 days and mean blood loss was 25060 mL. Postoperative complications occurred in 3 patients (23 %), but there was no surgical complications such as postoperative bleeding, bile leakage or abscess formation. 30-day mortality was 7.7% (1 patient). Late complications (37.5 %) were observed in 3 of the 8 patients who survived for more than 5 months after the surgery. Median survival after B3 cholangiojejunostomy was 9 months (range, 10 days-22 months). Median survival time was significantly greater in patients with hilar cholangio-carcinoma (11.8 months; range: 2-22 months) compared with those with gallbladder cancer (4.6 months; range: 10 days-11.5 months) ( P-0.032 log rank test; P-0.049 Tarone-Ware test). Intrahepatic B3 cholangiojejunostomy when combined with careful patient selection, can provide useful palliation from jaundice, pruritus and cholangitis with acceptable mortality and morbidity rates.
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7
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Ciesielczyk B, Murawa D. The results of palliative percutaneous drainage of biliary ducts. Rep Pract Oncol Radiother 2004. [DOI: 10.1016/s1507-1367(04)71011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Affiliation(s)
- S A Curley
- University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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9
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González J, Sanz L, Azcano E, Navarrete F, Martínez E. Morbimortalidad y supervivencia tras la paliación de la obstrucción maligna de la vía biliar. Cir Esp 2001. [DOI: 10.1016/s0009-739x(01)71785-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Maghfoor I. Metastatic small cell lung cancer causing biliary obstruction. Med Oncol 2000; 17:342-3. [PMID: 11114717 DOI: 10.1007/bf02782203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- I Maghfoor
- Division of Hematology/Medical Oncology, Memorial University of Newfoundland, Dr H Bliss Murphy Cancer Center, St John's, Canada
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11
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Yilmaz S, Kirimlioglu V, Katz DA, Caglikulekci M, Yilmaz M. Palliative decompression of obstructive hilar malignancies utilizing an extrahilar biliary approach. Dig Dis Sci 2000; 45:1585-93. [PMID: 11007110 DOI: 10.1023/a:1005569128877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Hilar cancers carry a dismal prognosis. Palliation of obstructive jaundice in patients with hilar cancer can be achieved by either surgical or nonsurgical means. Selection of the appropriate palliative measures is a challenging problem. Segmental bilioenteric anastomosis procedures were performed on 19 patients with hilar cancer. Seventeen of the bypasses were done to the segment III duct, known as the ligamentum teres approach, and two bypasses were to the segment V duct. Five patients, who had already been stented percutaneously or endoscopically, were operated on after the stents were clogged and a duodenal obstruction ensued. There were two postoperative deaths (10.5%) and four postoperative complications (21%). All of the 17 surviving patients experienced improvement in the level of jaundice postoperatively and the levels of serum total and direct bilirubin decreased by 78.9% and 84.2%, respectively. Two patients developed late cholangitis before death and were treated by external biliary drainage; one developed duodenal obstruction and was treated by gastrointestinal anastomosis. The mean length of hospital stay was 15.2 days. Mean survival was 8.2 months and the mean period of well-being was 7.8 months. Median survival was 7 months and median period of well being was 7 months. Three patients are still alive at 8, 8, and 24 months. These data suggest that the ligamentum teres approach offers effective palliation for patients with unresectable hilar cancer.
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Affiliation(s)
- S Yilmaz
- Inonu University Medical School, General Surgery Department, Malatya and Turkey Advanced Specialist Hospital, Ankara
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12
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Nomura T, Shirai Y, Hatakeyama K. Bacteribilia and cholangitis after percutaneous transhepatic biliary drainage for malignant biliary obstruction. Dig Dis Sci 1999; 44:542-6. [PMID: 10080147 DOI: 10.1023/a:1026653306735] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Cholangitis often develops after percutaneous transhepatic biliary drainage (PTBD) for malignancy. The aims of this retrospective study were to clarify whether or not bacteribilia and cholangitis increase with time after PTBD and to define the pathogenesis of bacteribilia and cholangitis after PTBD. One hundred twenty-eight patients underwent PTBD for malignancy. Both the cumulative incidences of bacteribilia (77%) and cholangitis (28%) showed an increase with time after PTBD. In 78% of patients with bacteribilia, bacteria from intestinal flora were detected in bile. Catheter malfunction (N = 17) or the presence of undrained bile ducts (N = 7) induced cholangitis. Proximal obstruction, because it often accompanied undrained ducts, had higher incidences of bacteribilia (P = 0.04) and cholangitis (P < 0.0001) than did distal obstruction. In conclusion, bacteribilia and cholangitis increase in incidence with time after PTBD. The primary cause of bacteribilia is the transpapillary reflux of intestinal flora. Catheter malfunction or undrained ducts cause cholangitis, provided underlying bacteribilia is present.
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Affiliation(s)
- T Nomura
- Department of Surgery, Niigata University School of Medicine, Niigata City, Japan
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13
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Affiliation(s)
- M F Chen
- Department of Surgery, Chang Gung University Medical College, Chang Gung Memorial Hospital, Taipei, Taiwan.
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14
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Affiliation(s)
- S A Curley
- M.D. Anderson Cancer Center, Houston, TX 77030, USA
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15
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16
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Affiliation(s)
- L H Blumgart
- Memorial Sloan-Kettering Cancer Center, New York, NY 10021
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Guthrie CM, Haddock G, De Beaux AC, Garden OJ, Carter DC. Changing trends in the management of extrahepatic cholangiocarcinoma. Br J Surg 1993; 80:1434-9. [PMID: 7504567 DOI: 10.1002/bjs.1800801128] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A series of 107 patients with cholangiocarcinoma diagnosed between January 1980 and December 1991 is reported. Changing patterns of investigation and treatment in the periods 1980-1985 and 1986-1991 are analysed. There was a decrease in the use of percutaneous transhepatic cholangiography in the second period (86 versus 51 per cent of patients) but increased use of endoscopic retrograde cholangiography (19 versus 71 per cent) and computed tomography (8 versus 59 per cent). The overall resectability rate (17 per cent) was similar to those of other reported series but greater in the second period (8 versus 21 per cent). Palliation by endoscopic and percutaneous stenting was associated with a high incidence of recurrent cholangitis (55 per cent) and jaundice (35 per cent). During the second 6-year period, more effective palliation was achieved by segment III cholangiojejunostomy with a lower incidence of recurrent cholangitis (19 per cent) and jaundice (19 per cent). Overall prognosis for patients with this condition is grim and efforts must usually be aimed at providing the most appropriate palliation.
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Affiliation(s)
- C M Guthrie
- University Department of Surgery, Royal Infirmary, Edinburgh, UK
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18
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Clements WD, Diamond T, McCrory DC, Rowlands BJ. Biliary drainage in obstructive jaundice: experimental and clinical aspects. Br J Surg 1993; 80:834-42. [PMID: 7690298 DOI: 10.1002/bjs.1800800707] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Jaundiced patients undergoing invasive diagnostic and therapeutic procedures are at increased risk of complications and death. Despite the large number of clinical and experimental investigations carried out to identify relevant risk factors, no single parameter has been found to be consistently useful in predicting morbidity or mortality. Biliary decompression was initially employed by surgeons and subsequently by interventional radiologists. More recently, endoscopic retrograde cholangiopancreatography has provided an alternative route for decompression of the biliary tree and preliminary data using this method are encouraging. Although there are enthusiastic proponents of various therapeutic techniques, controlled trials have not been convincing in highlighting the benefits of biliary drainage or in determining the best approach. This article reviews the literature pertaining to this complex surgical problem; an attempt has been made to balance the advantages and disadvantages of biliary decompression as palliation and/or preliminary treatment for extrahepatic biliary obstruction.
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Affiliation(s)
- W D Clements
- Department of Surgery, Queen's University of Belfast, UK
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19
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Lai EC, Chu KM, Lo CY, Fan ST, Lo CM, Wong J. Choice of palliation for malignant hilar biliary obstruction. Am J Surg 1992; 163:208-12. [PMID: 1371206 DOI: 10.1016/0002-9610(92)90102-w] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Clinical data from 50 consecutive patients with unresectable hilar tumors situated at or proximal to the common hepatic duct were retrospectively analyzed to aid in the selection of appropriate palliative measures. Thirty-four patients had cholangioenteric bypass (CEB) to either left (28 patients), right (3 patients), or both (3 patients) intrahepatic ductal systems. Sixteen patients had nonoperative drainage (NOD) established either endoscopically (4 patients), percutaneously (9 patients), or using a combined endoscopic-percutaneous approach (3 patients). When compared with patients with CEB, patients with NOD had more frequent medical problems (p less than 0.03) and lower serum albumin levels on admission (p less than 0.03). While comparable postprocedural complications (13 CEB patients versus 4 NOD patients) were observed, patients with NOD had a significantly higher hospital mortality (9 CEB patients versus 9 NOD patients, p less than 0.05). Excluding the 12 patients (6 CEB patients versus 6 NOD patients) who died within 30 days after drainage, the quality of survival of the remaining 38 patients was analyzed with reference to 6 objective parameters. Although patients with NOD had significantly more frequent admissions relating to their catheters (p less than 0.02), there was no qualitative difference in the survival rate between the two groups of patients. For selected high-risk patients with limited life expectancy, NOD should be offered. However, additional prospective studies are required to decide the best choice of palliation for patients who are not at such high risk.
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Affiliation(s)
- E C Lai
- Department of Surgery, University of Hong Kong, Queen Mary Hospital
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Abstract
The diagnosis of cholangiocarcinoma can now be made with greater rapidity and accuracy. In the clinical setting of obstructive jaundice, a CT scan or sonogram may suggest cholangiocarcinoma if dilated intrahepatic ducts are seen with a nondilated extrahepatic biliary tree. The diagnosis is confirmed by cholangiography, and the tumor is staged by the combination of cholangiography and angiography. If the tumor extensively involves both lobes of the liver or involves the main portal vein or hepatic artery, the lesion is considered unresectable. These patients are best palliated nonoperatively, but they should still have an attempt at a tissue diagnosis, as various other lesions can masquerade as cholangiocarcinoma. In comparison, if the tumor is confined to or is distal to the hepatic duct bifurcation, extends into only one lobe of the liver, or involves only the right or the left portal vein or hepatic artery, the lesion may be resectable, and exploration is indicated. As many as half of all patients explored with curative intent will have a successful resection. Various surgical options are appropriate for patients undergoing tumor resection, depending on the site and extent of the lesion. Similarly, several surgical options are possible for palliation in patients with unresectable cholangiocarcinoma. The role of radiotherapy in the management of cholangiocarcinoma is uncertain. Our results, like those of many other retrospective analyses, suggest that radiotherapy prolongs survival after curative resection as well as after palliative stenting. However, further data from randomized studies are necessary to support or refute this impression. Further studies of adjuvant chemotherapy or hormonal therapy will also be necessary to improve patient survival.
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Affiliation(s)
- C J Yeo
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
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Abstract
We reviewed the records of 340 patients with a tissue diagnosis of pancreatic cancer treated at UCLA Medical Center between 1973 and 1988. Sixty-one patients underwent pancreatic resection (group I), 173 had some form of surgical palliation (group II), and 106 had neither (group III). The diagnosis was made 1 to 2 months more quickly in the last 8 years of the review than in the first 8 years, but the effect of early diagnosis on curability was negligible. Biliary obstruction was best treated by cholecystojejunostomy or choledochojejunostomy, which were equally effective. Anastomoses to the jejunum were safer and more effective than were those to the duodenum for the relief of biliary obstruction. Gastrojejunostomy should be performed prophylactically as well as therapeutically. It was effective and safe in both settings. Surgical palliation for pancreatic cancer was generally effective and was associated with an operative mortality rate of less than 10%. However morbidity was high, with significant complications occurring in one third of cases.
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Affiliation(s)
- S M Singh
- Department of Surgery, UCLA School of Medicine
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Czerniak A, Blumgart LH. Hilar cholangiocarcinoma. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1989; 59:837-44. [PMID: 2479369 DOI: 10.1111/j.1445-2197.1989.tb07025.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- A Czerniak
- Department of Surgery, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Israel
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Bear HD, Turner MA, Parker GA, Lawrence W, Horsley JS, Messmer JM, Cho SR. Treatment of biliary obstruction caused by metastatic cancer. Am J Surg 1989; 157:381-5; discussion 385. [PMID: 2467569 DOI: 10.1016/0002-9610(89)90580-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Over an 8-year period, among 41 patients with obstructive jaundice caused by metastases to the liver or lymph nodes adjacent to the porta hepatis, palliative biliary decompression was established surgically in 11, by percutaneous transhepatic biliary drainage (PTBD) in 25, and by both methods in 2. Three patients had no drainage procedure performed. Early mortality after drainage occurred in 6 of 38 patients, and the median survivals (actuarial) for the remaining 32 patients were 4.5 months for the surgical group (range 2 to 21 months) and 4 months for the PTBD group (range 2 to 14 months). Although there were trends toward more frequent hospital readmissions and episodes of cholangitis in the PTBD group, the only statistically significant difference was in the number of catheter manipulations required. We concluded that when patients develop obstructive jaundice as a manifestation of metastatic cancer, useful palliation can be achieved by either surgical or percutaneous decompression.
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Affiliation(s)
- H D Bear
- Division of Surgical Oncology, Medical College of Virginia Station, Richmond 23298-0011
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Abstract
This study compares the efficacy of percutaneous transhepatic drainage (PTD) versus operative biliary decompression for patients with malignant obstructive jaundice. The utilization of preoperative PTD as a surgical adjuvant is also examined. The records of 90 patients with obstructed jaundice from two large community hospitals were reviewed. In the group of patients undergoing curative resections, no advantage was noted for the patients who received preoperative PTD. The patients receiving only surgery left the hospital 8 days sooner. For the patients undergoing palliative treatment, the group receiving only the surgery had the lowest morbidity and mortality and the longest survival rates. The patients receiving only PTD had the shortest hospital stay, but also had many complications, the highest mortality rate, and the shortest survival rate. The group receiving preoperative PTD followed by surgical decompression had more complications and stayed in the hospital longer, with no change in postoperative mortality.
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Affiliation(s)
- J Rosen
- Department of Surgery, Providence Hospital, Southfield, Michigan 48037
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McGrath PC, McNeill PM, Neifeld JP, Bear HD, Parker GA, Turner MA, Horsley JS, Lawrence W. Management of biliary obstruction in patients with unresectable carcinoma of the pancreas. Ann Surg 1989; 209:284-8. [PMID: 2466448 PMCID: PMC1493941 DOI: 10.1097/00000658-198903000-00006] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Clinical and pathologic data from 73 patients with unresectable carcinoma of the pancreas treated from 1980 to 1987 were reviewed to evaluate the efficacy of biliary enteric bypass and percutaneous transhepatic biliary drainage (PTBD) in the treatment of malignant biliary obstruction. Fifty-two patients underwent biliary enteric bypass with no operative deaths and with a 15% operative morbidity. These patients had a median postoperative hospitalization of 12 days. Four patients (8%) eventually developed recurrent jaundice, and three of these were successfully treated with PTBD. The median survival for these 52 patients was 7 months. Twenty-one patients underwent PTBD with an 81% technical-success rate. These patients had a 33% early complication rate and a 33% in-hospital mortality. The median hospitalization was 13 days postdrainage. Of the 14 patients surviving the initial hospitalization, 86% developed late complications requiring 16 hospital admissions and ten emergency room visits for a total of 155 days of hospitalization. The median survival for those patients undergoing PTBD was 4 months from the time of diagnosis and 2 months from the time of catheter drainage. Surgical bypass offers excellent palliation for malignant biliary obstruction with extremely low morbidity and mortality in properly selected patients; PTBD is useful in the treatment of those patients with extensive disease, who are poor surgical candidates, or who have failed previous surgical drainage. There is a role for both of these palliative procedures in the management of patients with biliary obstruction from pancreatic cancer.
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Affiliation(s)
- P C McGrath
- Department of Surgery, Medical College of Virginia, Richmond
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Gibson RN, Yeung E, Hadjis N, Adam A, Benjamin IS, Allison DJ, Blumgart LH. Percutaneous transhepatic endoprostheses for hilar cholangiocarcinoma. Am J Surg 1988; 156:363-7. [PMID: 2461105 DOI: 10.1016/s0002-9610(88)80187-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In patients with unresectable hilar cholangiocarcinoma, percutaneous transhepatic endoprosthesis insertion is one of the available methods of palliation. We reviewed our experience with it in 35 consecutive patients with hilar cholangiocarcinoma who were judged on clinical or radiologic evidence to be unsuitable for resective or palliative surgery. The 30-day mortality rate was 14 percent (5 of 35 patients). Of the remaining 30 patients, endoprosthesis placement was successful in 28, with 2 patients discharged with a permanent external drainage catheter. Twenty-four patients survived a median of 3 months (range 1 to 17 months), and 2 were lost to follow-up. Good or fair palliation of symptoms was achieved in 50 percent of the discharged patients and in 66 percent of those living longer than 3 months. We believe that percutaneous transhepatic endoprostheses can provide useful palliation in patients with hilar cholangiocarcinoma, even in the presence of advanced disease.
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Affiliation(s)
- R N Gibson
- Department of Diagnostic Radiology, Royal Postgraduate Medical School, Hammersmith Hospital, London, United Kingdom
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Longmire-Cook S, Malangoni MA. Forecast of surgical risk in pancreatic cancer. Am J Surg 1988; 155:A32. [PMID: 3344893 DOI: 10.1016/s0002-9610(88)80093-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Abstract
Fifty-five consecutive patients presenting to a Surgical Unit for management of malignant obstructive jaundice are reported in this paper. An increasing incidence of bile-duct carcinoma has been noted since the end of 1983. The hospital mortality for all cases was 15%, a figure which did not differ significantly from the 11% mortality associated with the surgical management of benign obstructive jaundice. The median survival of patients with malignant obstructive jaundice was 6 months and the 2 year survival 10%. The only long-term survivors were those in whom pancreaticoduodenectomy was employed. Until radical improvements in treatment are achieved, effective palliation must remain the goal for the surgeon. This means that there is a need for rapid diagnosis, rapid decision making and early intervention to restore bile flow to the intestine. The best palliative procedure has yet to be defined and the status of stent insertion, of surgical bypass procedures and of palliative resection of some tumours remain unclear. Similarly, the place of adjuvant chemotherapy and radiotherapy have not been clearly established. There is a real need for a trial of various methods of treatment which employs an evaluation that takes into account both duration and quality of life.
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Affiliation(s)
- J F Huang
- Department of Surgery, Westmead Hospital, NSW
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Speer AG, Cotton PB, Russell RC, Mason RR, Hatfield AR, Leung JW, MacRae KD, Houghton J, Lennon CA. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987; 2:57-62. [PMID: 2439854 DOI: 10.1016/s0140-6736(87)92733-4] [Citation(s) in RCA: 429] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with biliary obstruction due to malignant disease, and judged unfit for open operation, were randomised to have a biliary stent inserted either endoscopically via the papilla of Vater or percutaneously. Analysis after 75 patients had been entered showed that the endoscopic method had a significantly higher success rate for relief of jaundice (81% versus 61%, p = 0.017) and a significantly lower 30-day mortality (15% versus 33%, p = 0.016). The higher mortality after percutaneous stents was due to complications associated with liver puncture (haemorrhage and bile leaks). When stenting is indicated in elderly and frail patients the endoscopic method should be tried first.
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Abstract
A retrospective study of 97 patients with proximal bile duct cancer treated at the University of California, Los Angeles Medical Center was conducted to determine the benefits of different operative treatments. Eighty-nine patients were divided into three treatment groups: Group I, curative resection (29 patients); Group II, palliative resection (13 patients) and bypasses (8 patients); and Group III, operative intubation (39 patients). Two patients died before operation and six patients were treated without operation by percutaneous biliary decompression. High morbidity rate (53.8%) and mortality rate (69.2%) were encountered in 13 patients who had hepatic resection. Survival rates of the three treatment groups were comparable. For the 64 patients closely monitored after discharge, quality of survival was assessed according to six parameters: frequency of hospitalization for cholangitis; catheter-related problems; the percentage of days hospitalized; duration of jaundice; antibiotic requirements; and analgesic needs. Group I patients had the best qualitative survival, whereas Group II patients had the worst result when compared with either Group I (p less than 0.001) or Group III (p less than 0.005). Curative resection is recommended when it can be done without a concomitant hepatic resection. When noncurable disease is found on examination, operative intubation after dilatation is the preferred palliative measure.
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