Comparison of Efficacy and Safety between Endoscopic Retrograde Cholangiopancreatography and Percutaneous Transhepatic Cholangial Drainage for the Treatment of Malignant Obstructive Jaundice: A Systematic Review and Meta-Analysis

ACUTE KIDNEY INJURY FOLLOWING ACUTE CHOLANGITIS: A RISK MULTIPLIER FOR ADVERSE OUTCOMES AND HEALTHCARE UTILIZATION

ABSTRACT

Background: Acute kidney injury (AKI) is a common, fatal complication of acute cholangitis (AC). The link between AC and AKI is poorly understood. Aims: To delineate the incidence trends, clinical outcomes and healthcare utilization of inpatients with AKI following AC and to explore the risk factors for AKI following AC. Methods: This population-based retrospective study used the National Inpatient Sample database from 2010 to 2018 to compare the demographics, complications, in-hospital mortality and healthcare utilization between AC patients with and without AKI. Predictors of AKI and the prognostic impact of AKI on in-hospital outcomes were defined using multivariate logistic regression. Results: The overall incidence of AKI was 24.06% among AC patients. Its trend generally increased annually. AKI was associated with more complications, greater invasive therapy requirements, longer hospital stays, costlier total hospital charges, and higher in-hospital mortality. The risk factors for AKI following AC were advanced age, Black race, multiple comorbidities, large hospitals, teaching hospitals, urban hospitals, hospitals in the southern and western United States, choledocholithiasis/cholelithiasis, surgery, percutaneous transhepatic biliary drainage, deficiency anemia, congestive heart failure, coagulopathy, diabetes, hypertension, chronic liver disease, obesity, chronic kidney disease excluding end-stage renal disease, weight loss, acute pancreatitis, and severe sepsis. Female sex, private insurance, elective admission, and endoscopic retrograde cholangiopancreatography were protective factors against AKI in AC patients. Conclusion: AKI often follows AC and is strongly associated with poor prognosis and increased healthcare utilization. Healthcare professionals should make more efforts to identify patients with AC at risk of AKI and start management promptly to limit adverse outcomes.

Difficult cannulation during endoscopic retrograde cholangiopancreatography-needle-knife precut versus transpancreatic sphincterotomy on the basis of successful cannulation and adverse events

BACKGROUND

When cannulation is challenging during endoscopic retrograde cholangiopancreatography (ERCP), and the standard guidewire technique with sphincterotomy is unsuccessful, alternative cannulation techniques can be used to access the biliary tree. The purpose of this study was to compare the incidence of adverse events and cannulation success rates between transpancreatic sphincterotomy (TPS) and precut sphincterotomy (PCS).

METHODS

Data from the Swedish Registry for Gallstone Surgery and ERCP (GallRiks), collected from 2011 to 2022, were analyzed. A total of 105,303 ERCP procedures were recorded in GallRiks during the study period. After exclusions, the study population consisted of 47,486 ERCP procedures. Of these, 4547 received PCS and 3273 received TPS. The remaining 39,666 ERCP procedures with conventional sphincterotomy served as the control group. The primary endpoints were successful cannulation and adverse events within 30 days.

RESULTS

Successful cannulation was more frequent with the TPS technique than with the PCS technique (86.5% vs. 69.7%), but both groups had a lower cannulation rate than the control group (92.4%; OR-PCS 0.20, 95% CI 0.18-0.21; OR-TPS 0.58, 95% CI 0.52-0.64). The TPS group had a higher incidence of adverse events than the PCS group (24.1% vs. 18.8%) and both groups had a higher incidence of adverse events than the control group (15.5%; OR-PCS 1.25, 95% CI 1.15-1.36; OR-TPS 1.71, 95% CI 1.57-1.87). Adverse events for TPS were driven by a higher incidence of pancreatitis (10.5% vs. 6.4% vs. 4.5%; OR 2.53, 95% CI 2.23-2.86) and perforation (1.6% vs. 0.8% vs. 0.5%; OR 2.99, 95% CI 2.20-4.06) compared to both PCS and control.

CONCLUSION

TPS is more successful at cannulation than PCS; however, this success comes at a higher cost in terms of adverse events, particularly pancreatitis and perforation.

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.

Analysis of the efficacy of Percutaneous Transhepatic Cholangiography Drainage (PTCD) and Endoscopic Retrograde Cholangiopancreatography (ERCP) in the treatment of Malignant Obstructive Jaundice (MOJ) in palliative drainage and preoperative biliary drainage: a single-center retrospective study

PURPOSE

This study aimed to assess the safety and efficacy of percutaneous transhepatic cholangiography drainage (PTCD) and endoscopic retrograde cholangiopancreatography (ERCP) in palliative drainage and preoperative biliary drainage for treating malignant obstructive jaundice (MOJ).

METHODS

A total of 520 patients with MOJ who underwent PTCD or ERCP were enrolled and classified into palliative drainage group and preoperative biliary drainage group. Baseline characteristics, liver function, blood routine, complications were compared among the groups.

RESULTS

The technical success rates for PTCD and ERCP in palliative group were 97.1% and 85.9%. In palliative drainage group, PTCD had higher levels of total bilirubin (TB) reduction (53.0 (30.0,97.0) vs. 36.8 (17.9,65.0), p < 0.001) and direct bilirubin (DB) reduction (42.0 (22.0,78.5) vs. 28.0 (12.0,50.8), p = 0.001) than ERCP. However, PTCD was associated with higher rates of drainage tube displacement (20 cases, 11.8%), while ERCP had a higher incidence of biliary infection (39 cases, 22.8%) and pancreatitis (7 cases, 4.1%). In preoperative drainage group, PTCD achieved a 50% reduction in total bilirubin faster than ERCP (7.1 days vs. 10.5 days). And the time from palliation of jaundice to surgery was 24.2 days in PTCD group and 35.7 days in ERCP group, a statistically significant difference (Student's t test, p = 0.017).

CONCLUSION

Both PTCD and ERCP could improve liver function for MOJ patients. PTCD seems to offer better outcomes in jaundice reduction and liver function improvement in palliative drainage, but requires careful postoperative management. In preoperative biliary drainage, PTCD may be a better preoperative bridge to improve liver function and control infection.

Efficacy of Double-Lumen Biliary-Enteric Tube in Enteral Nutrition for Patients with Malignant Obstructive Jaundice

OBJECTIVE

This study aimed to evaluate the efficacy of a double-lumen biliary-enteric tube (DBET) for enteral nutrition (EN) in individuals with malignant obstructive jaundice (MOJ).

METHODS

A retrospective cohort study was conducted using data from a prospectively maintained single-center database, including patients with MOJ. In the intervention group, DBET placement was performed concurrently with percutaneous transhepatic cholangiodrainage and biliary stenting, followed by postoperative EN (DBET-EN). In the control group, deep vein catheterization was undertaken after endoscopic biliary stenting, and parenteral nutrition (PN) was provided. A multivariable generalized linear model was used to assess the association between DBET-EN and 6-month mortality.

RESULTS

A total of 74 patients were included in this study, comprising 28 patients in the intervention group (DBET-EN group) and 46 patients in the control group (PN group). Within the 6-month follow-up, 5 patients (17.9%) in the DBET-EN group and 20 (43.5%) in the PN group died. The multivariable generalized linear model demonstrated a significantly reduced 6-month mortality in the DBET-EN group compared to the PN group (adjusted odds ratio [OR]: 0.25, 95% CI: 0.08-0.81, P = 0.020). Secondary outcomes indicated that patients in the DBET-EN group had lower 9-month mortality rates and longer tube retention durations compared to the PN group (all adjusted P < 0.05). Postoperative liver function improved similarly in both groups. At 3, 6, and 9 months postoperatively, patient-generated subjective global assessment (PG-SGA) scores and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) scores were significantly higher in the DBET-EN group than in the PN group (P < 0.05).

CONCLUSION

The implementation of DBET for EN in patients in the advanced stage of MOJ proved to be a minimally invasive and safe intervention. It significantly improved patients' nutritional status and quality of life while reducing mortality.

Endoscopic ultrasound-guided biliary drainage vs percutaneous transhepatic bile duct drainage in the management of malignant obstructive jaundice

BACKGROUND

Malignant obstructive jaundice (MOJ) is a condition characterized by varying degrees of bile duct stenosis and obstruction, accompanied by the progressive development of malignant tumors, leading to high morbidity and mortality rates. Currently, the two most commonly employed methods for its management are percutaneous transhepatic bile duct drainage (PTBD) and endoscopic ultrasound-guided biliary drainage (EUS-BD). While both methods have demonstrated favorable outcomes, additional research needs to be performed to determine their relative efficacy.

AIM

To compare the therapeutic effectiveness of EUS-BD and PTBD in treating MOJ.

METHODS

This retrospective analysis, conducted between September 2015 and April 2023 at The Third Affiliated Hospital of Soochow University (The First People's Hospital of Changzhou), involved 68 patients with MOJ. The patients were divided into two groups on the basis of surgical procedure received: EUS-BD subgroup (n = 33) and PTBD subgroup (n = 35). Variables such as general data, preoperative and postoperative indices, blood routine, liver function indices, myocardial function indices, operative success rate, clinical effectiveness, and complication rate were analyzed and compared between the subgroups.

RESULTS

In the EUS-BD subgroup, hospital stay duration, bile drainage volume, effective catheter time, and clinical effectiveness rate were superior to those in the PTBD subgroup, although the differences were not statistically significant (P > 0.05). The puncture time for the EUS-BD subgroup was shorter than that for the PTBD subgroup (P < 0.05). Postoperative blood routine, liver function index, and myocardial function index in the EUS-BD subgroup were significantly lower than those in the PTBD subgroup (P < 0.05). Additionally, the complication rate in the EUS-BD subgroup was lower than in the PTBD subgroup (P < 0.05).

CONCLUSION

EUS-BD may reduce the number of punctures, improve liver and myocardial functions, alleviate traumatic stress, and decrease complication rates in MOJ treatment.

Value of preoperative biliary drainage in pancreatic head cancer patients with severe obstructive jaundice: A multicenter retrospective study

BACKGROUND

Pancreatic head cancer accompanied by obstructive jaundice is a common clinical situation. The aim of this study was to assess the impact of preoperative biliary drainage (PBD) on clinical outcomes in patients with severe obstructive jaundice.

METHODS

Patients with a bilirubin level of ≥250 μmol/L at diagnosis who underwent PBD were included. The primary endpoints and secondary endpoints were the postoperative severe complications rates. Secondary endpoints were the degree of improvement in general condition, predictors of severe postoperative complications, and the impact of PBD on patients with bilirubin levels >300 μmol/L.

RESULTS

In total, 289 patients were included, and 188 patients (65.1%) underwent PBD. The patients who met the American Society of Anesthesiologists (ASA) classification II-III stages decreased from 119 to 100 ( P = 0.047) after PBD. The overall severe complications were significantly more frequent in the direct surgery (DS) group than in the PBD group (34.7% vs. 22.9%, P = 0.031), especially the postoperative hemorrhage (6/43 [14.0%] vs. 9/35 [25.7%], P = 0.038) and intra-abdominal infection (6/43 [14.0%] vs. 10/35 [28.6%], P = 0.018). The ASA classifications II-III (odds ratio [OR]=2.89, 95% confidence interval [CI]: 1.38-4.31), P = 0.01) and DS (OR = 3.65, 95% CI: 1.45-7.08; P = 0.003) were independently associated with severe postoperative complications. The occurrence rate of severe postoperative complications in patients with a bilirubin level >300 μmol/L who underwent PBD was significantly lower than in patients who underwent DS (25.6% vs. 40.6%, P = 0.028), but the benefit of PBD was not observed in patients who had a bilirubin level between 250 and 300 μmol/L.

CONCLUSION

PBD is useful in reducing severe postoperative complications, especially in patients with bilirubin levels >300 μmol/L.

Correlation between functional drainage and survival in malignant biliary obstruction after percutaneous biliary drainage

Purpose

Malignant biliary obstruction (MBO) is common in patients with advanced malignant tumors, leading to poor prognosis and hindering antitumor therapy. The purpose of our study was to assess the survival outcomes for patients under therapy after percutaneous transhepatic biliary drainage (PTBD) and identify prognostic factors associated with survival in patients with MBO.

Methods

From July 2010 to February 2021, 269 patients with MBO secondary to malignant tumor were divided into two groups (functional success and non-functional success). Survival time and prognostic factors were analyzed by Kaplan-Meier curves and the Cox model.

Results

The overall median survival time after PTBD was 4.6 months (95 % IC:3.9-5.3). The 3- and 6-month survival rates were 68.0 % and 38.7 %, respectively. The median survival improved from 3.2 months to 8.4 months when the procedure achieved functional success. Multivariate analysis demonstrated that functionally successful drainage and antitumor treatment after PTBD were independent positive prognostic factors, but the total bilirubin after drainage and tumor size were independent negative predictive values.

Conclusions

Functionally successful drainage could prolong survival time in patients with malignant biliary obstruction. Palliative care after drainage can prolong patient survival and improve their quality of life.