Comparison of effect between nasobiliary drainage and biliary stenting in malignant biliary obstruction: a systematic review and updated meta-analysis

Biliary drainage in palliative and curative intent European patients with hilar cholangiocarcinoma and malignant hilar obstruction: a retrospective single center analysis

BACKGROUND AND AIMS

Relief of cholestasis in hilar cholangiocarcinoma is commonly undertaken in both curative and palliative treatment plans. There are numerous open questions with regard to the ideal biliary drainage strategy - including what constitutes clinical success (CS). In the existing data, curative patients and patients from the Western world are underrepresented.

PATIENTS AND METHODS

We performed a retrospective analysis of patients with complex malignant hilar obstruction (Bismuth-Corlette II and higher) due to cholangiocarcinoma who underwent biliary drainage at a German referral center between 2010 and 2020. We aimed to define CS and complication rates and directly compare outcomes in curative and palliative patients.

RESULTS

56 curative and 72 palliative patients underwent biliary drainage. In patients with curative intent, CS was achieved significantly more often regardless of what definition of CS was applied (e.g., total serum bilirubin (TSB) < 2 mg/dl: 66.1% vs. 27.8%, p = < 0.001, > 75% reduction of TSB: 57.1% vs. 29.2%, p = 0.003). This observation held true only when subgroups with the same Bismuth-Corlette stage were compared. Moreover, palliative patients experienced a significantly greater percentage of adverse events (33.3% vs. 12.5%, p = 0.01). Curative intent treatment and TSB at presentation were predictive factors of CS regardless of what definition of CS was applied. The observed CS rates are comparable to published studies involving curative patients, but inferior to reported CS rates in palliative series mostly from Asia.

CONCLUSIONS

Biliary drainage in complex malignant hilar obstruction due to cholangiocarcinoma is more likely to be successful and less likely to cause adverse events in curative patients compared to palliative patients.

A novel syringe tube combined guide-wire technique for repositioning a nasobiliary catheter in endoscopic nasobiliary drainage

BACKGROUND

In endoscopic nasobiliary drainage (ENBD), it is complicated to reposition the catheter from the mouth to nostril. We developed a new technique using an 1-mL syringe tube combined with guide-wire when repositioning an ENBD tube from mouth to nose. The aim of this study was to verify its utility.

METHODS

A single-center, prospective, randomized, controlled study was conducted between January 2021 and December 2022. Compared to traditional guide-wire technique, the new technique added a 1-mL syringe tube readily available in clinical work. The primary outcome was the ENBD repositioning time.The secondary outcomes included number of ENBD repositioning operations and technical success rate.

RESULTS

A total of 253 patients who underwent ENBD during the study period. Among them, 241 patients were enrolled in this study. The procedure time was significantly shorter in the new technique group than in the conventional group (60.7 vs. 98.7, p < 0.001). The median number of operations was 2 in both new technique and conventional technique groups(p = 0.36). Technical success was achieved in 95.0 %(113/119) of the new technique group and 98.4 % (120/122) of the conventional technique group(p = 0.14). Multiple linear regression analysis demonstrated that the new technique group (B = 36.9, 95%CI: 21.6 to 52.3, p < 0.001) was independent factor that reduce the ENBD repositioning time.

CONCLUSIONS

The 1-mL syringe tube combined guide-wire technique for repositioning ENBD tube could improve the efficiency and shorten the procedure time than the guide-wire technique. Meanwhile, It is easy to obtain for popularization and application.

Biliary drainage in malignant biliary obstruction: an umbrella review of randomized controlled trials

Background

There are still many controversies about biliary drainage in MBO, and we aimed to summarize and evaluate the evidence associated with biliary drainage.

Methods

We conducted an umbrella review of SRoMAs based on RCTs. Through July 28, 2022, Embase, PubMed, WOS, and Cochrane Database were searched. Two reviewers independently screened the studies, extracted the data, and appraised the methodological quality of the included studies. GRADE was used to evaluate the quality of the evidence.

Results

36 SRoMAs were identified. After excluding 24 overlapping studies, 12 SRoMAs, including 76 RCTs, and 124 clinical outcomes for biliary drainage in MBO were included. Of the 124 pieces of evidence evaluated, 13 were rated "High" quality, 38 were rated "Moderate", and the rest were rated "Low" or "Very low". For patients with MBO, 125I seeds+stent can reduce the risk of stent occlusion, RFA+stent can improve the prognosis; compared with PC, SEMS can increase the risk of tumor ingrowth and reduce the occurrence of sludge formation, and the incidence of tumor ingrowth in C-SEMS/PC-SEMS was significantly lower than that in U-SEMS. There was no difference in the success rate of drainage between EUS-BD and ERCP-BD, but the use of EUS-BD can reduce the incidence of stent dysfunction. For patients with obstructive jaundice, PBD does not affect postoperative mortality compared to direct surgery. The use of MS in patients with periampullary cancer during PBD can reduce the risk of re-intervention and stent occlusion compared to PC. In addition, we included four RCTs that showed that when performing EUS-BD on MBO, hepaticogastrostomy has higher technical success rates than choledochoduodenostomy. Patients who received Bilateral-ENBD had a lower additional drainage rate than those who received Unilateral-ENBD.

Conclusions

Our study summarizes a large amount of evidence related to biliary drainage, which helps to reduce the uncertainty in the selection of biliary drainage strategies for MBO patients under different circumstances.

Risk factors for achieving textbook outcome after laparoscopic duodenum-preserving total pancreatic head resection: a retrospective cohort study

INTRODUCTION

The risk factors for achieving textbook outcome (TO) after laparoscopic duodenum-preserving total pancreatic head resection (LDPPHR-t) are unknown, and no relevant articles have been reported so far. The aim of this study was to identify the risk factors for achieving TO after LDPPHR-t.

METHODS

The risk factors for achieving TO after LDPPHR-t were retrospectively evaluated by logistic regression analysis in 31 consecutive patients from May 2020 to December 2021.

RESULTS

All LDPPHR-t procedures were successfully performed without conversion. There was no death within 90 days after surgery and no readmission within 30 days after discharge. The percentage of achieving TO after LDPPHR-t was 61.3% (19/31). Among the six TO items, the postoperative complication of grade B/C postoperative pancreatic fistula (POPF) occurred most frequently with 22.6%, followed by grade B/C bile leakage with 19.4%, Clavien-Dindo≥III complications with 19.4%, and grade B/C postpancreatectomy hemorrhage with 16.1%. POPF was the major obstacle to achieve TO after LDPPHR-t. Placing an endoscopic nasobiliary drainage (ENBD) catheter and prolonged operation time (>311 min) were significantly associated with the decreased probability of achieving TO after LDPPHR-t (odd ratio (OR), 25.775; P =0.012 and OR, 16.378; P =0.020, respectively). Placing an ENBD catheter was the only significant independent risk factor for POPF after LDPPHR-t (OR, 19.580; P =0.017). Bile leakage was the independent risk factor for postpancreatectomy hemorrhage after LDPPHR-t (OR, 15.754; P =0.040). The prolonged operation time was significantly correlated with Clavien-Dindo grade≥III complications after LDPPHR-t (OR, 19.126; P =0.024).

CONCLUSION

Placing the ENBD catheter was the independent risk factor for POPF and achieving TO after LDPPHR-t. In order to reduce POPF and increase the probability of achieving TO, placing an ENBD catheter should be avoided prior to LDPPHR-t.

A single-center retrospective study comparing safety and efficacy of endoscopic biliary stenting only vs. EBS plus nasobiliary drain for obstructive jaundice

Purpose

Biliary drainage is an important modality for extrahepatic obstructive jaundice both in patients with palliative and resectable. Currently, endoscopic biliary drainage is preferred in clinical practice, including endoscopic nasobiliary drainage (ENBD) and endoscopic biliary stenting (EBS), both of which have their own advantages and disadvantages. The purpose of our study was to compare the safety and efficacy of endoscopic biliary stenting (EBS) only vs. EBS plus nasobiliary drain for obstructive jaundice.

Methods

We consecutively reviewed patients with endoscopic biliary drainage in our institution from November 2014 to March 2021. Combined (ENBD plus stent) and single approach (EBS only) were defined as combined approach and single modality, respectively, and all eligible patients were divided into a combined approach group and a single modality group. We compared combined vs. single modality approaches to investigate whether there were statistical differences in liver chemistries, postoperative adverse events, and stent patency time.

Results

In 271 patients, a total of 356 times endoscopic biliary drainages were performed. All eligible patients were divided into the combined approach group (n = 74) and the single modality group (n = 271). The combined approach was associated with a lower incidence of postoperative cholangitis and bleeding and greater improvement in liver chemistries, although it was not statistically significant. However, it was superior to the single modality group in terms of hospital stay (12.7 ± 5.2 vs. 14.5 ± 7.9 days, p = 0.020 &lt; 0.05) and stent patency time (8.1 ± 3.9 vs. 4.3±2.7 months, p = 0.001 &lt; 0.05).

Conclusion

Endoscopic combined (ENBD plus stent) drainage is a more advantageous biliary drainage method that is characterized by more adequate biliary drainage, a lower incidence of postoperative adverse events, and longer effective biliary drainage time.

Nasobiliary drainage: an effective treatment for pruritus in cholestatic liver disease

INTRODUCTION

Nasobiliary drains (NBDs) have been successfully used to manage intrahepatic cholestasis, bile leaks and obstructive cholangitis. It allows external drainage of bile, bypassing the ileum where bile salts are reabsorbed. We assessed the utility of placement with effect on markers of cholestasis and patient symptoms.

METHODS

Consecutive patients undergoing NBD over 12 years for the management of pruritus were retrospectively analysed. Recorded variables included patient demographics, procedural characteristics and response to therapy.

RESULTS

Twenty-three patients (14, 61% male) underwent 30 episodes of NBD. The median age was 26 years old (range 2-67 years old). A single procedure was carried out in 20. One patient each had two, three and five episodes of NBD. The most common aetiologies were hereditary cholestatic disease (n=17, 74%) and drug-induced cholestasis (n=5, 22%),NBD remained in situ for a median of 8 days (range 1-45 days). Significant improvement in bilirubin was seen at 7 days post-NBD (p=0.0324), maintained at day 30 (335 μmol/L vs 302 µmol/L vs 167 µmol/L). There was symptomatic improvement in pruritus in 20 (67%, p=0.0494) episodes. One patient underwent NBD during the first trimester of pregnancy after medical therapy failure with a good symptomatic response. The catheters were well tolerated in 27 (90%) of cases. Mild pancreatitis occurred in 4 (13%) cases.

CONCLUSION

NBD can be used to provide symptomatic improvement to patients with pruritus associated with cholestasis. It is well tolerated by patients. They can be used in pregnancy where medical management has failed.

Comparison of metal stents versus plastic stents for preoperative biliary drainage: a meta-analysis of five randomized controlled trials

BACKGROUND

Although routine preoperative biliary drainage (PBD) is generally not recommended for patients with malignant distal biliary obstruction (MDBO), it is still necessary in many cases. The objective of this study is to compare the effects of metal stents (MSs) and plastic stents (PSs) on PBD in patients with MDBO.

METHODS

All the randomized controlled trials (RCTs) that compared MS with PS for PBD and published from the date of database establishment to September 2020 were identified by searching the PubMed, EMBASE and Cochrane databases.

RESULTS

Five RCTs involving 445 patients were included. There were 201 cases in the MS group, with 244 in the PS group. Re-interventions (relative risk (RR) = 0.40, 95% confidence interval (CI) 0.21-0.75, P = 0.004), stent occlusions (RR = 0.36, 95% CI 0.18-0.75, P = 0.006), postoperative complications (RR = 0.76, 95% CI 0.59-0.97, P = 0.03) and preoperative cholangitis (RR = 0.19, 95% CI 0.05-0.78, P = 0.02) were lower in the MS group than in the PS group. Preoperative pancreatitis (RR = 2.11, 95% CI 1.06-4.19, P = 0.03) was higher in the MS group than in the PS group. No significant difference was observed in the overall preoperative complications, postoperative pancreatic fistulas, delayed gastric emptying, wound infections and postoperative bleeding between these two groups.

CONCLUSIONS

MS and PS exerted a similar effect on PBD, but PS had a higher risk of preoperative stent obstruction and postoperative complications, requiring more frequent interventions preoperatively. However, larger sample and higher quality RCTs are necessary for further verification.

Clinical application of enhanced recovery after surgery in the treatment of choledocholithiasis by ERCP

This study aims to investigate the effect of applying enhanced recovery after surgery methods (ERAS) in perioperative nursing of choledocholithiasis following endoscopic retrograde cholangiopancreatography (ERCP) for treatment of biliary calculus.Clinical data from 161 patients who underwent ERCP surgery in Wuhan Union Hospital from January 2017 to December 2019 were retrospectively analyzed. A total of 78 patients received perioperative nursing using the ERAS concept (experimental group) and 83 patients received conventional perioperative nursing (control group). Group differences were compared for the time to first postoperative ambulation, exhausting time, time to first defecation and eating, intraoperative blood loss, postoperative complication incidence (pancreatitis, cholangitis, hemorrhage), white blood cell (WBC), and serum amylase (AMS) values at 24 hours, duration of nasobiliary duct indwelling, length of hospital stay, and hospitalization expenses.No significant between-group differences were noted for demographic characteristics (age, sex, BMI, ASA score, and comorbidity) (P > .05). Time to first ambulation, exhausting time, time to defecation and eating, and nasobiliary drainage time were shorter in the experimental group than the control group, and the differences were statistically significant (P < .05). There was no significant between-group difference in postoperative WBC values at 24 hours (P > .05), but the experimental group's AMS values at 24 hours postoperation were significantly lower than those of the controls (154.93 ± 190.01 vs 241.97 ± 482.64, P = .031). Postoperative complications incidence was 9.1% in the experimental group, which was significantly lower than the 20.4% in the control group, and this difference was statistically significant (P = .039). Compared with the control group, nasobiliary drainage time (26.53 ± 7.43 hours vs 37.56 ± 9.91 hours, P < .001), hospital stay (8.32 ± 1.55 days vs 4.56 ± 1.38 days, P < .001), and hospitalization expenses (36800 ± 11900 Yuan vs 28900 ± 6500 Yuan, P = .016) were significantly lower in the experimental group.ERAS is a safe and effective perioperative nursing application in ERCP for treating choledocholithiasis. It can effectively accelerate patients' recovery and reduce the incidence of complications; therefore, it is worthy of being applied and promoted in clinical nursing.

Percutaneous biliary stent with intraluminal brachytherapy versus palliative surgery in the management of extrahepatic cholangiocarcinoma

BACKGROUND

To compare the efficacy and outcomes of self-expandable metallic stent combined with catheter-loaded iodine-125 seeds (SEMS-CL-¹²⁵I) brachytherapy versus conventional palliative surgery (PS) in advanced extrahepatic cholangiocarcinoma (EHCC).

METHODS

The retrospective analysis consisted of 101 advanced EHCC patients who received SEMS-CL-¹²⁵I (n = 67) or underwent PS (n = 34). The clinical characteristics, postoperative complications and overall survival (OS) were compared between the two groups.

RESULTS

Serum levels of bilirubin, transaminase, and albumin (ALB) were significantly improved at 1 month, 3 months, and 6 months postoperatively in both groups (all P < 0.05). At 1 month after operation, the level of ALB in SEMS-CL-¹²⁵I group was significantly higher than that in PS group (39.07 ± 3.83 vs. 36.60 ± 5.58 g/L, P = 0.015). No statistically significant difference was found in postoperative overall complications between the two groups (P = 0.052). Length of hospital stay was significantly shorter (P < 0.001), hospital costs were significantly less (P < 0.001), and OS was significantly better (P = 0.029) in SEMS-CL-¹²⁵I group compared to PS group. Multivariate analysis further identified PS (HR = 2.90, 95% CI 1.71-4.93, P < 0.001) and higher level of carbohydrate antigen 19-9 (HR = 2.67, 95% CI 1.36-3.79, P = 0.002) as independent predictors of worse OS.

CONCLUSION

SEMS-CL-¹²⁵I significantly improves outcomes compared with PS and could be a safe and effective treatment for advanced EHCC.