Operable malignant jaundice: To stent or not to stent before the operation?

Outcomes of preoperative biliary drainage from a single tertiary center: Is there still a role for plastic stents?

OBJECTIVES

Preoperative biliary drainage (PBD) can relieve symptoms of cholestasis, but carries risk of procedural complications. Metal stents have wider lumens and longer patency, although plastic stents (PS) remain in use. We reviewed the outcomes after PBD in patients with cholestasis.

METHODS

Patients with symptomatic cholestasis who were likely to wait for over 2 weeks before surgery and were thus treated with PBD between January 2011 and May 2015 were included. Patients were evaluated for stenting-related complications, time interval to surgery, resection rate, improvement in bilirubin level and surgical complications.

RESULTS

Forty patients underwent PBD by endoscopic retrograde cholangiopancreatography (ERCP). Of these, 36 patients received the placement of PS, one received a metal stent and the remaining three required percutaneous drainage due to unsuccessful biliary cannulation. Serum bilirubin declined from 172 μmol/L (baseline) to 14 μmol/L at 30 days (P < 0.0001). Median time interval from ERCP to surgery in all patients was 5 weeks (range 2-36 weeks). Preoperative stenting-related complications occurred in seven patients after a median of 3 weeks (range 1-6 weeks). Median time to surgery was similar in patients with and without stenting-related complications (5 weeks vs 4 weeks, respectively, P = 0.33). Surgery was completed in 32 (80%) patients, with a post-Whipple complication rate of 53%.

CONCLUSIONS

PBD using mostly PS was effective in reducing bilirubin levels and did not detrimentally affect time interval to surgery. Median time interval to stenting-related complication occurred after 3 weeks, suggesting PS may be most useful for short-term PBD.

[Percutaneous cholangiostomy for portal cholangiocarcinoma]

AIM

to analyze the efficacy of interventional methods in treatment of Klatskin tumor patients.

MATERIAL AND METHODS

Treatment of 133 patients with Klatskin tumor for the period 2000-2015 was analyzed. Bismuth I type was revealed in 28 (21.1%) cases, type II  - in 45 (33.8%) cases, type III - in 51 (38.3%) cases, type IV - in 9 (6.8%) cases. All patients underwent sonofluoroscopy-assisted percutaneous transhepatic cholangiostomy using self-fixing Pig tail 8Fr drains at the first stage followed by externointernal drainage or antegrade biliary stenting. We deployed 1-6 drains simultaneously or step by step depending on severity of biliary occlusion.

RESULTS

Technical success was achieved in all patients. Major postoperative complication such as drain dislocation followed by advanced biliary peritonitis was observed in 1 (0.8%) case. Minor complications occurred in 22 (16.5%) patients. In-hospital mortality was 7.5% (10 patients). The cause of death was severe liver-renal failure. Liver abscesses occurred in 13 patients after transpapillary externointernal drainage on background of temporary occlusion of biliary drain. This required interventional surgery.

CONCLUSION

Obstructive jaundice management should be performed using interventional techniques simultaneously or step by step if unresectable tumor or inoperable patient are present. Herewith it is advisable to restore bile flow in maximal volume of liver parenchyma. Use of uncovered self-expanding biliary stents for palliative treatment of Klatskin tumor may be realized in «hybrid» variant to control stent patency as well as for neoadjuvant therapy of tumor.

Current status of preoperative drainage for distal biliary obstruction

Preoperative biliary drainage (PBD) was developed to improve obstructive jaundice, which affects a number of organs and physiological mechanisms in patients waiting for surgery. However, its role in patients who will undergo pancreaticoduodenectomy for biliary obstruction remains controversial. This article aims to review the current status of the use of preoperative drainage for distal biliary obstruction. Relevant articles published from 1980 to 2015 were identified by searching MEDLINE and PubMed using the keywords “PBD”, “pancreaticoduodenectomy”, and “obstructive jaundice”. Additional papers were identified by a manual search of the references from key articles. Current studies have demonstrated that PBD should not be routinely performed because of the postoperative complications. PBD should only be considered in carefully selected patients, particularly in cases where surgery had to be delayed. PBD may be needed in patients with severe jaundice, concomitant cholangitis, or severe malnutrition. The optimal method of biliary drainage has yet to be confirmed. PBD should be performed by endoscopic routes rather than by percutaneous routes to avoid metastatic tumor seeding. Endoscopic stenting or nasobiliary drainage can be selected. Although more expensive, the use of metallic stents remains a viable option to achieve effective drainage without cholangitis and reintervention.

Efficacy of a dual-ring wound protector for prevention of incisional surgical site infection after Whipple's procedure (pancreaticoduodenectomy) with preoperatively-placed intrabiliary stents: protocol for a randomised controlled trial

INTRODUCTION

Among surgical oncology patients, incisional surgical site infection is associated with substantially increased morbidity, mortality and healthcare costs. Moreover, while adults undergoing pancreaticoduodenectomy with preoperative placement of an intrabiliary stent have a high risk of this type of infection, and wound protectors may significantly reduce its risk, no relevant studies of wound protectors yet exist involving this patient population. This study will evaluate the efficacy of a dual-ring wound protector for prevention of incisional surgical site infection among adults undergoing pancreaticoduodenectomy with preoperatively-placed intrabiliary stents.

METHODS AND ANALYSIS

This study will be a parallel, dual-arm, randomised controlled trial that will utilise a more explanatory than pragmatic attitude. All adults (≥18 years) undergoing a pancreaticoduodenectomy at the Foothills Medical Centre in Calgary, Alberta, Canada with preoperative placement of an intrabiliary stent will be considered eligible. Exclusion criteria will include patient age <18 years and those receiving long-term glucocorticoids. The trial will employ block randomisation to allocate patients to a commercial dual-ring wound protector (the Alexis Wound Protector) or no wound protector and the current standard of care. The main outcome measure will be the rate of surgical site infection as defined by the Centers for Disease Control and Prevention criteria within 30 days of the index operation date as determined by a research assistant blinded to treatment allocation. Outcomes will be analysed by a statistician blinded to allocation status by calculating risk ratios and 95% CIs and compared using Fisher's exact test.

ETHICS AND DISSEMINATION

This will be the first randomised trial to evaluate the efficacy of a dual-ring wound protector for prevention of incisional surgical site infection among patients undergoing pancreaticoduodenectomy. Results of this study are expected to be available in 2016/2017 and will be disseminated using an integrated and end-of-grant knowledge translation strategy.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier NCT01836237.

Vascular reconstruction combined with liver resection for malignant tumours

BACKGROUND

The resectability criteria for malignant liver tumours have expanded during the past two decades. The use of vascular reconstruction after hepatectomy has been integral in this process. However, the majority of reports are anecdotal. This is a retrospective analysis of the techniques, morbidity, mortality and risk factors of liver resections with vascular reconstruction based on a large series from a single centre.

METHODS

Patients who underwent hepatic resection combined with vascular resection and reconstruction between 1997 and 2009 were included in this study. Indications for surgery, morbidity and 90-day mortality are reported along with factors predictive of operative mortality.

RESULTS

Eighty-four patients had liver resection with 97 vascular resections and reconstruction. There were 44 men and 40 women with a mean(s.d.) age of 56·9(12·1) years. Mean(s.d.) follow-up was 37·3(34·1) months. All patients had primary or metastatic liver tumours. The perioperative morbidity rate was 62 per cent (52 patients) and the operative mortality rate 14 per cent (12). Predictors of operative mortality were: bilirubin level exceeding 34 µmol/ml (P = 0·023), indocyanine green retention rate at 15 min over 10 per cent (P = 0·031), duration of ischaemia (P = 0·011), amount of blood transfused (P = 0·025) and combined major extrahepatic procedure (P = 0·042). Actuarial 3- and 5-year survival rates were 44 and 26 per cent respectively.

CONCLUSION

Liver resection with combined vascular resection and reconstruction can be performed in selected patients with acceptable morbidity and mortality. The lack of therapeutic alternatives and the poor outcome of non-operative management seem to justify this approach. The identification of risk factors should help improve patient selection and postoperative outcome as well as facilitate objective risk communication with surgical candidates.

The effect of ursodeoxycholic acid in liver functional restoration of patients with obstructive jaundice after endoscopic treatment: a prospective, randomized, and controlled study

Background

In patients with obstructive jaundice, multi-organ dysfunction may develop.

Methods/Design

This trial is a prospective, open-label, randomized, and controlled study with the objective to evaluate the effect of ursodeoxycholic acid in liver functional restoration in patients with obstructive jaundice after endoscopic treatment. The aim of this study is to evaluate the effect of ursodeoxycholic acid in liver functional restoration of patients with obstructive jaundice after endoscopic treatment. The hypothesis of this trial is that patients with obstructive jaundice, in which will be administered UDCA, in the early phase after endoscopic intervention will have better and faster functional restoration of the liver than patients in the control group.

Patients with obstructive jaundice, randomly, will be divided into two groups: (A) test group in which will be administered ursodeoxycholic acid twenty-four hours after endoscopic procedure and will last fourteen days, and (B) control group.

Serum-testing will include determination of bilirubin, alanine transaminase, aspartate transaminase, gama-glutamil transpeptidase, alkaline phosphatase, albumin, and cholesterol levels. These parameters will be determined one day prior endoscopic procedure, and on the third, fifth, seventh, tenth, twelfth and fourteenth days after endoscopic intervention.

Discussion

This trial is a prospective, open-label, randomized, and controlled study to asses the effect of ursodeoxycholic acid in liver functional restoration of patients with obstructive jaundice in the early phase after endoscopic treatment.

Trial registration

ClinicalTrials.gov, NCT01688375

Metal stents: a bridge to surgery in hilar cholangiocarcinoma

BACKGROUND

Obstructive jaundice in patients with hilar cholangiocarcinoma is a known risk factor for hepatic failure after liver resection. Plastic stents are most widely used for preoperative drainage. However, plastic stents are known to have limited patency time and therefore, in palliative settings, the self-expanding metal stent (SEMS) is used. This type of stent has been shown to be superior because it allows for rapid biliary decompression and a reduced complication rate after insertion. This study explores the use of the SEMS for biliary decompression in patients with operable hilar cholangiocarcinoma.

METHODS

A retrospective evaluation of a prospectively maintained database at a tertiary hepatobiliary referral centre was carried out. All patients with resectable cholangiocarcinoma were recorded.

RESULTS

Of 260 patients referred to this unit with cholangiocarcinoma between January 2008 and April 2012, 50 patients presented with operable cholangiocarcinoma and 27 of these had obstructive jaundice requiring stenting. Ten patients were initially treated with SEMSs; no stent failure occurred in these patients. Seventeen patients initially received plastic stents, seven of which failed in the interval between stent placement and laparotomy. These stents were replaced by SEMSs in four patients and by plastic stents in three patients. Median time to laparotomy was 45 days and 68 days in patients with SEMSs and plastic stents, respectively.

CONCLUSIONS

Self-expanding metal stents provide adequate and rapid biliary drainage in patients with obstruction caused by hilar cholangiocarcinoma. No re-interventions were required. This probably reflects the relatively short interval between stent placement and laparotomy.

[Invasive procedures in patients hospitalized in Spanish internal medicine departments]

AIMS

Invasive procedures (IP) have become routine techniques that benefit an important number of patients on improving their quality of life or avoiding more aggressive treatments. We have conducted a study on the IPs performed in Spanish Internal Medicine (IM) Departments between 2005 and 2009.

PATIENTS AND METHODS

IP performed to patients admitted to Spanish Internal Medicine departments were analyzed based on the information obtained from the Minimum Basis Data Set (CMBD). IP was defined as the following: filter placement in the inferior vena cava, chest tube placement, biliary, esophageal and colon prosthesis placement, pleurodesis, nephrostomy, external biliary drain placement, gastrostomy tube placement, thoracocentesis and peritoneal catheter placement.

RESULTS

During the study period, a total of 75,853 invasive procedures on 70,239 admittances were performed in 2,766,673 patients (2.5%). IP subjects were younger (68.1 vs 71.4; P<.001), predominantly male (61.9 vs 53.2%; P<.001), with higher mortality (14.6 vs 9.9%; P<.001) and longer stay (18.4 vs 9.6 days; P<0.001). Cost of admittance was clearly higher than the rest of the patients (5,600€ vs 3,835€; P<.001).

CONCLUSIONS

IPs are performed on a low percentage of IM Department hospitalized patients. They are costly, entail high mortality and a longer stay period compared to the mean population admitted to IM. A considerable proportion of the patients receiving IP suffer from neoplastic diseases, frequently in advances stages, which justifies the high inhospital mortality of this population.

Repeat Procedures Within 30 days in Patients Stented for Malignant Distal Biliary Strictures: Experience of 508 Patients at a Tertiary Referral Center

Background

Stent related occlusion and migration remains a problem despite attempts to improve stent design over this time period. Flanged polyethylene plastic stents (FPS) remains the stent of choice in most centers. Early failure of stents placed for malignant extrahepatic biliary strictures (MEBS) has not previously been studied in detail. We set out to determine the incidence and reasons for biliary stent change within 30 days of the index procedure in a large tertiary center population during a period where (FPS) was the sole plastic stent used.

Methods

Retrospective analysis of endoscopic retrograde cholangiography (ERCP) was undertaken in patients who were stented for presumed or known MEBS between 1993 and 2001. Patients who required repeat stenting within 30 days were identified.

Results

All 508 patients were stented for MEBS. 5.7% of patients had a total of 34 repeat stenting procedures within 30 days of the index procedure; 27of 29 index stents were plastic, 2 were self-expandable metal stents (SEMS), 20 (3.9%) patients had stent failure as the reason for a stent exchange (plastic stent occlusion n = 15, mean time to stent change 14 ± 8.3 days; metal stent occlusion n = 2, mean time to stent change 24.5 ± 7.8 days; plastic stent migration n = 3, mean time to stent change 25 ± 5.3 days). There was a statistically significant difference in the time to stent change between the occluded plastic stent and migrated plastic stent cases (P = 0.045, 95% CI -21.7 to -0.29). 6 patients spent at least 2 additional days in hospital as a result of stent failure.

Conclusions

Early stent failure is an uncommon problem, especially in patients with SEMS. Early plastic stent failure appears to occur sooner with stent occlusion than with stent migration. Early stent failure is associated with significant morbidity and bears an economic impact in additional procedures and hospital stay.