Surgical site infection following pancreaticoduodenectomy in a referral cancer center in Mexico

BACKGROUND

Pancreaticoduodenectomy is the standard treatment for resectable periampullary cancer. Surgical site infections (SSI) are common complications with increased morbidity. The study aimed to describe the prevalence, risk factors, microbiology, and outcomes of SSI among patients undergoing pancreaticoduodenectomy.

METHODS

We conducted a retrospective study in a referral cancer center between January 2015 and June 2021. We analyzed baseline patient characteristics and SSI occurrence. Culture results and susceptibility patterns were described. Multivariate logistic regression was used to determine risk factors, proportional hazards model to evaluate mortality, and Kaplan-Meier analysis to assess long-term survival.

RESULTS

A total of 219 patients were enrolled in the study; 101 (46%) developed SSI. Independent factors for SSI were diabetes mellitus, preoperative albumin level, biliary drainage, biliary prostheses, and clinically relevant postoperative pancreatic fistula. The main pathogens were Enterobacteria and Enterococci. Multidrug-resistance rate in SSI was high but not associated with increased mortality. Infected patients had higher odds of sepsis, longer hospital stay and intensive care unit stay, and readmission rate. Neither 30-day mortality nor long-term survival was significantly different between infected and non-infected patients.

CONCLUSIONS

SSI prevalence among patients undergoing pancreaticoduodenectomy was high and largely caused by resistant microorganisms. Most risk factors were related to preoperative instrumentation of the biliary tree. SSI was associated with greater risk of unfavorable outcomes; however, survival was unaffected.

Comparison of Bilateral and Trisegment Drainage in Patients with High-Grade Hilar Malignant Biliary Obstruction: A Multicenter Retrospective Study

Background/Aims

Bilateral endoscopic drainage with self-expanding metallic stent (SEMS) can be used to effectively manage hilar malignant biliary obstruction. However, the benefits of using a trisegment drainage method remain unknown.

Methods

This study retrospectively reviewed the data of 125 patients with Bismuth type IIIa or IV unresectable malignant strictures who underwent bilateral endoscopic drainage using SEMSs at four tertiary centers. The patients were divided into the bilateral and trisegment drainage groups for comparison. The primary endpoint was stent patency and the secondary endpoints were technical success, technical and clinical success of reintervention, and overall survival.

Results

The technical success rates of the bilateral and trisegment drainage groups were 95% (34/36) and 90% (80/89) (p=0.41), respectively, with median stent patency durations of 226 and 170 days (p=0.26), respectively. Although the technical success of reintervention was not significantly different between the two groups (p=0.51), the clinical success rate of reintrvention was significantly higher in the trisegment drainage group (73% [11/15] vs 96% [47/49], p=0.009). The median survival times were 324 and 323 days in the bilateral and trisegment drainage groups, respectively (p=0.72). Multivariate Cox hazards model revealed no stent patency-associated factor; however, chemotherapy was associated with longer survival.

Conclusions

Although no significant difference was noted with respect to stent patency, significantly higher clinical success rates were achieved with reintervention using the trisegment drainage method than using the bilateral drainage method alone.

Biliary metal stents should be placed near the hilar duct in distal malignant biliary stricture patients

BACKGROUND

Endoscopic biliary drainage using a self-expandable metallic stent (SEMS) has been widely performed to treat distal malignant biliary obstruction (DMBO). However, the optimal position of the stent remains unclear.

AIM

To determine the ideal position for SEMS placement.

METHODS

In total, 135 DMBO patients underwent SEMS (uncovered or covered) placement over a ten-year period. A total of 127 patients with biliary obstruction between the junction of the cystic duct and Vater's papilla were enrolled. An SEMS was placed through the upper common bile duct 2 cm from the biliary hilar duct in 83 patients (Hilar group) or near the top of the biliary obstruction in 44 patients (Lower group). Technical and functional success, adverse events, and risk factors for SEMS dysfunction were evaluated.

RESULTS

The stent patency period was significantly longer in the Hilar group than in the Lower group (P value < 0.01). In multivariate analysis, the only statistically significant risk factor for SEMS dysfunction was being in the Lower group (hazard ratio: 9.94, 95% confidence interval: 2.25-44.0, P < 0.01).

CONCLUSION

A longer patency period was achieved by positioning the SEMS near the biliary hilar duct.

Stent placement above the sphincter of Oddi is a useful option for patients with inoperable malignant hilar biliary obstruction

BACKGROUND AND AIMS

Endoscopic biliary drainage (EBD) is essential for the management of malignant hilar biliary obstruction (MHBO). We prospectively evaluated the efficacy and safety of "inside-stent" therapy, where a plastic stent is placed above the sphincter of Oddi without endoscopic sphincterotomy, in patients with inoperable MHBO.

METHODS

This study was a multicenter, single-blinded, randomized controlled trial at three centers. Patients with inoperable MHBO were enrolled in this study, and randomly assigned to receive an inside-stent or conventional-stent therapy. The primary endpoint was cumulative stent patency of the initial stent. The secondary endpoints were second stent patency, technical and clinical success rate, adverse events, re-intervention rate, and overall patient survival.

RESULTS

Forty-three patients were randomly assigned to the inside-stent group (n = 21) or the conventional-stent group (n = 22). The median cumulative stent patency of the initial stent was 123 days in the inside-stent group and 51 days in the conventional-stent group (P = .031). For patients with the initial stent dysfunction in the conventional-stent group, the inside-stent was placed as a second stent, and its patency was significantly longer than that of the initial stent (P = .0001). The technical and clinical success rate, re-intervention rate, second stent patency, adverse events, and survival probability did not differ between the groups.

CONCLUSIONS

Inside-stent therapy appears to be useful not only as an initial stent but also as a second stent for patients with inoperable MHBO.

TRIAL REGISTRATION NUMBER

UMIN000004587.

Endoscopic or percutaneous biliary drainage in hilar cholangiocarcinoma: When and how?

Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dim prognosis. The role of preoperative and palliative biliary drainage has long been debated. The most common techniques are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD); however, recently developed endoscopic ultrasound-assisted methods are gaining more atention. Selecting the best available method in any specific scenario is crucial, yet sometimes challenging. Thus, this review aimed to discuss the available techniques, indications, perks, pitfalls, and timing-related issues in the management of hCCA. In a preoperative setting, PTBD appears to have some advantages: low risk of postprocedural complications (namely cholangitis) and better priming for surgery. For palliative purposes, we propose ERCP/PTBD depending on the experience of the operators, but also on other factors: the level of bilirubin (if very high, rather PTBD), length of the stenosis and the presence of cholangitis (PTBD), ERCP failure, or altered biliary anatomy.

Endoscopic or percutaneous biliary drainage in hilar cholangiocarcinoma: When and how?

Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dim prognosis. The role of preoperative and palliative biliary drainage has long been debated. The most common techniques are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD); however, recently developed endoscopic ultrasound-assisted methods are gaining more atention. Selecting the best available method in any specific scenario is crucial, yet sometimes challenging. Thus, this review aimed to discuss the available techniques, indications, perks, pitfalls, and timing-related issues in the management of hCCA. In a preoperative setting, PTBD appears to have some advantages: low risk of postprocedural complications (namely cholangitis) and better priming for surgery. For palliative purposes, we propose ERCP/PTBD depending on the experience of the operators, but also on other factors: the level of bilirubin (if very high, rather PTBD), length of the stenosis and the presence of cholangitis (PTBD), ERCP failure, or altered biliary anatomy.

Negative prognostic outcomes of percutaneous transhepatic biliary drainage in distal cholangiocarcinoma: a retrospective analysis using propensity score matching

BACKGROUND

The efficacy of different types of preoperative biliary drainage for cholangiocarcinoma has been debated over the past two decades. Controversy concerning the use of percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary drainage (EBD) still exists. This study aimed to compare the long-term outcomes between PTBD and EBD in patients with distal cholangiocarcinoma.

METHODS

Data of patients diagnosed with distal cholangiocarcinoma who underwent preoperative PTBD or EBD from January 1999 to December 2017 were analyzed retrospectively. Post-surgical outcomes, including the incidence of post-operative complications, peritoneal metastasis, disease-free survival, and overall survival, were analyzed. Survival analyses were also performed after propensity score matching in the PTBD and EBD groups.

RESULTS

The incidence of post-operative complications was similar in both groups. The 5-year estimated cumulative incidences for peritoneal metastasis were 14.7% and 7.2% in the PTBD and EBD groups, respectively (p = 0.192). The 5-year disease-free survival rates were 23.7% and 47.3% in the PTBD and EBD groups, respectively (p = 0.015). In the multi-variate analysis for overall survival, PTBD was an independent poor prognostic factor. The 5-year overall survival rates were 35.9% and 56.3% in the PTBD and EBD groups, respectively (hazard ratio 1.85, confidence interval 1.05-3.26, p = 0.035). The results after propensity score matching indicated a poorer prognosis in the PTBD group, with a 5-year survival rate of 35.9% in the PTBD group vs 56.0% in the EBD group (p = 0.044).

CONCLUSION

PTBD should be considered as a negative prognostic factor in distal cholangiocarcinoma patients.

Endoscopic stent placement above the sphincter of Oddi for biliary strictures after living donor liver transplantation

Background

Endoscopic balloon dilation and/or plastic stent placement has been a standard method for treating biliary strictures complicated post living donor liver transplantation (LDLT). The strictures may be refractory to endoscopic treatment and require long-term stent placement. However, consensus on the optimal period of the stent indwelling and usefulness of the inside stent does not exist.

Methods

We evaluated the long-term efficacy of stent treatment in patients with biliary stricture post LDLT. In addition, we compared the stent patency between inside stent and conventional outside stent.

Results

A total of 98 ERC sessions (median 6: range 1–14) performed on 16 patients receiving endoscopic treatment for biliary strictures post LDLT with duct-to-duct biliary reconstruction were analyzed. Biliary strictures successfully treated in 14 patients (88%) included 7 patients (44%) showing improvement of biliary strictures with repeated endoscopic stent placement. Stent replacement was carried out every 6 to 12 months for the remainder 7 patients (44%). Biliary stents were placed in 87 sessions (77 inside sessions and 10 outside sessions). Stent migration occurred 13 times (16%) and none of the inside stent sessions and the outside stent sessions, respectively. Median patency of inside stent and outside stent were 222 days (range; 8–1736) and 99 days (range; 7–356), respectively. The stent occlusion was significantly less in inside stent than in outside stent (p < 0.001). Stone formation was observed in 14 (18%) of the inside stent and 3 (30%) of the outside stent. Biliary stones were small and successfully removed endoscopically.

Conclusions

The endoscopic treatment using inside stent was useful in the management of biliary strictures after LDLT.

Worsening of Acute Cholangitis Caused by a Bile Duct Stone After Hospitalization: A Case Series

Acute cholangitis is a fatal condition if inadequately treated. It is possible to underestimate the severity of the condition because bacterial cultures are not immediately available. We evaluated the clinical features of patients with cholangitis due to bile duct stones who were diagnosed with severe bacteremia at the time of hospitalization, but not at the time of the initial visit. We conducted a retrospective analysis of cases of endoscopic retrograde cholangiopancreatography performed between January 2007 and October 2011 in patients with bile duct stones complicated by cholangitis. The severity of cholangitis was assessed based on the 2005 Japanese Evidence-Based Practice Guidelines for the Management of Acute Cholangitis and Cholecystitis (JG05). Of 130 cases, 23 were diagnosed as severe cholangitis, including 11 of bacterial cause. However, based on the JG05, two cases were classified as “mild” at initial assessment and nine cases as “moderate”. A history of endoscopic sphincterotomy (EST) was identified in the two cases classified as “mild” cholangitis. Obstruction by a bile duct stone, possibly due to reflux from the duodenum, can lead to rapid progression to sepsis in a short time. For patients with a history of EST, early biliary drainage is necessary to prevent rapid progression of bacterial cholangitis.

Comparison of efficacy and complications of endoscopic and percutaneous biliary drainage in malignant obstructive jaundice: a systematic review and meta-analysis

Background

Malignant obstructive jaundice is a common problem in the clinic. Currently, the generally applied treatment methods are percutaneous transhepatic biliary drainage (PTBD) and endoscopic biliary drainage (EBD). Nevertheless, there has not been a uniform conclusion published on either efficacy of the two types of drainage or the incidence rate of complications. Therefore, we conducted a systematic review and meta-analysis of studies comparing endoscopic versus percutaneous biliary drainage in malignant obstructive jaundice, to determine whether there is any difference between percutaneous and endoscopic biliary drainage, with respect to efficacy and incidence rate of overall complications.

Methods

The enrolled studies contain a total of three randomized controlled trials and eleven retrospective studies, which together encompass 2246 patients with PTBD and 8100 patients with EBD.

Results

Our analysis indicates that there is no difference between PTBD and EBD with regard to therapeutic success rate (%), overall complication (%), intraperitoneal bile leak, 30-day mortality, sepsis, or duodenal perforation (%). Cholangitis and pancreatitis after PTBD were lower than after EBD, with odds ratios (OR) of 0.48 (95% confidence interval (CI), 0.31 to 0.74) and 0.16 (95% CI, 0.05 to 0.52), respectively. Incidences of bleeding and tube dislocation for PTBD were higher than EBD, OR of 1.81 (95% CI, 1.35 to 2.44) and 3.41 (95% CI, 1.10 to 10.60).

Conclusions

This meta-analysis indicates certain advantages for both PTBD and EBD. In the clinical practice, it is advised to choose specifically either PTBD or EBD, based on location of obstruction, purpose of drainage (as a preoperative procedure or a palliative treatment) and level of experience in biliary drainage at individual treatment centers.

Prognostic impact of type of preoperative biliary drainage in patients with distal cholangiocarcinoma

BACKGROUND

Surgical results of patients with resected distal cholangiocarcinoma (DCC) were evaluated to elucidate prognostic impact of the type of preoperative biliary drainage (PBD).

METHODS

Eighty-eight patients with resected DCC were stratified into two groups according to the type of PBD: the percutaneous transhepatic biliary drainage (PTBD) group (n = 25) and the endoscopic biliary drainage (EBD) group (n = 63).

RESULTS

Overall 5-year survival rate of the patients in the PTBD group was poorer than in the EBD group (24% vs. 52%, P = 0.020). On univariate analysis, PTBD, pancreatic invasion, perineural invasion, and lymph node involvement were significant prognostic factors for poor overall survival. On multivariate analysis, PTBD was the only significantly independent prognostic factor for poor overall survival. The incidence of liver metastasis was significantly higher in the PTBD group than in the EBD group (32.0% vs. 13.3%, P = 0.034).

CONCLUSIONS

PTBD should be avoided as much as possible in patients with DCC since the patients who underwent PTBD had poorer overall survival and higher incidence of liver metastasis than those who underwent EBD.

A Comparison of Preoperative Biliary Drainage Methods for Perihilar Cholangiocarcinoma: Endoscopic versus Percutaneous Transhepatic Biliary Drainage

Background/Aims

Controversy remains over the optimal approach to preoperative biliary drainage in patients with resectable perihilar cholangiocarcinoma. We compared the clinical outcomes of endoscopic biliary drainage (EBD) with those of percutaneous transhepatic biliary drainage (PTBD) in patients undergoing preoperative biliary drainage for perihilar cholangiocarcinoma.

Methods

A total of 106 consecutive patients who underwent biliary drainage before surgical treatment were divided into two groups: the PTBD group (n=62) and the EBD group (n=44).

Results

Successful drainage on the first attempt was achieved in 36 of 62 patients (58.1%) with PTBD, and in 25 of 44 patients (56.8%) with EBD. There were no significant differences in predrainage patient demographics and decompression periods between the two groups. Procedure-related complications, especially cholangitis and pancreatitis, were significantly more frequent in the EBD group than the PTBD group (PTBD vs EBD: 22.6% vs 54.5%, p<0.001). Two patients (3.8%) in the PTBD group experienced catheter tract implantation metastasis after curative resection during the follow-up period.

Conclusions

EBD was associated with a higher risk of procedure-related complications than PTBD. These complications were managed properly without severe morbidity; however, in the PTBD group, there were two cases of cancer dissemination along the catheter tract.

Endoscopic biliary drainage as a bridging procedure to single-stage surgery for perforated choledochal cyst: a case report and review of the literature

Choledochal cyst (CC)—a congenital anomaly of the bile duct—is rare. We report a 28-year-old woman complaining of epigastralgia who was transferred to our hospital. Physical examination revealed severe tenderness to abdominal palpation without symptoms of diffuse peritonitis. Urgent contrast-enhanced abdominal computed tomography indicated the dilated common bile duct (CBD) was perforated, with a presumed diagnosis of perforated CC. Endoscopic external biliary drainage was performed immediately as a bridging procedure to the definitive surgery. Additional evaluations confirmed a type IVa CC, according to Todani’s classification, but no signs of malignancy. Twenty-two days after biliary drainage, laparotomy was performed. A large cystic mass was found in the CBD with a perforated scar on the right-side wall. Because inflammation around the pancreas head was too severe to perform cyst excision safely, the patient underwent subtotal stomach-preserving pancreatoduodenectomy. The postoperative course was uneventful, and the patient was discharged on the 29th postoperative day. Pathologic examination of a specimen showed no malignancy, and the patient has remained well during the 3-year follow-up. Our experience with this case suggests that definitive single-stage surgery for perforated CC in an adult can be performed safely owing to external biliary drainage as a bridging procedure, if manifestation of diffuse peritonitis is not evident.

Endoscopic retrograde cholangiopancreatography for diagnosis and treatment of duodenal papillary carcinoma: Analysis of 39 cases

AIM: To assess the value of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of duodenal papillary carcinoma.

METHODS: Thirty-nine patients with duodenal papillary carcinoma underwent ERCP and histopathologic examination. After that, different endoscopic treatments were taken according to the patients' condition and their wishes, which included endoscopic metal biliary drainage (EMBD), endoscopic retrograde biliary drainage (ERBD), endoscopic naso-biliary drainage (ENBD) and so on.

RESULTS: All the 39 patients who were considered to have duodenal papillary carcinoma by endoscopic examination were precisely diagnosed with the disease by histopathologic examination, and the rate of accurate diagnosis was 100%. With a success rate of 82.1%, 32 patients accepted endoscopic biliary drainage (EBD) successfully, of whom 7 received EMBD, 15 adopted ERBD, 6 underwent ENBD, and the left 4 were treated by both ENBD and EMBD/ERBD. 1 wk after EBD, the discomforts such as abdominal pain and distension were evidently relieved compared with the condition before operation. The levels of serum total bilirubin (STB), direct bilirubin (DB), alkaline phosphatase (ALP), aspartate aminotransferase (AST), glutamyltranspetidase (GGT), and alanine aminotransferase (ALT) were significantly decreased compared with the values before EBD (P < 0.05).

CONCLUSION: ERCP is an effective method for the diagnosis and palliative treatment of duodenal papillary carcinoma.

Risk factors for technical failure of endoscopic double self-expandable metallic stent placement by partial stent-in-stent method

BACKGROUND

Endoscopic double self-expandable metallic stent (SEMS) placement by the partial stent-in-stent (PSIS) method has been reported to be useful for the management of unresectable hilar malignant biliary obstruction. However, it is technically challenging, and the optimal SEMS for the procedure remains unknown. The aim of this study was to identify the risk factors for technical failure of endoscopic double SEMS placement for unresectable malignant hilar biliary obstruction (MHBO).

METHODS

Between December 2009 and May 2013, 50 consecutive patients with MHBO underwent endoscopic double SEMS placement by the PSIS method. We retrospectively evaluated the rate of successful double SEMS placement and identified the risk factors for technical failure.

RESULTS

The technical success rate for double SEMS placement was 82.0% (95% confidence interval [CI]: 69.2-90.2). On univariate analysis, the rate of technical failure was high in patients with metastatic disease and unilateral placement. Multivariate analysis revealed that metastatic disease was a significant risk factor for technical failure (odds ratio: 9.63, 95% CI: 1.11-105.5). The subgroup analysis after double guidewire insertion showed that the rate of technical success was higher in the laser-cut type SEMS with a large mesh and thick delivery system than in the braided type SEMS with a small mesh and thick delivery system.

CONCLUSIONS

Metastatic disease was a significant risk factor for technical failure of double SEMS placement for unresectable MHBO. The laser-cut type SEMS with a large mesh and thin delivery system might be preferable for the PSIS procedure.

Preoperative biliary drainage in hilar cholangiocarcinoma: When and how?

Hilar cholangiocarcinoma is a tumor of the extrahepatic bile duct involving the left main hepatic duct, the right main hepatic duct, or their confluence. Biliary drainage in hilar cholangiocarcinoma is sometimes clinically challenging because of complexities associated with the level of biliary obstruction. This may result in some adverse events, especially acute cholangitis. Hence the decision on the indication and methods of biliary drainage in patients with hilar cholangiocarcinoma should be carefully evaluated. This review focuses on the optimal method and duration of preoperative biliary drainage (PBD) in resectable hilar cholangiocarcinoma. Under certain special indications such as right lobectomy for Bismuth type IIIA or IV hilar cholangiocarcinoma, or preoperative portal vein embolization with chemoradiation therapy, PBD should be strongly recommended. Generally, selective biliary drainage is enough before surgery, however, in the cases of development of cholangitis after unilateral drainage or slow resolving hyperbilirubinemia, total biliary drainage may be considered. Although the optimal preoperative bilirubin level is still a matter of debate, the shortest possible duration of PBD is recommended. Endoscopic nasobiliary drainage seems to be the most appropriate method of PBD in terms of minimizing the risks of tract seeding and inflammatory reactions.

Oncological benefit of preoperative endoscopic biliary drainage in patients with hilar cholangiocarcinoma

Due to advances in endoscopic equipment and techniques, preoperative endoscopic biliary drainage (EBD) has been developed to serve as an alternative to percutaneous transhepatic biliary drainage (PTBD). This study sought to clarify the benefit of EBD in comparison to PTBD in patients who underwent radical resections of hilar cholangiocarcinoma. One hundred and forty-one patients underwent radical surgery for hilar cholangiocarcinoma between 2000 and 2008 were retrospectively divided into two groups based on the type of preoperative biliary drainage, PTBD (n = 67) or EBD (n = 74). We investigated if the different biliary drainage methods affected postoperative survival and mode of recurrence after median observation period of 82 months. The survival rate for patients who underwent EBD was significantly higher than those who had PTBD (P = 0.004). Multivariate analysis revealed that PTBD was one of the independent factors predictive of poor survival (hazard ratio: 2.075, P = 0.003). Patients with PTBD more frequently developed peritoneal seeding in comparison to those who underwent EBD (P = 0.0003). PTBD was the only independent factor predictive of peritoneal seeding. In conclusion, EBD might confer an improved prognosis over PTBD due to prevention of peritoneal seeding, and is recommended as the initial procedure for preoperative biliary drainage in patients with hilar cholangiocarcinoma.

Endoscopic biliary drainage by stent placement for carcinoma of the head of the pancreas with hepatic metastasis: a report of 16 cases

AIM: To evaluate the clinical significance of endoscopic biliary drainage by stent placement in the treatment of carcinoma of the head of the pancreas with hepatic metastasis.

METHODS: Sixteen patients with obstructive jaundice, who were diagnosed as carcinoma of the head of the pancreas with hepatic metastasis by imaging between May 2006 and December 2008, were included in the study. All patients underwent stent placement for endoscopic biliary drainage to cure obstructive jaundice.

RESULTS: Retroperitoneal lymph node metastasis was found in 5 patients. Of all patients, 12 underwent biliary drainage with expandable metallic biliary stents, 4 with plastic biliary stents, and 6 with pancreatic duct stents. Complete resolution of obstructive jaundice was achieved in all patients. Mental state, appetite and sleep were improved obviously in 75.0%, 25.0% and 37.5% of patients. The survival time was extended from 9 d to 134 d, with an average value of 81.4 d ± 50.2 d. The follow-up data showed that appreciable outcome and satisfactory outcome were achieved in 97% and 69% of patients, respectively.

CONCLUSION: Endoscopic biliary drainage by stent placement can not only cure completely obstructive jaundice but also improve survival quality in patients with carcinoma of the head of the pancreas with hepatic metastasis.

Endoscopic ultrasound-guided choledochoduodenostomy for treatment of ampullary cancer

We describe the case of a patient for whom choledochoduodenostomy was performed under endoscopic ultrasound (EUS) guidance as an alternative to percutaneous transhepatic biliary drainage (PTBD) for the treatment of obstructive jaundice. An 82-year-old man with ampullary cancer was considered operable, but he refused surgery. Endoscopic biliary drainage (EBD) with an 8.5-French plastic stent was performed 2 months later because of the development of obstructive jaundice. The EBD stent was occluded 5 months after the stent insertion, and EUS choledochoduodenostomy (EUS-CDS) was performed. Pneumoperitoneum occurred 1 day after the procedure, which resolved with conservative treatment. Six months later, multiple lymph node metastases occurred, and the patient was effectively treated by chemotherapy (S-1). The patient is still alive with a good quality of life more than 2 years after EUS-CDS. We conclude that EUS-CDS is an effective alternative to PTBD or EBD for patients with malignant biliary obstruction, especially due to ampullary cancer.

Histological changes at an endosonography-guided biliary drainage site: A case report

Endosonography-guided biliary drainage (ESBD) is a new method enabling internal drainage of an obstructed bile duct. However, the histological conditions associated with fistula development via the duodenum to the bile duct have not been reported. We performed ESBD 14 d preoperatively in a patient with an ampullary carcinoma and histologically confirmed changes in and around the fistula. The female patient developed no complications relevant to ESBD. Levels of serum bilirubin and hepatobiliary enzymes declined quickly, and pancreatoduodenectomy was carried out uneventfully. The resected specimen was sliced and stained with hematoxylin-eosin. Histological evaluation of the puncture site in the duodenum and bile-duct wall, and the sinus tract revealed no hematoma, bile leakage, or abscess in or around the sinus tract. Little sign of granulation, fibrosis, and inflammatory cell infiltration was observed. Although further large-scale confirmatory studies are needed, the findings here may encourage more active use of ESBD as a substitute for percutaneous transhepatic drainage in cases with failed/difficult endoscopic biliary stenting.

Endoscopic biliary drainage for patients with unresectable pancreatic cancer with obstructive jaundice who are to undergo gemcitabine chemotherapy

AIM: To assess optimum endoscopic biliary drainage (EBD) in cases with unresectable pancreatic cancer in the era of gemcitabine (GEM).

METHODS: Thirty patients with unresectable pancreatic cancer, who presented with jaundice and underwent chemotherapy using GEM after EBD were included in this study (GEM group). Fifteen cases with the same clinical manifestation and stage of pancreatic cancer treated with EBD alone were also included as controls. A covered metallic stent (CMS) or a plastic stent (PS) was used for EBD. The mean survival time (MST) in each group, risk factors of survival time, type of stent used and associated survival time, occlusion rate of stent, patency period of stent, and risk factors of stent occlusion were evaluated.

RESULTS: MST in the GEM group was longer than that in the control (9.9 mo vs 6.2 mo). In the GEM group, the survival time was not different between those who underwent metallic stenting and those who underwent plastic stenting. Stent occlusion occurred in 60% of the PS group and 7% of the CMS group. The median stent patency in the PS-GEM group and the CMS-GEM group was 5 mo and 7.5 mo, respectively. Use of a PS was the only risk factor of stent occlusion.

CONCLUSION: A CMS is recommended in cases presenting with jaundice due to unresectable pancreatic cancer, since the use of a CMS makes it possible to continue chemotherapy using GEM without repetition of stent replacement.

Endoscopic management of acute cholangitis in elderly patients

AIM: To evaluate clinical presentation, etiology, compli-cations and response to treatment in elderly patients with acute cholangitis.

METHODS: Demographics, etiology of biliary obstruc-tion, clinical features, complications and associated systemic diseases of 175 patients with acute cholangitis were recorded. Endoscopic biliary drainage was performed using nasobiliary drain or stent. The complications related to ERCP, success of biliary drainage, morbidity, mortality and length of hospital stay were evaluated.

RESULTS: Of 175 patients, 52 aged ≥ 60 years (groupI, age < 60 years; group II, age ≥ 60 years) and 105 were men. Fever was present in 38 of 52 patients of group II compared to 120 of 123 in groupI. High fever (fever ≥ 38.0°C) was more common in groupI(118/120 vs 18/38). Hypotension (5/123 vs 13/52), altered sensorium (3/123 vs 19/52), peritonism (22/123 vs 14/52), renal failure (5/123 vs 14/52) and associated comorbid diseases (4/123 vs 21/52) were more common in group II. Biliopancreatic malignancy was a common cause of biliary obstruction in group II (n = 34) and benign diseases in groupI(n = 120). Indications for biliary drainage were any one of the following either singly or in combination: a fever of ≥ 38.0°C (n = 136), hypotension (n = 18), peritonism (n = 36), altered sensorium (n = 22), and failure to improve within 72 h of conservative management (n = 22). High grade fever was more common indication of biliary drainage in groupIand hypotension, altered sensorium, peritonism and failure to improve within 72 h of conservative management were more common indications in group II. Endoscopic biliary drainage was achieved in 172 patients (nasobiliary drain: 56 groupI, 24 group II, stent: 64 groupI, 28 group II) without any significant age related difference in the success rate. Abdominal pain, fever, jaundice, hypotension, altered sensorium, peritonism and renal failure improved after median time of 5 d in 120 patients in groupI(2-15 d) compared to 10 d in 47 patients of group II (3-20 d). Normalization of leucocyte count was seen after a median time of 7 d (3-20 d) in 120 patients in groupIcompared to 15 d (5-26 d) in 47 patients in group II. There were no ERCP related complications in either group. Five patients (carcinoma gallbladder n = 3, CBD stones n = 2) died in group II and they had undergone biliary drainage after failure of response to conservative management for 72 h. There was a higher mortality in patients in group II despite successful biliary drainage (0/120 vs 5 /52). Length of hospital stay was longer in group II patients (16.4 ± 5.6, 7-30 d) than in groupIpatients (8.2 ± 2.4, 7-20 d).

CONCLUSION: Elderly patients with acute cholangitis have a high incidence of severe cholangitis, concomitant medical illnesses, hypotension, altered sensorium, peritonism, renal failure and higher mortality even after successful biliary drainage.