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La colangiopatía portal hace referencia a anomalías colangiográficas que se producen en pacientes con cavernomatosis portal, siendo progresiva, cursando con enfermedad biliar sintomática y anomalías graves de las vías biliares. Y, representa una complicación infrecuente de la hipertensión portal. Se describe el caso de un hombre de 53 años, con historia de larga data de hipertensión portal nocirrótica y cavernomatosis portal, quien presentó un episodio de enfermedad biliar obstructiva sintomática, y en estudios se documentó tejido fibrótico de extensión periportal ascendente con compresión extrínseca del colédoco distal y dilatación de la vía biliar extra e intrahepática. Por lo que se procedió a colangiopancreatografía retrógrada endoscópica, realizándose tratamiento paliativo, con papilotomía pequeña y colocación de endoprótesis biliar plástica, siendo exitoso por ausencia de complicaciones procedimentales, y mejoría clínica y parámetros bioquímicos. Finalmente, recibiendo de alta con indicación de seguimiento prioritario para recambios periódicos de endoprótesis biliares, y valoración por hepatología. La colangiopatía portal es una entidad rara que debe sospecharse en sujetos con hipertensión portal de origen no-cirrótico, con hallazgos imagenológicos de estenosis, angulaciones o dilataciones segmentarias, su tratamiento debe ser individualizado, y la terapia endoscópica es de elección en enfermedad biliar sintomática.
Portal cholangiopathy refers to cholangiographic abnormalities occurring in patients with portal cavernomatosis, being progressive, presenting with symptomatic biliary disease and severe biliary tract abnormalities. And, it represents an infrequent complication of portal hypertension. We describe the case of a 53-year-old man with a long history of non-cirrhotic portal hypertension and portal cavernomatosis, who presented an episode of symptomatic obstructive biliary disease, and studies documented fibrotic tissue of ascending periportal extension with extrinsic compression of the distal common bile duct and dilatation of the extra and intrahepatic biliary tract. Therefore, endoscopic retrograde cholangiopancreatography was performed, and palliative treatment with small papillotomy and placement of a plastic biliary endoprosthesis was successful due to the absence of procedural complications, and clinical improvement and biochemical parameters. Finally, the patient was discharged with indication of priority follow-up for periodic replacement of biliary stents, and evaluation by hepatology. Portal cholangiopathy is a rare entity that should be suspected in subjects with portal hypertension of non-cirrhotic origin, with imaging findings of stenosis, angulations or segmental dilatations, its treatment should be individualized, and endoscopic therapy is of choice in symptomatic biliary disease.
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Malignant obstructive jaundice is caused by direct invasion or compression of the biliary tract by malignant tumors of the bile duct, pancreas and other systems. Patients are often accompanied by symptoms such as malnutrition, low immune function, and organ damage. The treatments of active preoperative biliary drainage and reasonable reinfusion combined with enteral nutrition can help improve the safety of patients during the perioperative period, reduce postoperative complications, and improve the life quality of patients. This article reviewed the research progress of preoperative biliary drainage, bile recycling methods and precautions in patients with malignant obstructive jaundice, aiming to provide reference for clinical diagnosis and treatment practice.
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Objective To investigate the effect of Yinchenhao decoction on renal oxidative stress injury in rats with obstructive jaundice and its association with the regulation of the expression of nuclear factor erythroid 2-related factor 2 (Nrf2) and nuclear translocation. Methods A total of 32 male Sprague-Dawley rats were randomly divided into sham-operation group (S group), model group (O group), low-dose Yinchenhao decoction group (LY group), and high-dose Yinchenhao decoction group (HY group), with 8 rats in each group. For the rats in the S group, the upper common bile duct was isolated without ligation, and for those in the other groups, double ligation of the middle and upper 1/3 of the common bile duct was performed to establish a model of obstructive jaundice. After 7 days, the rats in the LY group and the HY group were given Yinchenhao decoction by gavage at a dose of 6.3 and 18.9 mL/kg, respectively, while those in the S and O groups were given an equal volume of distilled water by gavage every day for 7 consecutive days, and the rats were treated on day 14. ELISA was used to measure the serum levels of total bilirubin (TBil), direct bilirubin (DBil), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT), blood urea nitrogen (BUN), and creatinine (Cr); spectrophotometry was used to measure the activity of the oxidative stress factors superoxide dismutase (SOD) and malondialdehyde (MDA) in renal tissue; quantitative real- time PCR and Western blotting were used to measure the mRNA and protein expression levels of Nrf2, Kelch-like ECH-associated protein 1 (Keap1), and NAD(P)H quinone dehydrogenase 1 (NQO1) in renal tissue; immunohistochemistry was used to measure observe the nuclear translocation of Nrf2 protein in renal tissue. A one-way analysis of variance was used for comparison of continuous data between multiple groups, and the least significant difference t -test was used for further pairwise comparison within groups. Results Compared with the S group, the O group had significant increases in the levels of TBil, DBil, ALT、GGT, BUN, and Cr, a significant reduction in the activity of SOD, and a significant increase in the level of MDA (all P 0.05). Compared with the S group, the O group had a significant reduction in the positive rate of Nrf2 in cell nucleus in renal tissue ( P < 0.05), and compared with the O group, the LY group and the HY group had a significant increase in the positive rate of Nrf2 in cell nucleus ( P < 0.05). Conclusion Yinchenhao decoction can effectively alleviate renal injury caused by obstructive jaundice, possibly by upregulating the protein expression of Nrf2 in renal tissue and regulating the nuclear translocation of Nrf2 protein, so as to mediate the protein expression of downstream NQO1, regulate oxidative stress response caused by obstructive jaundice, and thereby alleviate renal injury in rats.
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Objective:To explore the risk factors and preventive strategies of pancreatitis after percutaneous transhepatic biliary drainage (PTBD) in patients with pancreatic cancer and obstructive jaundice.Methods:A total of 241 patients were retrospectively analyzed from May 2001 to October 2014 in Tianjin Medical University Cancer Institute and Hospital. The possibly correlated 9 factors were analyzed, including gender, age, hemoglobin level, total bilirubin level, degree of pancreatic duct dilatation, degree of pancreatic atrophy, degree of biliary stenosis, the pancreatic duct visualization, and drainage mode.Results:Univariate analysis suggested that pancreatic duct dilatation, pancreatic atrophy, visualized pancreatic duct and drainage mode were associated with the incidence of pancreatitis after PTBD ( P<0.05). Logistic regression analysis showed that visualization of pancreatic duct ( OR=6.33) was a risk factor for pancreatitis, while pancreatic duct dilatation ( OR=0.14), pancreatic atrophy ( OR=0.12) and external drainage ( OR=0.11) were protective factors for pancreatitis. Conclusion:In pateints with pancreatic cancer and obstructive jaundice, pancreatic duct dilatation and pancreatic atrophy predict low risk of pancreatitis after PTBD,while intraoperative pancreatic duct visualization and internal or external drainage may increase the incidence of postoperative pancreatitis.
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Objective:To investigate the effect of autophagy on liver injury with obstructive jaundice in Sprague-Dawley (SD) rats and its underlying mechanism.Methods:Thirty-five healthy male SD rats, SPF grade, aged 6-8 weeks, weighting 200-300 g, were divided into 5 groups with 7 rats in each group, including sham group (simple free common bile duct, without ligation, intraperitoneal injection of normal saline), obstructive jaundice (OJ) group (established by common bile duct ligation, intraperitoneal injection of normal saline), OJ group with 3-MA, OJ group with Rapamycin, and OJ group with 3-MA and VX-765. Morphological changes in liver tissues were analyzed with HE staining. Expression of autophagy-related protein Atg5 was detected by immunohistochemistry staining. Liver function was analyzed by automatic biochemical instrument and the level of serum interleukin (IL)-18 was detected using ELISA assay. Protein levels of autophagy related-proteins and endoplasmic reticulum stressed (ERs)-related apoptosis proteins were detected by Western Blot.Results:The relative expression of autophagy related protein Atg5 in OJ group was significantly higher than that in sham group [(5.0±1.0) vs. (2.8±1.3), t=-3.00, P<0.05]. Compared with sham group, the activity of autophagy was enhanced and the protein levels of Caspase-1/p-65 and IL-18 were significantly increased in OJ group. At the same time, apoptosis was induced by activating ERs. In OJ group, the autophagy inducer 3-MA improved the expression levels of Caspase-1/p-65 and IL-18, and aggravate liver injury. While after applying the autophagy agonist Rapamycin in OJ rat models, the expression of Caspase-1/p-65 and IL-18 was repressed and liver damage was also reduced. In addition, in rat OJ groups with 3-MA, inhibition of Caspase-1 by VX-765 could down regulate the expression of Caspase-1/p-65 and IL-18, and protect against liver injury. Conclusions:Both ERs related apoptosis and autophagy were activated after ligation of common bile duct. Besides, activation of autophagy could reduce OJ-induced liver injury in SD rats by inhibiting the Caspase-1/p-65 inflammatory pathway.
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Objective:To investigate the risk factor analysis and model prediction of bleeding after endoscopic retrograde cholangiopancreatography in patients with malignant obstructive jaundice (MOJ).Methods:A retrospective analysis was performed on 302 patients with MOJ treated with ERCP who were treated in the No. 363 Hospital Affiliated to Southwest Medical University from January 2015 to June 2021. The general clinical data of the patients were collected, and the biochemical indicators of the pancreatic and bile ducts were detected. The patients were followed up after discharge, and the patients were divided into a bleeding group ( n=47) and a control group ( n=255) according to whether the follow-up patients were bleeding after ERCP. Compared the general and clinical data of the two groups of patients, including age, gender, platelet count, presence of bile duct stones, acute cholangitis, acute pancreatitis, number of stones, intraoperative bleeding, pancreatic cancer, cholangiocarcinoma, large stone diameter, stone incarceration, duodenal papillary diverticulum, and pre-surgical incision. The measurement data that obey the normal distribution were represented by the mean±standard deviation ( ± s), and the two independent sample t test was used for the comparison between groups; the data that do not conform to the normal distribution were represented by M ( Q1, Q3), and the comparison between groups was used Mann-Whitney U test. The comparison of enumeration data between groups adopted chi-square test. Logistic multivariate regression was used to analyze the independent risk factors of postoperative bleeding after ERCP, and a nomogram prediction model was established and verified according to the independent risk factors of postoperative bleeding. Results:The two groups of patients were compared in age, gender, platelet count, bile duct stones, acute cholangitis, acute pancreatitis, the number of stones, intraoperative bleeding and other aspects, the difference was not statistically significant ( P>0.05). The percentages of pancreatic cancer, cholangiocarcinoma, large stone diameter, stone incarceration, duodenal papillary diverticulum, and surgical pre-incision in the bleeding group were 12.77%, 17.02%, 19.15%, 51.06%, 59.57%, and 14.89%, respectively. , the percentages of the control group were 3.92%, 5.10%, 9.02%, 19.22%, 17.65%, and 5.88%, and the difference was statistically significant between the two groups ( P<0.05). Taking postoperative bleeding as the dependent variable, and using the indicators with statistical differences in univariate analysis as independent variables, multivariate Logistic regression analysis showed that the patient had pancreatic cancer ( OR=1.838, 95% CI: 1.524-4.613, P=0.041), cholangiocarcinoma ( OR=2.548, 95% CI: 1.870-5.116, P=0.015), stone incarceration ( OR=3.078, 95% CI: 2.374-6.012, P<0.001), duodenum Intestinal papillary diverticula ( OR=1.140, 95% CI: 1.045-1.628, P<0.001), surgical pre-incision ( OR=1.640, 95% CI: 1.321-1.928, P<0.001) were associated with postoperative bleeding in MOJ patients after ERCP independent risk factors. The predictive ability of duodenal papillary diverticulum was the highest; the predictive ability of stone incarceration and cholangiocarcinoma was the second, and there was no significant difference between them; the predictive ability of pancreatic cancer, stone diameter, and pre-incision on bleeding after ERCP in MOJ patients smaller. Pancreatic cancer, cholangiocarcinoma, large stone diameter, stone incarceration, duodenal papillary diverticulum, and pre-incision scores were 42, 63, 28, 65, 76, and 34 points respectively, and the total score was 308 points corresponding to the nomogram model. The predictive power of the nomogram was 61.6%, and overall, the nomogram had good predictive performance. Harrell concordance index analysis and ROC curve were used to evaluate the model discrimination, the C-index calculation result was 0.826 (95% CI: 0.771-0.847), the ROC curve AUC was 0.843 (95% CI: 0.801-0.884), and the ROC prediction The value and the calculation result of C-index are relatively close. The model discrimination is applied in this study and has a certain prediction effect. The nomogram model in the Calibration curve predicted the probability of postoperative bleeding after ERCP in MOJ patients with high consistency with the actual probability. Conclusion:ERCP is safe and feasible for most patients with MOJ, but for patients with pancreatic cancer, bile duct cancer, large stone diameter, stone incarceration, and duodenal papillary diverticulum, it should be performed with caution, and preoperative incision should be avoided, to reduce the risk of postoperative bleeding. In addition, the nomogram model has a strong predictive ability in predicting bleeding after ERCP in patients with MOJ, which is worthy of reference in clinical research.
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Objective:To compare the clinical effect of three indwelling methods of plastic biliary stent on relieving obstructive jaundice caused by unresectable hilar cholangiocarcinoma.Methods:A retrospective study was performed on data of 61 patients with obstructive jaundice caused by unresectable hilar cholangiocarcinoma from April 2014 to December 2020 in Cancer Hospital, Chinese Academy of Medical Sciences. Plastic biliary stent placement was used to relieve jaundice, including 18 cases of intragastric indwelling at the end of biliary stent, 31 cases of duodenal papilla indwelling at the end of biliary stent, and 12 cases of horizontal portion of duodenum indwelling at the end of biliary stent. Incidence of fever within 2 weeks, perioperative mortality, 90-day obstruction rate, and median stent patency period were followed up and the results were analyzed.Results:The incidence of fever within 2 weeks of the three groups were significantly different [66.7% (12/18), 58.1% (18/31) and 16.7% (2/12), χ2=7.30, P=0.026]. There were no statistically differences in the perioperative mortality [0 (0/16), 3.2% (1/31) and 0 (0/10), χ2=1.09, P=1.000], 90-day obstruction rate [52.9% (9/17), 48.3% (14/29) and 40.0% (4/10), χ2=1.91, P=0.589], or median stent patency period (66.0 d, 91.5 d and 94.0 d, Z=4.96, P=0.084) among three groups. Conclusion:Patients with biliary plastic stents with ends placed at the horizontal portion of the duodenum show lower incidence of fever within two weeks after implantation, and similar median stent patency period, 90-day obstruction rate and perioperative mortality compared with intragastric indwelling and duodenal papilla indwelling groups. Therefore, biliary plastic stents with ends placed at the horizontal portion of the duodenum should be recommended as the preferred procedure.
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Objective:To explore the efficacy of endoscopic retrograde cholangiopancreatography (ERCP) biliary stent implantation in patients with unresectable malignant biliary stricture (MBS) and the influencing factors of overall survival.Methods:The clinical data of 346 patients who underwent ERCP biliary stent implantation due to MBS from May 2013 to October 2016 in Xijing Digestive Disease Hospital of Air Force Military Medical University, Shanxi Bethune Hospital and Mengchao Hepatobiliary Hospital of Fujian Medical University were retrospectively analyzed, and the efficacy, complications and risk factors affecting overall survival were also analyzed.Results:After ERCP biliary stent implantation, the levels of total bilirubin, γ-glutamyl transpeptidase, alkaline phosphatase and alanine aminotransferase were lower than those before surgery (all P < 0.01). The incidence of infection after operation was 14.7% (51/346), and the incidence of biliary infection was 13.0% (45/346). The incidence of post-ERCP pancreatitis (PEP) was 4.6% (16/346). The median survival time after ERCP was 131.0 d (70.3 d, 246.5 d). Multivariate Cox regression analysis showed that the independent risk factors affecting the overall survival patients included the hilar bile duct stenosis ( HR = 1.85, 95% CI 1.44-2.38, P < 0.01), preoperative bilirubin level exceeding the upper limit of normal level by 5 times ( HR = 1.75, 95% CI 1.30-2.36, P < 0.01), carbohydrate antigen 199 level exceeding the upper limit of normal level by 10 times ( HR = 1.27, 95% CI 1.00-1.61, P = 0.050), vascular and organ metastasis ( HR = 1.32, 95% CI 1.04-1.69, P = 0.023), and the poor jaundice decreasing level ( HR = 1.37, 95% CI 1.02-1.85, P = 0.037) . Conclusions:The ERCP biliary stent implantation is a safe and effective therapy for MBS. ERCP biliary stent implantation MBS patients with hilar bile duct stenosis, preoperative bilirubin levels more than 5 times of the upper limit of normal level, carbohydrate antigen 199 levels more than 10 times of the upper limit of normal level, vascular and organ metastasis, and poor jaundice decreasing level may have poor overall survival.
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Objective:To investigate the expression of intestinal alkaline phosphatase (IAP) in intestinal mucosa with bile deficiency and the effect of bile on the expression of IAP in intestinal epithelial Caco-2 cell model.Methods:Thirty healthy male SD rats were randomly divided into control group (Ctrl, n=10), external drainage group (ED, n=10) and obstructive jaundice group (OJ, n=10). Ileum specimens were collected on the 7th day after modeling. Western blot and immunohistochemical staining were used to determine the expression of IAP in rat intestinal mucosa. Different concentrations of human bile were used to treat on Caco-2 cells, and Western blot was used to detect the changes in IAP expression in Caco-2 cells. Results:Rat models were successfully established. The expression level of IAP in the intestinal mucosa of ED group [(9.19±1.67)%] was significantly lower than that of the Ctrl group [(15.09±0.61)%, P<0.05]; the expression of IAP in the intestinal mucosa of OJ group [(6.86±1.07)%] was significantly lower than that of the Ctrl group ( P<0.05). Through in vitro cell experiments, expression of IAP in Caco-2 cells was increased in a time and dose-dependent manner when treated with human bile. Conclusions:Bile deficiency in the intestine can cause inhibition of IAP in the intestinal mucosa. Bile can promote the expression of IAP in intestinal mucosal epithelial cells.
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ObjectiveTo investigate the clinical effect and safety of endoscopic nasobiliary drainage (ENBD) versus endoscopic biliary stenting (EBS) in preoperative biliary drainage for low-level malignant obstructive jaundice. MethodsChinese and English databases were searched for control studies on the clinical effect of ENBD versus EBS in preoperative biliary drainage for low-level malignant obstructive jaundice published up to August 2020. After quality assessment and data extraction were performed for the studies included, RevMan 53 software was used to perform the meta-analysis. ENBD and EBS were compared in terms of incidence rates of preoperative cholangitis and preoperative pancreatitis, stent dysfunction rate, overall incidence rate of complications before and after surgery, and rate of postoperative pancreatic leakage. ResultsSix studies involving 1182 patients were included. The meta-analysis showed that there were no significant differences between the ENBD group and the EBS group in incidence rate of preoperative pancreatitis (odds ratio ［OR］=0.66, 95% confidence interval ［CI］: 0.44-0.99, P=0.05), stent dysfunction rate (OR=1.14, 95% CI: 0.56-2.31, P=0.72), and overall incidence rate of complications before and after surgery (OR=0.69, 95% CI: 0.41-1.15, P=0.15). Compared with the EBS group, the ENBD group had significant reductions in incidence rate of preoperative cholangitis (OR=0.34, 95% CI: 0.23-0.50, P＜0.000 01) and rate of postoperative pancreatic leakage (OR=0.53, 95% CI: 0.32-0.88, P=0.01). ConclusionPreoperative biliary drainage with ENBD is superior to EBS in patients with well-diagnosed low-level malignant obstructive jaundice. More large multicenter randomized controlled trials are needed in the future to verify this conclusion.
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Objective:To systematically evaluate the clinical effect of biliary stent combined with intra-biliary radiofrequency ablation and stent alone in the treatment of malignant obstructive jaundice.Methods:The PubMed, Cochrane library, Embase, HowNet, Wanfang, Weipu were systematically searched, the search time was up to February 2021. To collect and compare the clinical efficacy studies of combined intra-biliary radiofrequency ablation in the treatment of patients with malignant obstructive jaundice before biliary stent placement. After literature screening, data extraction and quality assessment conducted by two independent reviewers. Meta-analysis was performed with the patients' 1-year survival rate, 6-month patency rate after biliary stent operation, and comparative changes in postoperative complications as the main outcome indicators.Results:Finally, 9 studies were included, comprising 2 randomized controlled studies (RCT) and 7 retrospective studies, involving a total of 443 patients, with 211 cases in the biliary stent combined with intra-biliary radiofrequency ablation group and 232 cases in the stent alone group. The results of meta-analysis showed that in two joint groups compared with the stent alone group, in overall analysis, the rate of re-obstruction of the biliary tract decreased 6 months after stenting ( OR=0.24, 95% CI: 0.13-0.42) and 1-year survival rate increased ( OR=3.79, 95% CI: 2.08-6.90), the differences are statistically significant ( P<0.001), there was no statistical difference in the complications ( P=0.13). In ERCP group, the rate of re-obstruction of the biliary tract decreased 6 months after stenting ( OR=0.21, 95% CI: 0.08-0.55), and the 1-year survival rate significant increase ( OR=3.63, 95% CI: 1.76-7.48), the differences are statistically significant ( P<0.01). In PTCD group, the rate of re-obstruction of the biliary tract decreased 6 months after stenting ( OR=0.25, 95% CI: 0.12-0.51), and the 1-year survival rate significant increase ( OR=4.13, 95% CI: 1.42-12.03), the differences are statistically significant ( P<0.01). Conclusion:Compared with the stent-only group, the combined group is safe and effective in treating malignant obstructive jaundice.
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RESUMEN Fundamento: el duodeno corresponde a la segunda localización, con más frecuencia se presentan en los divertículos gastrointestinales después del colon. El síndrome de Lemmel también conocido como ictericia obstructiva intermitente, presencia de divertículos duodenales próximos a la papila de Váter podría favorecer al desarrollo de enfermedades pancreatobiliares. Objetivo: presentar el caso de una adulta mayor con ictericia en mucosa y piel intermitente asociada con episodios febriles no cuantificados y dolor en hipocondrio derecho. Presentación del caso: paciente de 67 años de edad, femenina, con un síndrome ictérico obstructivo, sin presencia de coledocolitiasis u otra alteración del árbol biliar distinta a la presencia de un divertículo duodenal. Por esta sintomatología es remitido a consulta de Gastroenterología del Hospital Universitario Manuel Ascunce Domenech de la provincia Camagüey. Conclusiones: el síndrome de Lemmel es una enfermedad poco frecuente que debe tenerse en cuenta como causa de ictericia obstructiva.
ABTRACT Background: the duodenum corresponds to the second location where the gastrointestinal diverticula are most frequently presented after the colon. Lemmel's syndrome, also known as intermittent obstructive jaundice, presence of duodenal diverticula near the papilla of Vater could favor the development of pancreatic biliary diseases. Objective: to present the case of an older adult with jaundice in mucosa and intermittent skin associated with febrile episodes not quantified and pain in the right hypochondrium. Case report: a 67-year-old female patient with an obstructive jaundice syndrome, without the presence of choledocholithiasis or other alteration of the biliary tree other than the presence of a duodenal diverticulum. For this symptomatology is referred to Gastroenterology consultation. Conclusions: Lemmel's syndrome is a rare pathology that must be taken into account as a cause of obstructive jaundice.
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ObjectiveTo investigate the clinical value of ultrasound-guided real-time percutaneous transhepatic-cholangial or transhepatic-cholecyst drainage (PTCD) in the treatment of patients with acute obstructive cholangitis in primary hospitals. MethodsA retrospective analysis was performed for the clinical data of 38 patients with acute obstructive cholangitis who underwent ultrasound-guided real-time PTCD in Tengchong People’s Hospital from February 2012 to June 2018, and among these patients, 4 had malignant biliary obstruction and cholangitis and 34 had acute obstructive suppurative cholangitis caused by hepatolithiasis. ResultsOf all patients, 30 underwent puncture of the bile duct in the right lobe of liver, 6 underwent puncture of the bile duct in the left lobe of liver, and 2 underwent puncture of the gallbladder. The success rate of first-time needle insertion was 91.2% (35/38), and the overall success rate of puncture was 100%. There were no complications such as massive hemorrhage, biliary peritonitis, and biliary-vascular fistula. At 2 weeks after surgery, 89.5% (34/38) of the patients had a bilirubin level reduced by ≥1/2, and 32 patients (84.2%) had a level of alanine aminotransferase reduced to normal. As for the 34 patients with hepatolithiasis, second-stage surgeries including bile duct exploration/cholecystolithotomy and hepatic lobectomy were performed after the infection was under control, or they were referred to superior hospitals with tube indwelling for further treatment. The 4 patients with neoplastic bile duct obstruction were referred to superior hospitals with tube indwelling, among whom 3 underwent radical surgery and 1 underwent biliary stent placement via the former deep blind fistula. ConclusionUltrasound-guided real-time PTCD can be used as an effective, simple, and safe biliary drainage technique for the early treatment of acute biliary obstruction in primary hospitals. This technique has a high success rate and low requirements for medical equipment, and therefore, it holds promise for clinical application in primary hospitals after related technical procedures are standardized.
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Los neuromas del conducto biliar se desarrollan a partir de las fibras nerviosas simpáticas y parasimpáticas que envuelven la pared de la vía biliar. Mujer de 44 años de edad con antecedente de colecistectomía convencional seis meses previos al ingreso acude a emergencia por ictericia obstructiva de 15 días de evolución. En los estudios de imagen impresiona la presencia de una masa a nivel de las vías biliares considerándose el diagnostico de una neoplasia maligna. Por los antecedentes, ausencia de marcadores tumorales se decide realizar una biopsia percutánea sin resultados concluyente, realizándose posteriormente una intervención quirúrgica con estudio anatomo-patológico compatible con neuroma de amputación de vía biliar. El neuroma de amputación a nivel de la vía biliar es un tumor infrecuente. Puede manifestarse clínicamente como una ictericia obstructiva y suele simular a un tumor maligno de las vías biliares. El manejo quirúrgico es el tratamiento definitivo.
Neuromas of the bile duct develop from the sympathetic and parasympathetic nerve fibers that surround the wall of the bile duct. A 44-year-old woman with a history of conventional cholecystectomy six months prior to hospital admission attended emergency due to obstructive jaundice that lasted 15 days. In the imaging studies, the presence of a mass at the level of the bile ducts is considered, considering the diagnosis of a malignant neoplasm. Due to the antecedents, the absence of tumor markers, it was decided to perform a percutaneous biopsy without conclusive results, performing later a surgical intervention with anatomopathological study compatible with neuroma of biliary tract amputation. The amputation neuroma at the level of the bile duct is an infrequent tumor. It can manifest clinically as obstructive jaundice and usually simulates a malignant tumor of the bile ducts. Surgical management is the definitive treatment.
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Adult , Female , Humans , Postoperative Complications , Cholecystectomy/adverse effects , Common Bile Duct Neoplasms/complications , Jaundice, Obstructive/etiology , Neuroma/complications , Postoperative Complications/pathology , Common Bile Duct Neoplasms/pathology , Neuroma/pathologyABSTRACT
Abstract Objective: To evaluate the accuracy of percutaneous transhepatic biliary biopsy (PTBB) in patients with suspected biliary obstruction. Materials and methods: This was a retrospective analysis of 18 patients with obstructive jaundice who underwent PTBB. In each patient, three to ten fragments were collected from the lesion. The final diagnosis was confirmed in the pathology report. We also reviewed analyses of the results of laboratory tests performed before the procedure, as well as the Bismuth classification, clinical outcome, complications occurring during the procedure, access route, and materials used. Results: Technical success was achieved in 100% of the PTBB procedures. Among the 18 patients clinically diagnosed with bile duct stenosis, the pathological analysis confirmed that diagnosis in 17. In one case, the pathological findings were considered false-negative. The predominant tumor was cholangiocarcinoma (seen in 50% of the cases). Sixteen of the procedures (88.9%) were performed without complications. Transient hemobilia occurred in one case, and cholangitis occurred in another. Conclusion: PTBB is a safe, viable, simple technique with a high rate of true-positive results for the definitive diagnosis of obstructive jaundice.
Resumo Objetivo: Avaliar a precisão diagnóstica da colangiobiópsia trans-hepática percutânea (CBTP) em pacientes com suspeita de obstrução biliar. Materiais e Métodos: Análise retrospectiva de 18 pacientes apresentando icterícia obstrutiva foram submetidos a CBTP. Em cada paciente, 3 a 10 fragmentos foram coletados da lesão. O diagnóstico final foi confirmado por relatório anatomopatológico. Adicionalmente, foram registrados a análise laboratorial antes do procedimento, a classificação de Bismuth, o desfecho clínico, as intercorrências durante o procedimento, a via de acesso e os materiais utilizados. Resultados: A CBTP apresentou sucesso técnico em 100% dos casos. Dos 18 pacientes clinicamente diagnosticados com estenose biliar, 17 receberam diagnóstico patológico positivo. Em um caso os achados patológicos foram considerados falso-negativos. O colangiocarcinoma foi a neoplasia predominante (50%). Dezesseis (88,9%) procedimentos foram realizados sem intercorrências. Hemobilia transitória ocorreu em um caso e colangite em outro caso isolado. Conclusão: A CBTP é uma técnica segura, viável e simples, com alta taxa de verdadeiro-positivos para o diagnóstico definitivo de causas de icterícia obstrutiva.
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Abstract Purpose: To establish a new rat model, the pathogenesis of which is closer to the clinical occurrence of chronic obstructive jaundice with liver fibrosis. Methods: 90 SD rats were randomly divided into 3 groups. Group A common bile duct ligation, group B common bile duct injection compont and group C injection saline. The serum of three groups was extracted, and the liver function was detected by ELISA. HE staining, Masson staining and immunohistochemistry were used to detect liver pathology. Results: Group B showed a fluctuant development of jaundice, obstructive degree reached a peak at 2 weeks, and decreased from 3 weeks. HA, LA and PCIII were significantly higher than control group. 3 weeks after surgery, liver tissue fibrosis occurred in group B, and a wide range of fiber spacing was formed at 5 weeks. Immunohistochemistry showed that hepatic stellate cells were more active than the control group. Conclusion: Intra-biliary injection of Compont gel is different from the classic obstructive jaundice animal model caused by classic bile duct ligation, which can provide an ideal rat model of chronic obstructive jaundice with liver fibrosis.
Subject(s)
Animals , Female , Bile Ducts/drug effects , Disease Models, Animal , Gels/administration & dosage , Liver Cirrhosis/chemically induced , Aspartate Aminotransferases/blood , Reference Values , Azo Compounds , Time Factors , Bile Ducts/pathology , Bilirubin/analysis , Serum Albumin/analysis , Enzyme-Linked Immunosorbent Assay , Immunohistochemistry , Random Allocation , Reproducibility of Results , Rats, Sprague-Dawley , Eosine Yellowish-(YS) , Jaundice, Obstructive/chemically induced , Jaundice, Obstructive/pathology , Alkaline Phosphatase/blood , gamma-Glutamyltransferase/blood , Injections , Liver Cirrhosis/pathology , Methyl GreenABSTRACT
Objective@#To study the therapeutic value of endoscopic ultrasonography-guided hepaticogastrostomy(EUS-HG) for patients with high malignant biliary obstructive jaundice.@*Methods@#A total of 56 patients with high malignant obstructive jaundice hospitalized at the Second Affiliated Hospital of Nanjing Medical University and the Second Affiliated Hospital of Xuzhou Medical University from January 2014 to December 2017 were included in the study. There were 29 males and 27 females with median age of 72 (60-82) years. Patients were randomized into two groups according to the random number table, the EUS-HG group (n=20) treated with EUS-HG and the percuteneous transhepatic cholangiodrainge(PTCD) group (n=36) treated with PTCD. The operative success rate, curative effect, complications and operation cost were compared between the two groups, and the median unblock period of plastic double pig tail stent was observed.@*Results@#(1)The success rates were 100% in both groups. (2) Preoperative and one-month postoperative levels of the following were tested and compared. Levels of total bilirubin were 362.15±138.27 μmol/L, 56.85±28.57 μmol/L in the EUS-HG group and 356.47±130.69 μmol/L, 60.93±25.79 μmol/L in the PTCD group, respectively. Levels of alkaline phosphatase were 896.57±357.29 U/L, 146.59±48.63 U/L in the EUS-HG group and 883.65±364.32 U/L, 151.57±49.73 U/L in the PTCD group, respectively. Levels of alanine aminotransferase were 252.36±38.77 U/L, 60.29±31.57 U/L in the EUS-HG group and 246.26±32.57 U/L, 62.56±32.87 U/L in the PTCD group. Levels of aspartate aminotransferase were 259.37±30.64 U/L, 62.28±26.58 U/L in the EUS-HG group and 242.37±29.52 U/L, 60.28±29.57 U/L in the PTCD group, and there was no significant difference between the two groups (P>0. 05). CRP levels were 52.57±31.95 mg/L, 16.95±8.77 mg/L in the EUS-HG group and 53.42±35.79 mg/L, 25.13±14.77 mg/L in the PTCD group (P<0.05). (3)There was significant difference in remission rate of anorexia and abdominal distension between the two groups [80.0%(16/20) VS 52.8%(19/36), P<0.05]. There was no significant difference in symptom relief of jaundice, pruritus or abdominal pain between the two groups [90.0%(18 /20)VS 91.7%(33/36), P>0.05]. (4) The incidence of total complications in the EUS-HG group (20.0%, 4/20) was significantly lower than that in the PTCD group (47.2%, 17/36, P<0.05). (5)The cost of operation in the EUS-HG group (22 685.26±2 356.16 yuan) was slightly higher than that in the PTCD group (20 529.57±4 135.63 yuan, P>0.05). (6) The median unblock period of double pig tail plastic stents in EUS-HG group patients was 102 days.@*Conclusion@#EUS-HG is a safe and effective method for the treatment of high malignant biliary obstructive jaundice. It can be used as the first choice for treatment after failure of conventional ERCP.
ABSTRACT
Objective To study the therapeutic effects of EUS-guided biliary drainage (EUS-BD) using a nitinol fully covered self-expandable metal stents in patients with malignant obstructive jaundice after failed ERCP.Methods From January 2016 to January 2018,all patients with malignant obstructive jaundice who failed ERCP underwent EUS-guided biliary drainage using nitinol fully covered self-expandable metal stent at Affiliated Hangzhou First People' s Hospital,Zhejiang University School of Medicine.The operation success rate,liver functional recovery time,complication rate,length of hospital stay and survival time were observed.Results Of 36 patients who underwent EUS-guided biliary drainage,34 were successfully performed,with 19 through the stomach,and 15 through the duodenum.The operation success rate was 94.4％ (34/36).The liver functional recovery time of the 34 patients were 25.8 ±.6.5 days.One patient developed hemobilia and one cholangitis,both improved after conservative treatment.The total complication rate was 5.6％ (2/36).The hospital stay and survival time were 21.5 ± 4.7 days and 220.5 ± 54.8 days,respectively.Conclusion EUS-BD using nitinol fully covered self-expandable metal stents was a feasible and effective treatment in patients with malignant biliary obstruction after failed ERCP.
ABSTRACT
Combined obstruction of the bile duct and duodenum is a common occurrence in periampullary malignancies. The obstruction of gastric outlet or duodenum can follow, occur simultaneously, or precede biliary obstruction. The prognosis in patients with combined obstruction is particularly poor. Therefore, minimally invasive palliation is preferred in these patients to avoid morbidity associated with surgery. Endoscopic palliation is preferred to surgical bypass due to similar efficacy, less morbidity, and shorter hospital stay. The success of endoscopic palliation depends on the type of bilioduodenal stenosis and the presence of previously placed duodenal metal stents. Biliary cannulation is difficult in type II bilioduodenal strictures where the duodenal stenosis is located at the level of the papilla. Consequentially, technical and clinical success is lower in these patients than in those with type I and III bilioduodenal strictures. However, in cases with failure of endoscopic retrograde cholangiopancreatography, with the introduction of endoscopic ultrasound for biliary drainage, the success of endoscopic bilioduodenal bypass is likely to increase further. The safety and efficacy of endoscopic ultrasound-guided drainage has been documented in multiple studies. With the development of dedicated accessories and standardization of drainage techniques, the role of endoscopic ultrasound is likely to expand further in cases with double obstruction.
Subject(s)
Humans , Bile Ducts , Catheterization , Cholangiopancreatography, Endoscopic Retrograde , Constriction, Pathologic , Drainage , Duodenal Obstruction , Duodenum , Endoscopy , Gastric Outlet Obstruction , Jaundice, Obstructive , Length of Stay , Prognosis , Stents , UltrasonographyABSTRACT
Objective@#To investigate the effects of preoperative percutaneous transhepatic biliary drainage on surgical treatment of type Ⅲ and Ⅳ hilar cholangiocarcinoma.@*Methods@#Clinical data of 72 patients with hilar cholangiocarcinoma of the Bismuth-Corlette type Ⅲ and Ⅳ treated at Department of General Surgery,First Affiliated Hospital of Bengbu Medical College from January 2010 to December 2017 were analyzed retrospectively.Patients were divided into two groups based on whether PTBD was performed:a drained group and an undrained group.In the drained group,there were 31 patients,20 males and 11 females,aged (59.9±9.7)years (range: 39-73 years).Among them,14 patients underwent hepatectomy with half or more than half of the liver removed (extended hepatectomy)and 17 patients underwent non-anatomical hepatectomy in the hilar region (limited hepatectomy).In the undrained group,there were 41 patients, 26 males and 15 females, aged (60.8±7.8)years(range: 45-75 years).Among them, 17 patients underwent hepatectomy with half or more than half of the liver removed (extended hepatectomy)and 24 patients underwent non-anatomical hepatectomy in the hilar region (limited hepatectomy).Percutaneous transhepatic biliary drainage(PTBD)was used in the drained group.Under the guidance of ultrasound,one or more hepatobiliary ducts could be sufficiently drained,which had good effect and was not restricted by the obstruction location of hilar cholangiocarcinoma.The analysis of the measurement data was performed using t test,and the analysis of the count data was performed using χ2 test,and the survival curve was plotted using Kaplan-meier method.@*Results@#In total, 72 jaundiced patients with hilar cholangiocarcinoma underwent surgical treatment: 31 had PTBD prior to operation while 41 did not had PTBD.There were significant differences in ALT((93.2±21.4)U/L vs.(207.4±65.1)U/L),AST((87.6±18.1)U/L vs.(188.9±56.6)U/L)and total bilirubin((68.8±12.6)μmol/L vs.(227.5±87.7)μmol/L)between the patients after treatment and those before treatment(t=10.958, P=0.000; t=10.845, P=0.000; t=10.386, P=0.000).Compared with those in the undrained group, the operation time was shorter, the amount of intraoperative bleeding and the incidence of complications were lower in the drained group(t=-2.840, P=0.006; t=-3.698, P=0.000; χ2=4.108, P=0.043).There were no perioperative death cases in drained group and 2 perioperative death cases in undrained group.There was no significant difference in R0 resection rate between the two groups(χ2=0.778,P=0.378).The 1-,3-,5-year survival rate of patients in the drained group and the undrained group was 72.7%,34.2%, 13.7% and 72.8%, 31.5%, 11.8%, respectively.The difference was not statistically significant(all P>0.05).@*Conclusions@#The preoperative percutaneous transhepatic biliary drainage in patients with hilar cholangiocarcinoma of Bismuth-Corlette type Ⅲ and Ⅳ could effectively shorten operative time, reduce amount of intraoperative bleeding and incidence of postoperative complications,but have no significant effect on the R0 resection rate and survival rate.