Percutaneous Metallic Stent Placement for Palliative Management of Malignant Biliary Hilar Obstruction

OBJECTIVE: To investigate the outcomes of percutaneous metallic stent placements in patients with malignant biliary hilar obstruction (MBHO). MATERIALS AND METHODS: From January 2007 to December 2014, 415 patients (mean age, 65 years; 261 men [62.8%]) with MBHO were retrospectively studied. All the patients underwent unilateral or bilateral stenting in a T, Y, or crisscross configuration utilizing covered or uncovered stents. The clinical outcomes evaluated were technical and clinical success, complications, overall survival rates, and stent occlusion-free survival. RESULTS: A total of 784 stents were successfully placed in 415 patients. Fifty-five patients had complications. These complications included hemobilia (n = 19), cholangitis (n = 13), cholecystitis (n = 11), bilomas (n = 10), peritonitis (n = 1), and hepatic vein-biliary fistula (n = 1). Clinical success was achieved in 370 patients (89.1%). Ninety-seven patients were lost to follow-up. Stent dysfunction due to tumor ingrowth (n = 107), sludge incrustation (n = 44), and other causes (n = 3) occurred in 154 of 318 patients. The median overall survival and the stent occlusion-free survival were 212 days (95% confidence interval [CI], 186−237 days) and 141 days (95% CI, 126−156 days), respectively. The stent type and its configuration did not affect technical success, complications, successful internal drainage, overall survival, or stent occlusion-free survival. CONCLUSION: Percutaneous stent placement may be safe and effective for internal drainage in patients with MBHO. Furthermore, stent type and configuration may not significantly affect clinical outcomes.

Preoperative biliary drainage for perihilar cholangiocarcinoma: A Meta-analysis / 中华肝胆外科杂志

Objective To systematically review the effectiveness and safety of percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary drainage (EBD) for preoperative biliary drainage in patients with Klatskin Tumors.Methods The Pubmed,Embase,Web of Science,CNKI,VIP and WanFang Data from January 1998 to December 2017 were searched for published studies which compared endoscopic biliary drainage (EBD) with percutaneous transhepatic biliary drainage (PTBD) for preoperative biliary drainage.A Meta-analysis was then performed using the Revman 5.3 software.Results Seven cohort studies were included.There were 366 patients in the PTBD group,and 400 patients in the EBD groups.When compared with EBD,PTBD was associated with a lower risk of cholangitis (OR=0.31,95％ CI 0.20～0.48,P＜0.05),a lower risk of pancreatitis (OR=0.11,95％ CI 0.04 ～ 0.34,P＜0.05),and a lower risk of overall complications (OR=0.48,95％ CI 0.30 ～ 0.77,P=0.002).The rate of conversion from one procedure to the other was significantly lower in the PTBD group than the EBD group.The initial technical success rate and postoperative morbidity and mortality rates were similar in the 2 groups.Conclusion In patients with Klatskin tumors who require PBD,PTBD is a better initial biliary drainage method with lower incidences of procedure-related cholangitis,pancreatitis overall complications and conversion to other drainage procedures.

Ultrasound guided percutaneous transhepatic biliary drainage: an analysis of 479 patients / 中华肝胆外科杂志

Objective To analyze the clinical value of percutaneous transhepatic biliary drainage (PTBD) in the treatment of obstructive jaundice.Methods A total of 479 patients with obstructive jaundice were enrolled in PLA General Hospital from July 2015 to July 2017 underwent percutaneous transhepatic biliary drainage,the preoperative serum total bilirubin was 92 ～ 614 μmol/L,the target bile duct was 2 ～ 16 mm in diameter.The PTBD was ultrasound guided.Results All of the 479 patients underwent PTBD successfully,and 99.6％ showed evident alleviation of jaundice postoperatively.Conclusions Ultrasoundguided PTBD is an effective method for reducing jaundice for preoperative or palliative treatment in patients with obstructive jaundice.The method of operation is worthy of further study.

Current status and progress on preoperative biliary drainage of hilar cholangiocarcinoma / 中华肝胆外科杂志

Preoperative biliary drainage (PBD) is an important part of preoperative management of patients with hilar cholangiocarcinoma which could reduce serum total bilirubin,remove jaundice,improve liver function,and reduce the mortality and morbidity.Although PBD is widely used in biliary surgery now,there are still several controversial issues in clinical applications about the indication of PBD,the best way of PBD,implantation metastasis of PBD and so on.With the development of medical image and surgical technology,we had a better understanding of PBD now.This review summarizes the recent scenario and current advancement about the above-mentioned controversy.

Endoscopic Removal of Remained Drawstring After Percutaneous Transhepatic Biliary Drainage / 고신대학교의과대학학술지

The percutaneous transhepatic biliary drainage (PTBD) is an effective intervention as a palliative therapy for relieving a jaundice and cholangitis. It may be used in place of Endoscopic retrograde cholangiopancreatography (ERCP) in the obstructive biliary disease. Recently, by developing invasive procedures, the incidence of the complications such as bleeding and perforation has been increasing in the diagnosis and treatment of hepatobiliary disease. We report here on a case of remained drawstring after PTBD in a 85-year-old man. The patient was conducted PTBD for relieving a jaundice and cholangitis. And then the patient had complained of abdominal pain constantly. A few days later, we removed PTBD and attempted ERCP for removal of CBD stone. The ERCP showed remained drawstring around ampulla of vater and we removed it by IT knife. The drawstring was successfully removed.

Analysis of complications after ultrasound-guided PTBD / 中华肝胆外科杂志

Objective To investigate the reasons of complications after ultrasound-guided PTBD and explore measures for their management. Methods The clinical data of 753 patients with obstructive jaundice treated with ultrasound-guided PTBD in our hospital from January 2001 to June 2008were retrospectively analyzed. Results The 753 patients received a total of 791 treatments of PTBD.The occurring rates of severe, common, and long-term complications were 1.14 % (9/791), 11.88 %(94/791 ) and 4.3% (9/791), respectively. Only 1 patient died of manipulation-related complications.Conclusion Ultrasound-guided PTBD is an effective method for treatment of obstructive jaundice.

Significance of Intra & Extra Hepatic Duct Stone Removal via Percutaneous Transhepatic Biliary Drainage Tube in Patients Undergoing Laparoscopic Cholecystectomy

PURPOSE: One of the popular and widespread treatments for intra- & extra-hepatic duct (IEHD) stone associated gallbladder (GB) stone is laparoscopic cholecystectomy (LC) with stone removal through endoscopic retrograde cholangiopancreatography (below ERCP). Because LC with stone removal through percutaneous transhepatic biliary drainage (below PTBD) is well known for its safety and feasibility in removing IEHD stones, we did this study to see the significance (safety, feasibility, effectiveness etc) of PTBD and stone removal. METHODS: We compared the odds by collecting 71 retrospective cases, victims of IEHD stone associated GB stone from January, 2004 to December, 2007 in Chung-Ang University Hospital. Comparative analysis took place in 51 cases who underwent PTBD and 20 cases treated with ERCP. We excluded 6 patients who underwent PTBD for intra hepatic duct stone. Age, sex, American Society of Anesthesiologists score, pain, nausea, pre- and post- laboratory value, symptoms, size, location and number of stones, diameter of extra hepatic duct, recurrence and clearance rate, frequency of each procedure, complications, cost were investigated in this study. RESULTS: There were no statistical differences in each group in recurrence and clearance rate or frequency of procedure. However post-procedure pancreatitis and amylase level were significantly difference in each group. PTBD group experienced much longer hospital stay but was not significantly different. Although procedure cost is three times more expensive than that of PTBD group, there were no differences in total cost and patients' expenses between the two groups. CONCLUSION: PTBD would be an alternative solution in managing IEHD stone associated with GB stone for its lower rate of complication, higher clearance with minimal discomfort.

A Case of Implantation Metastasis of Gallbladder Cancer Following Percutaneous Transhepatic Biliary Drainage (PTBD) / 대한피부과학회지

The occurrence of metastatic cancer from the gallbladder to the skin is uncommon and only less than ten cases of distant cutaneous metastases of gallbladder cancer have been reported in literatures. However, cutaneous implantation metastases of gallbladder cancer following laparoscopic cholecystectomy or percutaneous biliary catheter have been described more commonly than distant metastasis. We present herein a case of cutaneous implantation metastasis of gallbladder adenocarcinoma at the sites of percutaneous transhepatic biliary drainage (PTBD).

Ultrasound-guided percutaneous transhepatic gallbladder or bile duct drainage in hepatobiliary diseases / 中国微创外科杂志

Objective To investigate the practical value of ultrasound-guided percutaneous transhepatic gallbladder drainage (PTGD) and percutaneous transhepatic bile duct drainage (PTBD)in the treatment of hepatobiliary diseases. Methods A total of 68 times of ultrasound-guided PTGD/PTBD were performed in 60 patients from December 2000 to December 2003, including 15 cases of acute pyogenic cholecystitis, 8 cases of acute severe cholangitis and 37 cases of malignant obstructive jaundice. Results Out of the 15 cases of acute pyogenic cholecystitis, PTGD was completed successfully in 14 cases and failed in 1 case which then required a conversion to open operation. The 37 cases of malignant obstructive jaundice had undergone 45 times of PTBD, which consisted of 42 times of successful drainage tube placement and 3 times of failure (2 cases of conversions to open operation and 1 case of quitting treatment). Out of the 37 cases, resection of bile duct carcinoma or palliative cholangiojejunostomy was conducted in 14 cases, stents were inserted into the bile ducts under radioscopy in 8 cases, and the drainage tubes were left in place permanently in 15 cases (the maximum survival time was over 2 years and the mean survival time was 9 months). Of the 8 cases of acute severe cholangitis, successful drainage was achieved in 6 cases, a conversion to open surgery was required in 1 case because of blocked drainage, and 1 patient died of the multiple organ failure (MOF). Complications included 2 cases of bile leakage, 3 cases of hemorrhage, 1 case of portal vein-bile duct fistula, and 7 cases of drainage tube dislocation or blockage. Conclusions Ultrasound-guided PTGD/PTBD is an effective alternative for bile duct drainage, with advantages of minimal invasion, simplicity and accurateness of performance, safety and fewer complications. It presents much clinical value for hepatobiliary diseases, especially acute cholecystitis.

Clinical experiences of Duct-to-Mucosa Pancreaticojejunostomy and PTBD in Pancreaticoduodenectomy(personal experiences of 93 cases) / 한국간담췌외과학회지

BACKGROUND: Pancreaticoduodenectomy is well established in the armamentarium of the surgeon treating periampullary carcinoma and benign lesion. With refinement of operative technique and more enlighting management during the postoperative period, the morbidity and mortality of this procedure have reduced significantly. Leakage of the pancreaticojejunal anastomosis has been a major complication after this procedure, frequently reported in an incidence of 5 percent to 15 percent. Therefore, authors retrospectivly reviewed about clinical experience of duct-to-mucosa anastomosis and PTBD in pancreaticoduodenectomy. OBJECTS & METHODS: The authors retrospectively reviewed the medical records of 93 patients who had undergone a pancreaticoduodenectomy with the duct-to-mucosa method between 1994 and 2000 by one surgeon. RESULTS: The male-to female ratio was 2.1:1(63:30) and mean age was 57 years old(range from 26 to 77). Thirty patients(32.6%) of 93 patients were distal common bile duct cancer, 22 patients(24%) were pancreatic head cancer, 21 patients(23%) were Ampulla of Vater cancer, 5 patients(5.4%) were chronic pancreatitis, 3 patient(3.3%) were duodenal cancer. The operative morbidity was 35.8%, and there was three perioperative mortality(3.2%). The mean operative time was 8.8 hours. A pancreatic fistula was diagnosed in 6 of the 93 patients(6.5%) and surgical intervention was done in 1 of the 6 patients. A PTBD for preoperatively biliary drainage was done 64 cases and complication related PTBD was 3 cases(4.7%, hemobilia). CONCLUSIONS: Even if this anastomotic technique requires a little more time and attention by the surgeon, we experienced that the low incidence of pancreatico-jejunal anastomosis related complication represents a validation of the method, and a motivation to adapt this anastomotic technique. But, this method is not absolute because surgeon's preference is most important factor in operation.

Subcutaneous Metastasis at the PTBD Catheter Insertion Site in Bile-duct Carcinomas: Report of two cases

Percutaneous transhepatic biliary drainage (PTBD) is the basis for most biliary interventional pro cedures, and the application of preoperative PTBD to patients who have malignant obstructive jaundice has a significant effect on overall morbidity, mortality, and patient survival by allowing selective application of the most appropriate therapeutic modality. There are few case reports on subcutaneous metastasis of bile-duct cancer. We recently observed a subcutaneous metastasis at the catheter insertion site after PTBD in two patients with bile-duct cancer. Although tumor-cell seeding along the catheter tract is a very rare complication, we think that PTBD requires more attention when a curative resection is planned.

Obstructive Jaundice in Patients with Gastric Cancer

PURPOSE: Although obstructive jaundice is a rare presentation, it is an ominous sign of poor prognosis in patients with gastric cancer. Thus, we investigated the incidence, the clinical features, the pathologic characteristics, the treatment modality, and the prognosis for obstructive jaundice in patients with gastric cancer. METHODS: A retrospective analysis was done for patients with gastric cancer who had presented with obstructive jaundice at Korea University Guro Hospital from January 1988 to December 1998. RESULTS: During that period, 2546 patients were diagnosed with gastric cancer, and obstructive jaundice was revealed in 20 (0.78%). The mean age was 58 13 years, and the sex ratio (male:female) was 5.7:1. Jaundice was the first presentation in two patients, and it developed in the other 18 patients during the follow-up period after the initial operation or chemotherapy. The level of total bilirubin was 16.7 8.1 mg/dl, and the cause of the jaundice was lymph-node enlargement at the porta hepatis. A percutaneous transhepatic biliary drainage (PTBD) was done in 17 patients, and improvement was seen in 13 (76%). The most common site of the obstruction was common hepatic duct (CHD) (60%). Antrally located, moderately differentiated and Borrmann type-III gastric cancers were commonly associated with obstructive jaundice. The mean duration from jaundice to death was 4.6 6.2 month. CONCLUSION: Obstructive jaundice is very rare in patients with gastric cancer and is associated with poor survival. Although the bilirubin level was decreased by a PTBD, the survival was not improved. An extended lymphadenectomy along the hepatoduodenal ligament is necessary to prevent obstructive jaundice due to recurrence particularly, in patients with antrally located, moderately differentiated and Borrmann type-III carcinomas.