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Objective To investigate the safety and efficacy of photodynamic therapy (PDT) for malignant obstruction of the biliary tract. Methods We retrospectively analyzed the clinical data of patients with malignant biliary obstruction treated by PDT in our medical center. On the basis of different treatment plans, the patients were categorized into the photodynamic only group and the combined treatment group, in which additional interventional operations, targeted therapy, or immunotherapy were arranged. The alterations in liver function, duration of biliary patency, and postoperative complications that occurred within one month were closely monitored in both groups. Results A total number of 19 patients were enrolled in this study. The technical success rate of PDT was 100%. The deterioration of liver function was not observed in any patients within one month after PDT. Within a maximum of 17.7 months follow-up, the patency rates of the biliary tract were 100.0%, 89.5%, 72%, and 64% at 1, 3, 6, and 12 months after the procedure, respectively. The mean biliary patency time was 6.9±0.8 months (95%CI: 5.2-8.7 months). Specifically, the biliary patency times for Bismuth type Ⅲ and Ⅳ were 7.5±1.1 and 6.1±1.3 months, respectively. The biliary patency time was around 3.3±0.7 months in the photodynamic only group and 7.9±0.9 months in the combined treatment group (P=0.017). Conclusion PDT for Bismuth Ⅲ-Ⅳ malignant biliary obstruction is safe and effective. Moreover, the period of biliary patency is greatly extended when PDT is combined with systemic therapy.
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Abstract In Malignant Hilar Biliary Stricture (MHBS) palliative biliary drainage is a frequent strategy, improving the quality of life, reducing pruritus, loss of appetite and relieving cholangitis. The endoscopic approach is an effective, although challenging procedure. This study aimed to evaluate technical and clinical success rates of biliary drainage by ERCP. This is a retrospective study including all patients with MHBS referred to Instituto do Cancer do Hospital de São Paulo (ICESP) submitted to biliary drainage by ERCP, between January 2010 and December 2017. Multivariable logistic regression was performed to evaluate predictors of clinical failure, as total bilirubin levels, Bismuth classification, number of hepatic sectors drained and presence of cholangitis. In total, 82 patients presenting unresectable MHBS were included in this study. 58.5% female and 41.5% male, with a mean age of 60±13 years. Bismuth classification grades II, IIIA, IIIB and IV were noted in 23.2%, 15.9%, 14.6% and 46.3%, respectively. Technical and clinical success was achieved in 92.7% and 53.7% respectively. At multivariable logistic-regression analyses, Bismuth IV strictures were related to higher clinical failure rates when compared to other strictures levels, with an Odds Ratio of 5.8 (95% CI 1.28‒20.88). In conclusion, endoscopic biliary drainage for malignant hilar biliary stricture had a high technical success but suboptimal clinical success rate. Proximal strictures (Bismuth IV) were associated with poor drainage outcomes.
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Objective To investigate the etiological characteristics of infection after percutaneous biliary drainage or stent implantation in patients with malignant biliary obstruction (MBO). Methods Clinical data were collected from MBO patients who underwent interventional therapy in Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, from January 2016 to December 2020 and had or were suspected of biliary tract infection, with samples submitted for bile culture and/or simultaneous blood culture. Analysis was performed for the aspects of positive rate of culture, flora distribution, consistency between blood culture and bile culture, and drug resistance rate of major pathogenic bacteria. Results A total of 219 patients were enrolled, among whom 105(47.95%) were positive for bile culture, and the composition ratios of Gram-negative bacteria, Gram-positive bacteria, and fungi were 64.89%, 28.24%, and 6.87%, respectively. A total of 69 patients had samples submitted for blood culture during the same period of time, among whom 33(47.82%) had positive results. Positive results of both bile culture and blood culture were observed in 25 patients, and consistency analysis showed that the patients with complete consistency, partial consistency, and complete inconsistency accounted for 36%(9/25), 20%(5/25), and 44%(11/25), respectively. Common Gram-negative bacteria were Escherichia coli , Klebsiella pneumoniae , and Enterobacter cloacae , with a relatively low level of drug resistance to antibiotics including cefoperazone/sulbactam, amikacin, and imipenem. Common Gram-positive bacteria were Enterococcus faecium and Enterococcus faecalis , with a relatively low level(< 15%) of drug resistance to antibiotics including vancomycin, linezolid, and teicoplanin. Conclusion Common pathogens of infection after percutaneous biliary drainage or stent implantation in MBO patients include Escherichia coli , Klebsiella pneumoniae , Enterococcus, and Enterobacter cloacae . There is a relatively low level of consistency between blood culture and bile culture, and thus samples should be submitted for both tests.
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Objective:To evaluate the safety and feasibility of double endoscopic bypass, namely endoscopic ultrasound-guided gastroenterostomy (EUS-GE) combined with endoscopic ultrasound-guided biliary drainage (EUS-BD), for malignant gastric outlet and biliary obstruction.Methods:A retrospective analysis was conducted on data of 10 patients with malignant gastric outlet and biliary obstruction who were not suitable for surgery or endoscopic retrograde cholangiopancreatography (ERCP) and treated by double endoscopic bypass in Nanjing Drum Tower Hospital from August 2017 to October 2020. The completion of therapy, clinical efficacy and post-procedure adverse events were analyzed.Results:Ten patients with different malignant cancer successfully underwent EUS-GE and EUS-BD, with procedure time of 60.5±22.3 min (30-100 min). There were no postoperative adverse events. EUS-GE was clinically successful in all 10 cases. Of the 10 EUS-BD cases, 9 were clinically successful, and 1 did not meet the criteria of clinical success. The median follow-up was 71 (37-120) days. None of the 10 patients had recurrent gastric outflow tract obstruction or biliary tract obstruction.Conclusion:Double endoscopic bypass is feasible and effective for patients with malignant gastric outlet and biliary obstruction and without surgery or ERCP opportunity.
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Background and Aim: The etiology of extrahepatic biliary obstruction (EHBO) ranges from benign disorders to pancreaticobiliary malignancy. We studied the demographic, clinical, laboratory, and endoscopic features of young patients with EHBO undergoing Endoscopic retrograde cholangiopancreatography (ERCP). Methods: We retrospectively analyzed one-year data of ERCP procedures performed on adult patients under 40 years of age. The diagnosis was based on a clinical and radiological basis with histopathological confirmation. Results: A total of 180 patients were included with a mean(±SD) age of 33.4(±5.8, range: 15-40) years, and 67.8% being female. Benign (67.2%) findings included choledocholithiasis (57.8%), benign biliary stricture (9.44%, post cholecystectomy stricture 82.3%), and malignant (32.8%) causes were gallbladder carcinoma (24.4%), cholangiocarcinoma (4.4%), periampullary carcinoma (2.8%), pancreatic head carcinoma (1.1%). Clinical presentation included jaundice (66.1%), pain abdomen (59.4%), pruritis (26.1%), weight loss (19.4%), anorexia, fever, and cholangitis (24.44%). Mean bilirubin levels (16.9 ±6.8 vs 4.6 ±4.1 mg/dl) and alkaline phosphatase (1170 ± 260.7 vs 439.3 ± 362.7 IU/mL) were higher in malignant causes, in comparison to benign. Stone retrieval using balloon during ERCP was successful in 79% of cases. Large (>15 mm) or impacted stones or those with biliary stricture failed stone extraction. In gallbladder carcinoma, adequate endoscopic biliary drainage was achieved in 68% of patients. Endoscopic biliary drainage was achieved in 75%, 80%, and 50% cases of cholangiocarcinoma, periampullary carcinoma, and pancreatic head carcinoma, respectively. Conclusion: Choledocholithiasis and gallbladder carcinoma are the most common benign and malignant causes of EHBO in young patients. The successful endoscopic therapeutic intervention could be achieved in most patients.
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Objective: We sought to analyze the efficacy and safety of preserving the Oddis sphincter during metallic biliary stent implantation in patients with malignant obstructive jaundice. Materials and Methods: In a retrospective analysis, 133 patients with malignant obstructive jaundice who were admitted to our hospital from January 2010 to January 2017 and who underwent metallic biliary stent implantation were divided into two groups – the Oddis sphincter retention group (n = 55) and the Oddis sphincter nonretention group (n = 78) – according to whether the Oddis sphincter was left untouched during stent placement. The patient clinical data as well as information on complications, time of stent patency, improvement in liver function, and decline of serum bilirubin were reviewed and evaluated. Statistical analysis was performed using the Statistical Package for the Social Sciences version 19.0 (IBM Corp., Armonk, NY, USA, USA) and Prism version 7 (GraphPad Software, San Diego, CA, USA). Results: The median follow-up time was 9.6 months (range: 1–20 months) and there was no significant difference in general clinical information between the two groups. However, the incidence rates of acute biliary infection, recurrent biliary infection, acute pancreatitis, chronic pancreatitis, and asymptomatic pancreatic enzyme levels were higher in the Oddis sphincter retention group and the differences were all statistically significant (P < 0.05). Conversely, there were no significant differences in bilirubin decline, liver function improvement, and stent patency between the two groups (P > 0.05). Conclusion: Leaving the Oddis sphincter untouched during biliary stent placement can reduce the incidence of postoperative complications, while there was no effect on stent patency or jaundice relief. Therefore, it is recommended to preserve the Oddis sphincter when the stenosis is more than 3 cm above the duodenal papilla
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Background: The aim of this study was to evaluate the potential inhibiting effects of vitamin C as an antioxidant against liver fibrosis and lipid peroxidation in the bile duct ligation- induced biliary obstruction of Wistar rats.Methods: A total of 25 male Wistar albino rats were divided into five groups: sham operated, control (bile duct ligation/BDL) without given vitamin C, BDL with vitamin C 75 mg, BDL with vitamin C 150 mg, and BDL with vitamin C 225 mg. Each group contained 5 animals. Vitamin C was given orally on day 3 after operation and after 14 days following vitamin C administration, all animals were performed laparotomy to obtain liver tissue samples for histopathological investigation of liver fibrosis and blood samples for malondialdehyde (MDA) as lipid peroxidation measurement.Results: The changes demonstrating hepatic fibrosis including moderate to markedly thickened wall of central veins, localized to diffuse perisinusoidal fibrosis, enlarged portal track, increased number of septa, and thickened width of septa were observed in BDL groups. MDA measurement were also observed in all groups. Treatment of biliary obstruction in BDL groups with vitamin C given orally attenuated liver damage. Both the MDA measurement and histopathologic investigation of hepatic fibrosis were observed to be reduced with the vitamin C treatment.Conclusions: Our data indicate that vitamin C inhibited liver fibrosis and lipid peroxidation in bile duct ligation-induced biliary obstruction of Wistar rats.
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Aim: Self.expandable metallic stent (SEMS) placement has been considered as the preferred treatment to relieve jaundice in nonsurgical patients. However, 50% of stents become stenosed within 3.6 months due to tumor ingrowth and epithelial hyperplasia. This study aims to evaluate the feasibility and efficacy of a newly designed brachytherapy biliary drainage catheter (BBDC) loaded with 125I seeds for palliation of malignant biliary obstruction (MBO). Methods: In this prospective study, patients with unresectable MBO underwent BBDC placement after SEMS placement at our center from September 2017 to April 2019. Results: A total of 21 patients with MBO were enrolled. The technical and clinical success rates were 100%. Total bilirubin, direct bilirubin, alanine aminotransferase, alkaline phosphatase, cancer antigen 19.9, and carcinoembryonic antigen levels significantly decreased during the 1.month follow.up (P < 0.05). Four patients (19%) had minor complications. During the median follow.up of 299 days, 13 patients (61.9%) developed stent occlusion. The 6.month stent patency and survival rates were 73.5% and 79.2%, respectively. The median stent patency and survival were 279 and 454 days, respectively. Conclusion: The use of BBDC loaded with 125I seeds is a feasible and effective method to prolong biliary stent patency in patients with MBO
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Malignant biliary obstruction (MBO) leads to obstructive jaundice as a result of bile excretion disorder, which may cause complications such as cholangitis, sepsis, hepatic failure and even life-threatening. Biliary drainage is an effective mean to relieve symptoms and improve patients'quality of life. At present, endoscopic retrograde cholangiopancreatography (ERCP) is the first-line palliative treatment for MBO patients without surgical opportunity. In recent years, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been gradually accepted as an alternative to percutaneous transhepatic biliary drainage (PTBD) in MBO with failed ERCP. The available evidence suggests that EUS-BD might even replace ERCP as the first-line procedure in patients with malignant distal biliary obstruction by experienced surgeons. This paper reviews the research progresses of EUS-BD in MBO.
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Objective@#To improve the awareness of emergency biliary obstruction (BO) disease, and to further improve the diagnosis and treatment ability of BO patients.@*Methods@#Data of the etiology, clinical manifestations, imaging data, laboratory tests, and emergency treatment outcomes in 63 BO patients were retrospectively analyzed.@*Results@#Common bile duct stones were the most common cause of BO patients (63.49%), followed by cholangiocarcinoma (19.05%); the most common clinical manifestations of BO patients were jaundice (90.48%), abdominal pain (87.30%), and fever (53.97%); the diagnostic ability of computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) in patients with BO was significantly higher than that of ultrasound (P<0.05), but there was no significant difference between CT and MRCP (P=1.000); compared with benign group, hemoglobin and albumin in malignant group were significantly lower, while total bilirubin and direct bilirubin were higher, with statistically significant difference (P<0.05). Most patients in BO patients improved after treatment, and the mortality rate of BO patients was 3.17%(2/63) at the end of emergency visit.@*Conclusions@#Common bile duct stones and cholangiocarcinoma are still the most common causes of emergency BO patients. The most common clinical manifestations of patients with emergency BO are jaundice, abdominal pain, and fever. Better than abdominal ultrasound, CT and MRCP have comparable diagnostic capabilities in the diagnosis of emergency BO patients. Anemia, hyperbilirubinemia and hypoproteinemia are alarm indicators for malignant tumors in emergency BO patients. Most patients can temporarily get better at the end of emergency visit.
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Objective To improve the awareness of emergency biliary obstruction (BO) disease,and to further improve the diagnosis and treatment ability of BO patients.Methods Data of the etiology,clinical manifestations,imaging data,laboratory tests,and emergency treatment outcomes in 63 BO patients were retrospectively analyzed.Results Common bile duct stones were the most common cause of BO patients (63.49％),followed by cholangiocarcinoma (19.05％);the most common clinical manifestations of BO patients were jaundice (90.48％),abdominal pain (87.30％),and fever (53.97％);the diagnostic ability of computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) in patients with BO was significantly higher than that of ultrasound (P ＜ 0.05),but there was no significant difference between CT and MRCP (P =1.000);compared with benign group,hemoglobin and albumin in malignant group were significantly lower,while total bilirubin and direct bilirubin were higher,with statistically significant difference (P ＜ 0.05).Most patients in BO patients improved after treatment,and the mortality rate of BO patients was 3.17％ (2/63) at the end of emergency visit.Conclusions Common bile duct stones and cholangiocarcinoma are still the most common causes of emergency BO patients.The most common clinical manifestations of patients with emergency BO are jaundice,abdominal pain,and fever.Better than abdominal ultrasound,CT and MRCP have comparable diagnostic capabilities in the diagnosis of emergency BO patients.Anemia,hyperbilirubinemia and hypoproteinemia are alarm indicators for malignant tumors in emergency BO patients.Most patients can temporarily get better at the end of emergency visit.
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OBJECTIVES: In cirrhotic children, infection events and sepsis are more frequent and more severe due to immune dysfunction. The objectives of the current study were therefore to develop an experimental model of infection and sepsis in cirrhotic weaning growing rats, by the use of bile duct ligation (BDL) and cecal ligation and puncture (CLP). Additionally, the correlation of the clinico-histopathological data and serial cytokine levels in septic cirrhotic and non-cirrhotic animals was studied. METHODS: Young Wistar rats of age 21 days and of weight between 70-90 g were divided into 12 groups according to the surgical procedure performed: sham (sacrificed after 2 or 4 weeks), BDL (sacrificed after 2 or 4 weeks), CLP (2- or 4-week old animals sacrificed after 12 or 24 hours), BDL+CLP (2- or 4-week old animals sacrificed after 12 hours). Histopathological studies and determination of serum levels of cytokines IL-1 beta, IL-10, and TNF-alpha, for studies of systemic infection, were performed. Murine sepsis scores (MSS) based on the clinical aspects just before euthanasia were also included. RESULTS: A transitory increase in IL-1, IL-10, and TNF-alpha levels was observed, with different patterns according to the groups. Two-hit groups tended to present with higher values of serum cytokines and histopathological scores than their septic non-cirrhotic counterparts. There was a correlation between mortality rate and MSS (p<0.0001). CONCLUSION: The model is feasible and may be utilized in studies on liver cirrhosis and infection in growing animals.
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Animals , Mice , Rats , Sepsis , Liver Cirrhosis , Reproducibility of Results , Rats, Wistar , Models, TheoreticalABSTRACT
ABSTRACT BACKGROUND: Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE: To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING: Cross-sectional study at a tertiary-level university hospital. METHODS: Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS: Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS: There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.
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Humans , Male , Female , Adult , Middle Aged , Aged , Cholangitis/diagnosis , Jaundice, Obstructive/diagnosis , Tertiary Care Centers , Hospitals, University , Patient Admission/statistics & numerical data , Referral and Consultation/statistics & numerical data , Bilirubin/analysis , Brazil/epidemiology , Patient Acceptance of Health Care , Drainage , Cholangitis/surgery , Cholangitis/epidemiology , Acute Disease , Cross-Sectional Studies , Retrospective Studies , Sensitivity and Specificity , Cholangiopancreatography, Endoscopic Retrograde/statistics & numerical data , Jaundice, Obstructive/surgery , Jaundice, Obstructive/epidemiology , Data AccuracyABSTRACT
Endoscopic transpapillary biliary drainage is the current standard of care for unresectable hilar malignant biliary obstruction (MBO) and bilateral metal stent placement is shown to have longer patency. However, technical and clinical failure is possible and percutaneous transhepatic biliary drainage (PTBD) is sometimes necessary. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is increasingly being reported as an alternative rescue procedure to PTBD. EUS-BD has a potential advantage of not traversing the biliary stricture and internal drainage can be completed in a single session. Some approaches to bilateral biliary drainage for hilar MBO under EUS-guidance include a bridging method, hepaticoduodenostomy, and a combination of EUS-BD and transpapillary biliary drainage. The aim of this review is to summarize data on EUS-BD for hilar MBO and to clarify its advantages over the conventional approaches such as endoscopic transpapillary biliary drainage and PTBD.
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Constriction, Pathologic , Drainage , Endosonography , Methods , Standard of Care , StentsABSTRACT
Early removal of a percutaneous transhepatic biliary drainage (PTBD) tube commonly causes pneumoperitoneum. However, we encountered a patient who developed pneumoperitoneum even with an indwelling PTBD tube. An 84-year-old man was admitted with type III combined duodenal and biliary obstruction secondary to metastatic bladder cancer. A biliary stent was placed using a percutaneous approach, and a duodenal stent was placed endoscopically. A large amount of subphrenic free air was detected after the procedures. Laboratory tests indicated intestinal perforation; however, peritoneal signs were absent. The patient was treated conservatively using an indwelling Levin tube. Seven days later, the massive amount of subphrenic free air disappeared. Follow-up tubography revealed unrestricted bile flow into the small intestine, and the PTBD tube was removed. Prolonged endoscopic procedures in patients with a PTBD tract communicating with the gastrointestinal tract can precipitate pneumoperitoneum. Clinicians should be careful to avoid misdiagnosing this condition as intestinal perforation.
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Aged, 80 and over , Humans , Bile , Drainage , Follow-Up Studies , Gastrointestinal Tract , Intestinal Perforation , Intestine, Small , Pneumoperitoneum , Stents , Urinary Bladder NeoplasmsABSTRACT
Pancreatic cancer is a major cause of cancer-related mortality and morbidity, and its incidence is increasing as the population is aging. On the other hand, significant improvement in the prognosis has not occurred. The absence of early diagnosis means that many patients are diagnosed only when they develop symptoms, such as jaundice, due to a biliary obstruction. The role of endoscopy in multidisciplinary care for patients with pancreatic cancer continues to evolve. Controversy remains regarding the best preoperative biliary drainage in patients with surgically resectable pancreatic head cancer. In general, patients undergoing a surgical resection usually do not require preoperative biliary drainage unless they have cholangitis or receive neoadjuvant chemotherapy. If biliary drainage is performed prior to surgery, the patient's condition and a multidisciplinary approach should be considered. With the increasing life expectancy of patients with pancreatic cancer, the need for more long-time biliary drainage or pre-operative biliary drainage is also increasing. Strong evidence of endoscopic retrograde cholangiopancreatography (ERCP) as a first-line and essential treatment for biliary decompression has been provided. On the other hand, the use of endoscopic ultrasound-guided biliary drainage as well as percutaneous biliary drainage has been also recommended. During ERCP, self-expandable metal stent could be recommended instead of a plastic stent for the purpose of long stent patency and minimizing stent-induced complications. In this review, several points of view regarding the relief of obstruction in patients with pancreatic cancer, and optimal techniques are being discussed.
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Humans , Aging , Cholangiopancreatography, Endoscopic Retrograde , Cholangitis , Decompression , Drainage , Drug Therapy , Early Diagnosis , Endoscopy , Hand , Head and Neck Neoplasms , Incidence , Jaundice , Life Expectancy , Mortality , Pancreatic Neoplasms , Plastics , Prognosis , StentsABSTRACT
Pancreatic cancer is a major cause of cancer-related mortality and morbidity, and its incidence is increasing as the population is aging. On the other hand, significant improvement in the prognosis has not occurred. The absence of early diagnosis means that many patients are diagnosed only when they develop symptoms, such as jaundice, due to a biliary obstruction. The role of endoscopy in multidisciplinary care for patients with pancreatic cancer continues to evolve. Controversy remains regarding the best preoperative biliary drainage in patients with surgically resectable pancreatic head cancer. In general, patients undergoing a surgical resection usually do not require preoperative biliary drainage unless they have cholangitis or receive neoadjuvant chemotherapy. If biliary drainage is performed prior to surgery, the patient's condition and a multidisciplinary approach should be considered. With the increasing life expectancy of patients with pancreatic cancer, the need for more long-time biliary drainage or pre-operative biliary drainage is also increasing. Strong evidence of endoscopic retrograde cholangiopancreatography (ERCP) as a first-line and essential treatment for biliary decompression has been provided. On the other hand, the use of endoscopic ultrasound-guided biliary drainage as well as percutaneous biliary drainage has been also recommended. During ERCP, self-expandable metal stent could be recommended instead of a plastic stent for the purpose of long stent patency and minimizing stent-induced complications. In this review, several points of view regarding the relief of obstruction in patients with pancreatic cancer, and optimal techniques are being discussed.
Subject(s)
Humans , Aging , Cholangiopancreatography, Endoscopic Retrograde , Cholangitis , Decompression , Drainage , Drug Therapy , Early Diagnosis , Endoscopy , Hand , Head and Neck Neoplasms , Incidence , Jaundice , Life Expectancy , Mortality , Pancreatic Neoplasms , Plastics , Prognosis , StentsABSTRACT
Objective To evaluate the efficacy of endoscopic ultrasound guided biliary drainage (EUS-BD) in patients with biliary obstruction and surgically altered anatomies.Methods We collected data from 33 patients with biliary obstruction and surgically altered anatomies from January 2016 to January 2018 in Zhejiang University School of Medicine Affiliated Hangzhou First People's Hospital who underwent EUS-guided biliary drainage after unsuccessful ERCP.The operation success rate,clinical success rate,complication rate,hospital stay were studied.Results Of 33 patients,31 were successfully operated and stented using endoscopic ultrasound puncture:14 patients through the stomach,17 patients through the duodenum;8 patients by the rendezvous approach.The operation success rate was 93.9％.Of the 33 patients,28 had a significant decrease in jaundice,with a clinical success rate of 84.9％.Complications consisted of 2 patients with bleeding and 1 patient with cholangitis.These patients improved after conservative treatment.The complications rate was 9.1％.The hospital stay was (12.4±5.7) d.Conclusion EUS-BD can be the first choice for patients with biliary obstruction and surgically altered anatomy after failed endoscopic retrograde cholangiograohv in centers with exoertise in EUS-BD procedures.
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Objective To design a new integrated portable biliary internal-external drainage catheter carrying125 I seeds used for the treatment of malignant biliary obstruction lesions so as to achieve the dual curative effects of biliary drainage and brachytherapy. Methods A total of 15 patients with malignant obstructive jaundice, who were admitted to the First Affiliated Hospital of Zhengzhou University, China, during the period from September 2016 to January 2018, were enrolled in this study. Biliary stent implantation was performed in all patients, which was followed by insertion of a new integrated portable biliary internal-external drainage catheter carrying125 I seeds. The technical success rate, clinical success rate, complications, stent patency time and patient survival rate were evaluated. Results The placement of the drainage tube was simple and smooth, and the technical procedure was successful in all patients. One month after treatment, the bilirubin level was decreased significantly when compared with preoperative one (P<0.01), while the blood indexes and immunological indicators showed no obvious changes (P>0.05) . After treatment, 2 patients (13.3％) developed cholangitis and 2 patients (13.3％) had small amount of biliary bleeding, which returned to normal after symptomatic treatment. No severe complications such as perforation of bile duct, massive bleeding, radiation enteritis and radioactive source leakage, etc., occurred. The patients were followed up for 55-402 days, 6 patients (40.0％) developed biliary re-obstruction. The median patency time of stent was 255 days, and 6-month stent patency rate was 64.5％. Five patients died and 10 patients survived, the 9-month survival rate was 64.3％, the median survival time was 368 days. Conclusion By using the new integrated portable biliary internal-external drainage catheter carrying125 I seeds, the effects of bile drainage and brachytherapy can be simultaneously achieved. Preliminary clinical practice indicates that this new drainage catheter is feasible, safe and effective, although its long-term efficacy needs to be clarified with further follow-up observations and controlled studies.
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Resumen Antecedentes y objetivos: la pancreatitis y la colecistitis son complicaciones mayores después de la postura de un stent metálico cubierto en el manejo de la obstrucción biliar distal maligna. Se pretende comparar el uso de un stent biliar cubierto convencional con un nuevo prototipo de stent biliar cubierto de morfología en flor con baja fuerza axial (FA) y fuerza radial (FR), y evaluar el impacto de las cifras de colecistitis y pancreatitis poststent. Métodos: se realizó un estudio prospectivo no aleatorizado en el que se comparó un grupo de 18 pacientes con stent biliar tipo flor (SF) con un grupo de pacientes que recibieron un stent biliar convencional (SC) con una relación 1:2, para el manejo de la obstrucción biliar distal maligna. Se evaluaron datos demográficos; el éxito técnico y clínico; así como la aparición de colecistitis y/o pancreatitis, tasas de migración y/u oclusión. Resultados: se evaluaron 18 pacientes en el grupo con SF (7 hombres, 39 %) con una edad mediana de 72 años y 36 pacientes (16 hombres, 44 %) en el grupo de SC con una edad mediana de 71 años. Se presentaron 3 casos de colecistitis y 4 casos de pancreatitis, todos ellos en el grupo de SC. Al explorar la asociación de los aspectos clínicos con respecto al tipo de stent, el análisis multivariado mostró diferencias estadísticamente significativas en 4 aspectos: la hemoglobina, la longitud de estenosis, la etiología y la oclusión del stent. Al evaluar los tiempos de supervivencia entre los pacientes con SC y SF, no se hallaron diferencias significativas en las funciones de supervivencia (log rank, p = 0,399). En el modelo de riesgos proporcionales de Cox, solo un aspecto mostró diferencias significativas frente a los tiempos de supervivencia: la presencia de metástasis. Conclusiones: el uso de un nuevo prototipo de stent SF (con surcos laterales) con menor FA y FR se relaciona con un menor índice de complicaciones como colecistitis y pancreatitis en comparación con el SC, en la paliación de las estenosis biliares malignas distales sin detrimento de su permeabilidad o migración y sin afectar la supervivencia de estos pacientes.
Abstract Background and objectives: Pancreatitis and cholecystitis are major complications following stenting with covered metallic stents to manage malignant distal biliary obstructions. We compare the use of a conventional covered biliary stent with a new prototype of a covered biliary stent with a flower-pedal structure that uses with low axial force and radial force in order to evaluate impacts on cholecystitis and pancreatitis after stenting. Methods: This is a non-randomized prospective comparison of a group of 18 patients stented with a flower-like biliary stent (FS group) with a group of 36 patients who received conventional biliary stents (CS group) ratio for management of malignant distal biliary obstructions. Demographic data and data about technical and clinical success including the appearance of cholecystitis and/or pancreatitis, migration rates and/or occlusion were evaluated. Results: The 18 FS group patients included 7 men (39%) and had a median age of 72 years. The 36 CS group patients included 16 men (44%) and had a median age of 71 years. There were three cases of cholecystitis and four cases of pancreatitis, all of which were in the CS group. Multivariate analysis showed statistically significant differences between the two groups in four clinical areas: hemoglobin, length of stenosis, etiology and occlusion of stents. No significant differences were found in survival time functions (Log Rank, p = 0.399). In Cox's proportional hazards model, the only significant difference with respect to survival times was found on the issue of whether or not metastasis was present. Conclusions: The use of the new prototype flower-like biliary stent with lateral grooves and lower axial force and radial force is related to a lower rate of complications such as cholecystitis and pancreatitis than the use of conventional stents for palliation of distal malignant biliary stenoses. The new stent has no detriments in terms of permeability or migration and did not affect the survival of these patients.