A case of pancreatic duct stones treated with electrohydraulic lithotripsy through a duodenal ulcer.

Video 1Crush the large-sized stones directly using an electrohydraulic lithotripsy device.

Randomized Controlled Trial of Modified Nasobiliary Fixation and Drainage Technique.

Objectives: We investigated the clinical efficacy of a modified nasobiliary fixation and drainage technique which was designed in an attempt to reduce unplanned extubation and tube blockage and improve bile drainage and the comfort of catheterized patients. Methods: From January 2019 to December 2020, 230 patients receiving Endoscopic nasobiliary drainage (ENBD) during hospitalization were recruited to this study. Participants were randomly allocated to 2 groups by using the block randomization method: in the control group: the conventional method of nasobiliary fixation was adopted after surgery; in the test group: intraoperative annular cutting of nasobiliary tubes was performed and the exposed catheter length was standardized. The modified "tube-nose-ear" three-step technique was performed after surgery. The clinical efficacy of a modified nasobiliary fixation and drainage technique was evaluated and compared between the test group and the control group. Results: The rate of unplanned extubation and incidence of complications were significantly lower in the test group than the control group. In addition, the rate of bilirubin decrease after drainage was higher in the test group. Patient discomfort during catheterization was also significantly reduced using the modified technique (P < 0.05). Conclusions: The modified technique of nasobiliary fixation and drainage technique can significantly reduce unplanned extubation and nasobiliary tube blockage after ENBD, facilitate biliary drainage, and improve patient comfort. This technique warrants wider application in clinical practice.

Sustained bile drainage decreases the organs injuries via inflammation-associated factors modulation in a severe acute pancreatitis rat model.

The timely and effective treatment for severe acute pancreatitis (SAP) is favorable to prognosis. Decompression of the bile duct might be a feasible way to decrease the progression of SAP. The present study investigated the effects of sustained bile external drainage on organs injury caused by SAP in Sprague-Dawley (SD) rats and the mechanisms involved. A total of 72 female SD rats weighting 190-230 g were randomly divided into four groups (n=18): Sham operation group (SOG), SOG + bile drainage group (BDG), SAP group, and SAP + BDG. Sodium taurocholate solution (4%; 1 mg/kg body weight) was used to set up SAP model via injection of retrograde puncture of biliopancreatic duct through the duodenum. A cannula was inserted into the bile duct and fixed externally to establish BDG model. At each time points (t=3, 6, 12; n=6), tissues from the liver, lung, and pancreas, and blood samples were collected. Serum amylase (AMY) was analyzed in all the samples. The levels of tumor necrosis factor-α (TNF-α), heme oxygenase-1 (HO-1), interleukin-10 (IL-10) and high mobility group box 1 (HMGB1) were detected by ELISA. Hematoxylin-eosin staining was performed to observe the histopathological changes, and nuclear transcription factor (NF)-κB-p65 levels in the pancreas were analyzed by western blotting. The data indicated that BDG alleviated the SAP progression and multiple organs injuries. Meanwhile, the histopathological changes of the pancreas, liver, and lungs were improved by BDG. BDG decreased the pathological scores of pancreas significantly (P<0.05). The levels of AMY, TNF-α, HMGB1, and NF-κB-p65 were significantly downregulated by BDG (P<0.05), while the level of HO-1 was upregulated and IL-10 was unchanged. In summary, BDG may attenuate the multiple organs injuries caused by SAP via downregulation of TNF-α, HMGB1, NF-κB-p65 and upregulation of HO-1.

[Perioperative antibiotic prophylaxis for pancreas resections with and without preoperative bile drainage : Is there room for improvement?] / Perioperative Antibiotikaprophylaxe bei Pankreasresektionen mit und ohne präoperative Galleableitung : Gibt es Verbesserungspotenzial?

BACKGROUND: Whether an immediate surgical treatment or preoperative bile drainage (PBD) should be performed in cases of obstructive jaundice caused by a pancreatic carcinoma has been a matter of controversy for decades. The aim of this study based on in-house patient data was to evaluate both the influence of PBD on septic complications and to analyze intraoperative bile samples in patients with PBD in order to formulate current recommendations for antibiotic treatment. MATERIAL AND METHODS: Relevant data from all pancreatic resections performed in this hospital from January 2013 to December 2017 were collected in a prospective database and were retrospectively analyzed. Depending on the presence of a PBD the collected data were checked for postoperative complications. In addition, the spectrum of bacteria on bile duct swabs was analyzed in patients with PBD and the sensitivity to ampicillin-sulbactam was tested according to the resistogram. Subsequently, an antibiotics recommendation for the practice was compiled. RESULTS: Within the period under consideration 197 pancreas resections were performed in this hospital, 122 of which were duodenopancreatectomies and 20 total pancreatectomies (n = 142). A PBD was performed in 28.2% (40/142) of the patients. There were no significant differences in mortality, intra-abdominal abscesses, post-pancreatectomy hemorrhages (PPH) or postoperative pancreatic fistulas (POPF) depending on a PBD. On the other hand, a significantly higher rate of postoperative wound infections was found in patients with PBD (+PBD 18/40, 45.0% vs. -PBD 13/102, 12.7%, P < 0.0001). Bacteriobilia was found in 86.8% (33/38) of patients with PBD. In 47.4% (18/38) of patients with PBD at least 1 detected bacterium of the bile duct culture was not sensitive to ampicillin-sulbactam. Regarding the antibiotics piperacillin-tazobactam 8 patients (21%) and ciprofloxacin or imipenem 4 patients each (10.5%) showed a bacterium with resistance. CONCLUSION: In general, the indications for a PBD should be strictly applied. If a PBD needs to be performed, perioperative antibiosis should be optimized to minimize subsequent complications. A hospital adjusted perioperative antibiotic prophylaxis should be developed and preoperatively obtained swab results, e. g. within endoscopic retrograde cholangiopancreatography (ERCP) can be used to increase the effectiveness of perioperative antibiotics. Based on an internal analysis of intraoperative bile duct swabs, ciprofloxacin is used in this hospital for the perioperative antibiotic treatment of patients with PBD.

Effect of Biliary Drainage on the Toxicity and Toxicokinetics of Amanita exitialis in Beagles.

Amatoxin poisoning induces delayed-onset acute liver failure, which are responsible for more than 90% of deaths in mushroom poisoning. It has been postulated from animal and human studies that biliary drainage interrupting enterohepatic amatoxin circulation may affect amatoxin poisoning. Dogs were randomly divided into four groups of six animals each. In 20 mg/kg and 60 mg/kg with biliary drainage groups, after accepting bile drainage operation, beagles were fed Amanita exitialis powder (20 or 60 mg/kg) in starch capsules. In control and bile drainage groups, the beagle dogs were fed with empty capsules. They were assessed for toxicity signs, biochemical and pathological changes, and peptide toxins in plasma, urine and bile. The data were directly compared with those from our published studies on Amanita exitialis-exposed beagles without biliary drainage. Amatoxins were rapidly absorbed and eliminated from plasma after Amanita exitialis ingestion. Amatoxins in 0⁻1-day urine accounted for more than 90% of the total urine excretion, and amatoxins in bile accounted for less than 20% of the total urine and bile excretion. The dogs with biliary drainage showed less severe toxicity signs and biochemical and pathological changes and much lower internal exposure than dogs without biliary drainage. Biliary drainage caused a more than 70% reduction in intestinal amatoxin absorption and could reduce amatoxin absorption from the gastrointestinal tract.

Endoscopic Ultrasound Guided Choledocho-Enterostomy by Using Lumen Apposing Metal Stent in Patients with Failed Endoscopic Retrograde Cholangiopancreatography: A Literature Review.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) has been the cornerstone in the management of malignant jaundice to provide symptomatic relief and/or to allow chemotherapy. Difficult biliary cannulation or the presence of concomitant duodenal obstruction may lead to its failure. METHOD: An extensive English literature search was done via PubMed and Google Scholar to identify 13 peer-reviewed original articles. RESULTS: Of 92 patients, 98.9% (91/92) successfully underwent EUS-guided biliary drainage by placement of a lumen-apposing metal stent (LAMS) across extrahepatic biliary tree and small bowel. Although technically challenging, a similar technical success was noted for patients with limited dilation of extrahepatic biliary tree (less than 1 cm) and altered gastrointestinal anatomy (Roux-en-Y, Whipple, or Billroth II). Of 91 patients, 98.9% (90/91) had clinical success. Procedure complications included perforation (2/92; 2.2%) and bleeding (1/92; 1.1%). Stent complications included obstruction (7/91; 7.7%), and migration (1/91; 1.1%) with all responding to endoscopic debridement of food or tumor, placement of plastic pigtail stent through the LAMS, or replacement with a new stent. No procedure-related mortality was noted. CONCLUSION: In the hands of an expert, EUS-guided biliary drainage with the use of LAMS is an efficacious and safe option for patients with distal malignant biliary stricture, not amenable to ERCP.

Preparation and pharmacokinetic study of asiatic acid loaded chitosan-deoxycholic acid polymeric micelles in rats / 中草药

Objective To prepare asiatic acid (AA) loaded chitosan-deoxycholic acid self-assembled micelles (AA-CS-DCA PMs) adopting chitosan-deoxycholic acid (CS-DCA) as carriers and investigate its pharmacokinetic characteristics in rats. Methods AA-CS-DCA PMs were prepared by ultrasonic dispersion method. The characteristics of micelles were evaluated by the distribution of particle size, Zeta potential, drug loading, encapsulation efficiency, and in vitro release. Model of bile drainage was established in conscious rats and pre-column derivatization HPLC method was used to determine the concentration of AA in bile. Moreover, the pharmacokinetics characteristics of AA-CS-DCA PMs in vivo was evaluated by tmax, Cmax and AUC0-t. Results The particle size was (70.5 ± 9.8) nm, the Zeta potential was (38.4 ± 0.8) mV, and encapsulation efficiency and drug loading were (77.8 ± 1.2)% and (11.7 ± 0.2)%, respectively. The in vitro release profile showed a sustained release property. In vivo study showed that Cmax of AA-CS-DCA group (26.05 ± 3.04) μg/h was 2.8 times higher than that of the control group (9.19 ± 1.12) μg/h; The tmax of AA-CS-DCA PMs group prolonged significantly (P < 0.05) in biliary excretion (2 h vs 1 h) and the elimination half-life t1/2 was 1.8 times of the control group [(2.68 ± 1.71) h vs (1.49 ± 0.38 h)]. In addition, the AUC0-24 h which reflected the degree of drug absorption increased by 200% compared with the control group [(99.05 ± 12.83) μg vs (33.56 ± 8.33) μg]. Conclusion The chitosan- deoxycholic acid self-assembled micelles can raise the concentration of AA and prolong the retention time in vivo, which effectively improve the oral bioavailability of AA.

Systematic review on management of perioperative iatrogenic injury of distal common bile duct / 中华肝胆外科杂志

Objective To study the effectiveness of different treatment modalities for iatrogenic injury of distal common bile duct during operation.Methods We browsed Chinese Medical Full-text Data-base with the term of “distal common bile duct injury”.All the clinical studies associated with perioperative latrogenic injury of distal common bile duct and adjacent tissue published after 1990 were enrolled,and we collected the clinical data,mortality and reoperation rate with different treatments for analysis.Results Thirty-four case series and case reports with 233 patients were included.14 patients with isolated duodenal injury were excluded.The overall mortality of the remaining 219 patients was 9.6％,and the reoperation rate was 17.4％.A total of 145 patients who were diagnosed with distal common bile duct injury during and after operation from 21 articles were compared.The mortality and reoperation rate were both 1.9％ among 106 patients who were diagnosed during operation.The figures were 43.6％,and 84.6％ among 39 patients who were diagnosed after operation,respectively.In 9 articles with 46 patients,the clinical outcomes of 21 patients who were treated by intraoperative suture was compared with 25 patients who underwent enhanced biliary and retroperitoneal drainage.The mortality and reoperation rates were 0 in both groups.Conclusions Early detection and management are crucial to perioperative common bile duct injury.Furthermore,no significant difference of clinical outcomes observed between bile drainage and perforation suture groups.

Clinical features and therapy of the elderly hepatic portal cholangiocarcinoma / 中国癌症杂志

Background and purpose:The morbidity of the elderly patients with hepatic portal cholangiocarcinoma is rising. Due to the characteristics of pathology,physiology and anatomy of the disease, most of the patients with cancer are not resectable, the main treatment consists of the diverting drainage and postoperative chemoradiation.We studied the clinical features and the effective therapeutic method for the elderly patients with hepatic portal cholangiocarcinoma. Methods:A retrospective analysis was performed in 28 cases of the elderly patients with hepatic portal cholangiocarcinoma who were treated between January 1995 and December 2005 in our hospital.Results:3 cases received surgery, 2 of them survived for over three years, another 3 cases were given operative exploration with 14 months of medium survival time. 22 cases were given internal or external drainage and received radiotherapy after operation, their survival time ranged from 5 months to 40 months.Conclusions:Surgery is the primary therapeutic method for elderly patients with hepatic portal cholangiocarcinoma. Internal or external drainage and radiotherapy could prolong survival time of the patients with unresectabke disease.