Percutaneous transhepatic drainage is safe and effective in biliary obstruction-A single-center experience of 599 patients.

BACKGROUND: Historically, surgical bilioenteric bypass was the only treatment option for extrahepatic bile duct obstruction, but with technological advancements, percutaneous transhepatic drainage (PTD) and endoscopic solutions were introduced as a less invasive alternative. Endoscopic methods may lead to a decreasing indication of PTD in the future, but today it is still the standard treatment method, especially in hilar obstructions. METHODS: In our retrospective data analysis, we assessed technical success rate, reintervention rate, morbidity, mortality, and the learning curve of patients treated with PTD over 12 years in a tertiary referral center. RESULTS: 599 patients were treated with 615 percutaneous interventions. 94.5% (566/599) technical success rate; 2.7% (16/599) reintervention rate were achieved. 111 minor and 22 major complications occurred including 1 case of death. In perihilar obstruction, cholangitis were significantly more frequent in cases where endoscopic retrograde cholangiopancreatography had also been performed prior to PTD compared to PTD alone, with 39 (18.2%) and 15 (10.5%) occurrences, respectively. DISCUSSION: The results and especially the excellent success rates demonstrate that PTD is safe and effective, and it is appropriate for first choice in the treatment algorithm of perihilar stenosis. Ultimately, we concluded that PTD should be performed in experienced centers to achieve low mortality, morbidity, and high success rates.

Percutaneous Intraductal Microwave Ablation and Self-expandable Metallic Stenting: A New Treatment Method for Malignant Extrahepatic Biliary Obstruction.

PURPOSE: To evaluate the patency and clinical efficacy of percutaneous intraductal microwave ablation (PIMWA) and uncovered self-expandable metallic stents (USEMs) in inoperable malignant extrahepatic biliary obstruction. MATERIALS AND METHODS: The procedures to be performed on patients with malignant inoperable extrahepatic biliary obstruction were decided by a multidisciplinary team including an interventional radiologist. In our study, 141 patients were evaluated retrospectively. Twenty-one patients who underwent PIMWA + USEMs with the MedWaves AveCure microwave system (AveCure® Intelligent Controller and Super-Flex Smart Catheter) and met the inclusion criteria were included in the study. Complications related to the intervention, stent patency, survival time, serum bilirubin levels, and the general condition of the patients were noted. RESULTS: The median stent patency and the median survival time were 108 and 143 days, respectively. The rates of 30-day, 2-month, 6-month and 8-month survival were 95.2%, 85.7%, 38.1%, and 14.3%, respectively. CONCLUSION: The PIMWA + USEMs procedure is a safe, effective, and minimally invasive alternative palliative treatment method in patients with malignant inoperable extrahepatic biliary obstruction.

New antireflux plastic stent for patients with distal malignant biliary obstruction.

BACKGROUND: Endoscopic biliary stenting is a well-established palliative treatment for patients with unresectable distal malignant biliary obstruction (MBO). However, the main problem with stent placement is the relatively short duration of stent patency. Although self-expanding metal stents (SEMSs) have a longer patency period than plastic stents (PSs), the higher costs limit the wide use of SEMSs. A PS with an antireflux valve is an attractive idea to prolong stent patency, but no ideal design for an antireflux PS (ARPS) has been proposed. We developed a new ARPS with a "duckbilled" valve attached to the duodenal end of the stent. AIM: To compare the patency of ARPSs with that of traditional PSs (TPSs) in patients with unresectable distal MBO. METHODS: We conducted a single-center, prospective, randomized, controlled, double-blind study. This study was conducted at the West China Hospital of Sichuan University. Consecutive patients with extrahepatic MBO were enrolled prospectively. Eligible patients were randomly assigned to receive either an ARPS or a TPS. Patients were followed by clinic visits or telephone interviews every 1-2 mo until stent exchange, death, or the final study follow-up in October 2018. The primary outcome was the duration of stent patency. Secondary outcomes included the rate of technical success, the rate of clinical success, adverse events, and patient survival. RESULTS: Between February 2016 and December 2017, 38 patients were randomly assigned to two groups, with 19 patients in each group, to receive ARPSs or TPSs. Stent insertion was technically successful in all patients. There were no significant differences between the two groups in the rates of clinical success or the rates of early or late adverse events (P = 0.660, 1.000, and 1.000, respectively). The median duration of stent patency in the ARPS group was 285 d [interquartile range (IQR), 170], which was significantly longer than that in the TPS group (median, 130 d; IQR, 90, P = 0.005). No significant difference in patient survival was noted between the two groups (P = 0.900). CONCLUSION: The new ARPS is safe and effective for the palliation of unresectable distal MBO, and has a significantly longer stent patency than a TPS.

Safety of Percutaneous Transhepatic Biliary Stenting in Patients with Obstructive Jaundice.

OBJECTIVE: To determine the safety of percutaneous transhepatic biliary stenting (PTBS) in patients with obstructive jaundice. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Department of Radiology, The Aga Khan University Hospital Karachi, Pakistan, from February 2012 to April 2013. METHODOLOGY: Patients with obstructive jaundice due to any cause referred for percutaneous transhepatic biliary stenting were included in the study. Patients were excluded if they had undergone previous ERCP, had guided transhepatic biliary stenting, previous percutaneous transhepatic biliary stenting and were lost to follow-up. Follow-up was taken at a 2, 4 and 6 week interval and clinical outcome was assessed as the difference between the bilirubin levels at base line and 6 weeks after PTBS, which was measured using Freidman's test. RESULTS: A total of 102 patients were included; 59 (58%) were males and 43 (42%) were females. The age ranged from 21 to 89 years. A total of 30 patients experienced complications making an overall complication rate of 29.4%; 20 experienced minor and 10 experienced major complications. Pain was the most frequent minor complication (n=15 patients, 14.7%) followed by biliary leakage, fever and cholangitis. Major complications included death in 10 (10%) patients followed by biliary peritonitis and septicemia. CONCLUSION: PTBS achieved satisfactory palliation with a low complication rate in patients with obstructive jaundice.

Endobiliary radiofrequency ablation for distal extrahepatic cholangiocarcinoma: A clinicopathological study.

BACKGROUND: Most patients with distal extrahepatic cholangiocarcinoma have developed jaundice or cholangitis at the time of initial diagnosis, which can delay surgery. We aim to evaluate the actual EB-RFA ablation volume and validated the clinical feasibility of preoperative endobiliary radiofrequency ablation (EB-RFA) for resectable distal extrahepatic cholangiocarcinoma. METHODS: The medical records of patients who underwent EB-RFA from July 2016 to June 2017 at a single tertiary academic medical center were reviewed. Inclusion criteria were patients with resectable distal extrahepatic cholangiocarcinoma who required preoperative biliary decompression. Clinical outcomes of EB-RFA were reviewed retrospectively and the surgical specimens were reevaluated. RESULTS: Of the eight patients who required a delayed operation, preoperative EB-RFA was successfully performed without serious complications including peritonitis, hemobilia, or perforation. Although curative resection was attempted in all patients, one patient underwent open and closure due to hepatic metastasis. Seven patients underwent curative surgical resection and the histology revealed that median maximal ablation depth was 4.0 mm (range, 1-6) and median effective ablation length (histological ablation length/fluorosocopic ablation length) was 72.0% (range, 42.1-95.3). CONCLUSIONS: EB-RFA partially ablated human cancer tissue and preoperative EB-RFA might be a safe and feasible in patients with distal extrahepatic cholangiocarcinoma who require a delayed operation. Ablation of the target lesion longer than the estimated length by fluoroscopy may improve the efficacy of EB-RFA.

Jaundice in the emergency department: meeting the challenges of diagnosis and treatment [digest].

There are approximately 52,000 visits a year to emergency departments for patients presenting with jaundice. While many of these patients will not have immediately life-threatening pathology, it is essential that the emergency clinician understands the pathophysiology of jaundice, as this will guide the appropriate workup to detect critical diagnoses. Patients who present with jaundice could require intravenous antibiotics, emergent surgery, and, in severe cases, organ transplantation. This issue will focus on the challenge of evaluating and treating the jaundiced patient in the ED using the best available evidence from the literature. [Points & Pearls is a digest of Emergency Medicine Practice.].

Jaundice in the emergency department: meeting the challenges of diagnosis and treatment.

There are approximately 52,000 visits a year to emergency departments for patients presenting with jaundice. While many of these patients will not have immediately life-threatening pathology, it is essential that the emergency clinician understands the pathophysiology of jaundice, as this will guide the appropriate workup to detect critical diagnoses. Patients who present with jaundice could require intravenous antibiotics, emergent surgery, and, in severe cases, organ transplantation. This issue will focus on the challenge of evaluating and treating the jaundiced patient in the ED using the best available evidence from the literature.

Long-term outcomes of early compared to late onset choledochocholedochal anastomotic strictures after orthotopic liver transplantation.

BACKGROUND: Endoscopic treatment of anastomotic biliary stricture (ABS) after liver transplantation (LT) has been proven to be effective and safe, but long-term outcomes of early compared to late onset ABS have not been studied. The aim of this study is to compare the long-term outcome of early ABS to late ABS. METHODS: Of the 806 adult LT recipients (04/2006-12/2012), 93 patients met the criteria for inclusion, and were grouped into non-ABS (no stenosis on ERCP, n=41), early ABS (stenosis <90 days after LT, 18 [19.3%]), and late ABS (stenosis ≥90 days after LT, 34 [36.5%]). A propensity matched control group for the ABS group (n=42) was obtained matched for outcome variables for age, gender, and calculated MELD score at listing. RESULTS: Mean number of ERCPs (2.33±1.3 vs 2.56±1.5, P=.69) were comparable between the groups; however, significantly better long-term resolution of the stricture was noted in the early ABS group (94.44% vs 67.65%, P=.04). Kaplan-Meier analysis revealed worst survival in the early ABS group compared to the non-ABS, late ABS, and control groups (P=.0001). CONCLUSION: LT recipients with early ABS have inferior graft survival despite better response to endoscopic intervention.

Resolution of Metallic Biliary Stent Allergic Reaction After Partial Stent Removal in a Patient with Nickel Sensitivity.

Local and systemic reactions to implanted metallic devices, particularly to those containing nickel, are well documented. Metal ions are released due to exposure of the metal to blood, proteins, other body fluids, and sheer mechanical stress. Metal ions then complex with native proteins and become antigens, which can elicit hypersensitivity reactions. Another case report depicts a specific allergic complication (early stent occlusion) related to metallic biliary stent implantation. We present a case of allergic symptoms, associated with eating, in a patient who developed nickel sensitivity after biliary metal stent placement confirmed by allergic skin testing to the same metallic biliary stent placed one year earlier. Symptoms resolved following partial removal of the non-epithelialized portion of the biliary stent.

Outcomes of management for biliary stricture after living donor liver transplantation with hepaticojejunostomy using short-type double-balloon enteroscopy.

BACKGROUND AND AIMS: To evaluate the outcomes of management for biliary stricture (BS) after living donor liver transplantation (LDLT) using short-type double-balloon enteroscopy. METHODS: This study retrospectively evaluated 20 patients who underwent endoscopic retrograde cholangiography using short-type double-balloon enteroscopy (sDB-ERC) upon suspicion of BS after LDLT with hepaticojejunal (HJ) reconstruction at Okayama University Hospital. RESULTS: Scope insertion to the HJ site and sDB-ERC succeeded in 85 % (17/20) and 82.4 % (14/17) of patients, respectively. Of 14 patients who required treatment for BS, 11 were successfully treated using sDB-ERC, and 3 were successfully treated using sDB-ERC and rendezvous procedures. Adverse events occurred in 2.9 % of all sessions (2/68). After resolution of BS, 7 patients (50 %) experienced a recurrence. Of these, 6 (85.7 %) were treated with only balloon dilation, and 1 (14.3 %) was treated with both balloon dilation and stent deployment (P = 0.029). CONCLUSIONS: sDB-ERC is a useful procedure for diagnosis and treatment for BS after LDLT with HJ reconstruction. Balloon dilation combined with stent deployment might be recommended for definite resolution of BS.

Comparison of intraductal ultrasonography-directed and cholangiography-directed endoscopic retrograde biliary drainage in patients with a biliary obstruction.

BACKGROUND/AIMS: Endoscopic retrograde biliary drainage (ERBD) has become a standard procedure in patients with a biliary obstruction. Intraductal ultrasonography (IDUS) has emerged as a new tool for managing extrahepatic biliary diseases. IDUS-directed ERBD can be performed without conventional cholangiography (CC). The goal of this study was to assess the effectiveness and safety of IDUS-directed ERBD compared to CC-directed ERBD in patients with an extrahepatic biliary obstruction. METHODS: A total of 210 patients who had undergone IDUS-directed ERBD (IDUS-ERBD, n = 105) and CC-directed ERBD (CC-ERBD, n = 105) between October 2013 and April 2014 were analyzed retrospectively. The primary outcome measure was the procedural success rate. Secondary outcome measures included clinical outcomes, total procedure time, radiation exposure time, and overall complication rates. RESULTS: The total technical success rate of ERBD was 100% (105/105) in the IDUS-ERBD and CC-ERBD groups. Mean procedure time was slightly prolonged in the IDUS-ERBD group than that in the CC-ERBD group (32.1 ± 9.9 minutes vs. 28.4 ± 11.6 minutes, p = 0.023). Mean radiation exposure time was one-third less in the IDUS-ERBD group than that in the CC-ERBD group (28.0 ± 49.3 seconds vs. 94.2 ± 57.3 seconds, p < 0.001). No significant differences in complication rates were detected between the groups. CONCLUSIONS: IDUS-ERBD was equally effective and safe as CC-ERBD in patients with an extrahepatic biliary obstruction. Although IDUS-ERBD increased total procedure time, it significantly decreased radiation exposure.

Use of the Conventional Side-viewing Duodenoscope for Successful Endoscopic Retrograde Cholangiopancreatography in Postgastrectomy Patients.

OBJECTIVES: The aim of this study was to evaluate the usefulness of the conventional side-viewing duodenoscope for successful endoscopic retrograde cholangiopancreatography (ERCP) in postgastrectomy patients. METHODS: A total of 220 consecutive patients with bile duct stones or a distal common bile duct stricture who had previously undergone gastrectomy and were referred for ERCP were analyzed for the outcome of their ERCP. All ERCP procedures were performed using a conventional side-viewing duodenoscope. In patients who had undergone a Billroth II gastroenterostomy and total gastrectomy with Roux-en-Y reconstruction, we also used the procedure of retrieval balloon-assisted enterography. RESULTS: The study group included 220 patients who had previously undergone gastrectomy (77 women and 143 men; mean age, 72.2 y; range, 11 to 93 y). The overall enterography success rate was 90.5% (199/220), and the diagnostic and ERCP success rates were both 88.6% (195/220). Endoscopy was unsuccessful in 21 patients who received Billroth II gastroenterostomy and Roux-en-Y reconstruction. After successful endoscopy, diagnostic and ERCP success was not achieved in 4 patients with Billroth II gastroenterostomy, with or without Braun anastomosis, due to cannulation failure. The procedure-related complication rate was 5.5% (12/220), including immediate bleeding (0.9%, 2/220), pancreatitis (4.1%, 9/220), and perforation (0.5%, 1/220). There were no procedure-related deaths. CONCLUSIONS: The side-viewing duodenoscope is a useful instrument for performing successful ERCP in patients postgastrectomy. In addition, retrieval balloon-assisted enterography may improve the enterography success rate in postgastrectomy patients with Billroth II and Roux-en-Y reconstruction.

Benign Biliary Strictures Treated with Fully Covered Metallic Stents in Patients with Surgically Altered Anatomy Using Double Balloon Enteroscopy.

INTRODUCTION: Surgically altered anatomy complicates endoscopic procedures of the pancreaticobiliary tree. Biliary strictures have been managed using percutaneous transhepatic techniques. MATERIALS AND METHODS: In recent years device-assisted enteroscopy (e.g., double balloon enteroscope [DBE]) has been used to gain access to the common bile duct. The length of the scope and its narrow, 2.8-mm working channel limit the use of standard endoscopic retrograde cholangiopancreatography (ERCP) devices. Therefore, shorter enteroscopes for ERCP have been developed. A fully covered self-expandable metallic stent (fcSEMS) cannot be used through the narrow channel. In conventional anatomy, benign biliary strictures have been treated using fcSEMS, requiring fewer endoscopies compared with multiple plastic stenting. RESULTS: Here we report the first case of fcSEMS deployment through the working channel of a novel, long DBE with a 3.2-mm working channel, and 2 cases with the conventional narrow-channel DBE, using the rendezvous technique, with fcSEMS insertion on a wire running along the enteroscope. CONCLUSIONS: These new techniques, here used on benign biliary strictures, are described in detail.