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.

Covered stents versus uncovered stents for the palliation of malignant extrahepatic biliary obstruction caused by direct tumor invasion: a cohort comparative study.

Biliary stenting is a well-established palliative treatment in patients with unresectable malignant biliary strictures. The aim of the present study was to compare clinical outcomes of covered and uncovered stents in patients with malignant extrahepatic biliary obstruction caused by direct tumor invasion. Patients diagnosed with malignant extrahepatic biliary obstruction caused by direct tumor invasion were enrolled in this study. Of these patients, 37 received ePTFE-covered stent placement and were prospectively studied, and 47 received uncovered stent placement and were retrospectively studied. The technical success rate, tumor ingrowth rate, complication rate, stent patency, and patient survival were evaluated for both groups. Stent placement was successful in all cases except one in the covered group due to stent kinking. Tumor ingrowth occurred exclusively in the uncovered group. No significant differences were observed for the complication rate and patient survival between the two groups. Three patients in the covered group experienced stent migration, whereas no patients did in the uncovered group. A significant difference was found regarding stent patency, which was greater for the covered group compared to the uncovered group. The placement of ePTFE-covered stents for the treatment of malignant biliary obstruction caused by direct tumor invasion was a safe and an effective method characterized by greater stent patency.

Partially covered self-expanding metal stent for unresectable malignant extrahepatic biliary obstruction: results of a large prospective series.

BACKGROUND: Endoscopic biliary stenting is a well-established palliative treatment in patients with unresectable malignant biliary strictures. Obstruction of uncovered self-expanding metal stent (SEMS) due to tumor ingrowth is the most frequent complication. Partially covered SEMS might increase stent patency but could favor complications related to stent covering, such as pancreatitis, cholecystitis, and migration. The aim of this study was to evaluate the efficacy and safety of partially covered SEMS in patients with an unresectable malignant biliary stricture. METHODS: Patients with malignant extrahepatic biliary obstruction treated endoscopically with partially covered SEMS were included in this multicenter, prospective, nonrandomized study. RESULTS: One hundred ninety-nine patients were endoscopically treated with partially covered SEMS in 32 Spanish hospitals. Clinical success after deep cannulation was 96%. Early complications occurred in 4% (3 pancreatitis, 2 cholangitis, 1 hemorrhage, 1 perforation, and 1 cholecystitis). Late complications occurred in 19.5% (18 obstructions, 10 migrations, 6 cholangitis without obstruction, 3 acute cholecystitis, and 2 pancreatitis), with no tumor ingrowth in any case. Median stent patency was 138.9 ± 112.6 days. One-year actuarial probability of stent patency was 70% and that of nonmigration was 86%. Multivariate analysis showed adjuvant radio- or chemotherapy as the only independent predictive factor of stent patency and previous insertion of a biliary stent was the only predictive factor of migration. CONCLUSIONS: The partially covered SEMS was easily inserted, had a high clinical success rate, and prevented tumor ingrowth. The incidence of possible complications related to stent coverage, namely, migration, pancreatitis, and cholecystitis, was lower than in previously published series.

Outcome of self-expandable metallic stents in low-grade versus advanced hilar obstruction.

BACKGROUND: Self-expandable metallic stents (SEMS) are known to provide a longer patency time than plastic stents for malignant biliary obstructions including hilar obstruction. However, studies that focus on the efficacy of SEMS in low-grade and advanced hilar obstructions are still scanty. METHODS: Ninety four patients with malignant hilar obstructions were enrolled (six were later excluded). Patients were divided into two groups according to their Bismuth levels. Group A were patients with Bismuth I (n = 53). Group B were patients with Bismuth II, III and IV (n = 35). Technical success, complications, jaundice resolution, stent patency time, and patients' survival were analyzed. RESULTS: Our intention-to-treat analysis showed that group A had a significant lower rate of post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis than group B; 16.1% versus 44.7%, (P < 0.01). Four patients from group B still had persistent jaundice. Our per protocol analysis demonstrated that median stent patency time in groups A and B were not statistically different (74 vs 60 days). Median survival time in groups A and B were also not statistically different (90 vs 75 days). In both groups, those without liver metastasis had significantly better patency and survival time than those with liver metastasis (P = 0.010 and 0.027, respectively). CONCLUSIONS: In patients with hilar obstruction, liver metastasis is one of the main factors that determine survival of the patient. Patency times of SEMS in both low-grade and advanced obstructions are comparable. However, in the advanced group, there is a significant risk of post-ERCP cholangitis.

[Possibilities of radical surgical treatment of patients with tumoral obstruction of extrahepatic biliary ducts].

Experience of radical surgical treatment of 32 patients, suffering extrahepatic biliary ducts (EBD) tumor, was analyzed. The respectability index of a Clatskin tumor have constituted 12.5%, and of the EBD middle portion--25%. In 8 patients an open operative intervention was performed and in 1--laparoscopic procedure was applied. The respectability index of a distal EBD tumors have constituted 29.6%. Postoperative lethality was 15.6%.

Permanent stenting in "unextractable" common bile duct stones in high risk patients. A prospective randomized study comparing two different stents.

BACKGROUND: Endoscopic sphincterotomy (ES) and stone extraction is the treatment of choice for bile duct stones. Therefore, if ES and conventional stone extraction fail, further treatment is mandatory. Insertion of a biliary endoprosthesis is an effective option. MATERIALS AND METHODS: We treated 30 high-risk patients (17 women and 13 men, mean age 82 years) affected by difficult common bile duct stones. The patients were randomly assigned preoperatively using closed envelopes (blind randomization) into two groups to receive insertion of polyethylene or hydrophilic hydromer-coated polyurethane stent, respectively. Follow-up was achieved by contacting referring physicians and patient's relatives. RESULTS: Biliary drainage was established in all patients. Early minor complications occurred in 28%. In all these patients, the stent was a definitive measure. Median follow-up was 38 months. Late complications occurred in 34%. Cholangitis was the most frequent. During follow up, 11 patients died, two as result of a biliary-related cause. No statistically significant difference was observed on different stents patency. CONCLUSION: Endoprosthesis insertion as a permanent therapy is an effective alternative to surgery or dissolution therapy. Therefore, biliary stenting should preferably be restricted to high-risk patients unfit for operative treatment and with a short life expectancy.

Long-term survival of dogs after cholecystoenterostomy: a retrospective study of 15 cases (1981-2005).

Fifteen dogs with extrahepatic biliary tract disease underwent cholecystoenterostomy. Long-term survivors were significantly older at presentation (mean age 140.5 months) than dogs that survived the first 20 days after surgery but subsequently died from causes related to the surgery or hepatobiliary disease (mean age 72 months). Dogs that died during the first 20 days had significantly more complications in the hospital than dogs that survived this period. The type of underlying hepatobiliary disease (i.e., benign or malignant) was not associated with either short-term outcome or long-term survival. Eight dogs died from causes related to surgery or hepatobiliary disease. Long-term complications included hepatic abscesses, acquired portosystemic shunts, pancreatitis, and vomiting.

Retrospective study of 28 cases of cholecystoduodenostomy performed using endoscopic gastrointestinal anastomosis stapling equipment.

Medical records were reviewed of 24 dogs and four cats that underwent cholecystoduodenostomy to relieve extrahepatic biliary obstruction. These procedures had been performed using a 30-mm endoscopic gastrointestinal anastomosis stapler. At presentation, most animals had clinical signs of vomiting and anorexia, and total bilirubin was elevated in both dogs (n=21) and cats (n=4). Pancreatitis (n=13), cholangiohepatitis (n=7), and neoplasia (n=6) were the most common underlying conditions. Sixteen dogs and two cats survived to their 2-week reevaluation. The most common cause of death was euthanasia (n=9) secondary to neoplasia (n=4), peritonitis (n=3), or respiratory arrest (n=2).

Treatment of pancreatitis-associated extrahepatic biliary tract obstruction by choledochal stenting in seven cats.

OBJECTIVES: To report the clinicopathological findings and outcome in cats with pancreatitis-associated extrahepatic biliary tract obstruction (EHBO) treated by choledochal tube stenting. METHODS: Medical records of cats with EHBO secondary to pancreatitis that underwent choledochal stenting were reviewed. Information on outcome was obtained by re-examination of the cat or by telephone interview with the owners. RESULTS: All cats had pancreatitis confirmed by histopathological examination of biopsy samples (n=6) or suspected based on gross examination at surgery (n=1). In six cats, a section of 3.5 to five French gauge red rubber catheter and in one cat a section of 22 G intravenous catheter were used as a choledochal stent. Two cats developed re-obstruction of the biliary tract within a week of the original surgery. One cat had confirmed episodes of ascending cholangitis postoperatively. Two cats had chronic intermittent vomiting in the postoperative period. Two cats died during the perioperative period. Five cats survived to discharge, three of which died seven to 24 months postoperatively and two of which remain alive to date. CLINICAL SIGNIFICANCE: Choledochal stenting is an alternative to biliary diversion for management of feline pancreatitis-associated EHBO in select cases. However, there may be greater morbidity with this technique in cats compared with dogs.

Extended lymphadenectomy in cephalic pancreatoduodenectomy. Personal observations.

BACKGROUND/AIMS: Long-term survival in patients with cancer of the pancreatic head is disappointing. Surgery is the only curative therapy. Unfortunately the prognosis of resected patients (10-15%) is extremely poor due to loco-regional cancer recurrence (50%). Lymphatic and perineural invasion may account for local recurrence. Japanese studies have reported the importance of an extended lymphadenectomy during the classic Whipple exeresis (40% of patients present lymph node metastases). METHODOLOGY: At the General Surgical Clinic of Pavia University 20 patients (14 men, 6 women, mean age 62.4 yr) with pancreatic head cancer (17 adenocarcinoma, 1 lymphoma, 2 carcinoma) underwent Whipple's exeresis with a regional (peripancreatic or R1) and juxta-regional (para-aortic or R2) lymphadenectomy according to the Ishikawa technique, between 1996-2000. R1 nodes consisted of lymph nodes at the pylorus, superior pancreatic head, common bile duct, anterior pancreaticoduodenal region, inferior pancreatic head and superior mesenteric vessels. R2 nodes consisted of lymph nodes at the superior and inferior pancreatic body, mid colic region, common hepatic duct, celiac axis and para-aortic region. RESULTS: The wide dissection was quite easy in patients with a serious cholestatic disease. Intraoperative mortality was 0%. Operative mortality was 5%. Postoperative complications (20%) consisted of 1 sepsis, 1 hepato-renal syndrome with hepatic coma, 1 intestinal obstruction by adhesive bands, and 1 wound infection. Eight patients (40%) died during a mean follow-up period of 6 months (neoplastic recurrence 50%). Notwithstanding the advanced disease (stage III 50%; N1+ 50%), 12 patients (60%) had a median postoperative survival rate of 18.4 months (range 1-48 months) without neoplastic recurrence. Tumor diameter was less than 4cm in 83.3% of cases. CONCLUSIONS: An earlier diagnosis (with tumor diameter <4 cm) can improve pancreatic head cancer prognosis. A wide surgical exeresis with R2 lymph nodes clearance together with surrounding connective and nervous tissue can remove micrometastases and better control local recurrence.

[Prognostic factors of mortality in the malignant biliary obstruction unresectable after the insertion of an endoscopic stent]. / Factores pronósticos de mortalidad en la estenosis biliar distal maligna irresecable después de la colocación de una prótesis endoscópica.

OBJECTIVE: To determine the factors prognostics of early mortality in the malignant billary estenosis after the endoscopic derivation. BACKGROUND DATA: The surgical, percutaneous or endoscopic derivation is the alternative of palliative treatment in the biliary obstruction unresectable. The factors prognostic the early mortality after surgical derivation are: hemoglobin < 10 g/dL, serum bilirubin > 10 mg/dL and serum albumin < 2.5 g/dL; for the percutaneous derivation they are the sanguineous urea more of 4.3 mmol/L and hemoglobin < 10.9 g/dL; whereas in the single endoscopic derivation type 3 of Bismuth and the infectious complications after the endoscopic colangiography and the absence of the clinical success were factors prognoses of early mortality. METHODS: Descriptive and retrospective analysis of 97 cases with malignant biliary obstruction. The factors were evaluated prognoses of early mortality. Univariated and bivaried analysis and of survival by the method of Kaplan-Meier was made curved. RESULTS: 97 cases were included that presented/displayed unresectable disease and had a biochemical control subsequent to the drainage. They were 58 women and 39 men. More frequent symptoms: ictericia, pain and prurito. 61 cases of distal obstruction and 36 with proximal obstruction. Twenty deaths (25.9%) happened within the 30 later days to the treatment. The bilirubin > 14 mg/dL and the proximal location were like predicting of early mortality. CONCLUSIONS: The obstruction biliary more frequent is located in choledocho distal and is of pancreatic origin. The main factors associated to early mortality are: the bilirubin > of 14 mg/dL and the proximal location reason why is important the suitable selection of patient candidates to endoscopic derivation. The survival is better in the distal obstruction.

Choledochal tube stenting for decompression of the extrahepatic portion of the biliary tract in dogs: 13 cases (2002-2005).

OBJECTIVE: To determine clinicopathologic features, surgical management, complications, and long-term outcome associated with diseases of the extrahepatic portion of the biliary tract treated via choledochal stent placement in dogs. DESIGN: Retrospective case series. ANIMALS: 13 dogs. PROCEDURE: Data were obtained from medical records, and follow-up information was obtained via reexamination or telephone interview with owners or referring veterinarians. RESULTS: 10 dogs had extrahepatic biliary obstruction (EHBO), 6 as a result of pancreatitis. Two dogs had rupture of the common bile duct associated with cholelithiasis. In 1 dog, a stent was placed prophylactically after gastroduodenostomy was performed for a perforated duodenal ulcer. Nine of 13 dogs survived the perioperative period and were discharged. No recurrence of EHBO or other complications developed in the discharged dogs while the stents were in place. Median follow-up period from surgery to last owner contact was 13.3 months. In 1 dog, the stent was removed endoscopically 10 months after surgery and EHBO recurred 9 months after stent removal because of cholangitis. In 4 of 5 dogs that were discharged from the hospital, in which the fate of the stent could be confirmed and the stent was secured to the duodenal wall with absorbable suture materials, the stents were passed in the feces 1 to 11 months after surgery. CONCLUSIONS AND CLINICAL RELEVANCE: Choledochal tube stenting is an effective method of decompression of the extrahepatic portion of the biliary tract in dogs and provides a less complex alternative to traditional cholecystoenterostomy techniques in select cases.

Palliation of unresectable periampullary neoplasms. "surgical" versus "non-surgical" approach.

BACKGROUND/AIMS: A series of 84 patients with unresectable periampullary neoplasms, observed during an eight-year period (1992-1999), is reviewed for a critical analysis of modalities of treatment and clinical outcome. Two different approaches, a preference for "non-surgical" palliation and a preference for "surgical" palliation, in two consecutive periods, are compared. METHODOLOGY: In the first period (1992-1995) endoscopic retrograde cholangiopancreatography with endoprosthesis insertion was performed routinely and, after diagnostic assessment, patients were divided into two groups: those with apparently resectable neoplasms, candidates for surgery, in whom the decision to perform a surgical palliation by biliary bypass was taken intraoperatively, and those with unresectable neoplasms, in whom the endoprosthesis insertion was considered as definitive palliation. Since January 1996, a different approach was started; surgical bypass was considered the palliation of choice and only patients unfit for surgery underwent endoscopic stenting. RESULTS: Evaluation of the results showed that the first strategy was associated with a high incidence of complications and unsatisfactory long-term results, with frequent hospital readmissions, poor quality of residual life and therefore failure of palliation. On the contrary, the latter approach with preference for surgical palliation was associated with lower morbidity and mortality, with persistent relief of symptoms and better quality of life in a larger percentage of patients. CONCLUSIONS: This study provides evidence that, in patients with unresectable periampullary carcinoma, surgical palliation provides better long-term results than endoscopic palliation. The results were also consistent with the advantage of associating a gastric bypass to the biliary bypass, also in the absence of gastric outlet obstruction.

[Surgical palliation for pancreatic cancer. The 25-year experience of a single reference centre]. / Chirurgisch palliative Therapie beim Pankreaskarzinom - 25 Jahre Erfahrungen eines einzelnen Referenzzentrums.

BACKGROUND: In spite of dynamic development of modern diagnostic and therapeutic methods, the long-term results of surgical therapy in pancreatic cancer are still unsatisfying. The aim of this study was to analyse long-term results of surgical palliation for pancreatic cancer in a pancreatic surgery centre. METHODS: We performed a retrospective analysis of 418 patients who underwent non-resective, palliative procedures for pancreatic cancer between 1975 and 1999. In order to compare two consecutive periods of time, the patients were divided in 2 groups; group I treated from 1975 to 1990 (n = 204), and group II from 1991 to 1999 (n = 214). RESULTS: Of all patients qualified for surgery, 281 (67.2 %) underwent surgical bypass, 107 (25.6 %) laparotomy, and in 30 cases surgical intervention was limited to implantation of endoprosthesis. A significant tendency towards double (i. e. biliary and gastric) anastomosis was observed (32.3 % vs. 74.8 %; p < 0.01) in patients who underwent bypass procedures. The postoperative morbidity was 16.3 %. The postoperative mortality rate was 5.7 % and significantly (p < 0.01) decreased from 10.3 % (group I) to 1.4 % (group II). No differences neither in mortality nor morbidity related to the type of performed surgery were found. The mean time of hospital stay was 15.5 +/- 6.9 days and showed no differences related to the type of intervention. Jaundice or symptoms of gastric outlet obstruction were observed in 16 % of patients in the follow-up period and concomitantly performed biliary and gastric bypasses were associated with the lowest rate of the late gastrointestinal obstruction (4 %). The median survival time was 169 days and only 4 % of patients survived 12 months. The univariate analysis of prognostic factors showed that location and stage of the tumour, the type of surgical intervention and bypass procedure influenced 1-year survival. The multivariate analysis using Cox proportional hazard model proved that only stage and location of the tumour had independent prognostic value. CONCLUSION: Surgical palliation for pancreatic cancer can be performed with acceptable morbidity and mortality rates. For tumours located in the head and body of the pancreas combined biliary and gastric bypass should be preferred. For cancers located in the tail of the pancreas gastric bypass should be performed routinely. Because surgical palliation can prevent gastric outlet obstruction by gastroenterostomy, endoscopic biliary stenting should be only performed in patients with pancreatic head cancers and simultaneous evidence of distal metastases as well as in older patients with high comorbidity.

Endogenous interferon gamma protects against cholestatic liver injury in mice.

Cholestatic patients suffer from high perioperative morbidity and mortality, but the pathophysiology is still unknown. Interferon gamma (IFN-gamma) may play a role during cholestasis. Therefore, bile duct ligation (BDL) was induced in IFN-gamma alpha-chain receptor-deficient (IFN-gammaR(1)-/-) and wild-type (IFN-gammaR(1)+/+) mice. BDL elicited increased IFN-gamma messenger RNA and protein levels in the liver. One week after BDL, IFN-gammaR(1)+/+ mice showed less severe jaundice and liver injury than IFN-gammaR(1)-/- mice, as reflected by lower bilirubin and liver enzyme levels. In accordance, livers of IFN-gammaR(1)+/+ mice displayed smaller areas of necrosis by two-thirds than IFN-gammaR(1)-/- mice on histopathologic examination (P <.05), whereas mitotic activity and proliferating cell nuclear antigen (PCNA) labeling index was more than twice as high in IFN-gammaR(1)+/+ mice (P <.05). Livers of IFN-gammaR(1)+/+ mice displayed higher rates of apoptosis as indicated by DNA fragmentation rate, the number of apoptotic bodies, and poly ADP-ribose polymerase (PARP) immunostaining. BDL was not associated with lethality in IFN-gammaR(1)+/+ mice; IFN-gammaR(1)-/- mice, however, died from 10 days onward and survival after 2 weeks was 62% (10 of 16). In conclusion, these data suggest that IFN-gamma protects against liver injury during extrahepatic cholestasis by stimulation of apoptosis and subsequent proliferation of hepatocytes, leading to elegant removal of damaged hepatocytes, thus preventing necrosis and concomitant inflammatory responses.

Ursodeoxycholic acid aggravates bile infarcts in bile duct-ligated and Mdr2 knockout mice via disruption of cholangioles.

BACKGROUND & AIMS: The effects of ursodeoxycholic acid (UDCA) in biliary obstruction are unclear. We aimed to determine the effects of UDCA in bile duct-ligated and in Mdr2 knockout (Mdr2(-/-)) mice with biliary strictures. METHODS: Mice fed UDCA (0.5% wt/wt) or a control diet were subjected to common bile duct ligation (CBDL), selective bile duct ligation (SBDL), or sham operation. UDCA was also fed to 2-month-old Mdr2(-/-) mice. Serum biochemistry, liver histology, and mortality rates were investigated. The biliary tract was studied by plastination, India ink injection, and electron microscopy. The effects of UDCA on biliary pressure were determined by cholangiomanometry. RESULTS: UDCA feeding in CBDL mice increased biliary pressure, with subsequent rupture of cholangioles and aggravation of hepatocyte necroses, resulting in significantly increased mortality. UDCA feeding in SBDL mice aggravated liver injury exclusively in the ligated lobe. Mdr2(-/-) mice developed liver lesions resembling sclerosing cholangitis characterized by biliary strictures and dilatations. UDCA induced bile infarcts in these animals. CONCLUSIONS: UDCA aggravates bile infarcts and hepatocyte necroses in mice with biliary obstruction via disruption of cholangioles as a result of increased biliary pressure caused by its choleretic action.

[Results of emergency ERCP in the treatment of acute biliary pancreatitis]. / Ergebnisse der notfallmässigen ERCP bei der Behandlung der akuten biliären Pancreatitis.

Indication for emergency ERCP (< 48 hours after onset of symptoms) with stone extraction from the common bile duct (CBD) in patients with biliary pancreatitis remains controversial. In our hospital emergency ERCP with stone extraction from CBD is part of the therapeutical concept in patients with biliary pancreatitis. The aim of the study was to elucidate retrospectively results and impact of this concept on morbidity and lethality in surgical intensive care patients. We included all patients with a documented indication for emergency ERCP. Among 4 466 patients (1. 1. 1999-31. 12. 2000) treated in the SICU, 37 (0.9 %) required an emergency ERCP due to a biliary pancreatitis. (26 females/11 males, 62.0 +/- 15.4 years). After ERCP stones were present in 32 of the 37 patients with subsequent successful endoscopic extraction in all cases but one. The mean duration from admission to ERCP was 11.6 +/- 10.1 hours. Bilirubin as well as amylase and lipase decreased after ERCP (p < 0.05). Only in one case an elevation of pancreatic enzymes over the pre-ERCP values was observed, an aggravation of pancreatitis was not seen in our series. In 5 of the 37 cases bile duct stones were not found after ERCP despite strong clinical suggestion (elevation of bilirubin and pancreatic enzymes, ultrasound). During the observational period 2 patients died, in one case possibly due to the ERCP. Emergency ERCP removed in our series the pancreatitis causing agent. Still considering the limitations of a retrospective study these positive results are stimulating us to continue with our therapeutical concept.

Feasibility and complications of endoscopic biliary drainage in patients with malignant biliary obstruction at King Chulalongkorn Memorial Hospital.

Currently the best curative therapy for primary malignant biliary tumor is surgery. Unfortunately, many patients present at a very late stage and only palliative biliary drainage is possible. Usually nonsurgical palliative biliary drainage means either percutaneous or endoscopic approach. In this series, the authors reported the rate of technical success and immediate complications in patients with malignant biliary obstruction who underwent endoscopic biliary drainage. From endoscopic retrograde cholangiopancreatography (ERCP) database between September 2000 and October 2001, there were 273 ERCP performed for obstructive jaundice. Of these, 50 patients with malignant tumor underwent 80 procedures for endoscopic biliary drainage. The patients were divided into three groups according to the cholangiographic findings and clinical diagnoses. Patients with carcinoma of the pancreatic head were categorized as group I (n=10). Group II (n=20) and III (n=20) were patients with extrahepatic cholangiocarcinoma and hilar cholangiocarcinoma respectively. All patients received either plastic or metallic endoprothesis placement for biliary drainage. All patients except two in group I had successful endoscopic treatment. Complications in group I, II and III were 15.4 per cent, 14.3 per cent and 53.1 per cent respectively. Only one patient in group II developed significant hypotension during the procedure. Another complication was defined as post procedure cholangitis. In conclusion endoscopic biliary drainage was technically feasible in 97.5 per cent of patients who had malignant biliary obstruction. In patients with hilar tumor the incidence of post procedure cholangitis was high (53.1%). Improvement in technique, avoiding unnecessary contrast injection, and draining the obstructed bile duct after injecting the contrast may improve the outcome and decrease the rate of post procedure cholangitis in these patients.

Long-term follow-up of patients with a clinically benign extrahepatic biliary stenosis and K-ras mutation in endobiliary brush cytology.

BACKGROUND: K-ras mutations in endobiliary brush cytology are an early event in carcinogenesis and justify a suspicion of malignancy in patients with extrahepatic biliary stenosis. However, K-ras mutations have been detected in specimens obtained by brushing of clinically benign extrahepatic biliary stenosis. The aim of this study was to determine whether these findings represent an early or false-positive diagnosis of cancer. METHODS: Cytologic specimens were obtained by brushing in 312 consecutive patients with extrahepatic biliary stenosis. Mutations in the K-ras oncogene were detected by an enriched polymerase chain reaction and allele-specific oligonucleotide hybridization assay. Eight patients with a K-ras mutation and a clinically benign extrahepatic biliary stenosis were followed. RESULTS: After a median follow-up of 65 months, 6 of the 8 patients were alive without evidence of malignancy. One patient died of congestive heart failure. The other patient died 60 months after the specimen was obtained, possibly because of chronic pancreatitis, although previously there had been suspicion of malignancy. Biopsy specimens from the papilla were negative for neoplasia and the K-ras analysis harbored the same mutation as previously found in the brush specimen. CONCLUSION: Based on long-term follow-up, the K-ras mutations in all 8 patients with a clinically benign extrahepatic biliary stenosis must be considered as confirmed false-positives. Nevertheless, a false-positive result is infrequent. Therefore, patients with a positive K-ras mutation in biliary cytologic specimens obtained by brushing still require careful, continuing follow-up.