Changes over time in treatment for obstructive jaundice.

Background: Obstructive jaundice can be instigated by benign or malignant lesions. These problems are treated with biliary decompression, which can be done either endoscopically or surgically. Aim: The aim of the study is to assess the advantages and limitations as well as the therapeutic and diagnostic benefits of ERCP in the treatment of obstructive jaundice. Methods: This cross-sectional study was held in the Departments of General Surgery, Liaquat University of Medical and Health Science, Jamshoro for one-year duration from January 2022 to December 2022. A total of 70 consecutive patients were included with purposive sampling and with the diagnosis of obstructive jaundice done with ERCP. Patients with prior diagnostic or therapeutic endoscopic intervention or gastric outlet obstruction or prior gastric surgery were excluded from this study. The results are summarized in a table and conclusions are made. Results: The study included 70 patients (45 males and 25 females) with mean age of 45 years (21-70 years). The most common malignant causes of obstructive jaundice are papillary carcinoma (8.6%), cholangiocarcinoma (17.1%) and pancreatic Carcinoma (27.1%). The most common benign cause was bile duct stone (30%), followed by round warm biliary tree (5.8%) and papillary stenosis (11.4%). 30(93.8%) of patients done with stenting with 92% of success rate. Biopsies were performed to diagnose 8.6% of papillary tumors. 45.7% of patients done with stenting with 93.8% of success rate. In the remaining cases, the success rate was 100%. the most common reason for not performing ERCP; duodenal stenosis in 2.9%, abnormal papillary position in 4.3%, complete papillary obstruction in 4.3% and ampulla was not found endoscopically in 7.1% of subjects. Acute pancreatitis was the most communal complication occurred in 5.7% of cases. Bleeding occurs in 4.3% of cases; 4.3% have acute cholangitis and perforation in 2.9%. Conclusions: In spite of its complications and limitations, ERCP is a reliable stenting procedure as a palliative and tissue diagnostic tool for blockage due to malignant tumor and in the treatment of obstructive jaundice and most benign diseases. In this study, the effectiveness of ERCP in the treatment of obstructive jaundice is satisfactory. Keywords: Cholangiocarcinoma, pancreatic carcinoma, ERCP, Obstructive jaundice, and Stenting.

Objective To observe the symptoms,short and long term effects of body gama-knife in treatment of obstructive jaundice caused by cholangiocarcinoma.Methods 76 patients with obstructive jaundice caused by cholangiocarcinoma were treated with OUR-QGD body gamma-knife.The single therapeutic dose was 3.0-4.0 Gy,isodose curves was 50.0 ％-65.0 ％,the total treatment time was 10-12 times.The liver function,blood routine and adverse effects were monitored.Results Among 76 patients,the jaundice symptoms of 69 cases were significantly reduced,the TBIL and ALT levels were significantly lower than that before treatment (P ＜ 0.05),the ORR was 88.16 ％ (67/76),DCR was 90.79 ％ (69/76).The median TTP was 8.8 months and the median OS was 13.4 months.Conclusions Body gamma-knife treatment for obstructive jaundice caused by cholangiocarcinoma can significantly improve symptoms of patients,and improve their life quality.This treatment has less adverse effects and satisfaction short-time and long-term effects. Key words: Bile duct neoplasms; Body gama-knife; Jaundice, obstructive; Efficacy

Laparoscopic cholecystostomy in treatment of obstructive jaundice

Objective To evaluate the treatment of obstructive jaundice caused by bile duct strictures after hepatic transcatheter arterial chemoembolization in hepatic tumor patients. Methods A retrospective review (Jun 1994 - Mar 2010) of databases at two institutions (Zhejiang Provincial People's Hospital and Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine) identified 15patients with obstructive jaundice caused by liver bile duct stricture after transcatheter arterial chemoembolization. There were 7 cases of primary liver cancer, 5 patients of liver hemangioma, 3 cases of metastatic liver cancer including 2 cases of colonic cancer and one of pancreatic cancer. Obstructive jaundice appeared in a period of 5 months to 16 months after TACE. The median time was 9 months. Results The obstructive jaundice was relieved by surgically constructed hepatobiliary drainage or PTC+stenting treatment in 13 cases and PTCD in 2 cases. All patients of hepatic hemangioma were doing well after treatment. Two cases of primary liver cancer patients with obstructive jaundice after TACE were followed up for 2 years with no recurrence of hepatic carcinoma and bile duct obstruction. The other 8 patients were followed up from 3months to 18 months until to their death from primary disease progress. Conclusions Surgery and or PTCD plus stent can effectively relieve the obstructive jaundice caused by TACE in benign or malignant liver tumors. Key words: Liver neoplasms; Bile duct diseases; Chemoembolizafion, therapeutic; Jaundice, obstructive

Objective To discuss the diagnosis,differential diagnosis and treatment of obstructive jaundice in infants.Methods Infants with obstructive jaundice were examined by ECT to obtain dynamic images of the liver,biliary tract and intestine to find out the position and nature of the obstruction.Results Eight patients with delayed nuclide imagining were diagnosed as obstructive jaundice of cholestasis.Five of which with aggravated jaundice were cured by biliary irrigation and 3 by medication.For 16 patients with congenital biliary atresia,10 were exterior hepatic types and 6 interior hepatic types.They had the nuclide image of liver and biliary tract.Ten cases of the exterior hepatic types and four cases of the interior types received the Kasai operation.And bile was drained after the surgery.Seven patients survived and 4 of interior heaptic types died postoperatively.Due to bile fistula,3 patients died after the hepato-porto-jejunostomy for internal drainage.Two patients of interior hepatic types who had no operation died of the hepatic failure.Conclusion The nature and position of obstructive jaundice could be identified by nuclide imaging.Young patients with jaundice of cholestasis could be treated by antiinflamation,liver function protection,Hymecromone and Dexamethasone for two weeks.Once the serum bilirubin rises,operation would be indicated.In the case of congenital biliary atresia,operation should be done earlier on the basis of medication. Key words: Obstructive jaundice; Biliary atresia; 99mTc-EhIDA; Diagnosis

Obstructive jaundice is characterized by complex management,more complications,slow recovery and long hospital stay due to special anatomy of the biliary tract system and the complicated pathophysiological changes.Enhanced recovery concept,which is the core of enhanced recovery after surgery,can be applied to the treatment of obstructive jaundice,which can alleviate stress responses,intervene early,reduce complications,shorten the length of hospital stay,reduce risk of readmission and average medical costs,its core concept consists in early removal of obstruction,recovering continuity of the biliary tract,normalizing the enterohepatic circulation of bile,accelerating the recovery the liver and other organs' function,and reducing postoperative complications.Based on this,Study Group of Biliary Tract Surgery in Chinese Society of Surgery of Chinese Medical Association,Hepatobiliary Committee of Bethune Charitable Foundation and Editorial Board of Chinese Journal of Surgery organized experts to make this consensus jointly. The consensus includes 17 recommendations about general contents,preoperative biliary drainage of obstructive jaundice and treatment of diseases related to obstructive jaundice.The consensus aims to provide a reference to the standardization and normalization of ERC in the treatment of obstructive jaundice in China.

Objective To explore the clinical value of ultrasound-guided percutaneous transhepatic cholangial drainage (PTCD) in the treatment of obstructive jaundice. Methods Eighty patients with obstructive jaundice who underwent ultrasound-guided PTCD in our hospital from May 2009 to May 2012 were followed up, and their records such as PTC tube number, the average operation time, postoperative 24h bile drainage and serum total bilirubin level were summarized retrospectively. Results Ninety-five PTC tubes were inserted in eighty patients, and the average indwelling time was 7-185(45±21) d. The mean time of operation was (30±15) min. The drainage of 24hours after operation was (415±214) ml. Serum total bilirubin of patients at time of two weeks after operation, one weeks after operation and pre-operation were (57±36)μmol/L, (116±56)μmol/L, and (354±150) μmol/L, P<0.01. Bile leakage and hemobilia occurred in two patients (2.5%). Conclusion Ultrasound-guided PTCD is a good choice for obstructive jaundice, for it is minimally invasive and safe. Key words: Ultrasound; Percutaneous transhepatic cholangial drainage (PTCD); Obstructive jaundice

7262 Biliary drainage for the palliative treatment of obstructive jaundice secondary to metastasis from gastric carcinoma.

To describe a simple one-step method involving percutaneous transhepatic insertion of an expandable metal stent (EMS) used in the treatment of obstructive jaundice caused by unresectable malignancies. Fourteen patients diagnosed with obstructive jaundice due to unresectable malignancies were included in the study. The malignancies in these patients were a result of very advanced carcinoma or old age. Percutaneous transhepatic cholangiography was performed under ultrasonographic guidance. After a catheter with an inner metallic guide was advanced into the duodenum, an EMS was placed in the common bile duct, between a point 1 cm beyond the papilla of Vater and the entrance to the hepatic hilum. In cases where it was difficult to span the distance using just a single EMS, an additional stent was positioned. A drainage catheter was left in place to act as a hemostat. The catheter was removed after resolution of cholestasis and stent patency was confirmed 2 or 3 d post-procedure. One-step insertion of the EMS was achieved in all patients with a procedure mean time of 24.4 min. Out of the patients who required 2 EMS, 4 needed a procedure time exceeding 30 min. The mean time for removal of the catheter post-procedure was 2.3 d. All patients died of malignancy with a mean follow-up time of 7.8 mo. No stent-related complication or stent obstruction was encountered. One-step percutaneous transhepatic insertion of EMS is a simple procedure for resolving biliary obstruction and can effectively improve the patient's quality of life.

The effect of therapeutic plasmapheresis combined with biliary drainage was evaluated in obstructive jaundice animal models. Plasma exchange (PE) using fresh-frozen plasma was carried out with biliary drainage (BD) on a canine jaundice model created by the ligation and resection of bile duct. Routine biochemical analyses were done following PE and BD. The result was compared with that of a BD only group. Plasma bilirubin level abruptly dropped after PE and was kept at a lower level, whereas the bilirubin level of the drainage alone group decreased gradually. Decreased plasma mitochondrial GOT level in the PE group suggests improvement of liver cell damage in obstructive jaundice. Mitochondrial function of liver tissue was evaluated following partial hepatectomy, which was carried out 2 days after PE along with BD in jaundice rat. Mitochondrial respiratory control ratio and ADP/O ratio following hepatectomy were improved in the PE group. The results suggest the improvement of hepatic functional reservoir by a single PE treatment in addition to BD treatment. These results show that PE can shorten the icteric period and may improve the hepatic functions after the treatment of malignant obstructive lesion in the biliary tract.

Currently, one of the most pressing issues for surgeons in the treatment of obstructive jaundice is the ability to assess the functional state of the liver and to detect and determine the degree of liver failure in a timely manner with simple and objective techniques. In this regard, the use of fluorescence spectroscopy method can be considered as one of the ways to improve the informativity of existing diagnostic algorithms in clinical practice and to introduce new diagnostic tools. Thus, the aim of the work was to study in vivo the functional state of liver parenchyma by the method of fluorescence spectroscopy implemented through a needle probe and assess the contribution of the main tissue fluorophores to reveal new diagnostic criteria. We compared data from 20 patients diagnosed with obstructive jaundice and 11 patients without this syndrome. Measurements were performed using a fluorescence spectroscopy method at excitation wavelengths of 365 and 450 nm. Data were collected using a 1 mm fiber optic needle probe. The analysis was based on the comparison of the results of deconvolution with the combinations of Gaussian curves reflecting the contribution of the pure fluorophores in the liver tissues. The results showed a statistically significant increase in the contribution of curves reflecting NAD(P)H fluorescence, bilirubin, and flavins in the group of patients with obstructive jaundice. This and the calculated redox ratio values indicated that the energy metabolism of the hepatocytes may have shifted to glycolysis due to hypoxia. An increase in vitamin A fluorescence was also observed. It may also serve as a marker of liver damage, indicating impaired vitamin A mobilization from the liver due to cholestasis. The results obtained reflect changes associated with shifts in the content of the main fluorophores characterizing hepatocyte dysfunction caused by accumulation of bilirubin and bile acids and after disturbance of oxygen utilization. The contributions of NAD(P)H, flavins, and bilirubin as well as vitamin A can be used for further studies as promising diagnostic and prognostic markers for the course of liver failure. Further work will include collecting fluorescence spectroscopy data in patients with different clinical effects of obstructive jaundice on postoperative clinical outcome after biliary decompression.

To study the technical method and clinical value of stent implantation through the rendezvous technique of percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) in patients with obstructive jaundice. Thirty-six patients with obstructive jaundice underwent the rendezvous technique of PTBD and ERCP after initially unsuccessful ERCP. The procedure of 36 cases were all successful. Sixteen cases underwent PTBD drainage from the bile duct through the right lobe approach and in 20 cases the left lobe approach was used. The one-stage procedure involved in the rendezvous technique of PTBD and ERCP was successful in 23 cases, while the other 13 cases underwent PTBD first and then rendezvous ERCP the next time. The serum total bilirubin 4 days later had decreased by 44.75%, and direct bilirubin had decreased by 45.61%. The main complication was infection of the bile duct. Stent implantation using the rendezvous technique of PTBD and ERCP is a new and feasible method to treat obstructive jaundice after initially unsuccessful ERCP. This may be of considerable value in clinical practice.

Safety and efficacy of irreversible electroporation in the treatment of obstructive jaundice in advanced hilar cholangiocarcinoma

Objective To evaluate the efficacy of advanced cancer treatment of obstructive jaundice by percutaneous biliary puncture and intensity modulated radiation therapy.Methods Nineteen patients with advanced cancer of obstructive jaundice were treated by skin biliary puncture combined with intensity modulated radiation therapy.Results In 19 patients evaluated by the WHO criteria,2 cases (10.5 ％) had complete response (CR),15 cases (78.9 ％) had partial response (PR),while 1 case (5.3 ％) had stable disease (SD) and 1 case (5.3 ％) got progressive disease (PD).Jaundice relieve rate was 94.7 ％ (18/19),6,8,12 months survival rates were 78.9 ％ (15/19),47.4 ％ (9/19),15.8 ％ (3/19),and the median overall survival time was 10 months.Conclusion Percutaneous biliary puncture combined with intensity modulated radiation therapy is well effective for patients with advanced cancer of obstructive jaundice,related toxicities are tolerable.These results indicate that further clinical study is of great worth. Key words: Biliary puncture; Intensity modulated radiation therapy; Cancer; Obstructive jaundice

Introduction Patients with liver metastases arising from breast cancer presenting with jaundice have poor prognoses; most patients are not treated aggressively. However, we report an improvement in the quality of life (QOL) of the patient by inserting a biliary stent as palliative surgical treatment. Case presentation The patient was a 63-year-old woman. She had left breast cancer and had undergone total mastectomy and axillar lymph node dissection approximately 20 years ago. Thereafter, chemotherapy and hormonal therapy were continued for approximately 5 years. Sixteen years after surgery, the patient presented with hepatic failure; furthermore, total bilirubin (T-Bil) levels had increased to 5.5 mg/dL. Imaging revealed multiple liver metastases and dilatation of the intrahepatic bile duct. A biliary stent was placed, and treatment for obstructive jaundice was administered. After 3 months, the patient was able to maintain QOL without any increase in T-Bil levels. Conclusion Palliative surgical treatment via biliary stenting for the onset of obstructive jaundice caused by liver metastases arising from breast cancer can be useful for maintaining patient QOL.