Hepatobiliary transported levofloxacin-loaded nanoparticles for treatment of bacterial biliary infection.

Objective To investigate the distribution, drug resistance of bile pathogenic bacteria, and the risk factors for biliary infection. Methods Clinical and laboratory data of patients hospitalized from January 2008 to October 2015 were reviewed for pathogenic bacteria and drug resistance, and the factors related to biliary tract infection were studied. Results Among all 320 cases, there were 249 cases of pathogenic bacteria in bile specimens, the positive rate was 77.81%. There were 356 strains of pathogenic bacteria of 40 species, including 244 strains of gram negative bacteria (68.54%), 93 strains of gram positive bacteria (26.12%) and 19 strains of fungi (5.34%). Top three bacteria were Escherichia coli (84 strains, 23.60%), Klebsiella pneumonia (60 strains, 16.85%), and Enterococcus faecium (40 strains, 11.24%). The Escherichia coli and Klebsiella pneumoniae had the highest drug resistance to cefazolin, and they had a lower drug resistance to cefoxitin and amikacin. The multivariate analysis showed that age≥60 years (AOR=2.311, 95%CI: 1.292-4.135)and the history of ERCP operation (AOR=3.475, 95%CI: 1.587-7.607) were independent risk factors for biliary tract infection. Conclusion Bacteria are mainly gram negative bacteria in the bile of patients with biliary tract infection, suggesting antibiotics with low resistant rate of gram-negative is the first choice. The age≥60 years and history of ERCP surgery are independent risk factors for patients with biliary tract disease. Measures to prevent biliary infections in high-risk patients should be taken. Key words: Biliary tract diseases; Bile; Bacteriology; Drug resistance; Risk factors

Objective: To investigate and analyze the distribution of main pathogenic bacteria in bile of patients with postoperative biliary infection after liver puncture percutaneous biliary drainage (PTCD) treatment and their sensitivity to different antibiotics. Methods: The patients (219 cases) with biliary tract infection after PTCD treatment were collected in June 2014-June 2016, the bile samples were gathered, and bacteria+fungus culture and drug sensitive test were performed and analyzed. Results: (1) The 219 bile samples were collected, a total of 253 strains were obtained, containing 20 kinds and including 194 strains of G- bacteria (76.7%) , 53 strains of G+ bacteria (20.9%) and 6 strains of fungus (2.4%) ; The top three G- bacteria were Escherichia coli (93 strains, 36.7%) , Klebsiella pneumoniae (39 strains, 15.4%) and Pseudomonas aeruginosa (18 strains, 7.1%) . The top two G+ bacteria were Enterococcus faecium (17 strains, 6.7%) and Enterococcus faecalis (14 strains, 5.5%) ; The fungi were mainly Candida albicans (3 strains, 1.2%) . (2) Antibacterial drugs with high sensitivity to G- bacteria included carbapenems, aminoglycosides and cephalosporins; Antibacterial drugs with high sensitivity to G+ bacteria included quinolones, oxazolanone and glycoside antibiotics. Fungi were sensitive to triazole antifungal drugs. Conclusions: G- bacteria are the main pathogenic bacteria in the bile of patients with biliary tract infection after PTCD treatment, followed by G+ bacteria and fungi, and some cases are mixed infection. Key words: Percutaneous biliary drainage; Biliary infection; Bacterial spectrum; Drug resistance; Antibiotic

Objective To investigate the changes of pathogens and antimicrobial susceptibility in patients with biliary tract infection during the past 30 years. Methods During the periods of 1981-1984, 1988-1998 and 2003-2013, each 100 patients treated with common bile duct exploratoration were selected from every period. Biopsied bile specimens were performed with bacteria culture and antimicrobial susceptibility tests. This study reviewed the changes in bilary pathogens and antimicrobial susceptibility test. Results From 1981 to 1984, the most common pathogens were Escherichia coli (59.2%) and Klebsiella pneumonia (28.9%). Mixed infection of these pathogens accounted for 16.9%. From 1988 to 1998, the types of pathogens significantly increased. Escherichia coli (33.1%) and Klebsiella pneumonia (16.5%) accounted for less than 50%. Mixed infection with Escherichia coli and Pseudomonas aeruginosa was the most common type. From 2003 to 2013, gram-negative bacteria were still the main pathogens, accounting for 61.8%. Escherichia coli and Pseudomonas aeruginosa accounted for 20.1% and 10.4%, respectively. Gram-positive bacteria increased significantly. Enterococcus faecium (22.2%) ranked the first. Mixed infection increased (36%), of which more than 50% was mixed pathogens of Escherichia coli and Enterococcus faecium. The incidence of fungi infection also increased (5.6%). Conclusions There was a remarkable change of pathogen category in the biliary infections over the past years. With an increase of gram-positive bacteria and fungi infection in clinical practice, antimicrobial susceptability results could be considered in choosing appropriate drug to avoid bacterial resistance. Key words: Biliary tract infection; Pathogen; antimicrobial susceptibility test; Resistant rate

Bile secretory immunoglobulin a in biliary infection and cholelithiasis

Biliary‒enteric bypass surgery, while relieving obstruction, disrupts the anatomical barrier of the biliary system, predisposing patients to biliary infections. However, comprehensive comparative analyses of biliary pathogen profiles, inflammatory responses, antimicrobial resistance and clinical characteristics in patients with and without a history of this surgery are limited. This study aimed to compare these aspects and their impact on clinical characteristics between these two patient groups. A single-center retrospective study was conducted on 74 patients who underwent percutaneous transhepatic biliary drainage (PTBD) for biliary tract infections between October 2020 and May 2024. Patients were divided into biliary-enteric bypass (n = 32) and nonbypass (n = 42) groups on the basis of surgical history. Data on demographics, bile cultures, inflammatory markers, antibiotic use, and multidrug-resistant organism (MDRO) were analysed. The bypass group had a significantly higher bile culture positivity rate (78.1% vs. 45.2%, p < 0.01; adjusted OR = 4.1, 95% CI: 1.5–11.2), with a predominance of Escherichia coli (34.4%) and Enterococcus faecium (21.9%). The MDRO infection rate was markedly higher in the bypass group (46.9% vs. 21.4%, p = 0.01; adjusted OR = 3.3, 95% CI: 1.2–9.1), accompanied by higher use of carbapenems (25.0% vs. 18.8%, p = 0.04). Preoperative inflammatory marker levels were significantly elevated in the bypass group (p < 0.01). Clinically, the bypass group experienced longer hospital stays (28.5 vs. 25.7 days, p = 0.04), a higher rate of treatment failure (31.3% vs. 11.9%, p = 0.04; adjusted OR = 3.5, 95% CI: 1.1–11.3), and higher total costs (8.9 vs. 7.6, p = 0.02) (ten thousand CNY). A history of biliary-enteric bypass is associated with a distinct and more severe biliary infection profile characterized by higher rates of bacterial colonization, MDROs, intense systemic inflammation, increased carbapenem reliance, and poorer clinical outcomes, including longer hospitalization, higher treatment failure rates, and increased costs.

Biliary tract infections are a worldwide problem, with a large financial burden on health care. Biliary infections can result from multiple causes, but the most common culprit is cholelithiasis. In the past decade, our knowledge of the mechanism of disease, microbiology of infections, and management options has grown enormously. Although at times perplexing, it is important to understand this information to allow for efficient, quality, and cost-effective health care.

(1) Background: Cholecystitis and cholangitis are among the most common diseases treated by general surgery. Gallstones lead to inflammation and bacterial infection of the biliary tract. Biliary infections can lead to live threatening bacteremia and liver abscesses. The true role of anaerobes remains unclear. (2) Methods: We retrospectively analyzed bacterial cultures from biliary samples obtained from bile ducts and gallbladders at our tertiary care center. Patient characteristics and clinical outcomes were analyzed. (3) Results: In our database of 1719 patients, 365 patients had microbial testing, of which 42 grew anaerobic bacteria. Anaerobes were more frequently cultured in patients with hepatic abscesses and gallbladder perforation. These patients were older and had more comorbidities than the control group. The overall outcomes of all patients were favorable and the resistance rate to commonly used antibiotics remained low. (4) Conclusions: Anaerobes in biliary tract infections appear to be underdiagnosed and more prevalent in the elderly with advanced disease. Due to low antibiotic resistance, the combination of source control and adjunct anti-infective treatment leads to favorable outcomes.

Malnutrition and sarcopenia are prevalent complications in cirrhosis. The relationship between sarcopenia and biliary infection in cirrhotic patients is not well understood. Our study aims to clarify this association. In this study, we leveraged data from a tertiary care hospital, enrolling patients with hepatitis B virus (HBV)-induced cirrhosis from 2022. An acute biliary tract infection was defined as the onset of acute cholecystitis or cholangitis within a year. Sarcopenia was identified based on established criteria and assessed using the L3 skeletal muscle index (SMI). A multivariate logistic regression model was constructed to analyze the relationship between sarcopenia and acute biliary tract infection. Receiver operating characteristic (ROC) curve analysis and smooth curve fitting were also conducted. This study enrolled a total of 262 patients with HBV-related cirrhosis, with an average age of 60 years and including 173 males. The primary causes for hospital admission were ascites and hepatic encephalopathy. Within the group with biliary infection, patients typically presented with higher white blood cell counts, lower platelet levels, and poorer indicators of liver and kidney function. In the multivariate analysis, after adjusting for various confounding factors, sarcopenia was associated with an odds ratio of 1.55 ( P = 0.002) for acute biliary infection. Smooth curve fitting revealed an approximately linear positive relationship between L3 SMI and acute biliary infection, with the area under the ROC curve for L3 SMI reaching 0.89, indicating a strong predictive value. Sarcopenia is associated with acute biliary infection in patients with HBV-related cirrhosis.

Objectives To access the bacteriology in patients with sepsis due to biliary tract infection to provide a basis for empirical selection of proper antibiotic treatment. Methods This is a single-center retrospective study on 214 patients with biliary tract infection admitted from August 2014 to July 2016 to the surgical intensive care units (ICU) of The First Affiliated Hospital of Sun Yat-sen University. To study the demographic information, sequential organ failure assessment (SOFA), usage of antibiotics before ICU and duration of ICU were analyzed. Bile, peritoneal drainage and blood samples were collected. Results 47 septic shock patients and 25 septic patients due to biliary tract infection were enrolled in the trial. The two groups (the shock group vs. the sepsis group) had a significant difference in the duration of ICU stay [(6.4±4.6) d vs. (2.3±1.8) d, P<0.05]. 48 strains of pathogens were isolated from the bile samples. The major pathogens were Escherichia coli (E. coli) (n=23, 47.9%), Enterococcus faecalis (n=8, 16.7%) and Enterococcus faecium (n=2, 4.2%). 80 strains of pathogens were isolated from the peritoneal drainage culture samples. E. coli, pseudomonas aeruginosa, and Klebsiella pneumoniae ranked the top 3 species, accounting for 26.3%, 11.3% and 7.5%, respectively. The sensitivity of E. coli isolated from bile to amikacin, imipenem and panipenem were all over 90.0%. Conclusions E. coli was the principal gram-negative bacterium in biliary infection induced sepsis. Early administration of carbapenemes may reduce the occurrence of septic shock in these patients. Key words: Antibiotics; Biliary tract infection; Sepsis; Bacteriological analysis

Objective To explore major risk factors for postoperative biliary tract infection associated with endoscopic retrograde cholangiography (ERC), and to evaluate endoscopic nasobiliary drainage (ENBD) for intervening the infection. Methods A total of 512 patients who underwent ERC at the First People′s Hospital of Yunnan Province from January 2010 to June 2016 were enrolled and divided into group A and B randomly. Group A underwent ENBD after ERC while group B without. The incidence rates of biliary tract infection in different causes and lesions were compared between the two groups. Results Among the 512 patients, there were 276 cases in group A and 236 cases in group B. The overall postoperative biliary infection rate was 4.30%(22/512). Patients in group A showed a smaller chance of developing postoperative biliary tract infection than that in group B [1.09%(3/276) VS 8.05%(19/236), χ2=15.00, P=0.000]. Malignant biliary obstruction was the most common cause (13.46%, 14/104) and the most common site was hepatic portal (13.43%, 9/67). Conclusion ENBD can ensure smooth drainage of bile duct therefore effectively prevent biliary tract infection after ERC, especially for patients with malignant biliary obstruction and hepatic portal lesion. Key words: Infection of biliary tract; Cholangiography, endoscopic retrograde; Endoscopic nasobiliary drainage

Objective To investigate the distribution of biliary bacteriology and their sensitivity to antibiotics in patients with biliary tract infection in Jinshan area in recent 3 years.Methods Bile specimens collected from 367 patients with cholelithiasis between June 2006 and June 2009 were cultured and tested for drug sensitivity to aerobic bacteria.The results were statistically analyzed.Results One hundred and fifty-six bacterial strains were found in 142 (38.7%) bile specimens including gram negative strains (97,62.2%),gram positive strains (51,32.7% ),and fungal strains (8,5.1%).Enterococcus (17.9%) was major pathogen and follwed by Escherichia coli (12.8%),staphylococcus (11.5%),Klebsiella pneumoniae (8.3%),Pseudomonas aeruginosa (7.7%).Whereas the mixed infection was found in 26 (18.3%) specimens.The positive rate of bacterial infection was 53.1% in patients over 60 years of age (X2=8.36,P 50% ).In gram positive strains,none was resistant to Vancomycin,11.3% to fosfomycin and 11.6% to chloromycetin.They were highly resistant to Penicillins,Ampicillin and Cefazollin (>40%).ConclusionsEnterococcus,Escherichia coli,Sstaphylococcus and Klebsiella pneumoniae are commonly seen pathogens in biliary tract infection in Jinshan area.Use of Sulperazone or TZP plus Amikacin and metronidazole is recommended.Imipenem and Vancomycins may be second choice in treatment of severe biliary infection and refractory infection. Key words: Bacterial infection; Bile; Drug resistance

Liver transplantation remains the only effective therapeutic option for patients with advanced primary sclerosing cholangitis (PSC). Approximately 5% of all liver transplants that are performed each year in adults in the United States are for PSC.1 As the long-term outcome of PSC patients following liver transplantation continues to improve, reaching over 80% at 5 years,1 there appears to be an increase in the number of patients developing recurrent PSC, which has emerged as clinically and academically important.2-4 Three remarkably similar studies from the American and British communities2-4 in this issue of Liver Transplantation provide further evidence of the cumulative effect of recurrent PSC on survival outcome and reveal some potential risk factors, which might provide insight into the pathogenesis of the primary and recurrent disease. ACR, acute cellular rejection; HLA, human leukocyte antigen; IBD, inflammatory bowel disease; PSC, primary sclerosing cholangitis. Recurrence of PSC in the hepatic graft was first reported by Lerut et al.5 in 1988. Despite controversy that followed shortly after this concept was introduced; the recognition of recurrent PSC is now firmly established in the liver transplant community. Recurrent PSC occurs in 2%-40% of the transplanted grafts.6 The variation is related in part to differences in diagnostic criteria and duration of follow-up. The use and timing of the protocol applied to detect biliary strictures and/or liver histology appears to be the most important factor for the disparity in the reported incidence of recurrent PSC. Given that cholangiographic features of recurrent PSC are not correlated with biochemical indices, cholangiographic studies only for clinical indications will underestimate the extent of this problem. Protocol cholangiography with a magnetic resonance technique may allow systemic and noninvasive evaluation of recipients with possibly full documentation of disease recurrence. The main problem with establishing a diagnosis of recurrent PSC is the lack of gold-standard diagnostic criteria. In addition, the diagnosis of recurrent PSC has been complicated by the knowledge that a variety of potential insults to the hepatic graft may result in biliary injury and stricturing. In particular, non-anastomotic biliary strictures in the liver allograft can occur because of the use of an ABO-incompatible allograft, chronic rejection, biliary tract infection, hepatic artery thrombosis, preservation injury, and prolonged cold ischemic time. Recently, a set of criteria has been proposed by a group of investigators from the Mayo Clinic7 to serve as a uniform clinicopathologic standard for the diagnosis of recurrent PSC. The diagnostic criteria consist of a confirmed diagnosis of PSC before transplantation; cholangiogram showing non-anastomotic biliary strictures occurring >3 months after liver transplantation; exclusion of other conditions associated with biliary strictures; and/or liver biopsy showing fibrous cholangitis and/or fibro-obliterative lesions. Thereafter, these diagnostic criteria have been increasingly used as the standard tool for diagnosis of recurrent PSC. In the three follow-up studies published in this issue of Liver Transplantation by Alexander et al.,2 Campsen et al.,3 and Cholangitas et al.,4 overall, 36 (14%) of 252 PSC patients had evidence of recurrent PSC as defined by the Mayo Clinic criteria, for whom cholangiography was performed when clinically indicated and/or protocol liver biopsy was consistent with PSC. The cumulative incidence of developing recurrent PSC in surviving patients at 1, 5, and 10 years posttransplantation was 2%, 12%, and 20%, respectively.3 Comparison with the nonrecurrent disease group showed that the duration of survival free of death or transplantation among recipients with recurrent disease was not significantly different.3, 4 The observed patient survival at 5 and 10 years after primary transplantation was 76%-85% and 61%-76%, respectively.3, 4 One-third of the recurrent disease patients had progressive disease ultimately requiring retransplantation, and some patients died of recurrent PSC.2-4 Similar to PSC in the native liver, the natural course of recurrent PSC is variable and difficult to predict. However, the prognosis of recurrent disease seems to be better than that of symptomatic PSC patients before liver transplantation. This may in part be due to a diagnosis of recurrent PSC being often made in the early course of the disease, or possibly the effects of immunosuppression may delay or modify disease expression within the graft. The pathogenesis of PSC remains unclear, but promising inroads have been made in elucidating genetic and immunologic mechanisms.1 Several human leukocyte antigen (HLA)–associated and non-HLA–associated genes have been implicated in the development of the disease.8, 9 Currently, there is increasingly evidence that susceptibility to PSC is conferred by the concurrent presence of HLA and non-HLA susceptibility alleles that favor production of high sustained levels of proinflammatory cytokines and recirculating gut-primed memory T cells.9 In a study of HLA class II alleles involving 265 PSC patients from five European countries,10 the HLA-DRB1*03, DQA1*0501, DQB1*02 (that is, DR3, DQ2) heterozygous genotype is associated with a more rapid progression of the disease, whereas the HLA-DR3, DQ2 homozygous genotype is positively associated with a risk of developing PSC.11 This observation indicates that association of HLA with the development and progression of PSC may be caused by different mechanisms.10 Therefore, it would be of interest to perform major histocompatibility complex typing in transplant recipients with recurrent PSC. Currently, the prognostic relevance of the particular HLA genes that confer disease recurrence was investigated by the University of Washington transplant group.2 The overall frequency of the HLA-DRB1*03, DQB1*02 haplotypes among their PSC recipients was higher than that among donor populations, and this confirms that this genotype is more commonly expressed in patients who have PSC.10 However, there was no difference in the frequency of this HLA haplotype between patients with recurrent PSC and those not having recurrence, and this suggests that this HLA haplotype represents a recipient-specific genetic predisposition to PSC and does not serve as an antigen for immune recognition in disease development. Interestingly, there was a higher incidence of HLA-DRB1*08, particularly in the absence of HLA-DQB1*04, in their recipients that eventually developed recurrent disease than in those that did not.2 This finding, however, should be cautiously interpreted because of the small number of patients. Reappearance of PSC in the liver allograft suggests that the mechanisms that lead to the initial development of the disease persist after transplantation. This would provide a wonderful opportunity to learn about the pathogenesis of the disease. However, factors determining disease development in the posttransplantation situation have been studied only to a limited extent. Several transplant groups have attempted to identify peritransplantation variables that may predict patients who will develop recurrent PSC. Potential risk factors associated with disease recurrence included recipient age,12, 13 male gender,14 gender mismatch,15 coexistent inflammatory bowel disease (IBD),13 presence of intact colon after liver transplantation,14 cytomegalovirus infection,12 recurrent acute cellular rejection (ACR),12 steroid-resistant ACR,16 and OKT3 therapy for steroid-resistant ACR.17 The reasons for these discrepant findings among these studies may be due to the small number of patients with recurrent disease as well as the differences in the study design, the diagnostic criteria, and the interesting and confounding variables considered in the regression model. The article by the University of Colorado Health Sciences Center transplant group3 published in this issue surprisingly shows that the presence of cholangiocarcinoma prior to liver transplantation was significantly predictive of recurrent PSC following transplantation. The pathway in which cholangiocarcinoma proceeds to recurrent disease remains unclear. In another series from the University of Washington,2 histologically proven ACR and steroid-resistant ACR were associated with an increased risk of the development of recurrent PSC after liver transplantation. That disease recurrence is more likely with ACR, an immune attack of the biliary epithelium, was first noted by Jeyarajah et al.12 in 1998. The association between ACR and recurrent PSC may arise because ACR may increase autoimmune epitopes that can lead to ductal damage.12 Patients who develop recurrent disease may also have a hyperresponsive immune system and hence have an increased risk of developing ACR.12 In the same study, they also noted that OKT3 monoclonal antibody therapy for refractory ACR was associated with a greater incidence of recurrent PSC.12 This observation, rather than indicating an adverse effect of OKT3, is more likely to represent an increased risk of recurrent PSC as a byproduct of ACR. In liver transplantation for PSC, corticosteroids not only are used to prevent and treat allograft rejection but also may be necessary to manage coexistent IBD.17 Furthermore, we have known that the prolonged use of corticosteroids may cause or worsen certain metabolic complications that occur after liver transplantation. Also, the effect of corticosteroids on the rate or severity of recurrent PSC is unclear. A previous published study by Kugelmas et al.17 of immunosuppression after liver transplantation showed that PSC recurrence was most often seen (but not significantly) in patients who received maintenance corticosteroids, and the time to recurrence was not associated with length of corticosteroid administration. Furthermore, a current study from the Royal Free Hospital transplant group4 in this issue showed that maintenance corticosteroids after liver transplantation were associated with an increased risk of recurrent PSC. The reason for this observation is unclear, whether it is greater immunosuppression, associated with graft rejection, or opportunistic (yet undefined) biliary infections, which may be from a leaky mucosa in IBD that leads to recurrence. On the basis of a higher likelihood of PSC recurrence and adverse metabolic consequences in patients exposed to corticosteroids chronically, early corticosteroid withdrawal should be recommended in the management of these recipients. This, however, must be weighed against the need for corticosteroids for control of graft rejection or colitis in patients with coexistent IBD. In summary, recurrent PSC is now established as an important clinical outcome after liver transplantation. Over time, this problem is likely to increase and exert more impact on patient and graft survival. Thus, further large-scale longitudinal multicenter studies will be necessary to assess the impact of recurrent PSC on long-term outcomes. The mechanism for recurrent PSC is unknown, but current data lend support to an association with rejection and corticosteroid therapy in susceptible patients. With respect to this growing problem, several critical questions can be posed as priorities for researchers in the future. What effect will novel immunosuppressive medications or rapid corticosteroid withdrawal protocols have on the incidence and severity of recurrent disease? Which patients are more likely to develop recurrence? What medication should be administered as preventive therapy for recurrence? Understanding the pathogenesis of the disease is a key to answering these questions.

The care of 40 patients with primary liver cancer with obstructive jaundice treated with liver puncture bile drainage or biliary stent implantation was reported. Treated with the interventional therapy, patients were observed closely to identify symptoms of hepatic encephalopathy and pain; diet care was well performed. Bile drainage tube and skin acre were performed carefully. Liver function, bilirubin and other biochemical indicators were monitored; occurrence of bleeding, acute pancreatitis, biliary tract infection, leakage of ascites around drainage tube and other complication were observed with good discharge instruction. After this operation, three rounds of liver had poor function, and hepatic encephalopathy and death occurred during hospitalisation. Seven patients had bloody bile drainage fluid after operation; eight had increased blood amylase; nine had biliary infection and four had leakage of ascites around the drainage tube. After positive treatment and care, the situation was improved with varied degrees of jaundice increase.

ObjectiveTo evaluate and compare the efficacy and safety of Endoscopic Nasobiliary Drainage (ENBD) and Percutaneous Transhepatic Cholangiography Drainage (PTCD) in patients with advanced Hilar Cholangiocarcinoma (HCCA) through a meta-analysis of clinical studies.MethodsWe searched Chinese and English databases, including China National Knowledge Infrastructure (CNKI), Wanfang database, PubMed, Embase, Scopus, and Web of Science, for relevant literatures on PTCD and ENBD for advanced HCCA clinical trials. Two investigators independently screened the literatures, and the quality of the included studies was evaluated using the Newcastle-Ottawa Scale (NOS). The primary endpoint was the success rate of biliary drainage operation, while secondary endpoints included Total Bilirubin (TBIL) change, acute pancreatitis, biliary tract infection, hemobilia, and other complications. R software was used for data analysis.ResultsA comprehensive database search, based on predefined inclusion and exclusion criteria, yielded 26 articles for this study. Analysis revealed that PTCD had a significantly higher success rate than ENBD [OR (95% CI) = 2.63 (1.98, 3.49), Z=6.70, P<0.05]. PTCD was also more effective in reducing TBIL levels post-drainage [SMD (95%CI) =-0.13 (-0.23, -0.03), Z=-2.61, P<0.05]. While ENBD demonstrated a lower overall complication rate [OR (95%CI) = 0.60 (0.43, 0.84), Z=-2.99, P<0.05], it was associated with a significantly lower incidence of post-drainage biliary hemorrhage compared to PTCD [OR=3.02, 95%CI: (1.94-4.71), Z= 4.89, P<0.01].ConclusionsThis meta-analysis compares the efficacy and safety of ENBD and PTCD for palliative treatment of advanced HCCA. While both are effective, PTCD showed superiority in achieving successful drainage, reducing TBIL, and lowering the incidence of acute pancreatitis and biliary infections. However, ENBD had a lower risk of post-drainage bleeding. Clinicians should weigh these risks and benefits when choosing between ENBD and PTCD for individual patients. Further research is needed to confirm these findings and explore long-term outcomes.

Efficacy of ertapenem in biliary tract infections in daily practice was retrospectively analyzed. Records of patients admitted to five Spanish hospitals (January 2007/February 2011) with biliary infections (cholecystitis/cholangitis) treated with ertapenem for ⩾72 hours were reviewed. A total of 187 patients (mean 63·8±19·3 years, 52·9% males) were identified. Up to 96 (51·3%) were operated, with cholecystectomy (97·9%) and primary laparoscopy approach (75%) as most frequent intervention. Non-operated patients presented higher age (71·0±17·5 vs 56·9±18·5 years; P<0·001), heart insufficiency (11·0 vs 3·1%; P = 0·044) and the Mortality in Emergency Department Sepsis score (2·99±2·26 vs 1·94±2·34; P<0·001); and longer length of stay (10·3±6·6 vs 9·1±7·0; P = 0·005). Mean duration of treatment was 6·89±3·38 days. Overall favourable response was 87·7% (95% CI = 83·0–92·4) at the end of treatment. In the multivariate analysis (P<0·001, R2 Cox = 0·10), non-favourable response was associated with Charlson index⩾5 (OR = 18·71; 95% CI: 1·26–278·55; P = 0·034), pericholecystic abscess (OR = 5·30; 95% CI: 1·26–22·37; P = 0·023) and >3 days from symptoms start to admission (OR = 3·02; 95% CI: 1·13–8·04; P = 0·027).