Benign Biliary Obstruction Research Articles

Endoscopic Ultrasound-Guided Rendezvous Technique Versus Precut Sphincterotomy as Salvage Technique in Patients With Benign Biliary Disease and Difficult Biliary Cannulation : A Randomized Controlled Trial.

The standard salvage technique used for difficult bile duct cannulation is precut sphincterotomy, whereas endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a relatively newer method. Prospective comparative data between these 2 techniques as salvage for biliary access in patients with benign biliary disease and difficult bile duct cannulation is lacking. To compare EUS-RV and precut sphincterotomy as salvage technique for difficult bile duct cannulation in benign biliary obstruction. Participant-masked, parallel-group, superiority, randomized controlled trial. (Clinical Trials Registry of India: CTRI/2020/07/026613). Tertiary care academic institute from July 2020 to May 2021. All patients with benign biliary disease and difficult bile duct cannulation requiring salvage strategy. Patients were randomly assigned by computer-generated randomized blocks sequence in 1:1 fashion to either EUS-RV or precut sphincterotomy. Patients with failure in EUS-RV were crossed over to precut sphincterotomy and vice versa. The primary outcome measure was technical success. The other outcome measures included procedure time, radiation dose, and adverse events. In total, 100 patients were randomly assigned to EUS-RV (n = 50) and precut sphincterotomy (n = 50). The technical success rate (92% vs. 90%; P = 1.00; relative risk, 1.02 [95% CI, 0.90 to 1.16]), median procedure time (10.1 vs. 9.75 minutes), and overall complication rate (12% vs. 10%; relative risk, 1.20 [CI, 0.39 to 3.68]) were similar between the 2 groups. Five patients (10%) in the EUS-RV group and 5 patients (10%) in the precut sphincterotomy group had developed post-endoscopic retrograde cholangiopancreatography pancreatitis. All failed cases in either salvage group could be successfully cannulated when crossed over to the other group. Single center study done by experts. Endoscopic ultrasound-guided rendezvous technique and precut sphincterotomy have similar success rates as salvage techniques in the technically challenging cohort of difficult bile duct cannulation for benign biliary disease, with acceptable complications rates. None.

Magnetic resonance cholangiopancreatography in differentiating benign and malignant biliary obstruction

Magnetic resonance cholangiopancreatography in differentiating benign and malignant biliary obstruction

Bile level of cytokeratin 7 as a diagnostic marker for cholangiocarcinoma: a case-control study in Egyptian patients

BackgroundCholangiocarcinoma (CCA) is an aggressive malignancy with a poor prognosis of less than 20% five-year survival rate. Early diagnosis is typically challenging due to asymptomatic characteristics at the earliest stages of the disease. This study aims to assess the potential utility of cytokeratin 7 (CK7) as a CCA diagnostic biomarker in bile. In total, 100 participants were included in this case-control study. Moreover, Group I had 30 CCA patients with malignant obstruction, and Group II had 20 patients with malignant biliary obstruction other than CCA formed. Group III included 20 patients with benign biliary obstruction, and 30 individuals undergoing cholecystectomy with no evidence of biliary obstruction made up the control group (Group IV). Bile samples were collected during endoscopic retrograde cholangiopancreatography or cholecystectomy for the control group. The CK7 levels in bile samples were measured using the enzyme-linked immunosorbent assay.ResultsThe bile level of CK7 was significantly higher in cholangiocarcinoma patients (1555.4 ± 302.7 pg/mL) than those of the patients with malignancies other than CCA (581.9 ± 227.5 pg/mL), patients with benign obstruction (439.5 ± 255.7 pg/mL), and the control group (53 ± 26.4 pg/mL) (p value < 0.001). Furthermore, CK7 was significantly higher in CCA patients than in those with other malignancies (p value < 0.001). Patients with CCA with hilar lesions had the highest values compared to those with distal lesions. ROC curve analysis revealed that bile CK7 at a cut point of >1030 pg/mL yielded an area under a curve of 1 (95% CI: 1.000–1.000) in differentiating CCA from other groups.ConclusionThe bile level of CK7 demonstrates outstanding performance that could help in diagnosing CCA.

Cholangiocarcinoma combined with biliary obstruction: an exosomal circRNA signature for diagnosis and early recurrence monitoring

Cholangiocarcinoma (CCA) is a highly malignant biliary tract cancer with currently suboptimal diagnostic and prognostic approaches. We present a novel system to monitor CCA using exosomal circular RNA (circRNA) via serum and biliary liquid biopsies. A pilot cohort consisting of patients with CCA-induced biliary obstruction (CCA-BO, n = 5) and benign biliary obstruction (BBO, n = 5) was used to identify CCA-derived exosomal circRNAs through microarray analysis. This was followed by a discovery cohort (n = 20) to further reveal a CCA-specific circRNA complex (hsa-circ-0000367, hsa-circ-0021647, and hsa-circ-0000288) in both bile and serum exosomes. In vitro and in vivo studies revealed the three circRNAs as promoters of CCA invasiveness. Diagnostic and prognostic models were established and verified by two independent cohorts (training cohort, n = 184; validation cohort, n = 105). An interpreter-free diagnostic model disclosed the diagnostic power of biliary exosomal circRNA signature (Bile-DS, AUROC = 0.947, RR = 6.05) and serum exosomal circRNA signature (Serum-DS, AUROC = 0.861, RR = 4.04) compared with conventional CA19-9 (AUROC = 0.759, RR = 2.08). A prognostic model of CCA undergoing curative-intent surgery was established by calculating early recurrence score, verified with bile samples (Bile-ERS, C-index=0.783) and serum samples (Serum-ERS, C-index = 0.782). These models, combined with other prognostic factors revealed by COX-PH model, enabled the establishment of nomograms for recurrence monitoring of CCA. Our study demonstrates that the exosomal triple-circRNA panel identified in both bile and serum samples serves as a novel diagnostic and prognostic tool for the clinical management of CCA.

How traditional Chinese medicine can prevent recurrence of common bile duct stones after endoscopic retrograde cholangiopancreatography?

Common bile duct stones, as a type of cholelithiasis, are a benign biliary obstruction that easily acute abdominalgia, and Endoscopic Retrograde Cholangiopancreatography (ERCP) is usually the first choice for clinical treatment. However, the increasing recurrence rate of patients after treatment is troubling clinicians and patients. For the prevention of recurrence after ERCP, there is no guideline to provide a clear drug regimen, traditional Chinese medicine however has achieved some result in the treatment of liver-related diseases based on the "gut-liver-bile acid axis". On the basis of this, this article discusses the possibility of traditional Chinese medicine to prevent common bile duct stones (CBDS) after ERCP, and we expect that this article will provide new ideas for the prevention of recurrence of CBDS and for the treatment of cholelithiasis-related diseases with traditional Chinese medicine in future clinical and scientific research.

Hyperbilirubinemia in hospitalized patients: Etiology and outcomes.

There is little information on the differential diagnosis and prognosis of hospitalized patients with hyperbilirubinemia. Here, we hypothesized that hyperbilirubinemia in hospitalized patients is associated with specific diseases and outcomes. This retrospective cohort analysis included patients admitted to the Medical University of South Carolina with a total bilirubin >3 mg/dL from January 9, 2015 to August 25, 2017. Collected clinical data included demographics, primary diagnosis, Charlson Comorbidity Index (CCI), laboratory data, and clinical outcomes. We separated and analyzed the cohort into seven primary diagnostic groups. We identified 1693 patients with a bilirubin level >3 mg/dL. The cohort was 42% female, had an average age of 54, average CCI of 4.8, and average length of stay of 13 days. The causes of hyperbilirubinemia included the following: primary liver disease (868/1693; 51%) with cirrhosis being most common (385/1693; 23%), benign biliary obstruction (252/1693; 15%), hemolytic anemia (149/1693; 9%), malignant biliary obstruction (121/1693; 7%), unknown etiology (108/1693; 6%), primary liver cancer (74/1693; 4%), and metastatic cancer to the liver (57/1693; 3%). Overall, the mortality/discharge to hospice rate in patients with a bilirubin >3 mg/dL was 30%, and was proportional to the severity of hyperbilirubinemia, including when controlling for the underlying severity of illness. Mortality was highest in patients with primary liver disease and malignancy and was lowest in patients with non-cancerous obstruction or hemolytic jaundice. Hyperbilirubinemia in hospitalized patients is most often due to primary liver disease, and identifies patients with a poor prognosis, particularly when caused by primary liver disease or cancer.

Identification of Microbial Species and Analysis of Antimicrobial Resistance Patterns in Acute Cholangitis Patients with Malignant and Benign Biliary Obstructions: A Comparative Study.

Background and Objectives: Acute cholangitis (AC) is still lethal if not treated promptly and effectively. Biliary drainage, also known as source control, has been acknowledged as the backbone treatment for patients with AC; nonetheless, antimicrobial therapy allows these patients to undergo non-emergent drainage procedures. This retrospective study aims to observe the bacterial species involved in AC and analyze the antimicrobial resistance patterns. Materials and Methods: Data were collected for four years, comparing patients with benign and malignant bile duct obstruction as an etiology for AC. A total of 262 patients were included in the study, with 124 cases of malignant obstruction and 138 cases of benign obstruction. Results: Positive bile culture was obtained in 192 (73.3%) patients with AC, with a higher rate among the benign group compared with malignant etiologies (55.7%.vs 44.3%). There was no significant difference between the Tokyo severity scores in the two study groups, identifying 34.7% cases of malignant obstruction with Tokyo Grade 1 (TG1) and 43.5% cases of TG1 among patients with benign obstruction. Similarly, there were no significant differences between the number of bacteria types identified in bile, most of them being monobacterial infections (19% in the TG1 group, 17% in the TG2 group, and 10% in the TG3 group). The most commonly identified microorganism in blood and bile cultures among both study groups was E. coli (46.7%), followed by Klebsiella spp. (36.0%) and Pseudomonas spp. (8.0%). Regarding antimicrobial resistance, it was observed that significantly more patients with malignant bile duct obstruction had a higher percentage of bacterial resistance for cefepime (33.3% vs. 11.7%, p-value = 0.0003), ceftazidime (36.5% vs. 14.5%, p-value = 0.0006), meropenem (15.4% vs. 3.6%, p-value = 0.0047), and imipenem (20.2% vs. 2.6%, p-value < 0.0001). Conclusions: The positive rate of biliary cultures is higher among patients with benign biliary obstruction, while the malignant etiology correlates with increased resistance to cefepime, ceftazidime, meropenem, and imipenem.

Endoscopic ultrasound guided biliary drainage in surgically altered anatomy: A comprehensive review of various approaches.

Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred modality for drainage of the obstructed biliary tree. In patients with surgically altered anatomy, ERCP using standard techniques may not be feasible. Enteroscope assisted ERCP is usually employed with variable success rate. With advent of endoscopic ultrasound (EUS), biliary drainage procedures in patients with biliary obstruction and surgically altered anatomy is safe and effective. In this narrative review, we discuss role of EUS guided biliary drainage in patients with altered anatomy and the various approaches used in patients with benign and malignant biliary obstruction.

Efficacy and safety of EUS-guided biliary drainage for benign biliary obstruction - A systematic review and meta-analysis.

ERCP is the first line of treatment for benign and malignant biliary obstruction and EUS-guided biliary drainage (EUS-BD) is usually used for patients who have failed ERCP. Recently, several studies have evaluated the role of EUS-BD in the management of benign biliary obstruction. This meta-analysis evaluates the efficacy and safety of EUS-BD in the management of benign biliary obstruction. We reviewed several databases from inception to July 8, 2022, to identify studies evaluating the efficacy and safety of EUS-BD in the management of benign biliary obstruction. Our outcomes of interest were technical success, clinical success, and adverse events. Pooled rates with 95% confidence intervals (CIs) for all outcomes were calculated using a random effects model. Subgroup analyses were performed including patients with normal anatomy versus surgically altered anatomy (SAA). Heterogeneity was assessed by I2 statistic. We included 14 studies with 329 patients. The pooled rate (95% CI) of technical success was 88% (83%, 92%). The pooled rate (95% CI) of technical success for patients with SAA and normal anatomy was 92% (85%, 96%) and 83% (75%, 89%), respectively. The pooled rates (95% CI) of clinical success and adverse events were 89% (83%, 93%) and 19% (13%, 26%), respectively. We found low heterogeneity in most of the analyses. EUS-BD is an effective and safe option in patients with benign biliary obstruction and should be considered after a failed attempt at ERCP or when ERCP is not technically possible.

Zastosowanie dostępu przezściennego w endoterapii zwężeń dróg żółciowych

Endoscopic retrograde cholangiopancreatography is a gold standard in treatment patients with biliary obstructions, ensuring transpapillary drainage - anatomical. It is an established method for treatment of patients with benign and malignant biliary obstruction. In the case of ineffectiveness of transpapillary drainage, the alternative is still percutaneous drainage of the bile ducts or surgical drainage. The development of advanced endoscopic ultrasonography techniques has enabled extra-anatomical approach to the bile ducts, making it possible not only to perform endoscopic anastomoses of the bile ducts with the digestive tract, but also to obtain extra-anatomic transpapillary access. This is an alternative to the existing methods of biliary drainage in the case of ERCP ineffectiveness.

Balloon enteroscopy-assisted endoscopic retrograde cholangiography and rendezvous procedures in patients with altered gastrointestinal anatomy

Background Standard endoscopic retrograde cholangiography (ERC) frequently fails to treat biliary obstruction in patients with altered gastrointestinal anatomy. Balloon enteroscopy-assisted ERC (BE-ERC) and combined percutaneous transhepatic endoscopic rendezvous procedures (PTE-RVs) may offer effective rescue approaches. Objective This study aimed to evaluate the efficacy and safety of BE-ERC and PTE-RV for the treatment of biliary obstruction in patients with altered gastrointestinal anatomy. Methods In this observational study, all patients with altered gastrointestinal anatomy underwent BE-ERC between 2003 and 2016 at a tertiary referral center. In case of procedural failure, a combined PTE-RV was performed in selected cases. Endpoints included the success and safety of the procedures. Results A total of 180 BE-ERC performed in 106 patients with altered gastrointestinal anatomy were included. Of the procedures, 76.7% were performed due to benign and 23.3% due to malignant biliary obstruction. BE-ERC was successful in 53% (96/180) of cases. In case of failure, in 23/32 cases a combined PTE-RV was successfully performed, improving the overall success rate of BE-ERC, including PTE-RV, to 66% (119/180). Benign biliary obstruction and repeated procedures were positive predictors of successful BE-ERC (odds ratio 6.8 (95% CI 2.7–17.0), p < .001 and odds ratio 4.1 (2.1–8.2), p < .001). Complications were significantly more frequent in combined PTE-RVs than in BE-ERC procedures alone (34.4% vs. 7.4%; p < .001). Conclusions BE-ERC is effective and safe for the endoscopic management of patients with altered gastrointestinal anatomy and percutaneous transhepatic rendezvous procedures can substantially increase success rates in selected cases.

S1841 The Curious Case of CA 19-9 in Mirizzi Syndrome

Introduction: Mirizzi Syndrome (MS) is a rare complication of gallstone disease, caused by an obstructing stone in the cystic duct or the gallbladder neck, leading to obstruction of the common hepatic duct. This case discusses the utility of EUS in improving diagnostic yield of MS and the importance of cancer screening in these patients. Case Description/Methods: A 44-year-old male with a history of gastritis presented with right upper quadrant (RUQ) abdominal pain, jaundice, and scleral icterus for one week. On exam, the patient was afebrile with mild RUQ abdominal tenderness. Labs showed a total bilirubin of 5.4 mg/dL, AST of 66 U/L, ALT of 228 U/L, and a total alkaline phosphatase of 159 U/L. Ultrasound demonstrated intra- and extrahepatic biliary dilation with suggestion of a shadowing stone within the common bile duct (CBD). The gallbladder wall was thickened with trace pericholecystic fluid. MRCP showed a 15 mm calculus presumed to be in the CBD, with a 16 mm CBD dilation. ERCP showed a filling defect in the midportion of the CBD, and a CBD stent was placed. Due to these findings, a CA 19-9 antigen was drawn, measuring 3038 U/mL. EUS was then performed, which visualized a cystic duct stone partially extending into the CBD– a finding consistent with MS. An enlarged lymph node was visualized in the porta hepatis region. FNA of the lymph node as well as CBD brushings from the ERCP were both negative for malignant cells. The patient was discharged and underwent a cholecystectomy two weeks later. Surgical findings were consistent with MS and a 20 mm stone was removed with the gallbladder. The intraoperative frozen section of the gallbladder was negative for malignant cells. (Figure) Discussion: Initial evaluation for MS should include an ultrasound or CT scan, followed by MRCP. The pooled sensitivity of MRCP for detecting CBD stones is around 87%. While MRCP is often used to diagnose MS, the anatomy may not be well visualized due to the proximity of the cystic duct to the CBD. EUS has a pooled sensitivity of 97% in detecting a CBD stone and can better visualize the biliary tract anatomy, aiding in diagnosis. Diagnosis of MS prior to surgery can be helpful in avoiding biliary tract injuries. MS evaluation should also include screening for malignancy, as MS has an association with gallbladder cancer. While elevated CA 19-9 levels are concerning for malignancy, they can also be seen in chronic benign biliary obstruction. It is important to obtain a CA 19-9 level when suspecting MS, both before and after stone removal.Figure 1.: A. MRI: A T2-weighted image showing a 15 mm filling defect (white arrow) within the cystic duct, partially extending into the common bile duct, consistent with an obstructing stone. Intrahepatic and extrahepatic biliary dilation is also seen. B. Endoscopic ultrasound: An ovoid, hyperechoic structure, measuring 11 mm x 15 mm, with shadowing suggestive of a gallstone at the level of the cystic duct and compression of the common bile duct. C. Endoscopic ultrasound: An irregularly contracted gallbladder (black arrow) with adjacent dilated common bile duct. D. Endoscopic ultrasound: Fine needle aspiration of an enlarged lymph node with well defined margins in the porta hepatis region, measuring 20 mm x 15 mm in maximal cross-sectional diameter. Color Doppler imaging was utilized prior to needle puncture to confirm a lack of significant vascular structures within the needle path.

Percutaneous transhepatic biliary drainage: a retrospective single-center study of 372 patients.

Complication rates in percutaneous transhepatic biliary drainage (PTBD) are non-uniform and vary considerably. In addition, the impact of peri-procedural risk factors is under-investigated. To compare success and complication rates of PTBD in patients with and without accompanying technical risk factors. A single-center retrospective study was conducted from January 2004 to December 2016. Patients receiving PTBD due to biliary obstruction or biliary leakage were included. Technical risk factors (non-distended bile ducts, ascites, obesity, anasarca, non-compliance) were assessed. Complications were classified according to the Society of Interventional Radiology. In total, 372 patients were included (57.3% men, 42.7% women; mean age = 66 years). Overall, 466 PTBDs were performed. Of the patients, 70.1% presented with malignancy and biliary obstruction; 26.8% had benign biliary obstruction; 3.1% had biliary leakage. Technical risk factors were reported in 57 (15.3%) patients. Overall technical success of initial PTBD was 98.7%, primary technical success was 97.9%. In patients with non-dilatated bile ducts, primary technical success was 68.2%. Overall complication rate was 15.0% (8.1% major complications, 6.9% minor complications). Neither major nor minor complications were more frequent in patients with technical risk factors (P > 0.05). In left-sided PTBD, hemorrhage was more frequent (P = 0.015). Patients with malignancy were significantly more affected by drainage-related complications (P = 0.004; odds ratio = 2.03). The mortality rate was 0.5% (n = 2). PTBD is a safe and effective method for the treatment of biliary obstruction and biliary leaks. Complication rates are low, even in procedures with risk factors.

Karaciğer hastalıklarında kullanılan skorlamalar malign-benign kolestaz ayrımında kullanılabilir mi?

Giriş ve Amaç: Kronik safra yolu hastalıkları hepatositlerde bilirübin ve karaciğerden ekskrete edilen toksinlere daha uzun süre maruziyete neden olarak hepatosit fonksiyonlarını bozmaktadır. Ayrıca karaciğerin primer maligniteleri gibi safra yolu malignitelerinin de fibrotik karakterde olduğunu öne süren yayınlar vardır. Bu bilgiler ışığında kronik ve malign safra yolu tıkanıklığı oluşturan kolestatik hastalıkların, akut ve benign safra yolu tıkanıklığı oluşturan hastalıklara göre karaciğer fonksiyonlarını daha fazla bozduğu ve karaciğer fibrozisini artırdığı düşünülebilir. Çalışmamızda rutin testlerle ölçülebilen ve karaciğer hastalıklarında kullanılan skorlardan; R-faktör, son dönem karaciğer hastalığı modeli/sodyum, albümin-bilirübin skoru, albümin-alkalen fosfataz oranı, aspartat aminotransferaz-trombosit oran indeksi, dört faktörü temel alan fibrozis indeksi (fibrozis-4) ve gama glutamil transpeptidaz-trombosit oranı’ndan hangilerinin malign nedenli kolestaz tanısını koymakta yardımcı bir yöntem olarak kullanılabileceğinin araştırılması hedeflenmiştir. Gereç ve Yöntem: Ondokuz Mayıs Üniversitesi Tıp Fakültesi Gastroenteroloji Kliniği’nde Temmuz 2019- Temmuz 2021 tarihleri arasında obstrüktif kolestaz tanısı alan hastaların dosyaları retrospektif olarak tarandı. Akut ve benign nedenli kolestaz tanısı alan hastalar Grup 1, kronik ve malign nedenli kolestaz tanılı hastalar Grup 2 olarak sınıflandırıldı. Hastaların ilk başvuru zamanındaki laboratuvar değerleri kullanılarak; R-faktör, son dönem karaciğer hastalığı modeli/sodyum, albümin-bilirübin skoru, albümin-alkalen fosfataz oranı, aspartat aminotransferaz-trombosit oran indeksi, fibrozis-4 indeksi ve gama glutamil transpeptidaz-trombosit oranı skorları hesaplandı, tanıları ile tanı anındaki skorları arasındaki ilişki değerlendirildi. Bulgular: Çalışmaya 116’sı erkek (%57.4), 86’sı kadın (%42.6) toplam 202 hasta dahil edildi. Grup 1’de 92 (%45.5), Grup 2’de 110 (%54.5) hasta yer almaktaydı. Grup 1 ve Grup 2 arasında demografik özellikler açısından anlamlı fark görülmedi. Grup 1’de sık görülen hastalıklar kolanjit, koledokolitiazis ve safra çamuru ile biliyer pankreatit iken Grup 2’de ise pankreas başı karsinomuydu. Değerlendirilen laboratuvar parametrelerinden alkalen fosfataz, total ve direkt bilirübin maligniteye işaret eden en önemli testlerdi (p &amp;lt; 0.001). Karaciğer hastalığı skorlarından R-faktör (p &amp;lt; 0.001), son dönem karaciğer hastalığı modeli/sodyum (p &amp;lt; 0.001) ve albümin-bilirübin skoru (p = 0.023) Grup 2, albümin-alkalen fosfataz oranı (p &amp;lt; 0.001), aspartat aminotransferaz-trombosit oran indeksi (p &amp;lt; 0.001) ve fibrozis-4 indeksi (p &amp;lt; 0.001) Grup 1 lehine anlamlıydı ancak gama glutamil transpeptidaz-trombosit oranı için her iki grup arasında anlamlı fark yoktu (p = 0.242). Tanı konma süreçleri içinde Grup 1’deki hastaların nihai tanıları çoğunlukla ultrasonografi ile konmakta iken (p &amp;lt; 0.001), Grup 2’deki hastalar bilgisayarlı tomografi ile tanı almaktaydı (p &amp;lt; 0.001). Sonuç: Çalışmamız kronik karaciğer hastalıklarında kullanılan skorlardan R-faktör, son dönem karaciğer hastalığı modeli/sodyum ve albümin-bilirübin skoru malign nedenli kolestatik hastalıkların tanısında, albümin-alkalen fosfataz oranı, aspartat aminotransferaz-trombosit oran indeksi ve fibrozis-4 indeksinin benign nedenli kolestatik hastalıkların tanısında yardımcı bir yöntem olarak kullanılabileceğini, gama glutamil transpeptidaz-trombosit oranının ise bu ayırımda kullanılamayacağını göstermektedir. Bu tip öngörücü skorlar, anamnez ve muayene bulguları ile birlikte yorumlanarak hastaların tetkik ve tedavi planlarının daha hızlı sağlanmasını kolaylaştırabilir.

Raritní příčina biliární obstrukce – kazuistika

We present a case study of a 47-year-old woman with cholecystolithiasis, in whom a diagnostic examination showed a solid-cystic lesion in the subhepatic region, oppressing the biliary tract. After completing examinations with imaging techniques (ultrasound, CT, MR) and endoscopic retrograde cholangiopancreatography (ERCP) with biliary drainage through a duodeno-biliary stent, the patient was directly indicated for a resection. Mucinous neoplasia of the biliary tract or cystic anomalies were considered as possible diagnoses prior to the surgery. The lesion was resected together with the adjacent gallbladder and biliary ducts. Surprisingly, the histological examination of the resected tissue showed a non-tumorous affection – adenomyomatosis of extrahepatic biliary ducts. Keywords: benign biliary obstruction – adenomyomatosis of gallbladder and biliary ducts

Optimizing indications for biliary drainage in chronic pancreatitis patients with benign biliary obstruction

Optimizing indications for biliary drainage in chronic pancreatitis patients with benign biliary obstruction

The Role of Endoscopic Ultrasound-guided Transmural Approach in the Management of Biliary Obstructions.

Background:Transpapillary biliary drainage in endoscopic retrograde cholangiopancreatography (ERCP) is an established method for treatment of patients with benign and malignant biliary obstruction. However, attempts to gain access to the biliary tract through the major duodenal papilla during ERCP have been unsuccessful in some patients. This study aims to determine the role of endoscopic ultrasonography (EUS)-guided transmural approach in biliary endotherapy in case of failed ERCP.Materials and Methods:A prospective analysis of the treatment outcomes of all 896 patients with obstructive jaundice secondary to biliary obstruction, who underwent endoscopic treatment in the years 2016-2021 at our institution.Results:Effective drainage of bile ducts through the major duodenal papilla during ERCP was achieved in 772/896 (86.16%) patients with biliary obstruction. In 124/896 (13.84%) patients [92 males, 32 females; mean age 63.52 (46 to 89) y] ERCP failed and EUS-guided transmural approach was performed. Benign biliary obstruction was identified in 17/124 (13.71%) patients; the remaining 107/124 (86.29%) were diagnosed with malignant biliary obstruction. EUS-guided endoscopic transpapillary biliary tract stenting with transmural access was performed in 21/124 (16.94%) patients; the remaining 103/124 (83.06%) required extra-anatomic transmural anastomosis of the bile ducts to the gastrointestinal tract. Technical success was achieved in 121/124 (97.58%) patients, while clinical success was achieved in 112/124 (90.32%). Complications were reported in 15/124 (12.1%) patients; with early complications in 12 and late complications in 3.Conclusions:Various methods of EUS-guided transmural access to bile ducts improves endotherapy outcomes of patients with biliary obstruction. Endoscopic transmural access is highly effective and associated with an acceptable number of complications.

Robotic biliary surgery for benign and malignant bile duct obstruction: a case series.

The majority of patients with benign or malignant biliary obstruction require surgical treatment with a bilio-enteric anastomosis. This requires fine dissection and advanced suturing. Robotic surgery may overcome some major limitations of conventional laparoscopic surgery. The precise role of robotic biliary surgery is, however, still to be defined. In our institution, patients requiring complex bile duct surgery were consecutively selected for minimally invasive robotic surgery from September 2020. All surgeries were undertaken using the da Vinci Xi Surgical System® (Intuitive Surgical, Sunnyvale, CA, USA). Intra-operative technique and postoperative outcome were analyzed. A total number of 14 patients underwent robotic biliary surgery for a variety of benign and malignant indications between September 2020 and May 2021. Six of fourteen patients (43%) had previous open abdominal surgery. Median blood loss was 25mL (range 10-120mL). There were no intra-operative complications and no conversions. Length of stay was between 3 and 11days without major postoperative morbidity. Robotic surgery for benign and malignant bile duct obstruction is efficient and safe in experienced hands. Referral to a high-volume expert center is, however, advised.

EUS-guided transhepatic biliary drainage: a large single-center U.S. experience

EUS-guided hepaticogastrostomy has been performed for many years with most published experience from outside the United States. The luminal access point can be from the esophagus, stomach, duodenum, or jejunum; biliary access can be either into the right or left intrahepatic system. Thus, we prefer the term EUS-guided transhepatic biliary drainage (ETBD). We describe what is believed to be the largest single-center U.S. experience of ETBD for management of benign and malignant biliary disease. This was a retrospective study of all ETBD conducted by 1 endoscopist between September 2014 and May2021. Two hundred fifteen patients underwent attempted ETBD: 85 for benign disease and 130 for malignant disease. Ninety-two patients (43%) had surgically altered anatomy (SAA). In 94 patients previously endoscopic attempts failed. The approach was transesophageal in 9, transgastric in 188, transduodenal in 5, and transjejunal in 5 patients. In 1 patient a bilateral approach was used. Standard fully covered self-expandable stents of 4- to 10-cm lengths and 8- or 10-mm diameters were used. Technical success was 95.3% and clinical success was 87.25%. Forty patients (18.6%) experienced adverse events (13 mild, 21 moderate, and 6 severe according to the modified American Society for Gastrointestinal Endoscopy lexicon). Mean follow-up was 257.31 ± 308.11 days for all patients (124.53 ± 229.86 days for benign disease and 457.27 ± 466.31 days for malignant disease). Seventy-four patients (34.4%) had died at the time of data collection (66 in the malignant cohort, 8 in the benign cohort). Of those with malignancy surviving >6 months, 17.4% required reintervention. ETBD is effective in the management of benign and malignant biliary obstruction for patients with SAA as well as native anatomy, with a modest adverse event rate.

Hepaticogastrostomía guiada por ecoendoscopía en pacientes con estenosis biliares malignas proximales. Serie de casos

Endoscopic retrograde cholangiopancreatography is the method of choice for draining both benign and malignant biliary obstruction. Given the failure or impossibility of this procedure, the options for draining the biliary tree are limited to percutaneous drainage, surgical biliary diversion, or endoscopic ultrasound-guided bile duct drainage. Echo-endoscopic biliary drainage is an effective alternative to endoscopic retrograde cholangiopancreatography failure and in recent years, it has been taking an increasingly important place because it is less invasive and has a lower rate of complications. Our aim is to report a series of cases of patients with proximal malignant biliary strictures, treated by means of an endoscopic ultrasound-guided liver-gastrostomy, as palliative treatment.