Biliary Decompression Research Articles

Sump syndrome: Diagnosis dilemmas and therapeutic approaches-A case series.

It is important to consider the diagnosis of Sump syndrome in patients with a history of open cholecystectomy, particularly in those who migrate from developing countries where alternative biliary interventions may be limited. The presentation may range from acute severe, mimicking acute ascending cholangitis, to chronic recurrent abdominal pain without evidence of inflammation. Management is a case-by-case decision, with principal management aims to decompress the biliary tract and address any underlying sepsis. Sump syndrome is a rare and often long-term complication of choledochoduodenostomy (CDD). The presentation and severity are variable, and management should be tailored to each patient based on several factors. Herein, we report three cases of sump syndrome, each demonstrating unique diagnostic dilemmas and therapeutic modalities. Case I describes a woman presenting with acute cholangitis, managed with percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP). Case II illustrates a similar presentation complicated by myocardial infarction, necessitating urgent biliary decompression via PTC and subsequent unsuccessful endoscopic stenting. Case III highlights the diagnostic difficulty in a stable patient with inconclusive diagnostic imaging. This case series emphasizes the importance of considering sump syndrome diagnosis in patients with a history of CDD or open cholecystectomy, especially in elderly patients and those who come from regions where alternative biliary interventions may be limited.

Acute cholangitis: a state-of-the-art review.

Acute cholangitis is a potentially life-threatening bacterial infection of the intra and/or extrahepatic bile ducts. It remains the second and third cause of community-acquired and hospital-acquired bacteremia, respectively, and is associated with mortality rates of up to 15%, despite advances in broad-spectrum antimicrobial therapy and improved access to emergency biliary tract decompression procedures. Even though not much has changed in recent years in terms of diagnosis or treatment, new data have emerged regarding multidrug-resistant bacteria that serve as etiologic agents of cholangitis. Moreover, different approaches in antibiotic regimes depending on severity grading and bile sample cultures as well as novel minimally invasive endoscopic procedures that can help when consecrated treatments such as endoscopic retrograde cholangiopancreatography (ERCP) fail, cannot be performed, or are unavailable have been proposed. This state-of-the-art review aims to offer a complete and updated assessment of the epidemiology, novel diagnostic and therapeutic methods, complications, and prognostic variables of acute cholangitis. The authors will review the prognostic implications of unusual complications, the relevance of regular bile samples and antibiograms, and their new role in guiding antibiotic therapy and limiting antibiotic resistance to present an organized and comprehensive approach to the care of acute cholangitis.

Dosimetric characteristics of self-expandable metallic and plastic stents for transpapillary biliary decompression in external beam radiotherapy.

There is little evidence regarding radiation dose perturbation caused by the self-expandable metallic stents (SEMSs) used for transpapillary biliary decompression. We aimed to compare SEMSs with plastic stents (PSs) and clarify their dosimetric characteristics. Fifteen SEMSs (10 braided and 5 lasercut type) and six PSs (diameter: 2.3-3.3mm) were inserted into a water-equivalent solid phantom. In total, 13 SEMSs had radiopaque markers, whereas the other two did not. Using radiochromic films, the dose difference adjacent to the stents at locations proximal, distal, and arc delivery to the radiation source was evaluated based on comparison to measurement of the dose delivery in phantom without any stent in place. The median values of the dose difference for each stent were used to compare the SEMS and PS groups.Results: The dose difference (median (minimum/maximum)) was as follows: proximal, SEMSs + 2.1% (1.8 / 4.7) / PSs + 5.4% (4.1 / 6.3) (p < 0.001); distal, SEMSs -1.0% (-1.6 /-0.4) / PSs -8.9% (-11.7 / -7.4) (p < 0.001); arc delivery, SEMSs 1.2% (0.9 / 2.3) / PSs 2.2% (1.6 / 3.6) (p = 0.005). These results demonstrated that the dose differences of SEMSs were significantly smaller than those of PSs. On the other hand, the dose difference was large at surface of the radiopaque markers for SEMSs: proximal, 10.3% (7.2 / 20.9); distal, -8.4% (-16.3 / -4.2); arc delivery, 5.5% (4.2 / 9.2). SEMSs for biliary decompression can be safely used in patients undergoing radiotherapy, by focusing on the dose distribution around the stents and by paying attention to local changes in the dose distribution of radiopaque markers.

Persistent hyperbilirubinemia following preoperative biliary stenting in patients undergoing anatomic hepatectomy predicts serious complications.

Biliary obstruction before liver resection is a known risk factor for post-operative complications. The aim of this study was to determine the impact of persistent hyperbilirubinemia following preoperative biliary drainage before liver resection. The ACS-NSQIP (2016-2021) database was used to extract patients with cholangiocarcinoma who underwent anatomic liver resection with preoperative biliary drainage comparing those with persistent hyperbilirubinemia (> 1.2mg/dL) to those with resolution. Patient characteristics and outcomes were compared with bivariate analysis. Multivariable modeling evaluated factors including persistent hyperbilirubinemia to evaluate their independent effect on serious complications, liver failure, and mortality. We evaluated 463 patients with 217 (46.9%) having hyperbilirubinemia (HB) despite biliary stenting. Bivariate analysis demonstrated that patients with HB had a higher rate of serious complications than those with non-HB (80.7% vs 70.3%; P = 0.010) including bile leak (40.9% vs 31.8%; P = 0.045), liver failure (26.7% vs 17.9%; P = 0.022), and bleeding (48.4% vs 36.6%; P = 0.010). Multivariable analysis demonstrated that persistent HB was independently associated with serious complications (OR 1.88, P = 0.020) and mortality (OR 2.39, P = 0.049) but not post-operative liver failure (OR 1.65, P = 0.082). Failed preoperative biliary decompression is a predictive factor for post-operative complications and mortality in patients undergoing hepatectomy and may be useful for preoperative risk stratification.

The effect of pre-operative biliary drainage in resectable periampullary lesions: a systematic review and meta-analysis.

The effect of a pre-operative biliary stent on complications after pancreaticoduodenectomy (PD) remains controversial. We conducted a meta-analysis according to the preferred reporting items for systematic reviews and meta-analyses guidelines, and PubMed, Web of Science Knowledge, and Ovid's databases were searched by the end of February 2023. 35 retrospective studies and 2 randomized controlled trials with a total of 12641 patients were included. The overall complication rate of the pre-operative biliary drainage (PBD) group was significantly higher than the no-PBD group (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.22-1.74; p < 0.0001), the incidence of post-operative delayed gastric emptying was increased in patients with PBD compared those with early surgery (OR 1.21, 95% CI: 1.02-1.43; p = 0.03), and there was a significant increase in post-operative wound infections in patients receiving PBD with an OR of 2.2 (95% CI: 1.76-2.76; p < 0.00001). PBD has no beneficial effect on post-operative outcomes. The increase in post-operative overall complications and wound infections urges the exact indications for PBD and against routine pre-operative biliary decompression, especially for patients with total bilirubin < 250 umol/L waiting for PD.

Endoscopic stenting of the common bile duct in choledocholithiasis in a 10-year-old child: a clinical observation

The paper describes a clinical observation of extrahepatic cholestasis in a 10-year-old child. Anatomical features required complex endoscopic surgery. The patient with jaundice and pain syndrome was hospitalized in the state of moderate severity with the history of the disease for more than a month. The study presents stages of outpatient and clinical laboratory and instrumental diagnostics. As a result, obstructive jaundice was revealed. Multi-stage endoscopic treatment was successfully performed. It revealed no signs of choledocholithiasis, but detected compression of the pancreatic part of the common bile duct without pathological changes in the head of the pancreas. Endoscopic stenting of the common bile duct and pancreatic duct was performed. Biliary hypertension was eliminated. Endoscopic methods of biliary decompression can be applied to older children. Pancreatic duct stenting can be performed to prevent postoperative pancreatitis. Atypical sphincterotomy provides access to the bile ducts.

ANTEGRADE METHODS OF BILIARY DECOMPRESSION IN TUMOR OBSTRUCTION OF THE BILIARY TRACT

Percutaneous transhepatic endoscopic ultrasound-guided intervention is a crucial method for addressing mechanical jaundice. This technique for restoring bile outflow enables the resolution of several medical and diagnostic issues with minimal invasiveness and fewer complications compared to traditional open surgical treatments. Most often, antegrade cholangiostomy is used in oncological practice, where the variety of clinical situations determines the indications for performing this intervention in different variants and with different goals. According to the world literature, at the moment, sufficient experience of transdermal technologies has been accumulated, their application in clinical practice has been worked out, which allows to recognize them, to a certain extent, as routine. The purpose of this work is to optimize biliary decompression in patients with tumor obstruction of the biliary tract, to improve the prevention of complications, to enhance the immediate results of treatment and the quality of life for this group of population. The study analyzed the examination and surgical treatment outcomes of 64 patients with tumor-related mechanical jaundice treated in surgical hospitals from 2017 to 2023. All patients underwent antegrade biliary drainage procedures, specifically percutaneous transhepatic cholangiostomy and bile duct stenting under ultrasound guidance, to achieve biliary decompression. Percutaneous transhepatic endoscopic interventions have become the primary method for biliary decompression in cases of bile duct obstruction due to tumors. These procedures, particularly for malignant tumors, are associated with relatively few complications and low mortality rates.

Predicting an unfavorable outcome in patients with liver failure associated with obstructive jaundice syndrome: a prospective observational study

INTRODUCTION: Specialized scales developed to assess survival and mortality of patients after liver transplantation have not been validated when applied to liver failure in the setting of obstructive jaundice. OBJECTIVE: To determine the prognostic value of multiparametric scoring scales and to identify predictors of unfavorable outcome in liver failure due to obstructive jaundice. MATERIALS AND METHODS: 53 patients with confirmed liver failure due to obstructive jaundice of benign etiology who underwent biliary decompression were included in this prospective, observational, single-center study. Depending on the outcome two groups were distinguished: with favorable (n = 27, 51 %) and with unfavorable outcome (n = 26, 49 %). The following time points were defined for the dynamic evaluation of the course of the disease: day 1, day 3, day 7, and day 11 after decompression. Statistical processing of the data was performed using IBM SPSS Statistics 22 software for social science data analysis. RESULTS: The sensitivity and specificity of the studied scales in predicting liver failure due to obstructive jaundice were calculated on the basis of receiver operating characteristic (ROC) analysis. The AUROC for the SOFA was 0.862, for the MELD — 0.882, for the APACHE II — 0.864, for the Child-Turcotte-Pugh — 0.813. The sensitivity and specificity values for the SOFA were 78.9 and 77.8 %, for the MELD — 80.8 and 79.7 %, for the APACHE II — 57.7 and 81.9 %, and for the Child-Turcotte-Pugh — 75.1 and 70.9 %, respectively. Albumin was an independent predictor of unfavorable outcome (AUC ROC 0.909, p = 0.01), sensitivity 88.6 %, specificity 85.2 %. CONCLUSIONS: The scales presented in the study and the biomarker candidate “albumin” showed significant prognostic ability, but low values of sensitivity and specificity (less than 80 %) in some points of the study require the search for additional predictors of unfavorable outcome of liver failure due to obstructive jaundice.

Acute Cholangitis GRADE II–III. The View of an Interventional Radiologist

Aim of study To evaluate the safety and efficacy of percutaneous transhepatic cholangiostomy (PTC) as a first-line intervention in the treatment of patients with acute cholangitis (AC) Grade II–III (TG 13/18).Material and methods The results of treatment of 42 patients with AC Grade II–III, who underwent PTC, were analyzed. The criteria for non-inclusion were the presence in patients of destructive cholecystitis and (or) acute pancreatitis, AC due to proximal block of the bile ducts, regardless of etiology, as well as the presence of cholangiogenic liver abscesses. Literature data were used as reference results of the use of endoscopic techniques. AC was diagnosed and its severity was determined in accordance with the diagnostic criteria TG 13/18. The control points of the study were the frequency of post-manipulation complications associated with PTC, as well as the immediate efficacy of cholangiostomy, assessed by the dynamics of Grade-status within 24 and 48 hours.Results In all 42 patients, PTC was technically successful. Major complications that might require a change in treatment tactics (significant hemobilia, bile peritonitis, bleeding into the abdominal cavity) were not observed. Two complications occurred: subcapsular hematoma (2.4%) and right-sided pleurisy (2.4%). When assessing the dynamics of Grade status, its significant decrease was found in the group of patients with initial Grade III after 24 hours (from 16 to 9 hours) and 48 hours (from 9 to 4 hours). In patients with initial Grade II status, in three cases it worsened to Grade III, which still persisted in one patient even in 48 hours. There was no in-hospital mortality in the examined patients.Conclusion Antegrade endobiliary intervention for acute cholangitis involves performing real-time monitored biliary decompression. Experience with the use of percutaneous interventions does not confirm the high risk and frequency of post-manipulation complications in comparison with endoscopic retrogradeprocedures. It seems obvious that there is a need for and the possibility of choosing both retrograde and antegrade methods of emergency biliary decompression in the arsenal of treatment for patients with acute cholangitis.

A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure

Video 1A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure.We report a case in which anterior and posterior drainage was performed using the partial stent-in-stent method via the transpapillary approach. The patient had a bismuth type IV biliary obstruction, but only the right hepatic lobe was drained due to obstruction of the left portal vein. For the recurrent stent dysfunction, the patient underwent placement of a plastic stent within an uncovered self-expanding metal stent to correct stent dysfunction. A 7F plastic stent inside a metal stent is shown.The patient later experienced stent failure and jaundice due to tumor progression and was admitted for plastic stent replacement. Neither imaging results nor symptoms suggested duodenal stenosis. The transpapillary approach was attempted first but was unsuccessful. Duodenoscopy was challenging to perform because of duodenal stenosis. Fluoroscopy confirmed the duodenal stenosis. The plastic stent was extracted using an upper endoscope. Multiple uncovered metal stents are shown (1 stent in the anterior bile duct and 2 stents in the posterior bile duct). Jaundice did not resolve despite plastic stent removal.The patient refused to undergo percutaneous biliary drainage, so a decision was made to perform an EUS-guided hepaticogastrostomy (HGS) instead. The left bile duct was observed in the stomach. The left bile duct was punctured with a 19-gauge FNA needle. A 0.025-inch hydrophilic guidewire was directed into the left bile duct. Enhancement of the bile duct showing malignant hilar biliary obstruction (bismuth IV) is seen. Insertion of the guide wire into the posterior bile duct is shown.The stent mesh was then dilated using a balloon dilator. However, there was difficulty inserting the catheter. Additional dilation was performed using a spiral dilator. This instrument is a tapered tip dilator that fits into 0.025-inch guidewires and is expandable to 7F. Insertion of a second guidewire with a larger caliber was done to straighten the bile duct and help stabilize stent insertion. A 0.035-inch hydrophilic guidewire into the posterior bile duct using a double-lumen cannula and insertion of a 0.025-inch hydrophilic guidewire into the anterior bile duct are shown.The stent mesh was then dilated using a spiral dilator. A metal stent was placed through the anterior bile duct at a steep angle. Insertion and deployment of the first uncovered self-expanding metal stent (8× 60mm) from the anterior bile duct into the left bile duct is shown. Multiple metal stents were implanted into the hilar area, and the new stent was placed using the partial stent-in-stent method to prevent overexpansion. Guidewire seeking the posterior bile duct from inside the deployed stent through the stent mesh is shown.The stent mesh was then dilated using a balloon dilator. Insertion and deployment of an uncovered self-expanding metal stent (8× 60mm) from the posterior bile duct to the left bile duct using the partial stent-in-stent method is shown. Enhancement of the bile duct shows drainage from the right bile duct. The fistula of the HGS was only dilated with the spiral dilator. The risk of bile leakage was low, so we decided to implant a plastic stent. A 7F× 15-cm plastic stent was placed from the posterior bile duct into the stomach. Anterior and posterior segment drainage by EUS-HGS with bridging stenting using the partial stent-in-stent method is shown, with left segment drainage by EUS-HGS with the plastic stent.We performed EUS-HGS on a patient with multiple metal stents in place. There were no adverse events, and total bilirubin levels were reduced by more than half within 2 weeks. Six months have passed without stent dysfunction.

Ectopic biliary varices as a cause of portal biliopathy and mechanical jaundice syndrome

The authors consider ectopic biliary varices as a possible cause of portal biliopathy in extrahepatic portal hypertension. The main diagnostic methods including ultrasound CT, MRI, endoscopic ultrasonography, cholangioscopy, difficulties of differential diagnosis and clinical manifestations of portal biliopathy are presented. Various treatment options including portosystemic shunting and endoscopic biliary decompression are discussed. The authors emphasize the role of differentiated treatment depending on bile duct lesions. The study not only reviews this problem, but also highlights the issues requiring further analysis for selection of optimal diagnostic and treatment methods.

Biliary Drainage For Sepsis Control In Acute Cholangitis: A Case Report

Acute cholangitis leading to sepsis is a common occurrence, especially in populations with a highprevalence of gallstones. Unfortunately, the mortality rate related to this issue is high. Recently,we had a case involving an elderly woman who initially had mild acute cholangitis, but it progressedinto a severe case. Respiratory and hematological issues developed, along with worsening septicparameters and liver functions. As a result, she was intubated, ventilated, and monitored in theintensive care unit (ICU). Urgent ERCP failed, but PTBD and percutaneous cholecystostomy wereinserted to aid in biliary decompression and sepsis control. Currently, she is recovering fromsepsis and plans for early ERCP and cholangiogram before definitive surgical intervention. Tohandle obstructed biliary sepsis, early biliary drainage is crucial for urgent biliary decompressionand sepsis control, alongside fluid resuscitation, intravenous antibiotics, and intensive care.

Cholangitis and Interruptions of Neoadjuvant Chemotherapy Associate with Reduced Overall and Progression-Free Survival in Pancreatic Cancer.

Interrupting chemotherapy may explain the reduced overall survival (OS) in patients with pancreatic cancer (PC) with cholangitis. Endoscopic biliary decompression (BD) with metallic stents results in fewer chemotherapy interruptions and a lower cholangitis rate compared with plastic stents. We aimed to determine the impact of cholangitis, neoadjuvant treatment (NAT) interruptions and biliary stent choice on PC patients' survival. We conducted a retrospective analysis of 162 patients with cancer of the head of the pancreas undergoing pancreatoduodenectomy after NAT and BD documenting progression-free survival (PFS) and OS. Data on BD, cholangitis, stent type, surgical radicality, and chemotherapy were collected. Survival was estimated based on the Kaplan-Meier method by using the log-rank test and multivariate Cox regression analysis. Median OS and PFS for patients with cholangitis (n = 33, 20%) were 26 and 8 months (95% confidence interval [CI] 20-32 and 5-10 months), respectively, compared with 36 and 17 months (95% CI 31-41 and 12-21 months; p < 0.001 for OS; p = 0.002 for PFS) for patients without cholangitis. Among patients without NAT interruptions median OS and PFS were 35 and 17 months (95% CI 31-40 and 12-21 months), falling to 26 and 7 months (95% CI 18-30 and 5-10 months) among those who experienced an NAT interruption caused by biliary stent failure (n = 26, 16%) (p = 0.039 for OS; p < 0.001 for PFS). We found no difference in OS or PFS between stent types. Cholangitis and NAT interruptions reduce OS and PFS among PC patients.

Performance and safety of diagnostic EUS FNA/FNB and therapeutic ERCP in patients with borderline resectable and locally advanced pancreatic cancer - results from a population-based, prospective cohort study

Objective: Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS FNA/FNB) and potential endoscopic retrograde cholangiopancreatography (ERCP) for biliary decompression are indicated in patients with pancreatic cancer before initation of primary chemotherapy. This study aims to investigate the performance and safety of these two procedures in patients with borderline resectable (BRPC) or locally advanced pancreatic cancer (LAPC). Methods: Endoscopy and pathology reports, and hospital records of consecutive patients with a radiological diagnosis of BRPC/LAPC included in a population based, protocol-driven study (NORPACT-2) were reviewed. Results: Of 251 patients, 223 (88.9%) underwent EUS-FNA/FNB, and 133 (53%) underwent ERCP. Repeated EUS attempts were performed in 33 (14.8%), eight (3.6%), and four (1.8%) patients. FNA was performed in 155 procedures, FNB in 30, and combined EUS-FNA/FNB in 83. Diagnostic accuracy was 86.1% for first EUS-FNA/FNB. The cumulative diagnostic accuracy for all attempts was 96%. False positive rate for malignancy was 0.9%. Of a total of 149 ERCP procedures, 122 (81.9%) were successful, and 27 (18.1%) were unsuccessful. Success rate of first ERCP attempt was 80.5% (107/133). Sixteen patients (12%) underwent a second attempt with a success rate of 93.8% (15 of 16). Combined EUS and ERCP was performed in 41 patients. Complications occurred in eight procedures (3%) after EUS-FNA/FNB, 23 procedures (15.3%) after ERCP, and four (9.8%) patients after combined EUS-FNA/FNB and ERCP. Conclusion: EUS-FNA/FNB and ERCP with biliary stenting in patients with BRPC/LAPC demonstrated acceptable performance and safety. Repeat procedures were performed with high success rates. Same session EUS-FNA/FNB and ERCP for biliary decompression is safe.

Obstructive jaundice: epidemiology, diagnosis and choice of optimal method of biliary decompression

Aim. To analyze epidemiological features and morbidity structure in obstructive jaundice, to estimate the results of diagnosis and treatment of this category of patients and to evaluate factors affecting the effectiveness of the treatment and diagnostic program.Materials and methods. The study was based on four-year experience of treatment of 484 patients with mechanical jaundice. Ultrasound, CT, MRI, endoscopic ultrasound, and cholangioscopy were used to diagnose the level of the obstruction and the causes of obstructive jaundice. The main method of decompression involved transpapillary interventions in 365 patients. Two patients underwent choledochoduodenostomy under endoscopic ultrasound guidance. Percutaneous transhepatic interventions and “rendezvous” method were applied in 82 cases.Results. The efficacy of transpapillary endoscopic retrograde procedures in obstructive jaundice accounted for 93.4%. Complications developed in 33 patients (8.4%) including postmanipulation pancreatitis – in 19 patients (4.9%), pancreatonecrosis – in 2 patients (0.5%), bleeding – in 9 patients (2.3%), retroduodenal perforation – in 2 patients (0.5%), Mallory–Weiss syndrome – in 1 patient (0.3%). The efficacy of antegrade percutaneous transhepatic interventions comprised 95.1%, while liver parenchyma bleeding developed in 3.7% of patients. In-hospital mortality amounted to 0.8% (malignant tumor progression).Conclusion. The increasing share of patients with mechanical jaundice in the structure of general surgical emergencies, as well as the need to use high-tech equipment for diagnosis and treatment, necessitate creating centers for treatment of patients with mechanical jaundice. Retrograde and antegrade minimally invasive surgeries for specific indications are considered to be the main methods of biliary decompression.

EUS-guided gallbladder drainage as second option of biliary decompression after failed ERCP for the management of malignant distal biliary obstruction

EUS-guided gallbladder drainage as second option of biliary decompression after failed ERCP for the management of malignant distal biliary obstruction

S3340 Dual Biliary Decompression: Endoscopic Ultrasound-Guided Gallbladder Drainage With Common Bile Duct Stenting in Malignant Biliary Obstruction and Acute Cholecystitis

S3340 Dual Biliary Decompression: Endoscopic Ultrasound-Guided Gallbladder Drainage With Common Bile Duct Stenting in Malignant Biliary Obstruction and Acute Cholecystitis

Elevated CA 19-9 is associated with worse survival in patients with resected ampullary adenocarcinoma

BackgroundThe prognostic utility of Carbohydrate Antigen 19-9 (CA 19-9) and Carcinoembryonic Antigen (CEA) in ampullary adenocarcinoma is unclear. We sought to evaluate the association between initial tumor marker levels and survival in patients with resected ampullary adenocarcinoma. MethodsThis was a single-institution, retrospective cohort study of consecutive patients who underwent pancreatoduodenectomy for ampullary adenocarcinoma from 1999 to 2021. CA 19-9 was assessed after biliary decompression. Contal and O'Quigley method determined optimal biomarker cutoff levels which were correlated with overall survival (OS) using the Kaplan-Meier method and Cox Proportional Hazards Regression. ResultsA total of 180 patients underwent pancreatoduodenectomy. Patients with CA 19-9 >100 U/mL had a shorter median OS (28 vs. 132 months, p < 0.001) compared to patients with CA 19-9 ≤ 100 U/mL at diagnosis. Survival was similar between pancreaticobiliary and intestinal tumor subtypes when CA 19-9 was >100 U/mL (OS:25 vs. 33 months, p = 0.415). By Cox regression analysis, CA 19-9 >100 U/mL was independently associated with worse OS (HR 2.8, p = 0.001). ConclusionsPreoperative CA 19-9 >100 U/mL was associated with shorter OS in patients with resected ampullary adenocarcinoma. CA 19–9 may be useful when counseling patients about prognosis or when considering the role of perioperative systemic therapy.

The Use of Inflammatory Markers for Treatment Response Monitoring in Acute Cholangitis: A Retrospective Cohort Study

IntroductionIn acute cholangitis (AC), monitoring treatment response to antimicrobial therapy allows for making timely decisions on early biliary decompression. The aims of this study were to compare the discriminating powers of traditional blood inflammatory markers and propose new inflammatory markers that have a better ability to distinguish between patients with and without biliary tract infection. MethodsThis was a retrospective cohort study. Patients who underwent endoscopic retrograde cholangio-pancreaticography for AC and those without biliary tract inflammation were randomly selected in the 4:3 ratio of their hospital admissions from our hospital endoscopic retrograde cholangio-pancreaticography database. The exclusion criterion was the absence of C-reactive protein (CRP) measurements. ResultsThe discriminating powers of the neutrophil count, lymphocytes, albumin, neutrophil-to-lymphocyte ratio, and CRP were superior to that of white blood cell (P1 < 0.005; P2 = 0.004; P3 < 0.0005; P4 < 0.0005; P5 < 0.0005). In monitoring treatment response in AC, lymphocyte count, albumin, neutrophil-to-lymphocyte ratio, and CRP were better than neutrophil count (P6 = 0.037, P7 < 0.005, P8, 9 < 0.0005). The area under the receiver operating characteristic curve (AUC) of CRP was higher than the AUC for lymphocytes, 96% (95% confidence interval [CI]: 94-98%) versus 81% (95% CI: 76-86%) (P < 0.0005), and larger than the AUC for albumin, 88% (95% CI: 84-92%) (P < 0.0005), indicating a greater discriminating power of CRP. However, the discriminating power of CRP-to-lymphocyte ratio (CLR) was more than that for CRP (P = 0.006) but equal to CRP-to-(lymphocytes∗albumin) ratio (CLAR) (P = 0.249). The AUCs of CLR and CLAR were both 98% (95% CI: 96-99%). ConclusionsCLR and CLAR have superior discriminating powers than traditional inflammatory markers used for monitoring treatment response in AC.

Internal versus external biliary drainage in malignant biliary obstructions: is there a difference in the rate of infection?

Percutaneous biliary drainage is a frequently used method to provide biliary decompression in patients with biliary obstruction. To investigate the between drainage type and infection risk in patients treated with internal-external and external biliary drainage catheterization for malignant biliary obstruction. A total of 410 patients with malignant biliary obstruction who underwent internal-external or external biliary drainage catheterization between January 2012 and October 2016 were retrospectively evaluated. We investigated the correlation between percutaneous biliary drainage technique and infection frequency by evaluating patients with clinical findings, bile and blood cultures, complete blood counts, and blood biochemistry. There was no statistically significant difference between the selected patient groups (internal-external or external biliary drainage catheter placed) in terms of age, sex, primary diagnosis, receiving chemotherapy, catheter sizes, and outpatient-patient status. After catheterization, catheter-related infection was observed in 49 of 216 (22.7%) patients with internal-external and 18 of 127 (14.2%) patients with external biliary drainage catheters, according to the defined criteria. There was no difference in infection rate after the biliary drainage in the two groups (P > 0.05). There was also no difference concerning frequently proliferating microorganisms in bile cultures. Internal-external biliary drainage catheter placement does not bring an additional infection risk for uninfected cholestatic patients whose obstruction could be passed easily in the initial drainage.