Biliary Decompression Research Articles

Contemporary analysis of complications associated with biliary stents during neoadjuvant therapy for pancreatic adenocarcinoma

BackgroundWith the increasing use of biliary stents for neoadjuvant therapy (NT) for pancreatic adenocarcinoma (PDAC), the risk of post-pancreaticoduodenectomy (PD) infection remains relevant. This study documents the contemporary incidence of stent-related complications (SRC) during NT and to analyze their impact on surgical infections. MethodsConsecutive patients from a single institution (2011–15) with resected PDAC treated with biliary decompression, NT, and PD were analyzed. Stent-related complications (SRC) were compared among patients with/without prospectively documented composite pre- and post-operative infections (surgical site infection [SSI], organ space infection [OSI], and cholangitis). ResultsOf 114 total patients, (median 164 days, initial stent to surgery), 95% had initial endoscopic (vs. percutaneous) stenting. Initial stents were often plastic (80/114, 70%), with 43/114 (38%) undergoing routine exchange to metal stent before NT. Fifteen (13%) patients had stent cholangitis during NT requiring antibiotics and/or stent exchange. There were 33/114 (29%) patients with SRC, requiring 66 exchanges. Post-PD rates of SSI, OSI, and cholangitis were 23%, 5%, and 4%, respectively [composite rate 30%]. On multivariate analysis, SRC were not associated with composite surgical infections (p > 0.05). ConclusionsAlthough SRC occurred in almost one-third of PDAC patients during NT, with appropriate intervention, there was no association with increased surgical infections.

Transhepatic forceps biopsy combined with biliary drainage in obstructive jaundice: safety and accuracy.

This study was conducted in order to investigate the safety and accuracy of percutaneous transluminal forceps biopsy (PTFB) during percutaneous biliary drainage (PTBD) in patients with a suspicion of malignant biliary stricture. Fifty consecutive patients with obstructive jaundice underwent PTFB during PTBD. Biopsy specimens were obtained using 5.2-F flexible biopsy forceps and these specimens were independently analysed by two pathologists. Consensus was obtained in case of discrepancy. Biopsy was considered as a true positive when tumour cells were retrieved. In the absence of tumour cells, comparison with available surgical findings and/or endoscopic ultrasound fine-needle aspiration (EUS-FNA) and/or percutaneous liver biopsy and/or imaging or clinical follow-up was made to distinguish true and false negatives. Specificity, sensitivity, positive predictive value, negative predictive value and accuracy were calculated. Influence of tumour location and pre-operative imaging findings was evaluated. Adverse events were reported. Biliary drainage and tissue sampling were achieved in 100% of patients. Sensitivity and specificity were 70 and 100%, respectively, while overall accuracy was 72%. After excluding the first 25 patients, accuracy and sensitivity for tissue sampling reached 80 and 78%, respectively. Sensitivity was better (87%) if stenosis was located at the upper part of the biliary tree, compared to the lower part (55%). In case of cholangiocarcinoma or intraductal invasion suspected on imaging, biopsy was contributive in 84 and 81% of patients, respectively. Four complications occurred consisting of one bile leak, two haemobilia and one pneumoperitoneum. PTFB combined with PTBD is a safe and effective technique for both histopathological diagnosis and biliary decompression of biliary strictures. Implications for patient care: • Percutaneous transbiliary forceps biopsy is technically feasible (100% of tissue sampling in our study) and is a safe technique. • Radiological management combining PTFB plus PTBD may allow diagnosis and treatment of the biliary stricture at the same time. • Sensitivity and accuracy for PTFB reached 78 and 80%, respectively, with a 100% specificity.

Endoscopic intervention and cholecystectomy in pregnant women with acute biliary pancreatitis decrease early readmissions

Acute biliary pancreatitis (ABP) is associated with increased rates of morbidity in pregnancy. Because there is a paucity of population-based studies evaluating ABP in pregnancy, we sought to investigate clinical outcomes in hospitalized pregnant women on a national level. By using the Nationwide Readmission Database (2011-2014), we identified all women (age≥18 years) with an index admission for ABP in the United States. Multivariate and propensity-score matched analyses were performed to evaluate the impact of pregnancy on the clinical outcomes of early readmission and severe acute pancreatitis (SAP) in ABP. There were 7787 hospitalizations for ABP in pregnant women during the study period. The rate of 30-day readmission was 16.26%; 57% of these early readmissions were due to adverse events of ABP. Compared with nonpregnant women with ABP, ERCP (21.1% vs 25.2%; P< .001) and cholecystectomy (52.8% vs 55.2%; P= .02) were performed less frequently during pregnancy. Propensity-score matched analysis revealed an increased risk of 30-day readmissions in pregnancy (odds ratio [OR], 1.96; 95% confidence interval [CI], 1.67-2.30), whereas there was no difference in the risk of SAP (OR, 1.09; 95% CI, 0.76-1.57). Multivariate analysis demonstrated that weekend admission (OR, 1.40; 95% CI, 1.10-1.79) and >1 week of hospitalization (OR, 1.75; 95% CI, 1.24-2.48) increased the risk of 30-day readmission, whereas ERCP (OR, 0.40; 95% CI, 0.27-0.57) and cholecystectomy (OR, 0.13; 95% CI, 0.10-0.18) reduced the odds of early readmission in pregnancy. Pregnant women with ABP less frequently undergo timely endoscopic biliary decompression and cholecystectomy. These modifiable factors can potentially lower early readmissions in pregnant women.

Laparoscopic management of hydatid cysts with biliary communication: Clips may rescue when suture fails-report of 3 cases.

Hydatid disease is a parasitic zoonosis caused by the larval form of the Echinococcus worm. Hepatic hydatidosis is the most common form of disease in humans. Centrally located, large hydatid cysts have the tendency to rupture into the adjoining bile duct and form a fistulous communication. Suture closure of the cystobiliary communication detected during surgery is recommended to avoid postoperative complications related to bile leak. In the era of minimally invasive surgery, laparoscopic management of the cystobiliary communication can be challenging, and laparoscopic suturing may not always be feasible. Postoperative endoscopic biliary decompression is necessary in such situations, but it has its own set of potential risk and complications. In this case report, we present a simple and easy technique for laparoscopic closure of the cystobiliary communication when suture ligation is technically not possible.

PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE – THE FIRST STEP IN THE TREATMENT OF MALIGNANT BILIARY OBSTRUCTION

Introduction. Percutaneous transhepatic biliary drai­nage (PTBD) comes as safe and effective alternative when endoscopic biliary decompression is unavaila­ble. However, PTBD as invasive procedure has its own risks and complications. Our aim was to evaluate the clinical outcomes and possible benefits of an ul­trasound guided percutaneous transhepatic biliary drainage as the first step in the palliative treatment of malignant biliary obstruction. Methods. Retrospective review of patients undergoing percutaneous transhepatic biliary drainage from Ja­nuary 2014 to December 2015 at the Department of Surgery, Hospital of the Lithuanian University of He­alth Sciences was performed. Patients were reviewed for demographic data, laboratory tests, complications, outcomes, hospital stay and mortality rate. Results. During the study period ninety nine patients (median age - 68 years, (44 - 95) received 124 biliary drainage procedures for malignant obstructive jaun­dice. Prior the percutaneous drainage fifty eight pa­tients (58.6%) were unsuccessfully treated by ERCP. Forty patients (40.4%) were diagnosed with periam­pullary tumours, thirty (30.3%) had proximal/hi­lar cholangiocarcinoma, and twenty nine (29.3%) had biliary obstruction due to metastatic disease. Acute cholangitis was present in fifty two (52.5%) patients. After drainage procedure total serum bi­lirubin decreased in eighty seven (87.9%) patients (from 293.72±131.9 μmol to 193.11±117.49 μmol, p&amp;lt;0.05). Reduction in Gammaglutamyl transferase and Alkaline phosphatase was observed in ninety four (94.9%) patients. Seventy patients (70.7%) underwent additional interval procedures. In 62 (88.6%) cases percutaneous transhepatic biliary stenting was per­formed. The mean hospital stay was 25.5±17.9 days (after percutaneous drainage - 19.9±17.3 days). Thirty four (34.3%) patients developed drainage related mor­bidity, with drainage catheter dislocation being most common (76.5% (n = 26). In hospital mortality rate was 27.3% (n = 27) with one drainage related death (procedure related mortality rate - 3.7%). Conclusions. Percutaneous transhepatic biliary drai­nage is relatively safe and effective method to reduce malignant obstructive jaundice, when other, less inva­sive drainage methods are unavailable or ineffective and acts as a necessary step in further palliative tre­atment.

Endobiliary radiofrequency ablation for distal extrahepatic cholangiocarcinoma: A clinicopathological study.

BackgroundMost patients with distal extrahepatic cholangiocarcinoma have developed jaundice or cholangitis at the time of initial diagnosis, which can delay surgery. We aim to evaluate the actual EB-RFA ablation volume and validated the clinical feasibility of preoperative endobiliary radiofrequency ablation (EB-RFA) for resectable distal extrahepatic cholangiocarcinoma.MethodsThe medical records of patients who underwent EB-RFA from July 2016 to June 2017 at a single tertiary academic medical center were reviewed. Inclusion criteria were patients with resectable distal extrahepatic cholangiocarcinoma who required preoperative biliary decompression. Clinical outcomes of EB-RFA were reviewed retrospectively and the surgical specimens were reevaluated.ResultsOf the eight patients who required a delayed operation, preoperative EB-RFA was successfully performed without serious complications including peritonitis, hemobilia, or perforation. Although curative resection was attempted in all patients, one patient underwent open and closure due to hepatic metastasis. Seven patients underwent curative surgical resection and the histology revealed that median maximal ablation depth was 4.0 mm (range, 1–6) and median effective ablation length (histological ablation length/fluorosocopic ablation length) was 72.0% (range, 42.1–95.3).ConclusionsEB-RFA partially ablated human cancer tissue and preoperative EB-RFA might be a safe and feasible in patients with distal extrahepatic cholangiocarcinoma who require a delayed operation. Ablation of the target lesion longer than the estimated length by fluoroscopy may improve the efficacy of EB-RFA.

Лікування доброякісних захворювань гепатикохоледоха, ускладнених обтураційною жовтяницею, з використанням антеградних ендобіліарних втручань

Мета. Аналіз результатів лікування доброякісних захворювань гепатикохоледоха (ГХ), ускладнених обтураційною жовтяницею (ОЖ), з урахуванням використання антеградних ендобіліарних втручань.&#x0D; Матеріали і методи. Ретроспективно та проспективно проаналізовано результати лікування 34 пацієнтів з доброякісними захворюваннями ГХ, ускладненими ОЖ, в Інституті з 2011 по 2017 р.&#x0D; Результати. Для біліарної декомпресії у 15 (44,1%) пацієнтів (1-ша група) застосували антеградні ендобіліарні втручання. У 19 (55,9%) пацієнтів (2-га група) спроби виконати ретроградні втручання виявилися неефективними. Після біліарної декомпресії 24 (70,6%) пацієнтам виконали реконструктивно-відновні операції із застосуванням розробленого способу лікування холедохолітіазу (ХЛ) (Пат. України на корисну модель №126337), 2 (5,9%) пацієнтам з «ендоскопічно складними» формами ХЛ виконали мініінвазивні комбіновані втручання з антеградного та ретроградного доступів.&#x0D; Висновки. Застосовуючи антеградні ендобіліарні втручання, ми знизили частоту розвитку ускладнень біліарної декомпресії із 78,9 до 6,7% (ускладнення констатували у 15 пацієнтів 2-ї та у 1 пацієнта 1-ї групи); частоту розвитку ускладнень після реконструктивно-відновних операцій з 52,6 до 6,7% (ускладнення констатували у10 пацієнтів 2-ї та у 1 пацієнта 1-ї групи), а також летальність з 10,5 до 6,7% (померли 2 пацієнти 2-ї та 1 пацієнт 1-ї групи).

Antegrade cholangiostomy: analysis and prevention of complications

Aim. To analyze complications of percutaneous transhepatic cholangiostomy depending on biliary obstruction level and drainage type.Material and methods. Percutaneous transhepatic biliary drainage was carried out in 974 patients with mechanical jaundice of different genesis. External drainage was predominantly performed for distal obstruction, external-internal suprapapillary – for proximal obstruction. Strictures of biliodigestive anastomosis were managed using percutaneous balloon dilatation and long-term external-internal drainage.Results. Overall morbility was 19.1%. Significant relationship between morbidity and obstruction level, drainage type and tubes quantity was detected. Drainage tube dislocation was the most common drainage-related complication both in proximal and distal obstruction. External-internal transpapillary drainage was followed by suppurative cholangitis and acute pancreatitis in 81.5% of cases. External-internal suprapapillary drainage was accompanied by acute cholangitis in 17.1% of patients and was determined by disconnection of subsegmental ducts that required additional drainage tubes placement. In most cases, complications were corrected by minimally invasive surgery and nonsurgical treatment. Overall mortality was 1.3% (0.3% in cases of distal obstruction and 1.8% in cases of proximal obstruction).Conclusion. Percutaneous transhepatic biliary drainage is a routine non-traumatic method of biliary decompression that may be successfully used irrespective to obstruction level and cause of jaundice. External-internal suprapapillary drainage is preferable for proximal biliary obstruction while external-internal transpapillary drainage should be avoided.

Cholestasis as a Diagnostic Challenge

Cholestasis results from an impairment in the excretion of bile acids and is caused by numerous disorders. Most of the time, the etiology can be predicted with a good history, physical examination and rational diagnostic testing. The most common causes of cholestasis include biliary obstruction, acute hepatitis, advanced cirrhosis, drug-induced liver injury (DILI), sepsis and malignancy. Even when the cause of cholestasis is apparent, additional mechanisms can contribute to or aggravate underlying liver pathology that manifests with prolonged hyperbilirubinemia. Here we report a patient with severe cholestasis who underwent extensive evaluation for unresolved jaundice. A 75-year-old lady presented to the hospital with worsening jaundice, diffuse pruritus, dark urine, pale colored stools, weight loss, palpitations and thinning of hair. Ultrasound revealed common bile duct stones and an Endoscopic retrograde cholangiopancreatography (ERCP) was done to remove the stones. As her elevated bilirubin levels did not improve after ERCP, liver biopsy was performed which showed stage 3 fibrosis and marked cholestasis consistent with congestion and outflow obstruction leading to congestive hepatopathy.Thyroid function tests were done to evaluate as part of the evaluation for abnormal liver function tests and were consistent with hyperthyroidism. An ultrasound of the neck revealed two nodules without calcification and irregular margins. A thyroid uptake scan revealed a pattern of Graves' disease. Echocardiogram showed severe tricuspid regurgitation. Her bilirubin dropped to 24 mg/dl and she was discharged with metoprolol, methimazole and ursodiol. The patient returned to the hospital after 15 days with worsening jaundice and labs showed bilirubin of 26.7 mg/dl (table 1). Ultrasound imaging showed no evidence of biliary obstruction. During her second hospitalization, her bilirubin started trending down to 13 mg/dl with subsequent improvement of symptoms. In this case, we postulate that hyperthyroidism might have worsened her heart failure, which contributed to the severity of congestive hepatopathy. Patient's condition improved despite the use of methimazole, which rules out DILI. Hence, prolonged cholestasis after ERCP can be a diagnostic dilemma. One should consider other etiologies, especially intrahepatic causes of cholestasis such as congestive hepatopathy,hyperthyroidism,DILI and sepsis when cholestasis fails to improve after biliary decompression.2264 Figure 1. Laboratory trends in bilirubin during hospital course

Primary Anaplastic Large Cell Lymphoma of the Pancreas: A Unique Pancreatic Neoplasm

Pancreatic malignancies are common, accounting for 15% of cancer patients in the United States. As 85% of pancreatic malignancies comprise of adenocarcinoma, physicians are generally less familiar with other types of pancreatic neoplasms. Here we report a case of anaplastic large cell lymphoma (ALCL), a rare subtype of non-Hodgkin's lymphoma, and one of the subtypes of T-cell lymphoma, presenting as a pancreatic mass causing acute pancreatitis. Recognition of ALCL is important as the disease is highly sensitive to chemotherapy, and thus carries a very good prognosis. A 64-year-old female presented to the emergency department with one week of abdominal pain and nausea. Physical exam revealed RUQ abdominal tenderness. Labs were significant for ALT 271 U/L, AST 234 U/L, ALP 706 U/L, total bilirubin 2.5 mg/dL, and lipase 115 U/L. A CT demonstrated pancreatic head edema with a poorly defined area of hypo-enhancement within the head. An MR showed a 1.5 cm stricture in the mid-distal CBD, as well as a 16 mm area of increased signal focus concerning for possible mass or pancreatitis in the pancreatic head. An EGD was performed, which revealed a 5 mm gastric body polyp with superficial erosion. An EUS revealed a 20 mm hypoechoic pancreatic head mass with invasion in the mid-CBD and the portal vein. Biopsies from the gastric body polyp and pancreatic head mass resulted as anaplastic lymphoma kinase (ALK)-positive ALCL. Patient underwent an ERCP for biliary decompression. The patient was started on CHOP with pegfilgrastim with good response. Our case of ALK-positive ALCL was unique in several aspects. First, ALK-positive ALCL usually affects children and young adults, while patients above the age of 55 typically present with ALK-negative ALCL. Second, patients with ALCL typically have B symptoms, but our patient presented with acute pancreatitis and obstructive jaundice. Third, contrary to ALCL's typical extranodal involvement of skin and bone, our patient had primary pancreatic and gastric involvement, which is exceedingly rare. To our knowledge, fewer than 10 cases of pancreatic ALCL have been reported. Overall, the prognosis of ALK-positive ALCL is considerably better, with a 5-year overall survival ranging from 70-90%, compared to 40-60% for ALK-negative ALCL. Patients with ALK-positive disease usually respond very well to CHOP. Patients with ALK-negative disease sometimes will require higher doses of chemotherapy followed by stem cell transplantation.1450_A.tif Figure 1: A gastric polyp was seen during EGD which was positive for ALK-positive anaplastic large cell lymphoma.1450_B.tif Figure 2: The pancreatic ALCL was seen invading the portal vein and the mid common bile duct on EUS1450_C.tif Figure 3: ALK-positive anaplastic large cell lymphoma involving the stomach and pancreas. (A) H+E stain; (B) CD-30 positive stain; (C) ALK positive stain

EUS-Guided Micro-Forceps Biopsy for the Diagnosis of Lymphoma

EUS-guided tissue acquisition is a standard modality used in the diagnosis of lymphoma. Historically, EUS-guided fine needle aspiration (FNA) has been used with highly variable diagnostic accuracy. EUS-guided fine needle biopsy (FNB) with core specimen acquisition has subsequently emerged as a potentially superior diagnostic procedure. More recently, the Moray micro-forceps device (U.S. Endoscopy, Mentor, Ohio), a through-the-needle biopsy forceps, has been approved for EUS-guided tissue acquisition of cystic lesions. We explored the use of the Moray micro-forceps to aid in the diagnosis of suspected lymphoma A 66-year-old man presented with jaundice and abdominal pain. A CT scan of the abdomen demonstrated a large, hypo-echoic retroperitoneal mass with periportal lymphadenopathy and biliary obstruction. The patient underwent EUS with FNA and microforceps biopsy of the retroperitoneal mass as well as ERCP for biliary decompression. FNA revealed cytomorphological features of non-Hodgkin's lymphoma with equivocal B-cell clonality on flow cytometry. The microforceps specimen demonstrated histologic and cytologic features of low-grade B-cell lymphoma. A 38 year-old woman presented with a several week history of abdominal pain and malaise. A CT scan of the abdomen demonstrated splenomegaly with perigastric and mesenteric adenopathy. EUS revealed a 30 mm hypo-echoic perigastric mass. FNB revealed cytological and histologic features consistent with low-grade small B-cell lymphoma. The micro-forceps specimen supported a concordant diagnosis with the FNB results. A 59 year-old man presented with weight loss and jaundice. A CT scan of the abdomen demonstrated multiple large peri-portal lymph nodes with associated biliary obstruction. EUS revealed multiple hypo-echoic masses in the periportal region. FNA revealed fragments of atypical lymphocytes with equivocal flow cytometry results. The micro-forceps specimen revealed histologic and cytologic features consistent with small B-cell lymphoma. In this case series, we observed that the Moray microforceps device can be utilized successfully in the diagnosis of suspected lymphoma. We further observed that the use of a micro-forceps biopsy may provide suitable specimens to allow for specific histologic diagnoses. Comparative effectiveness studies between FNA, FNB, and microforceps biopsy are warranted to determine hether the micro-forceps biopsy can serve an adjunctive role in EUS-guided diagnosis of lymphoma.2155_A Figure 1. Moray micro-forceps device (U.S. Endoscopy, Mentor, Ohio)2155_B Figure 2. EUS-guided micro-forceps biopsy

Changes in preoperative endoscopic and percutaneous bile drainage in patients with periampullary cancer undergoing pancreaticoduodenectomy in Ontario: effect on clinical practice of a randomized trial.

In 2010, a multicentre randomized controlled trial reported increased postoperative complications in pancreaticoduodenectomy (pde) patients undergoing preoperative biliary decompression (pbd). We evaluated the effect of that publication on rates of pbd at the population level. This retrospective observational cohort study identified patients undergoing pde for malignancy, 2005-2013, linking them with administrative health care databases covering medical services for a population of 13.5 million. Patients undergoing pbd within 6 weeks before their surgery were identified using physician billing codes and were divided into those undergoing pde before and after article publication, with a 6-month washout period. Chi-square tests were used to compare rates of pbd. Of 1997 pde patients identified, 963 underwent surgery before article publication, and 911, after (123 during the washout period). The rate of pbd was 47.5% before publication, and 41.6% after (p = 0.01). The lowest pbd rates occurred immediately after publication, in 2010 and 2011. Similar results were observed when the cohort was restricted to patients seen preoperatively by a gastroenterologist (n = 1412). Rates of pbd have declined a small, but significant, amount after randomized trial publication. Persistence of pbd might relate to suboptimal knowledge translation, the role of pbd in diagnosis of periampullary malignancy, and treatment of complications (cholangitis, severe hyperbilirubinemia) or anticipation of delay from diagnosis to surgery. The nadir in pbd rates after article publication and the subsequent rise suggest an element of transience in the effect of article publication on clinical practice. Further investigation into the reasons for persistent pbd is needed.

Temporary CBD Stenting with a Nelaton Tube Is a More Practical and Safer Option Than T-Tube Drainage after Conventional CBD Exploration for Choledocholithiasis.

Objective We are trying to investigate the possibility, safety, and benefits of replacing the role of T-tube by another more safe and effective procedure for biliary decompression in the case of common bile duct (CBD) exploration. Methods Our present study includes fifty consecutive patients who underwent a traditional CBD exploration due to choledocholithiasis. Patients were divided into 2 equal groups. In the 1st group, a spontaneously expelled Nelaton tube is placed in the CBD to aid in bile drainage to the duodenum, while in the 2nd group, a conventional T-tube is placed to decompress the CBD in the early postoperative (PO) days to a drainage bag. Operative and PO data as well as PO hospital stay time were recorded. All data were collected and statistically analyzed. Results The mean operative time and PO hospital stay days were significantly low (p value < 0.05) in the Nelaton tube drainage group compared with the T-tube drainage group. On the other hand, the mean time needed for the abdominal drain removal was significantly higher in the T-tube drainage group (p value < 0.05). Conclusion Nelaton tube with internal biliary drainage is effective and safer than T-tube drainage and it helps in reduction of the PO hospital stay time. In addition, it avoids all short-term complications of T-tube.

Minimally invasive biliary decompression methods in management of obstructive jaundice of malignant etiology

Minimally invasive biliary decompression methods in management of obstructive jaundice of malignant etiology

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

BackgroundIrreversible electroporation (IRE) has successfully been used for palliation of pancreatic and liver cancers due to its ability to ablate tumors without destroying nearby vital structures. To date, it has not been evaluated in patients with advanced hilar cholangiocarcinoma (AHC). This study presents a single-institution experience with IRE for management of obstructive jaundice in AHC. MethodsA single-institution database was queried for patients undergoing IRE for AHC after PTBD placement for relief of obstructive jaundice from 2010 to 2017 and compared to a control group treated with standard of care only (No IRE). ResultsTwenty-six patients underwent IRE for AHC after PTBD replacement. Three patients experienced complications, with two experiencing severe (≥ grade 3) complications. After IRE, median time to PTBD removal was 122 days (range 0–305 days) and median catheter-free time before requiring PTBD replacement was 305 days (range 92–458 days). In comparison, the 137 control patients had an admission rate of 59% (N = 80 patients) for PTBD infection, occlusion, or catheter related problem. ConclusionIRE safely achieves biliary decompression via tumor electroporation and allows PTBD removal for an extended period of time. In appropriately selected patients with obstructive jaundice in the setting of AHC, IRE can be used to increase catheter-free days and optimize overall quality of life.

Revision of bilateral self-expandable metallic stents placed using the stent-in-stent technique for malignant hilar biliary obstruction

BackgroundEndoscopic biliary decompression using bilateral self-expandable metallic stent (SEMS) placed using the stent-in-stent (SIS) technique is considered favorable for unresectable malignant hilar biliary obstruction (MHBO). However, occlusion of the bilateral SIS placement is frequent and revision can be challenging. This study was performed to investigate the efficacy, the long-term patency and the appropriate approach for revision of occluded bilateral SIS placement in unresectable MHBO. MethodsFrom January 2011 to July 2016, thirty-eight patients with unresectable MHBO underwent revision of occluded bilateral SIS placement. Clinical data including success rates and patency of revision, were retrospectively analyzed. ResultsThe technical success rate of revision was 76.3%. The clinical success rate of revision was 51.7% and mean patency of revision was 49.1 days. No significant predictive factor for clinical failure of revision was observed. The cell size of SEMS was not found to have significant effects on clinical success rates or revision patency. ConclusionsRevision of occluded bilateral SIS placement for MHBO showed fair patency and clinical success rate. Revision method and cell size of SEMS were not found to influence clinical outcomes.

Percutaneous cholecystostomy for biliary decompression in patients with cholangitis and pancreatitis.

ObjectiveThis study was performed to assess the effectiveness and safety of percutaneous cholecystostomy (PC) for biliary decompression.MethodsWe retrospectively analyzed our institution’s PC database from March 2015 to August 2017 and selected patients with biliary obstruction. The primary outcomes were the technical and clinical success rates. As secondary outcomes, adverse events and pain after PC were compared with those of patients who underwent PC for acute cholecystitis during the same period.ResultsTwenty patients underwent PC for biliary obstruction (cholangitis, 19; pancreatitis, 1). The technical and clinical success rates were 100%. The median serum total bilirubin level decreased considerably from 4.5 to 1.4 mg/dL after PC. An adverse event (catheter migration) occurred in 1 patient, and 17 patients developed pain after PC. During the same period, 104 patients underwent PC for cholecystitis. Adverse events occurred in 7 patients, and 62 developed pain. There was no significant difference in the adverse event rate between the cholangitis/pancreatitis and cholecystitis groups (5.0% vs. 6.7%, respectively), but pain occurred considerably more frequently in the cholangitis/pancreatitis group (94.4% vs. 63.9%, respectively).ConclusionsPC is an effective and safe method for biliary decompression in selected patients. However, attention should be paid to postoperative pain.

PrEoperAtive biliaRy (PEAR) drainage in malignant biliary obstruction – An observational cohort study to establish a novel score system to evaluate the necessity of biliary decompression prior to operation - Study proposal

PrEoperAtive biliaRy (PEAR) drainage in malignant biliary obstruction – An observational cohort study to establish a novel score system to evaluate the necessity of biliary decompression prior to operation - Study proposal

Stent Placement via ERCP vs. EUS in Pancreatic Cancer

While endoscopic retrograde cholangiopancreatography (ERCP) has been the standard of care for endoscopic biliary decompression in pancreatic cancer for

Clinical Feasibility of MR Elastography in Patients With Biliary Obstruction

The purpose of this study is to evaluate the clinical effect of liver stiffness measured using MR elastography (MRE) in patients with cholestasis due to biliary obstruction. In this retrospective study, 69 consecutive patients with no history of diffuse liver disease who underwent pancreaticobiliary imaging with MRE were included. Quantitative MRI parameters (i.e., liver stiffness, apparent diffusion coefficient, R2*, and proton density fat fraction) and laboratory results (i.e., aspartate aminotransferase, alanine aminotransferase, and total bilirubin levels) were measured. Patients were classified as having either normal bilirubin (group A; n = 49) or hyperbilirubinemia (group B; n = 20). Continuous variables were compared using the independent t test or Mann-Whitney U test. Correlation between parameters was analyzed using the Pearson correlation coefficient. The ROC curve analysis was used to evaluate the diagnostic performance and clinical effect of MRE. Liver stiffness was significantly higher in group B (mean ± SD, 3.8 ± 0.7 kPa) than in group A (2.8 ± 0.5 kPa) (p < 0.001); there were no differences in other MRI parameters. There were positive correlations between liver stiffness and total bilirubin (r = 0.609; p < 0.001), aspartate aminotransferase (r = 0.376; p = 0.001), and alanine aminotransferase (r = 0.285; p = 0.017) levels. There was a negative correlation between the degree of biliary decompression 1 week after bile drainage and liver stiffness (r = -0.71; p = 0.003). The sensitivity and specificity for predicting biliary decompression were 83.3% and 100%, respectively, at a liver stiffness cutoff of 4.0 kPa. Liver stiffness measured by MRE increases as cholestasis increases and can be a predictive factor for the sufficiency of biliary decompression after biliary drainage.