Biliary Decompression Research Articles

FEATURES OF DECOMPRESSION OF THE BILIARY TRACT IN PATIENTS WITH OBTURATION OF THE DISTAL PART OF THE COMMON BILE DUCT OF TUMOR ORIGIN

We conducted a retrospective and prospective analysis of the examination and treatment of 89 patients with cancer of the hepato-pancreato-duodenal zone complicated by mechanical jaundice. Cancer of the head of the pancreas was found in 69 patients, cancer of the major duodenal papilla was detected in 10 patients, cancer of the extrahepatic bile ducts – in 9 patients, and cancer of the duodenum – in 1 case. All patients were divided into 3 groups depending on the degree of jaundice. Operative treatment was performed in 86 patients. Of them, 13 were operated on at the height of jaundice, and 73 – after previous minimally invasive decompression of the biliary system. Postoperative complications were observed in 17 (19.1%) patients, 12 (16.4%) of whom were operated on at the height of jaundice, and 5 (6.8%) – after previous biliary decompression (second-stage operations). In 6 patients with severe jaundice who were operated on at the height of jaundice, complications occurred even after minor palliative operations. Thus, in the presence of severe jaundice with bilirubin level > 200 μmol/l, radical and palliative operations should be performed only in two stages, after preliminary decompression of the bile ducts. Decompression of the bile ducts allows the reduction of the preoperative period by 2–3 weeks.

Optimal timing of biliary drainage based on the severity of acute cholangitis: A single-center retrospective cohort study.

BACKGROUNDBiliary decompression is well known to greatly decrease the risks of mortality in acute cholangitis (AC). Although early biliary drainage is recommended by the treatment guidelines for AC, the best time for performing this procedure is yet to be established. Furthermore, since the clinical outcomes of patients with severe AC vary dramatically, screening for patients that could benefit the most from early drainage would be more beneficial than the drainage performed based on the severity grade criteria.AIMTo investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction.METHODSIn this retrospective monocenter cohort analysis, we reviewed 1305 patients who were diagnosed with AC according to the Tokyo guidelines 2018 at a Chinese tertiary hospital between July 2016 and December 2020. Demographic characteristics including age and sex, clinical and laboratory characteristics, and imaging findings of each patient were obtained from electronic medical records. We investigated the all-cause in-hospital mortality (IHM), hospital length of stay (LOS), and hospitalization costs associated with the timing of biliary drainage according to the severity grading and different dysfunctioning organs and predictors [age, white blood cell (WBC) count, total bilirubin, albumin, lactate, malignant obstruction, and Charlton comorbidity index (CCI)]. RESULTSBiliary drainage within 24 or 48 h in Grade III AC patients could dramatically decrease IHM (3.9% vs 9.0%, P = 0.041; 4% vs 9.9%, P = 0.018, respectively), while increasing LOS and hospitalization costs. Multivariate logistic analysis revealed that neurological, respiratory, renal, and cardiovascular dysfunctions, hypoalbuminemia, and malignant obstruction were significantly associated with IHM (odds ratio = 5.32, 2.541, 6.356, 4.021, 5.655, and 7.522; P < 0.001, P = 0.016, P < 0.001, P = 0.012, P < 0.001, and P < 0.001; respectively). Biliary decompression performed within 12 h of admission significantly decreased the IHM in AC patients with neurological dysfunction (0% vs 17.3%, P = 0.041) or with serum lactate > 2 mmol/L (0% vs 5.4%, P = 0.016). In the subgroup of AC patients with renal dysfunction, abnormal WBC count, hyperbilirubinemia, or hypoalbuminemia, early drainage (< 24 h) reduced the IHM (3.6% vs 33.3%, P = 0.004; 1.9% vs 5.8%, P = 0.031; 1.7% vs 5.0%, P = 0.019; 0% vs 27%, P = 0.026; respectively). The IHM was lower in patients with AC combined with hepatic dysfunction, malignant obstruction, or a CCI > 3 who had undergone biliary drainage within 48 h (2.6% vs 20.5%, P = 0.016; 3.0% vs 13.5%, P = 0.006; 3.4% vs 9.6%, P = 0.021; respectively).CONCLUSIONBiliary drainage within 12 h is beneficial for AC patients with neurological or cardiovascular dysfunction, while complete biliary decompression within 24 h of admission is recommended for treating patients with Grade III AC.

Optimal Timing and Outcomes of Minimally Invasive Approach in Acute Biliary Pancreatitis.

BackgroundWe analyzed the outcomes of early biliary decompression by a minimally invasive approach in acute biliary pancreatitis (ABP).Material/MethodA retrospective study was conducted on 143 patients with ABP who underwent biliary decompression by laparoscopic or endoscopic approach between January 2015 and March 2022. Data from the observation sheets and surgical protocols were analyzed in terms of demographic characteristics, clinical and paraclinical features at admission, comorbidities, therapeutic management, and outcomes.ResultsThe mean patient age was 62.3±11.4 years. Mild ABP had a higher frequency in men (75.5%) and urban areas (70.4%). The comorbidities associated with a higher risk of severe forms were diabetes mellitus (odds ratio [OR]: 11.250), chronic bronchopneumopathy (OR: 29.297), and ischemic coronary disease (OR: 2.784). The mean hospital stay was 7.6±3.8 days and was significantly higher in severe forms (10±2.4 days, P<0.001). The time from onset to presentation was significantly higher in severe vs mild forms (5.6 vs 1.8 days, P<0.001) and was associated with systemic and local complications. Creatinine over 2 mg/dL (OR: 4.821) and leukocytes >15 000/mmc at admission (OR: 3.533) were risk factors for systemic complications, while obesity was associated with increased local complications (OR: 5.179). None of the patients with an early presentation developed severe ABP.ConclusionsEarly biliary decompression, as soon as possible after onset, either by an endoscopic or minimally invasive approach, is a safe and effective procedure in ABP. The type of procedure and optimal timing should be individualized, according to the patient’s local and general features.

Retrospective analysis of management and outcomes of patients with malignant biliary obstruction.

e16266 Background: Malignant biliary obstruction (MBO) is commonly associated with pancreaticobiliary cancers (PBCa). It increases the risk for cholangitis, hepatic failure, and deconditioning, which delays systemic therapy. This study aims to identify predictors associated with MBO outcomes after biliary decompression. Methods: This single-center, retrospective study analyzed patients with MBO from 2016-2020 who underwent biliary drainage. Patient demographics, cancer history, intervention type, and date of last follow up were obtained. Descriptive statistics were used to summarize relevant variables. Baseline characteristics were compared using Chi squared tests. Kruskal Wallis test was used to identify whether there were significant difference among multiple groups. Results: Of the 59 patients included, mean age was 62 years and 75% had PBCa. Baseline characteristics were presented in Table. The mean survival time from MBO diagnosis was 227 days (range: 16-1446). Overall, 39% survived at the end of 6 months follow up. Of the 29 patients who received chemotherapy after decompression, they were younger (57 vs 66 years old, p = 0.004). History of prior chemotherapy was significantly associated with increased 180-day mortality (OR 0.75, CI 0.58-0.97, p = 0.033). There were no differences based on sex, race, primary cancer, stage, intervention type or bilirubin levels in chemotherapy initiation or 6-month survival. In those with MBO as initial presentation of cancer, they were older, had pancreatic or biliary cancer, non-metastatic disease, unresected primary tumors, treatment-naïve, and no survival difference compared to later MBO presentation. Conclusions: Diagnosis of MBO is significantly associated with mortality (61% at 6-months) in our patient population, similar to historical controls of 40-60%. This data suggests that younger patients and those treatment naïve were associated with receipt of subsequent therapy and better 6-month survival, respectively.[Table: see text]

Diagnosis and Treatment of Acute Cholangitis

Acute cholangitis is a clinical syndrome characterized by fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract. It can be a life-threatening condition if it is not recognized early. Patients with severe cholangitis may present with hypotension, and mental status changes. The most frequent causes of acute cholangitis are biliary calculi, benign biliary stricture, and malignancy. The most common pathogens isolated are gram-negative bacteria (&lt;i&gt;Escherichia coli&lt;/i&gt; , followed by &lt;i&gt;Klebsiella&lt;/i&gt; species and &lt;i&gt;Enterobacter&lt;/i&gt; species). A diagnosis of acute cholangitis requires evidence of systemic inflammation, cholestasis, and imaging with biliary obstruction. Imaging studies may consist of ultrasound, computed tomography, magnetic resonance cholangiopancreatography, and/or endoscopic ultrasound. The mainstay of treatment consists of fluid resuscitation, antibiotics, and biliary drainage. Penicillin/β-lactamase, third-generation cephalosporin, or carbapenem are all acceptable choices for first-line treatment. In patients with severe cholangitis, biliary drainage should be performed within 24 hours. Patients with severe acute cholangitis require urgent (within 24 hours) biliary decompression. Endoscopic retrograde cholangiopancreatography remains the preferred modality for biliary drainage. In conclusion, acute cholangitis is mostly treatable when recognized and treated early. Recognizing and initiating early treatment leads to markedly decreased patient morbidity and mortality.

Critically-Ill Patients with Biliary Obstruction and Cholangitis: Bedside Fluoroscopic-Free Endoscopic Drainage versus Percutaneous Drainage.

Severe acute cholangitis is a life-threatening medical emergency. Endoscopic biliary drainage (EBD) or percutaneous transhepatic biliary drainage (PTBD) is usually used for biliary decompression. However, it can be risky to transport a critical patient to the radiology unit. We aimed to compare clinical outcomes between bedside, radiation-free EBD and fluoroscopic-guided PTBD in patients under critical care. Methods: A retrospective study was conducted on critically ill patients admitted to the intensive care unit with biliary obstruction and cholangitis from January 2011 to April 2020. Results: A total of 16 patients receiving EBD and 31 patients receiving PTBD due to severe acute cholangitis were analyzed. In the EBD group, biliary drainage was successfully conducted in 15 (93.8%) patients. Only one patient (6.25%) encountered post-procedure pancreatitis. The 30-day mortality rate was no difference between the 2 groups (32.72% vs. 31.25%, p = 0.96). Based on multivariate analysis, independent prognostic factors for the 30-day mortality were a medical history of malignancy other than pancreatobiliary origin (HR: 5.27, 95% confidence interval [CI]: 1.01–27.57) and emergent dialysis (HR: 7.30, 95% CI: 2.20–24.24). Conclusions: Bedside EBD is safe and as effective as percutaneous drainage in critically ill patients. It provides lower risks in patient transportation but does require experienced endoscopists to perform the procedure.

C-Reactive protein / prealbumin coefficient, as a new marker in diagnosis and monitoring of the treatment efficacy in patients with malignant obstructive jaundice, complicated by ascending cholangitis

preoperative ascending cholangitis is one of the main factors of unsatisfactory treatment outcomes and prognosis in patients with malignant obstructive jaundice. The aim of our study was to evaluate the diagnostic value of CRP /PA coefficient in preoperative ascending cholangitis diagnosis, the effectiveness of preoperative preparation and the possibility of infectious complications, which will improve the treatment quality and prognosis of this cohort of patients. The end points of the study were: to determine the reference rate of the СRP/PA coefficient; to evaluate the coefficient value for cholangitis and its severity at the stages of treatment; assess its importance in detecting postoperative infectious complications. A one-center prospective study of the treatment results of 84 patients who underwent biliary decompression in the preoperative period was conducted. All patients were diagnosed with preoperative ascending cholangitis according to the Tokyo Guidelines, 2018 criteria - I grade - in 48 (57.1%) patients, II grade - in 36 (42.9%) patients. It was determined that the median СRP/PA in healthy patients was 0.01 (0.01-0.02) of the main surgical intervention was significantly higher - 0.21 (0.13-0.45) and 0.02 (0.01-0.03) than in healthy individuals - 0.01 (0.01-0.02) ); p &lt;0.001 and p = 0.004, respectively, we found a statistically difference between the medians of the СRP/PA level in patients with mild to moderate preoperative ascending cholangitis (p &lt;0.001), which is confirmed by the correlation between the severity grade of cholangitis and СRP/PA value (r = 0,381, p &lt;0,001). It was found that the preoperative biliary drainage increases the probability of reducing the СRP/PA level by 18% (R = 0,42, R2 = 0,18, p &lt;0,001), increase СRP/PA level before drainage is associated with the presence of mixed biliary tract infection in 25% cases (R2 (Nagelkerke) = 0.25, p = 0.002) and it's also associated with an increased the rate of infectious complications from postoperative wound by 18 .9% (R2 (Nagelkerke) = 0.189, p = 0.005). CRP/PA coefficient may indicate preoperative ascending cholangitis diagnosis and its severity ​​in patients with malignant obstructive jaundice. Increase СRP/PA level before preoperative biliary drainage is associated with the presence of mixed biliary tract flora and possibility of infectious complications. The dynamics of the coefficient value can show the efficacy of preoperative preparation after biliary decompression and predict correct time for surgery, which improves the treatment prognosis in postoperative period.

Procalcitonin to Predict Severity of Acute Cholangitis and Need for Urgent Biliary Decompression: Systematic Scoping Review.

Serum procalcitonin (PCT) has been reported as a potential biomarker to predict the severity of acute cholangitis (AC) or the need for urgent biliary decompression. This study aimed to identify and summarize the existing research about serum PCT and the severity of AC, and to find gaps towards which future studies can be targeted. Following the PRISMA extension for scoping reviews, MEDLINE, EMBASE, and Google Scholar were searched for all peer-reviewed articles with relevant keywords including “cholangitis” and “procalcitonin” from their inception to 13 July 2021. We identified six studies. All the studies employed a case-control design and aimed to evaluate the usefulness of serum PCT to predict the severity of AC with key identified outcomes. While the potential cut-off values of serum PCT for severe AC ranged from 1.8–3.1 ng/mL, studies used different severity criteria and the definition of urgent biliary decompression. No studies proposed cut-off PCT values for the need for urgent biliary decompression. This scoping review identified the current level of evidence regarding the usefulness of serum PCT in assessing the severity of AC. Further clinical research is warranted with a focus on standardized outcome measures employing prospective or experimental designs.

RECONSTRUCTIVE SURGERY IN PATIENTS WITH MALIGNANT DISEASES OF THE BILIARY TRACT COMPLICATED BY MECHANICAL JAUNDICE

The causes of mechanical jaundice (MJ) are benign and malignant diseases of the hepaticopancreaticoduodenal area. Literature sources indicate the development of MJ in 15-40 % of patients with gallstone disease and in the vast majority of patients with malignant neoplasms of the biliary tract. MJ of malignant etiology occurs in 40-67 % of patients.&#x0D; Aim. To study the results of the use of reconstructive surgery in patients with malignant diseases of the biliary tract complicated by mechanical jaundice.&#x0D; Materials and methods. An analysis of surgical treatment of 22 patients with malignant diseases of the biliary tract complicated by MJ in the SI “ V.T. Zatsev IGUS NAMSU ». Patients are divided into subgroups. Subgroup 1 - 11 (50 %) included patients treated with antegrade endobiliary interventions as biliary decompression. Subsequently, the reconstructive and restorative stage of surgical treatment was performed. Subgroup 2 - 11 (50 %) included patients who underwent reconstructive surgery without prior biliary decompression.&#x0D; Results of the research. After successful biliary decompression, 11 (50 %) patients underwent reconstructive surgery, which was included in 1 subgroup. The remaining 11 (50 %) patients in subgroup 2 underwent similar surgery without prior biliary decompression. In patients of subgroup 1 (n = 11 (50 %)) we performed percutaneous transhepatic cholangiodrainage for biliary decompression and MJ resolution. After its successful implementation, the reconstructive and restorative stage of surgical treatment was performed. This reduced the number of postoperative complications from 18.2 % to 9.1 % compared with subgroup 2 of patients who underwent surgery without prior biliary decompression.&#x0D; Conclusions. Performing reconstructive and reconstructive operations in conditions of high levels of serum bilirubin, cholangitis, hepatic failure is dangerous and is accompanied by a large number of complications in the postoperative period. In patients who underwent antegrade endobiliary interventions as a previous biliary decompression, complications were noted in 2 (18.2 %) cases and mortality was 9.1 % (1 patient), which reduced the number of postoperative complications by 9.1 % and mortality by 9.1 %. This is confirmed by studies that prove the benefits of antegrade endobiliary interventions in the preparation of patients for reconstructive surgery in comparison with their performance without the use of the latter.

Comparison of EUS-guided choledochoduodenostomy and percutaneous drainage for distal biliary obstruction: A multicenter cohort study.

ABSTRACTBackground and Objectives:Percutaneous transhepatic biliary drainage (PTBD) and EUS-guided choledochoduodenostomy (EUS-CD) are alternate therapies to endoscopic retrograde cholangiopancreatography with stent placement for biliary decompression. The primary outcome of this study is to compare the technical and clinical success of PTBD to EUS-CD in patients with distal biliary obstruction. Secondary outcomes were adverse events (AEs), need for reintervention, and survival.Methods:A multicenter retrospective cohort study from three different centers was performed. Cox regression was used to compare time to reintervention and survival and logistic regression to compare technical and clinical success and AE rates. Subgroup analysis was performed in patients with malignant biliary obstruction (MBO).Results:A total of 86 patients (58 PTBD and 28 EUS-CD) were included. The two groups were similar with respect to age, gender, and cause of biliary obstruction, with malignancy being the most common etiology (80.2%). EUS-CD utilized lumen-apposing metal stents in 15 patients and self-expandable metal biliary stents in 13 patients. Technical success was similar been EUS-CD (100%) and PTBD (96.6%; P = 0.3). EUS-CD was associated with higher clinical success compared to PTBD (84.6% vs. 62.1%; P = 0.04). There was a trend toward lower rates of AEs with EUS-CD 14.3% versus PTBD 29.3%, odds ratio: 0.40 (95% confidence interval [CI]: 0.12–1.33, P = 0.14). The need for reintervention was significantly lower among patients who underwent EUS-CD (10.7%) compared to PTBD (77.6%) (hazard ratio: 0.07, 95% CI: 0.02–0.24; P < 0.001). A sensitivity analysis of only patients with MBO demonstrated similar rate of reintervention between the groups in individuals who survived 50 days or less after the biliary decompression. However, reintervention rates were lower for EUS-CD in those with longer survival.Conclusion:EUS-CD is a technically and clinically highly successful procedure with a trend toward lower AEs compared to PTBD. EUS-CD minimizes the need for reintervention, which may enhance end-of-life quality in patients with MBO and expected survival longer than 50 days.

Pathological complete response achieved by gemcitabine plus cisplatin therapy for initially unresectable advanced gallbladder cancer: a case report

BackgroundConversion surgery for initially unresectable gallbladder cancer is rarely performed due to the low response rate for systemic chemotherapy, and a pathological complete response is seldom achieved.Case presentationA 67-year-old woman with jaundice was referred to our hospital and diagnosed with unresectable gallbladder cancer with extra-regional lymph node metastasis after examinations. After biliary decompression, gemcitabine plus cisplatin therapy was started. The tumor marker levels markedly decreased, and imaging studies revealed a reduction in the primary tumor and metastatic lymph nodes. The primary tumor and metastatic lymph node were still shrunk at 4 years after the start of gemcitabine plus cisplatin therapy, so we decided to perform conversion surgery. Gallbladder bed resection and lymph node dissection were performed. The pathological findings of the resected specimen showed only partial fibrosis in the gallbladder wall and no malignant findings in the dissected lymph nodes, indicating a pathological complete response. As of 24 months after the operation, she is alive without recurrence.ConclusionAlthough there have been only a few reports of conversion surgery for initially unresectable gallbladder cancer, it may be worthwhile to perform chemotherapy with the potential goal of subsequent conversion surgery.

EUS-guided versus percutaneous transhepatic cholangiography biliary drainage for obstructed distal malignant biliary strictures in patients who have failed endoscopic retrograde cholangiopancreatography: A systematic review and meta-analysis.

EUS-guided biliary drainage (EUS-BD) and percutaneous transhepatic cholangiography biliary drainage (PTC) are the two alternate methods for biliary decompression in cases where ERCP fails. We conducted a systematic review and meta-analysis of studies to compare the efficacy and safety of endoscopic and percutaneous biliary drainage for malignant biliary obstruction in patients with failed ERCP. A total of ten studies were included, fulfilling the inclusion criteria, including four retrospective studies and six randomized controlled trials. We compared the technical and clinical success rates and the acute, delayed, and total adverse events of EUS-BD with PTC. The odds ratios (ORs) and confidence intervals (CIs) were calculated. There was no difference between technical (OR: 0.47 [95% CI: 0.20–1.07]; P = 0.27) and clinical (OR: 2.24 [95% CI: 1.10–4.55]; P = 0.51) success rates between EUS-PD and PTC groups. Procedural adverse events (OR: 0.17 [95% CI: 0.09–0.31]; P = 0.03) and total adverse events (OR: 0.09 [95% CI: 0.02–0.38]; P < 0.01) were significantly different between the two groups; however, delayed adverse events were nonsignificantly different (OR: 0.73 [95% CI: 0.34–1.57]; P = 0.97). This meta-analysis indicates that endoscopic biliary drainage (EUS-BD) is equally effective but safer in terms of acute and total adverse events than percutaneous transhepatic biliary drainage (PTC) for biliary decompression in patients with malignant biliary strictures who have failed an ERCP.

Multimodal Approach to Acquired Bronchobiliary Fistula Secondary to Hepaticojejunostomy Stricture Following Yttruim-90 Therapy

Introduction: Bronchobiliary fistula (BBF) is an abnormal connection between the bronchial system and biliary tree. Bilioptysis (bilious-tinged sputum) is pathognomic of BBF. Mortality rate of BBF is as high as 12.7%. Method: A 56-year-old male who presented with stage IV pancreatic neuroendocrine tumor, underwent pancreaticoduodenectomy with partial hepatectomy, followed by Yttrium-90, and microwave ablation. Surveillance imaging, 2.5 years later, noted increase in hepatic lesions. Additional Yttrium-90 was poorly tolerated and patient was referred for peptide receptor radionuclide therapy. Ten months later patient presented with abdominal pain, cough with yellow-tinged sputum and history of recurrent pneumonia. Imaging demonstrated intrahepatic biliary dilation, peri-hepatic abscess and right-sided pleural effusion. Results: Patient underwent percutaneous drainage of abscess and chest tube placement. Persistent cough and sputum production prompted evaluation with HIDA (hepatobiliary iminodiacetic acid) and bronchoscopy, confirming BBF. Cholescintigraphy with single-photon emission computed tomography (NM-SPECT) localized the fistula tract to the right upper lobe of liver (Figure-1). Initially attempted biliary decompression with percutaneous transhepatic cholangiogram was unsuccessful due to failed cannulation of the hepaticojejunostomy, indicating complete stenosis at the anastomosis. Finally, the patient underwent resection of the hepaticojejunostomy with mobilization of the pancreaticobiliary limb and Kasai-type porto-enteric anastomosis between the pancreaticobiliary limb and hepatic duct. Complete resolution of symptoms and the bronchopulmonary fistula on follow up imaging, was noted. Conclusion: BBFs are rare, misdiagnosed, and difficult to treat. Although treatment with minimally invasive approach has favorable results, history of previous biliary reconstruction, may warrant multimodal treatments including percutaneous and complex surgical intervention.

SYNDROME OF "RAPID" BILIARY DECOMPRESSION IN COMMON BILE DUCT OBSTRUCTION OF VARIOUS ETIOLOGY

Surgical interventions performed on the background of obstructive jaundice are characterized by a significant risk of complications and characterized by high post-surgical mortality. The modern approach to the treatment of patients of this category regulates a certain sequence of treatment measures, provides for the implementation of minimally invasive interventions at the first stage of treatment. In some patients, despite adequate and minimally invasive bile excretion, the general condition can worsen. This condition, known as “rapid” biliary decompression syndrome, is a severe complication is difficult to treat and often fatal and requires further study. The aim of this study is to improve the results of treatment of patients with obstructive jaundice through timely prediction, early diagnosis and the use of effective therapy for the syndrome of "rapid" biliary decompression. The results of treatment of 76 patients with obstructive jaundice of various origins, who underwent 98 minimally invasive surgical interventions to eliminate biliary hypertension, were investigated. Complications of following the interventions were analyzed, including the “rapid” biliary decompression syndrome. Clinical and laboratory criteria and signs of “rapid” biliary decompression syndrome were formulated using the methods for calculating the rate of biliary decompression and the intensity of the decrease in bilirubin. When performing bile draining operations in patients with obstructive jaundice, one should expect the development of a syndrome of "rapid" biliary decompression. It can manifest both through individual signs and their combination that requires the immediate implementation of all the necessary therapeutic measures.

EVALUATION OF THE CHARACTER OF MICROBIAL FLORA AT THE STAGES OF TREATMENT IN PATIENTS WITH MALIGNANT OBSTRUCTIVE JAUNDICE

Relevance. The feasibility of preoperative billiary decompression (PBD) remains controversial in patients with malignant billiary obstruction (MOJ), due to the increased risk of multidrug-resistant (MDR), in most cases, catheter-associated microflora and postoperative infection complications. Analysis of biliary infection (BI) and its antibiotic sensitivity is an important aspect of clinical management of patients with resectable tumors of the pancreatobiliary region, which will improve treatment outcomes and reduce postoperative complications.&#x0D; Objective: to assess the nature of the microbial flora at the stages of treatment in patients with MOJ.&#x0D; Мaterials and methods. Prospective single-center cohort study of 136 patients with OJ. Patients were divided into two groups depending on the conduct of biliary decompression in the preoperative stage: group A (n = 84) – patients who underwent biliary decompression; group B (n = 52) – patients who did not perform biliary decompression. Collection of material (bile, drainage) for bacteriological examination was carried out in group A in three stages: 1) during PBD (stage I); 2) during the main surgery – ductus choledochus or endobiliary stent culture (stage II – intraoperative) and in the postoperative period for 3-5 days – culture of exudate from the drainage lumen (stage III – postoperative). In group B, material collection was performed – intraoperatively and postoperatively. The object of the study – microbial isolates, which were isolated in the above terms from the bile, which were identified by conventional methods of bacteriological laboratory. Aerobic and facultative anaerobic flora were studied. The taxonomic structure of microorganism (MO) was assessed by the level of acquired antimicrobial resistance, which is stratified by the European Center for Disease Control. During the bacteriological study, the sensitivity of MO to the following antibiotics was tested: ampicillin-sulbactam, ceftazidime, cefoperazone-sulbactam, ciprofloxacin, levofloxacin, piperacillin-tazobactam, meropenem, vancomycin.&#x0D; Results. BI identified in I stage of the study was represented by monomicrobial in 54.8% of patients and in 45.2% of cases by polymicrobial flora. At the II and III stages of treatment, mixed flora prevailed - 89.3% and 85.7% of cases, respectively. In group A, E. coli was most often sown at the PDB stage (44.5%). E.coli (34.1% and 26.8%) and Kl.pneumoniae were sown most often at the intra- and postoperative stages (20.8% and 28.0%). In group B, monomicrobial flora was presented in 96.2% of cases at the intraoperative stage, while in the postoperative period only in 42.3% of cases. The flora that prevailed in stages II-III of group B was represented by E. coli (31.5% and 29.4%), E. faecalis (18.5% and 15.3%), C.frendii (16.7% and 11.8%). &#x0D; Conclusions. Bacterial infection that causes cholangitis in patients with MOJ, detected primarily during interventional methods of biliary decompression is not a complication. PBD is a risk factor for MDR flora. Each additional day with biliary drainage increases the probability of developing antibiotic resistance by HR 0.17 (95% ВІ 0.07- 0.4), p&lt;0,001 at endobilliary stent placement, and at percutaneous transhepatic biliary drenage by HR 0.59 (95% CI 0.95-0.98), p &lt;0.042. Routine performance of bile culture, knowledge of nosocomial microbial background and indicators of its resistance, the primary method of Gram staining allows the use of early targeted antibiotic therapy, which prevents the development of MDR flora and improves the quality of the postoperative period. Strict adherence to escalation antibiotic therapy scheme at each stage of treatment can prevent the development of MDR flora. The development of new techniques to prevent the development of stent-associated colonization of MO is an important step in preventing bacteriobilia.

Pancreatoduodenal resection in the treatment of complicated forms chronic pancreatitis

Purposeof thestudy. Development ofindications for performing pancreatoduodenal resection in complicated forms of chronic pancreatitis.&#x0D; Materials and methods. In chronic pancreatitis, resection and drainage surgical interentions were performed in 142 patients. Pancreatoduodenal resection was performed in 13 patients with complicated forms of chronic pancreatitis. To assess the degree of pancreatic fibrosis, ultrasound elastography was used (in mode Shear Wave Elastography). The indications for pancreatoduodenal resection were the presence of a pronounced fibroinflammatory process in the head of the pancreas, the impossibility of excluding the development of an oncological process, developed complications (biliary hypertension, portal hypertension, duodenal stasis,&#x0D; Results. Among 13 patients with complicated forms of chronic pancreatitis, who underwent pancreatoduodenal resection, 12 (92,3%) patients had severe fibrosis, 1 (7,7%) had minor manifestations of fibrosis. Pancreatoduodenal resection was performed in 2 (15,4%) patients after preliminary biliary decompression, in 2 (15,4%) – after Pjustov-Frey surgery and cystojejunostomy.&#x0D; Conclusion. Progression of fibroinflammatory changes in the pancreatic parenchyma in chronic pancreatitis, leading to the development of complications (biliary hypertension, duodenal stasis), is an indication for the use of resection surgery.

Diagnostic approach and treatment specificity in patients with focal lesions of the biliopancreatic area complicated by mechanical jaundice.

Pancreatoduodenal resection (PDR) represents one of the most demanding procedures which is required in patients with a tumoral lesion at this level. The aim of the present article was to report the results of 272 patients submitted to such surgical procedures. All patients were divided into two groups: the main group, for whom the optimized decompression algorithm was used (n=112) and the control group, for whom preparation for PDR was carried out according to generally accepted standards (n=160). Upon admission to the hospital, the total bilirubin level in the main group was 274.6±5.9 µmol/l while in the control group this level was 270.4±4.6 µmol/l. PDR was performed in 272 of the patients. Whipple's terminolateral anastomosis was performed in 38/160 (23.7%) of patients in the control group; termino-terminal anastomosis according to Shalimov-Kopchak's method was imposed in 40/160 (25.0%) patients of the control group. Pancreatojejunoanastomosis with the imposition of a ductomucosal anastomosis was performed in 128 patients in total with 73 cases in the main group and in 55 cases in the control one. Pancreatogastroanastomosis with plunging of the pancreatic stump into the stomach stump was performed in 35 patients in total with 19 patients in the main group and 16 in the control group. Pancreatogastroanastomosis with plunging of the pancreatic stump into the 'stomach sleeve' was performed in 32 patients in total with 20 patients in the main group and 12 in the control group. The mortality rate in the main group was 6.3% (7 patients), and in the control group, 11.9% (19 patients). In conclusion, biliary decompression may improve the postoperative outcomes after pancreatic resection.

THE USE OF ANTEGRADE ENDOBILIARY INTERVENTIONS IN BENIGN DISEASES OF THE BILIARY TRACT COMPLICATED BY MECHANICAL JAUNDICE

Introduction. One of the most common manifestations of diseases of the biliary tract are strictures or stenoses. They can have malignant, inflammatory and traumatic etiology, as well as be accompanied by mechanical jaundice syndrome.&#x0D; Aim. To study the results of the use of antegrade endobiliary interventions in benign diseases of the biliary tract complicated by mechanical jaundice.&#x0D; Materials and methods. An analysis of surgical treatment of 34 patients with benign diseases of the biliary tract complicated by mechanical jaundice (MJ) in the SI “V.T. Zatsev IGUS NAMSU». Choledocholithiasis was the cause of MF in 21 (61.8 %) cases, stricture of the LV in 6 (17.6 %) and stricture of the biliodigestive anastomosis (BDA) in 7 (20.6 %) patients. BDA strictures developed after the following operations: biliobiliostomy — 1 (14.3 %), hepaticojejunostomy — 3 (42.9 %), choledochoduodenoanastomosis — 2 (28.5 %) and hepaticoduodenostomy — 1 (14.3 %) %).&#x0D; Research results. External percutaneous transhepatic cholangiodrainage was performed in 7 (46.7 %) patients, external-internal percutaneous transhepatic cholangiodrainage was performed in 6 (40 %), percutaneous transhepatic cholecystostomy was performed in 2 (13.4 %) patients. With slightly dilated intrahepatic ducts (&lt;5 mm) cholangiodrainage was established in 3 (20 %) patients. Of these, in 3 (20.0 %) cases, a separate percutaneous transhepatic cholangiodrainage of the right and left lobular ducts of the liver was performed. Performing percutaneous transhepatic cholangiography and percutaneous transhepatic cholangiodrainage allows to determine the level and nature of biliary block in a minimally invasive way, to perform biliary decompression and prevention of complications after an unsuccessful attempt at endoscopic treatment.&#x0D; Conclusions. By using antegrade endobiliary interventions, we were able to reduce the risk of biliary decompression complications compared with patients who had unsuccessful attempts at endoscopic treatment from 15 (78.9 %) to 1 (6.67 %), and to reduce the number of complications after reconstructive rehabilitation. operations from 10 (52.6 %) to 1 (6.67 %) and the mortality rate from 2 (10.5 %) to 1 (6.67 %).

Деякі особливості ведення хворих із вогнищевими захворюваннями біліопанкреатодуодеальної зони, ускладненими механічною жовтяницею

The aim of the current research was to compare the early results of pancreatoduodenal resection performing in patients with focal diseases of the biliopancreatoduodenal area complicated by obstructive jaundice syndrome, depending on the type of preoperative preparation. The results of surgical treatment of 272 patients who had been underwent pancreatoduodenal resection for focal diseases of the biliopancreatoduodenal zone complicated by the development of obstructive jaundice syndrome were analyzed. Patients, depending on the type of preoperative preparation, were randomized into two groups: the main group included 112 patients, who were prepared for surgery and predicted the course of the perioperative period in accordance with the original algorithm; and a comparison group (160 patients), in which the preparation was carried out only in a conservative way. Due to the original algorithm of detoxification with the use of biliary decompression in patients of the main group, the level of total bilirubin on the eve of pancreatoduodenal resection was 112.3 ± 2.7 μmol / L, while in the comparison group, where the preparation of patients for radical surgery was carried out without biliary drainage – 198.3 ± 3.3 μmol / L. The activity of alkaline phosphatase on the eve of PDR was 104.8 ± 1.3 U / L in the main group, and 270.8 ± 1.9 U / L in the comparison group (p &lt;0.05). On the eve of PDR, the activity of γ-glutamyltransferase decreased insignificantly – to 529 ± 29 U / L in the comparison group and to 485 ± 33 U / L in the main group (p &lt;0.05). The number of cases of life-threatening postoperative complications in the main group was 42 (37.5%), and in the comparison group – 102 (63.8%). Postoperative mortality in the main group was 6.3%, and in the comparison group – 11.9%.

Endoscopic biliary drainage for malignant distal biliary obstruction: Which is better - endoscopic retrograde cholangiopancreatography or endoscopic ultrasound?

Presently, following endoscopic ultrasound (EUS)‐guided biopsy, an endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stenting is performed for palliation of malignant distal biliary obstruction (MDBO). However, technical failure and postprocedure pancreatitis are limitations to ERCP. Endoscopic ultrasonography‐guided biliary drainage (EUS‐BD) after a failed ERCP has a 90% technical success rate and has been shown to be superior when compared to percutaneous methods, making EUS an increasingly recognized option for biliary drainage. Supporting this approach, findings from recently concluded randomized trials suggest that the safety profile and technical outcomes for EUS‐BD are comparable or even superior to that of ERCP for primary biliary decompression in patients with MDBO. Also, EUS‐BD is increasingly being utilized in patients with altered surgical anatomy in lieu of percutaneous techniques and balloon‐assisted enteroscopy. A growing body of evidence supports the notion that, in the future, EUS may become the primary modality by which biliary decompression is undertaken in the majority of patients with MDBO. The roadmap to this eventuality may require further optimization of procedural techniques, technological innovations, and cost reduction.