Biliary Drainage Procedures Research Articles

Recurrent pyogenic cholangitis: disease characteristics and patterns of recurrence.

Recurrent pyogenic cholangitis (RPC) is characterized by repeated infections of the biliary system with the formation of stones and strictures. The management aims are to treat acute cholangitis, clear the biliary ductal debris and calculi, and eliminate predisposing factors of bile stasis. Operative options include hepatectomy and biliary drainage procedures or a combination of both; nonoperative options include endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) guided procedures. This current study compares the operative and the nonoperative management outcomes in patients with RPC in 80 consecutive patients. In addition, we aim to evaluate our approach to the management of RPC over the past decade, according to the various degrees of severity and extent of the disease, and identify the patterns of recurrence in this complex clinical condition. Initial failure rate in terms of residual stone of operative compared with nonoperative treatment was 10.2% versus 32.3% (P = 0.020). Long-term failure rate for operative compared with non-operative treatment was 20.4% versus 61.3% (P = 0.010). Based on multivariate logistic regression, the only significant factors associated with failure were bilaterality of disease (OR: 8.101, P = 0.007) and nonoperative treatment (OR: 26.843, P = 0.001). The median time to failure of the operative group was 48 months as compared to 20 months in the nonoperative group (P < 0.010). Thus operative treatment is a durable option in long-term resolution of disease. Hepatectomy is the preferred option to prevent recurrent disease. However, biliary drainage procedures are also an effective treatment option. The utility of nonoperative treatment can achieve a reasonable duration of disease free interval with minimal complications, albeit inferior to operative management.

Optimal Procedure for Preoperative Biliary Drainage in Patients with Hilar Cholangiocarcinoma

Optimal Procedure for Preoperative Biliary Drainage in Patients with Hilar Cholangiocarcinoma

Bile acid-induced expression of farnesoid X receptor as the basis for superiority of internal biliary drainage in experimental biliary obstruction

Aims and objectives.The aim is to determine the efficacy of internal and external biliary drainage (ED) with special reference to the effect of bile acid on intestinal epithelium during experimental biliary obstruction. Methods.A total of 59 male Sprague Dawley rats were randomly assigned to four groups: (I) sham operation (SH); (II) obstructive jaundice (OJ); (III) OJ and ED; and (IV) OJ and internal biliary drainage (ID). The animals underwent surgical ligation of the bile duct on day 1. They were reoperated on day 8 for biliary drainage procedure. Blood cultures were obtained from portal vein and inferior vena cava on day 15. Samples were also drawn for serum total bile acid (TBA) and white blood cell (WBC) counts. The terminal ileum was harvested to study the tight junction-associated protein (“occludin”) and bile acid receptor (“farnesoid X receptor” [FXR]) using immunohistochemical method. Results.Serum TBA (118.9 ± 39.0 μmol/L) and WBC (11.4 ± 2.7 × 109/L) were significantly increased (p = 0.001) after bile duct ligation as compared with SH rats (38.0 ± 15.0 μmol/L and 5.5 ± 1.0 × 109/L, respectively; p = 0.001). The resulting mucosal lesion was high grade and the expressions of FXR and Occludin were decreased. After ED, there was slight decrease in total WBCs, whereas TBA levels declined significantly. The expression of FXR was minimal and Occludin showed no change (ED vs. OJ: p = 0.533). However, both WBC and TBA decreased after ID. The ileal structure, grade of mucosal lesion, and expression of FXR/Occludin were comparable with SH group (p > 0.05). The rate of bacterial translocation was: 57.1% (OJ); 62.5% (ID); and 80% (ED) with identical strains in cultures from the portal vein and inferior vena cava. Conclusion.Downregulation of TBA/FXR expression during biliary obstruction results in damage to intestinal epithelium. Unlike ED, ID restores FXR/Occludin expression in the terminal ileum through reappearance of intestinal bile acid, which thus appears to be a key factor in maintaining integrity of the epithelial barrier.

Endoscopic ultrasonography guided biliary drainage: Summary of consortium meeting, May 7th, 2011, Chicago

Endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred procedure for biliary or pancreatic drainage in various pancreatico-biliary disorders. With a success rate of more than 90%, ERCP may not achieve biliary or pancreatic drainage in cases with altered anatomy or with tumors obstructing access to the duodenum. In the past those failures were typically managed exclusively by percutaneous approaches by interventional radiologists or surgical intervention. The morbidity associated was significant especially in those patients with advanced malignancy, seeking minimally invasive interventions and improved quality of life. With the advent of biliary drainage via endoscopic ultrasound (EUS) guidance, EUS guided biliary drainage has been used more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that encompasses various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS guided biliary and pancreatic drainage techniques. This diversity has resulted in variations and improvements in EUS Guided biliary and pancreatic drainage; and over the years has led to an extensive nomenclature. The diversity of techniques, nomenclature and recent progress in our intrumentation has led to a dedicated meeting on May 7(th), 2011 during Digestive Disease Week 2011. More than 40 advanced endoscopists from United States, Brazil, Mexico, Venezuela, Colombia, Italy, France, Austria, Germany, Spain, Japan, China, South Korea and India attended this pivotal meeting. The meeting covered improved EUS guided biliary access and drainage procedures, terminology, nomenclature, training and credentialing; as well as emerging devices for EUS guided biliary drainage. This paper summarizes the meeting's agenda and the conclusions generated by the creation of this consortium group.

Endoscopic Guided Biliary Drainage: How Can We Achieve Efficient Biliary Drainage?

Currently, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary drainage for various pancreatico-biliary disorders. ERCP is successful in 90% of the cases, but is unsuccessful in cases with altered anatomy or with tumors obstructing access to the duodenum. Due to the morbidity and mortality associated with surgical or percutaneous approaches in unsuccessful ERCP cases, biliary endoscopists have been using endoscopic ultrasound-guided biliary drainage (EUS-BD) more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that incorporates various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS-BD techniques. Indications for EUS-BD include failed conventional ERCP, altered anatomy, tumor preventing access into the biliary tree and contraindication to percutaneous access (i.e., ascites, etc.). EUS-BD utilizing EUS-guided rendezvous technique is conducted by creating a tract from either the stomach or the duodenum into the bile duct. Although EUS-BD has rapidly been gaining attraction and popularity in the endoscopic world, the indications and methods have yet to be standardized. There are several access routes and techniques that are employed by advanced endoscopists throughout the world for BD. This article reviews the indications and currently practiced EUS-BD techniques, including indications, technical details (intrahepatic or extrahepatic approach), equipment, patient selection, complications, and overall advantages and limitations.

TG13 miscellaneous etiology of cholangitis and cholecystitis

This paper describes typical diseases and morbidities classified in the category of miscellaneous etiology of cholangitis and cholecystitis. The paper also comments on the evidence presented in the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG 07) published in 2007 and the evidence reported subsequently, as well as miscellaneous etiology that has not so far been touched on. (1) Oriental cholangitis is the type of cholangitis that occurs following intrahepatic stones and is frequently referred to as an endemic disease in Southeast Asian regions. The characteristics and diagnosis of oriental cholangitis are also commented on. (2) TG 07 recommended percutaneous transhepatic biliary drainage in patients with cholestasis (many of the patients have obstructive jaundice or acute cholangitis and present clinical signs due to hilar biliary stenosis or obstruction). However, the usefulness of endoscopic naso-biliary drainage has increased along with the spread of endoscopic biliary drainage procedures. (3) As for biliary tract infections in patients who underwent biliary tract surgery, the incidence rate of cholangitis after reconstruction of the biliary tract and liver transplantation is presented. (4) As for primary sclerosing cholangitis, the frequency, age of predilection and the rate of combination of inflammatory enteropathy and biliary tract cancer are presented. (5) In the case of acalculous cholecystitis, the frequency of occurrence, causative factors and complications as well as the frequency of gangrenous cholecystitis, gallbladder perforation and diagnostic accuracy are included in the updated Tokyo Guidelines 2013 (TG13). Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

SURGICAL MANAGEMENT OF IMPACTED LOWER COMMON BILE DUCT STONES

Common bile duct stones have been noted in 10-15% of patients with gall stones, these stones are either primary (formed in the common bile duct) or secondary (formed in the gallbladder and migrate down to the common bile duct). Their management includes ERCP, biliary drainage procedure and choledochal exploration. In this interventional study we reviewed transduodenal sphincteroplasty as an option for surgical treatment of impacted lower CBD stones from a point of morbidity and mortality. A prospective study conducted over a period of 10 years from 2000 to 2010 in Basrah Teaching General Hospital and private hospitals in Basrah. Twenty three patients with impacted lower CBD stones, there were 17 females (73.9%) and 6 males (26.1%) included in this study. The impacted lower CBD stones and surgical jaundice are the main indications for surgery to which 23 patients underwent TDS. All surgeries done in elective lists. In this prospective study, 23 patients who were diagnosed as impacted lower CBD stones managed by TDS,17 (73.9%) were females and 6 (26.1%) were males. In patients with impacted lower CBD stones who underwent TDS as an option for surgical treatment, 3 patients (13.04%) developed duodenal leak, 2 of them treated conservatively and improved, while 1 patient re-explored. Two patients (8.69%) developed mild cholangitis which respond to conservative measures. The hospital stay for all patients ranges 5–14 days postoperatively, with mean stay of 7 days. No reported cases of postoperative pancreatitis following TDS in this study. No mortality reported (0 %) in follow-up for 2 years in our study. It is concluded from this prospective study that TDS in the surgical management of impacted lower CBD stones with fibrosed ampulla (sphincter of oddi) is a feasible option with accepted incidence of duodenal leak and cholangitis among the biliary drainage procedures especially in an area where the facility of ERCP are not present or failed in addition of dense adhesions in supraduedenal area intra-operatively when decisions of open abdominal exploration done, make supraduedenal CBD exploration difficult and hazardous.

Risk Factors of Post Endoscopic Retrograde Cholangiopancreatography Bacteremia

Background/AimsBacteremia following endoscopic retrograde cholangiopancreatography (ERCP) is a severe complication, but the risk factors for this condition have not yet been clearly determined. Thus, the aim of this study was to investigate the risk factors of post-ERCP bacteremia.MethodsAmong patients who underwent ERCP from June 2006 to May 2009, we selected patients without any signs of infection prior to the ERCP procedures. Of these patients, we further selected those who experienced bacteremia after ERCP as well as two-fold age and sex-matched controls who did not experience bacteremia after ERCP procedures. We compared clinical, laboratory and technical aspects between these two groups.ResultsThere were 70 patients (3.1%) who developed bacteremia after ERCP. In the multivariate analysis, a history of previous liver transplantation, an elevated serum alkaline phosphatase level and an endoscopic retrograde biliary drainage procedure were independent risk factors of post-ERCP bacteremia (p=0.006, p=0.001, and p=0.004, respectively). The microbiologic analysis revealed the presence of gram-negative organisms in 80% of the cases, and 11 patients had infections with bacteria expressing extended spectrum β-lactamases. Pseudomonas infection was significantly more common in patients who received liver transplantation as compared to patients without transplantation (p=0.014).ConclusionsA history of liver transplantation, elevated serum alkaline phosphatase levels and endoscopic retrograde biliary drainage procedure were independent risk factors of post-ERCP bacteremia and require additional attention in future studies.

Mo1313 Use of Proton Pump Inhibitors (PPIs) is Associated With a Need for More Subsequent Biliary Drainage Procedures in Patients With Malignant Biliary Strictures Treated With a Self-Expanding Metal Stent (SEMS)

In patients with advanced malignancy, the role of SEMS placement is to provide patency of the biliary tree for the duration of the patient's limited life span. Several factors including microbial colonization, tissue hyperplasia, and tumor ingrowth have been hypothesized to cause biliary endoprothesis occlusion. While PPIs can alter the normal gastroduodenal acid physiology and may lead to small bowel bacterial overgrowth, it is unknown whether this can result promote biliary SEMS occlusion.

Hospital palliative care team survey of symptom control requirements of pancreatic cancer patients

BackgroundPancreatic cancer often presents late, treatment being palliative from diagnosis. Distressing symptoms are common, making quality of life and effective symptom control crucial.AimTo examine elements of care relating to symptom...

What end of life care do pancreatic cancer patients receive at a tertiary hepatobiliary unit?

BackgroundFor patients who present with advanced pancreatic cancer, prognosis is poor irrespective of treatment. Good end of life care is therefore essential.AimTo examine specific elements of care given to patients...

Long-term results of choledochoduodenostomy in benign biliary obstruction

To determine the long-term results of choledochodudenostomy in patients with benign billiary obstruction. This prospective study was conducted at Sheri Kashmir Institute of Medical Sciences Srinagar Kashmir, India over a period of 10 years from January 1997 to December 2007. The total number of patients who underwent choledochoduodenostomy during this period was 270. On the basis of etiology of biliary tract obstruction, patients were divided into a calculus group, an oriental cholangiohepatitis group, a benign biliary stricture group and others. Patients were followed for a variable period of 13 mo to 15 years. Choledochoduodenostomy (CDD) with duo-denotomy was performend in four patients. CDD with removal of T- tube, CDD with left hepatic lobectomy and CDD with removal of intra biliary ruptured hydatid was performed in three patients each. In the remaining patients only CDD was performed. Immediate post operative complications were seen in 63 (23%) patients, while long-term complications were seen in 28 (11%) patients, which were statistically significant. Three patients died during hospitalization while four patients died in the late post-operative period. Our conclusion is that CDD is safe and produces good long term results when a permanent biliary drainage procedure is required.

Endoscopic ultrasound guided biliary drainage

Endoscopic retrograde cholangio-pancreatography is the most appropriate technique for treating common bile duct and pancreatic duct stenosis secondary to benign and malignant diseases. Even if the procedure is performed by skillful endoscopist, there are patients in whom endoscopic stent placement is not possible. Common causes of failure include complex peri-papillary diverticula, prior surgery procedures, tumor involvement of the papilla, biliary sphincter stenosis, and impacted stones. Percutaneous trans-hepatic biliary drainage (PTBD) and surgical intervention carry morbidity and mortality. Recently endoscopic ultrasonography-guided biliary drainage has been reported as an alternative technique. Endoscopic ultrasonography-guided biliary drainage using either direct access or a rendezvous technique has attracted attention as an alternative procedure to PTBD, with a technical success between 75%-100% and with low complication rate. We have reviewed published data on EUS guided biliary drainage procedures with the aim of summarizing the efficacy and safety of this promising method.

WEO NEWSLETTER AND CONTENTS

WEO NEWSLETTER AND CONTENTS

What is Appropriate Procedure for Preoperative Biliary Drainage in Patients With Obstructive Jaundice Awaiting Pancreaticoduodenectomy?

The aims of this study were to compare the clinical outcomes of the preoperative drainage methods in patients with obstructive jaundice awaiting panreaticoduodenectomy and to determine, which procedure would be more effective for preoperative drainage. Among 239 patients undergoing pancreaticoduodenectomy for periampullary cancer, 77 with obstructive jaundice underwent percutaneous transhepatic biliary drainage (PTBD, n=34) or endoscopic biliary drainage (EBD, n=43). Median rate of decrease in bilirubin was 0.65 mg/d in PTBD group and 0.34 mg/d in EBD group (P=0.003). Median interval from preoperative drainage to pancreaticoduodenectomy were 11 days in PTBD group and 18 days in EBD group (P=0.009). Overall indwelling catheter-related complication rates were higher in "EBD" group compared with "PTBD" group (23.3% vs. 2.9%, P=0.019). No catheter occlusion developed in "PTBD" group, but 6 stent occlusions (13.3%) developed in "EBD" group (P=0.031). The mortality rate was not significantly different between the 2 groups. Percutaneous biliary drainage may be preferred for preoperative drainage in patients with obstructive jaundice awaiting pancreaticoduodenectomy due to rapid biliary decompression and lower frequency of catheter-related complications.

Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction

Malignant gastric outlet obstruction represents a terminal stage in pancreatic cancer. Between 5% and 25% of patients with pancreatic cancer ultimately experience malignant gastric outlet obstruction. The aim in palliating patients with malignant gastric outlet obstruction is to reestablish an oral intake by restoring gastrointestinal continuity. This ultimately improves their quality of life in the advanced stages of cancer. The main drawback to operative bypass is the high incidence of delayed gastric emptying, particularly in this group of patients with symptomatic obstruction. This study aimed to compare surgical gastrojejunostomy and endoscopic stenting in palliation of malignant gastric outlet obstruction, acknowledging the diversity and heterogeneity of patients with this presentation. This retrospective study investigated patients treated for malignant gastric outlet obstruction from December 1998 to November 2008 at Nepean Hospital, Sydney, Australia. Endoscopic duodenal stenting was performed under fluoroscopic guidance for placement of the stent. The operative patients underwent open surgical gastrojejunostomy. The outcomes assessed included time to diet, hospital length of stay (LOS), biliary drainage procedures, morbidity, and mortality. Of the 45 participants in this study, 26 underwent duodenal stenting and 19 had operative bypass. Comparing the stenting and operative patients, the median time to fluid intake was respectively 0 vs. 7 days (P < 0.001), and the time to intake of solids was 2 vs. 9 days (P = 0.004). The median total LOS was shorter in the stenting group (11 vs. 25 days; P < 0.001), as was the median postprocedure LOS (5 vs. 10 days; P = 0.07). Endoscopic stenting is preferable to operative gastrojejunostomy in terms of shorter LOS, faster return to fluids and solids, and reduced morbidity and in-hospital mortality for patients with a limited life span.

Bile bacterial flora and its in vitro resistance pattern in patients with acute cholangitis resulting from choledocholithiasis

Introduction. Cholangitis and biliary sepsis are severe infectious diseases, which are often observed in patients with choledocholithiasis. The antimicrobial therapy is effective if started as soon as the diagnosis is made. Therefore, the profile of bile pathogens and its susceptibility to a number of antibiotics were evaluated. Material and methods. Bile cultures and antibiograms from 92 patients hospitalized between January 2006 and December 2008 in a tertiary referral center for the treatment of biliary and pancreatic diseases (Central Teaching Hospital, Medical University of Silesia) were reviewed. Specimens were obtained from patients with acute cholangitis and confirmed choledocholithiasis during endoscopic (i.e. ERCP) and surgical (i.e. percutaneus transhepatic biliary drainage) procedures. The bile specimens were examined for pathogenic aerobic and anaerobic bacteria and fungi. Results. Sixty-five of 92 analyzed cultures were positive. A total of 69 pathogens were isolated: 47 (68.1%) Gram-negative bacteria, 18 (26.1%) Gram-positive bacteria, 2 (2.9%) anaerobes and 2 (2.9%) Candida. The predominant Gram-negative pathogens were Escherichia coli, Acinetobacter baumani complex, Klebsiella pneumoniae and Enterobacter cloacae. The most effective antibiotics against Gram-negative bacteria were imipenem, cefoperazone/sulbactam, piperacillin/tazobactam and cefepime (susceptibility 97.9%, 89.4%, 85.1% and 85.1%, respectively). The expenditure on antibiotics monotherapies and combined therapies was also analyzed. Conclusion. Our study shows that Gram-negative bacteria were the predominant bile pathogens found in patients with acute cholangitis. Piperacillin/tazobactam or ceftazidime may be the alternative to ciprofloxacin therapeutic option. The addition of ticarcillin/clavulanic acid to ciprofloxacin could also be considered. However, imipenem should remain a back-up antibiotic in the treatment of acute cholangitis.

Assuring Complete Laparoscopic Clearance of the Bile Duct

The aim of this study was to evaluate and compare the use of choledochoscopy, cholangiography, and laparoscopic ultrasound in ensuring bile duct clearance and the prevention of missed stones after laparoscopic exploration. Operative details of 439 consecutive patients who underwent laparoscopic bile duct exploration between April 1994 and February 2005 were collected prospectively. Thirty-six conversions, 8 failures, and 8 patients who had a biliary enteric drainage procedure were excluded. Follow-up was by postal questionnaire or via their GP if there was no response. One-year follow-up was complete in 95%. Patients underwent 253 transductal, 94 transcystic, and 29 radiological explorations. Laparoscopic ultrasound prompted immediate re-exploration of the bile ducts in six patients for stones missed by choledochoscopy. About 3.4% of patients presented with a missed stone within 1 year of surgery. The negative predictive values of choledochoscopy alone, choledochoscopy followed by postexploratory cholangiography and choledochoscopy followed by postexploratory laparoscopic ultrasound have been found to be 94.6%, 97.9%, and 97.4%, respectively. Double checking duct clearance with laparoscopic ultrasound after choledochoscopy is worthwhile, whereas cholangiography is not.

Sa1501 An Audit of ERCP in the Intensive Care Unit (ICU) Setting At a Tertiary Referral Centre

Sa1501 An Audit of ERCP in the Intensive Care Unit (ICU) Setting At a Tertiary Referral Centre Edward Britton, Mahesh Bhalme, Derrick F. Martin, Jayapal Ramesh Gastroenterology, University Hospital South Manchester, Manchester, United Kingdom; Radiology, University Hospital South Manchester, Manchester, United Kingdom Introduction: While the emergency use of ERCP in acute gallstone pancreatitis without concurrent cholangitis or jaundice remains under some debate, the use of early ERCP is universally accepted as best practice for the management of acute cholangitis. A proportion of these patients need ICU support for haemodynamic compromise and /or mechanical ventilation. There is however, little in the published literature documenting outcomes and standards in this patient population. Aim: To audit the indications, procedure and outcome of ERCP carried out in a North West hospital providing a tertiary service. Methods: From February 2000 to January 2010 the records of all consecutive ERCP procedures performed on patients in ICU were analysed using a standardised proforma. Results: Total of 22 /4565 (0.48%) procedures were identified during this period. Of these, 17 (77%) case notes were obtained and data extracted. Fifty-nine percent were male with a mean age were 73.2 years (34-92). Mean ASA grading of 2.4 (1-3). The most common indication for admission to ICU was septic shock in 88%, pancreatitis in 6% and needing respiratory support in 6%. Sixty-five percentage underwent mechanical ventilation; 53% required inotropic support and the mean eGFR was 51.00 (15-90). The mean time from ICU admission to procedure was 12.8 hours (2-36). ERCP was carried out under full GA in 41%; fentanyl/midazolam combination in 35% and fentanyl propofol in 24% .Indications were jaundice in 35%; obstructive LFT’s in 29%; cholangitis in 24% and pancreatitis in 12%. All procedures were carried out in the interventional radiology suite with 65% in prone position and the rest supine. The biliary cannulation success rate was 87.5% and the findings were dilated duct with evidence of recently passed stones in 5/14 (36%), ductal stones in 6/14 (43%), obstructed existing stent in 2/14 (14%) and biliary leak in 1/14 (7%). During the procedure, 86% underwent sphincterotomy and 71% underwent stent insertion. Two of the three failed patients underwent biliary drainage with PTC (5.9%) or surgical exploration (5.9%), whilst the other one was managed conservatively. No post ERCP pancreatitis or bleeding was recorded but there was one duodenal perforation (5.9%). The overall 30 day mortality following the procedure was 47% with a mean of 4.71 days (range 2-9 days) with no procedure related deaths. The average length of stay on ITU for those that survived was 13.22 days (1-39). Conclusions: Patients requiring ERCP in the ICU setting have a very high mortality despite early intervention, high success rate of biliary drainage and low procedure related complications. Further work with larger patient populations may allow better prediction of outcomes.

Are endoscopic or percutaneous biliary drainage effective forobstructive jaundice caused by hepatocellular carcinoma?

The prognosis of patients with obstructive jaundice caused by hepatocellular carcinoma (HCC) has been reported to be poor. The aims of this study were to determine whether effective biliary drainage in patients with obstructive jaundice caused by HCC can affect clinical outcome and to identify those factors that affect effective biliary drainage and clinical outcome. The clinical records of 68 patients with obstructive jaundice caused by HCC who underwent endoscopic or percutaneous transhepatic biliary drainage from 1 January 2004 to 31 December 2008 were analyzed. Effective biliary drainage was defined as a decrease in total bilirubin level of more than 30% of the preprocedural value within 4 weeks. (i) Effective biliary drainage was achieved in 51.5% of the patients who underwent a biliary drainage procedure. The independent risk factors for ineffective biliary drainage were total bilirubin more than 13 mg/dl and Child-Turcotte-Pugh class C. (ii) Patients with effective biliary drainage showed a significant improvement of Child-Turcotte-Pugh class and received additional treatment for HCC. (iii) The mean survival times of patients who received effective or ineffective biliary drainage were 247 and 44 days, respectively. (iv) The independent risk factors of mortality were an age of more than 63 years, ineffective biliary drainage, and no following treatment for HCC. When effective biliary drainage was achieved after an appropriate biliary drainage procedure in patients with obstructive jaundice caused by HCC, survival improved.