Endoscopic Biliary Decompression Research Articles

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

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

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

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

Endoscopic retrograde cholangiopancreatography and endoscopic decompression in the malignant obstruction of the extrahepatic biliary tracts – a retrospective analysis

Background. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic biliary decompression are of the highest priority among minimally invasive procedures for the correction of the malignant obstruction of the extrahepatic biliary tracts. For this purpose, nasobiliary drainage and plastic or metal stents are used. However, it is not always possible to perform the endoscopic drainage of biliary ducts when there is a malignant obstruction. Purpose – to assess the immediate results of the use of the ERCP and endoscopic biliary decompression in malignant obstruction of the extrahepatic biliary tracts depending on the degree of obstruction. Materials and methods. A retrospective analysis of 106 cases of the malignant obstruction of the extrahepatic biliary tracts was performed. Out of 106 patients, 43 (40,6%) were males, and 63 (59,4%) were females. The age range of the patients was from 42 to 90 (68,4±11,1) years. Obstruction at the level of the major duodenal papilla was in 18 (17%) patients; at the level of the distal third of the common bile duct – in 66 (62,3%) patients; at the level of the middle third of the common bile duct – in 11 (10,4%) patients; at the level of the proximal third of the common bile duct – in 11 (10,4%) patients. Results. Out of 106 patients we managed to perform the ERCP in 94 (88,7%), and in 79 (84%) of them endoscopic drainage was successful. The complications after the ERCP were observed in 9 (8,5%) patients. In the malignant obstruction of the extrahepatic biliary tracts at the level of the major duodenal papilla we managed to perform the ERCP and restore the bile outflow in 17 out of 18 patients. In the malignant obstruction of the common bile duct, we managed to perform the ERCP in 77 (87,5%) out of 88 patients. In the obstruction at the level of the distal third, the endoscopic drainage was successful in 50 (87,7%) out of 57 patients who had undergone the ERCP. In the obstruction of the middle and proximal thirds of the common bile duct, the endoscopic drainage was successful in 12 (60%) out of 20 patients in which we managed to perform the ERCP. In the tumoral obstruction of the common bile duct, decompression at the level of the distal third was more successful (p = 0,027). Taking into consideration the obstruction of the major duodenal papilla, endoscopic biliary decompression was much more effective in the obstruction at the level of the major duodenal papilla and the distal third of the common bile duct compared to the obstruction of more proximal regions of the common bile duct (p = 0,002). In the tumoral obstruction of the extrahepatic biliary tracts at the level of the middle and proximal thirds of the common bile duct, the development of acute pancreatitis was characteristic of this process (p = 0,027). Conclusions. The performed retrospective analysis of the use of the ERCP in the malignant obstruction of the extrahepatic biliary tracts showed higher effectiveness of the endoscopic decompression in the obstruction of the distal regions of the extrahepatic biliary tracts compared with the obstruction at the level of the middle and proximal thirds of the common bile duct. Acute pancreatitis as a complication of the ERCP and endoscopic surgeries was significantly more often observed in the obstruction at the level of the middle and proximal thirds of the common bile duct.

Значение лимфодренирующих операций в комплексном лечении неопухолевых механических желтух

The results of treatment of 118 patients with obstructive jaundice of non-tumor etiology have been analyzed. All patients were divided into control and main groups according to the volume of preoperative preparation and stages of surgical treatment. The control group consisted of 30 patients who were operated after a short-term standard preparation including cholecystectomy and biliary decompression. The main group consisted of 88 patients who underwent two- or three-stage surgical interventions on the biliary tract and lymphatic system, which included external drainage of the thoracic duct, endoscopic papillosphincterotomy and lymphovenous anastomosis. The mortality rate in the control group was 23.2%, of which 8% of patients with jaundice duration up to 10 days, 45% — with jaundice duration up to 14 days. In the main group, the overall mortality was 5.5%, which is 4.2 times lower than in the control group. Of those with a duration of cholestasis up to 10 days, there was no mortality, in patients with a duration of biliary occlusion up to 14 days, it was 7% and in patients with a duration of up to 3–6 weeks — 15%. According to the indications, lymphovenous anastomosis was performed in 39 patients; there was no mortality cases among these patients. During the study, it was confirmed that lymphatic drainage operations in combination with endoscopic biliary decompression help to reduce porto-lymphatic pressure, sanitize the biliary tract, reduce endogenous intoxication and improve treatment outcomes

Possible reasons for the regrettable results of patency of an inside stent in endoscopic transpapillary biliary stenting.

Endoscopic biliary decompression is a minimally invasive procedure for cholestasis since the first endoscopic retrograde cholangiopancreatography-guided biliary stenting performed by Soehendra and Reynders-Frederix. Among the endoscopic biliary decompression, endoscopic transpapillary biliary stenting (EBS), is a mainstream choice and presently has two methods of placement: stenting above the sphincter of Oddi (SO) (suprapapillary) and stenting across the SO (transpapillary). Stent patency is the most important concern for patients, endoscopists and physicians because it can affect both the life prognosis and treatment schedule of patients. Biliary stent occlusion can occur because of several factors. Among them, direct food impaction, biofilm formation, and sludge formation play important roles and are presumed to be theoretically overcome by EBS above the SO. Thus, EBS above the SO is expected to result in a longer patency than EBS across the SO. In the literature, there have been six comparative studies on EBS for distal biliary obstruction in which the stent was placed above or across the SO, including two randomized controlled trials (RCTs) with negative results of stenting above the SO. With respect to EBS for hilar biliary obstruction, there have been no RCTs, whereas four retrospective comparative studies with negative results and four retrospective comparative studies showing positive results of stenting above the SO have been reported. In this review, we focused on EBS above and across the SO, and summarized the positive and negative results of the two types of stenting to promote effective clinical practice and to provide a basis for future studies.

Endoscopic Biliary Decompression by Dual Stents in Elderly Patients with Acute Cholangitis of Severe Type Due to Choledocholithiasis.

Background/Aims: Both endoscopic nasobiliary drainage (ENBD) and a plastic stent placement have some limitations in biliary decompression of elderly patients with acute cholangitis of severe type (ACST) due to choledocholithiasis. Dual stent placement may improve bile drainage without obvious discomfort. Here, we evaluated its advantages in the biliary decompression of elderly patients with ACST. Materials and Methods: A total of 257 elderly patients (≥65 years) with ACST had undergone urgent endoscopic decompression by nasobiliary catheter (ENBD group), single plastic stent (single-stent group), or dual plastic stents (dual-stent group). The data of the three groups was compared retrospectively. Results: The demographic data of the patients in the three groups were comparable. After endoscopic decompression, the serum total bilirubin and γ-glutamyl transferase levels in the dual-stent group were decreased faster than that in the single-stent group (P < .05). The abdominal pain in the dual-stent group was dramatically slighter than that in the ENBD group (P < .05). Compared with two other groups, the acute physiology and chronic health evaluation II scores were decreased dramatically quicker (P < .05) and the length of intensive care unit stay was significantly shorter (P < .05) in the dual-stent group. In the second endoscopic retrograde cholangiopancreatography, the rate of complete stone clearance in the dual-stent group was significantly higher than that in the ENBD group (P < .05). Conclusions: Dual-stent placement might be a better choice for elderly patients with ACST due to choledocholithiasis in comparison with ENBD or a single-stent placement.

Use of self-expandable metallic stents for endoscopic biliary decompression decreases stent complications in pancreatic cancer patients receiving chemotherapy

BackgroundBoth plastic stents and self-expandable metallic stents (SEMSes) are used for endoscopic biliary decompression (BD) among patients with pancreatic cancer (PAC). Cholangitis or stent occlusion often interrupts or ends chemotherapy. We investigated cholangitis, stent occlusion, and chemotherapy interruption rates for SEMSes and plastic stents among patients receiving chemotherapy for PAC.Materials and methodsWe retrospectively analyzed data for 293 PAC patients who received a biliary stent at Helsinki University Hospital during 2000–2017. Patients received chemotherapy as palliative treatment (PT: n = 187) or neoadjuvant treatment (NAT: n = 106). Among participants, 229 had a plastic stent (PT: n = 138, NAT: n = 91) and 64 had a SEMS (PT: n = 49, NAT: n = 15).ResultsOverall, 15.6% (n = 10) of patients with SEMSes (PT: 20.4%, n = 10, NAT: 0%) and 53.0% (n = 121) of patients with plastic stents (PT: 69.3%, n = 95, NAT: 28.5%, n = 26) experienced one or more stent complications (p < 0.001). Cholangitis developed in 6.3% (n = 8) of PT patients with SEMSes. No patients with SEMSes receiving NAT (n = 15) experienced cholangitis. However, 31.9% (PT: 42.8%, n = 59, p = 0.001; NAT: 15.4%, n = 14, p = 0.211) of patients with plastic stents developed cholangitis. Among all patients receiving NAT or PT, cholangitis interrupted chemotherapy 6 times (9.4%) in SEMS patients and 61 times (26.6%) in plastic stent patients (p = 0.004). Stent occlusion without cholangitis interrupted NAT or PT 2 times (2.1%) in SEMS patients and 31 times (13.5%) in plastic stent patients (p = 0.023).ConclusionsSEMS is recommended for BD among patients with PAC receiving chemotherapy. Among both PT and NAT patients, patients with SEMS experience a lower stent failure rate, lower rate of cholangitis, and fewer chemotherapy interruptions than patients with plastic stents.

Risk prediction platform for pancreatic fistula after pancreatoduodenectomy using artificial intelligence.

BACKGROUNDDespite advancements in operative technique and improvements in postoperative managements, postoperative pancreatic fistula (POPF) is a life-threatening complication following pancreatoduodenectomy (PD). There are some reports to predict POPF preoperatively or intraoperatively, but the accuracy of those is questionable. Artificial intelligence (AI) technology is being actively used in the medical field, but few studies have reported applying it to outcomes after PD.AIMTo develop a risk prediction platform for POPF using an AI model.METHODSMedical records were reviewed from 1769 patients at Samsung Medical Center who underwent PD from 2007 to 2016. A total of 38 variables were inserted into AI-driven algorithms. The algorithms tested to make the risk prediction platform were random forest (RF) and a neural network (NN) with or without recursive feature elimination (RFE). The median imputation method was used for missing values. The area under the curve (AUC) was calculated to examine the discriminative power of algorithm for POPF prediction.RESULTSThe number of POPFs was 221 (12.5%) according to the International Study Group of Pancreatic Fistula definition 2016. After median imputation, AUCs using 38 variables were 0.68 ± 0.02 with RF and 0.71 ± 0.02 with NN. The maximal AUC using NN with RFE was 0.74. Sixteen risk factors for POPF were identified by AI algorithm: Pancreatic duct diameter, body mass index, preoperative serum albumin, lipase level, amount of intraoperative fluid infusion, age, platelet count, extrapancreatic location of tumor, combined venous resection, co-existing pancreatitis, neoadjuvant radiotherapy, American Society of Anesthesiologists’ score, sex, soft texture of the pancreas, underlying heart disease, and preoperative endoscopic biliary decompression. We developed a web-based POPF prediction platform, and this application is freely available at http://popfrisk.smchbp.org.CONCLUSIONThis study is the first to predict POPF with multiple risk factors using AI. This platform is reliable (AUC 0.74), so it could be used to select patients who need especially intense therapy and to preoperatively establish an effective treatment strategy.

Diagnostic inflammatory markers of acute cholangitis in liver transplant recipients.

Acute cholangitis (AC) after liver transplantation occurs in 8-12% patients and remains a significant cause of patients' morbidity and mortality. The 2018 Tokyo guidelines use white blood cell count and C-reactive protein (CRP) as diagnostic criteria in AC. However, these and other common inflammatory markers have not been assessed in immunosuppressed liver transplant (LT) recipients with AC. The aims of this study were to compare the discriminative powers of common inflammatory markers, define the best inflammatory marker and determine the diagnostic cut-off values for the inflammatory markers in LT recipients with AC. This was a retrospective cohort study. Over 16 years 212 LT recipients who underwent endoscopic biliary decompression were identified from hospital records. Thirty LT recipients with AC and 30 LT recipients without AC were randomly drawn in a 1:1 ratio. Among inflammatory markers, CRP had the highest discriminative power for diagnosing AC. The areas under the receiver operating characteristics curves for CRP, white blood cell count, lymphocyte count and neutrophil-to-lymphocyte ratio were 95% (95% confidence interval (CI): 91-98), 59% (95% CI: 50-68), 65% (95% CI: 53-77) and 70% (95% CI: 59-80), respectively. The cut-off value of CRP for diagnosing AC was equal to or above 9.5 mg/L. CRP has the best discriminative power compared with other commonly used inflammatory markers for diagnosing AC in LT recipients. The optimal cut-off value for CRP concentration in diagnosing AC is equal to or above 9.5 mg/L.

Ten year experience with choledochal cysts: Lessons learned

Presenter: Morgan Pfeiffer BS | Washington University, St. Louis Background: Choledochal cysts (CC) are rare congenital anomalies characterized by dilation of extra and/or intra-hepatic bile-ducts. Cyst excision with biliary reconstruction is the recommended treatment of choice because of risk of subsequent biliary malignancy which can persist even after resection. Limited data is available on natural history and long term outcomes in patients diagnosed and treated for CC. Methods: A single center retrospective review of patients diagnosed with CC between 2008 and 2018 was preformed. Patients were identified through institutional databases, and data pertaining to demographics, presenting symptoms, management, malignant transformation and long term outcomes was reviewed. Post-operative complications were classified using Clavien-Dindo scale. Results: Seventy-nine patients were diagnosed with CC during study period. 54 (68%) were type 1, 5 (6%) were type 2, 2 (2.5%) were type 3, 8 (10%) were type 4, 3 (4%) were type 5, and in 7 (8.5%) patients the cyst type was unknown. Sixty-one (77%) were female, and mean age at diagnosis was 27.2 years (SD= 24.21). The most common presenting symptoms were abdominal pain (29; 36.5%) and jaundice (10; 12.7%) Sixty-four (81%) patients underwent definitive surgical resection, 4 (6%) patients required endoscopic or percutaneous biliary decompression for symptoms, and 11 (14%) had no intervention and were followed with surveillance cross sectional imaging. In the surgery group, 59 (92%) had surgical resection of the extrahepatic bile duct with a cholecystectomy and Roux-En-Y hepaticojejunostomy. 4 (6.25%) patients had cholecystectomy for stone related symptoms. 1 (1.5%) had a Whipple. Thirty (48%) patients developed 49 postoperative complications. Twenty-six significant complications (Clavien-Dindo >3) were seen in 18 (28.5%) patients; 8 (26%) required PTC, 6 (16%) required ERCP, and 10 (30%) required an additional operation. There were no surgery related deaths. The average length of time with a PTC drain was 8.4 months (SD=10.2). The median length of follow up was 8.02 years (SD=3.47). Biliary malignancy was seen in 2 (2.5%) patients. One patient had an incidental diagnosis of T2 gallbladder cancer at age 55. One patient developed cholangiocarcinoma 12 years post-operatively at age 45. None of the resected patients had high grade dysplasia or invasive carcinoma present in excised cyst. Conclusion: The risk of developing cancer related to CC is low, especially in children and adolescents. Due to high surgery-associated morbidity and low cancer risk, it may be favorable to follow patients with imaging if they are asymptomatic.

Patients receiving chemotherapy for pancreatic cancer (PAC) have a lower rate for stent complications when self-expandable metallic stents (SEMS) are used for endoscopic biliary decompression

Patients receiving chemotherapy for pancreatic cancer (PAC) have a lower rate for stent complications when self-expandable metallic stents (SEMS) are used for endoscopic biliary decompression

924 How Successful Is Endoscopic Retrograde Cholangiopancreatography in Patients With Biliary Obstruction Post-Pancreaticoduodenectomy?

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is the accepted therapy for the management of biliary obstructions, however, in patients who have had previous pancreaticoduodenectomy (PD) (i.e. Whipple’s procedure), due to the altered surgical anatomy, the ability to perform ERCP is challenging. In this study, we examine our experience at a large tertiary cancer-center in performing ERCPs for biliary obstructions in patients who are post-PD. METHODS: This was a retrospective review from 2006 to 2018 of all patients referred for the management of biliary obstructions post-PD. Outcomes included technical success (ability to treat the stricture, e.g. dilation or placement of a stent) and clinical success (decrease in bilirubin to normal or 50% of peak value within 2 weeks) rates. RESULTS: A total of 66 patients were included in the study. The mean age was 67.7 years (SD +/- 11.6) and 58 patients (87.9%) were male. The most common indications for PD were duodenal adenocarcinoma (20 patients, 30.3%) followed by pancreatic adenocarcinoma (16, 24.4%). In terms of surgery, the mean length of the afferent limb was 45.7 cm (SD +/- 6.34). The most common indications for ERCP were cholangitis (31 patients, 49%), followed by a biliary obstruction without cholangitis (11, 16.7%). The mean length of procedure was 66.7 minutes (SD +/- 34.8). The hepaticojejunostomy (and/or choledochojejunostomy) was reached in 56 patients (84.8%). The most common endoscope used was a therapeutic upper endoscope (31 patients, 47%), followed by a regular upper endoscope (11, 16.7%) and a pediatric colonoscope (10, 15.2%). Cannulation of the biliary tree was successful in 55 patients (83.3%). The most common location for the stricture was at the anastomosis (41 patients, 80.4%), followed by distal extra-hepatic (8, 15.7%). Successful stents were placed in 31 patients (47%). There were no episodes of bleeding, perforation or pancreatitis post-ERCP. Four patients developed self-resolving fever post-procedure. The technical success rate was 75.8% (50 patients) while the clinical success rate was 71.2% (47 patients). CONCLUSION: ERCP post-PD can be challenging due to the surgical anatomy and inability to use common endoscopes and instruments. Our study demonstrates that nevertheless, endoscopic biliary decompression can still be successful by experienced endoscopists in the majority of patients post-PD, with minimal adverse events.

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.

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

Diagnostic inflammatory markers in acute cholangitis

BackgroundThe 2018 Tokyo guidelines for acute cholangitis (AC) use white cell count (WCC) as one of the diagnostic criteria. However, the 2018 Tokyo guidelines grading does not provide guidance for AC patients with normal WCC. In this situation, other inflammatory biomarkers also can be used to diagnose AC and grade severity, but their diagnostic values are yet undetermined. The aims of this study were to evaluate the discriminative powers of common inflammatory markers compared with WCC for diagnosing AC and to determine their diagnostic cutoff levels. MethodsThis was a retrospective cohort study. Over 2 y, 96 patients who underwent endoscopic biliary decompression were identified from the Auckland City Hospital Radiology Department database. Only patients with a confirmed diagnosis of AC were included in the study. Thirty-four patients with AC and 18 controls met eligibility criteria. ResultsComparing areas under the receiver operating characteristic curves, it was the lymphocyte count, neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP) that had the highest discriminative powers in diagnosing AC. Values of WCC for diagnosing AC were equal to or above 9.6 × 109/L, neutrophil count equal to or exceeding 4.9 × 109/L, lymphocyte count equal to or below 1.3 × 109/L, NLR 5.3 and above, albumin equal to or below 30.5 g/L, and CRP concentration 23.5 mg/L or above. ConclusionsLymphocyte count, NLR, and CRP have superior discriminative powers to WCC, albumin, and neutrophil count and can be useful in the diagnosis of AC.

Clinical Outcomes of Bilateral Stent-in-Stent Placement Using Self-Expandable Metallic Stent for High-Grade Malignant Hilar Biliary Obstruction.

PurposeEndoscopic bile duct decompression using bilateral self-expandable metallic stents (SEMSs) deployed via a stent-in-stent (SIS) method is considered a preferred procedure for malignant hilar biliary obstruction (MHBO). However, occlusion thereof occurs frequently. Here, we investigated stent patency duration and risk factors related to stent obstruction with bilateral SIS placement for MHBO at two large centers.Materials and MethodsThe present study reviewed data on patients with MHBO who underwent endoscopic biliary drainage using the SIS method. Clinical outcomes, including stent patency duration and patient overall survival, were analyzed. Factors associated with stent patency were evaluated using Cox proportional hazards models.ResultsSeventy patients with MHBO underwent endoscopic biliary drainage using the SIS method. Median age was 68 years old, and median follow-up duration was 140 days (interquartile range, 57–329). The proportion of high-grade MHBOs (Bismuth type IV) was 57.1%. Median stent patency duration with the SIS method was 108 days according to Kaplan-Meier curves. Median patient survival analyzed by the Kaplan-Meier method was 181 days. Multivariate analysis indicated that higher baseline bilirubin (> 6.1 mg/dL) as an independent risk factor related to stent patency (p<0.05).ConclusionIn endoscopic biliary decompression using SEMS placed with the SIS method, obstructive jaundice was a risk factor for stent patency. The SIS method for high-grade MHBO showed short stent patency.

TEMPO OF BILIARY DECOMPRESSION AND DYNAMICS OF INDICES OF THE SYNTHETIC FUNCTION OF LIVER AFTER TRANSPAPILLARY ENDOSCOPIC BILLIARY INTERVENTION IN PATIENTS WITH OBSTRUCTIVE JAUNDICE DUE TO CHOLEDOCHOLITHIASIS

The purpose of the work was to study the dynamics of indicators of synthetic function of the liver, depending on the rate of decompression of the bile duct after endoscopic transpapillary biliary intervention in patients with choledocholithiasis complicated by obstructive jaundice. For this purpose, 59 patients with choledocholithiasis complicated by obstructive jaundice who had transpapillary endoscopic biliary decompression were examined. The distribution of patients was divided into three groups, depending on the level of jaundice. When choosing the terms of the second stage of radical surgery on the bile duct in patients with obstructive jaundice due to choledocholithiasis after the previous transpaculary endoscopic decompression, it should be based on an assessment of the baseline of liver dysfunction indices and their dynamics in the post-decompression period, but not only on the levels of cholestasis.

Complicated Portal Cavernoma Cholangiopathy (PCC) in a Patient with Pre-existing TIPS Managed Successfully by Endoscopic Biliary Stenting

PCC is the presence of typical cholangiographic changes in patients with a portal cavernoma due to chronic portal vein thrombosis (PVT), in the absence of other biliary tract diseases. Symptomatic PCC is rare; estimates range between 5-38% of patients with PVT. A 41 year old black woman with a PMH of Hodgkin's lymphoma s/p chemotherapy, isolated factor VII deficiency, complicated cirrhosis s/p TIPS and PVT presented to GI clinic with RUQ pain, dark urine, and acholic stool. Physical examination revealed scleral icterus and RUQ tenderness. The total bilirubin was 3.3 MG/DL, AST 111 U/L, ALT 29 U/L, ALP 603, and INR 1.4. After hospitalization, MRCP and MRI pancreas revealed cavernous portal vein transformation and chronic intrahepatic biliary dilation compatible with PCC. There was narrowing of the biliary system at the confluence secondary to extrinsic compression from cavernous transformation. No CBD dilation or filling defects, pancreatic mass, or PD dilation was noted. ERCP with an occlusion cholangiogram revealed a normal CBD. Unexpected vigorous hemobilia was encountered. Cholangioscopy was limited by fresh blood and clots up to the confluence - a bleeding source could not be identified. Interventional Radiology was consulted. CT angiogram revealed no active bleeding. TIPS was patent. Overnight the patient developed fever, leukocytosis, increasing RUQ abdominal pain, and worsening bilirubin consistent with ascending cholangitis. Antibiotics were initiated. Emergent ERCP was performed. Balloon sweeps of the CBD extracted clots and re-precipitated hemobilia. Cholangiogram revealed turbulence and dilution of contrast at the confluence, suggesting a bleeding source in the vicinity. A fully covered metallic stent was deployed at the confluence. Cholangioscopy was performed through the stent. No active bleeding was noted. The patient did well post procedure with resolution of bleeding, pain, and fever. Treatment of complicated PCC is multi faceted. It involves endoscopic biliary decompression followed by portal decompression (proximal splenorenal shunt or TIPS). Patients who remain symptomatic may undergo biliary drainage surgeries (hepaticojejunostomy or choledochojejunostomy). Hemobilia has been reported rarely after balloon sweeps, attributed to suspected intracholedochal varices and managed successfully by covered metal stents.Figure 1Figure 2Figure 3