Endoscopic Biliary Stenting Research Articles

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.

A Retrospective Study of Biliary Drainage Strategies for Patients with Malignant Hilar Biliary Strictures.

PurposeThe main aim of this study was to compare the efficacy and safety of different biliary drainage strategies, including percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary stenting (EBS) and unilateral versus bilateral stenting, in patients with unresectable malignant hilar biliary strictures (MHBSs).Patients and MethodsThis was a retrospective review of patients with inoperable MHBSs who underwent biliary drainage by either EBS or PTBD. Efficacy and safety were compared between the two pathways and between unilateral and bilateral stenting in the EBS group. The survival duration was analyzed with K-M curves and Log rank tests.ResultsFrom January 2015 to December 2019, a total of 206 (126: EBS and 80: PTBD) patients with MHBSs were enrolled in our study and underwent 270 procedures (173: EBS and 97: PTBD). Bilateral stenting was superior to unilateral stenting in terms of clinical success (69.6% vs 50.6%, p=0.039), especially for patients with Bismuth type IV (70.0% vs 30.3%, p=0.002). A higher decrease in bilirubin was seen with PTBD in patients with Bismuth types III–IV (66.9 vs 36.7, p=0.006). A survival advantage was seen in successful drainage (227 days vs 82 days, p<0.001), lower tumor-node-metastasis (TNM) scores (I–II) (195 days vs 139 days, p=0.012), and cholangiocarcinoma (184 days vs 84 days, p=0.001).ConclusionFor patients with advanced MHBSs, bilateral stenting may achieve a better drainage effect than unilateral stenting, and PTBD may have a better performance in relieving cholestasis than EBS. Successful drainage and cholangiocarcinoma may provide greater long-term survival benefits.

Treatment of Hepatic Hydatid Disease: Role of Surgery, ERCP, and Percutaneous Drainage: A Retrospective Study.

Failure to follow the World Health Organization's Informal Working Group on Echinococcosis guidance or having limited experience in the management of cystic echinococcosis (CE) in endemic or nonendemic areas of the world may lead to risky unnecessary procedures. Medical records of all patients undergoing surgery for hepatic hydatid disease at the gastroenterologic surgery and general surgery departments of our hospital between December 2014 and October 2019 were collected and reviewed retrospectively. Demographic characteristics, the size and number of the cysts preoperative liver function tests, surgical treatment, endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage (PD), morbidity, and treatment outcomes were reviewed. Of 122 patients included in the study, 77 (63, 1%) were female and 45 (36, 9%) were male individuals and their mean age was 44.95 years. CE1 was identified in 13 patients (10.6%) CE2 in 66 patients (54.1%), CE3a in 7 patients (5.8%), CE3b in 28 patients (22.9%), and CE4 in 8 patients (6.6%). Twenty patients (16.4%) with a cystobiliary fistula in the liver, obstructive jaundice, and postoperative bile leak underwent ERCP. PD was performed in patients with fluid in the hepatic hydatid cyst pouch, increased pouch size because of bile collection, and clinical symptoms postoperatively. Patients presenting with persistent bile leak despite PD underwent ERCP and were treated with endoscopic sphincterotomy and stent placement. Patients with PD were followed by keeping the percutaneous drain open and closed for a while to create pressure difference in the cyst pouch after ERCP. The percutaneous drain was removed in the next 14 to 21 days after checking the pouch size, whereas the common bile duct stents were removed 2 months later after performing a follow-up cholangiography. ERCP should be the primary method for the diagnosis and treatment for hepatic hydatid cysts ruptured into the ducts. İn some cases, high-flow hydatid cysts with rupture into the bile ducts or persistent biliary fistulas can be treated with ERCP and endoscopic sphincterotomy, biliary stent, PD, and nasobiliary drainage without the need for surgical intervention.

Optimal drainage of anastomosis stricture after living donor liver transplantation.

Endoscopic biliary stenting (EBS) with a fully covered, self-expandable metallic stent (FC-SEMS) and plastic stent (PS) is safe and efficient for biliary anastomotic strictures (ASs) after a deceased donor liver transplantation. Limited studies have investigated the use of FC-SEMSs for biliary strictures post-living donor liver transplantation (LDLT). We compared the resolution rate of biliary ASs post-LDLT and the 12-month recurrence rates post-stent removal between EBS with an FC-SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). Patients with biliary ASs after an LDLT (mean age: 57.3years, 76.1% men) hospitalized between 2014 and 2017 were enrolled. Endoscopic retrograde cholangiopancreatography (ERCP) was repeated every 3-4months. Patients were followed-up for at least 1-year post-stent removal. Of the 75 patients enrolled, 16, 20, and 39 underwent EBS with an FC-SEMS, PS, and PTBD, respectively. Median follow-up period was 39.2months. Fewer ERCP procedures were needed in the FC-SEMS group than in the PS group (median, 2 vs. 3; P = 0.20). Median stent indwelling periods were 4.7, 9.3, and 5.4months in the FC-SEMS, PS, and PTBD groups, respectively (P = 0.006). The functional resolution rate was lower in the PS group (16/20) than in the FC-SEMS (16/16) or PTBD (39/39) group (P = 0.005). The radiologic resolution rate was higher in the FC-SEMS group (16/16) than in the PS group (14/20) (P = 0.07). The 12-month recurrence rates showed no significant differences (FC-SEMS, 4/16; PS, 3/16; PTBD, 6/39; P = 0.66). The rates of complications during treatment differed significantly between the groups (P = 0.04). Stent migration occurred in 1 (6.3%) and 5 (25.0%) patients in the FC-SEMS and PS groups, respectively (P = 0.59). EBS with an FC-SEMS is comparable with EBS with a PS or PTBD in terms of biliary stricture resolution and 12-month recurrence rates. The use of FC-SEMSs is potentially effective and safe for biliary AS resolution after LDLT.

The pigtail stenting treatment for the Biliary leakage After the Liver hydatid cyst operation: A case report

Echinococcus granulosis commonly involve the liver and are mostly seen in Turkey . One of the early complication following the surgery for liver hydatid cyst is biliary leakage (B.L.) which’s incidence is %4.5-26. Endoscopic sphincterotomy (E.S.) and biliary stenting are usually successful in treating B.L. In this case, I’m presenting endoscopic treatment for the B.L. after the liver hydatid cyst operation.

Long Slimmer Metal Stent Is Feasible and Effective for Endoscopic Dual Stent-by-Stent Placement in Malignant Hilar Biliary Stricture.

Bilateral endoscopic biliary stenting remains technically challenging, which limits its wider clinical application. We have developed a novel long (10-12cm) and slimmer (6mm) self-expanded metal stent. The aim of this study was to evaluate the feasibility, efficacy, and safety of the new metal stent for palliative treatment of malignant hilar biliary strictures (MHBS). This retrospective study of prospectively collected data included 45 patients with unresectable malignant hilar biliary strictures of Bismuth type II or higher. A pair of long slimmer metal stents were sequentially placed into the intrahepatic duct using the stent-by-stent mode. The success rate and short- and long-term clinical outcomes were observed. The technical success rate was 100%, with a mean procedure time of 43.7 ± 11.5min. The clinical success was achieved in 44 patients (97.8%). Early adverse events included mild acute pancreatitis (n = 2) and cholangitis (n = 3). Later cholangitis occurred in 14 of the 45 patients due to stent occlusions. The median stent patency was 260days (95% CI 228.3-291.7). Stent malfunctions occurred in 23 of the 45 patients, and 15 of them received bilateral endoscopic plastic stents placements. The technical success for the re-intervention was 100% with the mean procedure time of 24.3 ± 4.5min. The median overall survival of the whole group was 229days (95% CI 171.2-286.8). The long slimmer metal stent for bilateral endoscopic stent-by-stent placement proved to be safe, feasible, and effective for MHBS and facilitates endoscopic re-intervention as well.

Comparison of Curative Effect between Nasobiliary Drainage and Biliary Stenting in Malignant Biliary Obstruction: A Systematic Review and Meta-Analysis

Background: To compare the efficacy of endoscopic nasobiliary drainage (ENBD) and endoscopic biliary stenting (EBS) in preoperative biliary drainage (PBD). Methods: ENBD and EBS related literature of patients with malignant biliary obstruction published before September 2019 were collected from PubMed, EMBASE, and Cochrane Library for comparison analysis. Revman 5.3 statistical software was used for analysis. Results: Nine studies were used for our comparative study. A total of 1435 patients were included, which consisted of 813 in the ENBD group and 622 in the EBS group. Meta-analysis showed that patients with malignant biliary obstruction who received ENBD had reductions in the rates of preoperative cholangitis (RR = 0.44, 95% CI = 0.34-0.58, P < 0.00001), preoperative pancreatitis (RR = 0.69, 95% CI = 0.50-0.95, P =0.02), stent dysfunction (RR = 0.58, 95% CI = 0.43-0.80, P =0.0008), morbidity (RR = 0.77, 95% CI = 0.64-0.93, P = 0.007) and postoperative pancreatic fistula (RR = 0.65, 95% CI = 0.45-0.92, P = 0.02) compared with patients who received EBS. Conclusions: The rates of preoperative cholangitis, preoperative pancreatitis, post-operative pancreatic fistula, stent dysfunction, and morbidity of ENBD patients were lower than those of EBS patients. In clinical practice, the physical condition of each patient and their tolerance should be fully considered. ENBD should be given priority. EBS should be replaced if stent dysfunction or intolerance occurs.

Primary endoscopic bile duct stone removal for severe acute cholangitis: a retrospective study.

Introduction:While the Tokyo Guidelines 2018 suggest primary stone removal for mild to moderate cholangitis, a guideline for severe acute cholangitis is not mentioned. We, therefore, investigated the clinical outcomes of patients with severe acute cholangitis to confirm the usefulness and safety of primary stone removal.Method:This study included 104 severe acute cholangitis patients without gallstone pancreatitis diagnosed at our institution between January 2014 and December 2020. Patients with percutaneous transhepatic biliary drainage as the primary drainage, bile duct stenosis, and endoscopically unidentified bile duct stones were excluded from this study. The clinical results of 14 patients with primary stone removal (primary group) and 23 patients with elective stone removal (elective group) were then retrospectively examined (excluding abnormal values due to underlying diseases).Results:Upon comparing the patient characteristics between groups, the elective group had significantly higher cardiovascular dysfunction (57% vs 7%; p = 0.004), septic shock (39% vs 0%; p = 0.006), disseminated intravascular coagulation treatment (57% vs 14%; p = 0.016), and positive blood cultures (91% vs 43%; p = 0.006) than those in the primary group. Endoscopic sphincterotomy for naïve papilla (90% vs 21%; p = 0.01) and endoscopic nasobiliary drainage (50% vs 9%; p = 0.014) were higher in the primary group, while endoscopic biliary stenting (7% vs 87%; p < 0.001) was lower than that in the elective group.Discussion:There were no significant differences in adverse events or complete stone removal rates between the two groups. In the primary group, the period from the first endoscopic retrograde cholangiopancreatography to stone removal (0 days vs 12 days; p < 0.001) and hospitalization period (12 days vs 26 days; p = 0.012) were significantly shorter and the hospitalization cost ($7731 vs $18758; p < 0.001) was significantly lower than those in the elective group.Conclusion:If patients are appropriately selected, bile duct stones may be safely removed for the treatment of severe acute cholangitis.

Preoperative biliary drainage: blessing or curse for patients undergoing pancreaticoduodenectomy?

Background: Preoperative biliary drainage by means of endoscopic biliary stenting is thought to improve outcomes by re-establishing enterohepatic circulation prior to pancreaticoduodenectomy. However, recent evidence suggests that it may be associated with increased postoperative infective complications. Objective: The objective of this study was to evaluate the relationship between preoperative biliary stenting and postoperative infectious complications. We also investigated the correlation of intraoperative bile bacteriology to postoperative bacterial culture from wound infection or deeper collection. Material and methods: All patients who underwent Pancreaticoduodenectomy at Shaukat Khanum Memorial Cancer Hospital and Research Centre from January 2014 to December 2018 were included in the study. Results: Out of 161 patients, 119 (74%) patients underwent pre-operative endoscopic biliary stenting before pancreatoduodenectomy. The overall morbidity rate was 65% and 30-day mortality was 3%. Intra-operative bile cultures were positive in 67% patients of which 37% patients had polymicrobial growth. The most common organism isolated was e-coli (35%). Bile and wound cultures had similar microbial growth in 21% patients. On comparison, bile cultures were positive in 78% of stented patients versus 33.33% in the group with no stents (p= 0.000). We found significantly higher rates of both superficial surgical site and deep incisional infections in the stented group (p=0.012, p=0.045). There was no statistical difference in the overall complications and mortality rates amongst the two groups. Conclusion: Preoperative ERCP and stent placement is a risk factor for infective complications following pancreaticoduodenectomy.

Totally Laparoscopic and Conventional Open Living Donor Right Hepatectomy: A Comparative Study of Outcomes

Although laparoscopic liver resection has progressively developed with increased surgical experience and the improvement of laparoscopes and specialized instruments, only a limited number of centers have performed laparoscopic living donor hepatectomy(LDRH) . We describe the experiences and outcomes associated with LDRH in adult-to-adult LDLT in order to assess the safety of the totally laparoscopic technique in donors. Between December 2014 and October 2018, we performed 97 cases of living donor right hepatectomy. Among them, 50 donors underwent totally laparoscopic living donor right hepatectomy and 47 donors underwent conventional open living donor right hepatectomy. We retrospectively reviewed the medical records to ascertain donor safety and the reproducibility of LDRH. The total operation time was longer (367.0±74.3 vs 323.5±62.5; P=.002) and the warm ischemic time was also longer(9.2±4.6 vs 1.8±1.6;P< .002) in LDRH group. However, the length of postoperative hospital stay was similar in both groups and no donors in LDRH group required blood transfusion, conversion to open surgery, or reoperation. There was no postoperative mortality. Postoperative complication of Clavien-Dindo classification III or more was identified in only one donor who had a minor bile leakage from the cutting edge of the right hepatic duct stump requiring endoscopic biliary stent insertion. All the liver function tests returned to normal ranges within 2 weeks. In conclusion, our study reveals LDRH seems to be a safe and feasible procedure with acceptable outcomes. However, LDRH can be initially attempted after attaining sufficient experience in laparoscopic hepatectomy and LDLT techniques.

第4回 切除不能例の胆道ドレナージ法―内視鏡的胆管ステンティングを中心に

第4回 切除不能例の胆道ドレナージ法―内視鏡的胆管ステンティングを中心に

Palliative surgical treatment of patients, suffering proximal tumoral affection of biliary ducts and the jaundice syndrome

Objective. To compare the efficacy of methods of miniinvasive palliative treatment of malignant hilar strictures with the jaundice syndrome.&#x0D; Materials and methods. Into the investigation 71 patients, suffering proximal obturation jaundice of tumoral genesis, were included. The patients were divided into three Groups: Group I - 26 patients, to whom external-internal suprapapillary cholangiostomy was done; Group II - 28 patients, in whom transcutaneous transhepatic antegrade endobiliary stenting was performed; Group III -17 patients, to whom endoscopic retrograde biliary stenting was accomplished.&#x0D; Results. Technical success in all the Groups have constituted 100%; clinical one - in 94.0%: in Group I - 96.2%, in Group II - 89.3%, and in group III - 82.4% (p&gt;0.05). In Group I general rate of morbidity was lesser, including cholangitis and pancreatitis. The duration of cholangitis was lesser as well. Cumulative survival were the highest in Group of patients, to whom external-internal suprapapillary cholangiostomy was performed (135 days at average), while the least one - in Group of the patients, in whom endoscopic retrograde biliary stenting was done (90,6 days). In Group of patients, to whom transcutaneous transhepatic antegrade endobiliary stenting was performed, this index have constitited 101.2 days.&#x0D; Conclusion. In proximal strictures of biliary ducts of tumoral genesis on background of jaundice the priority method of palliative treatment must be external-internal suprapapillary cholangiostomy, while the second-line of surgical treatment must constitute transcutaneous transhepatic antegrade endobiliary stenting. Endoscopic retrograde biliary stenting owes the lowest priority.

Arteriovenous malformation in the pancreatic head initially mimicking a hypervascular mass treated with duodenum-preserving pancreatic head resection: a case report

BackgroundThe mainstay treatment for arteriovenous malformation in the pancreatic head (Ph-AVM) is standard pancreatectomy, especially pancreaticoduodenectomy (PD), or interventional endovascular treatment. We report the first case of Ph-AVM treated with duodenum-preserving pancreatic head resection (DPPHR) performed to preserve the periampullary organs.Case presentationA 59-year-old man presenting with back pain underwent contrast-enhanced computed tomography followed by angiography of the anterior superior pancreaticoduodenal artery. He was diagnosed with Ph-AVM and indicated for DPPHR with preservation of the periampullary organs; Ph-AVM’s benign nature seldom requires lymph node dissection. During the operation, the right colon was mobilized and the omental bursa was released to expose the periampullary structures. The pancreas was transected just above the superior mesenteric vein. The inferior pancreaticoduodenal artery and papillary arteries branching from the posterior superior pancreaticoduodenal artery were carefully preserved to maintain the blood flow to the lower bile duct and papilla of Vater. The remnant pancreas was reconstructed with pancreaticogastrostomy using the modified Blumgart method. Pathological examination of the resected specimen revealed an irregular course of the arteries and veins concomitant with marked dilation throughout the pancreatic head. The patient was pathologically diagnosed with Ph-AVM. He developed hematemesis caused by a rupture of the pseudoaneurysm on postoperative day 20 and underwent coil embolization. A bilio-enteric fistula and stenosis of the common bile duct were found and treated by placement of an endoscopic biliary stent. At the 8-month follow-up, the Ph-AVM had not recurred.ConclusionsCompared to PD, DPPHR confers the clinical benefit of preserving the periampullary organs, although further studies are needed to confirm this. Therefore, the choice of this procedure should be based on the surgical morbidities and long-term outcome of the patient.

Whipple Procedure: A Five-Year Clinical Experience in Tertiary Care Center.

Introduction: Whipple procedure is one of the major surgeries performed in tertiary care centers. Once considered a high mortality procedure is now being practicing with mortality declining to less than 5%. This study describes our five-year experience of the Whipple procedure in terms of preoperative, operative, and postoperative parameters of patients undergoing surgery in a local tertiary care setting.Material and Methods: This was a non-randomized interventional study that was conducted at the Surgical Department of Services Hospital Lahore from January 2014 to December 2018. A total of 57 Whipple procedures were performed during this period. Demographic data, presenting symptoms, physical signs, past medical history, preoperative stenting details, intra-operative duration of surgery, postoperative course and complications, pathology, and causes of postoperative death were collected on a pre-designed questionnaire. Data were entered and analyzed by using SPSS 22 (IBM Corp., Armonk, USA).Results: Out of 57 patients, 19 were females and 38 were males. The mean age of patients was 53±05 years. The most common presenting symptom was jaundice 39 (68.4%), followed by abdominal pain 32 (56.1%). The mean size of the tumor on CT-scan was 2.8±1.4 cm, the mean operation time was 315±38.3 min, mean blood loss during surgery was 500±130 ml, and mean hospital stay was 10±6 days. The major postoperative complication was the pancreatic fistula (12%). Twenty-one out of 39 patients presented with jaundice had undergone preoperative biliary stenting by endoscopic retrograde biliary stenting. The most common histological diagnosis was adenocarcinoma of pancreas 19 (33.3%). Out of 57 patients, nine (15.8%) patients expired in the first 30 days and the most frequent cause of mortality was septic shock.Conclusion: In this study, the most common presentation of patients undergoing Whipple procedure was obstructive jaundice, the most frequent operative complication was pancreatic fistula, and the most prevalent histopathology was carcinoma of the pancreas. Perioperative parameters such as mean operative time, mean blood loss during surgery, and mean length of hospital stay were comparable with other studies. However, mortality in this study was slightly higher. It can be concluded that with meticulous surgical technique, securing hemostasis strictly and standard critical care postoperatively can decrease morbidity and mortality after the Whipple procedure.

Obstructive jaundice with a biliary clot post-endoscopic sphincterotomy treated with clipping and endoscopic biliary stenting.

Obstructive jaundice with a biliary clot post-endoscopic sphincterotomy treated with clipping and endoscopic biliary stenting.

S1577 What’s 7-cm Long, Has Poked Holes in the Small and Large Bowel, and Is Now Guilty of Causing Rectal Perforation? A Biliary Stent!

INTRODUCTION: Endoscopic biliary stenting plays a major role in the management of pancreaticobiliary disease. Unfortunately, even this novel idea comes with complications. Some of these risks include stent occlusion, cholangitis, and pancreatitis. Stent migration, although rare, has also been described, with more cases associated with plastic stents as compared to metal stents. More unlikely still is resultant perforation, as most dislodged stents remain in the bowel without causing clinical symptoms until ultimately excreted in the stool. This case report aims to discuss the first example of rectal perforation caused by a migrated biliary stent. CASE DESCRIPTION/METHODS: Our patient is a 77-year old female who presented to the emergency room for abdominal pain. She has a significant history of recurrent pancreatitis complicated by bile duct stricture requiring multiple visits for common bile duct stent placement. The patient was admitted two months prior for acute pancreatitis. At that time, an ERCP revealed rapid tapering of the bile duct at the level of the ampulla with subsequent intervention via placement of a 10-French 7-cm plastic stent. During this visit, a CT scan of the abdomen revealed migration of the previously placed stent to the rectosigmoid colon, along with diverticulosis. Specifically, the proximal portion was seen located in the wall of the left lateral sigmoid colon and distal portion of the stent had perforated the right aspect of the rectal vault. A flexible sigmoidoscopy was performed with successful extraction through the anus. DISCUSSION: The most common site of perforation by a biliary stent is the duodenum. The most likely reason for this is that the duodenum is largely retroperitoneal, and therefore fixed. Furthermore, anatomic proximity also plays a part as the major papilla is located in the second part of the duodenum. Bowel fixation in a hernial sac, presence of adhesions, and diverticular disease all seem to be associated with increasing risk of perforation due to the impedance of peristalsis. Our case is unique as the stent perforated the distal rectum, which is anatomically extra-peritoneal. Extra-peritoneal organs are embedded in connective tissue hence making them fixed-thus increasing risk of perforation. It was most probably her diverticular disease which predisposed her to the rectal wall perforation. The diverticulum acted as an anchor, essentially trapping the stent proximally. The distal end was free to poke and prod, eventually perforating the rectal wall.

Endoscopic biliary stenting as the risk factor for cholangitis after endoscopic ultrasound in patients with biliary strictures.

Endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) are established as efficient and safe diagnostic modalities. However, the risk of cholangitis after EUS/EUS-FNA (post-EUS cholangitis) in patients who have biliary strictures has not been fully examined. We retrospectively reviewed 136 consecutive inpatients with biliary strictures who received EUS/EUS-FNA at our hospital from April 2012 to September 2017 and evaluated complications that occurred by the next day after EUS/EUS-FNA. Patients with percutaneous biliary drainage, those in whom it was difficult to reach the duodenum, and those receiving concurrent endoscopic retrograde cholangiopancreatography were excluded. We included 121 patients (147 cases); 90 patients were malignant. Endoscopic biliary stenting (EBS) with plastic stents had already been performed in 86 cases. Post-EUS cholangitis was observed in 4.1% (6/147). No other EUS-related complications were observed. The incidence of cholangitis with EBS was significantly higher than that in the cases without EBS (7.0% [6/86] vs 0% [0/61], P=0.042). Biliary enzyme elevation was also identified as a risk factor of cholangitis. Endoscopic biliary stenting was identified as a risk factor associated with post-EUS cholangitis in patients with biliary strictures. Endoscopists should pay attention to post-EUS cholangitis, especially in cases with EBS and biliary enzyme elevation.

Anatomical landmarks for Percutaneous Transhepatic External Biliary Drainage (PTBD)

PTBD is used for temporary decompression of an obstructed biliary system prior to surgical resection as it is believed to reduce major post operative complications. This is preferred over endoscopic biliary stenting (EBS)by most as EBS induces an inflammatory response making resection difficult. For palliation of malignant biliary obstruction and as treatment for common bile duct stones endoscopy is preferred. PTBD is used if endoscopy fails. In this subset internalization for malignancies and surgery for calculi are done once the patient's general condition improve.

Long-Term Safety of Endoscopic Biliary Stents for Cholangitis Complicating Choledocholithiasis: A Multi-Center Study.

Background: Treatment of cholangitis complicating choledocholithiasis includes biliary sphincterotomy and stone extraction. In certain cases of elderly comorbid patients with high risk for definitive endoscopic treatment, biliary stenting is the only measure for relieving biliary obstruction. Aim: We aimed to report the safety of retained biliary stone. Methods: a multi-center, retrospective case-control study conducted at two Israeli medical centers from January 2013 to December 2018 including all patients 18 years of age or older who underwent ERCP and biliary stent insertion for the treatment of acute cholangitis due to choledocholithiasis. Results: Three-hundred and eight patients were identified. Eighty-three patients had retained long-term biliary stents of more than 6 months (group A) from insertion compared to 225 patients whose biliary stents were removed within a 6-month period (group B). The mean follow-up in group A was 66.1± 16.3 vs. 11.1 ± 2.7 weeks in group B. Overall complications during the follow-up were similar between groups A and B (6% vs. 4.9%, OR 1.24, Chi square 0.69). Similarly, the rate of each complication alone was not different when comparing group A to group B (3.6%, 1.2% and 1.2% vs. 2.7%, 0.44% and 1.8%) for cholangitis, stent related pancreatitis and biliary colic, respectively (Chi square 0.85). Even after 12 months, the rates of overall complications and each complication alone were not higher compared to less than 12 months (Chi square 0.72 and 0.8, respectively). Conclusion: endoscopic biliary stenting for cholangitis complicating choledocholithiasis is safe for the long-term period without increase in stent related complications.

Biliary Drainage Before and After Liver Resection for Perihilar Cholangiocarcinoma.

Perihilar cholangiocarcinoma (PHC) is a rare tumor that requires surgical resection for a potential cure. The role of preoperative biliary drainage has long been debated, given its treatment of biliary sepsis and decompression of the future liver remnant (FLR), but high procedure-specific morbidity. The indications, methods, and outcomes for preoperative biliary drainage are discussed to serve as a guide for perioperative management of patients with resectable PHC. Multiple studies from the literature related to perihilar cholangiocarcinoma, biliary drainage, and management of the FLR were reviewed. Commonly employed preoperative biliary drainage includes endoscopic biliary stenting and percutaneous transhepatic biliary drainage. Drainage of the FLR remains controversial, with most experts recommending drainage of the only in patients with an FLR <50%. Biliary drainage for resectable PHC requires a patient-specific approach with careful determination of the FLR and balancing of potential morbidity with the benefits of drainage.