Endoscopic Retrograde Biliary Stenting Research Articles

MANAGEMENT OF TUMOUR OBSTRUCTIONS OF DISTAL PART OF COMMON BILE DUCT USING RETROGRADE BILIARY STENTING

The aim of this study is to improve endobiliary stenting in patients with tumour obstruction of the distal part of common bile duct, as well as to promote the prevention of complications, and improve immediate results of treatment and quality of life of patients.
 The study included 68 patients who took the course of treatment at surgical hospitals from 2018 to 2022 and underwent endoscopic transpapillary stenting of the common bile duct for mechanical jaundice. In 37 patients, stenting was performed using a plastic stent, in 31 patients stenting was performed using a nitinol stent. Results of endobiliary stenting, complications, effectiveness and safety of stenting were evaluated.
 All patients underwent stening of the common bile duct. During endoscopic retrograde biliary stenting, only 5 patients had complications in the form of bleeding from the area of large duodenal papilla that was stopped endoscopically. In early postoperative period, 12 patients had following complications: migration of plastic stent into duodenum (3 cases), obturation of plastic stent (1 case), acute secondary pancreatitis (6 cases), and cholangitis (2 cases). In 64 out of 68 patients, endobiliary stenting provided satisfactory outcomes resulting in the decompression of external bile ducts.
 Endoscopic transpapillary stenting of common bile duct is a low-traumatic, safe and effective method of the decompression of biliary tract when it is obstructed by a tumour. Depending on the expected life expectancy we should use nitinol stents (≥ 6 months) or plastic one (of ≤ 6 months).

The impact of minimally invasive palliative decompression of bile ducts on quality of life in patients with distal malignant mechanical jaundice

Palliative treatment for mechanical jaundice is aimed at improving patient quality of life (QoL) and prolonging life. The current QoL studies indicate that there is limited evidence on various techniques for decompression of bile ducts (BD) in terms of their impact on quality of life in patients with distal malignant mechanical jaundice, and their data are contradictory.
 The aim of the study is to evaluate the effect of minimally invasive palliative techniques on QoL in patients with distal mechanical jaundice (MJ) after palliative decompression of bile ducts.
 Materials and methods. From 2017 to 2021, 98 patients who underwent palliative decompression of bile ducts for distal MJ of malignant origin were examined. A validated MOS SF‑36 questionnaire was used to assess patient QoL. The survey was conducted before the minimally invasive intervention and 2 months after it. Depending on the technique used for decompression of BD, patients were divided into the following groups: percutaneous transhepatic biliary drainage (PTBD) — 25, internal‑external transpapillary biliary drainage (IETBD) — 19, internal‑external biliary‑jejunal drainage (IEBJD) — 29, and endoscopic retrograde biliary stenting (ERBS) — 25.
 Results. Before treatment, a low level of patient QoL was detected in all groups on all scales of physical and psychological components of health (all p > 0.05). After 2 months, in the PTBD group, the indicator of the Mental Component Summary (MCS) decreased by an average of 6.9 ± 1.2 points (due to the deterioration of the indicator of social functioning scales by 12.5 ± 5.0 points and mental health by 11.1 ± 1.8 points), while the indicator of the Physical Component Summary (PCS) improved by 11.3 ± 1.1 points. In the IETBD and IEBJD groups, there was an improvement in MCS (by 11.7 ± 1.3 points and 13.0 ± 1.1 points, respectively) and PCS (by 5.2 ± 1.2 and 8.6 ± 1.1 points). With regard to MCS and PCS, slight improvement (by 4.7 ± 2.2 and 2.0 ± 1.9 points) was observed in the ERBS group.
 Conclusions. The IEBJD technique provided important advantages in comparison with other minimally invasive palliative techniques for decompression of BD in terms of its impact on patient QoL. Patients in the IEBJD group had better PCS scores (on average, 47.3 ± 1.3 points) compared to the IETBD (42.1 ± 1.5 points) and ERBS (39.1 ± 1.3 points, p < 0.05) groups, and those in the PTBD group (46.2 ± 1.4 points) had better scores than patients in the IETBD group (p < 0.05). In the IETBD and IEBJD groups, MCS scores were better 41.9 ± 1.1 and 40.3 ± 1.1 points, respectively) compared to the PTBD (22.6 ± 0.9 points) and ERBS (34.0 ± 1.1 points, p < 0.05) groups, and in the ERBS group, they were better than in the PTBD group.

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.
 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.
 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>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.
 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.

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.

Endoscopic Biliary Stenting for Malignant Obstructive Jaundice

Aim. To identify opportunities for endoscopic retrograde biliary stenting for malignant obstructive jaundice and to compare long-term results of stenting using plastic and self-expanding metal stents. Material and Methods. We analyzed the results of endoscopic methods of di-agnostics and treatment of inoperable patients with malignant obstructive jaundice, as well as incidence of early and late complications of biliary stenting as the final treatment. Total number of patients were 160 people which were divided into 2 groups by 80 patients. In the 1st group plastic biliary stents with the diameter of 3–3.5 mm (10–11.5 Fr) were used for bile ducts drainage. In the 2nd group covered self-expanding metal stents with the diameter of 10 mm (28–30 Fr) were applied. All patients underwent a comprehensive diagnostic program including traditional ultrasound (US), computer tomography (CT), EUS (EUS) and endoscopic retrograde cholangiopancreaticography (ERCP). Results. Early postoperative complications were observed in 7 (8.7%) and 5 (6.7%) patients in the 1st and 2nd group respectively. Remote complications such as recurrent obstructive jaundice and/or cholangitis in various time periods after discharge occurred 2 times more often in the 1st group (28 out of 80 patients) than in the 2nd group (12 out of 80 patients) that required repeated hospitalizations and re-stenting. Malignant duodenal stenosis arose in 20 (12.5%) patients. Average time was 8.2 months. Conclusion. Endoscopic retrograde stenting can be used as an effective final method of bile ducts decompression in patients with inoperable pancreatobiliary tumors complicated by obstructive jaundice. The term of plastic biliary and self-expanding metal stents function was 119.9 ± 131.4 days (4 months) and 257.5 ± 91.3 days (8.6 months) respectively. Improvement of equipment and tools, use of antegrade techniques combined with EUS-guided interventions, pyloroduodenal self-expanding stents allow to bypass pre-existing limitation with duodenal neoplastic stenosis.

The effects of different preoperative biliary drainage methods on complications following pancreaticoduodenectomy.

The objective of this study was to investigate the effects of different preoperative biliary drainage (PBD) methods on complications in jaundiced patients following pancreaticoduodenectomy. We retrospectively analyzed 270 extrahepatic bile duct cancer patients who underwent pancreaticoduodenectomy. A total of 170 patients without PBD treatment were defined as the non-PBD group. According to different PBD methods, 45, 18, and 37 patients were classified into the percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD), and endoscopic retrograde biliary stent (ERBS) groups, respectively. Clinical characteristics and complications were compared among the 4 groups.Preoperative cholangitis occurred in 14 (8.2%) and 8 (21.6%) patients in the non-PBD and ERBS group, respectively (P = 0.04). Compared with the non-PBD group, delayed gastric emptying (DGE) and wound infection occurred significantly more often in the ERBS group. The incidence of severe complications was significantly lower in the PTBD group than the non-PBD group (P = 0.03). Postoperative hospital stay and complication rates were significantly higher in the ERBS group than the PTBD group. There were no significant differences in complications between ENBD and other groups.In conclusion, PTBD can improve surgical outcomes by reducing severe complication rate in jaundiced patients following pancreaticoduodenectomy. ERBS increased the rates of DGE and wound infection due to high incidence of cholangitis before operative intervention and should be avoided. ENBD carried no special effect on complications and needs further analysis.

Retrograde biliary stenting in patients with pancreatobiliary diseases

Aim. To evaluate the results of retrograde biliary stenting in patients with pancreatobiliary diseases. Methods. In 2008-2012, 85 retrograde biliary stenting procedures were performed in 65 patients (28 men and 37 women) with pancreatobiliary diseases aged 33 to 86 years. Obstructive jaundice was diagnosed in 44 of 65 patients (in 67% of cases), ascending cholangitis - in 14 (21%) patients. Endoscopic biliary stenting was performed in 47 patients with benign pancreatobiliary diseases (chronic and post-surgical pancreatitis, benign common bile duct stricture, Mirizzi syndrome, intradiverticular papilla, common bile duct bile stones) and in 18 patients with malignancies (cancers of pancreas head, bile ducts and papillary cancer). Plastic biliary stents with a (diameter 2.5 to 3.3 mm) were used for stenting. Results. Endoscopic biliary stenting allows to resolve the clinical manifestations of оbstructive jaundice and cholangitis, to eliminate pain, to prevent the development of pancreatitis, to prepare patients for surgery. Serious complications of biliary stenting (stent migration in common bile duct, acute cholangitis) were observed in 5 of 85 procedures (5.9% of cases), and all were resolved after repeated endoscopic intervention. Conclusion. Endoscopic retrograde biliary stenting is a safe and effective treatment option for patients with both benign and malignant pancreatobiliary diseases, it is characterized by low rate of specific complications (5.8%) and had reduced the risk of acute pancreatitis in patients with papillostenosis and stricture of the common bile duct terminal part down to 3%.

Endoscopic retrograde cholangiopancreatography in managements of postoperative biliary leakage

Objective To evaluate the diagnostic and therapeutic value of endoscopic retrograde cholangiopancreatography （ERCP） for postoperative biliary leakage. Methods Data of 120 patients who developed biliary leakage after hepatobiliary operations and underwent ERCP from January 2003 to December 2008 were retrospectively reviewed. Results There were 71 cases of extra-hepatic biliary leakage （type Ⅰ ）, 39 intra-hepatic biliary leakage （ type Ⅱ） and 10 cystic duct leakage （ type Ⅲ ）, among which endoscopic nasobiliary drainage （ENBD） was performed in 76 cases, endoscopic retrograde biliary stent drainage （ERBD） in 35, ERBD plus ENBD in 3, endoscopic sphincterotomy （EST） in 2, endoscopic metal biliary endoprothesis （EMBE） in 1 and ERCP/elated procedures failed in 3 patients. A total of 98 （81.7%） patients were successfully followed up. Bile leakage was completely controlled in 85 patients （ 86. 7% ） at a mean time of 18.2 ±7.0 d. Leakage of type Ⅲhad the highest cure rate of 100% and the shortest cure time of 8.2 ±3.5 d. For leakage of type Ⅰ and Ⅱ developed after non-liver transplantation operations, the success rate and cure time were significantly better than those after liver transplantation （ P 〈 0.01 ）. Conclusion ERCP is safe and effective for the diagnosis and treatment of biliary leakage after hepatobiliary operations, and can be the first choice of managements, especially in biliary leakage of type Ⅲ. Key words: Cholangiopancreatography, endoscopic retrograde; Postoperative complications ; Biliary leakage

Endoscopic Ultrasonography-Guided Cystogastrostomy for Large Pancreatic Pseudocyst with Obstructive Jaundice − A Case Report −

The patient was a 45-year-old man with a history of heavy drinking. A pseudocyst about 30 mm in diameter was found in the head of his pancreas. About four weeks later an upper abdominal mass, abdominal pain and obstructive jaundice were confirmed. Abdominal CT revealed that the cyst had increased in size to about 60 mm, compressing the lower common bile duct and the surrounding digestive tract. Therefore endoscopic ultrasonography-guided cystogastrostomy following percutaneous transhepatic biliary drainage (PTBD) was performed. Postoperatively, the cyst quickly decreased in size and jaundice improved. Because of persistent common bile duct stenosis, an endoscopic retrograde biliary stent was implanted. There has been no recurrence at ten months after the endoscopic therapy. While invasive surgery is generally employed in the treatment of pancreatic pseudocyst complicated by obstructive jaundice, EUS-guided cystogastrostomy appears to be a useful procedure, particularly when considering the relatively minor degree of surgical invasion.

Determining required stent length in endoscopic retrograde biliary stenting

Endoscopic retrograde biliary stenting is widely used in the management of benign and malignant biliary strictures. 1-4 Successful stent placement requires accurate determination of the length of stent required to cross the stricture. Two methods are currently used to determine this length. The first involves taking measurements from the cholangiogram obtained prior to stenting. This method has the limitation of requiring these measurements be accurately adjusted for radiographic magnification as well as requiring the endoscopist to leave the patient.