Internal Biliary Drainage Research Articles

Third-generation cephalosporin for antimicrobial prophylaxis in pancreatoduodenectomy in patients with internal preoperative biliary drainage

The aim of the present study was to investigate whether the incidence of surgical site infection after pancreatoduodenectomy decreased after changing the prophylactic antibiotic to a third-generation cephalosporin in patients with unknown preoperative bile culture results after biliary drainage. In a retrospective study of 138 pancreatoduodenectomy patients who underwent endoscopic biliary stenting and for whom recent preoperative bile culture results were unavailable, cefazolin sodium hydrate was administered as perioperative prophylactic antibiotic therapy from 2010 to 2014 (n = 69); whereas ceftriaxone was administered from 2014 to 2017 (n = 69) based on the results of institutional culture surveillance. The incidence of surgical site infection was compared between the two groups and the risk factor of surgical site infection was also evaluated. The incidence of overall surgical site infection in the ceftriaxone group was significantly lower than that in the cefazolin sodium hydrate group for both Clavien-Dindo grade ≥II (28% versus 52%, P = .005) and Clavien-Dindo grade ≥IIIa (20% vs 41%, P = .016). A multivariate analysis revealed that the prophylactic administration of cefazolin sodium hydrate was associated with a higher incidence of overall surgical site infection in both Clavien-Dindo grade ≥II and Clavien-Dindo grade ≥IIIa (odds ratio 2.56, P = .019; odds ratio 3.03, P = .020, respectively). In the cefazolin sodium hydrate group, most of the patients with positive perioperative cultures had Enterobacteriaceae, which were intrinsically resistant to cefazolin sodium hydrate, and most were susceptible to ceftriaxone. The prophylactic administration of third-generation cephalosporin reduced the incidence of surgical site infection after pancreatoduodenectomy in patients who underwent preoperative endoscopic biliary stenting.

ERCP for Jaundice in Perihilar Cholangiocarcinoma Can Increase Survival

Endoscopic retrograde cholangiopancreatography (ERCP) is often used to provide internal biliary drainage (as opposed to percutaneous biliary drains) in

Endoscopic Ultrasound-Guided Gallbladder Drainage After Roux-En-Y Gastric Bypass: It Can Hide, but It Can‘t Run!

In patients with acute cholecystitis who are non-operative candidates, percutaneous cholecystostomy (PC) catheter placement is used for gallbladder decompression Removal of the catheter can lead to recurrence of cholecystitis. Leaving drain in place can cause infection, pain and dislodgment. Routine catheter maintenance and exchanges adversely affect quality of life. EUS-guided approach may be used to convert PC drainage to internal biliary drainage. 33-year-old woman with a history of Roux-en-Y gastric bypass presented with septic shock. She was actively abusing alcohol (MCV 105), malnourished (Albumin 2.0), coagulopathic (INR 2.0), thrombocytopenic (Platelets 58 k), and requiring frequent large volume paracentesis Abdominal CT scan showed acute acalculous cholecystitis. Patient started on broad spectrum antibiotics, vasopressors, deemed to be a prohibitive operative candidate and underwent placement of an 8 French decompression PC catheter (Fig 1) by Interventional Radiology. Due to severe discomfort from the PC catheter, taken for conversion to internal biliary drainage via endoscopic ultrasound. Stricture found at the G-J anastomosis. Contrast injected across the stricture, confirming a patent jejunal limb. Stricture was dilated to 18 mm. EUS scope maneuvered into the jejunal limb, gallbladder visualized endosonographically. Hyperechoic material consistent with sludge seen within an enlarged gallbladder. Site within the jejunum chosen, where gallbladder wall was within 1 cm (Fig 2). Gallbladder punctured with a 19 gauge FNA needle under EUS guidance. 10 mm by 10 mm cautery-enhanced LAMS placed creating a cholecystojejunostomy. 7 Fr by 4 cm plastic double pigtail stent placed through LAMS to maintain patency of the metal stent and prevent the backwall of gallbladder from impacting the metal stent causing bleeding or dislodgement (Fig 3). The patient did well following EUS-guided cholecystojejunostomy. 3 weeks later, a cholecystogram was performed. Contrast flowed from a decompressed gallbladder and into the jejunum across a patent cholecystojejunostomy via the LAMS. The PC catheter was then removed. The patient did well and was discharged home. EUS guided-conversion of percutaneous gallbladder drainage to internal drainage via a cholecystojejunostomy using a LAMS in a non-surgical patient with Roux-en-y gastric bypass is feasible, although the procedure is technically challenging and requires more expertise compared to primary EUS-guided gallbladder drainage.1702_A Figure 1 No Caption available.1702_B Figure 2 No Caption available.1702_C Figure 3 No Caption available.Watch the video: https://goo.gl/rfav8w

Temporary CBD Stenting with a Nelaton Tube Is a More Practical and Safer Option Than T-Tube Drainage after Conventional CBD Exploration for Choledocholithiasis.

Objective We are trying to investigate the possibility, safety, and benefits of replacing the role of T-tube by another more safe and effective procedure for biliary decompression in the case of common bile duct (CBD) exploration. Methods Our present study includes fifty consecutive patients who underwent a traditional CBD exploration due to choledocholithiasis. Patients were divided into 2 equal groups. In the 1st group, a spontaneously expelled Nelaton tube is placed in the CBD to aid in bile drainage to the duodenum, while in the 2nd group, a conventional T-tube is placed to decompress the CBD in the early postoperative (PO) days to a drainage bag. Operative and PO data as well as PO hospital stay time were recorded. All data were collected and statistically analyzed. Results The mean operative time and PO hospital stay days were significantly low (p value < 0.05) in the Nelaton tube drainage group compared with the T-tube drainage group. On the other hand, the mean time needed for the abdominal drain removal was significantly higher in the T-tube drainage group (p value < 0.05). Conclusion Nelaton tube with internal biliary drainage is effective and safer than T-tube drainage and it helps in reduction of the PO hospital stay time. In addition, it avoids all short-term complications of T-tube.

Biliary complications after pediatric liver transplantation: risk factors and impact on patient and graft survival

Introduction: Biliary complications (BCs) are seen in upto 50% of pediatric liver transplant (PLT) recipients and can significantly increase procedural morbidity. Methods: Retrospective review of all patients developing BC after PLT at tertiary care hospital from 2002-2016. Outcomes were compared with PLT recipients who did not develop BCs (control) and risk factors were identified. Results: BCs were seen in 18% (34/187) PLT recipients during study period: 5 leaks, 25 strictures, 4 leaks+strictures. There was no difference between BC and control groups in recipient age, sex, weight, etiology, type of biliary reconstruction, and cold and warm ischemia times. BC group had significantly higher proportion of Caucasians (94% vs 77%), living donors (23% vs 8%), internal biliary drainage (biliary stent/T-tubes) (50% vs 24%), rejection (17% vs 5%) and 30- and 90-day readmission rates (p<0.05). 5/34 (15%) required surgery (biliary revision in 3, re-PLT in 2) while remaining were successfully managed with PTC and ERCP. There was no difference in 1-,5- and 10-yr overall survival (100%,90%,86% BC vs 91%,88%,88% control) and graft survival (94%,78%,58% BC vs 84%,80%,79% control). Multivariate analysis identified use of partial grafts (living donor, insitu-split or reduced-size), use of internal biliary drainage, and rejection as independent predictors of BCs, while use of internal biliary drainage was independently associated with decreased patient survival. Conclusions: Partial liver grafts, internal biliary drainage, and rejection are associated with higher BC rates after PLT. BCs do not significantly impact overall patient or graft survival.

Internal biliary drainage for isolated posterior segmental biliary obstruction: a case report

BackgroundBiliary system anatomical abnormalities can be preoperatively detected on magnetic resonance imaging; therefore, some presume that the number of bile duct injuries should decline. However, once a bile duct injury occurs, repair may be difficult. There are various ways to repair bile duct injuries, but successful repair may be exceptionally difficult.Case presentationA 72-year-old Japanese man underwent a pancreaticoduodenectomy due to a diagnosis of middle bile duct cancer. We had a complication of an isolated posterior segmental biliary obstruction when pancreaticoduodenectomy was performed. We conducted a drip infusion cholecystocholangiography-computed tomography test to determine the positional relationship between his bile duct and elevated jejunum. To secure the bile duct we punctured the bile duct under computed tomography guidance, and the hepaticojejunal anastomosis site was visualized by inserting an endoscope. We vibrated the bile duct wall by inserting a guide wire through a puncture needle and verified the vibrations with the endoscope. We observed a partially compressed elevated jejunal wall upon guide wire insertion; therefore, we could verify a puncture needle penetration into the elevated jejunum by endoscope on insertion. We also successfully inserted an 8.5-Fr pigtail catheter into the elevated jejunum. We removed all drains after percutaneously inserting an uncovered metallic stent. Our patient’s subsequent clinical course was unremarkable. He visits our institution as an out-patient and has had no stent occlusion even after 6 months.ConclusionsWhen repairing bile duct injuries, it is important to accurately determine the positional relationships between the injured bile duct and the surrounding organs.

Internal biliary drainage superior to external biliary drainage in improving gut mucosa barrier because of goblet cells and mucin-2 up-regulation.

Backgroud: Obstructive jaundice increases intestinal permeability, but the pathological mechanisms remain obscure, which results in debates about the necessity of performing preoperative biliary drainage in patients with obstructive jaundice. Mucin-2 (MUC2) and goblet cells regulated by bile acids play an important role in maintaining the function of intestinal mucosal barrier. The present study was to investigate the role of goblet cells and MUC2 in obstructive jaundice and evaluate the effect of biliary drainage on intestinal permeability.Study design: We enrolled patients with malignant biliary obstruction and controls. We also did animal studies with four groups of rats: sham operation, obstructive jaundice, internal biliary drainage, and external biliary drainage. Histopathological analysis, biochemical measurement, and electron microscopy examination were done on pertinent samples.Results: Compared with the control group, the small intestinal mucosa was significantly damaged; goblet cells and MUC2 were significantly decreased and serum endotoxin level was significantly increased in patients and rats with obstructive jaundice. Biliary drainage, especially internal biliary drainage, significantly increased goblet cells and MUC2 and attenuated the damage of small intestinal mucosa.Conclusions: In obstructive jaundice condition, goblet cells and MUC2 were reduced which were involved in the damage of intestinal mucosa barrier; biliary drainage increased goblet cells and MUC2, repaired mucosa layer and restored the intestinal mucosa barrier function.

Biliary complications after pediatric liver transplantation

Background: Biliary complications (BCs) are seen in upto 50% of pediatric liver transplant (PLT) recipients and can significantly increase procedural morbidity. Methods: Retrospective review of all patients developing BC after PLT at tertiary care hospital from 2002 to 2016. Outcomes were compared with PLT recipients who did not develop BCs (control) and risk factors were identified. Results: BCs were seen in 18% (34/187) PLT recipients during study period: 5 leaks, 25 strictures, 4 leaks + strictures. There was no difference between BC and control groups in recipient age, sex, weight, etiology, type of biliary reconstruction, and cold and warm ischemia times. BC group had significantly higher proportion of Caucasians (94% vs 77%), living donors (23% vs 8%), internal biliary drainage (biliary stent/T-tubes) (50% vs 24%), rejection (17% vs 5%) and 30- and 90-day readmission rates (p < 0.05). 5/34 (15%) required surgery (biliary revision in 3, re-PLT in 2) while remaining were successfully managed with PTC and ERCP. There was no difference in 1-,5- and 10-yr overall survival (100%, 90%, 86% BC vs 91%, 88%, 88% control) and graft survival (94%, 78%, 58% BC vs 84%, 80%, 79% control). Multivariate analysis identified use of partial grafts (living donor, insitu-split or reduced-size), use of internal biliary drainage, and rejection as independent predictors of BCs, while use of internal biliary drainage was independently associated with decreased patient survival. Conclusion: Partial liver grafts, internal biliary drainage, and rejection are associated with higher BC rates after PLT. BCs do not significantly impact overall patient or graft survival.

Development of an external-to-internal convertible endoscopic biliary drainage device - a preliminary prospective feasibility study.

Background and study aims Endoscopic nasobiliary drainage (ENBD) for a malignant stricture in the bile duct has some advantages over endoscopic biliary stenting (EBS). However, ENBD may cause nasopharyngeal discomfort. We developed an external-to-internal convertible endoscopic biliary drainage (ETI-EBD) device that enables both internal and external drainage to occur during a single endoscopy. Patients and methods This device consists of three parts, comprising a 5-Fr ENBD tube (250 cm) (ENBD-t), an 8.5-Fr EBS tube (7 cm) (EBS-t), and an 8-Fr pusher tube for EBS (230 cm) (P-t). The EBS-t is mounted over the ENBD-t at the distal end of the ENBD-t. The P-t is also placed over the ENBD-t. After an endoscopic sphincterotomy, the EBS-t of the device is inserted into the papilla, then the duodenal endoscope is withdrawn, leaving the device in place. After ENBD, only the ENBD-t was withdrawn from the P-t. At this point, the EBS-t was isolated and left without endoscopy or radiography. Results ETI-EBD was successfully placed in all consecutive 21 patients (100 %). The release of EBS-t from ENBD-t wit was successfully completed in 19 patients (90.5 %). There were 4 patients with kink of P-t when exchanging this device from the mouth to the nose. It was difficult for 2 patients to withdraw the ENBD-t because of poor lubrication performance. There were no significant complications associated with the use of the device. Conclusion This device allows for both external and internal biliary drainage with a single endoscopy.

Endoscopic Gastrojejunostomy: A Novel Approach to Roux Obstruction Following Roux-en-Y Hepaticojejunostomy: 2017 Presidential Poster Award

Roux-en-Y hepaticojejunostomy (RYHJ) is a procedure generating a direct connection between the hepatic bile ducts and the jejunum. Major indications include biliary strictures and iatrogenic injuries while studies have also indicated a role in biliary cancer. We present a novel endoscopic treatment of a Roux limb obstruction following RYHJ for a cholangiocarcinoma. A 75-year-old female with a history significant for cholangiocarcinoma involving the extra-hepatic biliary tract underwent a RYHJ following complete biliary duct resection. Two months following surgery, she presented with abdominal pain with labs suggestive of cholestatic disease. Abdominal CT revealed a very large distended Roux limb (Figure 1), thus a percutaneous biliary drain (PBD) was subsequently placed. One month later, trial of internal biliary drainage was unsuccessful. Cholangiogram noted a patent PBD and hepaticojejunal anastomosis, however again indicated obstruction. To avoid open repair, endoscopic therapy was performed. Following a normal EGD, EUS revealed a dilated Roux limb abutting the gastric antrum (Figure 2). This was confirmed by visualization of both guide wire advancement and contrast injection into the PBD. Initial fistulizing was attempted using a Hot AXIOSTM stent system; however, device deployment failed. Under EUS, a 19g FNA needle was introduced into the limb with advancement of a guide wire. The FNA needle was exchanged for needle-knife instrumentation and multiple cutting passes were performed. The fistula was dilated with an 8mm balloon and two double-pigtail stents were deployed with excellent biliary return (Figure 3). Directional flow was verified under fluoroscopy with contrast injection through her PBD. Lastly, a cholangioscopy performed through the PBD, further confirmed the pigtail catheter placement within the Roux limb. Follow-up cholangiogram 2 weeks later noted patent stents, and the PBD was removed. Multiple EUS-guided techniques have been described in the literature for biliary obstructions. In 2014, a “modified RYHJ” reported fixing the distal Roux limb to the anterior gastric wall for secured endoscopic access should the need arise. However, this has not been universally implemented. Thus, with the recent paradigm shift to minimally invasive endoscopic interventions in an effort to circumvent invasive surgical repair, we have described a safe alternative for the treatment of Roux limb obstructions following a “traditional” RHYJ.Figure: CT abdomen and pelvis noting a distended Roux limb adjacent to the liver.Figure: EUS noting a distended Roux limb abutting the gastric antrum.Figure: Direct visualization with EGD of two double-pigtail stents within the gastric antrum.

Bile acid receptor TGR5 overexpression is associated with decreased intestinal mucosal injury and epithelial cell proliferation in obstructive jaundice

Bile acids stimulate intestinal epithelial proliferation invitro. We sought to investigate the role of the bile acid receptor TGR5 in the protection of intestinal epithelial proliferation in obstructive jaundice. Intestinal tissues and serum samples were obtained from patients with malignant obstructive jaundice and from bile duct ligation (BDL) rats. Intestinal permeability and morphological changes in the intestinal mucosa were observed. The functions of TGR5 in cell proliferation in intestinal epithelial injury were determined by overexpression or knockdown studies in Caco-2 and FHs 74 Int cells pretreated with lipopolysaccharide (LPS). Internal biliary drainage was superior to external biliary drainage in recovering intestinal permeability and mucosal histology in patients with obstructive jaundice. In BDL rats, feeding of chenodeoxycholic acid (CDCA) decreased intestinal mucosa injury. The levels of PCNA, a marker of proliferation, increased in response to CDCA feeding and were paralleled by elevated TGR5 expression. CDCA upregulated TGR5 expression and promoted proliferation in Caco-2 and FHs 74 Int cells pretreated with LPS. Overexpression of TGR5 resulted in increased PCNA, cell viability, EdU incorporation, and the proportion of cells in S phase, whereas knockdown of TGR5 had the opposite effect. Our data indicate that bile acids promote intestinal epithelial cell proliferation and decrease mucosal injury by upregulating TGR5 expression in obstructive jaundice.

Peritonitis Caused by Internal Migration of the Percutaneous Transhepatic Biliary Drainage Catheter

ê²½í”¼ê²½ê°„ë‹´ì¦™ë°°ì•¡ìˆ ì€ 담석, 양성협착, ì• ì„±ì¢ ì–‘ 등에 의한 폐쇄성 황달을 감압시키기 위한 ë°©ì‚¬ì„ í•™ì  방법이다. 담관을 통한 담즙의 내부배액이 회복되면 경피경간담즙배액도관은 ê²½í”¼ì ìœ¼ë¡œ ì œê±°í• ìˆ˜ 있다. 본례에서는 병상에서 경피경간담즙배액 도관을 ì œê±°í• ë•Œ, 도관이 복강으로 이동하여 복막염이 ë°œìƒí•˜ì˜€ê³ ê²½êµ¬ë‚´ì‹œê²½ìœ¼ë¡œ 도관을 ì œê±°í•˜ì˜€ë‹¤. 경피경간담즙배액 도관을 ì œê±°í• ë•ŒëŠ” 도관이 복강으로 이동하지 않도록 주의하여야 하며, 부주의로 인하여 도관이 복강으로 이동하였을 경우에는 경구내시경으로 도관을 ì œê±°í• í›„ 있다. Keywords: 도관, ë‹´ì¦™ì •ì²´, 배액, 복막염, 내시경

Palliative internal biliary drainage for obstructive jaundice due to tumors of hepatopancreatobiliary area

Palliative internal biliary drainage for obstructive jaundice due to tumors of hepatopancreatobiliary area

Can Endoscopic Nasobiliary Drainage Involving Two Catheters Be Used to Treat Various Conditions?

Can Endoscopic Nasobiliary Drainage Involving Two Catheters Be Used to Treat Various Conditions?

A prospective, multicenter study of a double stent system for palliative treatment of malignant extrahepatic biliary obstructions.

A double stent system (covered stent in uncovered stent) was designed to provide long-term patency without tumor ingrowth or stent-related complications, such as stent migration, cholecystitis, or pancreatitis. To investigate the safety and efficacy of double stents in patients with malignant extrahepatic biliary obstructions. This prospective, nonrandomized, multicenter study enrolled 160 consecutive patients (102 men; mean age, 64 years; range, 33-91 years) with malignant extrahepatic biliary obstructions treated with a double stent system from January 2010 to March 2012. The technical success rate of the double stent placement was 100%. No stent migration was observed. Procedure-related minor (self-limiting hemobilia [n = 6] and cholangitis [n = 2]) and major (pancreatitis [n = 16], cholecystitis [n = 3], and hepatic abscess [n = 2]) complications occurred in a total of 29 patients. The mean serum bilirubin level, which was 8.9 ± 5.6 mg/dL before drainage, decreased to 2.2 ± 4.6 mg/dL 1 month after stent placement (P < 0.001). Successful internal drainage was achieved in 148 patients (92.5%). During the mean follow-up period of 205 days, acute cholecystitis (n = 3) and hepatic abscess (n = 2) occurred in five patients. The median patient survival and stent patency time were 135 days (95% confidence interval [CI], 96-160 days) and 114 days (95% CI, 83-131 days), respectively. Of 153 patients, 22 (14.4%) presented with stent dysfunction due to sludge incrustation (n = 17), tumor overgrowth (n = 4), or blood clot (n = 1), and required repeat intervention. Tumor ingrowth was not observed in any of these patients. Percutaneous treatment of malignant extrahepatic biliary obstruction using a double stent safely and effectively achieves internal biliary drainage.

Different techniques for biliary diversion in progressive familial intrahepatic cholestasis

BackgroundProgressive familial intrahepatic cholestasis (PFIC) is a cholestatic liver disease of childhood. Pruritus resulting from increased bile salts in serum might not respond to medical treatment, and internal or external biliary drainage methods have been described. In this study, we aimed to evaluate different internal drainage techniques in patients with PFIC. Patients and methodsBetween 2009 and 2014, seven children (4 male, 3 female, 3months–5years old), (median 2years of age) with PFIC were evaluated. The patients were reviewed according to age, gender, complaints, surgical technique, laboratory findings and outcome. In each two patients, cholecystoileocolonic anastomosis, cholecystojejunocolonic anastomosis and cholecystocolostomy were performed. Cholecysto-appendico-colonic anastomosis was the technique used in one patient. ResultsJaundice and excessive pruritus were the main complaints. One of the patients with cholecystoileocolonic anastomosis died of comorbid pathologies (cirrhosis, adhesive obstruction and severe sepsis). Temporary rectal bleeding was observed in all the patients postoperatively. Regardless of the surgical technique, pruritus was dramatically decreased in all the patients in the postoperative period. ConclusionRegardless of the technique, internal biliary diversion methods are beneficial for the relief of pruritus in PFIC patients. Selection of the surgical method might vary depending on the surgeon's preference and the surgical anatomy of the gastrointestinal system of the patient.

Impact of bacterial contamination of the abdominal cavity during pancreaticoduodenectomy on surgical-site infection

Several risk factors for complications after pancreaticoduodenectomy have been reported. However, the impact of intraoperative bacterial contamination on surgical outcome after pancreaticoduodenectomy has not been examined in depth. This retrospective study included patients who underwent pancreaticoduodenectomy and peritoneal lavage using 7000 ml saline between July 2012 and May 2014. The lavage fluid was subjected to bacterial culture examination. The influence of a positive bacterial culture on surgical-site infection (SSI) and postoperative course was evaluated. Risk factors for positive bacterial cultures were also evaluated. Forty-six (21.1 per cent) of 218 enrolled patients had a positive bacterial culture of the lavage fluid. Incisional SSI developed in 26 (57 per cent) of these 46 patients and in 13 (7.6 per cent) of 172 patients with a negative lavage culture (P < 0.001). Organ/space SSI developed in 32 patients with a positive lavage culture (70 per cent) and in 43 of those with a negative culture (25.0 per cent) (P < 0.001). Grade B/C pancreatic fistula was observed in 22 (48 per cent) and 48 (27.9 per cent) respectively of patients with positive and negative lavage cultures (P = 0.010). Postoperative hospital stay was longer in patients with a positive lavage culture (28 days versus 21 days in patients with a negative culture; P = 0.028). Multivariable analysis revealed that internal biliary drainage, combined colectomy and a longer duration of surgery were significant risk factors for positive bacterial culture of the lavage fluid. Intraoperative bacterial contamination has an adverse impact on the development of SSI and grade B/C pancreatic fistula following pancreaticoduodenectomy.

EUS-guided gallbladder drainage with a lumen-apposing metal stent (with video)

Nonsurgical techniques for gallbladder drainage are percutaneous, and endoscopic. EUS-guided transmural gallbladder drainage (EUS-GBD) is a relatively new approach, although data are limited. Our aim was to describe the outcome after EUS-GBD with a lumen-apposing metal stent (LAMS). This was a retrospective review of prospectively collected data on 15 nonsurgical patients who underwent EUS-GBD for various indications. Procedures were performed at 3 tertiary care centers with expertise in the management of complex biliary problems. The main outcome measures were technical and clinical success and adverse events. Fifteen patients (8 male, 7 female) with a median age of 74 years (range 42-89) underwent EUS-GBD by using a LAMS to decompress the gallbladder (7 patients calculous cholecystitis, 4 acalculous cholecystitis, 2 patients biliary obstruction, 1 patient gallbladder hydrops, 1 patient symptomatic cholelithiasis). Patients were nonsurgical candidates according to the American Society of Anesthesiologists Physical Status Classification System; findings were class IV or higher in 9 patients and advanced malignancies in 6. Percutaneous transhepatic gallbladder drainage (PT-GBD) was refused by all patients and was further precluded by perihepatic ascites in 3 patients, coagulopathy or need for anticoagulation in 4 patients, and need for internal biliary drainage in 2 patients. Transduodenal access and stenting was achieved in 14 of 15 patients and transgastric stenting was achieved in 1. Technical success was achieved in 14 of 15 patients (93%), whereas clinical success was achieved in all 15 patients with a median follow-up of 160 days. One mild adverse event (postprocedure fever for 3 days) was noted. The limitations of this study are the small select group of patients and retrospective study design. EUS-GBD with a LAMS is technically safe and effective for decompressing the gallbladder for cholecystitis and biliary or cystic duct obstruction in patients who are poor surgical candidates.

Systematic review with meta-analysis of studies comparing primary duct closure and T-tube drainage after laparoscopic common bile duct exploration for choledocholithiasis.

With advances in laparoscopic instrumentation and acquisition of advanced laparoscopic skills, laparoscopic common bile duct exploration (LCBDE) is technically feasible and increasingly practiced by surgeons worldwide. Traditional practice of suturing the dochotomy with T-tube drainage may be associated with T-tube-related complications. Primary duct closure (PDC) without a T-tube has been proposed as an alternative to T-tube placement (TTD) after LCBDE. The aim of this meta-analysis was to evaluate the safety and effectiveness of PDC when compared to TTD after LCBDE for choledocholithiasis. A systematic literature search was performed using PubMed, EMBASE, MEDLINE, Google Scholar, and the Cochrane Central Register of Controlled Trials databases for studies comparing primary duct closure and T-tube drainage. Studies were reviewed for the primary outcome measures: overall postoperative complications, postoperative biliary-specific complications, re-interventions, and postoperative hospital stay. Secondary outcomes assessed were: operating time, median hospital expenses, and general complications. Sixteen studies comparing PDC and TTD qualified for inclusion in our meta-analysis, with a total of 1770 patients. PDC showed significantly better results when compared to TTD in terms of postoperative biliary peritonitis (OR 0.22, 95% CI 0.06-0.76, P = 0.02), operating time (WMD, -22.27, 95% CI -33.26 to -11.28, P < 0.00001), postoperative hospital stay (WMD, -3.22; 95% CI -4.52 to -1.92, P < 0.00001), and median hospital expenses (SMD, -1.37, 95% CI -1.96 to -0.77, P < 0.00001). Postoperative hospital stay was significantly decreased in the primary duct closure with internal biliary drainage (PDC + BD) group when compared to TTD group (WMD, -2.68; 95% CI -3.23 to -2.13, P < 0.00001). This comprehensive meta-analysis demonstrates that PDC after LCBDE is feasible and associated with fewer complications than TTD. Based on these results, primary duct closure may be considered as the optimal procedure for dochotomy closure after LCBDE.

P-156 Biliary drainage in patients with extrahepatic bile ducts cancer and obstructive jaundice

Introduction: The malignant stenosis of extrahepatic bile ducts mostly affect confluence of the right and left hepatic duct (Klatskin tumors), followed by adenocarcinomas with distal location (periampullary tumors) and tumors of middle part. Biliary drainage is an important part of the treatment of extrahepatic bile ducts tumors. There are some contradictions on different types and methods of resolving the obstructive jaundice. To present and analyze the results of the application of different types of biliary drainage in patient with malignant stenosis of extrahepatic bile ducts, admitted in the Department of General and Hepato-pancreatic Surgery, University Hospital “Alexandrovska”, Sofia, Bulgaria for a period of 6 years. Methods: Between 2009-2014 year in the Department of General and Hepato-pancreatic Surgery were treated 64 patients with extrahepatic bile duct cancer, complicated with obstructive jaundice. The distribution of men to women is 1.37:1. The average age is 64 years. According to the classification of Longmire with perihilar tumors were 31 patients, middle part of the biliary tract was affected in 2 patients and 31 patients was with distal part lesions (10 with adenocarcinoma of common bile duct and 21 with adenocarcinoma of papilla Vateri). According to the classification of Bismuth-Corlette, with type I was two patients, with type II – 3, with type IIIa – 3, with type IIIb – 2, with type IV - 21. The methods used for biliary drainage in radical surgery (18 patients or 11.52%) were: tumor resection with bilio-digestive anastomosis with or without protective biliary drainage. In palliative surgery (25 patients or 16%) were administered: transtumoral internal/external biliary drainage (15 patients), internal biliary drainage (8 patients), external biliary drainage (2 patients). In 15 patients were administered percutaneous transhepatic external / internal-external biliary drainage and 1 - endoscopic prosthesis. In 5 patients obstructive jaundice was treated conservatively. Results: In 55 patients (85.9%) obstructive jaundice is resolved. During hospitalization, death occurred in 9 patients (29.03%). Complications were detected in 11.5%: insufficiency of the anastomosis, drainage obstruction, bleeding of the drainages, pancreatitis, cholangitis, wound infection. There is disagreement in opinions about preoperative biliary drainage in radical surgery. In advanced disease and contraindications for radical surgery, palliative biliary drainage is justified in order to improve the quality of life and reduce the pruritus. Conclusion: Management of obstructive jaundice in patient with malignant stenosis of extrahepatic bile ducts is an essential part of the complex treatment. More research is needed to assess the place and role of different types of biliary drainage.