Malignant Obstructive Jaundice Research Articles

Comparative Study of the Results of Operations in Patients with Tumor and Non-Tumor Obstructive Jaundice Who Received and Did Not Receive Antioxidant Therapy for the Correction of Endotoxemia, Glycolysis, and Oxidative Stress.

Purpose: To compare the results of surgical treatment and changes in biomarkers of cholestasis, endotoxicosis, cytolysis, lipid peroxidation, glycolysis disorders, and inflammation in patients with benign and malignant obstructive jaundice (OJ) in patients receiving and not receiving antioxidant pharmacotherapy (AOT). Patients and methods: The study included 113 patients (aged 21–90 years; 47 males and 66 females) who received surgical intervention for OJ due to non-malignant (71%) or malignant tumor (29%) etiologies. Patients were divided into two groups: Group I (n = 61) who did not receive AOT and Group II (n = 51) who received AOT (succinate-containing drug Reamberin) as part of detoxification infusion therapy. The surgical approach and scope of interventions in both groups were identical. Dynamic indicators of endotoxicosis, cholestasis, and cytolysis (total, direct, and indirect bilirubin, alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [AP] and gamma-glutamyltransferase [GGT]), kidney function (urea), lipid peroxidation (malonic dialdehyde, MDA), inflammation (leukocytosis), and glycolysis disorders (lactate dehydrogenase (LDH), glucose) were evaluated. Results: Tumor jaundice, unlike non-tumor jaundice, persisted and was characterized by a more severe course, a higher level of hyperbilirubinemia, and lipid peroxidation. The prognostic value of the direct (and total) bilirubin, MDA, glycemia, and leukocytosis levels on the day of hospitalization, which increased significantly in severe jaundice and, especially, in deceased patients, was established. Decompression interventions significantly reduced levels of markers of liver failure, cytolysis, cholestasis, and lipid peroxidation on day 3 after decompression by 1.5–3 times from initial levels; this is better achieved in non-tumor OJ. However, 8 days after decompression, most patients did not normalize the parameters studied in both groups. AOT favorably influenced the dynamics (on day 8 after decompression) of total and direct bilirubin, ALT, AST, MDA, and leukocytosis in non-tumor jaundice, as well as the dynamics of direct bilirubin, AST, MDA, glucose, and LDH in tumor jaundice. Clinically, in the AOT group, a two-fold reduction in the operative and non-operative complications was recorded (from 23% to 11.5%), a reduction in the duration of biliary drainage by 30%, the length of stay in intensive care units was reduced by 5 days, and even hospital mortality decreased, especially in malignancy-induced OJ. Conclusion: A mechanism for the development of liver failure in OJ is oxidative stress with the appearance of enhanced lipid peroxidation and accompanied by hepatocyte necrosis. Inclusion of AOT in perioperative treatment in these patients improves treatment outcomes.

Clinical profile, management, and outcome of obstructive jaundice patient at a tertiary care center: A prospective study

Background: There are various causes of obstructive jaundice, choledocholithiasis is the commonest cause. Patients with obstructive jaundice need early diagnosis to established level and nature of obstruction in biliary system. The history and clinical examination in arriving at a correct pre-operative diagnosis in almost always possible today because of advances in imaging techniques over the decades. Presents study attempts to determine the various causes, age and sex pattern in Extra Hepatic obstructive jaundice. Aims and Objectives: The aim of the study was to study clinical profile, management, and outcome of obstructive jaundice, patient at a tertiary care center: A prospective study. Materials and Methods: The present hospital based prospective interventional study was conducted on patients with obstructive jaundice, those were admitted in the Department of General Surgery at GSVM Medical College Kanpur, patients of age more than 12 years both sex after obtaining the consent form the patient or their relatives were studied during the period of study from January 2020 to October 2021. Results: Of the 50 patients; 29 (58%) were female and 21 (42%) were male, their mean age being 51.10 years. Malignant obstructive jaundice was seen in 19 (38%) patients while 31 (62%) had benign etiology. Amongst the obstructive jaundice cases; pain in abdomen (100%) was commonest symptoms and icterus (100%) was the most common sign. The most common malignancy was Carcinoma (Ca) of the head of pancreas 09 (18%) followed by distal common bile duct (CBD) cholangiocarcinoma 04 (08%), and hilar cholangiocarcinoma 03 (06%). Choledocholithiasis 25 (50%) was the most common benign cause followed by benign stricture of common bile duct 03 (06%). Conclusion: Obstructive jaundice is one of the common causes of surgically amenable jaundice. Its etiology is varied and diagnosis usually depends on appropriate imaging. Proper diagnosis and treatment is necessary as delay in the diagnosis may cause irreversible pathological changes causing increased morbidity and mortality.

Management of massive bilothorax post-percutaneous trans-hepatic biliary drainage

BackgroundIatrogenic bilothorax is an infrequent major complication of percutaneous trans-hepatic biliary drainage (PTBD) and optimal treatment remains under-reported. The authors herein describe a case of PTBD complicated by a massive bilous effusion.Case presentationAn 80-year-old male underwent PTBD due to malignant obstructive jaundice (total bilirubin 20.0 mg/dL). Following discharge, the patient was readmitted with severe dyspnea and recurrence of jaundice (total bilirubin 15.0 mg/dL). CT depicted the drainage catheter traversing the right costophrenic sulcus, complete obliteration of the right pleural space, no aerated right lung parenchyma and left mediastinal shift. The pleural effusion was successfully drained, and the biliary drainage catheter tract was sealed with Gelfoam pledgets and coils, to prevent bilopleural fistula formation and recurrence of the effusion.ConclusionsIn this case, a successful totally percutaneous management of iatrogenic bilothorax following PTBD is described. Due to the potential of rapid clinical deterioration and empyema formation, immediate evaluation and treatment are warranted. Prompt pleural drainage with antibiotic therapy and bile flow diversion from the pleural cavity are required.

C-Reactive protein / prealbumin coefficient, as a new marker in diagnosis and monitoring of the treatment efficacy in patients with malignant obstructive jaundice, complicated by ascending cholangitis

preoperative ascending cholangitis is one of the main factors of unsatisfactory treatment outcomes and prognosis in patients with malignant obstructive jaundice. The aim of our study was to evaluate the diagnostic value of CRP /PA coefficient in preoperative ascending cholangitis diagnosis, the effectiveness of preoperative preparation and the possibility of infectious complications, which will improve the treatment quality and prognosis of this cohort of patients. The end points of the study were: to determine the reference rate of the СRP/PA coefficient; to evaluate the coefficient value for cholangitis and its severity at the stages of treatment; assess its importance in detecting postoperative infectious complications. A one-center prospective study of the treatment results of 84 patients who underwent biliary decompression in the preoperative period was conducted. All patients were diagnosed with preoperative ascending cholangitis according to the Tokyo Guidelines, 2018 criteria - I grade - in 48 (57.1%) patients, II grade - in 36 (42.9%) patients. It was determined that the median СRP/PA in healthy patients was 0.01 (0.01-0.02) of the main surgical intervention was significantly higher - 0.21 (0.13-0.45) and 0.02 (0.01-0.03) than in healthy individuals - 0.01 (0.01-0.02) ); p <0.001 and p = 0.004, respectively, we found a statistically difference between the medians of the СRP/PA level in patients with mild to moderate preoperative ascending cholangitis (p <0.001), which is confirmed by the correlation between the severity grade of cholangitis and СRP/PA value (r = 0,381, p <0,001). It was found that the preoperative biliary drainage increases the probability of reducing the СRP/PA level by 18% (R = 0,42, R2 = 0,18, p <0,001), increase СRP/PA level before drainage is associated with the presence of mixed biliary tract infection in 25% cases (R2 (Nagelkerke) = 0.25, p = 0.002) and it's also associated with an increased the rate of infectious complications from postoperative wound by 18 .9% (R2 (Nagelkerke) = 0.189, p = 0.005). CRP/PA coefficient may indicate preoperative ascending cholangitis diagnosis and its severity ​​in patients with malignant obstructive jaundice. Increase СRP/PA level before preoperative biliary drainage is associated with the presence of mixed biliary tract flora and possibility of infectious complications. The dynamics of the coefficient value can show the efficacy of preoperative preparation after biliary decompression and predict correct time for surgery, which improves the treatment prognosis in postoperative period.

Successful endoscopic drainage of malignant obstructive jaundice in patients with situs inversus totalis: Two cases report.

Introduction and importanceAlthough endoscopic techniques in situs inversus totalis (SIT) have been reported, endoscopic retrograde cholangiopancreatography (ERCP) in patients with situs inversus totalis (SIT) remains difficult to every hepatobiliary surgeon. To investigate the differences of each position, ERCP was used to perform through two different body positions.Case presentationHerein we report a 63-year-old woman presented with epigastric pain for 2 months and jaundice for 7 days and a 51-year-old man with presented jaundice for 7 days. Preoperative examination revealed situs inversus totalis and gallbladder carcinoma with diffuse dilatation of the biliary tree. ERCP was used to perform by using two different body positions. In addition, the ERCP combined with percutaneous transhepatic cholangial drainage (PTCD) was performed in the second patient.Clinical discussionThe different endoscopic approaches are used in different positions, the endoscopist should be familiar with mirror symmetrical anatomy. We argue that the prone position has a higher surgical success rate and ERCP combined with PTCD will be easier in SIT patients.ConclusionERCP in SIT patients is generally safe and it will be easier by combining with PTCD.

Two approaches in the treatment of malignant obstructive jaundice using nitinol stents

The article presents our experience of observing two different approaches for endoscopic retrograde drainage in patients with malignant pathology of the pancreatobiliary zone, complicated by the bile duct obstruction. In one case, in case of dysfunction of the installed uncovered stent as a result of incrustation with bile salts and/or tumor invasion, stent-to-stent restenting was performed. In the second case, if it was impossible to pass the guidewire retrogradely beyond the area of the tumor narrowing, an alternative method was used – bringing it down by percutaneous transhepatic access towards the endoscope to install a retrograde stent delivery system along it using the "Rendezvous" method.

The impact of preoperative biliary drainage on postoperative outcomes in patients with malignant obstructive jaundice: a retrospective analysis of 290 consecutive cases at a single medical center

BackgroundThe efficacy of preoperative biliary drainage (PBD) has been debated for several decades, and yet indications for PBD remain controversial. The aim of this study was to compare the postoperative morbidity and mortality in patients with malignant obstructive jaundice undergoing direct surgery versus surgery with PBD.MethodsAll consecutive patients with malignant obstructive jaundice who underwent radical resection between June 2017 and December 2019 at Zhongshan Hospital were analyzed retrospectively. The study population was divided into two groups: PBD group (PG) and direct surgery group (DG). The subgroups were chosen based on the site of obstruction. Perioperative indicators and postoperative complications were compared and analyzed.ResultsA total of 290 patients were analyzed. Postoperative complications occurred in 134 patients (46.4%). Patients in the PG group had a lower overall rate of postoperative complications compared with the DG group, with perioperative total bilirubin (TB) identified as an independent risk factor in multivariate analysis (hazard ratio = 1.004; 95% confidence interval 1.001–1.007; P = 0.017). Subgroup analysis showed that PBD reduced the complication rate in patients with proximal obstruction. In the proximal-obstruction subgroup, a preoperative TB level > 162 μmol/L predicted postoperative complications.ConclusionsPBD may reduce the overall rate of postoperative complications among patients with proximal malignant obstructive jaundice.Trial registrationClinicalTrials.gov, 2018ZSLC 24. Registered May 17, 2018, https://clinicaltrials.gov/.

Factors related to stent patency and early elimination of jaundice using bile duct stent combined with iodine-125 seed implantation in malignant obstructive jaundice.

Biliary stents combined with percutaneous or endoscopic ultrasound-guided iodine-125 seed implantation into primary tumor have been confirmed to relieve malignant obstructive jaundice (MOJ), and prolong patient's stent patency. The aim of the study was to evaluate meaningful clinical application indications and better guide the application of this technology. Patients with MOJ, who have received bile duct stenting combined with iodine-125 (125I) seed implantation from October, 2010 to April, 2022, were retrospectively analyzed. Univariate and multivariate analyses were adopted to indicate factors of stent patency in MOJ and influencing factors of jaundice reduction at one week after surgery. A total of 90 patients were enrolled into the study, including 52 males (57.8%) and 38 females (42.2%), with a mean age of 68.66 ±12.53 years. The median stent patency was 8 months. No serious adverse events occurred during follow-up. Multivariate analysis showed that Child-Pugh score (HR = 2.221, 95% CI: 1.081-4.562), biliary infection (HR = 1.901, 95% CI: 1.084-3.335), and pre-operative jaundice duration (HR = 1.977, 95% CI: 1.106-3.533) were the independent risk factors for stent patency. Child-Pugh B/C (OR = 4.647, 95% CI: 1.080-19.982) and bile duct infection (OR = 3.583, 95% CI: 1.095-11.725) were the independent risk factors for jaundice reduction at one week after surgery. MOJ patients treated with biliary stents combined with 125I seed implantation, and patients with better pre-operative liver function and no biliary tract infection, present not only longer biliary stent patency, but also better early jaundice reduction.

EUS-guided hepaticogastrostomy in patients with obstructive jaundice after failed or impossible endoscopic retrograde drainage: A multicenter, randomized phase II Study.

Over the last two decades, EUS-guided hepaticogastrostomy (EUS-HGS) has emerged as a therapeutic alternative for patients with biliary obstruction and failed ERCP. Percutaneous transhepatic biliary drainage (PTBD) as the gold standard is associated with relevant morbidity and need for re-intervention. The aim of our work was to evaluate in a phase II study the safety and efficacy profile of EUS-HGS. A PTBD arm was considered a control group. We conducted a prospective, randomized, noncomparative phase II study in three French tertiary centers involving patients with benign or malignant obstructive jaundice after failure of ERCP. Patients were randomized to either PTBD or EUS-HGS. Fifty-six patients (mean age 64 years) have been included between 2011 and 2015. Twenty-one underwent PTBD and thirty-five were drained using EUS-HGS. An interim analysis after the inclusion of 41 patients revealed an unexpected high 30-day morbidity rate for PTBD (13 out of 21 patients), justifying to stop randomization and inclusion in this control arm in 2013. The primary objective was reached with 10 out of the 35 EUS-HGS patients (28.6%) having observed complications (90%-level bilateral exact binomial confidence interval [CI] [16.4%-43.6%], left-sided exact binomial test to the objectified 50% unacceptable rate P = 0.0083). Both methods achieved comparable technical success rate (TSR) and clinical success rate (CSR) (TSR: PTBD 100% vs. EUS-HGS 94.3%, P = 0.28; CSR: PTBD 66.7% vs. EUS-HGS 80%, P = 0.35). Long-term follow-up showed EUS-HGS patients being at lower risk for re-intervention (relative risk = 0.47, 95% CI [0.27-0.83]). In cases of ERCP failure, EUS-HGS is a valuable alternative for biliary drainage with a high TSR and CSR. PTBD is associated with an unacceptable 30-day morbidity rate, whereas EUS-HGS seems to have a decent safety profile, suggesting that it may be the treatment of choice in appropriately selected patients.

Clinical Characteristics, Treatment, and Prognosis of Patients with Obstructive Jaundice in Tertiary Care Facilities: A Prospective Study

Background: Obstructive jaundice can have a number of reasons, but choledocholithias is the most frequent. Obstructive jaundice patients frequently complain of pruritus, jaundice, pale faeces, dark urine, and yellow skin and eyes. Today, because to improvements in imaging technology over the years, a precise pre-operative diagnosis is nearly always attainable. The study's goals were to examine the clinical characteristics and treatment of patients with obstructive jaundice. Methods: Patients with obstructive jaundice who were admitted to the Department of Hepatology at SCB Medical College, Cuttack, Odisha, were the subject of the current hospital-based prospective interventional study. Patients of age greater than 12 years of either sex were studied during the study period of two years after providing written consent. Results: The mean age of the 50 patients was 51.10 years, with 29 (58%) female and 21 (42%) male patients. 19 (38%) of the patients had malignant obstructive jaundice, while 31 (62%) had benign causes. The most frequent symptoms and signs of obstructive jaundice were abdominal pain (100%) and icterus (100%) respectively. The most frequent cancer was cholangiocarcinoma (Ca) of the head of pancreas (Ca) of 2009 (18%), followed by cholangiocarcinoma of the distal common bile duct (CBD) of 2004 (08%), and hilar cholangiocarcinoma of 2003 (06%). The most frequent benign cause was choledocholithiasis 25 (50%) followed by benign stricture of common bile duct 03 (06%). Conclusion: One of the frequent reasons of surgically treatable jaundice is obstructive jaundice. Its cause is diverse, and the right imaging is typically required for diagnosis. As delayed diagnosis may result in permanent pathological alterations that increase morbidity and death, proper diagnosis and treatment are essential.

Current Status of Ultrasound-guided Percutaneous Transhepatic Cholangial Drainage in the Treatment of Malignant Obstructive Jaundice

Malignant obstructive jaundice (MOJ) is mostly biliary obstruction caused by digestive malignant tumor, which causes serious complications such as hyperbilirubinemia and which greatly affects the life of patients. The traditional treatment of MOJ is Laparotomy. In recent years, palliative treatment such as percutaneous transhepatic cholangial drainage (PTCD) has been widely implemented. Although the method of PTCD is simple and safe, some controversies about its efficacy, complications and contraindications are still being debated. This paper reviews the clinical application and research status of PTCD in the treatment of MOJ.

Palliative decomprression in malignant obstructive jaundice: focus on the liver function

Background and Study Aim: to investigate the impact of endoscopic and laparoscopic palliative decompression of the common bile duct on the liver function of patients with obstructive jaundice caused by tumor growth. 
 Materials and Methods. 48 patients were involved in the study with diagnosed incurable tumors and severe mechanical jaundice in the period from 2011 to 2017 years. Palliative decompression of the common bile duct was performed for all of them: endoscopic methods in 30 patients and laparoscopic hepaticojejunostomy – in 18 patients. Every subgroup was randomized by age, sex, duration of jaundice, and major biochemical parameters determined before surgery. Patients were monitored following next 6 months after decompression. Before surgery, 1, 7 and 14 days, as well as 3 and 6 months after decompression liver function markers were checked: prothrombin time, INR index, serum total protein and albumin with routine methods.
 Results. Laparoscopic decompression of the common bile duct by hepaticojejunostomy leads to faster recovery of liver function (manifested by a steady decrease in prothrombin time, INR index and an increase in serum total protein and albumin in next 3-6 months) compared to endoscopic methods.
 After endoscopic decompression in this period, the prothrombin time and INR index are significantly higher, the content of total protein and albumin in the serum is lower in comparison to laparoscopic decompression. The indicators of hepatodepressive syndrome significantly deteriorate, 3-6 months after the procedure of endoscopic decompression, which is associated with the development of complications in 30.0% of patients.
 Conclusions. Laparoscopic decompression of the common bile duct by forming a hepaticojejunoanastomosis is accompanied by faster restoring of liver function markers compared to endoscopic methods in patients with inoperable periampullary tumors.

Percutaneous biliary stent combined with brachytherapy using 125I seeds for treatment of unresectable malignant obstructive jaundice: A meta-analysis.

BACKGROUNDMalignant obstructive jaundice (MOJ) is a common pathologic manifestation of malignant biliary obstruction. Recently, several clinical trials have explored the clinical effectiveness of intraluminal 125I seed-based brachytherapy for MOJ patients, and various outcomes have been reported.AIMTo assess the efficacy and safety of percutaneous biliary stents with 125I seeds compared to conventional metal stents in patients with unresectable MOJ.METHODSA systematic search of English-language databases (PubMed, Embase, Cochrane Library, and Web of Science) was performed to identify studies published prior to June 2020 that compared stents with or without 125I seeds in the treatment of unresectable MOJ. The outcomes analyzed included primary outcomes (stent patency and overall survival) and secondary outcomes (complications and liver function parameters).RESULTSSix randomized controlled trials and four retrospective studies involving 875 patients were eligible for the analysis. Of the 875 included patients, 404 were treated with 125I seed stents, while 471 were treated with conventional stents. Unadjusted pooled analysis demonstrated that compared to conventional stents, 125I seed stents extended the stent patency time [hazard ratio (HR) = 0.36, 95% confidence interval (CI) = 0.28-0.45, P < 0.0001] and overall survival period (HR = 0.52, 95%CI = 0.42–0.64, P < 0.00001). Subgroup analyses based on the type of 125I seed stent and type of study design showed consistent results. However, there were no significant differences in the occurrence of total complications [odds ratio (OR) = 1.12, 95%CI = 0.75-1.67, P = 0.57], hemobilia (OR = 1.02, 95%CI = 0.45-2.3, P = 0.96), pancreatitis (OR = 1.79, 95%CI = 0.42-7.53, P = 0.43), cholangitis (OR = 1.13, 95%CI = 0.60-2.13, P = 0.71), or pain (OR = 0.67, 95%CI = 0.22-2, P = 0.47). In addition, there were no reductions in the levels of serum indices, including total bilirubin [mean difference (MD) = 10.96, 95%CI = -3.56-25.49, P = 0.14], direct bilirubin (MD = 7.37, 95%CI = -9.76-24.5, P = 0.4), alanine aminotransferase (MD = 7.52, 95%CI = -0.71-15.74, P = 0.07), and aspartate aminotransferase (MD = -4.77, 95%CI = -19.98-10.44, P = 0.54), after treatment. Publication bias was detected regarding the outcome overall survival; however, the conclusions were not changed after the adjustment.CONCLUSIONPlacement of stents combined with brachytherapy using 125I seeds contributes to a longer stent patency and higher overall survival than placement of conventional stents without extra complications or severe liver damage. Thus, it can be considered an effective and safe treatment for unresectable MOJ.

Improving rehabilitation and quality of life after percutaneous transhepatic cholangiography drainage with a rapid rehabilitation model.

BACKGROUNDPercutaneous transhepatic cholangiography drainage (PTCD) effectively treats biliary obstruction. However, patients must maintain the drainage tube after hospital discharge, which may interfere with daily life and work, potentially causing psychological distress. Postoperative rehabilitation is crucial, and strengthened nursing interventions can shorten recovery time.AIMThe aim was to evaluate an inpatient model to shorten rehabilitation duration and improve quality of life after PTCD.METHODSA total of 118 patients with malignant obstructive jaundice who were admitted to our hospital between May 2018 and January 2021 were included and divided into observational (with therapy) and control (no therapy) groups of 59 each.RESULTSThe observational group had fewer hospitalization days than the control group. The complication, the PTCD fixed-tube prolapse, and tube-related admission rates within 3 mo after PTCD were significantly lower in the observation group than in the control group (P < 0.05). The fatigue, pain, nausea, vomiting, pruritus, emaciation, and fever scores after PTCD decreased in both groups compared with the scores before PTCD (P < 0.05). The quality of life scores after the intervention were higher in the observation than in the control group (P < 0.05).CONCLUSIONThe model promoted rehabilitation after PTCD, reduced post-PTCD complications, and the tube-related admissions in the 3 mo after the procedure, and improved the quality of life.

Self-expandable metallic stent with 125I seed strand in malignant biliary obstruction: a self-made delivery system and novel implantation method.

BackgroundMalignant obstructive jaundice (MOJ) has a low immediate surgery rate (10–20%) and a poor post-resection survival rate. Although several clinical results have demonstrated the safety and efficacy of stent placement combined with radioactive seeds, the existing implantation methods are time consuming and prone to error. In this study, we introduced a self-made delivery system and novel implantation method for a self-expandable metallic stent (SEMS) with 125I seed strand and evaluated its feasibility and efficacy in MOJ patients.MethodsOur self-made delivery system was applied to 61 patients (39 males and 22 females, mean age 66.36±10.73 years) from October 2018 to June 2020 in our center with a novel implantation method. The preparation and manipulation processes were described in detail. Technical and clinical successes were recorded, and stent patency and overall survival (OS) were assessed. A P value of less than 0.05 indicated a significant difference.ResultsStents with 125I seed strands were successfully placed in all 61 participants with our novel implantation method. The clinical success rate was 96.7%, and no severe procedure-related complications were found except bile leakage through puncture in 1 participant. The median duration of primary stent patency was 120 (37, 233.5) days, and the median OS was 169 (41, 270) days.ConclusionsOur self-made delivery system with a novel SEMS implantation method with 125I seed strand was feasible and effective for MOJ patients and significantly simplified the current implantation approach.

Preliminary application of brachytherapy with double-strand 125I seeds and biliary drainage for malignant obstructive jaundice.

To evaluate the efficacy and safety of brachytherapy with double-strand 125I seeds and biliary drainage for malignant obstructive jaundice. 42 patients with obstructive jaundice because of extrahepatic cholangiocarcinoma were enrolled. 22 patients (group A) received a biliary stent with common drainage tube implantation, and 20 patients (group B) received a biliary stent with double-strand 125I seeds radiotherapy drainage tube placement. The length, location and pathological stage of biliary stricture were recorded in the two groups. Total bilirubin (TBIL), direct bilirubin (DBIL), IgA, IgG, IgM, alanine aminotransferase and white blood cell (WBC) count were measured before and after percutaneous transhepatic cholangial drainage (PTCD). Tumor diameter was measured before and three months after PTCD, and the difference were calculated. Stent patency time, survival time, and complications were recorded. There was no significant difference in the length, location and pathological stage of biliary stenosis between the two groups. There was no significant difference in TBIL, DBIL, IgA, IgG, IgM, alanine aminotransferase and WBC count between the two groups before or after PTCD (P > 0.05). Three months after PTCD, tumors growth in group A and tumors shrinkage in group B. The difference in tumor size between the two groups before and after PTCD was statistically significant (P < 0.05). The average stent patency times in groups A and B were 3.55 ± 0.76months and 8.76 ± 1.85months, respectively (P < 0.05). The average survival times in groups A and B were 133.5 ± 27.8days and 252.5 ± 114.5days, respectively (P < 0.05). There was no statistically significant difference in the incidence of complications between the two groups (P > 0.05). Double-strand 125I seeds radiotherapy biliary drainage tubes can safely and effectively control tumors, prolong the patency of biliary stents, and prolong patient survival.

A Predictive Model Based on the Gut Microbiota Improves the Diagnostic Effect in Patients With Cholangiocarcinoma

Cholangiocarcinoma (CCA) is a malignant hepatic tumor with a poor prognosis, which needs early diagnosis urgently. The gut microbiota has been shown to play a crucial role in the progression of liver cancer. Here, we explored a gut microbiota model covering genera Burkholderia-Caballeronia-Paraburkholderia, Faecalibacterium, and Ruminococcus_1 (B-F-R) for CCA early diagnosis. A case-control study was conducted to enroll 53 CCA patients, 47 cholelithiasis patients, and 40 healthy controls. The feces samples and clinical information of participants were collected in the same period. The gut microbiota and its diversity of individuals were accessed with 16S rDNA sequencing, and the gut microbiota profile was evaluated according to microbiota diversity. Finally, four enriched genera in the CCA group (genera Bacteroides, Muribaculaceae_unclassified, Muribaculum, and Alistipes) and eight enriched genera in the cholelithiasis group (genera Bifidobacterium, Streptococcus, Agathobacter, Ruminococcus_gnavus_group, Faecalibacterium, Subdoligranulum, Collinsella, Escherichia-Shigella) constitute an overall different microbial community composition (P = 0.001). The B-F-R genera model with better diagnostic value than carbohydrate antigen 19-9 (CA19-9) was identified by random forest and Statistical Analysis of Metagenomic Profiles (STAMP) to distinguish CCA patients from healthy controls [area under the curve (AUC) = 0.973, 95% CI = 0.932–1.0]. Moreover, the correlative analysis found that genera Burkholderia-Caballeronia-Paraburkholderia were positively correlated with body mass index (BMI). The significantly different microbiomes between cholelithiasis and CCA were found via principal coordinates analysis (PCoA) and linear discriminant analysis effect size (LEfSe), and Venn diagram and LEfSe were utilized to identify four genera by comparing microbial compositions among patients with malignant obstructive jaundice (MOJ-Y) or not (MOJ-N). In brief, our findings suggest that gut microbiota vary from benign and malignant hepatobiliary diseases to healthy people and provide evidence supporting gut microbiota to be a non-invasive biomarker for the early diagnosis of CCA.

Predicting Inchinkoto efficacy, in patients with obstructive jaundice associated with malignant tumors, through pharmacomicrobiomics

Inchinkoto (ICKT) is a popular choleretic and hepatoprotective herbal medicine that is widely used in Japan. Geniposide, a major ingredient of ICKT, is metabolized to genipin by gut microbiota, which exerts a choleretic effect. This study investigates the relationship between stool genipin-producing activity and diversity of the clinical effect of ICKT in patients with malignant obstructive jaundice. Fifty-two patients with malignant obstructive jaundice who underwent external biliary drainage were included. ICKT was administered as three packets per day (7.5 g/day) for three days and 2.5 g on the morning of the fourth day. Stool samples were collected before ICKT administration and bile flow was monitored on a daily basis. The microbiome, genipin-producing activity, and organic acids in stools were analyzed. The Shannon-Wiener (SW) index was calculated to evaluate gut microbiome diversity. The stool genipin-producing activity showed a significant positive correlation with the SW index. Stool genipin-producing activity positively correlated with the order Clostridia (obligate anaerobes), but negatively correlated with the order Lactobacillales (facultative anaerobes). Moreover, stool genipin-producing activity was positively correlated to the concentration valeric acid, but negatively correlated to the concentration of lactic acid and succinic acid. The change of bile flow at 2 and 3 days after ICKT administration showed significant positive correlation with genipin-producing activity (correlation coefficient, 0.40 and 0.29, respectively, P < 0.05). An analysis of stool profile, including stool genipin-producing activity, may predict the efficacy of ICKT. Modification of the microbiome may be a target to enhance the therapeutic effect of ICKT.

Hepatic arterial infusion chemotherapy following simultaneous metallic stent placement and iodine-125 seed strands for advanced cholangiocarcinoma causing malignant obstructive jaundice: a propensity score matching study.

This study aims to evaluate the effectiveness and safety of hepatic arterial infusion chemotherapy (HAIC) following the simultaneous placement of self-expandable metallic stent (SEMS) and iodine-125 (125I) seed strands for the management of advanced cholangiocarcinoma (CCA) patients presenting with malignant obstructive jaundice (MOJ). Data from 74 patients with MOJ caused by advanced CCA treated with stent placement with 125I seed strands with or without HAIC between November 2015 and October 2020 were analysed retrospectively. Eighteen patients received 5 sessions of HAIC after SEMS placement with 125I seed strands (HAIC group), and 56 patients only underwent SEMS placement with 125I seed strands and served as controls (control group). HAIC consisted of infusions of gemcitabine (600-1000mg/m2 given over 30min) followed by oxaliplatin (60-100mg/m2 given over 2h), with an interval of 4weeks. Propensity score matching (PSM) analysis was used to adjust for differences in the baseline characteristics of the groups (including age, total bilirubin, and serum alanine aminotransferase level). Overall survival (OS), stent patency, and adverse events were compared between the two groups. OS and stent patency were significantly better in patients in the HAIC group than in those in the control group (median survival time: before PSM, 362 vs. 185days, p = 0.005; after PSM, 357 vs. 183days, p = 0.012; median duration of stent patency: before PSM, 294 vs. 156days, p = 0.001; after PSM, 287 vs. 183days, p = 0.039). All adverse reactions were controllable by temporary symptomatic treatment. Serious complications and treatment-related deaths were not observed. Our preliminary study showed that HAIC following SEMS placement with 125I seed strands is effective and safe for the management of advanced CCA patients presenting with MOJ and could improve stent patency and patient survival.

Comparison among the Role of Different Imaging Techniques in Diagnosis of Malignant Lesions Causing Obstructive Jaundice

Introduction: The expanding spectrum of therapeutic options for patients with Obstructive /surgical jaundice makes it necessary for the surgeon to precisely assess the etiology, location, level and extent of disease before operation. Aims were to compare the diagnostic accuracy, sensitivity and specificity of different imaging techniques like ultrasonography (USG), Computed tomography (CT) and Magnetic Resonance Cholangiopancreatography (MRCP) and Endoscopic Retrograde Cholangiopancreatography (ERCP) in evaluation of patients with malignant obstructive jaundice and correlation of histopathological findings after surgical/ therapeutic intervention. Methods: It was a prospective observational study conducted in the Department of General Surgery and Hepatobilliary unit, Dhaka Medical College Hospital and Bangabandhu Sheikh Mujib Medical University, Dhaka during January 2015 to December 2015 for duration of one year to find out the role of different imaging techniques in diagnosis of malignant lesions causing obstructive jaundice in 50 cases who fulfilled the inclusion criteria. Initial USG evaluation was followed by CT scan, MRCP and ERCP. The results were read by radiologists blinded to other imaging findings. Surgically fit patients with a stage of resectability should be offered the option of surgical resection for cure. For unresectable malignancies, the choice is between surgical palliation/bypass and ERCP with drainage. The characteristic surgical findings or ERCP features and histopathological diagnosis were recorded methodically as final. Results: Malignant obstructive jaundice is the commonest amongst the males and mean age was 47.56 ± 13.191 and the commonest etiology was Ca head of pancreas (30%). Diagnostic accuracy of MRCP (98%) in the diagnosis of malignant obstructive jaundice was relatively high (98%) as compared to ERCP (89.5%), CT (91.43%), USG (89.97%) in malignant obstructive jaundice respectively. In the diagnosis of malignant diseases, MRCP was more sensitive (95.83%) as compared to ERCP (89%), CT scan (91.67%) and ultrasonography (78.17%). Regarding specificity MRCP (100%) was the high in comparison among ERCP (94%), CT (90.91%) and USG (96.15%).Conclusion: It is concluded that malignant obstructive jaundice is the commonest amongst the males. Ca head of pancreas was the commonest malignant etiology in malignant obstructive jaundice. MRCP was superior to among USG, CT scan or ERCP in studying the malignant lesions. J Bangladesh Coll Phys Surg 2021; 39: 233-240