Percutaneous Transhepatic Biliary Drainage Group Research Articles

Preoperative biliary drainage for perihilar cholangiocarcinoma: A Meta-analysis

Objective To systematically review the effectiveness and safety of percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary drainage (EBD) for preoperative biliary drainage in patients with Klatskin Tumors. Methods The Pubmed, Embase, Web of Science, CNKI, VIP and WanFang Data from January 1998 to December 2017 were searched for published studies which compared endoscopic biliary drainage (EBD) with percutaneous transhepatic biliary drainage (PTBD) for preoperative biliary drainage. A Meta-analysis was then performed using the Revman 5.3 software. Results Seven cohort studies were included. There were 366 patients in the PTBD group, and 400 patients in the EBD groups. When compared with EBD, PTBD was associated with a lower risk of cholangitis (OR=0.31, 95% CI 0.20~0.48, P<0.05), a lower risk of pancreatitis (OR=0.11, 95% CI 0.04~0.34, P<0.05), and a lower risk of overall complications (OR=0.48, 95% CI 0.30~0.77, P=0.002). The rate of conversion from one procedure to the other was significantly lower in the PTBD group than the EBD group. The initial technical success rate and postoperative morbidity and mortality rates were similar in the 2 groups. Conclusion In patients with Klatskin tumors who require PBD, PTBD is a better initial biliary drainage method with lower incidences of procedure-related cholangitis, pancreatitis overall complications and conversion to other drainage procedures. Key words: Percutaneous transhepatic biliary drainage (PTBD); Endoscopic biliary drainage (EBD); Preoperative biliary drainage (PBD); Perihilar cholangiocarcinoma; Meta-analysis

EUS-guided versus percutaneous biliary access in patients with obstructive jaundice due to gastric cancer

BackgroundGastric cancer is sometimes complicated by obstructive jaundice. However, ERCP may be challenging in patients who have advanced gastric cancer, or recurrent gastric cancer after surgical resection that is complicated by obstructive jaundice. In such cases, percutaneous transhepatic biliary drainage (PTBD) is considered. Recently, EUS-guided biliary drainage (EUS-BD) has been developed. We conducted a retrospective study to compare the efficacy of EUS-BD and PTBD in patients with obstructive jaundice due to gastric cancer. MethodsPatients with gastric cancer complicated with obstructive jaundice who were contraindicated for standard ERCP were enrolled. ResultsA total of 47 consecutive patients were enrolled during the study period. The technical success rates of PTBD and EUS-BD were 88.9% (16/18) and 96.7% (29/30), respectively (P = 0.64). The stent patency period, including patient death was equivalent between the two groups (EUS-BD vs. PTBD: 188.4 days vs. 200.9 days, P = 0.974). Time to stent dysfunction in the EUS-BD group (391.1 days) was not significantly different as compared to that in the PTBD group (398.1 days) (P = 0.78). Adverse events were relatively severe in the PTBD group. ConclusionsGiven the relative severity of adverse events in the PTBD group, EUS-BD might be the procedure of choice for gastric cancer patients with contraindications by inability to perform ERCP.

Endoscopic versus percutaneous biliary drainage in patients with resectable perihilar cholangiocarcinoma: a multicentre, randomised controlled trial

In patients with resectable perihilar cholangiocarcinoma, biliary drainage is recommended to treat obstructive jaundice and optimise the clinical condition before liver resection. Little evidence exists on the preferred initial method of biliary drainage. We therefore investigated the incidence of severe drainage-related complications of endoscopic biliary drainage or percutaneous transhepatic biliary drainage in patients with potentially resectable perihilar cholangiocarcinoma. We did a multicentre, randomised controlled trial at four academic centres in the Netherlands. Patients who were aged at least 18 years with potentially resectable perihilar cholangiocarcinoma requiring major liver resection, and biliary obstruction of the future liver remnant (defined as a bilirubin concentration of >50 μmol/L [2·9 mg/dL]), were randomly assigned (1:1) to receive endoscopic biliary drainage or percutaneous transhepatic biliary drainage through the use of computer-generated allocation. Randomisation, done by the trial coordinator, was stratified for previous (attempted) biliary drainage, the extent of bile duct involvement, and enrolling centre. Patients were enrolled by clinicians of the participating centres. The primary outcome was the number of severe complications between randomisation and surgery in the intention-to-treat population. The trial was registered at the Netherlands National Trial Register, number NTR4243. From Sept 26, 2013, to April 29, 2016, 261 patients were screened for participation, and 54 eligible patients were randomly assigned to endoscopic biliary drainage (n=27) or percutaneous transhepatic biliary drainage (n=27). The study was prematurely closed because of higher mortality in the percutaneous transhepatic biliary drainage group (11 [41%] of 27 patients) than in the endoscopic biliary drainage group (three [11%] of 27 patients; relative risk 3·67, 95% CI 1·15-11·69; p=0·03). Three of the 11 deaths among patients in the percutaneous transhepatic biliary drainage group occurred before surgery. The proportion of patients with severe preoperative drainage-related complications was similar between the groups (17 [63%] patients in the percutaneous transhepatic biliary drainage group vs 18 [67%] in the endoscopic biliary drainage group; relative risk 0·94, 95% CI 0·64-1·40). 16 (59%) patients in the percutaneous transhepatic biliary drainage group and ten (37%) patients in the endoscopic biliary drainage group developed preoperative cholangitis (p=0·1). 15 (56%) patients required additional percutaneous transhepatic biliary drainage after endoscopic biliary drainage, whereas only one (4%) patient required endoscopic biliary drainage after percutaneous transhepatic biliary drainage. The study was prematurely stopped because of higher all-cause mortality in the percutaneous transhepatic biliary drainage group. Post-drainage complications were similar between groups, but the data should be interpreted with caution because of the small sample size. The results call for further prospective studies and reconsideration of indications and strategy towards biliary drainage in this complex disease. Dutch Cancer Foundation.

3:00 PM Abstract No. 160 Obstructive cholangiocarcinoma: hilar location as an indication for initial percutaneous management

The best initial therapy for hilar biliary obstruction is unclear: endoscopic retrograde cholangio-pancreatography (ERCP) is utilized by many clinicians, despite evidence suggesting that percutaneous transhepatic biliary drainage (PTBD) may be more appropriate in this setting [1]. The purpose of this study is to identify the influence of cholangiocarcinoma location on therapy outcomes. Records of 122 patients with newly diagnosed cholangiocarcinoma requiring biliary decompression from 2007 to 2016 were retrospectively reviewed. Preprocedural MRI was used to classify tumor location for 84% of patients. When this was not available, fluoroscopic procedural images were used. Hilar cholangiocarcinoma (Klatskin tumor) was present in 74 patients, and 41 had tumor involving the common hepatic and/or common bile ducts but not the hilum. PTBD was the initial therapy for 57 patients, and 65 were initially treated by ERCP. Therapeutic success was defined as resolution of hyperbilirubinemia to below 2.5 mg/dL, a level at which systemic chemotherapy can be safely administered. Of the group receiving initial ERCP treatment, 18/33 (55%) patients with hilar cholangiocarcinoma required conversion to PTBD within 30 days, compared to 4/28 (14%) with cholangiocarcinoma of the common hepatic or common bile ducts. Patients with hilar tumors are therefore over three times more likely to fail endoscopic management (p = 0.001). Immediately apparent technical failure of ERCP stent placement occurred in 9/33 (27%) patients with hilar tumors. The ERCP and PTBD treatment groups had average pretreatment serum total bilirubin concentrations of 17.5 and 17.4 mg/dl, respectively. In both treatment groups, half of the patients reached therapeutic success within the period of available follow-up data. The PTBD group had a shorter mean time to therapeutic success of 33 days vs. 41 days for the ERCP group. Hilar location of cholangiocarcinoma is a strong predictor of failure of endoscopic management. PTBD as the first-line therapy for these patients could minimize the number of procedures performed and the associated complication risks. MRI is useful to determine which treatment best suits a patient.

ENBD is Associated with Decreased Tumor Dissemination Compared to PTBD in Perihilar Cholangiocarcinoma

BackgroundLittle is known regarding the risk of tumor dissemination when percutaneous biliary drainage is used before surgical resection of perihilar cholangiocarcinoma (PHC). We aimed to compare the incidence of tumor dissemination after preoperative endoscopic nasobiliary drainage (ENBD) with that after percutaneous transhepatic biliary drainage (PTBD) for PHC. MethodsData from 208 consecutive patients who underwent PHC resection between 2000 and 2013 were retrospectively analyzed. The influence of drainage type on incidence of tumor dissemination was examined. Seventy-six patients underwent ENBD (37%), 87 underwent PTBD (42%), and 45 underwent surgery without preoperative biliary drainage (WD, 22%). ResultsThe respective 2- and 5-year estimated cumulative incidences of tumor dissemination in the ENBD group (11.8/14.6%) were lower than in the PTBD group (28.8/35.9%, p = 0.003) and equivalent to that in the WD group (11.2/15.9%, p = NS). PTBD (hazard ratio [HR] vs. ENBD, 2.80) was an independent risk factor for postoperative tumor dissemination in the multivariate analysis. The 2- and 5-year disease-specific survival rates were higher in the ENBD group (67.6/47.3%) than in the PTBD group (56.6/27.8%, p = 0.032) and equivalent to that in the WD group (64.9/53.8%, p = NS). However, drainage type was not an independent risk factor in multivariate analysis of disease-specific survival. ConclusionFor patients with PHC, the associated risk of postoperative tumor dissemination in the ENBD group was lower than in the PTBD group and equivalent to that in the WD group. Thus, ENBD is the ideal procedure for preoperative biliary drainage.

Endoscopic ultrasound-guided hepaticogastrostomy versus percutaneous transhepatic drainage for malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatography: a retrospective expertise-based study from two centers.

Background:Percutaneous transhepatic biliary drainage (PTBD) is widely performed as a salvage procedure in patients with unresectable malignant obstruction of the common bile duct (CBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) or in case of surgically altered anatomy. Endoscopic ultrasound-guided hepaticogastrostomy (EU-HGS) is a more recently introduced alternative to relieve malignant obstructive jaundice. The aim of this prospective observational study was to compare the outcome, efficacy and adverse events of EU-HGS and PTBD.Methods:From April 2012 to August 2015, consecutive patients with malignant CBD obstruction who underwent EU-HGS or PTBD in two tertiary-care referral centers were included. The primary endpoint was the clinical success rate. Secondary endpoints were technical success, overall survival, procedure-related adverse events, incidence of adverse events, and reintervention rate.Results:A total of 51 patients (EU-HGS, n = 31; PTBD, n = 20) were included. Median survival was 71 days (range 25–75th percentile; 30–95) for the EU-HGS group and 78 days (range 25–75th percentile; 42–108) for the PTBD group (p = 0.99). Technical success was achieved in all patients in both groups. Clinical success was achieved in 25 (86%) of 31 patients in the EU-HGS group and in 15 (83%) of 20 patients in the PTBD group (p = 0.88). There was no difference in adverse events rates between the two groups (EU-HGS: 16%; PTBD: 10%) (p = 0.69). Four deaths within 1 month (two hemorrhagic and two septic) were considered procedure related (two in the EU-HGS group and two in the PTBD group). Overall reintervention rate was significantly lower after EU-HGS (n = 2) than after PTBD (n = 21) (p = 0.0001). Length of hospital stay was shorter after EU-HGS (8 days versus 15 days; p = 0.002).Conclusions:EU-HGS can be an effective and safe mini invasive-procedure alternative to PTBD, with similar success and adverse-event rates, but with lower rates of reintervention and length of hospitalization.

Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage after failed endoscopic retrograde cholangiopancreatography: a meta-analysis.

The failure rate of endoscopic retrograde cholangiopancreatography for biliary cannulation is approximately 6%–7% in cases of obstructive jaundice. Percutaneous transhepatic biliary drainage (PTBD) is the procedure of choice in such cases. Endoscopic ultrasound-guided biliary drainage (EGBD) is a novel technique that allows biliary drainage by echoendoscopy and fluoroscopy using a stent from the biliary tree to the gastrointestinal tract. Information in PubMed, Scopus, clinicaltrials.gov and Cochrane review were analyzed to obtain studies comparing EGBD and PTBD. Six studies fulfilled the inclusion criteria. Technical (odds ratio (OR): 0.34; confidence interval (CI) 0.10–1.14; p=0.05) and clinical (OR: 1.48; CI 0.46–4.79; p=0.51) success rates were not statistically significant between the EGBD and PTBD groups. Mild adverse events were nonsignificantly different (OR: 0.36; CI 0.10–1.24; p=0.11) but not the moderate-to-severe adverse events (OR: 0.16; CI 0.08–0.32; p≤0.00001) and total adverse events (OR: 0.34; CI 0.20–0.59; p≤0.0001). EGBD is equally effective but safer than PTBD.

Preoperative Biliary Drainage in Patients with Resectable Perihilar Cholangiocarcinoma: Is Percutaneous Transhepatic Biliary Drainage Safer and More Effective than Endoscopic Biliary Drainage? A Meta-Analysis

PurposeTo determine the best initial procedure for performing preoperative biliary drainage in patients with resectable perihilar cholangiocarcinoma (PHCC). Materials and MethodsMEDLINE/PubMed and the Cochrane database were searched for all studies published until June 2016 comparing endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD) for preoperative biliary drainage. Meta-analysis was performed by using Review Manager 5.3 software. ResultsFour retrospective studies were identified that met the criteria. The analysis was performed on 433 patients who underwent preoperative biliary drainage for resectable PHCC. Of those, 275 (63.5%) had EBD and 158 (36.5%) had PTBD as the initial procedure. The overall procedure-related morbidity rate was significantly lower in the PTBD group than in the EBD group (39 of 147 [26.5%] vs 82 of 185 [44.3%]; odds ratio [OR], 2.23; 95% confidence interval [CI], 1.39–3.57; P = .0009). The rate of conversion from one procedure to the other was significantly lower in the PTBD group than in the EBD group (8 of 158 [5.0%] vs 73 of 275 [26.5%]; odds ratio, 4.76; 95% CI, 2.71–8.36; P < .00001). Pancreatitis occurred only in the EBD group (25 of 275 [9.0%] vs 0 of 158; OR, 7.46; 95% CI, 3.02–18.44; P < .0001). The cholangitis rate was significantly lower in the PTBD group than in the EBD group (12 of 158 [7.6%] vs 93 of 275 [33.8%]; OR, 5.41; 95% CI, 2.75–10.63; P < .00001). ConclusionsThis meta-analysis shows that PTBD has a lower rate of complications than EBD as the initial procedure to perform preoperative biliary drainage in resectable PHCC. PTBD is associated with less conversion and lower rates of pancreatitis and cholangitis.

Prognostic impact of type of preoperative biliary drainage in patients with distal cholangiocarcinoma

BackgroundSurgical results of patients with resected distal cholangiocarcinoma (DCC) were evaluated to elucidate prognostic impact of the type of preoperative biliary drainage (PBD). MethodsEighty-eight patients with resected DCC were stratified into two groups according to the type of PBD: the percutaneous transhepatic biliary drainage (PTBD) group (n = 25) and the endoscopic biliary drainage (EBD) group (n = 63). ResultsOverall 5-year survival rate of the patients in the PTBD group was poorer than in the EBD group (24% vs. 52%, P = 0.020). On univariate analysis, PTBD, pancreatic invasion, perineural invasion, and lymph node involvement were significant prognostic factors for poor overall survival. On multivariate analysis, PTBD was the only significantly independent prognostic factor for poor overall survival. The incidence of liver metastasis was significantly higher in the PTBD group than in the EBD group (32.0% vs. 13.3%, P = 0.034). ConclusionsPTBD should be avoided as much as possible in patients with DCC since the patients who underwent PTBD had poorer overall survival and higher incidence of liver metastasis than those who underwent EBD.

A meta-analysis and systematic review: Success of endoscopic ultrasound guided biliary stenting in patients with inoperable malignant biliary strictures and a failed ERCP.

Background:In patients with inoperable malignant biliary strictures, endoscopic retrograde cholangiopancreatography (ERCP) guided biliary stenting fails in 5% to 10% patients due to difficult anatomy/inability to cannulate the papilla. Recently, endoscopic ultrasound guided biliary drainage (EUS-BD) has been described.Primary outcomes were to evaluate the biliary drainage success rates with EUS and compare it to percutaneous transhepatic biliary drainage (PTBD). Secondary outcomes were to evaluate overall procedure related complications.Methods: Study selection criteria:Studies evaluating the efficacy of EUS-BD and comparing EUS-BD versus PTBD in inoperable malignant biliary stricture patients with a failed ERCP were included in this analysis.Data collection and extraction:Articles were searched in Medline, PubMed, and Ovid journals. Two authors independently searched and extracted data. The study design was written in accordance to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Subgroup analyses of prospective studies and EUS-BD versus PTBD were performed.Statistical method:Pooled proportions were calculated using fixed and random effects model. I2 statistic was used to assess heterogeneity among studies.Results:Initial search identified 846 reference articles, of which 124 were selected and reviewed. Sixteen studies (N = 528) that met the inclusion criteria were included in this analysis. In the pooled patient population, the percentage of patients that had a successful biliary drainage with EUS was 90.91% (95% CI = 88.10–93.38). The proportion of patients that had overall procedure related complications with EUS-PD was 16.46% (95% CI = 13.20–20.01). The pooled odds ratio for successful biliary drainage in EUS-PD versus PTBD group was 3.06 (95% CI = 1.11–8.43). The risk difference for overall procedure related complications in EUS-PD versus PTBD group was −0.21 (95% CI = −0.35 to −0.06). Relative risk for infectious complications and bile leak in EUS-BD versus PTBD was 0.25 (95% CI = 0.07–0.94) and 0.33 (95% CI = 0.12–0.87), respectively.Conclusions:In patients with inoperable malignant biliary strictures who failed an ERCP guided biliary stenting, EUS-BD seems to be an excellent management option and superior to PTBD with higher successful biliary drainage rates and relatively fewer complications.

Issue Highlights

Issue Highlights

The type of preoperative biliary drainage predicts short-term outcome after major hepatectomy.

Endoscopic nasobiliary drainage (ENBD) is increasingly preferred to percutaneous transhepatic biliary drainage (PTBD) for patients undergoing major hepatectomy including hemihepatectomy or trisectorectomy with extrahepatic bile duct resection. The study was aimed to evaluate whether postoperative outcomes differed according to the types of biliary drainage. Patients who underwent major hepatectomy with bile duct resection for biliary tract cancer between December 2000 and March 2015 were classified into four groups according to their initial biliary drainage type. The preoperative management and postoperative morbidity were compared. Totally, 280 patients were classified into the following groups: no biliary drainage (n = 109), PTBD (n = 99), ENBD (n = 28), and endoscopic retrograde biliary drainage (ERBD; n = 44). Preoperative catheter management including tube exchange or additional tube placement due to cholangitis or poor drainage was most frequently required in the ERBD group (PTBD, 18%; ENBD, 14%; ERBD, 43%; P < 0.01). By the time of hepatectomy, 141 patients underwent at least one PTBD (PTBD(+)) and 30 patients were managed only with endoscopic biliary drainage (PTBD(-)). The incidence of major postoperative morbidities (Clavien-Dindo grade ≥ III) in PTBD(+) and PTBD(-) group was 23 and 3%, respectively (P = 0.01). A multivariate analysis among 171 patients with biliary drainage showed PTBD(+) (P = 0.04; odds ratio = 8.50; 95% confidential interval [CI], 1.10-65.45) and red blood cells transfusion (P < 0.01; odds ratio = 2.72; 95% CI, 1.22-6.09) were independent predictors of major morbidity. The type of preoperative biliary drainage was associated with the perioperative outcomes of major hepatectomy. Sticking to endoscopic biliary drainage was associated with lower risk of postoperative major morbidity.

Percutaneous biliary drainage is oncologically inferior to endoscopic drainage: a propensity score matching analysis in resectable distal cholangiocarcinoma.

The aim of this study was to evaluate whether percutaneous transhepatic biliary drainage (PTBD) increases the incidence of seeding metastasis and shortens postoperative survival compared with endoscopic biliary drainage (EBD). A total of 376 patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy following either PTBD (n=189) or EBD (n=187) at 30 hospitals between 2001 and 2010 were retrospectively reviewed. Seeding metastasis was defined as peritoneal/pleural dissemination and PTBD sinus tract recurrence. Univariate and multivariate analyses followed by propensity score matching analysis were performed to adjust the data for the baseline characteristics between the two groups. The overall survival of the PTBD group was significantly shorter than that of the EBD group (34.2% vs 48.8% at 5years; P=0.003); multivariate analysis showed that the type of biliary drainage was an independent predictor of survival (P=0.036) and seeding metastasis (P=0.001). After two new cohorts with 82 patients each has been generated after 1:1 propensity score matching, the overall survival rate in the PTBD group was significantly less than that in the EBD group (34.7% vs 52.5% at 5years, P=0.017). The estimated recurrence rate of seeding metastasis was significantly higher in the PTBD group than in the EBD group (30.7% vs 10.7% at 5years, P=0.006), whereas the recurrence rates at other sites were similar between the two groups (P=0.579). Compared with EBD, PTBD increases the incidence of seeding metastasis after resection for distal cholangiocarcinoma and shortens postoperative survival.

Percutaneous Preoperative Biliary Drainage for Resectable Perihilar Cholangiocarcinoma: No Association with Survival and No Increase in Seeding Metastases.

Background Endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD) are both used to resolve jaundice before surgery for perihilar cholangiocarcinoma (PHC). PTBD has been associated with seeding metastases. The aim of this study was to compare overall survival (OS) and the incidence of initial seeding metastases that potentially influence survival in patients with preoperative PTBD versus EBD.MethodsBetween 1991 and 2012, a total of 278 patients underwent preoperative biliary drainage and resection of PHC at 2 institutions in the Netherlands and the United States. Of these, 33 patients were excluded for postoperative mortality. Among the 245 included patients, 88 patients who underwent preoperative PTBD (with or without previous EBD) were compared to 157 patients who underwent EBD only. Survival analysis was done with Kaplan–Meier and Cox regression with propensity score adjustment.ResultsUnadjusted median OS was comparable between the PTBD group (35 months) and EBD-only group (41 months; P = 0.26). After adjustment for propensity score, OS between the PTBD group and EBD-only group was similar (hazard ratio, 1.05; 95 % confidence interval, 0.74–1.49; P = 0.80). Seeding metastases in the laparotomy scar occurred as initial recurrence in 7 patients, including 3 patients (3.4 %) in the PTBD group and 4 patients (2.7 %) in the EBD-only group (P = 0.71). No patient had an initial recurrence in percutaneous catheter tracts.ConclusionsThe present study found no effect of PTBD on survival compared to patients with EBD and no increase in seeding metastases that developed as initial recurrence. These data suggest that PTBD can safely be used in preoperative management of PHC.

A Comparison of Outcomes of Endoscopic Retrograde Cholangiopancreatography Versus Percutaneous Transhepatic Biliary Drainage in the Management of Obstructive Jaundice From Hepatobiliary Tuberculosis: The Philippine General Hospital Experience

not have significantly higher odds of PN (adjusted odds ratio [AOR]1⁄41.24, 95% C.I. 0.97-1.59, P 1⁄4 .089) or PAN (AOR1⁄41.77, 95% C.I. 1.00-3.13, P 1⁄4 .052), except in lower-risk subjects where the odds of PAN was marginally higher in the “distal HP” group than the “no distal polyp” group (AOR1⁄41.97, 95% C.I. 1.01-3.85, P 1⁄4 .048). Overall, the “distal polyp” group had significantly lower odds of PN than the distal TA group (AOR1⁄40.55, 95% C.I. 0.40-0.76, P < .001). The increased risk of PN and PAN among those with distal HPs was modest. CONCLUSION: Recommending colonoscopy for every patient with distal HPs detected by screening sigmoidoscopy is not supported by the present findings.

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.

Percutaneous transhepatic and endoscopic biliary drainage for malignant biliary tract obstruction: a meta-analysis

BackgroundVarious malignant tumors can obstruct the extrahepatic biliary tract. Two major techniques for restoring bile flow in this circumstance are endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD).We conducted a meta-analysis to compare the effectiveness and safety of the two techniques.MethodsMedline, EMBASE and the Cochrane Library database were searched for articles published between January 1980 and December 2013. The outcome measures were therapeutic success rate (primary), 30-day mortality rate and overall complications.ResultsOf 264 screened articles, 3 randomized controlled trials comprising an aggregate total of 183 cancer patients were included in the meta-analysis. Our analysis showed no significant difference in restoration of bile flow between patients treated with EBD and those treated with PTBD (odds ratio (OR) = 2.34, 95% confidence interval (CI) = 0.32 to 17.16, P = 0.401). However, the result of sensitivity analysis indicated that the study conducted by Speer et al. influenced the pooled estimates. After the Speer et al. study was excluded, the therapeutic success rate of patients treated with PTBD was significantly greater than that of those who underwent EBD (OR = 5.48, 95% CI: 2.26 to 13.28, P < 0.001). The 30-day mortality and complication rates were similar in the EBD and PTBD groups.ConclusionsThe results of our meta-analysis indicate that PTBD had a higher therapeutic success rate than EBD in the treatment of malignancy-induced biliary obstruction. The mortality and complication rates of the two techniques were similar.Electronic supplementary materialThe online version of this article (doi:10.1186/1477-7819-12-272) contains supplementary material, which is available to authorized users.

Biliary drainage for obstructive jaundice caused by unresectable hepatocellular carcinoma: the endoscopic versus percutaneous approach

For palliative treatment of the obstructive jaundice associated with unresectable hepatocellular carcinoma (HCC), percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde biliary drainage (ERBD) has been performed. PTBD is preferred as an initial procedure. Little is known about the better option for patients with obstructive jaundice caused by unresectable HCC. Sixty patients who had received ERBD or PTBD for the palliative treatment of obstructive jaundice caused by unresectable HCC between January 2006 and May 2010 were included in this retrospective study. Successful drainage, drainage patency, and the overall survival of patients were evaluated. Univariate analysis revealed that the overall frequency of successful drainage was higher in the ERBD group (22/29, 75.9%) than in the PTBD group (15/31, 48.4%) (P=0.029); but multivariate analysis showed marginal significance (P=0.057). The duration of drainage patency was longer in the ERBD group than in the PTBD group (82 vs 37 days, respectively, P=0.020). Regardless of what procedure was performed, the median survival time of patients who had a successful drainage was much longer than that of the patients who did not have a successful drainage (143 vs 38 days, respectively, P<0.001). Besides PTBD, ERBD may be used as the initial treatment option to improve obstructive jaundice in patients with unresectable HCC if there is a longer duration of drainage patency after a successful drainage.

Endoscopic or Percutaneous Biliary Drainage for Klatskin Tumors?

PurposeControversy exists regarding the preferred biliary drainage technique in patients with Klatskin tumors because few comparative studies exist. This study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD). Materials and MethodsConsecutive patients (N = 129) with Klatskin tumors treated with initial EBD or PTBD were identified, and their clinical histories were retrospectively reviewed. The primary endpoint was the time to therapeutic success (TTS), defined as the time between the first drainage and a total bilirubin measurement of 40 μmol/L or lower. ResultsEBD was the first biliary decompression procedure performed in 87 patients; PTBD was performed first in 42. Technical success rates (78% with EBD vs 98% with PTBD; P = .004) and therapeutic success rates (49% vs 79%, respectively; P = .002) were significantly lower in the EBD group than in the PTBD group. Forty-four patients in the EBD group (51%) subsequently underwent PTBD before therapeutic success was achieved or antitumoral treatment was started. Median TTSs were 61 days in the EBD group and 44 days in the PTBD group, and multivariate analysis showed a hazard ratio of 0.63 (95% confidence interval, 0.41–0.99; P = .045). In patients treated with surgery or chemotherapy with or without radiation therapy, median times to treatment were 76 and 68 days in the EBD and PTBD groups, respectively (P = .76). Cholangitis occurred in 25% and 21% of patients in the EBD and PTBD groups, respectively (P = .34). ConclusionsPTBD should be seriously considered for biliary decompression when treating patients with Klatskin tumor.

Endoscopic Nasobiliary Drainage and Percutaneous Transhepatic Biliary Drainage for the Treatment of Acute Obstructive Suppurative Cholangitis: A Retrospective Study of 37 Cases

This study compared the effectiveness and safety of endoscopic nasobiliary drainage(ENBD) to percutaneous transhepatic biliary drainage(PTBD) for the treatment of acute obstructive suppurative cholangitis (AOSC). AOSC patients were assigned to undergo either ENBD (n=22) or PTBD(n=15). In the ENBD group, the procedure was successfully completed in 19 patients (86.4%), where- as it was converted to PTBD in 3 patients (13.6%) due to the failure of antegrade cholangiography. All the patients in the PTBD group underwent first- or second-look PTBD successfully. ENBD is effective for the treatment of AOSC, facilitating subsequent endoscopic or surgical intervention. PTBD is an effective and safe alternative to ENBD in patients unsuitable for ENBD.