Percutaneous Transhepatic Biliary Drainage Research Articles

IMPROVEMENT IN QUALITY OF LIFE FOLLOWING PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE FOR MALIGNANT OBSTRUCTIVE JAUNDICE: AN INSTITUTION-BASED OBSERVATIONAL STUDY

Purpose: Long-term prognosis of patients with obstructive jaundice due to malignant biliary disease is very dismal. These patients are treated mainly for palliation of symptomatic jaundice and related complications. To alleviate symptomatic jaundice, three modalities of treatment are generally employed – bilio-enteric bypass, Percutaneous Transhepatic Biliary Drainage (PTBD) and Endoscopic Retrograde Cholangiopancreatography guided stenting. However, minimal data is available comparing the pre-procedure and post-procedure Quality of Life (QOL) of these patients. Aims of the Study: To study the pre-procedure & post-procedure QOL of patients undergoing PTBD. Methodology: We studied patients who underwent PTBD in between January 2017 and June 2021, attending our tertiary-care hospital with malignant obstructive jaundice, with high-up biliary obstruction. An observational study was conducted to compare the QOL before and after procedure using the EORTC-QLQ-30 Symptom Scale Score. Results:The majority (80%) had the diagnosis of carcinoma gallbladder. Maximum number of patients (75%) presented with a pre-procedure bilirubin value of more than 15 mg/dl. These patients showed significant bilirubin decrement by day 7. Follow-up at 1 month and 3 months following PTBD demonstrated significant improvement in global health status, physical status, emotional, cognitive and social QOL score. Some deterioration in the QOL score was noted at 6 months follow-up, which might be related to recurrence or stent blockade. Conclusion: Overall improvement in post-procedure QOL was observed during follow-up analysis of the subjects. The increase in financial burden could be attributed to the maintenance of drainage catheter (wound management bags, treatment of infections) and cost of frequent hospital visits after the procedure.

Ultrasound-guided percutaneous transhepatic biliary drainage for distal biliary malignant obstructive jaundice

The main cause of distal biliary malignant obstructive jaundice (DBMOJ) is the stricture of the extrahepatic biliary tract by malignant tumors, including pancreatic head and uncinate process cancer, low-grade cholangiocarcinoma, duodenal cancer, papillary duodenal cancer and other malignant tumors. The most effective treatment is radical pancreaticoduodenectomy. However, preoperative obstructive jaundice can affect the patient’s liver function and blood coagulation function, increase local inflammation and oedema, and make surgery more difficult. Patients with severe obstructive jaundice require preoperative biliary drainage, which can be achieved by various methods, including ultrasound endoscopic biliary drainage (EUS-EBD) and endoscopic retrograde biliary drainage (ERBD). The latter is mainly divided into endoscopic nasobiliary drainage and endoscopic biliary stent. Some patients underwent percutaneous transhepatic biliary drainage (PTBD) when ERBD and EUS-EBD failed. In this study, we aimed to identify PTBD in DBMOJ and to further investigate the role of the puncture pathway in DBMOJ. The relationship between PTBD and bile duct internal diameter was confirmed by analysing and collating clinical data. In this study, DBMOJ was grouped according to bile duct internal diameter and liver function was used as an indicator to examine the improvement in liver function with PTBD in patients undergoing DBMOJ. Analysis of puncture complications showed that PTBD puncture was safe. DBMOJ with different bile duct internal diameters had different rates of liver function improvement after PTBD. The right-side approaches had significantly lower alanine aminotransferase (ALT) and alanine transaminase (AST) than the left-side approaches. This study showed that PTBD for DBMOJ is associated with a low complication rate and good reduction of jaundice. Liver function recovery was faster in patients with DBMOJ treated with PTBD in the right-sided approach compared with the left-sided approach. PTBD is an effective tool to be used in patients who have failed ERBD and EUS-EBD.

A Novel Use of Autologous Fibrin by Intracatheter Injection in Persistent Postoperative Biliary Defects: Technical Note on a Preliminary Experience.

To introduce percutaneous selective injection of autologous platelet-rich fibrin as a novel technique for persistent bile leakage repair and sharing the results of our preliminary experience. Seven patients (57.1% females; mean age 69.6 ± 8years) with the evidence of persistent bile leak secondary to hepatobiliary surgery and ineffective treatment with percutaneous transhepatic biliary drainage were submitted to fibrin injection. Platelet-rich fibrin, a dense fibrin clot promoting tissue regeneration, was obtained from centrifuged patient's venous blood. Repeated percutaneous injections through a catheter tip placed in close proximity to the biliary defect were performed until complete obliteration at fistulography. Technical and clinical success were evaluated. Bile leaks followed pancreaticoduodenectomy in five and major hepatectomy in two patients. Technical success defined as fibrin injection at BD site was achieved in all seven patients, and clinical success defined as a complete healing of the BD at fistulography was achieved in six patients. The median time to BD closure was 76.7 ± 40.5days and the average procedure number was 3 ± 1 per patient. In one patient, defect persistance after four treatments required gelatin sponge injection. No major complications occurred. One case of post-procedural transitory hyperpirexia was registered. In persistent biliary defects, despite prolonged biliary drainage stay, percutaneous injection of autologous platelet-rich fibrin appears as a readily available and feasible emergent technique in promoting fistulous tracts obliteration still mantaining main ducts patency.

Myiasis in Percutaneous Transhepatic Biliary Drainage Site

AbstractThe infection of dipterous larvae causes myiasis. It is generally associated with unsanitary conditions. An interventional radiologist rarely comes across myiasis. We report a case of myiasis around a percutaneous transhepatic biliary drainage (PTBD) tube. A 31-year-old man from a rural area underwent left PTBD for cholangiocarcinoma and was discharged with an internal–external drain. Two weeks later, he presented with pain in the local site, pruritus, and bile leakage. He was found to have maggots around the PTBD tube with poor wound hygiene. Treatment included turpentine oil instillation and oral and topical ivermectin, accompanied by manual removal of the larva.

Placing Plastic Stent via Percutaneous Transhepatic Biliary Drainage following Failure of Endoscopic Retrograde Cholangiopancreatography: Review of Case Series

AbstractThe aim of this study is to describe the technical procedure, patency, and complications of percutaneous biliary plastic stent insertion following failure of the endoscopic approach. The data from 11 patients who underwent percutaneous plastic biliary stent placement following endoscopic approach failure between March 2022 and December 2023 were retrospectively evaluated. Stent placement was successful in all patients. Reduction of the total serum bilirubin level was achieved in all patients. No major complications occurred in all patients. A plastic stent provided enough drainage for patients with patency in our studies for up to 5 months.

Magnetic compression anastomosis for the treatment of complete biliary obstruction after cholecystectomy

Background & AimsPost-cholecystectomy biliary strictures can be treated surgically or non-surgically. Although endoscopic or percutaneous treatments are the preferred approaches, these methods are not feasible in cases where complete stricture occlusion prevents the successful passage of a guidewire. The utility of magnetic compression anastomosis (MCA) in patients with post-cholecystectomy complete biliary obstruction that cannot be treated conventionally was evaluated. MethodsMCA was performed in 10 patients with post-cholecystectomy biliary strictures that did not resolve with conventional endoscopic or percutaneous treatment. One magnet was delivered through the percutaneous transhepatic biliary drainage tract, and another was advanced via endoscopic retrograde cholangiopancreatography(ERCP) of the common bile duct. After magnet approximation and recanalization, a fully covered self-expandable metal stent (FCSEMS) was placed for 3 months and then replaced for a further 3 months. Stricture resolution was evaluated after FCSEMS removal. ResultsAmong the 10 patients who underwent MCA for post-cholecystectomy biliary stricture, the biliary injury was Strasberg type B in 2, type C in 3, and type E in 5. Recanalization was successful in all patients (technical success rate 100%). The mean follow-up period after recanalization was 50.2 months (range 13.2–116.8 months). Partial restenosis after MCA occurred in two patients at 24.1 and 1.6 months after stent removal. ERCP with FCSEMS placement resolved the recurrent stenosis in both patients. ConclusionsMCA is a useful alternative nonsurgical treatment for complete biliary obstruction after cholecystectomy that cannot be resolved by conventional methods.

Clinical Utility of the Tokyo Guidelines 2018 for Acute Cholangitis in the Emergency Department and Comparison with Novel Markers (Neutrophil-to-Lymphocyte and Blood Nitrogen Urea-to-Albumin Ratios).

Introduction: The Tokyo Guidelines 2018 (TG2018) is a scoring system used to recommend the clinical management of AC. However, such a scoring system must incorporate a variety of clinical outcomes of acute cholangitis (AC). In an emergency department (ED)-based setting, where efficiency and practicality are highly desired, clinicians may find the application of various parameters challenging. The neutrophil-to-lymphocyte ratio (NLR) and blood urea nitrogen-to-albumin ratio (BAR) are relatively common biomarkers used to assess disease severity. This study evaluated the potential value of TG2018 scores measured in an ED to predict a variety of clinical outcomes. Furthermore, the study also compared TG2018 scores with NLR and BAR scores to demonstrate their usefulness. Methods: This retrospective observational study was performed in an ED. In total, 502 patients with AC visited the ED between January 2016 and December 2021. The primary endpoint was to evaluate whether the TG2018 scoring system measured in the ED was a predictor of intensive care, long-term hospital stays (≥14 days), percutaneous transhepatic biliary drainage (PTBD) during admission care, and endotracheal intubation (ETI). Results: The analysis included 81 patients requiring intensive care, 111 requiring long-term hospital stays (≥14 days), 49 requiring PTBD during hospitalization, and 14 requiring ETI during hospitalization. For the TG2018 score, the adjusted OR (aOR) using (1) as a reference was 23.169 (95% CI: 9.788-54.844) for (3) compared to (1). The AUC of the TG2018 for the need for intensive care was 0.850 (95% CI: 0.815-0.881) with a cutoff of >2. The AUC for long-term hospital stays did not exceed 0.7 for any of the markers. the AUC for PTBD also did not exceed 0.7 for any of the markers. The AUC for ETI was the highest for BAR at 0.870 (95% CI: 0.837-0.899) with a cutoff value of >5.2. Conclusions: The TG2018 score measured in the ED helps predict various clinical outcomes of AC. Other novel markers such as BAR and NLR are also associated, but their explanatory power is weak.

Interventional Treatment of Malignant Biliary Obstruction: Is It Time to Change the Paradigm?

Introduction. Biliary obstruction is a common manifestation of biliopancreatic malignancies, and its relief is an essential part of the treatment algorithm. Currently, there are three techniques to manage malignant biliary obstruction—endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic biliary drainage (PTBD), and endoscopic ultrasound-guided biliary drainage (EUS-BD). ERCP has been adopted as a first-line treatment modality but EUS-BD is gradually emerging as a viable alternative. The aim of the current article is to assess the clinical outcomes of the three nonsurgical biliary drainage procedures. Materials and methods. A total of 102 consecutive patients with unresectable biliopancreatic malignancy inducing biliary obstruction and subjected to palliative treatment by means of ERCP, EUS-BD, or PTBD were retrospectively included in the study. Results. No difference in clinical and technical success of the procedures was found: ERCP—97.2% technical; 88.9% clinical; PTBD—94.4% technical, 72.2% clinical; EUS-BD—90% technical; 83.3% clinical. Adverse events (AEs) and reinterventions were significantly more common in PTBD (38.9% and 52.8%) and ERCP (27.9% and 25%) compared to EUS-BD (10% and 3.3%). Total duration of hospital stay and number of hospitalizations were lower in the EUS-BD compared to PTBD and ERCP groups. Conclusions. In the presence of adequate expertise, EUS-BD may be superior to PTBD and ERCP in achieving and sustaining biliary drainage in the setting of unresectable malignancy.

Choledochal Cyst with Pancreas Divisum – Surgical Insight into A Rare Association


 
 
 
 Congenital pancreaticobiliary anomalies like pancreatic divisum (PD), choledochal cysts (CDC), anomalous pancreaticobiliary ductal union (APBDU) have been reported in 5.7% of patients undergoing magnetic resonance cholangiopancreatography. CDC’s are characterized by abnormal dilatations of the intrahepatic and/or extrahepatic portion of the biliary tree and can be complicated by cystolithiasis, cholangitis, pancreatitis and malignant transformation necessitating surgical managemnet. While CDCs are commonly associated with APBDU, combination of CDC with PD is rare and a potential surgical challenge. We report a case of recurrent cholangitis in a patient with CDC and coincidental classic PD and illustrate how preoperative identification, fastidious dissection technique to safeguard both the pancreatic ducts and simple intraoperative preemptive strategies may decrease consequences of distal stump blowout. PD, pancreatic divisum; CBD, common bile duct; CDC, choledochal cysts; APBDU, anomalous pancreaticobiliary ductal union; MRCP, magnetic resonance cholangiopancreatography; DOS, Duct of Santorini; DOW, Duct of Wirsung; PTBD, percutaneous transhepatic biliary drainage; RYHJ, roux en Y hepaticojejunostomy.
 
 
 

Current interventional options for palliative care for patients with advanced-stage cholangiocarcinoma.

Primary biliary tract tumors are malignancies that originate in the liver, bile ducts, or gallbladder. These tumors often present with jaundice of unknown etiology, leading to delayed diagnosis and advanced disease. Currently, several palliative treatment options are available for primary biliary tract tumors. They include percutaneous transhepatic biliary drainage (PTBD), biliary stenting, and surgical interventions such as biliary diversion. Systemic therapy is also commonly used for the palliative treatment of primary biliary tract tumors. It involves the administration of chemotherapy drugs, such as gemcitabine and cisplatin, which have shown promising results in improving overall survival in patients with advanced biliary tract tumors. PTBD is another palliative treatment option for patients with unresectable or inoperable malignant biliary obstruction. Biliary stenting can also be used as a palliative treatment option to alleviate symptoms in patients with unresectable or inoperable malignant biliary obstruction. Surgical interventions, such as biliary diversion, have traditionally been used as palliative options for primary biliary tract tumors. However, biliary diversion only provides temporary relief and does not remove the tumor. Primary biliary tract tumors often present in advanced stages, making palliative treatment the primary option for improving the quality of life of patients.

Percutaneous Biliary Interventions in Pediatric Patients

AbstractPercutaneous biliary interventions have become standard for a variety of indications in pediatric patients. They offer a minimally invasive approach to managing biliary pathologies often associated with liver transplantation and hepatobiliary surgery. Interventions include the insertion of drainage catheters for bilomas, percutaneous transhepatic cholangiography for diagnostic purposes, and percutaneous transhepatic biliary drainage for the treatment of biliary leaks and cholestasis. Sonography, computed tomography, and fluoroscopy are used to guide the procedures. This review aims to demonstrate the indications and technical aspects of percutaneous biliary interventions in pediatric patients with a special focus on radiation protection.

Role of advanced endoscopy in the management of inflammatory digestive diseases (pancreas and biliary tract).

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS-elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self-expanding metal stents for stent placement for pancreatic duct stenosis and EUS-guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS-guided drainage using a double-pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen-apposing metal stents have led to advances in the treatment of walled-off necrosis after acute pancreatitis. EUS-guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self-expanding metal stents in difficult-to-treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS-guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case.

Preliminary clinical application of novel magnetic navigation and ultrasound-guided percutaneous transhepatic cholangiography drainage through the right liver duct for malignant obstructive jaundice

Objective: To analyze the clinical application value of a novel magnetic navigation ultrasound (MNU) combined with digital subtraction angiography (DSA) dual-guided percutaneous transhepatic biliary drainage (PTCD) through the right hepatic duct for the treatment of malignant obstructive jaundice. Methods: Randomized controlled trial. The clinical data of 64 patients with malignant obstructive jaundice requiring PTCD through the right hepatic duct at the Hepatobiliary Center of the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province People's Hospital) from December 2018 to December 2021 were retrospectively analyzed. The MNU group (n=32) underwent puncture guided by a novel domestic MNU combined with DSA, and the control group (n=32) underwent puncture guided by traditional DSA. The operation time, number of punctures, X-ray dose after biliary stenting as shown by DSA, patients' tolerance of the operation, success rate of the operation, pre- and post-operative total bilirubin, and incidence of postoperative complications were compared between the two groups. Results: The operation time of the MNU group was significantly shorter than that of the control group [(17.8±7.3) vs. (31.6±9.9) min, t=-6.35,P=0.001]; the number of punctures in the MNU group was significantly lower [(1.7±0.6) vs. (6.3±3.9) times, t=-6.59, P=0.001]; and the X-ray dose after biliary stenting as shown by DSA in the MNU group was lower than that in the control group [(132±88) vs. (746±187) mGy, t=-16.81,P<0.001]; Five patients in the control group were unable to tolerate the operation, and two stopped the operation, however all patients in the MNU group could tolerate the operation, and all completed the operation, with a success rate of 100% (32/32) in the MNU group compared to 93.8%(30/32) in the control group; the common complications of PTCD were biliary bleeding and infection, and the incidence of biliary bleeding (25.0%, 8/32) and infection (18.8%, 6/32) in the MNU group was significantly lower than that in the control group, 53.1% (17/32) and 28.1% (9/32), respectively. Conclusion: Magnetic navigation ultrasound combined with DSA dual-guided PTCD through the right biliary system for the treatment of malignant obstructive jaundice is safe and feasible.

Percutaneous Transhepatic Sphincterotome–Guided Management of Post–Living Donor Liver Transplant Biliary Anastomotic Stricture: An Innovative Approach

ABSTRACT Post–liver transplantation biliary complications remain a serious concern and are associated with reduced patient and graft survival. Among various biliary complications, anastomotic stricture (AS) is the most frequent and challenging one. The frequency of AS after living donor liver transplantation (LDLT) is higher as compared to deceased donor liver transplantation. The management involves endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic biliary drainage, but refractory cases necessitate surgical revision. We present a case of complex biliary AS in a 63-year-old man after LDLT. The conventional approaches including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and cholangioscope-guided interventions remained unsuccessful. An innovative approach using a wire-guided sphincterotome through percutaneous transhepatic route successfully managed the complex post-LDLT AS. This is perhaps the first reported case of novel utilization of sphincterotome through transhepatic route for the management of AS in LDLT, averting major surgical interventions with related morbidity and mortality.

Establishment of Diagnostic Reference Levels in Portuguese Interventional Radiology departments

PurposeTo establish Portuguese Diagnostic Reference Levels (DRLs), for six body fluoroscopy guided interventional procedures (FGIP). MethodA retrospective study was conducted in five interventional departments most representative of Interventional Radiology (IR) practice. Dose values, in terms of air kerma area product (PKA in Gy.cm2), air kerma at the patient entrance reference point (Ka,r in mGy), and exposure parameters (fluoroscopy time (FT) and number of cine runs) were collected. Examinations were selected per procedure (at least 20), according to the antero-posterior and lateral diameter mean value (±5 cm), measured on previous Computed Tomography (CT) examinations. ResultsData of 489 body FGIP show a large variation on dose values per procedure and per department. National DRLs in terms of PKA were 20.2 Gy.cm2 for Percutaneous transhepatic biliary drainage (PTBD), 98.2 Gy.cm2 for Bronchial artery embolisation (BAE), 247.7 Gy.cm2 for Transarterial chemoembolisation (TACE), 331.6 Gy.cm2 for Inferior epigastric arteries embolisation (IEAE), 312.0 Gy.cm2 for Transjugular intrahepatic portosystemic shunt (TIPS) and 19.3 Gy.cm2 for Endovascular treatment of femoral popliteal arteries (ETFPA). ConclusionsThis is the first study reporting Interventional Radiology DRLs in Portugal and we propose preliminary national estimates for the six more common body FGIP. The results of this study will be presented and discussed with all Portuguese IR departments, to promote procedures optimisation.

Accessibility to ERCP-performing hospitals among patients with pancreatic cancer living in SEER regions.

The two most common interventions used to treat painless jaundice from pancreatic cancer are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD). Our study aimed to characterize the geographic distribution of ERCP-performing hospitals among patients with pancreatic cancer in the United States and the association between geographic accessibility to ERCP-performing hospitals and biliary interventions patients receive. This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database for pancreatic cancer from 2005 to 2013. Multilevel models were used to examine the association between accessibility to ERCP hospitals within a 30- and 45-min drive from the patient's residential ZIP Code and the receipt of ERCP treatment. A two-step floating catchment area model was used to calculate the measure of accessibility based on the distribution across SEER regions. 7464 and 782 patients underwent ERCP and PTBD, respectively, over the study period. There were 808 hospitals in which 8246 patients diagnosed with pancreatic cancer in SEER regions from 2005 to 2013 received a procedure. Patients with high accessibility within both 30- and 45-min drive to an ERCP-performing hospital were more likely to receive an ERCP (30-min adjusted odds ratio [aOR]: 1.53, 95% confidence interval [CI]: 1.17-2.01; 45-min aOR: 1.31, 95% CI: 1.01-1.70). Furthermore, in the adjusted model, Black patients (vs. White) and patients with stage IV disease were less likely to receive ERCP than PTBD. Patients with pancreatic cancer and high accessibility to an ERCP-performing hospital were more likely to receive ERCP. Disparities in the receipt of ERCP persisted for Black patients regardless of their access to ERCP-performing hospitals.

Factors affecting survival in patients undergoing percutaneous transhepatic biliary drainage for malignant biliary obstruction.

The general approach to malignant biliary obstruction (MBO) is to provide drainage in all patients with jaundice. However, the procedure is often palliative, and its contribution to survival is debated. This study aimed to investigate prognostic factors in patients undergoing percutaneous transhepatic biliary drainage (PTBD) for MBO. All laboratory values were divided into two groups based on median values: low and high. Chi-square analysis was performed for dichotomous data. The time from the PTBD procedure to the date of death or last follow-up was considered overall survival (OS). Univariate and multivariate analyses were calculated using the Cox regression model. A total of 152 patients were included in the study, of whom 84 (55.3%) were male. The median OS was 71 ± 12.6 days (95% CI: 46.3-95.7). The 1, 3, 6, and 12-month OS rates were 74.3%, 45.2%, 29.2%, and 13%, respectively. In the multivariate analysis, comorbidity (p=0.029), Eastern cooperative oncology group performance status (ECOG PS) (p=0.007), pre-PTBD albumin (p=0.025), post-PTBD aspartate aminotransferase (p=0.025), chemo naive (p<0.001), and post-PTBD chemotherapy (CT) (p=0.01) were found to be independent prognostic factors. In patients with poor prognosis MBO, the decision for PTBD should be made multidisciplinarily, taking into consideration ECOG PS, comorbidities, albumin levels, and prior CT status.

Value of magnetic resonance cholangiopancreatography in the evaluation of biliary obstruction

Background: Obstructive jaundice is a common clinical condition that causes many complications, especially septic shock. Magnetic resonance cholangiopancreatography (MRCP) plays an important role in determining the cause, extent, and complications of biliary obstruction. Purposes: To investigate the value of magnetic resonance cholangiopancreatography in the diagnosis of biliary obstruction. Materials and Methods: A descriptive cross-sectional study was conducted at Hue University of Medicine and Pharmacy Hospital from January 2019 to November 2022. Forty-four patients with biliary obstruction who underwent MRCP, and percutaneous transhepatic cholangiography (PTC, a step in the procedure of percutaneous transhepatic biliary drainage) were retrospectively analyzed. Results: The mean age was 62.75 ± 13.29 years. Male/female ratio was 1.3/1. The most common cause of obstruction was biliary malignancy (56,9%). Bilateral intrahepatic duct dilation (54.5%) and hilar obstruction (65.9%) were predominant. On MRCP, abrupt cut-off of the duct, irregular margin, and asymmetric biliary stricture. There was a good to very good concordance between MRCP and PTC in determining the site of dilatation, site of obstruction, and characteristics of biliary obstruction. Compared with PTC, MRCP had a sensitivity of 100% and a specificity of 89.5% in the evaluation of abrupt cut-off; a sensitivity of 90.5% and a specificity of 100% in detecting biliary stricture. Conclusion: MRCP is useful in a comprehensive evaluation of the biliary tract including anatomy and variations as well as site, degree, extent, etiologies, and complications of obstruction. MRCP should be included in the routine workup of patients with biliary obstruction who might be candidates for percutaneous biliary intervention. Key words: Biliary obstruction, magnetic resonance cholangiopancreatography, percutaneous transhepatic cholangiography, percutaneous transhepatic biliary drainage.

Portal vein stenting in recurrent or locally advanced peri-hilar cholangiocarcinoma

BackgroundRecurrent or locally advanced peri-hilar cholangiocarcinoma (PHCC) usually involves the portal vein (PV) leading to significant stenosis. With disease progression, clinical symptoms such as ascites, bleeding, and hepatic insufficiency are usually observed. Little is know about the benefit of PV stenting in relieving the symptoms associated to portal hypertension and allowing anticancer therapies. The aim of this study is to review our experience in PV stenting for PHCC patients. MethodsFrom 2014 to 2022, data from PHCC patients underwent PV stenting at Verona University Hospital, Italy, were reviewed. The indications were: gastrointestinal bleeding from esophagus-gastric varices, ascites not responsive to medical therapy, severe thrombocytopenia, liver insufficiency (hepatic jaundice, coagulopathy, and/or hyperammoniemia), or asymptomatic high-grade PV stenosis. Cavernous transformation and intrahepatic thrombosis in both sides of the liver were considered contraindication. Systematic anticoagulation therapy was not administered. ResultsTechnical success was achieved in all 16 (100 %) patients. The improvement of clinical symptoms were observed in 12 (75 %) patients. Anticancer therapy was administrated in 11 (69 %) patients. 2 (13 %) complications were observed: 1 biliary injury and 1 recurrent cholangitis that required a percutaneous trans-hepatic biliary drainage placement. Stent occlusion for tumor progression occurred in 1 patient and a re-stenting procedure was successfully performed. No case of thrombotic stent occlusion was observed during follow up. The 1-year stent patency was 86 % and the median patency period was 8 months (IQR, 4–12). ConclusionPV stenting is a feasible and safe palliative treatment that improves clinical condition, allow anticancer therapies, and provide a better quality of life.

EUS-guided hepaticogastrostomy versus percutaneous transhepatic biliary drainage after failed ERCP: A propensity score-matched analysis.

Background and study aims Percutaneous transhepatic biliary drainage (PTBD) is the traditional second-line option after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a viable alternative to PTBD. Our study aimed to compare outcomes of EUS-HG and PTBD for benign and malignant biliary diseases following failed ERCP. Patients and methods This single-center study retrospectively analyzed patients undergoing EUS-HG and PTBD for benign and malignant biliary disorders. A propensity score-matched analysis was performed using age, sex, and Charlson Comorbidity Index. The primary outcome was clinical success, which we defined as a decrease in total bilirubin by ≥ 50% at 2 weeks for malignant disease and resolution of the biliary disorder for benign disease. Results In total, 41 patients underwent EUS-HG and 138 patients underwent PTBD. After propensity score matching in a 1:2 ratio, 32 EUS-HG patients were matched with 64 PTBD. Technical success was achieved in 29 of 32 (91%) for EUS-HG and 63 of 64 (98%) for PTBD ( P =0.11). Clinical success was 100% for EUS-HG and 75% for PTBD ( P =0.0021). EUS-HG was associated with a lower adverse event rate (EUS-HG 13% vs. PTBD 58%, P <0.0001), shorter procedure duration (median 60 vs. 115 minutes, P <0.0001), shorter post-procedure length of stay (median 2 vs. 4 days, P <0.0001), and fewer reinterventions (median 1 vs. 3, P <0.0001). Conclusions Our results suggest that EUS-HG is superior to PTBD in the treatment of benign and malignant biliary disorders after failed ERCP.