Percutaneous Transhepatic Cholangial Drainage Research Articles

Splenic subcapsular hematoma following endoscopic retrograde cholangiopancreatography: A case report and review of literature

BACKGROUND Splenic injury following endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication. The literature contains around 30 articles reporting various degrees of splenic injuries resulting from ERCP since the first report of splenic rupture after ERCP in 1989. CASE SUMMARY This report describes a case of splenic hematoma and stent displacement in a 69-year-old male patient who developed these conditions 7 days after undergoing ERCP and stenting. The patient had bile duct stenosis caused by a malignant tumor that was obstructing the bile duct. The diagnosis was confirmed by epigastric computed tomography and magnetic resonance cholangiopancreatography. The patient was successfully treated with percutaneous transhepatic cholangial drainage, endoscopic pyloric stent placement, and conservative management. The causes of splenic injury following ERCP are discussed. CONCLUSION ERCP has the potential to cause splenic injury. If a patient experiences symptoms such as abdominal pain, decreased blood pressure, and altered hematology after the procedure, it's important to be thoroughly investigated for postoperative bleeding and splenic injury.

Surgical treatment and prognosis analysis of hilar cholangiocarcinoma

Objective: To investigate the surgical treatment effect and prognostic factors of hilar cholangiocarcinoma. Methods: This is an ambispective cohort study. From August 2005 to December 2022,data of 510 patients who diagnosed with hilar cholangiocarcinoma and underwent surgical resection at the Hepatobiliary Center of the First Affiliated Hospital of Nanjing Medical University were retrospectively collected. In the cohort,there were 324 males and 186 females,with an age of (M (IQR)) 63(13)years (range:25 to 85 years). The liver function at admission was Child-Pugh A (343 cases,67.3%) and Child-Pugh B (167 cases,32.7%). Three hundred and seventy-two(72.9%) patients had jaundice symptoms and the median total bilirubin was 126.3(197.6) μmol/L(range: 5.4 to 722.8 μmol/L) at admission. Two hundred and fourty-seven cases (48.4%) were treated with percutaneous transhepatic cholangial drainage or endoscopic nasobiliary drainage before operation. The median bilirubin level in the drainage group decreased from 186.4 μmol/L to 85.5 μmol/L before operation. Multivariate Logistic regression was used to identify the influencing factors for R0 resection,and Cox regression was used to construct multivariate prediction models for overall survival(OS) and disease-free survival(DFS). Results: Among 510 patients who underwent surgical resection,Bismuth-Corlett type Ⅲ-Ⅳ patients accounted for 71.8%,among which 86.1% (315/366) underwent hemi-hepatectomy,while 81.9% (118/144) underwent extrahepatic biliary duct resection alone in Bismuch-Corlett type Ⅰ-Ⅱ patients. The median OS time was 22.8 months, and the OS rates at 1-,3-,5-and 10-year were 72.2%,35.6%,24.8% and 11.0%,respectively. The median DFS time was 15.2 months,and the DFS rates was 66.0%,32.4%,20.9% and 11.0%,respectively. The R0 resection rate was 64.5% (329/510), and the OS rates of patients with R0 resection at 1-,3-,5-and 10-year were 82.5%, 48.6%, 34.4%, 15.2%,respectively. The morbidity of Clavien-Dindo grade Ⅲ-Ⅴ complications was 26.1%(133/510) and the 30-day mortality was 4.3% (22/510). Multivariate Logistic regression indicated that Bismuth-Corlett type Ⅰ-Ⅲ (P=0.009), hemi-hepatectomy and extended resection (P=0.001),T1 and T2 patients without vascular invasion (T2 vs. T1:OR=1.43 (0.61-3.35),P=0.413;T3 vs. T1:OR=2.57 (1.03-6.41), P=0.010;T4 vs. T1, OR=3.77 (1.37-10.38), P<0.01) were more likely to obtain R0 resection. Preoperative bilirubin,Child-Pugh grade,tumor size,surgical margin,T stage,N stage,nerve infiltration and Edmondson grade were independent prognostic factors for OS and DFS of hilar cholangiocarcinoma patients without distant metastasis. Conclusions: Radical surgical resection is necessary to prolong the long-term survival of hilar cholangiocarcinoma patients. Hemi-hepatectomy and extended resection,regional lymph node dissection and combined vascular resection if necessary,can improve R0 resection rate.

Development of the Readiness for Hospital Discharge Scale for Patients with Bile Duct Carcinoma Catheterized After Percutaneous Transhepatic Cholangial Drainage: A Validity and Reliability Study.

We develop the Readiness for Hospital Discharge Scale (RHDS) for patients with bile duct carcinoma catheterized after percutaneous transhepatic cholangial drainage (PTCD) and test the reliability and validity of the scale, so as to provide a quantitative tool for evaluating the discharge readiness of patients catheterized after PTCD. The initial scale was developed following literature review, qualitative interviews, expert consultation, and other methods based on Meleis' Theory of Transition. We selected a total of 286 patients with bile duct carcinoma catheterized after PTCD from four tertiary A-grade hospitals in Nantong City. We conducted a cross-sectional survey using the initial scale to test the validity and reliability of the scale. RHDS for patients catheterized post-PTCD consisted of five dimensions, with a cumulative variance contribution rate of 74.6%. The Cronbach's α coefficient of the scale was 0.856, and that of each dimension was between 0.740 and 0.891; the scale-content validity index (S-CVI) was 0.875. RHDS for patients with bile duct carcinoma catheterized after PTCD developed in this study, has good reliability and validity, and can be a useful tool for evaluating the discharge readiness of patients with bile duct carcinoma catheterized after PTCD.

Endoscopic reintervention after unilateral metal stent deployment for MHBO using SIS method.

Endoscopic biliary drainage is the main treatment for unresectable malignant hilar biliary obstruction (MHBO). Recurrent biliary obstruction (RBO) often occurs after unilateral metal stent deployment. Endoscopic reintervention can be complex for this problem, especially for drainage of the contralateral bile duct. The stent-in-stent (SIS) method is a possible solution to this problem. Our objective was to evaluate the safety and feasibility of the SIS method for endoscopic reintervention in patients with RBO due to MHBO after unilateral metal stent deployment. Eleven patients with MHBO received endoscopic reintervention using the SIS method to manage RBO after unilateral metal stent deployment. Clinical data, including technical and clinical success, procedure time, adverse events and complications, stent patency, RBO of the revisionary stent, and survival time were recorded. Nine patients (82%) achieved technical success, and all 9 of them also achieved clinical success. The 2 unsuccessful cases received percutaneous transhepatic cholangial drainage. The median procedure time was 73 minutes. The 3 adverse events were post-endoscopic retrograde cholangiopancreatography pancreatitis, cholangitis, and liver abscess. 6 patients (67%) experienced RBO of the revisionary stent, the median time to RBO of the revisionary stent was 95.5 days, the median survival time after reintervention was 111 days, and the median overall survival time was 305.5 days. Endoscopic reintervention after previous unilateral metal stent deployment using the SIS method appears to be safe and technically feasible for MHBO patients who experience RBO.

Percutaneous transhepatic cholangial drainage or antibiotic therapy worsens response to immunotherapy in advanced cholangiocarcinoma

BackgroundBile duct obstruction is a common issue for patients with advanced cholangiocarcinoma (CCA). Percutaneous transhepatic cholangial drainage (PTCD) is often required to relieve the obstruction. However, PTCD may alter the intestinal microbiota, which can affect the efficacy of immunotherapy. Antibiotics (ATB) can also have significant immunomodulatory effects by perturbing the gut microbiota. Therefore, this study aimed to investigate whether PTCD or ATB therapy is associated with overall survival (OS) or progression-free survival (PFS) in patients with advanced CCA receiving first-line chemotherapy plus immune checkpoint blockade (ICB) in clinical practice. We also explored whether the gut microbiota changes after receiving PTCD.MethodsWe conducted a single-center retrospective analysis of PTCD and ATB therapy in patients with advanced CCA. PTCD was performed before ICB initiation, and ATB was administered within 1 month before and 6 weeks after ICB initiation. Our primary outcomes were PFS and OS. Moreover, we used 16s rRNA sequencing to analyze fecal and bile samples obtained from patients who underwent PTCD.ResultsIn total, 107 patients with CCA were included. Among patients who did not undergo PTCD, ICB plus chemotherapy significantly improved OS vs. chemotherapy alone (hazard ratio [HR] 0.21, 95% confidence interval [CI] 0.09–0.45, p < 0.0001). PFS was also significantly improved in patients who received ICB plus chemotherapy compared with chemotherapy alone (HR 0.36, 95% CI 0.16–0.80, p = 0.0024). However, ICB plus chemotherapy did not improve survival compared with chemotherapy alone among patients who received PTCD. Overall changes in the fecal microbiota of patients after PTCD involved significant reductions in which Escherichia − Shigella.ConclusionsThe use of ATB or PTCD in patients with CCA receiving ICB was associated with worse OS compared with chemotherapy alone, and PTCD affects the gut microbiota. Escherichia − Shigella was significantly reduced in feces of patients after PTCD.

A Combination of Enteral and Parenteral Nutrition Better Supports Postoperative Prognosis of Patients with Malignant Obstructive Jaundice

A total of 120 patients admitted to affiliated hospitals of the North Sichuan Medical College between September 2020 and June 2022 were recruited for this study and received percutaneous transhepatic cholangial drainage. Patients in the control group received parenteral nutrition support, whereas patients in the treatment group received parenteral and combined enteral nutrition support. Compared to the control group, the time of first exhaustion and defecation in the treatment group was faster, and the postoperative activity time and hospital stay were shorter. Serum albumin and prealbumin levels in both groups decreased on the 1st day after surgery and recovered on the 7th day, with the treatment group reaching higher levels. After surgery, the decline in alanine aminotransferase, aspartate aminotransferase, total bilirubin, and direct bilirubin levels was higher in the treatment group. CD4+, CD8+ levels, and CD4+/CD8+ ratios in both groups were elevated, with the treatment group showing higher levels. The occurrence of complications in the treatment group was lessened relative to the control group. In summary, enteral combined parenteral nutrition support for patients with malignant obstructive jaundice after surgery can promote faster recovery of gastrointestinal function, improve nutritional status, facilitate the recovery of liver function, and promote immune function.

A novel method of ultrasound-guided positive staining using indocyanine green fluorescence in laparoscopic anatomical liver resection of segments VII and VIII.

Recently, in many Asian centers, laparoscopic anatomical liver resection (LALR) using the indocyanine green (ICG) fluorescence imaging technique has been increasingly applied in resecting hepatocellular carcinoma, even in colorectal liver metastases. However, LALR techniques have not been fully standardized, especially in right superior segments. Due to the anatomical position, prevailing positive staining using a PTCD (percutaneous transhepatic cholangial drainage) needle was superior to negative staining in right superior segments hepatectomy, while it was difficult to manipulate. Herein, we design a novel method of ICG-positive staining for LALR of right superior segments. Between April 2021 and October 2022, we retrospectively studied patients in our institute who underwent LALR of right superior segments using a novel method of ICG-positive staining, which comprised a customized puncture needle and an adaptor. Compared to the PTCD needle, the customized needle was not limited by the abdominal wall and could be punctured from the liver dorsal surface, which was more flexible to manipulate. The adapter was attached to the guide hole of the laparoscopic ultrasound (LUS) probe to ensure the precise puncture path of the needle. Guided by preoperative three-dimensional (3D) simulation and intraoperative laparoscopic ultrasound imaging, we punctured the transhepatic needle into the target portal vein through the adaptor and then slowly injected 5-10ml of 0.025 mg/ml ICG solution into the vessel. LALR can be guided by the demarcation line under fluorescence imaging after injection. Demographic, procedural and postoperative data were collected and analyzed. In this study, 21 patients underwent LALR of the right superior segments with ICG fluorescence-positive staining, and the procedures had a success rate of 71.4%. The average staining time was 13.0 ± 6.4min, the operative time was 230.4 ± 71.7min, R0 resection was 100%, the postoperative hospital stay was 7.1 ± 2.4 days, and no severe puncture complications occurred. The novel customized puncture needle approach seems to be feasible and safe for ICG-positive staining in LALR of right superior segments, with a high success rate and a short staining time.

Study of preserving the PTCD tube after laparoscopic pancreaticoduodenectomy.

Severe jaundice patients undergoing laparoscopic pancreaticoduodenectomy (LPD) tend to choose percutaneous transhepatic cholangial drainage (PTCD) for preoperative biliary drainage. However, there are few studies on whether to preserve PTCD drainage tubes after surgery. This study tentatively discusses that jaundice patients preserving the PTCD tube have similar postoperative recovery to that in ordinary patients undergoing LPD. We retrospectively reviewed 46 patients who underwent LPD between June 2019 and April 2022 at our department. They were divided into a drainage group with 16 patients and a normal group with 30 patients according to whether PTCD was performed. Patient demographics, perioperative data, and postoperative outcomes were observed and counted. The preoperative total bilirubin in the drainage group was significantly higher than that in the normal group. There was no significant difference in age, body mass index, American Society of Anesthesiologists grade, hemoglobin, albumin, operation time, postoperative hospital stay, or total complication rate between the 2 groups. The PTCD tube was preserved in all 16 patients after the operation, and only 1 patient (6.3%) developed PTCD-related postoperative complications, which were dislocations. It is safe and effective to choose PTCD to reduce jaundice before surgery and preserve PTCD tubes after surgery for moderate and severe jaundice patients who plan to undergo standardized and streamlined LPD. These patients achieve similar postoperative recovery of LPD as no-drainage patients.

Is percutaneous drainage better than endoscopic drainage in the management of patients with malignant obstructive jaundice? A meta-analysis of RCTs.

To compare the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangial drainage (PTCD) in the treatment of malignant obstructive jaundice, a systematic review and meta-analysis of published studies was undertaken to assess the differences between the two procedures in terms of efficacy and safety. From November 2000 to November 2022, the Embase, PubMed, MEDLINE, and Cochrane databases were searched for randomized controlled trials (RCTs) on the treatment of malignant obstructive jaundice with ERCP or PTCD. Two investigators independently assessed the quality of the included studies and extracted the data. Six RCTs, including 407 patients, were included. The results of the meta-analysis showed that the overall technical success rate in the ERCP group was significantly lower than that in the PTCD group (Z=3.19, P=0.001, OR=0.31 (95% CI: 0.15-0.64)), but with a higher overall procedure-related complication incidence rate (Z=2.57, P=0.01, OR=0.55 (95% CI: 0.34-0.87)). The incidence of procedure-related pancreatitis in the ERCP group was higher than that in the PTCD group (Z=2.80, P=0.005, OR=5.29 (95% CI: 1.65-16.97)), and the differences were statistically significant. No significant difference was observed between the two groups when the clinical efficacy, postoperative cholangitis, and bleeding rate were compared.Both treatments for malignant obstructive jaundice were efficacious and safe. However, the PTCD group had a greater technique success rate and a lower incidence of postoperative pancreatitis.The present meta-analysis has been registered in PROSPERO.

Comparison of Efficacy and Safety between Endoscopic Retrograde Cholangiopancreatography and Percutaneous Transhepatic Cholangial Drainage for the Treatment of Malignant Obstructive Jaundice: A Systematic Review and Meta-Analysis

Background: At present, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangial drainage (PTCD) are frequently used for reducing malignant obstructive jaundice (MOJ). However, it is controversial as to which method is superior in terms of efficacy and safety. Objectives: The aim of this study was to compare the safety, feasibility, and clinical benefits of ERCP and PTCD in matched cases of MOJ. Methods: The Web of Science, Cochrane, PubMed, and CNKI databases were searched systematically to identify studies published between January 2000 and December 2019, without language restrictions, that compared ERCP and PTCD in patients with MOJ. The primary outcome was the success rate for each procedure. The secondary outcomes were the technical success rate, serum total bilirubin level, length of hospital stay, hospital expense, complication rate, and survival. This meta-analysis was performed using Review Manager 5.3. Results: Sixteen studies met the inclusion criteria, including 1,143 cases of ERCP and 854 cases of PTCD. The analysis demonstrated that jaundice remission in PTCD was equal to that in ERCP (mean difference [MD], 1.19; 95% confidence interval [CI]: −0.56 to –2.93; p = 0.18). However, the length of hospital stay in the ERCP group was 3.03 days shorter than that in the PTCD group (MD, −2.41; 95% CI: −4.61 to −0.22; p = 0.03). ERCP had a lower rate of postoperative complications (odds ratio, 0.66; 95% CI: 0.42–1.05); however, the difference was not significant (p = 0.08). ERCP was also more cost-efficient (MD, −5.42; 95% CI: −5.52 to −5.32; p < 0.01). Further, we calculated the absolute mean of hospital stay (ERCP:PTCD = 8.73:12.95 days), hospital expenses (ERCP:PTCD = 5,104.13:5,866.75 RMB), and postoperative complications (ERCP:PTCD = 11.2%:9.1%) in both groups. Conclusion: For remission of MOJ, PTCD and ERCP had similar clinical efficacy. Each method has its own strengths and weaknesses. Considering that ERCP had a lower rate of postoperative complications, shorter hospital stay, and higher cost efficiency, ERCP may be a superior initial treatment choice for MOJ.

Application value of computed tomography and magnetic resonance imaging three-dimensional reconstruction and digital subtraction angiography in percutaneous transhepatic cholangial drainage.

This study aims to explore the application value of computed tomography (CT) three-dimensional (3D) reconstruction, magnetic resonance imaging (MRI) 3D reconstruction, and conventional digital subtraction angiography (DSA) fluoroscopy in percutaneous transhepatic cholangial drainage (PTCD). The clinical data of 180 patients with obstructive jaundice requiring PTCD from December 2017 to December 2021 were retrospectively analyzed. Following PTCD, CT 3D reconstruction, MRI 3D reconstruction, and conventional DSA fluoroscopy were conducted, after which the surgical success rates, liver function results, and postsurgical complications were compared. The puncture accuracies under CT 3D reconstruction, MRI 3D reconstruction, and conventional DSA fluoroscopy were 90.0% (54/60), 96.7% (58/60), and 80% (48/60), respectively. The degree of jaundice and epigastric discomfort was relieved in all three groups after surgery, while a significant reduction in the levels of total bilirubin and direct bilirubin was observed relative to the levels before surgery (P < 0.05). The incidences of complications in the CT 3D reconstruction, MRI 3D reconstruction, and conventional DSA fluoroscopy groups were 6.7% (4/60), 3.3% (2/60), and 13.3% (8/60), respectively, and the differences among the three groups were statistically significant (P < 0.05). Conducting conventional enhanced CT and MRI scans in patients before surgery might be more practical than the conventional puncture method. Among the methods under study, MRI 3D reconstruction was found to be safer and more feasible than CT 3D reconstruction and conventional DSA fluoroscopy in PTCD. MRI 3D reconstruction could reduce the degree of jaundice, improve the success rate of surgery, reduce the incidence of complications due to surgery, and improve the patients' tolerance to surgery.

Risk Factors Related to Early Biliary Complications After Liver Transplantation: a Single-Center Analysis

The aim of this study was to evaluate the risk factors of early biliary complications (EBC) after liver transplantation (LT) and seek effective treatments based on our single-center experience. A total of 124 adult patients were divided into a non-EBC group and EBC group. EBC usually accounts for biliary leakage, biliary stricture, biliary stones, sphincter of Oddi dysfunction, and transient jaundice within 3 months after LT. Statistical analysis including logistic regression was performed to determine EBC risk factors. All procedures complied with the Helsinki Congress and the Declaration of Istanbul. Non-EBC (n=95) and EBC (n=29) were finally compared, which had no difference in their general characteristics. EBC occurred in 29 patients (26.92%): 1 biliary hemorrhage (3.45%), 7 biliary leakage (24.13%), and 16 biliary stricture (55.18%), and 5 others (17.24%). Of all EBC patients, endoscopic retrograde cholangiopancreatography (68.96%) was higher used to deal with complications than conservative treatment (10.35%), percutaneous transhepatic cholangial drainage (17.24%), and surgical treatment (3.45%). On univariate analyses, risk factors for EBC were bilirubin (P = .014), warm ischemia time (WIT) (P = .020), second WIT (P = .042), and operative time (OT) (P = .033). On multivariate analysis, independent risk factors for BC were WIT (P = .011) and OT (P = .049). The presence of WIT and OT were the independent risk factors for the development of EBC. In addition, we also confirmed that endoscopic retrograde cholangiopancreatography was beneficial and safe in the management of EBC after LT.

Long-term efficacy of percutaneous transhepatic cholangioscopy-guided photodynamic therapy for postoperative recurrent extrahepatic cholangiocarcinoma

BackgroundCholangiocarcinoma recurs frequently following excision surgery and is usually inoperable, while radiotherapy, chemotherapy, and immunotherapy are of limited benefit. As palliative care, percutaneous transhepatic cholangial drainage (PTCD) can relieve biliary obstruction, prevent jaundice, and maintain quality of life (QOL), but does not improve overall survival. In contrast, photodynamic therapy (PDT) has been demonstrated to prolong the survival of inoperable cancer patients. ObjectiveThis study evaluated the clinical efficacy of percutaneous transhepatic cholangioscopy (PTCS)-guided PDT following PTCD versus PTCD alone for recurrent inoperable cholangiocarcinoma. MethodsThe case files of 39 patients with postoperative recurrence were retrospectively analyzed, including 18 receiving PTCS-guided PDT (PTCS-PDT group) and 21 receiving PTCD only as a control (PTCD group). Survival time was compared by Kaplan-Meier analysis and log-rank test, and QOL by the Functional Assessment of Cancer Therapy–Hepatobiliary (FACT-HEP) questionnaire. Clinicodemographic factors, including serum bilirubin and adverse reaction rates, were compared by Student's t-test or Fisher's exact test. The maximum follow-up period was 71 months. ResultsMedian survival time was significantly longer in the PTCS-PDT group than the PTCD group (23 months vs. 10 months, P = 0.00001). At 6 and 12 months post-treatment, total FACT-HEP score was lower in the PTCS-PDT group (P < 0.05), indicating improved QOL. There was no significant difference in total adverse events incidence between groups (19 [51.4%] vs. 15 [71.4%]; P = 0.131). ConclusionPTCS-guided PDT can prolong survival and improve the QOL of patients with postoperative cholangiocarcinoma recurrence without increasing complications. Significant and/or new findingsCompared to PTCD alone, PTCS-guided PDT significantly prolonged the survival time of patients with postoperative recurrent extrahepatic cholangiocarcinoma. Photodynamic therapy also improved patient quality of life by facilitating timely removal of the PTCD drainage tube. PTCS-guided PDT did not increase surgery-related complications except for skin phototoxicity, which can be easy avoided and treated.

Analysis of the Bacterial Spectrum and Key Clinical Factors of Biliary Tract Infection in Patients with Malignant Obstructive Jaundice after PTCD.

Objective To analyze the bacterial spectrum and key clinical factors associated with biliary tract infections following percutaneous transhepatic cholangial drainage (PTCD) for malignant obstructive jaundice (MOJ). Methods This retrospective study comprised patients with MOJ who were treated with PTCD from 1st June 2016 to 31st December 2020. Patient clinical data, development of postprocedure biliary tract infections, spectrum of pathogenic bacteria, and drug sensitivity were analyzed, focusing on antibiotic drug resistance and identifying key associated risk factors for postoperative biliary tract infections. Results Of the 528 study patients, 80 were diagnosed with postoperative biliary tract infections, 58 of whom had pathogenic bacteria detected in their bile samples. A total of 90 strains of pathogenic bacteria and 3 strains of fungi were detected; the top 4 were Escherichia coli, Klebsiella pneumoniae, Enterococcus faecium, and Pseudomonas aeruginosa. By univariate analysis, a positive bile culture following PTCD was closely correlated with both the location and degree of preoperative obstruction and the preoperative bilirubin level. Moreover, the results of logistic regression analysis concluded that complete obstruction and a high preoperative total bilirubin level prior to PTCD were independent risk factors for a positive bile culture following PTCD. Conclusion Biliary tract infections following PTCD for MOJ were principally due to Escherichia coli, and bacteria in the bile were statistically more likely to be detected in patients with complete obstruction and high preoperative bilirubin levels.

The efficacy and safety of blunt impingement followed by a sharp recanalization technique in hemodialysis patients with refractory central vein occlusion: a single-center experience.

BackgroundCentral vein occlusion (CVO) is a serious problem in hemodialysis patients. There is an unsatisfactory result for refractory CVO by sharp recanalization alone. This study evaluated the efficacy and safety of blunt impingement followed by sharp recanalization for the treatment of CVO in hemodialysis patients.MethodsThis study retrospectively examined hemodialysis patients with CVO who failed to recanalize using standard guidewire and catheter techniques in our department. In the first instance, all CVOs were recanalized using blunt impingement techniques, including a 6-Fr long sheath (Cook Incorporated, Bloomington, IN USA) and an 8-Fr sheath of Rosch-Uchida Transjugular Liver Access Set (RUPS-100; Cook Incorporated, Bloomington, IN, USA). If this was not successful, sharp recanalization devices were applied, including the stiff tip of a guidewire (Terumo, Tokyo, Japan), the RUPS-100, and the percutaneous transhepatic cholangial drainage (PTCD) needle (Cook Incorporated, USA). All patients were followed up at least 4 months postoperatively. The technical success rate, arteriovenous access patency rates, and operation-related complications were analyzed.ResultsThe procedural success rate was 100.0% (30 of 30). Thirty patients with CVO underwent blunt impingement with a technique success rate of 70.0% (21 of 30), and 9 patients received sharp recanalization after failed blunt impingement, with a technique success rate of 100.0% (9 of 9). The primary patency rates at 6 and 12 months postoperatively were 86.7% and 53.3%, respectively. The primary assisted patency rates were 93.3% and 63.3%, and the secondary patency rates were 93.3% and 70.0% at 6 and 12 months, respectively. One major procedure-related complication was detected, namely, a small injury of the superior vena cava (SVC) wall in a patient receiving recanalization via the stiff end of a guidewire, but this did not require further treatment.ConclusionsIt is potentially effective and safe for interventionalists to use blunt impingement followed by sharp recanalization techniques to treat chronic CVO that is refractory to traversal using traditional catheter and guidewire techniques.

Acute cholangitis due to food reflux after self‐expanding metal stent implantation without duodenal obstruction: A case report

AbstractAcute cholangitis has been reported as an uncommon adverse event after self‐expandable metallic stent (SEMS) implantation. Herein, we report a case of an acute cholangitis caused by duodenal refluxate without duodenal obstruction. A 62‐year‐old woman received SEMS for an obstructive jaundice caused by a pancreatic head adenocarcinoma. She had been in stable condition until her percutaneous transhepatic cholangial drainage (PTCD) was clamped on the second postoperative day, and when a high fever and severe right epigastric pain developed. Fecal‐impacted bowel loops were found through abdominal X‐rays, and food contents were drained from PTCD afterward. Acute cholangitis caused by SEMS migration was initially suspected, and SEMS revision was performed two times, which did not improve the chymus reflux from PTCD. Metoclopramide was given after the second SEMS revision, and post‐procedural upper gastrointestinal series with urografin shows no duodenal obstruction. No febrile event has been noted since the administration of metoclopramide. Acute cholangitis after SEMS implantation without duodenal obstruction could develop in patient with moderate to severe constipation. Prompt post‐procedural prophylactic prokinetics for few days may prevent such episodes.

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.

Percutaneous transhepatic cholangial drainage combined with intra-tumoral iodine-125 seeds implantation and chemotherapy for locally progressive pancreatic head cancer with obstructive jaundice.

To investigate the clinical efficacy of percutaneous transhepatic cholangial drainage (PTCD) combined with intra-tumoral iodine-125 (125I) particle implantation and chemotherapy in the treatment of locally advanced pancreatic head cancer (LAPHC) with obstructive jaundice. Twenty-one patients with LAPHC with obstructive jaundice were selected, and routine examination before surgery to determine location of obstruction and degree of bile duct dilatation was performed. All 21 patients underwent PTCD first, and usual examinations, including liver and kidney function, were re-examined after operation. When the liver function recovered significantly, patients were treated with seed implantation and systemic chemotherapy after surgery. Clinical efficacy and complications of 21 patients were observed, and changes in survival time and serum level of tumor markers were analyzed. After combined treatment, there were 3 cases of complete response (CR), 12 cases of partial response (PR), 3 cases of stable disease (SD), and 3 cases of progressive disease (PD) in 21 patients. The overall effective rate was 71.43%, and the local control rate was 85.71%. The pain relief was statistically significant one month after treatment, compared with that before treatment (VAS scores: 6.76 ±2.25 vs. 3.25 ±1.92, p < 0.001), and the rate of pain relief was 71.43% (15/21). In all patients, jaundice, abdominal pain, and abdominal distension improved to different degrees after surgery, and the skin pruritus disappeared. Bilirubin and transaminase improved to varying degrees 3 days, 1 week, and 4 weeks after treatment (p < 0.05). Cancer antigen 199 (CA-199), carcinoembryonic antigen (CEA), and cancer antigen 125 (CA-125) after combination therapy, achieved statistically significant differences (t = 9.525, 10.378, 3.262, respectively, p < 0.05). The overall survival time of 21 patients was 11.6 months, ranging from 3.9 to 22.6 months. For LAPHC patients with obstructive jaundice, PTCD combined with particle implantation and chemotherapy is clinically effective in improving the quality of life and prolonging survival.

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.

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.