Percutaneous Transhepatic Cholangiodrainage Research Articles

Feasibility of Percutaneous Transhepatic Cholangiodrainage in Patients Without Biliary Tract Dilation and Symptomatic Biliary Leakage Following Upper Abdominal Surgery

Feasibility of Percutaneous Transhepatic Cholangiodrainage in Patients Without Biliary Tract Dilation and Symptomatic Biliary Leakage Following Upper Abdominal Surgery

Percutaneous transhepatic cholangiodrainage as optional therapy for symptomatic biliary leakage without biliary tract dilation following upper abdominal surgery

Percutaneous transhepatic cholangiodrainage as optional therapy for symptomatic biliary leakage without biliary tract dilation following upper abdominal surgery

Impact of Reconstruction Methods on Outcome of Pancreatoduodenectomy in Pancreatic Cancer Patients

Local recurrence is one of the most frequent forms of pancreatic cancer recurrence, although local recurrence is rare for other periampullary cancers. Because the type of recurrence and outcome differ depending on the type of cancer, these factors should be considered when the type of reconstruction is chosen. Fifty-four pancreatoduodenectomies were performed in patients with ductal adenocarcinoma of the pancreas from 1994 to 2001. Billroth I reconstruction was performed in 27 consecutive patients before 1999, and thereafter Billroth II reconstruction was performed in another consecutive 27 patients. Postoperative nasogastric intubation and the duration before oral ingestion were longer for Billroth I patients than Billroth II patients. Seven complications occurred in Billroth I patients, whereas there were two complications in Billroth II patients. Disease-free survival and overall survival were not different between the two groups; however, bypass operations were required in nine patients of the Billroth I group and in one patient of the Billroth II group. Percutaneous transhepatic cholangio-drainage (PTCD) procedures were required in six patients of the Billroth I goup and in two patients of the Billroth II group. The Billroth II reconstruction may have some advantages over the Billroth I reconstruction in terms of postoperative oral ingestion and avoiding bypass surgery and PTCD at the time of recurrence.

NonInvasive Approach for Refractory Enterovaginal Fistula

Enterovaginal fistula is generally difficult to treat, and a surgical treatment is often chosen. There are many cases that require extended bowel resection for severe adhesion in the pelvic cavity and just as many cases of postoperative complications. The present case involves a 61‐year‐old female. After radical operation for ovarian cancer, a recurrence was recognized in the pelvic cavity despite chemotherapy. After that, recurrence was found in the pelvic cavity, and low anterior resection combined with the resection of recurrent tumor was performed.Enterovaginal fistula and pelvovaginal fistula were found from the 10th postoperative day; therefore urethral catheter was placed transvaginally. Those fistulas were simplified afterwards, and the tube for percutaneous transhepatic cholangio drainage (PTCD) was placed and then removed after several exchanges. After that, enteric juice was identified for a few days, but the fistula was completely closed, and no recurrence was found.It is easy for discharge from enterovaginal fistula to increase because of the anatomical position the fistula; since there is no appropriate device for this fistula, treatment is difficult. It seems that, in selected cases in which the patient heals conservatively without losing quality of life for patients, it is possible to place a tube in an appropriate position under the x‐ray and change it step by step.

Percutaneous transhepatic papillary balloon dilation as a therapeutic option for choledocholithiasis.

For choledocholithiasis, endoscopic therapy, including endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilation (EPBD), is now standard. However, the procedure of endoscopic therapy is very complicated and sometimes incomplete for reasons of anatomical anomalies. Therefore, we started performing percutaneous transhepatic papillary balloon dilations (PTPBD) instead of endoscopic therapy for choledocholithiasis 1 year ago for some selected patients. We report our technical methods of PTPBD. First, percutaneous transhepatic cholangiodrainage (PTCD) was performed under ultrasound guidance. Via the drainage route, the balloon catheter was inserted until the common bile duct was reached. Then, cholangiography was performed and the stones were identified. The balloon was maintained in the inflated state with 4 ml air at the papilla of Vater for 3 min. Next, the stones were pushed out rapidly into the duodenum with the same balloon catheter. If the stone diameter was larger than 8 mm, then basket lithotripsy was performed before balloon dilation. Five patients underwent PTPBDs. The bile duct stones were successfully pushed out into the duodenum in all patients. The first three patients required two sessions for complete stone clearance due to technical problems; however, the last two patients needed only one session. There were no deaths and no complications. We recommend that PTPBD might be a feasible and alternative therapeutic option for choledocholithiasis.

Postnatal management for prenatally diagnosed choledochal cysts

Purpose The aim of this study was to determine an appropriate postnatal management plan for prenatally diagnosed congenital biliary dilatation (CBD). Methods Between 1962 and 2002, 5 (5.9 %) of 85 patients had CBD diagnosed prenatally and were examined clinically. Of these 5 patients, 2 (group A) underwent delayed primary definitive surgery after percutaneous transhepatic cholangiodrainage (PTCD), 1 (group B) underwent early definitive surgery in the neonatal period, and 2 (group C) underwent delayed primary definitive surgery without PTCD in early infancy (within 6 months after birth). The clinical data, operative findings, intra- and postoperative complications, and follow-up were evaluated in these 3 groups. Results There were no postoperative complications, such as catheter-related complications, in group A. However, there was adhesion around the choledochal cyst, and the operation was therefore difficult in group A. The diameter of the anastomosis in the hepaticojejunostomy was small, and the cyst wall was thin in group B. Consequently, anastomotic leakage of the hepaticojejunostomy occurred in group B. Neither operative nor postoperative complications such as anastomotic leakage or stenosis occurred in group C. Slight fibrosis of Glisson’s sheath was seen in 2 patients of groups A and C. No liver cirrhosis was seen in any group. Conclusions The authors propose that asymptomatic patients should undergo elective definitive surgery by 6 months of age. For symptomatic patients, especially when a differential diagnosis of type I cystic biliary atresia is doubtful, early definitive surgery is needed before 2 months of age. PTCD appears to be indicated only under certain circumstances, and delayed primary definitive surgery should be performed as early as possible thereafter.

Implementation of the diagnosis procedure combination in specific-function hospitals.

A Nobel medical payment system, the Diagnosis Procedure Combination (DPC), was implemented in Nippon Medical School Hospital and 81 other specific-function hospitals in 2003. This payment system depends on the length of hospital stay and diagnosis and medical procedures, and differs from the existing payment system, which depends on a piece rate. The daily payment differs for among almost 2,500 groups of DPC defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10), and procedures, such as operations (K and J codes of the existing payment system). One of the most important outcomes may be a decrease in lengths of hospital stay, because the range of mean lengths of stay in specific-function hospitals has been officially stated to be 14 to 30 days, and the difference between the longest and shortest mean is almost double. The new medical payment system should stimulate competition among hospitals. In order to decrease the length of stay, we developed clinical pathways for patients undergoing surgery, such as laparoscopic cholecystectomy, gastrectomy, and inguinal hernia operations, as well as clinical protocols for the surgical procedures, such as percutaneous transhepatic cholangiodrainage (PTCD) and percutaneous endoscopic gastrostomy (PEG). Health care is undergoing a challenging transition, and we must improve patient care and clinical practice.

Rupture of a Hepatic Artery Pseudoaneurysm Induced by Percutaneous Transhepatic Cholangio-Drainage

Rupture of a Hepatic Artery Pseudoaneurysm Induced by Percutaneous Transhepatic Cholangio-Drainage

Strategy of management for congenital biliary dilatation in early infancy

Purpose: The aim of this study was to establish the optimal management strategy of congenital biliary dilatation (CBD) in early infancy. Methods: Over the last 15 years, 14 patients with CBD in early infancy (within 5 months), including 3 antenatally diagnosed patients, were treated in the authors' department. Of the 14 patients, 7 (50%) underwent early definitive surgery (E group), and the other 7 (50%) underwent delayed primary definitive surgery after percutaneous transhepatic cholangiodrainage (PTCD; D group). Both groups were compared retrospectively using clinical data. Results: Pretreatment status and backgrounds of the patients were clinically homogeneous between the 2 groups. The total length of hospital stay was significantly longer in the D group. As short-term complications, 1 patient in the E group was compromised with hepatolithiasis, and 3 patients in the D group were compromised with catheter-related complications. Other clinical data, such as age at definitive surgery, blood loss, pathologic fibrosis of the liver, jaundice-free day, and long-term complications were not significantly different between the 2 groups. Conclusions: The authors propose that the standard of management should be early definitive surgery with wide anastomosis before 2 months of age. However, PTCD might be used under strict consideration of indication and careful management for patients with extremely poor surgical risk. J Pediatr Surg 37:1173-1176. Copyright 2002, Elsevier Science (USA). All rights reserved.

経皮経肝胆道ドレナージ経路に播種性転移をきたした胆嚢癌の1例

経皮経肝胆道ドレナージ経路に播種性転移をきたした胆嚢癌の1例

7264 Clinical outcome of percutaneous-duodenal bile duct stent of the yamakawa type.

Introduction: In case of obstructive jaundice and failure of endoscopic stenting percutaneous transhepatic cholangio-drainage (PTCD) as well as Yamakawa stents are able to decompress intrahepatic bile ducts. Yamakawa stents are deployed percutaneously and unlike PTCD are advanced further through the tumor stenosis into the duodenum allowing internal bile drainage. Only in case of stent dysfunction, the percutaneous Yamakawa outlet has to be opened enabling immediate percutaneous bile drainage as well as subsequent clearing of stent occlusion. Since Yamakawa stents allow intracorporal bile drainage into the duodenum collecting bags are avoided and bile loss syndrome is prevented. Aim: We studied the clinical outcome of Yamakawa stents in pat. with malignant jaundice. Methods: During the last two years (from 8/97 to 11/99) we treated 827 pat. suffering from malignant jaundice in our clinic. In 8.2% (68/827) of cases endoscopic stenting was impossible or insufficient. These pat. receive either PTCD or Yamakawa stents (8 to 14 Fr., Pflugbeil Co., Germany). Results: In 68 pat. we performed percutaneous decompression of malignant jaundice. 62 pat. received PTCD. Later on, we exchanged PTCD to Yamkawa stent in 28 (45.2%) pat.. 6 further pat. had primarily received Yamakawa stents. Finally, we managed a total of 34 Yamakawa stent patients (20 male, 14 female, mean age: 69.2 years, range: 33-94 years). Pat. with Yamakawa stents suffered from gastric cancer (n=7), pancreatic cancer (n=7), Klatskin tumor (n=9), gall bladder cancer (n=4) and 7 metastases of distant tumors. Yamakawa stenting significantly reduced cholestasis (bilirubin < 2 mg/l). Complication related to Yamakwa stenting occured in terms of percutaneous bleeding (n=2), bilioma (n=3), pleural fistula (n=1), cholangitis (n=2) and hemobilia (n=1). All complications were moderate, conservatively treated without procedure related mortality. During the follow up 38% (13/34) pat. died due to tumor progress (follow up: 3.5 months, range: 2-8 months). Furthermore, 62% (20/34) of pat. are still alive (follow up: 6.8 months, range: 1-24 months). Discussion: Yamakawa stents compared to PTCD offer higher comfort and improved quality of life to pat. suffering from malignant jaundice. Physiological bile drainage can be achieved by Yamakawa stents avoiding bile loss syndrome. Futher advantageous are increased pat. comfort as well as easier stent maintainance in case of stent occlusion. Conclusively, we recommend to replace PTCD by Yamakawa stents whenever possible.

A case of primary sclerosing cholangitis that cholangial stricture was improved by conservative treatment with percutaneous transhepatic cholangio drainage

A case of primary sclerosing cholangitis that cholangial stricture was improved by conservative treatment with percutaneous transhepatic cholangio drainage

THE EFFECT OF A KANPO MEDICINE, INCHINKO-TO FOR THE BILIRUBIN REDUCTION RATE AFTER BILIARY DRAINAGE ON THE PATIENTS WITH OBSTRUCTIVE JAUNDICE

In this study, we focused on 24 patients with obstructive jaundice due to malignant disease of the biliary tract who underwent biliary drainage such as percutaneous transhepatic cholangio-drainage (PTCD). We analyzed the effect that administration of a Kanpo medicine, Inchinko-to, had on reduction of bilirubin level after biliary drainage. After biliary drainage, subjects were randomly allocated into a drainage-only (control) group, or a drainage/Inchinko-to combination group (Inchinko-to combination group). The Inchinko-to combination group was given a total of 7.5g per day of inchinko-to, either for four weeks, or before the surgery. During this period, changes in liver function parameters and subjective symptoms were observed and compared between the two groups. Thirteen patients were randomized into the control group and 11 into the Inchinko-to combination group. Of the latter, one patient was not evaluable due to failure in taking the medicine. No significant differences in background factors were seen between the two groups. The bilirubin reduction rate (b)s, indicating the effectiveness in improving the patient's jaundice were -0.057±0.019 for the control group and -0.079±0.021 for the Inchinko-to combination group in T-Bil., and -0.058±0.024 for the control group and -0.078±0.022 for the Inchinko-to combination group in D-Bil. In both cases, the Inchinko-to combination group had significantly (p<0.05) lower values than those of control group, confirming that administration of Inchinko-to significantly improved the patient's jaundice following biliary drainage. Using Inchiko-to in combination also improved such subjective symptoms as loss of appetite and general fatigue. Compared with drainage-only, the administration of Inchinko-to after biliary drainage shortened the time needed for jaundice to improve in patient with obstructive jaundice, suggesting a possibility that it may consequently reduce postoperative risks such as liver impairment.

Changes in serum and bile tumor necrosis factor &alpha; before and after percutaneous transhepatic cholangio-drainage for obstructive jaundice

Changes in serum and bile tumor necrosis factor &alpha; before and after percutaneous transhepatic cholangio-drainage for obstructive jaundice

Mirizzi syndrome caused by xanthogranulomatous cholecystitis: Report of a case

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder. In severe cases, inflammation extends to adjacent structures, and XGC is sometimes confused with a malignant neoplasm. We recently diagnosed XGC as the preoperative cause of Mirizzi syndrome in a patient based on the clinical course. The patient was admitted because of obstructive jaundice, with gallbladder carcinoma as the suspected cause. The gallbladder was swollen with gallstones and the serum level of carbohydrate antigen 19-9 (CA19-9) was 3070 U/ml at admission. A percutaneous transhepatic cholangiodrainage (PTCD) was done, and the common hepatic duct as well as the right and left hepatic ducts were found to be obstructed. Later, the CA19-9 level and swelling of the gallbladder decreased and the obstruction of the bile ducts disappeared. A cholecystectomy was performed and the intraoperative pathohistological diagnosis of chronic cholecystitis was made from frozen sections. The pathohistological diagnosis of XGC was made from paraffin-embedded sections. Mirizzi syndrome such as that seen in our patient is a rare complication of XGC. XGC occasionally causes extensive inflammation; thus, performing a conventional cholecystectomy can be unsafe. However, in our opinion, a total, not subtotal, cholecystectomy should be done whenever possible because the incidence of gallbladder carcinoma accompanied with XGC is higher than that with ordinary cholecystitis or gallstones.

A CASE OF MALIGNANT LYMPHOMA OF THE PANCREAS

Malignant lymphoma of the pancreas is extremely rare. We report such a case with a review of the literature. A 68-year-old man was admitted to the hospital because of obstructive jaundice. Abdominal computed tomography and ultrasonography showed a solid mass in the head of the pancreas and swollen gallbladder and bile duct. Percutaneous transhepatic cholangiodrainage was performed. Cholangiography visualized a circum-ferential stenosis at the lower common bile duct. With a preoperative diagnosis of cancer of the pancreas, a total panceatectomy was performed for the tumor invaded the body of the pancreas. The excised tumor was 6.0×4.0×2.5 cm in size. The pthological and immunohistochemical study showed diffuse large cell type (T-cell) and Ki-1 lymphoma.

Echocardiography-guided pericardiocentesis with a needle attached to a probe

Pericardiocentesis with a needle attached to a probe was performed under two-dimensional echocardiographic guidance in 9 patients with pericardial effusion after cardiac operations. The first 5 mm of the tip of a puncture needle for percutaneous transhepatic cholangiodrainage is scratched with a scalpel to give the tip high echo intensity. When the probe is placed on the skin, the direction of puncture at that probe angle appears automatically on the monitor.

MUCUS PRODUCING INTRAHEPATIC BILE DUCT CARCINOMA RECURRED IN THE PTCD FISTULA -REPORT OF A CASE-

Percutaneous transhepatic cholangiodrainage (PTCD) and percutaneous transhepatic choledochoscopy (PTCS) can be employed as preoperative diagnosis of bile duct cancer, when caution should be exercised to posibble complications including intrahepatic hemangioma, choleperitonitis, peritonitis carcinomatosa, and implantation of cancer cells. This time we experienced a case of mucus producing bile duct carcinoma recurred in the PTCD fistula. A 51-year-old woman underwent preoperative PTCD with a diagnosis of intrahepatic bile duct cancer. On the 34th day after hepatectomy or 49th day after a PTCD tube was inserted, an induration was felt in subcutaneous tissue at the fistula which was the same site as the PTCD tube was inserted. With a diagnosis of recurrence to the subcutaneous tissue at the PTCD fistula, the tumor was excised. Histopathological findings of the site was the same as those of intrahepatic bile duce carcinoma. However, on the 150th day after the PTCD tube was inserted, another induration was felt at the same site. It was diagnosed as re-recurrence, and an excision of the tumor and associated resection of the 7 and 8th libs and diaphragm were performed. In a review of the literature, recurrence of bile duct cancer to the PTCD fistula is rare, but there may arise some future problem in the management of PTCD.

A CASE OF CARCINOMA OF THE BILIARY SYSTEMS PRODUCING α-FETOPROTEIN

A 68-year-old woman was admitted to the hospital because of an upper abdominal pain. Ultrasonography and CT-scan revealed a tumor in the gallbladder, obstruction of the common bile duct and remarkable swelling of lymph nodes. Hematological examinations showed obstructive liver dysfunction and a high α-fetoprotein (AFP) level of 503ng/ml. The AFP subfraction analyzed by crossed immunoaffinoelectrophoresis with lentil lectin and concanavalin A was not hepatocellular type. Percutaneous transhepatic cholangiodrainage was attempted, but soon after the inserted tube was dislodged, requiring an emergency surgery. A curative operation was impossible, because metastatic lymph nodes has surrounded the large vessels very tightly. We performed choledochocystectomy and biliojejunal anastomosis for mass reduction and biliary drainage. AFP temporarily decreased after the operation, but it increased gradually till she died of carcinomatosa peritonitis 5 months postoperatively. Histologically the tumor was poorly differentiated adenocarcinoma and a small number of tumor cells at the bile duct were positive for AFP-immunostaining. An analysis of the doubling time of AFP in cancers of the biliary systems seen in the literature indicates the need for the intensive treatment including radical surgery.

A RESECTED CASE OF SYNCHRONOUS DOUBLE CANCER FOUND AT THE PANCREAS AND KIDNEY

A 55-year-old male was admitted to the hospital because of obstructive jaundice. Percutaneous transhepatic cholangio-drainage was performed and cholanigography showed an irregular stenosis of the common bile duct, indicating a pancreatic cancer. Ultrasonography, computed tomography and angiography indicated a tumor in the lower part of the right kidney, suggesting a renal cancer. Pancreatoduodenectomy and right nephrectomy were carried out simultaneously under a diagnosis of synchronas double cancer of the pancreas and kidney. Pathologically, the tumor of the pancreas was well differentiated tubular carcinoma, and another tumor of the right kidney was renal cell carcinoma (clear cell subtype). Postoperative course has been uneventful up to 16 months after the operation. Double cancers including pancretic cancer have been reported in about 10% of all pancreatic cancers. However, double cancer found at the pancreas and kidney is uncommon. Only seven cases have been reported in the literature so far. In this paper, a case of synchronous double cancer found at the pancreas and kidney is presented with a review of the literature.