Previous Drainage Procedure Research Articles

Risk Factors for Hemorrhagic Adverse Events in Percutaneous Transhepatic Biliary Drainage: A Prospective Multicenter Study

PurposeTo determine risk factors (RFs) for hemorrhagic adverse events (AEs) associated with percutaneous transhepatic biliary drainage (PTBD) and to develop a risk assessment model. Materials and MethodsThis was a multicenter, prospective, case control study between 2015 and 2020. Adults with an indication for PTBD were included. Patients who had undergone recent previous drainage procedures were excluded. Multiple variables were controlled. The exposure variables were the number of capsular punctures and passes (using the same puncture). A multivariate analysis was performed (logistic regression analysis). ResultsA total of 304 patients (mean age, 63 years ± 14 [range, 23–87 years]; female, 53.5%) were included. Hemorrhagic AEs occurred in 13.5% (n = 41) of the patients, and 3.0% (n = 9) of the cases were severe. Univariate analysis showed that the following variables were not associated with hemorrhagic AEs: age, sex, bilirubin and hemoglobin levels, type of pathology, portal hypertension, location of vascular punctures, ascites, nondilated bile duct, intrahepatic tumors, catheter features, blood pressure, antiplatelet drug use, and tract embolization. Multivariate analysis showed that number of punctures (odds ratio [OR], 2.5; P = .055), vascular punctures (OR, 4.1; P = .007), fatty liver or cirrhosis (OR, 3.7; P = .021), and intrahepatic tumor obstruction (Bismuth ≥ 2; OR, 2.4; P = .064) were associated with hemorrhagic AEs. Patients with corrected coagulopathies had fewer hemorrhagic AEs (OR, −5.5; P = .026). The predictability was 88.2%. The area under the curve was 0.56 (95% confidence interval, 0.50–0.61). ConclusionsPreprocedural and intraprocedural RFs were identified in relation to hemorrhage with PTBD. AE risk assessment information may be valuable for prediction and management of hemorrhagic AEs.

Expanding the indications for pancreas resection and autologous islet cell transplantation (IAT) in both adults and children

Introduction: Pancreas resection combined with IAT is a controversial procedure with limited experience in the UK and is not funded by the NHS. We present our experience of IAT in patients with chronic pancreatitis and pancreatic trauma including the UK's first paediatric transplant. Methods: We have performed 6 pancreatic resections with IAT over 18 months. 3 patients with chronic pancreatitis (2 hereditary, 1 idiopathic) have undergone total pancreatectomy and IAT. Two patients had previous Frey procedures. 3 patients (2 adults, 1 child) sustained blunt pancreatic trauma and underwent extended left pancreatectomy combined with IAT. Complications were graded according to the Clavien-Dindo classification. Results: In the chronic pancreatitis group the islet yield was low due to fibrosis /previous drainage procedures (<50,000 IEQ). The first patient is now opiate independent and the remaining 2 patients continue on reducing doses. All have marked improvement in their quality of life. All require low dose insulin analogue therapy with in vivo C-peptide secretion. In contrast the trauma patients had a much greater islet yield (99,750–298,149 IEQ). All are insulin independent. There were no complications related to portal vein infusion and no deaths, one patient required re-laparotomy for an infected collection. Conclusions: Pancreatectomy and IAT can be used as a salvage procedure in patients who have failed all other therapy but in our opinion results would be superior if performed earlier in the course of their disease. It is also a feasible management option for complex pancreatic trauma in both adults and children.

Dual Modality Drainage for Symptomatic Walled-Off Pancreatic Necrosis Reduces Length of Hospitalization, Radiological Procedures, and Number of Endoscopies Compared to Standard Percutaneous Drainage

BackgroundSymptomatic walled-off pancreatic necrosis (WOPN) treated with dual modality endoscopic and percutaneous drainage (DMD) has been shown to decrease length of hospitalization (LOH) and use of radiological resources in comparison to standard percutaneous drainage (SPD). AimThe aim of this study is to demonstrate that as the cohort of DMD and SPD patients expand, the original conclusions are durable. MethodsThe database of patients receiving treatment for WOPN between January 2006 and April 2011 was analyzed retrospectively. PatientsOne hundred two patients with symptomatic WOPN who had no previous drainage procedures were evaluated: 49 with DMD and 46 with SPD; 7 were excluded due to a salvage procedure. ResultsPatient characteristics including age, sex, etiology of pancreatitis, and severity of disease based on computed tomographic severity index were indistinguishable between the two cohorts. The DMD cohort had shorter LOH, time until removal of percutaneous drains, fewer CT scans, drain studies, and endoscopic retrograde cholangiopancreatography (ERCPs; p < 0.05 for all). There were 12 identifiable complications during DMD, which were successfully treated without the need for surgery. The 30-day mortality in DMD was 4% (one multi-system organ failure and one out of the hospital with congestive heart failure). Three patients receiving SPD had surgery, and three (7%) died in the hospital. ConclusionDMD for symptomatic WOPN reduces LOH, radiological procedures, and number of ERCPs compared to SPD.

Chronic inflammatory changes seen in gallbladders of patients with pancreatico-biliary malunion years after transduodenal sphincterotomy: is it a precursor for gallbladder carcinoma?

Common pancreaticobiliary channel malunion (PBM) is known to be associated with increased frequency of gallbladder (GB) cancer in adults. Few studies have reported the presence of histological changes in the GB following transduodenal drainage procedures in children with PBM. The aim of this study was to document the histological changes in the GB in children who underwent interval prophylactic cholecystectomy up to 18 years following PBM drainage procedure. All children who underwent open transduodenal sphincterotomy (TDS) for symptomatic PBM followed by prophylactic synchronous (open) and interval (laparoscopic) cholecystectomy between 1987 and 2007 were studied retrospectively. Eight children with PBM were identified. The median age at initial presentation and open transduodenal sphincterotomy was 8 months (1 month-3.5 years). The average interval between open TDS and prophylactic cholecystectomy was 5.5 years (0-18 years). Two children had synchronous TDS and cholecystectomy. At initial presentation, all patients presented with obstructive jaundice. Mild common bile duct dilatation was encountered in all patients. The dilated ducts returned to normal, and remained normal after transduodenal sphincterotomy. Histopathology in seven out of eight GB specimens (87.5%) showed microscopic evidence of chronic inflammation. Chronic cholecystitis (n = 7), Rokitansky-Aschoff sinuses (n = 3), cholesterosis (n = 1) and intestinal metaplasia (n = 1) were observed in the GB biopsies. Only one patient, who had TDS and a synchronous cholecystectomy in the neonatal period, did not have histological changes in the GB. Average follow-up in years ranged between 3 months and 19 years (from TDS) with a median of 8 years, and between 3 months and 6 years (from cholecystectomy) with a median of 2 years. Chronic inflammatory changes were found in seven of eight GB specimens from patients with PBM despite previous drainage procedure in six patients and in one of two patients who underwent synchronous TDS and cholecystectomy. These changes may be the precursor of malignant transformation in GB of patients with PBM.

Adult Choledochal Cyst

Choledochal cyst is a rare disease in adults. Excellent results have been achieved with proper management. However, malignancy complicating choledochal cyst still carries a dismal prognosis despite radical surgery. The aim of this study was to review the clinical course and operative results of the disease in adulthood, with emphasis on the occurrence of malignancy. A retrospective review of adult patients who underwent surgery for choledochal cysts in a 12-year period was performed. Of the 25 adults, 80% were female and the median age was 30 years. A total of 32% of patients had previous drainage procedures for their choledochal cyst disease. Malignancy was noted in five patients (20%). There were significantly more males among the patients with malignancy than among those with benign disease (60% vs 10%), a greater number of older patients (median age, 39 vs 27 years) and more impaired liver function tests, but there was no difference in terms of incidence of previous drainage procedures between the two groups. There was no operative mortality; operative morbidity was 36%. No significant long-term complications were noted in the benign group but three of the five patients with malignancy died or developed recurrence within a few months after surgery. The prognosis for patients with malignancy complicating choledochal cyst remains poor despite aggressive radical surgery such as Whipple's operation or additional hepatectomy. Malignancy should be suspected in older and male patients who present with jaundice or impaired liver function tests. Total cyst excision and hepaticojejunostomy is an effective and safe treatment for patients with the common type I choledochal cyst in order to reduce the chance of subsequent development of malignancy.

The Whipple Operation: The Classical Surgical Procedure to Treat Chronic Pancreatitis

Pancreaticoduodenectomy remains the gold standard for the various resection operations that are used to treat pain in chronic pancreatitis. It is used most commonly when: (1) the pancreatic duct is normal in diameter; (2) the head of the pancreas is enlarged, and contains calcifications and cysts; (3) a previous drainage procedure was ineffective, and, even in the absence of pain, (4) when there is concern about the presence of a pancreatic neoplasm in the head of the gland. The operative mortality rate is < 5%, and about 90% of patients experience long-term pain relief.

Endoscopic management of peptic ulcer disease.

This article reviews the authors' experience with endoscopic management of duodenal ulcer and ulcers occurring after a previous drainage procedure. Patients with complications of duodenal ulcer and ulcers occurring after a previous drainage procedure still require surgical management. Virtually all operations for duodenal ulcer include some form of vagotomy. American surgeons in academic centers prefer highly selective vagotomy in suitable candidates. Video-directed laparoscopic and thoracoscopic operations have been done for all complications of duodenal ulcer except for acute hemorrhage. The authors have performed laparoscopic operation on eight patients with intractable chronic duodenal ulcer, seven patients with gastroesophageal reflux disease combined with duodenal ulcer, one patient with chronic duodenal ulcer and gastric outlet obstruction, and one patient with acute perforation. Operations performed included omentopexy, anterior seromyotomy plus post truncal vagotomy, and highly selective vagotomy. Seven patients had a simultaneous Nissen fundoplication; and the patient with obstruction underwent concomitant pyloroplasty and vagotomy. Six patients with intestinal ulcers occurring after a previous drainage procedure were treated with thoracoscopic vagotomy. Techniques used are shown. There has been one recurrent ulcer in the laparoscopic group after anterior seromyotomy plus posterior truncal vagotomy. The patient treated by omentopexy for duodenal perforation recovered gastrointestinal function promptly with no further difficulty, but eventually died of primary medical disease. Patients undergoing thoracoscopic vagotomy have all become asymptomatic. Postoperative hospital stay after highly selective vagotomy, anterior seromyotomy plus posterior truncal vagotomy, or thoracoscopic vagotomy was 1-5 days. Laparoscopic management of duodenal ulcers is feasible. Larger numbers of patients with longer follow-up are essential. Ulcers occurring after a drainage procedure deserve thoracoscopic vagotomy.

Pancreaticoduodenectomy. A 40-year experience.

One hundred six pancreaticoduodenectomies, including 10 cases done for benign disease were reviewed, retrospectively, and 51 factors analyzed. There is a significant difference in survival based upon final pathologic diagnosis. Five-year survivals were 0% for adenocarcinoma of the pancreas, 38% for duodenal carcinoma, 24% for CBD caracinoma, 30% for ampullary carcinoma, 24% for other cancers not considered part of the ampullary carcinoma, 24% for other cancers not considered part of the ampullary region, and 100% for those with benign disease (chi 2 = 24.66, df = 5, p = 0.0002). Four statistically significant poor prognostic factors were identified, including age greater than 51 years, serum bilirubin level greater than 6 mg/dl, SGOT greater than 100, and a previous drainage procedure. Results of this study seem to indicate that the pancreaticoduodenectomy has limited indications in adenocarcinoma of the pancreas, but remains the procedure of choice for all other periampullary lesions including suspicious lesions with a negative biopsy at the time of surgery.