Transhepatic Biliary Stenting Research Articles

Outcomes in percutaneous stenting of non-hepato-biliary/pancreatic malignant jaundice

The aim of this study is to review the practice and outcomes at our institution of percutaneous transhepatic placement of metallic biliary stents for non-hepato-biliary/pancreatic (non-HBP) malignant obstructive jaundice. A retrospective review was performed of the records of all patients undergoing transhepatic stenting for non-HBP malignant obstructive jaundice over a 7-year period. A total of 25 patients were successfully stented and linear regression analysis of a variety of demographic, clinical and laboratory markers against survival was performed. Survival after stenting varied from 1 to 1354 days (median 58, mean 152). An initial bilirubin level less than 300 micromol/L (P=0.01) and a reduction of greater than 50% in bilirubin post stenting (P=0.02) were strong predictors of improved survival. Older patients survived longer than younger ones (P<0.01). There was a weak association of survival with an albumin>30 g/L (P=0.06), but no statistically significant correlation with creatinine or haemoglobin levels or active tumour treatment after stenting. There were few major complications from the procedures. Transhepatic metallic biliary stenting for non-HBP malignant biliary obstruction is a safe and effective procedure, and with careful patient selection, significant periods of survival and palliation of jaundice can be achieved.

Interval Biliary Stent Placement Via Percutaneous Ultrasound Guided Cholecystostomy: Another Approach to Palliative Treatment in Malignant Biliary Tract Obstruction

Percutaneous cholecystostomy is a minimally invasive procedure for providing gallbladder decompression, often in critically ill patients. It can be used in malignant biliary obstruction following failed endoscopic retrograde cholangiopancreatography when the intrahepatic ducts are not dilated or when stent insertion is not possible via the bile ducts. In properly selected patients, percutaneous cholecystostomy in obstructive jaundice is a simple, safe, and rapid option for biliary decompression, thus avoiding the morbidity and mortality involved with percutaneous transhepatic biliary stenting. Subsequent use of a percutaneous cholecystostomy for definitive biliary stent placement is an attractive concept and leaves patients with no external drain. To the best of our knowledge, it has only been described on three previous occasions in the published literature, on each occasion forced by surgical or technical considerations. Traditionally, anatomic/technical considerations and the risk of bile leak have precluded such an approach, but improvements in catheter design and manufacture may now make it more feasible. We report a case of successful interval metal stent placement via percutaneous cholecystostomy which was preplanned and achieved excellent palliation for the patient. The pros and cons of the procedure and approach are discussed.

Assistance of CT/MR images to plan for one-stage stent placement in biliary obstructions

This study describes and evaluates a simple method of percutaneous intervention planning in order to treat obstructed biliary systems using computed tomography (CT) or magnetic resonance imaging (MRI). CT (n=18) and MRI (n=31) examinations, which were performed during the imaging work-up of 31 patients with malignant biliary obstruction, were used to plan transhepatic percutaneous biliary intervention. The appropriate intrahepatic duct, the entry point on the skin, and the puncture direction and depth were determined on axial CT or MR images. Under fluoroscopic guidance, a 21-G needle was used for puncture, and the puncture was followed by a percutaneous transhepatic cholangiography, the placement of a stent, and the placement of an external drainage catheter. The biliary system was successfully accessed on the first attempt in 16 patients (51.6%). Second or third attempts were required in eight (25.8%) and two (6.4%) patients, respectively, whereas more than three attempts were necessary for the remaining five (16.3%) patients. One-stage percutaneous transhepatic biliary stent placement was performed in 29 patients (93.5%). Two (n=1) and three (n=1) interventional sessions were required in order to successfully complete stent placement in the remaining two cases. The mean fluoroscopy time for one-stage biliary stent placement was 12.6 min +/- 2.6 min, and no major complications were noted. Thorough CT/MRI-based planning is suggested prior to the interventional treatment of malignant biliary obstruction so as to reduce the number of needle passes, the duration of the procedure, the fluoroscopy time, and the number of complications.

Placement of percutaneous transhepatic biliary stent using a silicone drain with channels

This report describes a method for percutaneous transhepatic biliary stenting with a BLAKE Silicone Drain, and discusses the usefulness of placement of the drain connected to a J-VAC Suction Reservoir for the treatment of stenotic hepaticojejunostomy. Percutaneous transhepatic biliary drainage was performed under ultrasonographic guidance in a patient with stenotic hepaticojejunostomy after hepatectomy for hepatic hilum malignancy. The technique used was as follows. After dilatation of the drainage root, an 11-Fr tube with several side holes was passed through the stenosis of the hepaticojejunostomy. A 10-Fr BLAKE Silicone Drain is flexible, which precludes one-step insertion. One week after insertion of the 11-Fr tube, a 0.035-inch guidewire was inserted into the tube. After removal of the 11-Fr tube, the guidewire was put into the channel of a 10-Fr BLAKE Silicone Drain. The drain was inserted into the jejunal limb through the intrahepatic bile duct and was connected to a J-VAC Suction Reservoir. Low-pressure continued suction was applied. Patients can be discharged after insertion of the 10-Fr BLAKE Silicone Drain connected to the J-VAC Suction Reservoir. Placement of a percutaneous transhepatic biliary stent using a 10-Fr BLAKE Silicone Drain connected to a J-VAC Suction Reservoir is useful for the treatment of stenotic hepaticojejunostomy.

Percutaneous transhepatic biliary stenting: The first experience and results of the Hospital of Kaunas University of Medicine

Malignant biliary obstruction may be caused by cholangiocarcinoma and other nonbiliary carcinomas. At the time of diagnosis, 90% of patients with malignant obstructive jaundice may benefit from palliative treatment only. The objective of palliation is to relieve jaundice-related symptoms, prevent cholangitis, prolong survival, and improve quality of life. Percutaneous transhepatic biliary stenting is a well-established procedure used in patients with malignant obstruction of intra- and extrahepatic bile ducts. Twelve patients (9 women, 3 men; mean age, 68 years; range, 44-88 years) with inoperable malignant biliary obstruction were selected for percutaneous transhepatic biliary stenting with metallic stents in the period from January to December 2007. Technical and clinical success rate in this patient series was 83% and 80%, respectively. Minor and major complications occurred in 17% and 8% of cases, respectively, which is in the range reported by the others. This is our first experience of percutaneous transhepatic biliary stenting at the Hospital of Kaunas University of Medicine and, to our knowledge, the first reported patient series in Lithuania. These first results encourage expanding effective palliation by the employment of the percutaneous transhepatic biliary stenting in patients with nonresectable malignant biliary obstruction or in case of a recurrent disease after curative surgery. The cost effectiveness of percutaneous transhepatic biliary stenting against percutaneous transhepatic biliary drainage has yet to be evaluated in a prospective manner. However, immediate clinical benefits and positive short-term outcomes are unequivocal.

Venoplasty of hepatic venous outflow with a venous patch in domino liver transplantation

The domino donor (DD) was a 16-year-old boy with homozygous familial hypercholesterolemia. He received a whole liver graft from a 9-year-old deceased donor. We designed the hepatic outflow to be reconstructed by side-to-side cavocaval anastomosis for the first liver transplantation, so the DD hepatectomy was performed with preservation of the inferior vena cava (IVC) and the stumps of 3 hepatic veins were preserved as long as possible. DD, domino donor; IVC, inferior vena cava; LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. At the back-table, the hepatic veins of the domino graft were jointed together easily (Fig. 1) by 6/0 prolene. A vein graft including the lower portion of the IVC in continuity with the left and right common iliac veins from the deceased donor was used. The graft was opened longitudinally to become a venous patch. One midline incision of the vein patch was done appropriately to be anastomosed with hepatic veins by 6/0 prolene sutures (Fig. 2). The external edge of the vein patch was further fashioned to be a wide cuff (Fig. 3). The domino liver graft. The orifices of RHV, MHV, and LHV were jointed together by 6/0 prolene sutures. Abbreviations: LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. The midline of the venous patch was incised appropriately to be anastomosed with hepatic veins by 6/0 prolene sutures. Abbreviations: LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. The external edge of the vein patch was further fashioned to be a wide cuff. Abbreviations: LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. The second recipient was a 59-year-old man with hepatitis B cirrhosis and hepatocellular carcinoma. The recipient's hepatectomy was performed with preservation of the IVC. The domino liver was implanted in the standard piggyback fashion by the suturing of the reconstructed suprahepatic venous cuff to the junction of all 3 hepatic veins of the recipient with clamping of the IVC but without venous-venous bypass. The cold ischemic time, warm ischemic time, and operative blood loss were 480 minutes, 34 minutes, and 450 cc, respectively, for the DD and 435 minutes, 38 minutes, and 3300 cc, respectively, for the second recipient. The DD was discharged on the 19th postoperative day with an uneventful recovery. The second recipient was discharged on the 12th postoperative day but was readmitted for anastomotic bile leakage 8 days after discharge. He was treated by a percutaneous transhepatic biliary stent and subsequently was well with normal liver functions. The Doppler ultrasound showed normal triphasic flow into all major hepatic veins of the domino liver 6 weeks after transplantation. There have been a few reports regarding the techniques of outflow reconstruction for conditions similar to our case.1-4 Our case followed the technique described by Cescon et al.,4 and the successful outcome reassures us of the usefulness of this technique. In addition, we suggest side-to-side caval anastomosis5 for the first whole liver implantation in order to retrieve longer stumps of hepatic veins of the domino liver. The long stumps of hepatic veins are easily jointed together, and this in turn makes the vein-patch technique for outflow reconstruction of the domino liver graft easier.

Primary Sclerosing Cholangitis: Role of Extrahepatic Biliary Resection

Most centers advocate orthotopic liver transplantation (OLT) for patients with primary sclerosing cholangitis (PSC) and cirrhosis. Management of PSC patients without cirrhosis remains controversial. We examined the results of extrahepatic biliary resection (EHBR) for PSC. Between 1981 and 2006, 126 patients with PSC underwent EHBR (n = 77) or OLT (n = 49). Data on biliary drainage procedures, perioperative morbidity, and longterm survival were collected and analyzed. Of 77 patients undergoing EHBR, mean preoperative bilirubin level was 5.6 mg/dL. Nine (11.7%) patients had cirrhosis. Most patients had preoperative biliary drainage (ERCP, 61.0%; PTC, 67.5%). At operation, 73 (94.8%) patients underwent EHBR, including hepatic duct bifurcation. Most patients also had insertion of bilateral transhepatic silicone elastomer biliary stents; 4 (5.2%) underwent EHBR with stent insertion plus hepatectomy. For EHBR patients, perioperative complication rate was 38.7% and 30-day mortality was 3.9%. Bilirubin levels significantly decreased postoperatively (mean drop 3.8 mg/dL; p < 0.01). At 3 years, 57.1% of patients had no PSC-related readmissions, and 16.2% had more than 3. At a median followup of 10.5 years, 5- and 10-year survival was 76.4% and 52.7%, respectively. Cholangiocarcinoma did not develop in any patients, and only seven required OLT. Factors associated with worse survival included postoperative bilirubin >or= 2 mg/dL and history of cirrhosis (both p < 0.001). In patients undergoing EHBR, noncirrhotic patients had significantly better longterm outcomes versus cirrhotic patients (10-year survival, 60.2% versus 12.0%; p < 0.001). In contrast, 10-year survival of OLT patients with cirrhosis was 57.0%. Noncirrhotic patients with PSC can be successfully managed with EHBR. EHBR for noncirrhotic patients is associated with low perioperative morbidity, few readmissions, no new cholangiocarcinomas, and 10-year survival > 60%. OLT should be reserved for patients with PSC and associated hepatic cirrhosis.

The Role of Sonography in Imaging of the Biliary Tract

Sonography is the recommended initial imaging test in the evaluation of patients presenting with right upper quadrant pain or jaundice. Dependent upon clinical circumstances, the differential diagnosis includes choledocholithiasis, biliary stricture, or tumor. Sonography is very sensitive in detection of mechanical biliary obstruction and stone disease, although less sensitive for detection of obstructing tumors, including pancreatic carcinoma and cholangiocarcinoma. In patients with sonographically documented cholelithiasis and choledocholithiasis, laparoscopic cholecystectomy with operative clearance of the biliary stone disease is usually performed. In patients with clinically suspected biliary stone disease, without initial sonographic documentation of choledocholithiasis, endoscopic ultrasound or magnetic resonance cholangiopancreatography is the next logical imaging step. Endoscopic ultrasound documentation of choledocholithiasis in a postcholecystectomy patient should lead to retrograde cholangiography, sphincterotomy, and clearance of the ductal calculi by endoscopic catheter techniques. In patients with clinical and sonographic findings suggestive of malignant biliary obstruction, a multipass contrast-enhanced computed tomography (CT) examination to detect and stage possible pancreatic carcinoma, cholangiocarcinoma, or periductal neoplasm is usually recommended. Assessment of tumor resectability and staging can be performed by CT or a combination of CT and endoscopic ultrasound, the latter often combined with fine needle aspiration biopsy of suspected periductal tumor. In patients whose CT scan suggests hepatic hilar or central intrahepatic biliary tumor, percutaneous cholangiography and transhepatic biliary stent placement is usually followed by brushing or fluoroscopically directed fine needle aspiration biopsy for tissue diagnosis. Sonography is the imaging procedure of choice for biliary tract intervention, including cholecystostomy, guidance for percutaneous transhepatic cholangiography, and drainage of peribiliary abscesses.

Intraoperative Transhepatic Biliary Catheter Insertion Technique for Biliary Reconstruction: Early Results

Biliary complications are critical problems in liver transplantation. Herein, we retrospectively analyzed the early results of an intraoperative transhepatic biliary catheter insertion technique for biliary reconstruction. Since November 2004, we have used this technique in 66 patients (32 children and 34 adults). In the new technique, a 5- F Kumpe catheter is inserted into the biliary system in 2 steps. One step is completed at the back table; the second step is completed during the recipient operation. Fourteen patients received whole-liver grafts, 25 received a right lobe, and 27 received a left-lateral or a left lobe. The mean graft weight–to–body weight ratio in the living-donor liver transplantations was 1.6% ± 1.0% (range, 0.8%–4.1%). Intraoperative transhepatic biliary catheter insertion was performed with a duct-to-duct anastomosis in 60 patients and with a Roux-en-Y hepaticojejunostomy in 6 patients. Five biliary complications occurred in 4 patients. Two of these 4 patients had bile leakage from the anastomotic site during the early postoperative period. Biliary stenoses developed at the anastomotic site in 2 patients and from a nonanastomotic site in 1 patient in the late postoperative period. In conclusion, this new technique of biliary reconstruction with intraoperative biliary catheter insertion has significantly reduced our complication rate. Transhepatic biliary stenting seems to prevent biliary complications and makes it simple to maintain percutaneous access in the event that problems arise. Intraoperative transhepatic biliary catheter insertion at the back table is a safe means of providing good biliary drainage after liver transplantation.

Results of Biliary Reconstructions in Liver Transplantation at Our Center

Biliary complications are some of the most critical problems in liver transplantation. Despite various refinements in surgical technique, different types of liver transplantations are associated with significant numbers of biliary problems. In this study, we analyzed the results of biliary reconstructions in 127 liver transplant recipients at our center from April 2001 to May 2006. Through November 2004, we used different techniques for biliary reconstruction in 66 of these patients, including duct-to-duct (DD) anastomoses, Roux-en-Y hepaticojejunostomy (RYHJ), anastomoses over T tubes or stents, and anastomoses without stenting. During the first period, we used a DD anastomosis in 15 cadaveric whole liver grafts and in 25 right lobe and 12 left lobe or left lateral segment grafts from living-related donors. RYHJ was preferred in 2 cadaveric and 12 left lateral segment grafts. Beginning in November 2004, we employed intraoperative transhepatic biliary catheter insertion in 61 patients (29 children, 32 adults). In the most recent 61 cases of 13 liver grafts from cadavers and 48 from living-related donors, 14 patients (2 children and 12 adults) received whole-liver grafts, 22 (all adults) a right lobe, and 26 (all children) a left lateral or left lobe. Intraoperative transhepatic biliary catheter insertion was performed with DD anastomosis in 55 cases and with RYHJ in 6 cases. The mean complication rate decreased from 24% to 8.1% during the period using a new biliary reconstruction technique. Five biliary complications occurred in four patients. The new technique of biliary reconstruction using intraoperative biliary catheter insertion has significantly reduced the biliary complication rate. Transhepatic biliary stenting prevents biliary complications and maintains percutaneous access when problems arise. Intraoperative transhepatic biliary catheter insertion at the back table is a safe way to provide good biliary drainage after liver transplantation.

Cholecystitis After Metallic Stent Placement in Patients With Malignant Distal Biliary Obstruction

Cholecystitis after metallic stent (MS) placement is an issue requiring attention. From our experience, cholecystitis seemed to occur mainly in patients with tumor involvement to the cystic duct orifice. The aim of the present study was to identify risk factors for cholecystitis in patients treated with covered or uncovered MS. We analyzed 246 patients who received MS placement (covered MS in 171 and uncovered in 75) between August 1997 and May 2005 for the treatment of unresectable distal malignant biliary obstruction. Causative diseases were as follows: pancreatic cancer in 162, papillary cancer in 10, bile duct cancer in 41, and metastatic nodes in 33 patients. Tumor involvement to orifice of the cystic duct (OCD) was diagnosed based on cholangiography and intraductal ultrasonography. Cholecystitis after MS placement was found in 13 patients (5.3%). There was no significant difference in the incidence of cholecystitis between covered (5.8%) and uncovered (4.0%) MS. By univariate analysis, tumor involvement of the OCD, MS placed above the papilla, and stricture located at midportion were associated significantly with cholecystitis. By multivariate analysis, only tumor involvement of the OCD was a risk factor, with an odds ratio of 47.206 (95% confidence interval, 5.84-381.60). Cholecystitis after MS placement is associated with tumor involvement to the orifice of the cystic duct, regardless of the type of stent.

Occupational Radiation Exposure from Fluoroscopically Guided Percutaneous Transhepatic Biliary Procedures

The aim of this study was to determine occupational dose levels for projections commonly used in fluoroscopically guided percutaneous transhepatic biliary (PTB) drainage and stent placement procedures. Exposure data from 71 consecutive PTB examinations were analyzed to determine average examination parameters for biliary drainage and stent placement procedures. An anthropomorphic phantom was exposed at three projections common in PTB interventions according to the actual geometric parameters recorded in the patient study. Scattered air-kerma dose rates were measured for neck, waist, and gonad levels at various sites in the interventional radiology laboratory. To produce technique- and instrumentation-independent data, dose rate values were converted to dose-area product (DAP)-normalized air-kerma values. In addition, sets of thermoluminescent dosimetry crystals were placed in both hands of the interventional radiologist to monitor doses during all PTB procedures. Isodose maps of DAP-normalized air-kerma doses in the interventional laboratory for projections commonly used in PTB procedures are presented. To facilitate effective dose estimation, normalized dosimetric data at the interventional radiologist's position are presented for left and right access drainage procedures, metallic stent placement only, and drainage and metallic stent placement in one-session procedures with and without under-couch shielding. Doses to the hands of interventional radiologists are presented for left and right transhepatic biliary access and metallic stent placement. Body level-specific normalized air-kerma distributions from commonly used projections in PTB procedures may be useful to accurately quantify dose, maximum workloads, and possible radiogenic risks delivered to medical personnel working in the interventional radiology laboratory. Normalized dose data presented will enable occupational exposure estimation from other institutions.

A New Technique for Bile Duct Reconstruction in Liver Transplantation

Biliary complications are one of the most important problems in liver transplantation. Despite various refinements of surgical technique, liver transplantation is associated with significant numbers of biliary problems. In this article, we describe our novel “intraoperative transhepatic biliary catheter insertion” technique for biliary reconstruction in 29 patients, since November 2004 comparing results before and after its implementation. 5-F Kumpe catheter is inserted into the biliary system in two steps. The first is completed at the back table, and the second during the recipient operation. The grafts were from cadavers in 10 cases, with the remaining ones from living donors. Ten patients received whole-liver grafts, 11 received a right lobe, and eight received a left-lateral lobe or left lobe. The mean weight of the living donor grafts was 598 g (range = 270 to 975 g). The mean graft weight-to-body weight ratio in the living donor liver transplantations was 1.6% ± 1.0% (range, 0.8% to 4.1%). Intraoperative transhepatic biliary catheter insertion was performed with a duct-to-duct anastomosis in 27 cases and with a Roux-en-Y hepaticojejunostomy in two cases. The only biliary complication was one case (3.4%) of bile leakage from the anastomotic site. This rate is significantly lower than that for duct-to-duct biliary reconstructions prior to the new catheter technique (13.0%; P < .05). This new technique of biliary reconstruction with intraoperative biliary catheter insertion has significantly reduced our biliary complication rate. Transhepatic biliary stenting prevents biliary complications and makes it simple to maintain percutaneous access in case such problems arise. However, further studies are needed to compare incidence rates of biliary complications when our novel technique is used versus other surgical techniques.

Radiation Dose and Risk from Fluoroscopically Guided Percutaneous Transhepatic Biliary Procedures

To estimate radiation dose and associated risks after fluoroscopically guided percutaneous transhepatic biliary (PTB) drainage and stent implantation procedures. Organ and effective doses, normalized to dose-area product (DAP), were estimated for PTB procedures with use of a Monte Carlo transport code and an adult mathematical phantom. Exposure parameters from 51 consecutive patients were used to determine average examination parameters for biliary drainage and stent implantation procedures. Thermoluminescent dosimeters were used in an anthropomorphic phantom to verify Monte Carlo calculations. Radiation-induced cancer and genetic risks were estimated. The results consist of doses normalized to DAP so patient dose from any technique and x-ray unit can be easily calculated for left and right biliary access and for separate or combined biliary and metallic stent implantation sessions. A good agreement was found between Monte Carlo-calculated data and data derived from thermoluminescent dosimetry. The average effective dose varied from 1.8 to 5.4 mSv depending on procedure approach (left vs right access) and procedure scheme. A maximum effective dose of 13 mSv was estimated for 30 minutes of fluoroscopy. Doses delivered to patients undergoing PTB procedures are comparable to those that arise from computed tomography protocols. Radiation-induced cancer risk may be considerable for young patients undergoing PTB drainage and stent implantation procedures.

Inward and Outward Migration of Covered Metallic Stent in Patients with Unresectable Malignant Distal Biliary Obstruction

Inward and Outward Migration of Covered Metallic Stent in Patients with Unresectable Malignant Distal Biliary Obstruction Hiroyuki Isayama, Yousuke Nakai, Osamu Togawa, Toshihiko Arizumi, Saburo Matsubara, Hiroshi Kogure, Yukiko Ito, Natsuyo Yamamoto, Naoki Sasahira, Kenji Hirano, Takeshi Tsujino, Nobuo Toda, Yutaka Komatsu, Minoru Tada, Haruihiko Yoshida, Takao Kawabe, Masao Omata Background & Aim: Endoscopic or transhepatic biliary stenting has become widely accepted as a standard procedure for palliation of jaundice in patients with malignant biliary obstruction. Recently, various types of metallic stents, including polyurethane-covered Wallstent (PCW), polyurethane-covered Diamond stents (PCD) and silicone covered-Wallstent (SCW), are available. We have reported that covered metallic stents have longer patency to prevent tumor ingrowth (Gastrointest Endosc 2002, Gut 2004). More recently, however, disadvantages characteristic of those stents are noticeable. Of those, stent migration is one of the most common and serious ones. Therefore, we conducted the present study to elucidate the clinical features in cases with migration. Patients & Methods: From August 1997 to August 2004, we managed 180 patients with unresectable malignant distal biliary obstruction treated with covered metallic stent (pancreatic cancer 109, bile duct cancer 34, gallbladder cancer 7, papillary cancer 8 and metastatic nodes 22). PCW, PCD and SCW were used in 21, 57 and 102 patients, respectively. Their Medical records were retrospectively reviewed. We defined the stent migrated above the stricture was ‘‘inward migration’’ and distally migrated into the duodenum was ‘‘outward’’. Results: Twenty patients developed migration 2.5 months in mean after stent insertion. Nine had inward migration and 11 outward. All the patients with inward migration were accompanied by cholestasis or cholangitis. Inward migration seems to be mainly due to inappropriate designing of stent length and placement site. Stents were more shortened than expected. On the other hand, among 11 patients with outward migration, none showed cholangitis or cholestasis. The migration was accidentally found by follow-up abdominal X-ray. Nine with outward migration had favorable response to anticancer. Of those, 4 did not show symptoms even after stent was detached. Conclusions: Inward migration was associate serious symptomatic complications such as cholangitis. However, this type of migration may be avoided by directing careful attention to designing stent length and placement site. On the other hand, outward migration occurred in patients with favorable response to anticancer treatment and might not lead to more serious condition.

The Cost-effectiveness Analysis of Percutaneous Transhepatic Metal Versus Plastic Biliary Stent Implantation for Treating Malignant Biliary Obstruction (Multiple Center Investigation)

Objective: To compare metal versus plastic biliary stent implantation for treatment of malignant biliary obstruction in cost-effectiveness ratio (CER). Methods: Percutaneous transhepatic self-expandable metal stent (MS, n=61) or 10F plastic stent (PS, n=34) implantation was performed in 95 patients with malignant biliary obstruction in three hospitals of Guangdong province. All patients were followed up until death or at least one year after the procedure. Kaplan-Meier analysis was used to compare the survival and stent patency rates of the patients in the two groups. CERs of two groups were calculated. The main indexes were CERsurvival period (total cost/median survival period), CERpatency period (total cost/median patency period). Results: The total costs of treatment were 53177±3139 yuan (RMB) in MS group and 42564±4950 yuan (RMB) in PS group respectively (P>0.05). CER in MS group was superior to that in PS group (CERsurvival period was 237.4 yuan /d vs 452.6 yuan /d, respectively; CERpatency period was 231.2 yuan /d vs 472.9 yuan /d, respectively). Conclusion: The metal stent implantation is superior to the plastic stent in the CER for treatment of malignant biliary obstruction.

Biliary complications of living related pediatric liver transplant patients.

Patients who undergo living related left lateral segment liver transplants have been reported to have a high incidence of biliary complications and some studies suggest that most patients will ultimately need operative revision. We reviewed our experience with living related transplantation in pediatric recipients to examine the occurrence of biliary complications and the utility of percutaneous biliary procedures in their management. Over a 10-yr period, 48 living donor transplants were performed in 47 patients. Sixteen patients (33%) had biliary complications. Complications included 10 leaks (20%) and eight strictures (17%). Although leaks were treated predominantly with operation, other biliary complications were treated almost exclusively non-operatively. Self limited leaks that lead to biloma accumulation were most often treated via percutaneous catheter drainage and all strictures were treated using percutaneous transhepatic biliary cholangioplasty and stenting. Sixty-seven percent of biliary complications underwent non-operative biliary intervention. Most strictures were focal anastomotic strictures and were successfully treated with cholangioplasty although multiple interventions were necessary and patients required stenting for an average of 13 months. Three of eight strictures were diffuse in nature and these included the only patient who required retransplantation. Graft survival with respect to biliary complications was 94%; 1 yr, 5 yr and overall patient survival for those with biliary complications was 88, 88 and 81%, and for the entire living related group was 84, 81 and 77%, respectively. Although biliary complications are frequent in pediatric living related transplantation, they are not associated with decreased patient survival. Excepting significant bile leaks, the majority can be treated non-operatively via biliary cholangioplasty and stenting. Strictures are especially amenable to this technique which, in our experience, has been successful at decreasing or postponing the need for retransplantation.

Biliary tract carcinoma

The key to successful management of biliary tract carcinoma is early diagnosis and a multidisciplinary team approach involving a hepatobiliary surgeon, therapeutic endoscopist, and oncologist. Management depends on the location of the tumor ( proximal or distal), and resectability. Distal tumors that are resectable are best treated with radical pancreaticoduodenectomy, while nonresectable distal tumors are treated by using endoscopic or percutaneous biliary stents for biliary decompression. Treatment of proximal resectable tumors depends on the Bismuth Classification. Bismuth I and II tumors can be resected without concomitant hepatic resection, and Bismuth III and IV tumors require local tumor and hepatic parenchymal resection. Nonresectable proximal tumors are best treated with percutaneous transhepatic biliary stents. The role of chemotherapy, radiotherapy, and photodynamic therapy in these patients remains investigational.

Surgical Treatment of Biliary Tract Infections

Despite major advances in surgical and nonsurgical therapy, biliary tract infections remain a significant cause of morbidity and mortality. The two classic biliary tract infections most commonly encountered are acute cholecystitis (either calculous or acalculous) and acute cholangitis. In addition, bile leakage associated with bile duct injuries during laparoscopic cholecystectomy has become a problem not infrequently encountered by surgeons. Acute calculous cholecystitis results from a combination of mechanical, biochemical, and infectious mechanisms, initiated by stone impaction in the cystic duct. After instituting empiric antibiotics, early laparoscopic cholecystectomy should be performed. Although conversion to open cholecystectomy is more common than in chronic cholecystitis, there appears to be no increased morbidity or mortality in that setting. Acute acalculous cholecystitis usually occurs in critically ill patients and may present both a diagnostic and therapeutic dilemma. Aggressive management, however, is warranted, both because of the critical nature of illness in these patients and the high incidence of perforation. Percutaneous cholecystostomy is indicated, particularly in high-risk patients both for diagnosis and treatment. Acute cholangitis results from a combination of bactibilia and biliary obstruction. The majority of patients can be successfully managed with intravenous antibiotics and fluid resuscitation. In those patients in whom initial management is not successful, biliary drainage, which is best accomplished nonoperatively, should be instituted. There is a very limited role for early surgical intervention in acute suppurative cholangitis. Biliary leaks resulting in bile "peritonitis" or bilomas are common sequelae of laparoscopic bile duct injury. Although surgeons may feel it is necessary to operate urgently, delineation of the proximal biliary anatomy via percutaneous transhepatic cholangiography and biliary stent placement is the appropriate first step in management. This procedure will usually control the bile leak and allow delineation of the anatomy and opportune timing of definitive reconstruction.

Liver Abscess after Central Bisegmentectomy with Reconstruction of the Right Posterior Segment Artery: A Case Report

A 68-year-old female was admitted with obstructive jaundice caused by gallbladder cancer invading the liver bed and hepatic hilum. The patient underwent a central bisegmentectomy, followed by bilateral hepaticojejunostomy with a transhepatic biliary stent and reconstruction of the right posterior segment artery. The color of the right posterior segment improved after arterial reconstruction, although good pulsation was not obtained in the right posterior segment artery. The patient had a febrile postoperative course. On the 22nd postoperative day,<i>Bacteroides</i> sp. was recovered from the arterial blood. On the 27th postoperative day, a CT examination revealed 2 liver abscesses in the right posterior segment, which was less enhanced than the left lateral segment. The right biliary stent penetrated the center of both abscesses, but the left lateral segment was intact. Percutaneous drainage of the liver abscesses was performed with intensive chemotherapy. The aspirated pus grew<i>Pseudomonas aeruginosa, Enterococcus faecalis, Enterobacter cloacae</i> and unidentified gram-positive rods, but was free of fungus. The liver abscesses gradually resolved, and the pateint was discharged on the 78th postoperative day. Since the right posterior segment differed from the left lateral segment only by arterial reconstruction, it is suggested that arterial insufficiency may be of primary importance in the pathogenesis of the liver abscesses observed in this patient.