Treatment Of Malignant Obstructive Jaundice Research Articles

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

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

Clinical efficacy of single/double 125I-seed strands combined with biliary stents in the treatment of malignant obstructive jaundice

Objective: To compare the clinical efficacy of single/double 125I-seed strands combined with biliary stents in the treatment of malignant obstructive jaundice. Methods: Totally 67 cases of patients with malignant obstructive jaundice who received single/double125I-seed strands combined with biliary stents implantation from September 2018 to December 2021 were analyzed retrospectively. Among them, 36 patients received single 125I-seed strands combined with biliary stents (single strand group) and 31 patients received double 125I-seed strands combined with biliary stents(double strands group). The technical success rate, clinical success rate, complications, biochemical and tumor indexes at 8 weeks after operation [total bilirubin (TB), direct bilirubin (DB), alanine transaminase (ALT), aspartate transaminase (AST), carbohydrate antigen 19-9 (CA19-9)], stent patency time (SP), median progression-free survival time (mPFS) and median survival time (mOS) were analyzed. Results: There was no significant difference (P>0.05) in technical success rate (100% vs 100%), clinical success rate (97.2% vs 96.8%) and major complications (5.6% vs 6.5%) between single strand group and double strands group. There were significant differences in TB, DB, ALT, AST and CA19-9 indicators between the two groups before and 8 weeks after operation (all P<0.05), but there was no significant difference in the difference value of preoperative and postoperative 8-week indicators between the two groups (all P>0.05).The SP and mPFS of double-stranded stents were longer than those of single-stranded stents.[8.6 months (95%CI:6.9-10.4) vs 6.2 months (95%CI:5.8-6.6), 3.2 months (95%CI:3.0-3.4) vs 3.0 months (95%CI:2.9-3.1), all P<0.05]. The mOS of single and double strands groups was 11.2 months (95%CI:8.3-14.1) and 13.4 months (95%CI:9.9-16.9) respectively, with no statistical difference (P=0.137). Conclusion: Compared with single 125I-seed strands, double 125I-seed strands can prolong biliary SP and mPFS, but the long-term survival index still needs further observation.

Iodine-125 Seed Strand Implantation Combined with Biliary Stent for the Treatment of Malignant Obstructive Jaundice

Extrahepatic or intrahepatic bile duct stenosis and obstruction can lead to malignant obstructive jaundice (MOJ). Surgical treatment is an effective method, but for patients who cannot undergo surgery or miss the opportunity for surgery, biliary stent combined with 125I implantation can improve obstruction symptoms, relieve biliary obstruction, and improve liver function. This study was to investigate the efficacy of 125I implantation, single biliary stent and percutaneous transhepatic drainage (PTCD) in the treatment of MOJ. 107 patients with MOJ were included. Thirty-seven patients (study group) received biliary stent implantation of 125I particle radiotherapy drainage tube, and 35 patients (sem group) received biliary stent implantation of ordinary drainage tube. 35 patients (PTCD group) underwent PTCD interventional surgery. Biliary stenosis site, Child-Pugh grade and malignant tumor were recorded in the three groups. The changes of liver function before and after treatment were detected, and the survival time, stent patency time, and the occurrence of complications were recorded. All three groups achieved technical success. Liver function was improved in all patients (TBIL, DBIL and ALT were significantly decreased, and P values were all less than 0.05). This study demonstrates that 125I seed beam implantation combined with biliary stent implantation can be considered a safe treatment option for patients with MOJ. This treatment can improve median overall survival, improve liver function, prolong stent patency time.

Safety and efficacy of self-expandable metallic stent combined with 125I brachytherapy for the treatment of malignant obstructive jaundice

BackgroundSeveral previous studies demonstrated that the combination of self-expandable metallic stents (SEMS) and 125I seed implantation might prolong stent patency and obtain survival benefits for malignant obstructive jaundice (MOJ) patients. However, these studies rarely mentioned a comparison between CT-guided intratumoral 125I seed implantation and intraluminal 125I seed strand insertion combined with stenting for the management of MOJ. This study aimed to further evaluate the safety and efficacy of SEMS combined with 125I brachytherapy in the management of unresectable MOJ.MethodsFifty-nine patients with unresectable MOJ were retrospectively included from March 2018 to June 2021. The main therapeutic outcomes were evaluated in terms of stent patency, and overall survival. Cumulative stent patency and overall survival rates were calculated by Kaplan–Meier survival analysis. Both clinical and treatment factors associated with survival were analyzed.ResultsTechnical success was achieved in all patients. The clinical success rate was 94% (32/34) in the seeds group and 92% (23/25) in the control group, no significant difference was found (p =1.000). The median duration of stent patency was significantly longer in the 125I brachytherapy group compared with the control group (289 days vs. 88 days, respectively, p =0.001). The 125I brachytherapy group demonstrated a significantly better median overall survival rate than the control group (221 days vs. 78 days, respectively, p =0.001). In multivariate analysis, stents with 125I brachytherapy (p =0.004) was a significant favorable prognostic factor that affected patient survival. No significant difference was observed between CT-guided 125I seed implantation and 125I seed strand insertion in stent patency (p =0.268), and overall survival (p =0.483).ConclusionSEMS combined with 125I brachytherapy is safe and effective for treating MOJ. 125I brachytherapy may help to maintain stent patency and prolong overall survival. There was no significant difference between CT-guided 125I seed implantation with SEMS and 125I seed strand insertion with SEMS in stent patency and overall survival.

Prognostic effects of different malignant obstructive jaundice sites on percutaneous biliary intervention: A retrospective controlled study.

To compare the survival prognosis of percutaneous transhepatic biliary stenting (PTBS) in the treatment of malignant obstructive jaundice (MOJ) at different horizontal sites. A total of 120 patients with MOJ who underwent biliary stenting were retrospectively included and analyzed and divided into the high-position group (36 patients), middle-position group (43 patients), and low-position group (41 patients) according to biliary obstruction plane by biliary anatomy. Kaplan-Meier curves were used to test for differences in the overall survival (OS), risk assessment of death and potential risk factors for 1-year survival were analyzed using multifactorial Cox regression. The median survival of the high-, middle-, low-position groups were 16, 8.6, and 5.6 months, with a statistically significant difference (P = 0.017). The 1-year survival rate was 67.6%, 41.9%, and 41.5% in the high-, middle-, low-position groups (P < 0.05), and the 1-year risk of death was 2.35 and 2.93 times higher in the medium- and low-position groups, respectively. The incidences of the main complications were 25%, 48.8%, and 65.9% in the high-, middle-, and low-position groups, respectively, (P = 0.002). While the differences in median stent patency were not statistically significant (P > 0.05) in the groups, alanine transaminase, aspartate transaminase, and total bilirubin levels decreased gradually in each group at 1 month and 3 months after interventional therapy (P < 0.001), while there was no significant difference in the decrease between the groups. Different levels of biliary obstruction in patients with MOJ affect survival, especially at 1 year, where high obstruction treated with PTBS has a low incidence of complications and a low risk of death.

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.

Bending the distal tip of a guidewire aids in cannulation of an occluded uncovered biliary metal stent.

Biliary metal stent implantation is an effective treatment for malignant obstructive jaundice. But it's well known that stents put in for a long time can become occluded and cause jaundice and cholangitis. At this time, endoscopic intervention is usually required to replace the stent or re-insert the stent. Re-cannulation for metal stent occlusion is challenging because the guide wire may pass through the side holes of the uncovered metal stents, resulting in prolonged surgical time and exposure to radiation. Here we present a small tip that may help endoscopists complete the re-cannulation of an uncovered metal stent in a very short time.

Percutaneous biliary stent combined with brachytherapy for malignant obstructive jaundice: a multicenter retrospective controlled study

Objective: To investigate the efficacy, safety and prognostic factors of percutaneous biliary stent combined with iodine-125 seed chain brachytherapy (radiotherapy) in the treatment of malignant obstructive jaundice. Methods: Data of 107 cases with malignant obstructive jaundice treated with percutaneous biliary stent implantation from January 2017 to December 2020 were retrospectively analyzed. Among them, 58 cases received biliary stent combined with iodne-125 seed chain brachytherapy (study group), and 49 cases received biliary stent implantation (control group). The changes of bilirubin, stent patency time, complications, overall survival (OS) and prognostic factors were analyzed in both groups. Results: The incidence of complications in the study group and the control group were 17.2% and 18.3% respectively, and the difference was not statistically significant (P=0.974). Serum total bilirubin levels were decreased significantly in both groups at one month after surgery (P<0.001). Postoperative stent patency time was significantly better in the study group (10.0±1.6 months) (95% CI: 8.2～12.5) than that in the control group (5.2±0.4 months) (95% CI: 4.1～6.0, P<0.001). The median OS was longer in the study group (11.2±1.8 months) (95% CI: 9.2～12.8) than that in the control group (8.0±1.1 months) (95% CI: 8.0～12.8, P<0.001). Multivariate analysis result showed that stent combined with brachytherapy (HR=0.08, 95% CI:0.04～0.15, P<0.001) and receiving further anti-tumor therapy after surgery (HR=0.27, 95% CI:0.15~0.49, P<0.001) were independent risk factors affecting the patency of biliary stents. Preoperative percutaneous transhepatic biliary drainage (HR=0.46, 95%CI:0.28～0.74, P=0.002), stent combined with brachytherapy (HR=0.23, 95%CI:0.14～0.39, P<0.001) and receiving further anti-tumor therapy after surgery (HR=0.37, 95%CI:0.22～0.61, P<0.001) were independent risk factors affecting OS. Conclusion: Percutaneous biliary stent combined with brachytherapy is safe and effective in the treatment of malignant obstructive jaundice, which can significantly prolong the patency time of biliary stent and the survival time of patients.

Two approaches in the treatment of malignant obstructive jaundice using nitinol stents

The article presents our experience of observing two different approaches for endoscopic retrograde drainage in patients with malignant pathology of the pancreatobiliary zone, complicated by the bile duct obstruction. In one case, in case of dysfunction of the installed uncovered stent as a result of incrustation with bile salts and/or tumor invasion, stent-to-stent restenting was performed. In the second case, if it was impossible to pass the guidewire retrogradely beyond the area of the tumor narrowing, an alternative method was used – bringing it down by percutaneous transhepatic access towards the endoscope to install a retrograde stent delivery system along it using the "Rendezvous" method.

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.

Long term Assessment of Combined endoscopic-radiologic Rendezvous Technique For Treatment of Malignant Obstructive Jaundice

Long term Assessment of Combined endoscopic-radiologic Rendezvous Technique For Treatment of Malignant Obstructive Jaundice

Malignant obstructive jaundice: justification of the method of biliary decompression

Aim. To show the optimal algorithm of diagnostic and treatment of malignant obstructive jaundice, which allows to increase the effectiveness of primary surgery, reducing the number of complications and mortality in the operated patients.Materials and methods. The results of examination and surgical treatment of 325 patients with malignant obstructive jaundice who underwent minimally invasive decompression of the biliary tract were studied. Based on the results of treatment, an algorithm for examining and treating patients with malignant obstructive jaundice has been formed and tested.Results. Using such criterial like severity of obstructive jaundice by E.I. Galperin, anatomical level of biliary tract occlusion and staging oncology process by TNM classification could help to choose the rational method for its surgical treatment and determine the risk of complications and mortality. At the level of biliary occlusion I and II, endoscopic stenting is a fairly successful inter-vention with a minimum of complications. For a level III block, the operation of choice is percutaneous transhepatic drainage. Cholecystostomy is advisable in case of level I block below the cystic duct in flow level and class “C” obstructive jaundice or for technical impossibility to apply a different method.Realization of the developed algorithm allowed resolving obstructive jaundice in a palliative option in 71.4% of patients and preparing 28.6% for surgical treatment.Conclusion. Implementation of an improved algorithm for the diagnosis of malignant obstructive jaundice makes it possible to justify the choice of a rational option for its surgical treatment, increase the effectiveness of interventions and reduce postoperative mortality.

Clinical efficacy of laparoscopic modified loop cholecystojejunostomy for the treatment of malignant obstructive jaundice

ObjectiveThis study was performed to summarize our experience and investigate the safety and efficacy of laparoscopic modified loop cholecystojejunostomy for the treatment of malignant obstructive jaundice.MethodsThirteen patients with malignant obstructive jaundice who underwent laparoscopic modified loop cholecystojejunostomy from March 2015 to March 2016 were retrospectively reviewed. The patients’ characteristics, operation time, postoperative intestinal recovery time, length of hospital stay, postoperative bilirubin level, and complications were analyzed.ResultsThe patients were followed up as outpatients for 2 years. Nine patients with pancreatic head carcinoma, one patient with periampullary carcinoma, and three patients with distal bile duct carcinoma successfully underwent laparoscopic modified loop cholecystojejunostomy. The mean operation time was 176 ± 45 minutes, and the mean length of hospital stay was 9.5 ± 2.8 days. The serum total bilirubin concentration and gamma-glutamyl transferase concentration significantly decreased on postoperative day 7. The median follow-up time was 7 months. No patients developed bile leakage or required a reoperation.ConclusionsLaparoscopic modified loop cholecystojejunostomy is not only safe and minimally invasive, but it is also feasible for patients with malignant obstructive jaundice.

EUS- versus ERCP-guided biliary drainage for malignant biliary obstruction: evidence from randomized controlled studies

Background: Endoscopic retrograde cholangiopancreatography-guided biliary drainage (ERCP-BD) is the first-line technique for the management of malignant biliary obstruction. Previous evidence demonstrated that endoscopic ultrasound-guided biliary drainage (EUS-BD) is technically safe and feasible, and EUS-BD has been used as the alternative palliative treatment when ERCP fails. We aimed to compare the therapeutic efficacies and procedure-associated complications of EUS-BD and ERCP as the first treatment option. Methods: Studies comparing efficacies and complications of EUS-BD and ERCP-BD for the management of malignant biliary obstruction published before January 25, 2019 were searched. The patient characteristics, variables regarding to the therapeutic efficacies and procedure-associated complications of EUS-BD were compared to that of ERCP-BD by meta-analyses. Results: After screening 821 studies, three randomized clinical trials (RCTs) comparing the therapeutic efficacies and complications of EUS-BD and ERCP-BD for the palliative treatment of malignant obstructive jaundice were included. No significant difference was found between EUS-BD and ERCP-BD regarding to the technical success rate, clinical success rate, procedure time, and stent patency at 3 months and 6 months. The incidence of overall adverse events was also similar between the two groups. EUS-BD showed higher frequency of stent patency at 12 months. In addition, EUS-BD showed significant decreased incidence of procedure-associated pancreatitis [odds ratio (OR) =0.08, 95% confidence intervals (CI): 0.01 to 0.62, P=0.02) and reintervention rate (OR =0.25, 95% CI: 0.12 to 0.54, P=0.0004). Conclusions: Compared to ERCP-BD, EUS-BD showed equivalent therapeutic efficacy with decreased incidence of pancreatitis and reintervention rate. EUS-BD, like ERCP-BD, could be the first-line technique for the management of malignant biliary obstruction.

Efficacy of percutaneous transhepatic biliary drainage combined with transarterial chemoembolization in treatment of malignant obstructive jaundice

Objective To observe the efficacy of percutaneous transhepatic biliary drainage (PTBD) combined with transarterial chemoembolization (TACE) in treatment of malignant obstructive jaundice, and to evaluate its application value in clinic. Methods A total of 82 patients with malignant obstructive jaundice who received PTBD from January 2017 to January 2019 in Taiyuan Central Hospital were collected. The patients were divided into the experimental group who received TACE (41 cases) and the control group who could not receive TACE (41 cases) after PTBD. Clinical symptoms, liver function, tumor markers, drainage tube patency rate and survival time of the two groups were compared before and after the treatment. T-test and chi-square test were used for statistical analysis, and Kaplan-Meier method was used for survival analysis. Results A total of 93 drainage tubes were placed in 82 patients, and 109 TACE treatments were performed in the experimental group. PTBD and TACE both had successful results. After PTBD, 72 patients felt jaundice and obvious alleviation of other clinical symptoms. There were no serious complications after PTBD and TACE. Postoperative follow-up results showed that compared with the total bilirubin (TBIL) [(269±113) μmol/L], the direct bilirubin (DBIL) [(159±74) μmol/L], alanine transaminase (ALT) [(118±40) U/L] and aspartate aminotransferase (AST) [(111±55) U/L] before the operation, the TBIL [(46±11) μmol/L], DBIL [(28±10) μmol/L], ALT [(35±12) U/L] and AST [(33±12) U/L] in the experimental group were decreased significantly 3 months after the operation, and the differences were statistically significant (all P 0.05). The level of carbohydrate antigen-199 in the experimental group at 6 months after PTBD was lower than that in the control group [(426±136) U/ml vs. (569±204) U/ml; t=19.457, P < 0.05]. There were statistical differences in the patency rate of the both groups at 6, 9 and 12 months after PTBD (all P < 0.05). The median survival time in the experimental group was longer than that in the control group (310.4 d vs. 234.5 d; χ 2=12.678, P < 0.05). Conclusion The effect of PTBD in patients with malignant obstructive jaundice is obvious. The combination with TACE after PTBD can prolong the survival of patients and it is worthy of clinical application. Key words: Jaundice, obstructive; Pancreatic neoplams; Bile duct neoplams; Percutaneous transhepatic biliary drainage; Transarterial chemoembolization

Malignant obstructive jaundice: approaches to minimally invasive biliary decompression

Modern approaches to surgical treatment of malignant obstructive jaundice are reviewed in the article. The advantages and disadvantages of various types of minimally invasive biliary decompression are emphasized.

Antegrade biliary stenting for obstructive jaundice

Objective. To determine the role bile duct stenting with self-expandable metallic stents in the treatment of malignant obstructive jaundice. Material and methods. Eight-year experience of palliative antegrade stenting with self-expandable metallic stents was analyzed. There were 218 patients with malignant obstructive jaundice. Distal and proximal obstruction was diagnosed in 118 (54%) and 100 (46%) patients, respectively. We have used self-expandable metallic covered, partially covered and bare-metal stents with diameter of 10, 8 and 6 mm and length of 40, 60 and 80 mm. Results. Technical success in antegrade two-stage installation of self-expandable stents have been achieved in 208 (99%) patients. There were 230 deployed self-expandable metallic stents. Seven (3%) patients underwent simultaneous stenting of right and left hepatic ducts and confluence area with bare-metal stents. Stenting of right or left hepatic ducts and confluence area with partially covered stents was carried out in 34 (16%) patients. Other 59 (27%) patients with proximal biliary obstruction and no separation of lobar bile ducts underwent stenting with 27 partially covered and 31 covered stents. Distal obstruction was managed by using of covered stents as a rule (63%). Complications after antegrade biliary stenting occurred in 29 (13%) patients. Conclusion. Antegrade biliary stenting with metallic self-expandable stents is effective and minimally invasive approach. Moreover, it is comparable with conventional palliative interventions aimed at bile outflow recovery.

Biliary Stent with 125I Seeds vs. Simple Biliary Stent for Malignant Obstructive Jaundice: A Systematic Review and Meta-Analysis

Aim: To assess the safety, feasibility and efficacy of 125I seeds irradiation stents compared with conventional selfexpandable metal stents (SEMS) to treat malignant obstructive jaundice (MOJ). Methods: A systematic search of English and Chinese databases, from January 1980 to December 2017, was conducted. All prospective random trials comparing SEMS and the various form of irradiation stent with 125I seeds to treat MOJ were included. Results: Overall, six studies with 276 patients were eligible in current analysis. Of reported 276 patients, 138 patients were subjected to irradiation stents while 138 patients to SEMS. The irradiation stents are associated with a longer survival (hazard ratio (HR) 0.46, IV, random, 95% confidence interval (CI) 0.34-0.63; p<0.001, I2=0%) and stent patency (HR 0.45, IV, random, 95% CI 0.25-0.80; p=0.007, I2=59%) than conventional SEMS. There are no differences in total complications rate (relative risk (RR) 0.75, M-H, random, 95% CI 0.41-1.38; p=0.35, I2=0%), hemobilia (RR 0.34, M-H, random, 95% CI 0.07-1.64; p=0.18, I2=0%), pain (RR 0.87, M-H, random, 95% CI 0.29-2.61; p=0.80, I2=0%), and cholangitis (RR 1.33, M-H, random, 95% CI 0.32-5.48; p=0.69, I2=0%). Also, no differences were observed in all indexes, which included total bilirubin (TBIL) (weighted mean difference (WMD) -5.52, IV, random, 95% CI -20.58-9.54; p=0.47, I2=33%), direct bilirubin (DBIL) (WMD 7.38, IV, random, 95% CI -8.00-22.75; p=0.35, I2=0%), alanine aminotransferase (ALT) (WMD 2.76, IV, random, 95% CI -14.05-19.57; p=0.75, I2=64%), aspartate aminotransferase (AST) (WMD 9.49, IV, random, 95% CI -9.31-28.29; p=0.35, I2=0%). Conclusions: According to limited source data, the current meta-analysis suggests that the irradiation stent is a feasible, safe treatment of MOJ, with longer survival and stent patency. Application of irradiation stent with antitumor effect does not add extra adverse events compared to SEMS stent.

Utility of Endoscopic Ultrasound-Guided Hepaticogastrostomy with Antegrade Stenting for Malignant Biliary Obstruction after Failed Endoscopic Retrograde Cholangiopancreatography

Background: Endoscopic ultrasound (EUS)-guided biliary drainage (BD) is a well-recognized alternative BD method after unsuccessful endoscopic transpapillary drainage. EUS-guided hepaticogastrostomy (HGS) with antegrade stenting (AGS) was recently applied to the treatment of malignant obstructive jaundice. Objective: To assess the efficacy and safety of HGS combined with AGS for treatment of malignant biliary stricture-induced obstructive jaundice. Design: Retrospective cohort study. Setting: Single academic tertiary care center. Patients: From January 2006 to December 2014, endoscopic retrograde cholangiopancreatography was attempted in patients with obstructive jaundice; it was successful in 641 patients and impossible in 154 patients (postsurgically altered anatomy or duodenal stenosis, n = 101; difficult cannulation, n = 53). In total, 145 patients underwent EUS-guided BD; HGS and HGS with AGS were attempted in 42 patients (Group A, January 2006-August 2011) and 37 patients (Group B, September 2011-December 2014), respectively. Interventions: Under EUS and fluoroscopy guidance, HGS and HGS with AGS were performed via needle puncture, guidewire insertion, puncture-hole dilation, and stent placement. Main Outcome Measurements: Groups A and B were compared in terms of technical success, functional success, adverse event rates, re-intervention rates, patient survival time, and time to stent dysfunction or patient death. The two groups were also compared in a subgroup analysis of only 28 patients who underwent chemotherapy. Results: The technical success rate was significantly higher in Group A than B (97.6 vs. 83.8%, p = 0.03). The functional success rate was comparable between the two groups (90.2 vs. 90.3%), although the rate of adverse events was significantly higher in Group A than B (26.1 vs. 10.8%, p = 0.03). The re-intervention rate tended to be higher in Group A than B (16.7 vs. 8.1%, p = 0.25). Groups A and B did not differ significantly in terms of median overall patient survival (75 vs. 61 days, p = 0.70) or median time to stent dysfunction or patient death (68 vs. 63 days, p = 0.08). Among patients who underwent chemotherapy, there was no difference in overall patient survival time between the two groups (121 vs. 157 days, p = 0.08), although time to stent dysfunction or patient death was significantly shorter in Group A than B (71 vs. 95 days, p = 0.02). Conclusion: Although the technical success rate of HGS with AGS was lower than that of HGS, HGS with AGS was superior to HGS in terms of adverse event rate and stent patency in patients receiving chemotherapy.