Treatment Of Obstructive Jaundice Research Articles

Multiple stents in treatment of obstructive jaundice associated with Klatskin's tumor.

Multiple stents in treatment of obstructive jaundice associated with Klatskin's tumor.

Is Growth Influencing Diameter and Function of Laparoscopic TESA Hepaticojejunostomy? A Comparison of Adult Minipigs and Juvenile Domestic Swine

Current treatment of obstructive jaundice includes endo-scopicstenting and open surgical bypass. To combine the advantages of surgical bypass with the minimal invasive approach of endoscopic stenting we developed a laparoscopic technique, transient endoluminally stented anastomosis (TESA). As shown previously, small-diameter anastomoses (e.g., hepaticojejunostomy) by TESA technique can be performed reliably in growing domestic swine. This further preclinical trial was designed to exclude growth of the animals as the main reason for these excellent results. After ligation of the common bile duct, a laparoscopic Roux-en-y hepaticojejunostomy was performed 7 days later by TESA with a reabsorbable radiopaque polyglycolic acid stent. In group A (n = 7) growing domestic pigs and in group B (n = 5) adult mini-pigs were operated on. Laboratory parameters were controlled weekly. Stent degradation was followed by weekly abdominal x-ray. At necropsy 6 months after surgery, cholangiography was performed and the anastomoses were measured. Mean weight gain was 140.7 ± 10.9 kg in domestic pigs versus 5.8 ± 1.6 kg in minipigs. Cholestasis normalized within 7 days postoperatively. Duration of stenting was not significantly different between groups. Cholangiography at necropsy showed immediate runoff through the anastomoses in both groups. The diameter of the anastomosis was 4.7 ± 0.5 mm in group A versus 3.0 ± 0.4 mm in group B (p = 0.03). In conclusion, functionality of the small-diameter TESA hepaticojejunostomy is not related to age and growing factors in pigs, justifying its application in human as the next step of investigation.

Methods of Prolonging Biliary Patency

Methods of Prolonging Biliary Patency Lindsay Machan, M.D. BILIARY placement is well established as an effective treatment for obstructive jaundice when a surgical cure is not possible 0). In patients with benign biliary obstruction, permanent stent placement is controversial, but, in malignancies, is well accepted. Metallic stents appear more efficacious than plastic stents for malignant obstructions but the choice of stent should be decided on a case by case basis. Regardless of the clinical scenario and the choice of stent, stent occlusion remains the major problem facing the intelventional radiologist managing a patient with biliary obstruction. An occluded biliary stent is a contaminated foreign body that contains bacteria; recurrent biliary obstruction is, therefore, complicated by cholangitis and sepsis. Acute or chronic occlusion can occur with plastic or metallic prostheses and in each instance there are specific predisposing factors. These will be addressed separately, but common factors that influence both patency for both plastic and metallic stents are stent diameter, high gradient across the tube, and biliary rheology. Dehydration adversely affects biliary rheology and should be avoided.

Alternation of monocyte function in patients with obstructive jaundice.

Patients with obstructive jaundice have a high susceptibility to infection in the process of treatment and the reason for this is not fully understood. It was postulated that it may bear some relations to abnormalities of immune function. In this article, 28 cases of obstructive jaundice were selected to investigate alternation of monocyte immune function with the purpose of exploring mechanism of high susceptibility to infection from the perspective of immunology. The results showed that interleukin 1 production by monocytes significantly decreased and prostaglandin E2 increased, HLA-DR expression of monocytes was remarkably depressed. HLA-DR expression of monocytes was further decreased with recovery slower than non-jaundiced patients after operation. All this may be responsible for high susceptibility to infection in the process of treatment of obstructive jaundice.

Endoscopic stenting for palliation of malignant biliary obstruction. A review of progress in the last 15 years.

Since the late 1970s, endoscopic biliary stenting has become a standard palliative treatment for obstructive jaundice due to malignancies of the pancreas and the hepatobiliary system. Despite the high initial success rate in achieving biliary drainage, endoscopic stenting therapy has been limited by the clogging of biliary stents, usually after four to five months, due to formation of adherent bacterial biofilm and accumulation of biliary sludge. Various methods for the prevention of bacterial adhesion and prolongation of stent patency have been investigated, including prophylactic antimicrobial agents and bile salts, new stent materials, and new stent designs. Recently, the introduction of self-expandable metal stents has significantly improved the duration of stent patency but the cost is considerably higher. Each method has its own merits as well as specific problems. This article reviews the pathogenesis of biofilm formation on the biliary stents and the latest status of research in avoiding stent occlusion.

Omitting side-holes in biliary stents does not improve drainage of the obstructed biliary system: A prospective randomized trial

Sludge, which occludes biliary stents, forms mainly around the side-holes of such stents. It has been reported that omitting the side-holes results in less sludge formation and theoretically improves drainage. To compare the clinical efficacy of biliary stents with and without side-holes, we randomized patients with malignant or benign strictures to receive 10FG polyethylene stents either with side-holes (SH) or without side-holes (NSH). The patients were seen at 4, 12, 20, and 28 weeks after stenting for symptom evaluation and serum liver enzyme and bilirubin assays. The stents were replaced only when clinical symptoms of cholangitis developed. Each group included 35 patients. The mean age of patients in the SH group was 68 years, and the ratio of men to women was 1:1.3. In the NSH group, the mean age of patients was 67 years, and the ratio of men to women was 1:1.4. Eight patients with SH stents and eight with NSH stents died before the stents were removed; two NSH stents migrated into the duodenum. During a mean follow-up period of 8.1 weeks (range, 1.1 to 28 weeks for the SH group and 0.6 to 28 weeks for the NSH group), 18 stents were found to be occluded in the SH group and 17 in the NSH group. The median time before total occlusion was 7.8 weeks (range, 2.6 to 28) for SH stents and 7.9 weeks (range, 0.6 to 28) for NSH stents ( p > 0.1, NS). The occluded stents removed from these patients were freeze-dried and weighed to quantitate the sludge blocking the stent lumen. The mean (± SD) weight gain for SH stents was 4.0 ± 1.7 mg/cm and for NSH stents 4.3 ± 2.2 mg/cm ( p > 0.1, NS). In conclusion, the benefits of omitting side-holes in polyethylene stents used in the treatment of obstructive jaundice cannot be substantiated. (Gastrointest Endosc 1994;40:321-5.)

Therapeutic effect of plasma exchange with the biliary drainage in the treatment of obstructive jaundice.

The effect of therapeutic plasmapheresis combined with biliary drainage was evaluated in obstructive jaundice animal models. Plasma exchange (PE) using fresh-frozen plasma was carried out with biliary drainage (BD) on a canine jaundice model created by the ligation and resection of bile duct. Routine biochemical analyses were done following PE and BD. The result was compared with that of a BD only group. Plasma bilirubin level abruptly dropped after PE and was kept at a lower level, whereas the bilirubin level of the drainage alone group decreased gradually. Decreased plasma mitochondrial GOT level in the PE group suggests improvement of liver cell damage in obstructive jaundice. Mitochondrial function of liver tissue was evaluated following partial hepatectomy, which was carried out 2 days after PE along with BD in jaundice rat. Mitochondrial respiratory control ratio and ADP/O ratio following hepatectomy were improved in the PE group. The results suggest the improvement of hepatic functional reservoir by a single PE treatment in addition to BD treatment. These results show that PE can shorten the icteric period and may improve the hepatic functions after the treatment of malignant obstructive lesion in the biliary tract.

The diagnosis and treatment of obstructive jaundice

The diagnosis and treatment of obstructive jaundice

INTRAHEPATIC BILIARY-INTESTINAL BYPASS IN MALIGNANT JAUNDICE

There is still dispute as to the best treatment for obstructive jaundice of malignant origin when the bile ducts are blocked high in the porta hepatis. Intrahepatic duct-to-jejunal anastomoses provide a surgical solution which frees the patient from the need to wear external appliances. A series of eight patients having such anastomoses have been studied to determine the adequacy of bilirubin clearance, the durability of relief from jaundice, the length of hospital stay, the operative mortality and survival from the time of surgery. Intrahepatic bypasses were shown to allow bilirubin clearance in the lower range of normal. Freedom from jaundice persisted until death at a median time of 5 months from operation. Cholangitis was not a problem in any patient postoperatively. There was only one operative death. The major disadvantage of the technique arose from the hospital stay, a median of 30 days. It is suggested that all these factors should be considered in studies to compare surgical bypass with endoscopic or percutaneous methods for the relief of malignant jaundice.

Internal endoprosthesis as treatment of obstructive jaundice in pancreatitis.

In five patients with pancreatitis, obstructive jaundice was relieved by internal drainage of the biliary tract with an endoprosthesis inserted by percutaneous transhepatic technique. The average duration of treatment was 3.5 months. The endoprosthesis were removed by means of a duodenoscope, and jaundice did not recur.

Carcinoma of the liver: cytopathologic diagnosis.

Primary cancer of the liver is a rare disease, especially in countries with temperate climates. It is reported to be found in only 0.3% of all autopsies in these countries. An exact diagnosis is not always easy, especially in the elderly. In three aged patients, cytologic examination of material obtained from the liver by aspiration after puncture with a thin needle, indicated the diagnosis. Cytologic examination of aspirated liver tissue, although it can never be a substitute for biopsy, may be very useful not only in diagnosis but in monitoring the treatment of obstructive jaundice in elderly patients.

The diagnosis and treatment of obstructive jaundice: From the surgical standpoint of view

The diagnosis and treatment of obstructive jaundice: From the surgical standpoint of view

Recent Advances in the Treatment of Obstructive Jaundice

Recent Advances in the Treatment of Obstructive Jaundice