One-stage versus two-stage management for concomitant gallbladder stones and common bile duct stones in patients with obstructive jaundice

No consensus exists regarding the optimal management of concomitant gallbladder stones and common bile duct stones (CBDS). Previous studies showed a significant association between the presence of obstructive jaundice and increased risk of postoperative complications and conversion to open surgery. This retrospective study evaluated the effectiveness and safety of one-stage (laparoscopic cholecystectomy [LC] plus laparoscopic common bile duct exploration) management versus two-stage (preoperative endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy + LC) management for patients with obstructive jaundice, concomitant gallbladder stones, and CBDS. One-stage management (n = 88) or two-stage management (n = 122) was used for 210 eligible patients between January 2009 and March 2011. Both types of management proved to be effective and safe. No significant difference was observed in terms of stone clearance from the common bile duct (CBD), postoperative morbidity, mortality, or conversion to open surgery. However, one-stage management was more cost-effective and decreased the number of procedures. In addition, postoperative hospital stay and operative time were shorter for patients who received one-stage management. Especially for patients with CBD greater than 1 cm in diameter, one-stage management is a better choice.

[Long-term survival of a patient with metachronous lymph node metastasis and bile duct tumor thrombus due to hepatocellular carcinoma successfully treated with repeated surgery]

A 64-year-old man with hepatocellular carcinoma located in the left lateral lobe and segment 5 was referred to our hospital for surgical treatment. We performed left lateral sectionectomy and segmentectomy 5. The pathological diagnosis was moderately to poorly differentiated hepatocellular carcinoma, and the pathological stage was stage III. Eight months later, intrahepatic recurrence in segment 1 and lymph node metastasis in the hepatoduodenal ligament occurred. Partial resection of segment 1 was performed, and the metastatic lymph node was surgically removed. Twenty four months after the first operation, lymph node metastases along the lesser curvature and retropancreatic space were extirpated. Lymph node metastases along the common hepatic artery were removed 76 months after the first operation. The patient developed jaundice 88 months after the initial surgery, and the bile duct tumor thrombus derived from intrahepatic recurrence in segment 1 caused obstructive jaundice. After percutaneous transhepatic biliary drainage, we performed median sectionectomy and bile duct tumor thrombus removal without bile duct resection. At his 8-year follow-up visit after the primary operation, the patient was healthy and did not show any signs of recurrence. Lymph node metastasis and bile duct tumor thrombus are rare patterns of hepatocellular carcinoma recurrence, and aggressive surgery can result in long-term survival when complete resection is anticipated.

[A case of recurrent transverse colon cancer invading the pancreas and duodenum successfully treated with biliary and duodenal stenting]

We report a case of recurrent transverse colon cancer invading the pancreas and duodenum that was successfully treated with biliary and duodenal stenting. A 46-year-old man underwent ascending colostomy for the treatment of obstructive transverse colon cancer with hepatic metastasis. Chemotherapy achieved a partial response, but the levels of tumor markers later began to rise again. He then underwent right hemicolectomy and partial hepatectomy. Post-operative chemotherapy was administered, but the recurrent tumor caused obstructive jaundice and duodenal obstruction. These were successfully treated with biliary and duodenal stenting, and the patient was able to remain at home and maintain his quality of life.

Three-dimensional computed tomographic cholangiography as a novel diagnostic tool for evaluation of bile duct invasion of perihilar cholangiocarcinoma

BACKGROUND/AIMS

This study assessed the results of preoperative evaluation of ductal invasion by perihilar cholangiocarcinoma, imaged using 3-dimensional (3D) CT cholangiography compared to conventional endoscopic retrograde cholangiography (ERC) and magnetic resonance cholangiopancreatography (MRCP).

METHODOLOGY

ERC, MRCP and 3D-CT cholangiography were planned in 24 patients with preoperatively diagnosed perihilar cholangiocarcinoma. Evaluations of bile duct images using each of 3 modalities were classified into 2 groups (the Visualization uncertain (VU) group and the Visualization certain and clear (VCC) group) according to the quality of biliary images. The results of pathological assessments and preoperative radiological evaluations were compared.

RESULTS

In the bile duct evaluation, the rates between the 2 groups were not significantly different across the three modalities. 3D-CT cholangiography evaluated tumour involvement most clearly in patients with obstructive jaundice (p = 0.044), and ERC evaluated biliary tree more clearly compared to MRCP or 3D-CT cholangiography in patients without obstructive jaundice (p = 0.051). For evaluation of pathological tumor invasion in the VCC group, 3D-CT cholangiography enabled a correct diagnosis in 7 of 11 patients, and R0 resection was achieved in 8 of 11 patients.

CONCLUSIONS

3D-CT cholangiography offers accurate preoperative assessment of bile duct invasion by perihilar cholangiocarcinoma, especially in patients with obstructive jaundice.

[Four cases of double bypass surgery involving choledochojejunostomy and gastrojejunostomy for inoperable peripancreatic head cancer]

Peripancreatic head cancer often causes obstructive jaundice and duodenal obstruction, which reduces the quality of life and hinders the administration of anti-cancer drugs. Here, we report 4 cases of double bypass surgery( biliary and gastric) for the treatment of inoperable peripancreatic head cancer. The patients' ages ranged from 64 to 72 years. Two patients had pancreatic head cancer and 2 had ampullary cancer. No postoperative morbidity was observed and all 4 patients resumed oral intake within 5 days after surgery and began receiving chemotherapy within 1 month after surgery. There was immediate relief of biliary obstruction in all 3 patients with obstructive jaundice. None of the patients experienced recurrence of obstructive jaundice requiring biliary drainage. Two patients who died of cancer were able to consume food orally just before they died. Although bypass surgery is more invasive than endoscopic stenting, it may be safe and useful not only for palliation, but also for induction or continuation of chemotherapy.

Primary sclerosing cholangitis in patient with celiac disease complicated by cholecystic empyema and acute pancreatitis

BACKGROUND

The association of celiac disease and sclerosing cholangitis is a well known, although unusual, pathologic feature of autoimmunity.

METHODS

A 64 year old patient presenting with sub-acute cholangitis and pancreatitis, treated with cholecystectomy and endoscopic sphincterotomy. The post-operative course, complicated by cholestatic jaundice, and subsequent clinical complications are described, showing how the diagnosis of sclerosing cholangitis was outlined after the Endoscopic Retrograde Cholangio-Pancreatography (ERCP) and confirmed by liver biopsy. Long term treatment with Ursodeoxycholic acid has gradually normalized bilirubin values, while cholestasis enzymes are gradually decreasing. After 18 months bleeding from oesophageal varices ensued, which was controlled through endoscopic ligation.

CONCLUSIONS

The diagnosis of primary sclerosing cholangitis should be taken into account when cholangitis is associated with other immunity derangements and segmentary dilatations of the intra-hepatic bile ducts, but no dilatation of the main bile duct is noticed at imaging or endoscopy. Recovery of hepatic function should be always attempted before bringing the patient to surgery, in order to avoid postoperative hepatic decompensation.

Tuberculous lymphadenitis as a cause of obstructive jaundice

Obstructive jaundice secondary to abdominal tuberculosis is extremely rare. We present a patient with jaundice secondary to compression of the common bile duct by TB lymphadenitis. A 49-year-old woman was admitted to our department for nausea,epigastric pain and jaundice. Abdominal ultrasonography and computer tomography scan were suggestive of stenosis of the distal common bile duct caused by a retro pancreatic mass. At laparotomy, an enlarged lymph node behind the head of the pancreas was found, causing compression and stenosis of the distal parts of the choledochus. The lymph node frozen section analysis showed epithelioid granuloma with caseous necrosis,strongly suggesting tuberculous origin. Choledochoduodenal anastomosis was performed. Definitive pathohistological examination confirmed TB lymphadenitis. ATB should be considered as a potential cause of jaundice especially in immuno compromised patients and endemic areas. Diagnosing abdominal tuberculosis can be a challenging task. No satisfactory diagnostic gold standard is available so that in most cases the diagnosis cannot be reached before exploratory laparotomy.Early detection enables successful conservative treatment and eliminates the necessity of surgery.

A novel technique for endoscopic ultrasound-guided biliary drainage

AIM: To describe a successful endoscopic ultrasound (EUS)-guided biliary drainage technique with high success and low complication rates.

METHODS: The recorded data of consecutive patients who presented to Siriraj Gastrointestinal Endoscopy Center, Siriraj Hospital in Bangkok, Thailand for treatment of malignant obstructive jaundice but failed endoscopic retrograde cholangiopancreatography and underwent subsequent EUS-guided biliary drainage were retrospectively reviewed. The patients’ baseline characteristics, clinical manifestations, procedure details, and post-procedure follow-up data were recorded and analyzed. Clinical outcomes were assessed by physical exam and standard laboratory tests. Technical success of the procedure was defined as completion of the stent insertion. Clinical success was defined as improvement of the patient’s overall clinical manifestations, in terms of general well-being evidenced by physical examination, restoration of normal appetite, and adequate biliary drainage. Overall median survival time was calculated as the time from the procedure until the time of death, and survival analysis was performed by the Kaplan-Meier method. The Student’s t-test and the χ² test were used to assess the significance of inter-group differences.

RESULTS: A total of 21 cases were enrolled, a single endoscopist performed all the procedures. The mean age was 62.8 years (range: 46-84 years). The sex distribution was almost equal, including 11 women and 10 men. Patients with failed papillary cannulation (33.3%), duodenal obstruction (42.9%), failed selective cannulation (19.0%), and surgical altered anatomy (4.8%) were considered candidates for EUS-guided biliary drainage. Six patients underwent EUS-guided choledochoduodenostomy and 15 underwent EUS-guided hepaticogastrostomy. The technique using non-cauterization and no balloon dilation was performed for all cases, employing the in-house manufactured tapered tip Teflon catheter to achieve the dilation. The technical success and clinical success rates of this technique were 95.2% and 90.5%, respectively. Complications included bile leakage and pneumoperitoneum, occurred at a rate of 9.5%. None of the patients died from the procedure. One patient presented with a biloma, a major complication that was successfully treated by another endoscopic procedure.

CONCLUSION: We present a highly effective EUS-guided biliary drainage technique that does not require cauterization or balloon dilation.

Obstructive jaundice due to pancreatic metastasis from non-small cell lung cancer

We report a 67-year-old female patient, recently diagnosed to have non-small cell lung cancer (NSCLC). On first PET (positron emission tomography) examination in October 2009, no distant metastasis. Four months later, second PET examination was done, detecting pancreatic foci in the uncinate process and in the tail of the pancreas measuring 22 mm which were more likely to be metastatic rather than primary origin. The patient underwent chemotherapy and radiotherapy. After 1 month of follow up, jaundice was noticed. Laboratory exams and MRCP showed obstructive jaundice. ERCP was performed with biliary stenting for palliative treatment. Symptomatic metastatic lesions of the pancreas from carcinoma of the lung are extremely rare. Typically, the patients remain asymptomatic until their disease reaches a fairly advanced stage, and therapeutic options are then limited to palliative measures.

[Peculiarities of performance of endoscopic transpapillary interventions in the early period after cholecystectomy]

The peculiarities of performance of endoscopic transpapillary interventions (ETI) during the early period after cholecystectomy were studied up. There were examined 1788 patients, aged from 18 to 90 yrs old, in whom postcholecystectomy syndrome was diagnosed. Emergent interventions were performed in 780 (43.6%) patients (main group). Into the comparison group 1008 (56.4%) patients were included, who were admitted to the hospital in 0.5-552 (Me 36) months after cholecystectomy conduction. The indications to perform the urgent endoscopic intervention were excessive transdrainage biliary output (more than 350 ml a day) from a subhepatic indignation (in 442 patients) and the obturation jaundice presence (in 338). Using ETI the cause of biliary obstruction in the early postoperative period was established in 93.5% of patients. Miniinvasive methods were applied in 82.2% patients of the main group and in 93.4%--of the comparison group.

Self-expanding metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline-resectable pancreatic cancer: outcomes in 241 patients

BACKGROUND AND AIM

Obstructive jaundice caused by distal biliary obstruction can present in up to 70 % of patients with localized cancer of the head of the pancreas. The aim of this study was to report our experience in using self-expanding metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline resectable carcinoma of the pancreatic head.

METHODS

We performed a retrospective study evaluating patients from two tertiary referral centers. Two-hundred and forty-one patients with resectable and borderline resectable pancreatic carcinoma underwent ERCP with metal biliary stent placement between September 2006 and August 2011. We assessed the effectiveness of SEMS to adequately decompress the biliary tree, procedural success, patient survival, stent patency, and stent-related complications.

RESULTS

Two-hundred and forty-one patients were evaluated [123 male, mean age (± SD) 67.4 ± 9.8 years; resectable 174, borderline resectable 67]. Patients with borderline-resectable cancer underwent neoadjuvant therapy and restaging before possible curative surgery. Successful placement of a metal biliary stent was achieved in all patients and improved jaundice. Patients were followed for mean duration of 6.3 months. The overall survival was 49 % at 27 months. Fourteen (5.8 %) patients experienced stent occlusion; the mean time to stent occlusion was 6.6 (range 1-20) months. Immediate complications included: post-ERCP pancreatitis (n = 14), stent migration (n = 3), and duodenal perforation (n = 3). Long-term complications included stent migration (n = 9) and hepatic abscess (n = 1). A total of 144/174 patients deemed to have resectable cancer at time of diagnosis underwent curative surgery. Due to disease progression or the discovery of metastasis after neoadjuvant therapy, only 22/67 patients with borderline-resectable cancer underwent curative surgery.

CONCLUSIONS

SEMS should be considered for patients with obstructive jaundice and resectable or borderline resectable pancreatic cancer, especially if surgery is not planned immediately as a result of preoperative chemoradiation. These stents appear to be safe and effective.

Metal stents: a bridge to surgery in hilar cholangiocarcinoma

BACKGROUND

Obstructive jaundice in patients with hilar cholangiocarcinoma is a known risk factor for hepatic failure after liver resection. Plastic stents are most widely used for preoperative drainage. However, plastic stents are known to have limited patency time and therefore, in palliative settings, the self-expanding metal stent (SEMS) is used. This type of stent has been shown to be superior because it allows for rapid biliary decompression and a reduced complication rate after insertion. This study explores the use of the SEMS for biliary decompression in patients with operable hilar cholangiocarcinoma.

METHODS

A retrospective evaluation of a prospectively maintained database at a tertiary hepatobiliary referral centre was carried out. All patients with resectable cholangiocarcinoma were recorded.

RESULTS

Of 260 patients referred to this unit with cholangiocarcinoma between January 2008 and April 2012, 50 patients presented with operable cholangiocarcinoma and 27 of these had obstructive jaundice requiring stenting. Ten patients were initially treated with SEMSs; no stent failure occurred in these patients. Seventeen patients initially received plastic stents, seven of which failed in the interval between stent placement and laparotomy. These stents were replaced by SEMSs in four patients and by plastic stents in three patients. Median time to laparotomy was 45 days and 68 days in patients with SEMSs and plastic stents, respectively.

CONCLUSIONS

Self-expanding metal stents provide adequate and rapid biliary drainage in patients with obstruction caused by hilar cholangiocarcinoma. No re-interventions were required. This probably reflects the relatively short interval between stent placement and laparotomy.

[Mirizzi syndrome: experience at Spanish Hospital of Veracruz]

BACKGROUND

Mirizzi syndrome is a complication of gallbladder stones impacted in Hartmann's pouch or cystic duct with compression of the bile duct. The diagnosis is made by imaging studies, although most of them are found through intraoperative surgical findings. Treatment is cholecystectomy and bile duct restoration when needed.

OBJECTIVE

to analyze a series of cases of Mirizzi syndrome and compare the results with those published in the literature.

CLINICAL CASE

We report 4 cases with Mirizzi syndrome in a cohort of 1,034 cases studied in the Hospital Español of Veracruz over 21 years.

RESULTS

In our series the frequency of Mirizzi syndrome was 0.38%, the average age was 32.1 ± 58.4 years, 50% were male gender and 25% had jaundice with a demonstrable liver profile. In 1 case, ultrasound suggested Mirizzi syndrome and percutaneous cholangiography and computed tomography confirmed the diagnosis. All patients underwent laparoscopic cholecystectomy, and 2 transcystic cholangiographies were performed. One case was classified as Type I-A and three as type I-B. (Beltran and Csendes). The postoperative evolution was satisfactory in all and no mortality was presented.

CONCLUSIONS

Mirizzi syndrome should be suspected in patients with gallstones who develop obstructive jaundice and it must be confirmed with imaging studies. The surgeon must take extreme precautions to avoid accidental injury to the bile ducts.

Obstructive jaundice and melena caused by hemocholecyst: A case report

A hemocholecyst (HC) is a clot-filled gallbladder caused by bleeding into its lumen. Obstructive jaundice caused by the compression of HC to the hilar biliary tract is likely to be misdiagnosed as cholangiocarcinoma and is extremely rare. We herein report a case of obstructive jaundice and melena caused by HC. A 57-year-old male patient presented with right upper quadrant pain associated with icteric sclera and melena was suspiciously diagnosed as having malignant cholangiocarcinmoa by abdominal ultrasonography, computed tomography and magnetic resonance imaging. Laparotomy found a hematoma in the gallbladder. The hematoma spread to the left hepatic lobe forming an exogenous mass which compressed the hilar biliary tract. Radical cholecystectomy and bile duct exploration with T-tube drainage were performed. Histopathological examination revealed massive necrosis of the gallbladder mucosa with inflammatory cells infiltration as well as intraluminal hematoma formation. One month after operation, a T-tube cholangiography revealed a normal biliary tree. We suggest that HC should be considered in patients with obstructive jaundice and melena after common causes are ruled out.

[Hepatic dysfunction correction in patients with obturation jaundice]

Comparative analysis of results of examination and treatment of 54 patients, suffering obturation jaundice syndrome, is presented. The presence and severity of hepatic dysfunction was determined in accordance to indices of cytolysis and cholestasis syndromes, and its severity--in accordance to V. P. Zinevich criteria (1986). There was established, that timely elimination of obturation jaundice, using miniinvasive interventions and subsequent conduction of complex hepatotropic therapy, using L-ornitin L-aspartate, permits to correct hepatic dysfunction effectively.

[Preliminary clinical study of percutaneous transhepatic bipolar radiofrequency ablation catheter in the treatment for malignant biliary obstructive jaundice and biliary stent re-stenosis]

OBJECTIVE

To preliminary observe the feasibility and safety of bipolar radiofrequency ablation catheter in the treatment of malignant biliary obstructive jaundice and biliary stent re-stenosis.

METHODS

Four patients with malignant obstructive jaundice caused by terminal cancer received ablation therapy for biliary obstruction by percutaneous transhepatic bipolar radiofrequency ablation catheter. The normal tunnel of biliary was reconstructed rapidly to restore the outflow tract of bile. The procedural practicality, clinical safety and operative complications were analyzed.

RESULTS

The ablation therapy was successful for 4 patients. The mean operating duration was 40 min without any 30-day mortality. No postoperative complications such as massive hemorrhage, biliary fistula, biliary infection, hemothorax, pneumothorax, chylothorax, chole-heart syndrome, liver penetrating wound and biliary peritonitis etc. occurred. Cholangiectasis improved markedly after biliary tract reconstruction with general declines of serum total bilirubin and direct bilirubin. One case with biliary stent re-stenosis was re-blocked postoperatively. The average patency time of biliary tract and stent was 124 (90 - 171) days in 4 cases. Conditions were created for further anti-tumor treatment.

CONCLUSION

Percutaneous transhepatic bipolar radiofrequency ablation catheter can reestablish the canal rapidly for malignant biliary obstructive jaundice and stent re-stenosis so as to enhance the therapeutic efficacy.

[A case of extrahepatic bile duct metastasis from gastric cancer]

A 56-year-old man was admitted with obstructive jaundice. Abdominal computed tomography and endoscopic retrograde cholangiopancreatography showed circumferential stenosis with irregular wall in lower bile duct, but the cytology of biliary brushing was no malignancy. The patient was given a diagnosis of gastric carcinoma with bone and skin metastasis. He died 2 months after the first hospital admission and autopsy was performed. The histological findings of gastric and bile duct tumor revealed signet ring cell carcinoma. The immunohistological findings of both tumors were identical. We definitively diagnosed this case as metastasis of gastric carcinoma to the bile duct.

Etiology and epidemiology of obstructive jaundice in Continental Croatia

The etiology and epidemiology of obstructive jaundice in Continental Croatia has been studied in 174 patients. The objective of this research was also to explore the importance and efficiency of endoscopic retrograde cholangiopancreatography (ERCP) as a non-surgical method of treatment of obstructive jaundice in the population of Continental Croatia. Obstructive jaundice is the illness of elderly population which is also confirmed by the information on the average age of our patients. The frequency of illness is higher among female population, and the most frequent cause of obstructive jaundice are gallstones (54.1% of patients). In 29.8% of patients the primary or secondary malignant disease was the cause of blockage in gall flow and subsequent jaundice, and the most frequent malignant cause of obstructive jaundice is pancreas cancer in 11.5% of patients. The mean value of serum concentrations of total bilirubin, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase and gamma glutamiltransferase 24 hours before the biliary decompression by ERCP has been significantly above the upper referential value, and 24 hours after the ERCP it has dropped to normal with their statistically significant difference (p < 0.0001). The normal values of markers for synthetic liver function (total proteins and prothrombin time) have been noticed as well as elevated values of inflammatory markers in obstructive jaundice independently of etiology. Out of the total number of patients, 37.7% required the surgical treatment while 60.3% of patients were treated by ERCP, i.e. either the stone extraction or the implantation of endobiliary stent was performed.

Periampullary carcinoma: better prognosis with early pre-stenting referral to surgery

This study was undertaken to find out reasons of delayed referral for surgical treatment and to assess the effect of delayed referral on management and prognosis of patients with periampullary carcinoma. Patients with histopathologically proved periampullary carcinoma (n=41) during the period January 2010 to December 2010 who had been admitted into the department of surgery, Bangabandhu Sheikh Mujib Medical University, Shahbagh, Dhaka, Bangladesh (BSMMU) were included in this study. Information of the patient was retrieved from medical records. Patients and relatives were interviewed for reasons of delay in seeking surgical help. Patients were divided into two groups: Group I: those who admitted to surgical unit within one month (6 days to 1 month) of noticing jaundice (n=13), and Group II: those who admitted to surgical unit after one month (1.2 months to 18 months) of noticing jaundice (n=28). Parameters were compared between two groups. Patients in group II were poor liver function and nutritional status needed more supplementary therapy in perioperative period. The incidence of distant metastasis and ascites were more frequent in Group II than Group I patients. Definitive procedure (Whipple's operation) was possible in 53.8% patients in Group I whereas only 7.1% in Group II patients (p <0.05). The reasons for delay referral to surgery were due to patient's ignorance, superstition and fear of receiving operative treatment. Delay in diagnosis of periampullary carcinoma as a cause of jaundice and immediate relief of jaundice with ERCP and stenting is another important cause of delay in seeking definitive operative treatment. Awareness of public as well as general physicians is required for early referral of patients with periampullary carcinoma to surgery. Joint assessment of these patients by Gastroenterologist and Hepatobiliary surgeons before internal biliary drainage will improve prognosis.

[Implantation of plastic and metal stents to biliary tract in obstructive jaundice in material of Surgery Department of 4th Military Clinical Hospital in Wroclaw]

INTRODUCTION

A method of treatment for malignant bile duct strictures depends on early diagnosis, location and extent of tumor infiltration. Patients eligible for radical surgery should be operated.

AIM OF THE STUDY

The authors used plastic and metal prostheses in the treatment of biliary tract cancer cholestasis.

MATERIAL AND METHODS

Retrospective analysis was done in 2730 endoscopies performed in the Laboratory of the Department of Endoscopic Surgery, 4th Military Hospital in Wroclaw in 2008-2011. The authors analyzed 441 cases of prosthetic biliary cancer.

RESULTS

223 patients (51%) were treated for pancreatic head tumor, 98 pts (22%)--for papilla of Vater tumor, 85 pts (19%)--due to Klatskin tumor and 35 pts (8%)--due to tumor of the gallbladder. Plastic prostheses were inserted in 228 (65.4%) patients, self-expanding metal prostheses--in 21 patients (4.9%). Dilatation of the bile duct or the inserted prosthesis was performed in 48 (11.1%) pts. 27 patients (6.1%) had endoscopic treatment failure. 32 patients (7.3%) had following complications of biliary prosthesis: bleeding into the bile duct, into the digestive tract--4 cases (1%), the migration of the prosthesis--7 (1.6%), cholangitis--21 cases (4.7%).

CONCLUSIONS

Palliative biliary stenting is a safe method that provides efficient drainage of bile. It shows a definitive advantage over percutaneous, biliary transhepatic drainage.

[Differential diagnostic strategy in obstructive jaundice]

An analysis of effectiveness of diagnostic noninvasive and invasive measures for obstructive jaundice was made using clinical findings of 383 patients. The efficacy of these measures was assessed and limits were determined in relation to etiology of obstructive jaundice and the condition of extrahepatic bile ducts. The criteria of selection of diagnostic methods were detected on preoperative and intraoperative stages. The rational report of diagnostic strategy was formulated.

[The bile-diverting methods in long-term obstructive jaundice]

There were examined 59 patients, admitted to hospital for residual choledocholithiasis, complicated by durable (during more than 2 weeks) obturation jaundice, who were treated in 2009-2012 yrs. In 37 patients (the first group) endoscopic papillosphincterotomy was conducted and choledocholithoextraction, in 22 (the second group)--after endoscopic papillosphincterotomy and choledocholithoextraction nasobiliary drainage was performed during 3-8 days. Besides the conventional clinical and instrumental investigations, there were examined also the spectrum of conjugated and nonconjugated biliary acids in the blood plasm, as the indices of the bile toxicity and early markers of hepatic insufficiency occurrence. There was established in the blood serum of both groups of patients the content increase of the biliary acids toxic fractions. In the patients of the second group the toxic fractions of biliary acids disappearance was observed trustworthy earlier, than in patients of the first group.

[Long-term treatment results and quality of life of the patients, operated on the reason of chronic pancreatitis, complicated by the obstructive jaundice]

Methods of surgical treatment of the patients, operated on the reason of chronic pancreatitis, complicated by the obstructive jaundice, were comparatively analyzed. 25 patients received pancreatoduodenal resection, 19 patients had the Bern variant of Beger operation. The quality of life was assessed with the use of MOS-SF-36. The duodenum preserving resection of the head of the pancreas showed better long-term results then pancreatoduodenal resection. Those patients, who received biliodigestive anastomosis as the basic operation, showed no good results at all.

[Multilevel drainage of bile ducts in obstructive jaundice and cholangitis]

The data of combined application of low invasive intervention on bilious tree were analyzed in 63 patients with the obstructive jaundice and cholangitis. An indication for operation and the option of performing multilevel drainage were validated in patients with the obstruction of bile-excreting system and cholangitis. The technique of percutaneous intraluminal biopsy of hepaticocholedoch with atherectomic camera was supposed. The data obtained allow the application of given approach during the treatment of patients with the severe stage of the disease.

Biliary drainage for obstructive jaundice caused by unresectable hepatocellular carcinoma: the endoscopic versus percutaneous approach

BACKGROUND

For palliative treatment of the obstructive jaundice associated with unresectable hepatocellular carcinoma (HCC), percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde biliary drainage (ERBD) has been performed. PTBD is preferred as an initial procedure. Little is known about the better option for patients with obstructive jaundice caused by unresectable HCC.

METHODS

Sixty patients who had received ERBD or PTBD for the palliative treatment of obstructive jaundice caused by unresectable HCC between January 2006 and May 2010 were included in this retrospective study. Successful drainage, drainage patency, and the overall survival of patients were evaluated.

RESULTS

Univariate analysis revealed that the overall frequency of successful drainage was higher in the ERBD group (22/29, 75.9%) than in the PTBD group (15/31, 48.4%) (P=0.029); but multivariate analysis showed marginal significance (P=0.057). The duration of drainage patency was longer in the ERBD group than in the PTBD group (82 vs 37 days, respectively, P=0.020). Regardless of what procedure was performed, the median survival time of patients who had a successful drainage was much longer than that of the patients who did not have a successful drainage (143 vs 38 days, respectively, P<0.001).

CONCLUSION

Besides PTBD, ERBD may be used as the initial treatment option to improve obstructive jaundice in patients with unresectable HCC if there is a longer duration of drainage patency after a successful drainage.

Biliary plastic stent as a matrix core for lithogenesis in the common bile duct: a rare cause of jaundice

BACKGROUND

The obstruction of the main bile duct by a foreign body, followed by lithogenesis at that level, is rarely encountered in the literature especially when the foreign body is a plastic biliary stent. We have not found referrals concerning the stone formation as a complication at the level of a biliary stent.

CASE REPORT

A 59-year-old female patient was referred with abdominal pain and jaundice. The patient had had a biliary prosthesis inserted 42 months earlier for treatment of biliary stenosis and fistula, complications that occurred after a laparoscopic cholecystectomy. Imaging investigations evidenced the presence of obstructive jaundice and the biliary stent with gall stones adherent on its surface. After the failure of an endoscopic extraction attempt, surgical intervention ensured the removal of the stent and the gallstones formed on its surface.

CONCLUSION

The particularity of the case consists of the rarity of such a complication after biliary stenting. At the same time, it emphasizes the need for postoperative follow-up, in order to avoid this kind of complication, potentially fatal.

[Portal hypertensive biliopathy--an unusual cause of obstructive jaundice]

Biliary symptoms may be an unusual presentation of portal hypertension, especiaLly in patients with portal vein thrombosis. This is a case report of a patient who developed acute and chronic portal vein thrombosis that presented as obstructive jaundice. The discussion will focus on diagnostic modalities and therapeutic options.

Which patients with advanced cancer and biliary obstruction benefit from biliary stenting most? An analysis of prognostic factors

BACKGROUND

Patients with advanced cancer may present with obstructive jaundice. Biliary stenting is the treatment of choice. However, which patients benefit most is not well-defined, yet. Our aim was to delineate the clinical factors affecting prognosis.

MATERIAL AND METHODS

Charts of 140 patients with advanced cancer who underwent biliary stenting were retrospectively analyzed. Their median age was 63.5 years. Of these patients, 73 (52.1 %) were male, 32 (22.9 %) had ECOG PS 1 and 81 (57.9 %) had PS 2. The most frequent cancer types were cholangiocellular cancer (64, 45.7 %) and pancreatic cancer (36, 25.7 %).

RESULTS

Median overall survival (OS) was 141 (95 % CI, 100.7-185.3) days. Female patients lived longer (161.0 vs. 124.0 days) (p = 0.036). Those patients with colorectal cancer lived the longest (667.0 days), followed by cholangiocellular (211.0 days), and gastric cancers (106.0 days) (p = 0.004). The distribution of primary diagnosis differed significantly between sexes: cholangiocellular cancer was present in 22 (30.1 %) out of 73 men and 42(62.7 %) out of 67 women (chi-square p < 0.001). There was a trend for longer overall survival if ALT (p = 0.08) and AST (p = 0.06) were normalized after stent insertion. Of the 137 patients, 63 (45.5 %) did not experience any complication. In 74 patients with complications, there were 39 (28.5 %) episodes of cholangitic infections and 35 (25.5 %) biliary obstructions. In three patients, we could not find data on infections.

CONCLUSION

Underlying malignancy, hence the natural biology and the therapeutic expectations are probably the most important factors which must be considered during decision-making.

[A long-term survival case of biliary tract cancer treated with multimodality therapy]

A 64-year-old man with obstructive jaundice underwent percutaneous transhepatic biliary drainage, and bile cytology diagnosed adenocarcinoma. The operation ended with exploratory laparotomy because of severe cirrhosis, and thus, S-1 therapy was started after radiation therapy (50 Gy) with an endoscopic retrograde biliary drainage (ERBD) tube. After 37 months, an abdominal computed tomography(CT) scan detected dilation of the intrahepatic biliary tract without recurrence, and we therefore detained a biliary expandable metallic stent instead of the causal obstruction of the ERBD tube. Subsequent CT scan and upper gastrointestinal endoscopy detected stenosis and a thickened wall of the duodenum because of recurrence, and thus, we detained a duodenal stent and started gemcitabine therapy. The patient is alive 70 months after the initial consultation. We report herein a long-term survival case of biliary tract cancer treated with multimodality therapy.

Rhabdomyosarcoma of the common bile duct: an unusual cause of obstructive jaundice in a child

Biliary rhabdomyosarcoma (RMS) is a rare malignancy of childhood. The radiological findings and clinical presentation of the tumor can mimic an entirely different pathology. The incidence of RMS has impeded the development of a standardized form of treatment. A four-year-old child with botryoid RMS in the common bile duct is reported herein to emphasize the role of surgery in the small-sized tumor and the role of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and relief of biliary obstruction before total excision.

[Endoscopic retrograde biliary drainage for the liver metastases from colorectal cancer and obstructive jaundice]

The success of biliary drainage in patients with liver metastases from colorectal cancer and obstructive jaundice influences its prognosis greatly. In this study, we report a retrospective evaluation of endoscopic retrograde biliary drainage in patients with liver metastases from colorectal cancer and obstructive jaundice.

MATERIALS AND METHODS

From April 2004 to December 2011, 9 patients with liver metastases from colorectal cancer and obstructive jaundice who underwent endoscopic biliary drainage were evaluated retrospectively.

RESULTS

The mean serum levels of total bilirubin, aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase improved significantly after biliary drainage. The median survival time after biliary drainage was 133 days. Only 4 cases were able to resume chemotherapy after biliary drainage, and their prognosis was significantly better than patients who were not able to resume chemotherapy(p=0.014).

DISCUSSION

Endoscopic biliary drainage in patients with liver metastases from colorectal cancer and obstructive jaundice was effective, led to the resumption of chemotherapy, and improved prognosis. However, sufficient consideration of the patient's prognosis and performance status is required in order to perform biliary drainage.

The effectiveness of endoscopic retrograde cholangiopancreatography in the management of patients with jaundice at Cipto Mangunkusumo Hospital, Jakarta

AIM

to evaluate endoscopic retrograde cholangiopancreatography (ERCP) benefits in treating patients with clinical appearance of yellowish discoloration.

METHODS

a descriptive retrospective cross-sectional study was performed on 122 patients at Cipto Mangunkusumo Hospital from January 2008 to December 2010. The main complained was yellowish discoloration of the skin. ERCPs were performed as appropriate, and then the distribution of disease entity, results of procedure and complications were noted.

RESULTS

subjects of this study consist of 63 males (52%) and 59 females (48%), 7 patients have undergone ERCP 2 times. Data showed 63 cases (51%) were indicated by stone and 52 cases (43%) by tumor/mass and 7 cases by infection (6%). Ten out of 122 cases (7%) showed normal results. Difficult canulation was encountered in 23 cases (18%) as access to the CBD could not be obtained. From 53 cases with stone, the extraction was successful in 43 (81%) including while 12 procedures with high grade of difficult ERCP left stone remnants (23%), and the remaining 10 procedures entailed stones retention (19%). Radioopaque stones found in 2 cases (4%) and radioluscent in 51 cases (96%). Stent placement was done in CBD (30 cases, 83%), pancreatic duct (4 cases, 11%), and extraneous CBD (2 cases, 5%). Complications found 3 cases (2%) migration stent outside CBD in 2 cases, 1 case with crand radioluscentin 51 acked basket.

CONCLUSION

ERCP procedure is really helpful in assisting clinicians to diagnose and manage therapeutic measures, especially in pancreaticobilliar tract disorder, while performing stone extraction and stent placement.

[A case of pancreatic mucinous carcinoma invading the common bile duct with obstructive jaundice]

A 75-year-old man was admitted to our hospital for further investigation of obstructive jaundice due to a mucin-producing bile duct tumor. ERCP revealed dilatation of the common bile duct and a filling defect in the bile duct. Because of obstructive jaundice, an EBD tube was placed and bile was drained. Contrast-enhanced CT showed a low density 2-cm mass, in the pancreatic head containing some enhanced parts in the tumor. MRI revealed the tumor to be a low-intensity mass on T2-weighted image. After recovery from the obstructive jaundice, pancreaticoduodenectomy was performed under a diagnosis of invasive mucinous carcinoma penetrating the common bile duct from the pancreatic head, resulting in obstruction of the common bile duct. Postoperatively histopathological diagnosis of the resected specimen showed mainly mucinous carcinoma originating from the pancreatic head without a component of intraductal papillary-mucinous tumor.

Ten years single center experience in percutaneous transhepatic decompression of biliary tree in patients with malignant obstructive jaundice

BACKGROUND

Percutaneous transhepatic biliary drainage (PTBD) is a method of biliary tree decompression, applied as palliative treatment in patients with malignant biliary tree critical stenosis/obstruction, but also as a potentially curative treatment in patients with non-malignant biliary tree stenosis. Novel instrumentation dedicated to PTBD has been designed in recent years, which makes it possible to perform more advanced procedures in patients with severe extensive malignant biliary tree stenosis/obstruction.

OBJECTIVES

The first primary goal of the study was to compare both the rate and types of short- and long-term complications in patients who had undergone PTBD between 2000 and 2006 with patients treated between 2007 and 2011. The second primary goal of the study was to work out an original algorithm of efficient management in patients undergoing PTBD. An additional goal was to assess the efficacy of PTBD and the overall survival of the patients.

MATERIAL AND METHODS

One-hundred twenty-eight consecutive PTBD procedures performed between 2000 and 2006 in patients with malignant biliary jaundice were analyzed retrospectively. Similarly, retrospective analysis of 73 consecutive procedures in patients with malignant biliary jaundice performed between 2007 and 2011 was carried out. Subsequently, the results of both subsets were compared to each other. The PTBD procedure was guided fluoroscopy each time. PTBD involved external biliary drainage and/or stenting of the strictured/occluded segments of extra- and intrahepatic biliary ducts.

RESULTS

The analysis demonstrated a statistically significant decrease in the overall incidence of short- and long-term complications in patients undergoing PTBD in 2007-2011 in comparison to the subset treated in 2000-2006. Among the early complications, a significant decrease in sub- and pericapsular contrasted bile leaks was shown. The evaluation of long-term complications demonstrated lower incidence of the falling out of the draining catheter. The implementation of novel instrumentation made it possible to perform biliary stenting in 63.7% cases of common bile duct (CBD) obstruction (vs. 37.5% in procedures carried out in 2000-2006). However, no statistically significant difference in survival between the two analyzed subsets was demonstrated.

CONCLUSIONS

The analysis of rate and types of complications made it possible to establish authors own algorithm of management in different types of biliary obstructions and strictures. The modification of procedure technique, pos-tinterventional management and usage of the new generation of low-profile instrumentation for percutaneous access dedicated to PTBD has resulted in a significant reduction of the complication rate in the last 5 years. Higher frequency of CBD stenting improves the quality of life in this subset of patients.

[A case of hepatic peribiliary cysts in a patient with alcoholic liver cirrhosis]

Hepatic peribiliary cysts (HPCs) are characterized by cystic dilatations of the peribiliary glands located throughout the branches of the biliary systems. Specifically, they are mainly located along the hepatic hilum and major portal tracts. The natural history and prognosis of HPCs are uncertain. In fact, almost all HPCs have been discovered incidentally during radiological examination or autopsy, and they are considered to be clinically harmless. Recently, several cases of HPCs associated with obstructive jaundice or liver failure were reported in patients with pre-existing liver disease in several studies. However, until now there have been no reports of such a case in Korea. Herein, we report a case of HPCs that show a disease course with a poor prognosis. These HPCs developed in a 47-year-old man with progressive alcoholic liver cirrhosis.

Endoscopic retrograde cholangiopancreatography for distal malignant biliary stricture

Endoscopic biliary stent placement is widely accepted as palliation for malignant biliary obstruction or as a treatment of benign biliary stricture. Although various biliary stent designs have become available since self-expandable metallic stents were introduced, no single ideal stent has been developed. An ideal stent should be patent until death, or surgery, in patients with resectable malignant biliary obstruction. Fewer complications, maneuverability, cost-effectiveness, and removability are also important factors. Alternatively, should we develop a novel method for biliary drainage other than biliary stenting via endoscopic retrograde cholangiopancreatography? This article reviews the current status of biliary stenting for malignant biliary obstructions.

[Jaundice as the first symptom of HELLP syndrome--case report]

Jaundice is a rare symptom of the HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) and is diagnosed in only 5% of the patients with this condition. However jaundice is related with sever presentation of the disease and associated with higher mortality The aim of this paper was to present a case of 24-year-old patient with jaundice as the first symptom of severe HELLP syndrome. A review of the literature about symptoms and treatment of HELLP syndrome and differential diagnosis of jaundice in pregnancy was done as well.

Acute myeloid leukemia presenting as obstructive jaundice

Jaundice as a presenting feature of pediatric acute myeloid leukemia is rare. We report two cases of AML who presented with obstructive jaundice, one with a malignant stricture at the common bile duct and other with a granulocytic sarcoma obstructing the bile duct. The prognosis is poor in these patients.

[Intestine microbiocenosis in mechanical jaundice caused by obturation of biliary ducts]

AIM

Study the composition of bile and feces microflora in patients with mechanical jaundice of various geneses.

MATERIALS AND METHODS

66 feces and 25 bile samples during nasobiliary decompression were studied bacteriologically.

RESULTS

In all patients disorders of normal intestine microflora were detected. Patient bile in 84% of cases was infected by bacteria among which enterococci and urease positive enterobacteria predominated. In 30% of cases in patients identical species of bacteria were simultaneously detected in bile samples and in high titers (6.0 - 6.5 lg CFU/ml) in feces.

CONCLUSION

In mechanical jaundice caused by biliary duct obturation in all the patients dysbiotic events of digestive tract are registered, that defines the necessity to improve bacteriological examination of patients with mechanical jaundice and reasonability of disrupted normal intestine microflora correction.

[Obstructive jaundice by genodermatosis--case report]

BACKGROUND

Neurofibromatosis type I, or Recklinnghausen disease, is the most frequently occurring neurofibromatosis, in 1/3000-11,5000 of children born. This disease is a genodermatosis with 1/3000-1/5000 autosomal dominant transmission. Incriminated in the pathological appearance of the disease gene is located on chromosome 17, gene product, neurofibromina, is a protein involved in controlling cell differentiation and proliferation. Skin manifestations can be associated with the same papillary tumors and the internal organ. Treatment is surgery for larger tumors. Worse prognosis in malignant developpment, with the lower quality of life in the presence of complications, as in this case: mechanical obstructive jaundice.

MATERIAL AND METHOD

Patients aged 75 years, admitted for obstructive jaundice (progressive, pruritic), cutaneous papillomas (0.5-3 cm) on the trunk and several hyperpigmented brown spots (5-6 cm diameter). Cutaneous lesions (45 years old) have been previously diagnosed by histological examination.

RESULTS

We did surgery under general anesthesia: cholecystectomy, intraoperative choledocoscopy of bile duct. In the last portion of bile duct we found pedicled tumors. We did partial excision of tumors and coledoco-duodenoanastomosis in healthy tissue. Histological examination showed neurofibrodermatoza type I. Discharge 12 days postoperatively.

CONCLUSIONS

Preoperative diagnosis suggested the possibility of mechanical jaundice by malignancy. Etiologic diagnosis of this rare form of obstructive jaundice could not be established before surgery, only by histological examination of the excised tumors.