Internal-external percutaneous transhepatic biliary drainage for patients with malignant obstructive jaundice

Pathophysiological consequences and treatment strategy of obstructive jaundice

Obstructive jaundice (OJ) is a common problem in daily clinical practice. However, completely understanding the pathophysiological changes in OJ remains a challenge for planning current and future management. The effects of OJ are widespread, affecting the biliary tree, hepatic cells, liver function, and causing systemic complications. The lack of bile in the intestine, destruction of the intestinal mucosal barrier, and increased absorption of endotoxins can lead to endotoxemia, production of proinflammatory cytokines, and induce systemic inflammatory response syndrome, ultimately leading to multiple organ dysfunction syndrome. Proper management of OJ includes adequate water supply and electrolyte replacement, nutritional support, preventive antibiotics, pain relief, and itching relief. The surgical treatment of OJ depends on the cause, location, and severity of the obstruction. Biliary drainage, surgery, and endoscopic intervention are potential treatment options depending on the patient's condition. In addition to modern medical treatments, Traditional Chinese medicine may offer therapeutic benefits for OJ. A comprehensive search was conducted on PubMed for relevant articles published up to August 1970. This review discusses in detail the pathophysiological changes associated with OJ and presents effective strategies for managing the condition.

Effectiveness of a new approach to minimally invasive surgery in palliative treatment of patients with distal malignant biliary obstruction

BACKGROUND

Palliative endoscopic biliary drainage is the primary treatment option for the management of patients with jaundice which results from distal malignant biliary obstruction (DMBO). In this group of patients, decompression of the bile duct (BD) allows for pain reduction, symptom relief, chemotherapy administration, improved quality of life, and increased survival rate. To reduce the unfavorable effects of BD decompression, minimally invasive surgical techniques require continuous improvement.

AIM

To develop a technique for internal-external biliary-jejunal drainage (IEBJD) and assess its effectiveness in comparison to other minimally invasive procedures in the palliative treatment of patients with DMBO.

METHODS

A retrospective analysis of prospectively collected data was performed, which included 134 patients with DMBO who underwent palliative BD decompression. Biliary-jejunal drainage was developed to divert bile from the BD directly into the initial loops of the small intestine to prevent duodeno-biliary reflux. IEBJD was carried out using percutaneous transhepatic access. Percutaneous transhepatic biliary drainage (PTBD), endoscopic retrograde biliary stenting (ERBS), and internal-external transpapillary biliary drainage (IETBD) were used for the treatment of study patients. Endpoints of the study were the clinical success of the procedure, the frequency and nature of complications, and the cumulative survival rate.

RESULTS

There were no significant differences in the frequency of minor complications between the study groups. Significant complications occurred in 5 (17.2%) patients in the IEBJD group, in 16 (64.0%) in the ERBS group, in 9 (47.4%) in the IETBD group, and in 12 (17.4%) in the PTBD group. Cholangitis was the most common severe complication. In the IEBJD group, the course of cholangitis was characterized by a delayed onset and shorter duration as compared to other study groups. The cumulative survival rate of patients who underwent IEBJD was 2.6 times higher in comparison to those of the PTBD and IETBD groups and 20% higher in comparison to that of the ERBS group.

CONCLUSION

IEBJD has advantages over other minimally invasive BD decompression techniques and can be recommended for the palliative treatment of patients with DMBO.

Metallic stent placement versus catheter drainage for malignant bilioenteric anastomotic stricture

PURPOSE

The purpose of the study was to compare self-expandable metallic stent placement with catheter drainage for malignant bilioenteric anastomotic stricture in terms of efficacy and safety.

MATERIALS AND METHODS

This study included 54 patients with malignant bilioenteric anastomotic stricture treated from March 2016 to February 2021. Twenty-seven patients underwent insertion of self-expandable metallic stent (Stent group); the remaining twenty-seven patients underwent internal-external catheter drainage (Catheter group). Technical success was defined as successful placement of stent or drainage catheter in the appropriate position; clinical success was defined as a 20% reduction in serum bilirubin within 1 week after the procedure, compared with baseline. Complications, duration to stent/catheter malfunction, and overall survival were evaluated.

RESULTS

Technical success was achieved in all patients in both groups. In the Stent group, 21 patients received one stent and the other 6 patients required two stents. Clinical success rates were similar between the groups [Stent group, 92.6% (25/27); Catheter group, 88.9% (24/27)]. There were no major complications. The median duration to stent/catheter malfunction was significantly longer in the Stent group (130 days) than in the Catheter group (82 days; P = 0.010). The median overall survival was also significantly longer in the Stent group (187 days) than in the Catheter group (118 days; P = 0.038).

CONCLUSION

Self-expandable metallic stent placement might be better than internal-external catheter drainage for malignant bilioenteric anastomotic stricture in terms of the duration before stent/catheter malfunction and patient survival.

External-Internal Biliary-Jejunal Drainage in Palliative Treatment of Distal Mechanical Jaundice

Введение. Метод выбора дренирования желчных протоков у пациентов с дистальной злокачественной механической желтухой (ДЗМЖ) остается дискуссионным.Цель. Разработать и внедрить в клиническую практику методику наружно-внутреннего билиарно-еюнального дренирования и сравнить ее результаты с ретроградным эндоскопическим стентированием при паллиативном лечении дистальной механической желтухи.Материалы и методы. В проспективное исследование вошло 54 пациента с ДЗМЖ: 29 пациентам выполнена разработанная методика наружно-внутреннего билиарно-еюнального дренирования (группа НВБЕД); 25 – эндоскопическое ретроградное билиарное стентирование (группа ЭРБС) с использованием непокрытых металлических стентов. НВБЕД проводилась с использованием предложенного дренажа, устанавливаемого посредством чрескожного чреспеченочного доступа, при этом конец дренажа с дистальной группой боковых отверстий размещался в начальных петлях еюнум, проксимальная группа боковых отверстий – в расширенных желчных протоках над стенозом.Точками исследования были клинический успех процедуры, частота и характер осложнений, накопленная выживаемость, накопленное время проходимости стента.Результаты. Клинический успех процедуры достигнут в группе НВБЕД у 82,1% пациентов, в группе ЭРБС – у 84,0% (р>0,05).В группе НВБЕД осложнения возникли у 5 (17,9%) пациентов, в группе ЭРБС – у 16 (64,0%) (р=0,002), в том числе холангит – у 10,3% против 36,0% (р=0,024) и панкреатит у 6,9%, против 36,0% (р=0,023) соответственно.При использовании НВБЕД накопленное выживание составило 252,3 дня (95% ДИ: 207,5–297,1) против 203,3 дня (95% ДИ: 164,5–242,1) в группе ЭРБС (р=0,072). Это мы связываем со снижением частоты холангита в группе НВБЕД. В целом накопленное выживание составило 248,9 дня (95% ДИ: 212,2–285,5) при отсутствии у пациентов эпизодов холангита против 168,8 дня (95% ДИ: 132,3–205,4) при наличии холангита (р=0,005).У пациентов с холангитом накопленное время проходимости стентов составляло 157,1 дня (95% ДИ: 132,1–182,1), при отсутствии холангита – 269,6 дня (95% ДИ: 230,3–309,0), р=0,005. У пациентов с НВБЕД закупорки просвета дренажа не наблюдали.Заключение. Предложенная методика наружно-внутреннего билиарно-еюнального дренирования при паллиативном лечении дистальной механической желтухи предпочтительнее эндоскопического ретроградного билиарного стентирования.

Introduction. The choice of bile duct drainage in patients with distal malignant obstructive jaundice (DMOJ) remains controversial.Purpose. To develop and introduce into clinical practice a technique for external-internal biliary- jejunal drainage and compare its results with retrograde endoscopic stenting in palliative treatment of DMOJ.Materials and methods. The prospective study included 54 patients with DMOJ: 29 patients underwent the developed method of external-internal biliary-jejunal drainage (NVBED group); 25 – endoscopic retrograde biliary stenting (ERPS group) using metal stents. NVBED was carried out using the proposed drainage installed by means of a percutaneous transhepatic approach, while the end of the drainage with the distal group of lateral holes was located in the initial loops of the jejunum, the proximal group of lateral holes – in the dilated bile ducts above the stenosis.The points of the study were the clinical success of the procedure, frequency and nature of complications, accumulated survival rate, accumulated time of stent patency.Results. Clinical success of the procedure was achieved in 82.1% of patients in the NVBED group, and 84.0% of patients in the ERHD group, p>0.05.In the IVBED group, complications occurred in 5 (17.9%) patients, in the ERHD group – in 16 (64.0%) patients, p=0.002, including cholangitis – in 10.3% versus 36.0% (p=0.024) and pancreatitis – in 6.9% versus 36.0% (p=0.023), respectively.When using NVBED, the cumulative survival was 252.3 days (95% CI: 207.5–297.1) versus 203.3 days (95% CI: 164.5–242.1) in the ERBS group (p=0.072). We associate this with the decrease of the incidence of cholangitis in the IVBED group. Thus, the overall cumulative survival was 248.9 days (95% CI: 212.2–285.5) in the absence of cholangitis episodes versus 168.8 days (95% CI: 132.3–205.4) in the presence of cholangitis, p=0.005.In patients with cholangitis, the cumulative time of stent patency was 157.1 days (95% CI: 132.1– 182.1); in the absence of cholangitis – 269.6 days (95% CI: 230.3–309.0, p=0.005. In patients with NVBED, the drainage lumen blockage was not observed.Conclusion. The proposed method of external-internal biliary-jejunal drainage for palliative treatment of distal obstructive jaundice is preferable in comparison with endoscopic retrograde biliary stenting.

A Clinical Study on Juheli (Recombinant Human Interleukin - 11) in the Second Prevention of Chemotherapy Induced Thrombocytopenia

OBJECTIVE

to investigate the effect and side effects of recombinant human interleukin - 11 (rhIL - 11, in Chinese Juheli, produced by Qi Lu Biotechnology CO., LTD) in the second prevention of chemotherapy induced thrombocytopenia (CIT).

METHODS

Cancer patients with CIT were recruited and were treated with rhIL - 11 (treatment phase, TP), and in the following cycle, all these patients administered with rhIL - 11 24 hours immediately after chemotherapy (preventive treatment phase, PTP). Duration and severity of thrombocytopenia between two phases were compared.

RESULTS

for patients in TP or PTP, nadir values of platelet were (29.28±20.08)?109/L and (45.24±19.66)?109/L, duration of thrombocytopenia in TP and PTP was (11.52±4.33) and (8.20±+2.77)days, recovery time was (19.40±3.89)and (13.44±3.02)days, duration of rhIL - 11 administration was 10.68±2.46)and (6.28±1.77)days, number of patients needing platelet infusion was 16and4 respectively, all differences were statistically significant (p value were 0.007, 0.002, 0.000, 0.000, 0.034 respectively). For TP and PTP, number of patients with hemorrhage was 8 and 4, duration of bleeding was (5.00±0.82) and (4.50 ± 0.71) days respectively, with no statistically significant difference. Adverse reactions mainly included fever, edema, arrhythmia, joint pain, fatigue, skin rash, headache, dizziness, etc., all were not statistically significant between TP and PTP.

CONCLUSION

rhIL - 11 could be well tolerated and is effective that could reduce the duration, severity of CIT, platelet transfusion, and incidence of bleeding, as well as shorten the recovery time, duration of rhIL - 11 administration. Thus, rhIL - 11 could be commended in the second prevention of CIT for patients with cancer.

Safety and Efficacy of a Mouth-Rinse with Granulocyte Colony Stimulating Factor in Patients with Chemotherapy-Induced Oral Mucositis

OBJECTIVE

To assess the safety and effectiveness of a mouth-rinse with G-CSF (JiSaiXin, produced by NCPC Biotechnology Co., Ltd) in treating patients with chemotherapy-induced oral mucositis (CIM).

METHOD

A consecutive cohort of patients with advanced cancers and CIM were treated with mouth-rinse G-CSF. All chemotherapy for patients with advanced cancers was adopted from regimens suggested by NCCN guidelines. The mouth-rinse with G-CSF at a dose of 150-300ug plus 100ml-500ml normal saline was started from the time of oral mucositis was confirmed and continuously used for at least 7 days as one course. After at least two courses of treatment, safety and efficacy were evaluated.

RESULTS

There were 7 female and 7 male patients with advanced cancer and CIM recruited into this study, including 5 with colorectal, 2 with lung, 1 patient with gastric, 1 with cervical and 1 with pancreatic cancer, as well as 2 patients with diffuse large B cell lymphomas, 1 with nasopharyngeal and 1 with gastric cancer. The median age was 57 (41-79) years. Grade 1 to 2 myelosuppression was observed in 3/14 patients, and Grade 4 myelosuppression in 1/14. Adverse effects on the gastrointestinal tract were documented in 5/14 patients, and were Grade 1 to Grade 3. No treatment related death was documented. Regarding CIM, the median response time to mouth rinse of G-CSF was 2 (1-5) days, and all patients with CIM demonstrated a positive response.

CONCLUSIONS

Mouth-rinse with G-CSF proved to be safe and effective in treating patients with advanced cancers and CIM. However, further randomized controlled studies should be conducted to clarify the effectiveness of this treatment with other lesions.

FDG-PET/CT Manifestation of Tumor Seeding Along Percutaneous Biliary Drainage Catheter Tract

A 55-year-old man with liver metastases from colon cancer developed obstructive jaundice secondary to bile duct compression from tumor burden, which required percutaneous biliary drainage until subsequent internal biliary stent could be placed. Follow-up FDG-PET/CT performed 2 months after removal of percutaneous biliary drainage catheter revealed FDG avid metastases along the catheter tract, extending from anterior abdominal wall to the peripheral liver at the insertion site of previous biliary catheter.