肝门区转移癌所致梗阻性黄疸的内镜支架引流治疗临床效果分析

目的探讨内镜治疗肝门区转移癌所致梗阻性黄疸的临床应用价值。方法2006年开始随机选择自愿应用内镜治疗的晚期肝门区转移癌所致梗阻性黄疸患者,应用内镜胆道塑料内支架技术解除胆道梗阻,观察操作成功率、生存期等评价指标。共治疗肝门转移癌梗阻性黄疸患者38例,其中肝癌13例,胆囊癌3例,胃癌14例,食管癌2例,回肠腺癌1例,胰腺癌5例。结果所有患者治疗成功且临床黄疸完全消退,随访生存期92～521d,平均（185．42±104．41）d。随访观察5例患者更换胆道支架,更换时间3～14个月,平均（8．6±4．1）个月,其中支架移位1例,胆泥阻塞2例,肿瘤阻塞2例。结论内镜支架引流术是肝门区转移癌所致梗阻性黄疸的一种有效治疗方法,具有较高的治疗成功率,可以一定程度延长患者的生存期。     

Extrahepatic Obstructive Jaundice Due to Colorectal Cancer

A prospective registry of patients with obstructive jaundice referred for percutaneous bile duct drainage found six patients with extrahepatic obstruction due to colorectal cancer in a 21-month period. This cause of jaundice in patients with colorectal cancer is not uncommon, and deserves routine diagnostic consideration, even in the presence of intrahepatic metastases. Percutaneous biliary drainage was beneficial for four of the six patients.     

Extrahepatic biliary obstruction caused by metastatic breast carcinoma.

We describe our experience with seven patients who had extrahepatic biliary obstruction caused by metastatic breast cancer. The interval from the original diagnosis of breast cancer to the development of jaundice averaged 40 months, with a range of 9 months to 8 years. All patients were treated with surgical decompression, radiation, transhepatic catheter drainage, chemotherapy, or a combination of these modalities. Resolution of jaundice was achieved in six patients. Prolonged survival was realized in three; one patient lived for more than 6 years after surgical bypass, and two are alive and well at present (greater than 11 months after relief of biliary obstruction). Extrahepatic biliary obstruction by metastatic breast carcinoma should be distinguished from jaundice due to hepatic parenchymal destruction by this tumor; while the latter implies end-stage cancer, the former has the potential for significant palliation and prolonged survival.     

Clinical impact of biliary drainage and jaundice resolution in patients with obstructive metastases at the hilum

OBJECTIVES: For patients presenting with progressive liver or lymph node metastases (LM) causing obstructive jaundice, survival without adequate biliary drainage is very brief. The aim of this study was to assess the impact of endoscopic drainage for biliary obstruction secondary to LM at the hilum on subsequent administration of chemotherapy and on patient outcome. METHODS: Thirty-five patients were studied and underwent insertion of plastic and/or metal stents, endoscopically (80%) or percutaneously and endoscopically (20%), to obtain complete resolution of jaundice. LM originated from colon (n = 16), gastric (n = 5), breast (n = 5), pancreatic (n = 3), and miscellaneous cancers (n = 6). Bile duct strictures were Bismuth type I-II in 13 patients and type III in 22. RESULTS: The overall rate of success (i.e., complete resolution of jaundice) was 86% after a median of three procedures per patient (range, 1-7). Pruritus, jaundice, nausea, abdominal pain, and anorexia improved significantly in 88, 86, 75, 66, and 50% of cases, respectively. Overall median survival was 4 months and was 6.5 versus 1.8 months (p < 0.05) in the groups of patients whose jaundice resolved completely versus incompletely. The type of stricture did not affect survival. Patients with colon and breast cancer who were eligible for second line chemotherapy after optimal drainage had the longest survival (12-16 months). CONCLUSIONS: In our patients with obstructive LM, endoscopic biliary drainage completely resolved jaundice in 86% and improved clinical symptoms and survival, thus enabling these patients to have additional chemotherapy.     

Obstructive icterus in patients with hepatic tumor. Result of non-surgical biliary drainage

Seventeen patients with biliary obstruction and hepatic tumors were treated by endoscopic or percutaneous transhepatic drainage with an endoprothesis. There were 9 men and 8 women (mean age = 61 +/- 13 years). Four patients had primary hepatic carcinoma and 13 had hepatic metastases. Decrease of serum bilirubin of more than 75 percent was achieved in 12 of the patients (71 percent). The success rate was related to the level of the biliary obstacle and not to the importance of hepatic parenchymal involvement. Failure was significantly more frequent (p = 0.003) in patients with type III hilar strictures compared to the other patients with pedicular or type I and II hilar strictures. Cholangitis was the major complication (29 percent) and occurred only in the patients with type III hilar strictures. Mortality was 24 percent at 30 days. This rate was 57 percent in the group of patients with type III hilar strictures and significantly higher (p = 0.015) than other patients. Cumulative survival was better in patients with relief of jaundice than that observed in the other patients (p less than 0.01). Two patients with metastatic carcinoma of the breast treated by chemotherapy survived more than 20 months without jaundice. Analysis of these data indicates that in patients with hepatic tumors and obstructive jaundice, palliative treatment with endoprothesis can provide relief of jaundice and that prolonged survival may be observed in patients with chemosensible tumors.     

Result of endoscopic biliary drainage in hilar cholangiocarcinoma

Patients with hilar obstruction usually require bilateral biliary drainage. The prognosis of patients who fail bilateral biliary drainage after contrast injection into both intrahepatic ducts is poor due to a high infection rate in the undrained segments. The incidence of post-endoscopic retrograde cholangiopancreatography cholangitis in those with successful bilateral biliary drainage was less, but still significant. Incomplete subsegmental intrahepatic duct drainage is suggested to be responsible for post-biliary drainage cholangitis in cases of advanced hilar tumors. This study was undertaken to determine the incidence of post-endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and stent clogging in different types of malignant biliary obstruction after biliary drainage. From our endoscopic retrograde cholangiopancreatography database, there were 63 patients who underwent endoscopic biliary drainage between September 2000 and November 2001, for malignant biliary obstruction. Sixty-one endoscopic retrograde cholangiopancreatographies had biliary drainage performed (2 patients who failed biliary drainage were excluded). We divided our patients into 3 groups: Group 1 = Bismuth I, Group 2 = Bismuth II, and Group 3 = Bismuth III and IV. All but 2 Group 1 patients had successful biliary endoprosthesis (plastic [n = 13], metallic [n = 12], failed [n = 2]) placement into an extrahepatic duct. All patients from Group 2 (n = 10) and 20 patients from Group 3 (n = 26) had successful bilateral biliary drainage. Unilateral biliary drainage was performed in 6 patients from Group 3, each with a plastic endoprosthesis. The incidence of post-biliary drainage cholangitis (new onset of fever >38.5 degrees C with leukocytosis), jaundice resolution (normal bilirubin level), and the duration of endoprosthesis patency were compared among the 3 groups. The incidences of post-endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and the duration of endoprosthesis patency were: Group 1 (4%, 96%, and 87.2 days, respectively), Group 2 (10%, 100%, and 69.1 days, respectively) and Group 3 (57.7%, 73.1%, and 41.3 days, respectively). Of those patients who did not undergo surgery, patients from Group 3 required endoprosthesis exchange sooner than others. The outcome of biliary drainage in patients with advanced hilar tumors (Bismuth III or IV) was poorer than hilar tumor at earlier stages (Bismuth I or II).     

Endoscopic Stent Placement for Obstructive Jaundice Secondary to Metastatic Malignancy

In patients with malignancy, jaundice may result from hepatic infiltration or metastatic lymph nodal compression along the bile duct. We attempted endoscopic stent placement on 31 consecutive patients with biliary obstruction from malignant adenopathy, with and without computerized tomographic (CT) scan evidence of hepatic parenchymal metastases. Endoscopic or combined endoscopic-percutaneous decompression was accomplished in 28 patients. Fifteen patients (53.6%) had CT evidence of concomitant metastatic disease to the liver. Thirteen patients had obstructing adenopathy only. Mean survival for patients with hepatic metastases after relief of extrahepatic obstruction was 117.4 days (range 9-386 days). Mean survival after biliary decompression in patients without hepatic involvement was significantly longer at 364.3 days (range 52-1098 days; p = 0.0087). Bilirubin levels fell in all patients in this group. No patient died from complications of obstruction or stent placement. Our data support the conclusion that patients with extrahepatic metastatic biliary obstruction without hepatic metastases have improved survival, compared with patients with both obstruction and hepatic involvement. In the absence of hepatic parenchymal involvement, endoscopic stent placement can safely and effectively palliate metastatic extrahepatic obstruction. Controlled trials are needed to assess the effect of such stenting on survival.     

Effect of percutaneous biliary drainage on serum levels of tumor markers in patients with obstructive jaundice

BACKGROUND/AIMS: Some tumor markers such as CA 19-9 are shown to be increased in obstructive jaundice due to either benign or malignant causes. In this study the clinical importance of raised serum levels of tumor markers have been evaluated, with particular reference to obstructive jaundice and percutaneous biliary drainage. METHODOLOGY: We conducted a prospective longitudinal before-after trial. Twenty-one patients with obstructive jaundice were investigated, 5 with benign obstruction and 16 with malignant disease. All patients were examined with abdominal CT prior to biliary drainage. All patients underwent percutaneous transhepatic cholangiography, and 20 of 21 patients underwent percutaneous biliary drainage within 3 days after the CT examination. RESULTS: The mean CA 19-9 at presentation was lower in the group with benign disease (95 +/- 60.9 IU/mL) than those with malignancy (461.9 +/- 331.4 IU/mL). The mean CA 19-9 level in the benign group 1 week after drainage was 12 +/- 11.8 IU/mL. The mean CA 19-9 level in the malignant group after drainage was 249.7 +/- 279.5 IU/mL. CONCLUSIONS: A prominently high serum CA 19-9 level at the presentation and a high serum CA 19-9 level after successful biliary drainage should prompt investigation for a malignant etiology of obstructive jaundice.     

ERCP在不明原因肝外阻塞性黄疸的临床应用

目的探讨内镜逆行胰胆管造影（ERCP）在经常规检查不明原因肝外阻塞性黄疸的临床应用价值。方法收集经B超、cT和,或MRCP检查诊断不明原因胆胰疾病或肝外胆管梗阻病人45例,男28例,女17例,年龄21—80岁,均行ERCP术。结果45例病人行ERCP术,其中42例诊断为胆道微结石（Biliary microlithiasis,BML）,42例均行乳头扩张术／EST4-胆道取石术;3例为胆总管下端炎性狭窄而行胆道内支架植入术;1例ERCP取石术后并发轻症胰腺炎,经内科保守治疗后痊愈,l例因腹痛再发行胆囊切除术,其余患者经ERCP治疗后腹痛、黄疸均缓解。结论BML是不明原因肝外阻塞性黄疸的主要原因,ERCP是不明原因肝外阻塞性黄疸安全、有效的诊断及治疗手段。     

Extrahepatic portal venous obstruction and obstructive jaundice: approach to management

BACKGROUND: Patients with long-standing extrahepatic portal venous obstruction (EHPVO) develop extensive collaterals in the hepatoduodenal ligament as a result of enlargement of the periportal veins. These patients are also prone to develop obstructive jaundice as a result of strictures and/or choledocholithiasis. Surgical management of obstructive jaundice in such patients becomes difficult in the presence of these collaterals. AIM: To review the approach to management of patients with EHPVO and obstructive jaundice. METHODS: Retrospective review of patients with EHPVO and obstructive jaundice requiring surgical and/or endoscopic management between 1992 and 2002. RESULTS: Thirteen patients (nine males, aged 12-50 years) with EHPVO and obstructive jaundice were evaluated. No patient had underlying cirrhosis or hepatocellular carcinoma. Five patients (group A) had biliary stricture; three (group B) had choledocholithiasis; and five (group C) had biliary stricture with choledocholithiasis. Primary surgical management was performed in group A (portosystemic shunt in four-strictures resolved in three; hepaticojejunostomy in one). In group B (n = 3) endoscopic stone extraction was successful in two patients. One patient underwent staged procedure (portosystemic shunt followed by biliary surgery). In group C, initial endoscopic management failed in four patients in whom it was attempted. All five patients thereafter underwent surgery (staged procedure, one; choledochoduodenostomy, one; devascularization, one; abandoned, two). Repeat postoperative endoscopic management was successful in two of the group C patients. Overall (group B and C), massive intraoperative hemorrhage occurred in three patients (one died). Postoperative hemorrhage occurred in one patient. CONCLUSION: In patients with EHPVO and obstructive jaundice, primary biliary tract surgery has significant morbidity and mortality. Endoscopic management should be the preferred modality. In patients with endoscopic failure, a staged procedure (portosystemic shunt followed by biliary surgery) should be preferred. Strictures alone may resolve after a portosystemic shunt. Endoscopic stenting may be required as an adjunct.     

Extrahepatic biliary stenoses after hepatic arterial infusion (HAI) of floxuridine (FUdR) for liver metastases from colorectal cancer.

Hepatic arterial infusion of floxuridine is an effective treatment for unresectable hepatic metastases from colorectal cancer. Despite its pharmacological advantage of higher tumor drug concentration with minimal systemic toxicity, hepatic arterial infusion of floxuridine is characterized by regional toxicity, including hepatobiliary damage resembling idiopathic sclerosing cholangitis (5-29% of treated cases). Unlike previous reports describing biliary damage of both intrahepatic and extrahepatic ducts, a case series of extrahepatic biliary stenosis after hepatic arterial infusion with floxuridine is herein described. Between September 1993 and February 1999, 54 patients received intraarterial hepatic chemotherapy based on continuous infusion of floxuridine (dose escalation 0.15-0.30 mg/kg/day for 14 days every 28 days) plus dexamethasone 28 mg. Twenty-seven patients underwent laparotomy to implant the catheter into the hepatic artery, the other 27 patients receiving a percutaneous catheter into the hepatic artery through a transaxillary access. Five patients (9.2%) developed biliary toxicity with jaundice and cholangitis (3 cases), alterations of liver function tests and radiological features of biliary tract abnormalities. They received from 9 to 19 cycles (mean 14.5 +/- 6.3 cycles) of floxuridine infusion with a total drug delivered dose ranging from 20.3 to 41.02 mg/kg (mean: 31.4 +/- 13.5 mg/kg). Extrahepatic biliary sclerosis was discovered by computed tomography scan and ultrasound, followed by endoscopic retrograde cholangiopancreatography and/or percutaneous cholangiography in 3 cases. Radiological findings included common hepatic duct complete obstruction in 1 case, common hepatic duct stenosis in 2 cases, common bile duct obstruction in 1 case, and intrahepatic bile ducts dilation without a well-recognized obstruction in 1 case. Two patients were treated by sequentially percutaneous biliary drainage and balloon dilation while 1 patient had an endoscopic transpapillary biliary prosthesis placed. Percutaneous or endoscopic procedures obtained the improvement of hepatic function and cholestatic indexes without subsequent jaundice or cholangitis. In two patients suppression of floxuridine infusion allowed the improvement of hepatic function. The present series suggests that in some patients receiving hepatic arterial infusion of floxuridine extrahepatic biliary stenosis may represent the primary event leading to a secondary intrahepatic biliary damage that does not correlate with specific floxuridine toxicity but results from bile stasis and infection, recurrent cholangitis and eventually biliary sclerosis. Aggressive research for extrahepatic biliary sclerosis is advised, since an early nonsurgical treatment of extrahepatic biliary stenosis may prevent an irreversible intrahepatic biliary sclerosis worsening the prognosis of metastatic liver disease.     

Role of percutaneous transhepatic biliary drainage in patients with obstructive jaundice caused by local recurrence of gastric cancer

BACKGROUND/AIMS: We reviewed the medical records of patients with obstructive jaundice caused by the local recurrence of gastric cancer to clarify the role of percutaneous transhepatic biliary drainage (PTBD). METHODOLOGY: Eleven patients with a mean age of 60.1 years (range: 51-71 years) underwent PTBD because of obstructive jaundice caused by the extrahepatic recurrence of gastric cancer. RESULTS: Jaundice was relieved in all the patients, and the serum total bilirubin (T-bil) level decreased from 12.2 to 2.1 mg/dL. No major complications associated with the execution of PTBD occurred. Although various symptoms caused by jaundice, such as anorexia, itching, nausea, abdominal pain, and fever, were relieved in all the patients within one week after PTBD, general fatigue persisted in 3 patients and abdominal fullness persisted in one. Seven of the 11 patients were discharged from the hospital after the execution of PTBD and remained at home for a median of 93 days. The median survival time (MST) of the remaining 4 patients who could not be discharged was 48 days. Chemotherapy was added in 5 patients after the execution of PTBD; these patients exhibited a significantly longer MST of 247 days, compared to 62 days among the patients who did not receive chemotherapy (P=0.0176). CONCLUSIONS: PTBD was safely conducted and improved the quality-of-life of patients with obstructive jaundice caused by the local recurrence of gastric cancer. Furthermore, the use of chemotherapy after PTBD might prolong patient survival although RCT (randomized controlled trial) study should be performed to assess the precise effect of chemotherapy after PTBD.     

内镜下金属支架引流术治疗肝门部胆管癌和肝外恶性胆道梗阻临床观察

临床上恶性胆道梗阻性疾病预后较差。对于不能手术切除者,通常选择内镜下置人胆道支架以解除梗阻,然而该技术对进展期肝门部肿瘤的疗效报道不一。目的：探讨内镜下金属支架引流术对肝门部胆管癌和肝外恶性胆道梗阻的疗效和并发症发生情况。方法：纳入上海交通大学附属第一人民医院2006年6月～2009年6月收治的82例接受ERCP下置入自膨式金属胆道支架引流治疗的恶性胆道狭窄患者,根据病变部位分为肝门部胆管癌组和肝外恶性胆道梗阻组,对其ERCP参数和术后6个月随访记录进行回顾性分析,并分析随访期间急性胆管炎发生的危险因素。结果：两组支架置入成功率均为100％。与肝外恶性胆道梗阻组相比,肝门部胆管癌组术后1周总胆红素降低显效率较低,术后6个月内急性胆管炎发生率增高,初次发生时间提前,支架再狭窄率增高（P=0．000）。ERCP术中括约肌切开为随访期间发生急性胆管炎的危险因素（P=0．004,OR：8．196）。结论：内镜下金属支架引流术对肝门部胆管癌的疗效不及肝外恶性胆道梗阻,且更易早期发生急性胆管炎和支架再狭窄,术中括约肌切开可增加术后急性胆管炎的发生风险。     

Clinical outcomes of biliary drainage of malignant biliary obstruction due to colorectal cancer metastases: A systematic review

Background and aimsMalignant biliary obstruction is an ominous complication of metastatic colorectal cancer (mCRC). Biliary drainage is frequently performed to relieve symptoms of jaundice or enable palliative systemic therapy, but effective drainage can be difficult to accomplish. The aim of this study is to summarize literature on clinical outcomes of biliary drainage in mCRC patients with malignant biliary obstruction.MethodsWe searched Medline and EMBASE for studies that included patients with malignant biliary obstruction secondary to mCRC, treated with endoscopic and/or percutaneous biliary drainage. We summarized available data on technical success, clinical success, adverse events, systemic therapy administration and survival after biliary drainage.ResultsAfter screening 3584 references and assessing 509 full-text articles, seven cohort studies were included. In these studies, rates of technical success, clinical success and adverse events varied between 63%-94%, 42%-81%, and 19%-39%, respectively. Subsequent chemotherapy was administered in 17%-56% of patients. Overall survival varied between 40 and 122 days across studies (278-365 days in patients who received subsequent chemotherapy, 42-61 days in patients who did not).ConclusionsSuccessful biliary drainage in mCRC patients can be challenging to achieve and is frequently associated with adverse events. Overall survival after biliary drainage is limited, but is significantly longer in patients treated with subsequent systemic therapy. Expected benefits of biliary drainage should be carefully weighed against its risks.     

Neutrophil chemotaxis in bile duct-obstructed rats,and effect of internal biliary drainage

BACKGROUND/AIMS: Our previous studies demonstrated enhanced neutrophil chemotaxis in bile duct-ligated, obstructive jaundice rats. In the present study, we produced a reversible obstructive jaundice model in rats. The efficacy of the present model in producing sufficient bile flow blockade and subsequent internal biliary drainage was assessed. Furthermore, the effect of internal biliary drainage on neutrophil chemotaxis was evaluated. METHODOLOGY: Bile duct was obstructed with a polyester tape attached with a stainless steel coil. Internal biliary drainage was performed by removing the tape. Rats were subjected to either 10 days' bile duct obstruction or 4 days' bile duct obstruction followed by 6 days' internal biliary drainage. Some animals underwent conventional bile duct ligation and dissection for 4 or 10 days. Neutrophil chemotaxis was evaluated with a modified Boyden method using interleukin-8 (recombinant rat Gro-beta) as chemoattractant. RESULTS: The present technique produced sufficient obstructive jaundice as evidenced by increases in serum alanine aminotransferase and total bilirubin throughout the observation period, the values of which were insignificant with those induced by the conventional method. Internal biliary drainage effectively normalized these values. Similarly, neutrophil chemotaxis was enhanced with both procedures, and increased neutrophil chemotaxis was significantly decreased after drainage. CONCLUSIONS: The present reversible obstructive jaundice method is as efficacious as the conventional method for producing obstructive jaundice, and internal biliary drainage could be readily available. With the present model, neutrophil overactivity in obstructive jaundice was effectively alleviated by internal biliary drainage. The result may support the role of preoperative biliary drainage in the prevention of postoperative septic complications.     

Human neutrophil functions in obstructive jaundice

BACKGROUND/AIMS: The effect of obstructive jaundice on neutrophil function has not been extensively studied. Therefore, the present study aimed at evaluating the effect of obstructive jaundice on human neutrophils. METHODOLOGY: Twelve patients with obstructive jaundice due to common bile duct obstruction underwent endoscopic biliary drainage. Neutrophil functions (chemotaxis and superoxide anion generation) were evaluated before and 7 days after drainage. RESULTS: Neutrophil chemotaxis in response to FMLP (formyl-methionyl-leucyl-phenylalanine) or interleukin-8 was abnormally increased before drainage, and was normalized after drainage. Similarly, enhanced superoxide anion generation in response to FMLP or phorbol myristate acetate before drainage was alleviated after drainage. CONCLUSIONS: The results suggest neutrophil overactivity in patients with obstructive jaundice. The ameliorating effect of biliary drainage on neutrophil overactivity might play a role in the prevention of postoperative complications.     

Vascular reconstruction of the hepatic artery using the gastroepiploic artery: a case report.

A 59 year-old woman with obstructive jaundice secondary to proximal bile duct carcinoma underwent percutaneous transhepatic biliary drainage (PTDB). This revealed complete obstruction of the bifurcation of the hilar hepatic duct and encasement of the right hepatic artery. Wedged hilar hepatectomy with combined resection of the extrahepatic bile duct, gallbladder, and the encased right hepatic artery was performed. The hepatic artery was reconstructed using an in situ right gastroepiploic artery (GEA) pedicle graft. The anastomosis was protected with fatty tissue from the greater omentum. This technique can be used to reconstruct the hepatic artery after radical surgery for malignant hepatobiliary and pancreatic disease.     

Treatment of benign biliary strictures in chronic pancreatitis by self-expandable metal stents

AIM: To determine the efficacy the value of self-expandable metal stents in patients with benign biliary strictures caused by chronic pancreatitis. METHOD: 61 patients with symptomatic common bile duct strictures caused by alcoholic chronic pancreatitis were treated by interventional endoscopy. RESULTS: Initial endoscopic drainage was successful in all cases, with complete resolution of obstructive jaundice. Of 45 patients who needed definitive therapy after a 12-months interval of interventional endoscopy, 12 patients were treated with repeated plastic stent insertion (19.7%) or by surgery (n = 30; 49.2%). In 3 patients a self-expandable metal stent was inserted into the common bile duct (4.9%). In patients treated with metal stents, no symptoms of biliary obstruction occurred during a mean follow-up period of 37 (range 18-53) months. The long-term success rate of treatment with metal stents was 100%. CONCLUSIONS: Endoscopic drainage of biliary obstruction by self-expandable metal stents provides excellent long-term results. To identify patients who benefit most from self-expandable metal stent insertion, further, prospective randomized studies are necessary.     

Biliary Tract Obstruction Secondary to Malignant Lymphoma: Experience at a Referral Center

Lymphoma is a rare cause of biliary obstruction and, on cholangiography, may mimic other causes of obstructive jaundice. The optimum treatment for these patients is unclear. The aim of this study is to evaluate the incidence, clinical and imaging findings, management, and outcome of biliary obstruction caused by lymphoma. Our database was searched retrospectively for patients with biliary obstruction due to lymphoma between 1999 and 2005. Biliary obstruction secondary to lymphoma was found in 7 (0.6%) of 1123 patients with malignant biliary obstruction. One patient had benign biliary obstruction related to lymphoma. Of the eight patients (five male, three female; mean age, 34.50 ± 17.93 years), four had Hodgkin’s disease and four had non-Hodgkin’s lymphoma. Biliary obstruction occurred as part of the initial or early presentation of lymphoma in two patients. The most common cause of obstruction was compression of the biliary tract by enlarged lymph nodes (six patients). Cholangiographic appearances were diverse: narrowing of the common bile duct (six patients), splayed and narrowed common bile duct (one patient), and multiple strictures and dilatations of the intrahepatic bile ducts (one patient). Biliary drainage was performed in all patients including endoscopic stent placement in six patients, nasobiliary drainage in one, and choledochoduodenostomy in one. Hyperbilirubinemia resolved in all but one of the patients with a stent; however, none could be maintained in a stent-free condition. Five patients died within 1 year after onset of jaundice. One of the surviving patients developed a late benign stricture at the site of the earlier lymphoma. We conclude that lymphoma should be considered in the differential diagnosis of obstructive jaundice, particularly in younger patients. We suggest that biliary drainage by the endoscopic or percutaneous route is necessary for the treatment of these patients. Late benign strictures may develop. Biliary obstruction is a sign of poor prognosis in lymphoma.     

EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: Report of 6 cases

BACKGROUND: Only a few cases have been reported of EUS-guided drainage of obstructed pancreatic or bile ducts. An initial experience with EUS-guided rendezvous drainage after unsuccessful ERCP is reported. METHODS: EUS-guided transgastric or transduodenal needle puncture and guidewire placement through obstructed pancreatic (n=4) or bile (n=2) ducts was attempted in 6 patients. Efforts were made to advance the guidewire antegrade across the papilla or surgical anastomosis. If guidewire passage was successful, rendezvous ERCP with stent placement was performed immediately afterward. RESULTS: EUS-guided duct access and intraductal guidewire placement was accomplished in 5 of 6 cases, with successful traversal of the obstruction, and rendezvous ERCP, with stent placement in 3 of 6 cases (two biliary, one pancreatic). The procedure was clinically effective in all successful cases (two patients with malignant obstructive jaundice, one with relapsing pancreatitis after pancreaticoduodenectomy). There was one minor complication (transient fever) but no pancreatitis or duct leak after successful or unsuccessful procedures. CONCLUSIONS: EUS is a feasible technique for allowing rendezvous drainage of obstructed biliary or pancreatic ducts through native papillae or anastomoses after initially unsuccessful ERCP.