WHICH TYPES OF DRAINAGE TUBE SHOULD WE SELECT FOR ENDOSCOPIC BILIARY DRAINAGE? CURRENT STATUS

Biliary drainage is a standard procedure for cholangitis or obstructive jaundice due to biliary obstruction. However, criterion for the selection of types of drainage tube is not established. The authors analyzed the types of drainage tube used in the University of Tokyo, Tokyo, Japan, during the month of June 2005, and they treated 63 cases. For drainage for cholangitis (31), the authors used endoscopic naso‐biliary drainage (ENBD) tube in 74.1% and plastic stent in 25.9%. In contrast, for the cholestesis cases (16), the authors used ENBD tube in 37.5% and plastic stent in 63.5%. For the unresectable biliary malignancy cases (8) with improved jaundice, the authors used covered metallic stent in seven distally stricture cases and uncovered metallic stent in one proximally stricture case. The remaining eight cases received plastic stent placement. There were six cases of residual common bile duct stones and two cases of prevention of cholangitis after papillectomy. For the patients with unresectable biliary malignancies at distal portion, the authors consider that covered metallic stent is a standard endoprosthesis. For drainage for cholangitis, the authors used ENBD tube because bile juice flow is able to be checked any time. However, the authors used plastic stent rather than ENBD tube for the drainage of cholestesis. A larger study for selection of drainage tube for these aspects is needed in the future.     

经内镜胆管内引流治疗恶性胆道梗阻的探讨

为缓解胆道梗阻，对２８例恶性胆道梗阻（ＭＢＯ）患者行经内镜胆管内引流术（ＥＢＤ）。结果２５例（８９％）插管成功，共插管４４次，７Ｆ管３次，１０Ｆ２５次，１２Ｆ１６次。２３例（９２％）减黄有效，ＥＢＤ后第３天胆红素平均下降４６．３％，肝外胆管径平均回缩５８．６％，减黄有效者腹胀迅速消失或减轻。首次插管维持有效引流时间１４１．５±１５１．２天，早、中期并发胆管炎４０％，１年以上生存１７％。结果表明ＥＢＤ减黄效果和症状改善是显著的，胆红素下降与胆管径回缩相平行。认为胆管是否屈曲及乳头括约肌切开术的好坏是ＥＢＤ成败的关键；腹胀再现，有胆道感染症状及Ｂ超见肝外胆管扩张为通管的指征。ＥＢＤ适合高龄或高危人群的ＭＢＯ患者，对延长生存期有重要的价值。     

Clinical signiifcance of isolated biliary candi-diasis in patients with unresectable cholangio-carcinoma

BACKGROUND: The frequency of isolated biliary candidiasis is increasing in cancer patients. The clinical signiifcance of isolated biliary candidiasis remains unclear. We analyzed the risk factors of biliary candidiasis and outcomes of the patients with unresectable cholangiocarcinoma after percutaneous transhepatic biliary drainage (PTBD).
METHODS: Among 430 patients who underwent PTBD between January 2012 and March 2015, 121 patients had unresectable cholangiocarcinoma. Bile and blood samples were collected for consecutive fungal culture.
RESULTS: The study cohort included 49 women and 72 men with a median age of 71 years. Multivariate analysis showed that cancer progression (P=0.013), concurrent presence of another microorganism (P=0.010), and previous long-term (>7 days) antibiotic use (P=0.011) were potential risk factors of biliary candidiasis. Chemotherapy was not associated with overall biliary candidiasis (P=0.196), but was signiifcantly related to repeated biliary candidiasis (P=0.011). Patients with isolated biliary candidiasis showed remarkably reduced survival compared with those without [median overall sur-vival (OS): 32 vs 62 days,P=0.011]. Subgroup analysis was also performed. Patients with repeated candidiasis had markedly decreased survival compared with those with transient candi-diasis (median OS: 30 vs 49 days,P=0.046). Biliary candidiasis was identiifed as a poor prognostic factor by univariate and multivariate analyses (P=0.033). Four cases of repeated can-didiasis (4/19, 21%) showedCandida species in consecutive blood culture until the end of the study, but others showed no candidemia.
CONCLUSIONS: Isolated biliary candidiasis may be associ-ated with poor prognosis in patients with unresectable chol-angiocarcinoma. Especially, repeated biliary candidiasis may have the possibility of progression to candidemia. We suggest that biliary dilatation treatment or antifungal agents might be helpful for patients with biliary candidiasis.     

Endoscopic Biliary Drainage for Acute Obstructive Cholangitis: Analysis of 100 Consecutive Patients

Abstract: Acute obstructive suppurative cholangitis is a life-threatening condition and prompt biliary decompression is essential if the patient is to survive. One hundred patients with acute obstructive (suppurative) cholangitis were treated by simple endoscopic cannulation for biliary drainage. Forty-eight patients had common duct stones alone, 33 patients had additional stones in the gallbladder, and 18 patients had stones in the intrahepatic ducts. Another patient had a confluence stone. Twenty-six patients had undergone endoscopic sphincterotomy. Bile duct dilatation was present in only 25 of 47 patients (53%) studied by ultrasound tomography. Biliary decompression was achieved in 98 patients. One tortuous distal bile duct and one oversized stone were the causes of failure in two patients. Forty-seven patients proved to have suppurative cholangitis. Most patients felt instant and dramatic relief of their syniptoms. Bleeding at sphinctetomy was the only complication associated with the decompression ocurring in 2 patients. Bending (2 patients) and withdrawal (2 patients) of a nasobiliary catheter, and nasal bleeding (1 patient) were the complications related to nasobiliary drainage. Two patients with suppurative cholangitis died despite successful decompression performed 3 and 5 days after the onset of cholangitis. This delay seemed responsible for their deaths. Thus the mortality rate was 2.0% for all the patients arid 4.3% for those with suppurative cholangitis. These results suggest that endoscopic cannulation, which is feasible even in the absence of bile duct dilatation, is a prompt, safe, and effective procedure for emergency biliary decompression for the treatment of acute obstructive (suppurative) cholangitis.     

Technical aspects of biliary reconstruction in adult living donor liver transplantation

BACKGROUND: The last decade has witnessed great progress in living donor liver transplantation worldwide. However, biliary complications are more common in partial liver transplantation than in whole liver transplantation. This is due to an impaired blood supply of the hilar bile duct during organ procurement and recipient surgery, commonly encountered anatomical variations, a relatively small graft duct, and complicated surgical techniques used in biliary reconstruction. DATA SOURCES: MEDLINE and PubMed we...     

经内镜胆管内引流治疗恶性胆道梗阻的探讨

为缓解胆道梗阻，对２８例恶性胆道梗阻（ＭＢＯ）患者行经内镜胆管内引流术（ＥＢＤ）。结果２５例（８９％）插管成功，共插管４４次，７Ｆ管３次，１０Ｆ２５次，１２Ｆ１６次。２３例（９２％）减黄有效，ＥＢＤ后第３天胆红素平均下降４６．３％，肝外胆管径平均回缩５８．６％，减黄有效者腹胀迅速消失或减轻。首次插管维持有效引流时间１４１．５±１５１．２天，早、中期并发胆管炎４０％，１年以上生存１７％。结果表明ＥＢＤ减黄效果和症状改善是显著的，胆红素下降与胆管径回缩相平行。认为胆管是否屈曲及乳头括约肌切开术的好坏是ＥＢＤ成败的关键；腹胀再现，有胆道感染症状及Ｂ超见肝外胆管扩张为通管的指征。ＥＢＤ适合高龄或高危人群的ＭＢＯ患者，对延长生存期有重要的价值。     

ENDOSCOPIC STENT DRAINAGE FOR MALIGNANT BILIARY OBSTRUCTION: THE KOREAN EXPERIENCE

Endoscopic biliary drainage (EBD) is the treatment of choice for biliary obstruction caused by unresectable pancreaticobiliary malignancies. Clogging is an unsolved problem of the plastic stent. A self‐expanding metal stent (SEMS) was developed to overcome this limitation. Total resource utilization was reported to be lower with SEMS compared with plastic stents in the West. However, in Korea, the average total cost is estimated to be higher in the metal stent group. The use of SEMS should be indicated if the survival is expected to be more than 3 months. Covered SEMS was introduced to overcome the problem of tumor ingrowth into the uncovered stent. Patency rates for covered SEMS tended to be greater than uncovered SEMS, but the complication rate in covered SEMS was higher than uncovered SEMS due to migration, occlusion of the cystic duct, of a contralateral hepatic duct, or of pancreatic duct. Stents without clogging or migration, with antitumor or biodegradable properties are being investigated. For unresectable hilar cholangiocarcinoma (HC) of Bismuth type III or IV, unilateral percutaneous transhepatic biliary drainage (PTBD) and subsequent internal stent causes less cholangitis and longer patency than EBD or PTBD alone. However, the result with EBD is good if the Bismuth type of biliary obstruction is I or II. Photodynamic therapy may improve survival of patients with unresectable cholangiocarcinoma. Preoperative biliary drainage is not usually necessary except for HC. Procedure‐related complication and inflammation of the operative field resulting from endoscopic nasobiliary drainage or endoscopic retrograde biliary drainage are expected to cause surgical difficulties and to affect postoperative complications.     

ROLE OF ENDOSCOPIC NASOBILIARY DRAINAGE INDICATION AND BASIC TECHNIQUE

Endoscopic nasobiliary drainage (ENBD) plays an important role in the treatment of patients with obstructive jaundice. Nowadays, ENBD is widely performed for not only biliary drainage, but also for gallbladder, pancreatic duct, and pancreatic cyst drainage. Herein is presented the indications for ENBD and its technique.     

Biliary cystadenocarcinoma followed up as benign cystadenoma for 10 years

We describe a case of biliary cystadenocarcinoma that showed a longterm clinical course. A 69-year-old Japanese man was admitted to our hospital because of abdominal discomfort. The patient had been diagnosed with benign cystadenoma of the liver at another hospital in 1987 and had been followed up for 10 years. Abdominal ultrasonography (US) and computed tomography (CT) scan demonstrated a unilocular cystic lesion, which included multiple conspicuous papillary protrusions in the left hepatic lobe. Left lateral segmentectomy was performed, and intraoperative cholangiography revealed a communication between the cystic tumor and intrahepatic bile duct. The tumor contained clear mucinous fluid and enfolded multiple yellowish papillary projections on the cystic wall. Histological examination showed the tumor to be biliary cystadenocarcinoma. The patient is doing well 4 years after the operation.     

A Case of Biliary Cystadenocarcinoma Followed up for Five Years

We report on a case of an 80-year-old male with autopsy-confirmed biliary cystadenocarcinoma. The tumor's growth was followed up for five years. CT findings on first admission revealed that the cyst walls of the tumor were smooth. However, a CT taken four years later showed large cysts with irregular walls which were growing invasively and expanding beyond the liver. The patient died of liver dysfunction caused by obstructive jaundice due to the liver tumor, and an autopsy was performed. Histologic examination of the autopsy material revealed a multilocular tumor that was identified as being a biliary cystadenocarcinoma and microscopic lung metastases were seen. The character of the multilocular cyst with septations covered by papillary proliferation of atypical columnar epithelium and many remaining portions with low grade dysplasia led us to suspect the tumor was derived from a cystadenoma.     

Biliary disease after liver transplantation: the experience of the King Faisal Specialist Hospital and Research Center, Riyadh

BACKGROUND AND AIM: The biliary tract has been referred to as the "Achilles heel" of liver transplantation. The aim of this study was to document the frequency, clinical presentation and management of biliary complications after liver transplantation in the King Faisal Specialist Hospital and Research Center (KFSH&RC), Riyadh, Saudi Arabia. METHODS: The liver transplant clinic at KFSH&RC has registered and followed 220 patients (150 male and 70 female patients; age 40.6 +/- 18.6 years; pediatric 33, adult 187) during the period from 1987 to June 2003. A total of 235 transplants were carried out on these patients. Cadaveric liver transplants had been carried out on 202 patients, non-heart beating liver transplant in three patients, live donor liver transplants in 11 and split transplant in four. Biliary reconstruction was duct-to-duct anastomosis in 147 patients and Roux-en-Y in 73. Biliary complications were suspected on clinical and biochemical parameters and confirmed using imaging techniques. RESULTS: Forty patients (18.2%) developed 53 biliary complications. These included bile leak in 16, strictures in 25, calculi in eight, and sphincter of Oddi dysfunction and possible recurrence of primary sclerosing cholangitis in the donor duct in two patients each. Bile leaks were observed in the early postoperative period (median period 30 days, range 1-150 days, 95% confidence interval [CI] 8-51). Leakage occurred at the anastomotic site in 13 patients. Patients presented with bilious drainage (n = 6), abdominal pain at T-tube removal (n = 3), fever (n = 2), sepsis (n = 1), dyspnea (n = 1) and abnormal liver tests (n = 3). Eleven patients had intra-abdominal bilious collections. Two patients were treated conservatively, eight patients had ultrasound-guided aspiration of biloma, five had biliary stenting at endoscopic retrograde cholangiopancreatography and two patients needed surgery. There were four deaths, two of which were related to bile leak, one patient was left with permanent external biliary drainage and four patients had biliary strictures in the follow-up period. Biliary strictures occurred at a median period of 360 days (range 4-2900 days; 95% CI 50-670) after the transplant. Hepatic artery thrombosis caused biliary strictures in three, while 21 strictures were localized to the anastomotic site. Biliary strictures presented with elevated liver tests in five patients, progressive cholestasis in five, cholangitis (with septicemia in five) in 11, abdominal pain in two and acute pancreatitis in three patients. Repeat sessions of endoscopic or percutaneous dilatation and stenting (mean sessions 4.4/patient, range 3-7) were attempted in 20 patients to relieve strictures, with success in only nine patients. Seven patients had surgery. Four patients with biliary strictures died. Biliary calculi developed late in the follow-up period and had the appearance of biliary casts in five and sludge in three patients. Eleven (27.5%) patients with biliary disease died compared with 35 (19.4%) patients without biliary disease. CONCLUSIONS: Biliary complications occurred in 18.2% of patients after liver transplantation and included biliary leak and biliary strictures with or without calculi. Management involved a combination of endoscopic, radiologic and operative procedures. Biliary complications caused considerable morbidity and mortality in liver transplant patients.     

MALIGNANT BILIARY OBSTRUCTION: A COMPARISON OF COST FOR A USE OF METAL OR PLASTIC STENT FOR PALLIATION IN JAPANESE HEALTH CARE SYSTEM

Endoscopic treatment with endoprosthesis for obstructive jaundice is a well‐accepted method for palliation of obstructive jaundice and its associated symptoms. Yet, there is no consensus whether a plastic stent or metal stent to be used. The longer patency period with metal stent is a definite advantage but its high cost limits its routine use. The best use of metal stent is accomplished with consideration of patients’ predicted prognosis and a medical cost in Japan. We used a simulated case scenario to calculate a cost for metal stent and non‐metallic stent. Metal stent use would cost about 437 000 yen per patient at 6 months compared with 276 000–329 000 for non‐metallic stents, and thus metal stent use appears to be more costly in current Japanese medical system. Longer patency rate with covered metal stent would make metal stent more favorable, and less frequent procedure would be beneficial for patients who are at their terminal stage of diseases. Alternatively, many patients would not need stent replacement after first biliary stent placement due to the nature of underlying diseases. In addition to a development of an ideal stent and an appropriate technique, our research should also aim at determining who would benefit most for each stent in our own practice, preferably in prospective randomized trial.     

Biliary Cystadenoma of the Common Bile Duct with Secondary Biliary Cirrhosis

Abstract A case of cystadenoma of the common bile duct is described. An erroneous diagnosis made in a young woman caused secondary biliary cirrhosis with fatal outcome. The diagnosis of cirrhosis should never be established without thorough visualization of the entire biliary tract in patients with biochemical or clinical jaundice of unknown origin.     

Endoscopic ultrasound-guided choledochoduodenostomy for treatment of ampullary cancer

We describe the case of a patient for whom choledochoduodenostomy was performed under endoscopic ultrasound (EUS) guidance as an alternative to percutaneous transhepatic biliary drainage (PTBD) for the treatment of obstructive jaundice. An 82-year-old man with ampullary cancer was considered operable, but he refused surgery. Endoscopic biliary drainage (EBD) with an 8.5-French plastic stent was performed 2 months later because of the development of obstructive jaundice. The EBD stent was occluded 5 months after the stent insertion, and EUS choledochoduodenostomy (EUS-CDS) was performed. Pneumoperitoneum occurred 1 day after the procedure, which resolved with conservative treatment. Six months later, multiple lymph node metastases occurred, and the patient was effectively treated by chemotherapy (S-1). The patient is still alive with a good quality of life more than 2 years after EUS-CDS. We conclude that EUS-CDS is an effective alternative to PTBD or EBD for patients with malignant biliary obstruction, especially due to ampullary cancer.     

CASE REPORT: Two cases of biliary papillomatosis with unusual associations

Papillomatosis arising from the biliary tree is a well recognized but rare entity. We encountered two patients with this condition. However, one of them had associated hepatocellular carcinoma and cirrhosis and the other had concomitant recurrent pyogenic cholangitis. To our knowledge, these associations have not been reported before. We, therefore, present these clinical problems and highlight the added difficulty in the management of these patients.     

UNILATERAL VERSUS BILATERAL DRAINAGE USING SELF‐EXPANDABLE METALLIC STENT FOR UNRESECTABLE HILAR BILIARY OBSTRUCTION

Background: There is no consensus on the choice of either unilateral or bilateral drainage in stent placement for patients with unresectable hilar biliary obstruction. The aim of the present study was to clarify which drainage method is superior. Methods: We retrospectively reviewed 82 patients with hilar biliary obstruction who underwent metallic stenting. These patients were divided into a unilateral drainage group (Uni group) and a bilateral drainage group (Bi group). Results: There was no significant difference between the groups in median survival time, median stent patency period, and median complication‐free survival time. The most frequent complication was stent obstruction, followed by cholangitis. Liver abscess was found at a higher frequency in the Bi group (17.6%) than in the Uni group (1.5%) (P = 0.0266). There was no significant difference between the groups in the occurrence of two or more complications (P = 0.247), life‐threatening severe complications (P = 0.0577), and stent obstruction by sludge (P = 0.0912). Conclusion: When compared with bilateral biliary drainage, unilateral biliary drainage is associated with a lower incidence of liver abscess as well as a comparable outcome of stent patency time and complication‐free survival. We therefore propose that hilar biliary obstruction can be treated first by unilateral drainage with a metallic stent and by bilateral drainage only in patients who develop cholangitis in the contralateral biliary tree.     

Preoperative biliary drainage for hilar cholangiocarcinoma

Hilar cholangiocarcinomas grow slowly, and metastases occur late in the natural history. Surgical cure and long-term survival have been demonstrated, when resection margins are clear. Preoperative biliary drainage has been proposed as a way to improve liver function before surgery, and to reduce post-surgical complications. Percutaneous transhepatic biliary drainage (PTBD) with multiple drains was previously the preferred method for the preoperative relief of obstructive jaundice. However, the introduction of percutaneous transhepatic portal vein embolization (PTPE) and wider resection has changed preoperative drainage strategies. Drainage is currently performed only for liver lobes that will remain after resection, and for areas of segmental cholangitis. Endoscopic biliary drainage (EBD) is less invasive than PTBD. Among EBD techniques, endoscopic nasobiliary drainage (ENBD) is preferable to endoscopic biliary stenting (EBS), because secondary cholangitis (due to the retrograde flow of duodenal fluid into the biliary tree) does not occur. ENBD needs to be converted to PTBD in patients with segmental cholangitis, those with a prolonged need for drainage, or when the extent of longitudinal tumor extension is not sufficiently well characterized.     

Novel biliary self-expanding metal stents: indications and applications

Endoscopic insertion of a self-expanding metal stent (SEMS) through a malignant common bile duct stricture is the first line of palliation for malignant jaundice. Patency of these stents remains a major concern. SEMS dysfunction can result from tumor ingrowth, overgrowth and/or clogging. Initial SEMS modifications involved covering the central part of the stent in order to reduce ingrowth and ultimately increase patency. Fully covered stents became available shortly after reports of their use in human patients. The potential removability and radial strength of SEMS have led to evaluation of their use in new indications including benign biliary strictures, post sphincterotomy bleeding and perforation. Other aspects of development include the addition of features such as anti-reflux valves, drug elution and spontaneous biodegradability. These aspects and their clinical implications are reviewed and discussed.