Lower incidence of complications in endoscopic nasobiliary drainage for hilar cholangiocarcinoma

AIM: To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma. METHODS: In total, 118 patients with hilar cholangiocarcinoma underwent endoscopic management [endoscopic nasobiliary drainage (ENBD) or endoscopic biliary stenting] as a temporary drainage in our institution between 2009 and 2014. We retrospectively evaluated all complications from initial endoscopic drainage to surgery or palliative treatment. The risk factors for biliary reintervention, post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis, and percutaneous transhepatic biliary drainage (PTBD) were also analyzed using patient- and procedure-related characteristics. The risk factors for bilateral drainage were examined in a subgroup analysis of patients who underwent initial unilateral drainage. RESULTS: In total, 137 complications were observed in 92 (78%) patients. Biliary reintervention was required in 83 (70%) patients. ENBD was significantly associated with a low risk of biliary reintervention [odds ratio (OR) = 0.26, 95%CI: 0.08-0.76, P = 0.012]. Post-ERCP pancreatitis was observed in 19 (16%) patients. An absence of endoscopic sphincterotomy was significantly associated with post-ERCP pancreatitis (OR = 3.46, 95%CI: 1.19-10.87, P = 0.023). PTBD was required in 16 (14%) patients, and Bismuth type III or IV cholangiocarcinoma was a significant risk factor (OR = 7.88, 95%CI: 1.33-155.0, P = 0.010). Of 102 patients with initial unilateral drainage, 49 (48%) required bilateral drainage. Endoscopic sphincterotomy (OR = 3.24, 95%CI: 1.27-8.78, P = 0.004) and Bismuth II, III, or IV cholangiocarcinoma (OR = 34.69, 95%CI: 4.88-736.7, P < 0.001) were significant risk factors for bilateral drainage. CONCLUSION: The endoscopic management of hilar cholangiocarcinoma is challenging. ENBD should be selected as a temporary drainage method because of its low risk of complications.     

Endoscopic ultrasound-guided biliary drainage:Bilateral systems drainage via left duct approach

Endoscopic ultrasound(EUS)-guided biliary drainage is accepted as a less invasive,alternative treatment for patients in whom endoscopic retrograde cholangiopancreatography has failed. Most patients with malignant hilar obstruction undergo EUSguided hepaticogastrostomy. The authors present the case of a 77-year-old man with advanced hilar cholangiocarcinoma who had undergone a rouxen-Y hepaticojejunostomy several months prior. He developed progressive jaundice and a low-grade fever that persisted for one week. The enteroscopic-assisted endoscopic retrograde cholangiopancreatography failed,thus the patient was scheduled for EUS-guided biliary drainage. In order to obtain adequate drainage,both intrahepatic systems were drained. This report describes the technique used for bilateral drainage via a transgastric approach. Currently,only a few different techniques for EUS-guided right system drainage have been reported in the literature. This case demonstrates that bilateral EUS-guided biliary drainage is feasible and effective in patients with hilar cholangiocarcinoma,and thus can be used as an alternative to percutaneous biliary drainage.     

Early repeat endoscopic retrograde cholangiopancreatography: Predictive factors and interventions required

Background/aims: Early repeat endoscopic retrograde cholangiopancreatography may be required due to various conditions in patients who underwent planned endoscopic retrograde cholangiopancreatography. We aimed to assess the factors leading to early repeat endoscopic retrograde cholangiopancreatography and to determine the patients who need closer follow-up. Materials and Methods: A total of 691 patients with a mean age of 60.3±16.4 years who had naive papilla on endoscopic retrograde cholangiopancreatography were involved in the study. The patients who required repeat endoscopic retrograde cholangiopancreatography were identified. Presentations, predictive factors, treatment modalities, and outcomes of the patients were investigated. Results: Early repeat endoscopic retrograde cholangiopancreatography was needed in 19 (2.7%) patients. The most common presentation was cholangitis in 10 (52.6%) and unresolved jaundice in 4 (21.1%). Multivariate analysis identified biliary stricture (p=0.024), stricture at the hilus (p=0.005) and unilateral drainage in the presence of hilar stricture (p=0.017) as the independent risk factors for early repeat endoscopic retrograde cholangiopancreatography. Stent migration or dysfunction was the most common underlying cause. Therapeutic interventions were nasobiliary drainage in 13, stent exchange in 4 and stone removal in 2. Additionally, percutaneous drainage in 4 patients, drainage of abscess in 2 patients and percutaneous drainage of gallbladder in 1 patient were performed. Three patients died due to their underlying illness. Conclusions: Unilateral stenting especially in hilar strictures is a predictive factor for early repeat endoscopic retrograde cholangiopancreatography with high mortality. These patients should be under close follow-up.     

Outcome of self-expandable metallic stents in low-grade versus advanced hilar obstruction

Background: Self‐expandable metallic stents (SEMS) are known to provide a longer patency time than plastic stents for malignant biliary obstructions including hilar obstruction. However, studies that focus on the efficacy of SEMS in low‐grade and advanced hilar obstructions are still scanty. Methods: Ninety four patients with malignant hilar obstructions were enrolled (six were later excluded). Patients were divided into two groups according to their Bismuth levels. Group A were patients with Bismuth I (n = 53). Group B were patients with Bismuth II, III and IV (n = 35). Technical success, complications, jaundice resolution, stent patency time, and patients’ survival were analyzed. Results: Our intention‐to‐treat analysis showed that group A had a significant lower rate of post‐endoscopic retrograde cholangiopancreatography (ERCP) cholangitis than group B; 16.1% versus 44.7%, (P < 0.01). Four patients from group B still had persistent jaundice. Our per protocol analysis demonstrated that median stent patency time in groups A and B were not statistically different (74 vs 60 days). Median survival time in groups A and B were also not statistically different (90 vs 75 days). In both groups, those without liver metastasis had significantly better patency and survival time than those with liver metastasis (P = 0.010 and 0.027, respectively). Conclusions: In patients with hilar obstruction, liver metastasis is one of the main factors that determine survival of the patient. Patency times of SEMS in both low‐grade and advanced obstructions are comparable. However, in the advanced group, there is a significant risk of post‐ERCP cholangitis.     

肝门部胆管癌Bismuth分型与经内镜胆道塑料支架引流术后并发症及退黄效果之间的关系

目的:评估肝门部胆管癌Bismuth分型与经内镜胆道塑料支架引流术(ERBD)术后并发症及退黄效果之间的关系.方法:收集已确诊为肝门部胆管癌、且不能或不愿接受外科治疗的,在南昌大学第二附属医院消化科行ERBD的患者.分析各型肝门部胆管癌之间在行ERBD术后胆管炎、胰腺炎、出血发生率以及退黄效果的差异.结果:Bismut...     

Endoscopic ultrasound‐guided biliary drainage of hilar biliary obstruction

Only 20–30% of patients with hilar cholangiocarcinoma (CC) are candidates for potentially curative resection. However, even after curative (R0) resection, these patients have a disease recurrence rate of up to 76%. The prognosis of hilar cholangiocarcinoma (CC) is limited by tumor spread along the biliary tree leading to obstructive jaundice, cholangitis, and liver failure. Therefore, palliative biliary drainage may be a major goal for patients with hilar CC. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is an established method for palliation of patients with malignant biliary obstruction. However, there are patients for whom endoscopic stent placement is not possible because of failed biliary cannulation or tumor infiltration that limits transpapillary access. In this situation, percutaneous transhepatic biliary drainage (PTBD) is an alternative method. However, PTBD has a relatively high rate of complications and is frequently associated with patient discomfort related to external drainage. Endoscopic ultrasound‐guided biliary drainage has therefore been introduced as an alternative to PTBD in cases of biliary obstruction when ERCP is unsuccessful. In this review, the indications, technical tips, outcomes, and the future role of EUS‐guided intrahepatic biliary drainage, such as hepaticogastrostomy or hepaticoduodenostomy, for hilar biliary obstruction will be summarized.     

三种非手术胆管引流方法治疗肝门部恶性胆道梗阻的疗效评估

目的探讨不同非手术胆管引流方法治疗肝门部恶性胆道梗阻（MHBO）的疗效和并发症发生率。方法245例MHBO患者分为3组,其中内镜治疗组86例、经皮治疗组104例、内镜与经皮联合组（联合治疗组）55例。245例患者中,BismuthⅠ型31例、Ⅱ型24例、Ⅲ型108例、Ⅳ型74例。对各组患者的临床资料进行回顾性分析,并对其中具有可比性的数据进行统计学处理。结果内镜治疗组、经皮治疗组和联合治疗组减黄有效率分别为82．4％（56／68,除外18例近期并发胆管炎行PTBD者）、72．1％（75／104）和89．1％（49／55）,其中Bismuth Ⅲ型患者减黄有效率分别为78．6％（22／28,除外7例近期并发胆管炎行PTBD者）、69．8％（30／43）和90．0％（27／30）,且Ⅲ型患者中双侧引流减黄有效率89．5％（34／38）明显优于单侧引流73．0％（46／63）。内镜治疗组近期并发胆管炎19例,发生率为22．1％（19／86）,明显高于经皮治疗组的5．8％（6／104）和联合治疗组的5．5％（3／55）（P均〈0．05）。Bismuth Ⅲ型及以上患者中,内镜、经皮及联合治疗组近期胆管炎发生率分别为33．3％（18／54）、6．6％（5／76）和5．8％（3／52）,内镜治疗组明显高于其他两组（P〈0．05）。结论对于不能手术的MHBO,内镜和（或）经皮方法减黄治疗有效,但内镜治疗胆管炎发生率高;Bismuth Ⅲ型及以上患者内镜与经皮联合治疗胆管炎并发症发生率低,减黄效果好。     

Retrospective cohort study Lower incidence of complications in endoscopic nasobiliary drainage for hilar cholangiocarcinoma

AIM:To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma.METHODS:In total,118 patients with hilar cholangiocarcinoma underwent endoscopic management[endoscopic nasobiliary drainage(ENBD)or endoscopic biliary stenting]as a temporary drainage in our institution between 2009 and 2014.We retrospectively evaluated all complications from initial endoscopic drainage to surgery or palliative treatment.The risk factors for biliary reintervention,post-endoscopic retrograde cholangiopancreatography(post-ERCP)pancreatitis,and percutaneous transhepatic biliary drainage(PTBD)were also analyzed using patient-and procedure-related characteristics.The risk factors for bilateral drainage were examined in a subgroup analysis of patients who underwent initial unilateral drainage.RESULTS:In total,137 complications were observed in92(78%)patients.Biliary reintervention was required in 83(70%)patients.ENBD was significantly associated with a low risk of biliary reintervention[odds ratio(OR)=0.26,95%CI:0.08-0.76,P=0.012].Post-ERCP pancreatitis was observed in 19(16%)patients.An absence of endoscopic sphincterotomy was significantly associated with post-ERCP pancreatitis(OR=3.46,95%CI:1.19-10.87,P=0.023).PTBD was required in 16(14%)patients,and Bismuth type III or IV cholangiocarcinoma was a significant risk factor(OR=7.88,95%CI:1.33-155.0,P=0.010).Of 102 patients with initial unilateral drainage,49(48%)required bilateral drainage.Endoscopic sphincterotomy(OR=3.24,95%CI:1.27-8.78,P=0.004)and Bismuth II,III,or IV cholangiocarcinoma(OR=34.69,95%CI:4.88-736.7,P0.001)were significant risk factors for bilateral drainage.CONCLUSION:The endoscopic management of hilar cholangiocarcinoma is challenging.ENBD should be selected as a temporary drainage method because of its low risk of complications.     

经内镜胆管引流术375例评价

为评价经内镜胆管引流术在梗阻性黄疸、急性化脓性胆管炎等疾病中的应用效果，在１４１６例次逆行性胰胆管造影检查（ＥＲＣＰ）中，发现有胆道梗阻、胆道感染或为预防胆道感染即时行经内镜胆管引流术３７５例。结果成功３６２例，成功率为９６．５％；其中鼻胆管引流（ＥＮＢＤ）２２５例，塑料内支撑管引流（ＥＲＢＤ）９１例，金属支架引流（ＥＭＢＥ）４６例；其疗效满意率分别为９１．６％、９１．２％、９７．８％。早期胆管炎发生率分别为０．９％、５．５％、２．２％。结果提示经内镜胆管引流术是减除梗阻性黄疸、治疗急性化脓性胆管炎、预防ＥＲ－ＣＰ后感染和防止结石嵌顿安全而且有效的方法。     

Combined percutaneous and endoscopic procedures for bile duct obstruction: simultaneous and delayed techniques compared

BACKGROUND/AIMS: In patients with obstructive jaundice, when the endoscopic approach fails to achieve biliary drainage, percutaneous cannulation and combined endoscopic/percutaneous endoprosthesis insertion can be performed simultaneously or in stages. This study compared these two approaches. METHODOLOGY: Over a three-year period 41 patients were studied. All had obstructive jaundice for which endoscopic drainage had failed. In 22 patients (group 1) percutaneous transhepatic drainage was followed a few days later by combined endoscopic and percutaneous procedure. In 19 patients (group 2) the percutaneous transhepatic drainage and combined drainage were performed at the same session. In the multiple stage group the mean interval between the first endoscopic retrograde cholangiopancreatography and final combined procedure was 9 days (SD 5.2). The groups were similar for sex, underlying pathology and reasons for failure of endoscopic approach. Group 1 patients were older 73 vs. 65 years (p < 0.05). RESULTS: Patients in group 2 had a more rapid recovery and discharge home: mean 6 days, compared to mean 18 days from the initial procedure for group 1 (p < 0.001). Five patients died of their disease without leaving hospital (4 in group 1, 1 in group 2). In each group drainage failed in 1 patient. Complications were more common in group 1: 73% vs. 37% (p < 0.05). Pancreatitis (3 vs. 2) and septicemia (4 in group 1, 3 in group 2) were similar but group 1 had complications from the external drain: cholangitis and pyrexia in 4 patients, 3 bile leaks, and 1 catheter displacement. CONCLUSIONS: When endoscopic drainage alone fails, a combined percutaneous/endoscopic procedure should only be performed if it can be carried out simultaneously.     

Partial stent-in-stent placement of biliary metallic stents using a short double-balloon enteroscopy

Endoscopic intervention is less invasive than percutaneous or surgical approaches and should be considered the primary drainage procedure in most cases with obstructive jaundice. Recently, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) using double-balloon enteroscopy (DBE) has been shown to be feasible and effective, even in patients with surgically altered anatomies. On the other hand, endoscopic partial stent-in-stent (PSIS) placement of self-expandable metallic stents (SEMSs) for malignant hilar biliary obstruction in conventional ERCP has also been shown to be feasible, safe and effective. We performed PSIS placement of SEMSs for malignant hilar biliary obstruction due to liver metastasis using a short DBE in a patient with Roux-en-Y anastomosis and achieved technical and clinical success. This procedure can result in quick relief from obstructive jaundice in a single session and with short-term hospitalization, even in patients with surgically altered anatomies.     

Does the addition of endoscopic sphincterotomy to stent insertion improve drainage of the bile duct in acute suppurative cholangitis?

BACKGROUND: The treatment of patients with bile duct stones and acute suppurative cholangitis is emergent biliary decompression either by endoscopic sphincterotomy, nasobiliary drainage, or stent insertion. The aim of this retrospective study was to determine whether endoscopic sphincterotomy, in addition to an internal endoprosthesis, improves outcome for patients with acute suppurative cholangitis. METHODS: A total of 74 patients with acute suppurative cholangitis and bile duct stones were included in the study; 37 had endoscopic sphincterotomy before insertion of plastic stent (Group 1), and 37 had a plastic stent inserted through an intact papilla (Group 2). RESULTS: The success rates for stent insertion in Groups 1 and 2 were, respectively, 89.2% and 86.5% (p = 1.000). The complication rates in Group 1 and Group 2 were, respectively, 10.8% and 2.7% (p = 0.358). The median (interquartile range 25th-75th percentile) durations of hospital stay for patients in Group 1 and Group 2 were, respectively, 6.5 (4-11) days and 7 (5-12) days (p = 0.614). The median (interquartile range) lengths of time for resolution of jaundice in Group 1 and Group 2 were, respectively, 3 (2-6) days versus 4 (2-5) days (p = 0.981). CONCLUSIONS: Endoscopic sphincterotomy, in addition to biliary stent insertion, is not required for successful biliary decompression in patients with severe acute cholangitis.     

SINGLE‐SESSION ENDOSCOPIC BILATERAL Y‐CONFIGURED PLACEMENT OF METAL STENTS FOR HILAR MALIGNANT BILIARY OBSTRUCTION

Background: The aim of this study was to evaluate the efficacy and safety of endoscopic bilateral biliary metal stent placement for hilar malignant obstruction. Patients and Methods: Twenty patients with unresectable malignant hilar biliary obstruction who had undergone endoscopic bilateral Y‐configured biliary drainage with metal stents were enrolled as a study group (YMS group). Thirty‐seven patients who had undergone bilateral drainage with plastic stents were selected as a historical control (PS group). Two newly designed metal stents for bilateral Y‐configured placement were endoscopically deployed in a partial stent‐in‐stent manner in one session. Technical success, early complications, and stent patency were evaluated. Results: The technical success rate in the YMS group was 100%. Mild post‐endoscopic retrograde cholangiopancreatography pancreatitis occurred in one patient in the YMS group and in two in the PS group. The success rate of biliary decompression was 95% in the YMS group and 89% in the PS group (P = 0.65). During a median follow‐up period of 7.3 months, the incidence of stent occlusion in the YMS group was significantly lower than that in the PS group (30% vs 62%, P = 0.028). Mean stent patency in the YMS group was 250 days and that in the PS group was 115 days (P = 0.0061). Risk factors for stent occlusion were bile duct cancer (P = 0.035) and the PS group (P = 0.07) by multivariate analysis. Conclusion: Single‐session endoscopic bilateral biliary placement of newly designed metal stents for hilar malignant obstruction is safe and useful with a high technical success rate and a long patency period.     

Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents

BACKGROUND: Endoscopic management of malignant hilar biliary obstruction is controversial with respect to optimal types of stents and extent of drainage. This study evaluated outcomes of selective MRCP and CT-targeted drainage with self-expanding metallic stents. METHODS: Consecutive patients undergoing attempted palliative ERCP for malignant hilar biliary obstruction were prospectively followed. Whenever possible, management strategy included evaluation and staging for potential resectability before ERCP, with primary placement of metallic stents at the first ERCP in nonsurgical candidates, and early conversion to a metallic stent when a tumor proved to be unresectable. MRCP and/or CT were used to plan selective guidewire access, opacification, and drainage only of the largest intercommunicating segmental ducts. Unilateral stent placement was intended in all cases except for selected patients with Bismuth II cholangiocarcinoma. RESULTS: Thirty-five patients were included. Bismuth classification was I, 10; II, 6; III, 8; and IV, 11. Tumor origin was bile duct (17), gallbladder (5), and metastatic (13). Metallic stents were placed in 27 patients as the initial stent, and in 8 after plastic stent placement. Initial stents were placed endoscopically in 33 patients and percutaneously in 2 patients in whom lumenal tumor precluded ERCP. Stent placement was unilateral in 31 patients and bilateral in 4 patients. There were no episodes of cholangitis or other complications within 30 days after any procedures. Initial metallic stents were clinically effective in 27 (77%) of the 35 patients. Additional percutaneous drainage in 3 patients who did not respond to initial stent placement did not resolve jaundice. Median patency of first metallic stents was 8.9 months for patients with primary bile duct tumors and 5.4 months for all patients, and was not related to Bismuth classification. No further intervention was needed in 25 (71%) patients. CONCLUSIONS: Unilateral metallic stent placement by using MRCP and/or CT to selectively target drainage provides safe and effective palliation in most patients with malignant hilar biliary obstruction.     

A modern approach to malignant hilar biliary obstruction

Management of patients with malignant hilar biliary obstruction is challenging for all specialists involved in their care. Evaluation should focus on potential surgical resection, which offers the principal chance of cure; liver transplantation is offered as an experimental treatment at a few centers. Attempt at curative surgical resection is appropriate for selected tumors and often requires partial hepatectomy. Diagnosis and staging is now facilitated by the use of magnetic resonance cholangiopancreatography (MRCP), spiral computed tomography, and endoscopic ultrasonography, which should largely supplant invasive cholangiography. Use of endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography should be limited primarily to palliation of jaundice in patients with unresectable tumors and to establish tissue diagnoses in ambiguous cases. Palliation of jaundice is optimal with self-expanding metallic stents. Safe and effective drainage can be achieved by using MRCP for targeted endoscopic placement of unilateral metal stents in most cases, with bilateral stents rarely required unless undrained ducts are contaminated. Other palliative modalities for bile duct tumors include surgical bypass, intraluminal and external beam radiation therapy, chemotherapy, and photodynamic therapy.     

放置金属支架姑息性解除恶性胆道梗阻57例

目的内镜法放置胆道支架,姑息性治疗胆管恶性梗阻的最大缺陷是支架的阻塞,造成阻塞的重要原因之一是通常的塑料支架口径较小,而放置可膨式金属支架使得内引流中口径达到1cm.方法我们从1994年4月-1996年5月放置膨胀式金属道支架治疗57例无法根治的恶性梗阻性黄疸患者,其中采用内镜法置管54例,经皮肝穿刺法3例.结果导丝定位后支架放置的成功率为95%,2例发生胆管炎,经保守治疗得以控制.术后两周内黄疸完全消退21例,明显减退23例,然而9例患者在平均147d 后由于引流失效出现晚期胆管炎.全组有23例术前采用鼻胆管和3例采用内置管临时性引流,临时性引流具有可预先了解引流效果和控制炎症的优点.结论对于无法切除的恶性胆道梗阻患者,放置金属胆道支架可有效解除黄疸,改善生活质量,但欲获得最佳疗效,需严格掌握置管指证.为获得持久的引流效果.肿瘤两端支架的长度不宜短于2cm;对肝门部胆管癌,Bismuth 分型对挑选合适的引流部位有较大的参考价值.     

Preoperative biliary drainage for biliary tract and ampullary carcinomas

We posed six clinical questions (CQ) on preoperative biliary drainage and organized all pertinent evidence regarding these questions. CQ 1. Is preoperative biliary drainage necessary for patients with jaundice? The indications for preoperative drainage for jaundiced patients are changing greatly. Many reports state that, excluding conditions such as cholangitis and liver dysfunction, biliary drainage is not necessary before pancreatoduodenectomy or less invasive surgery. However, the morbidity and mortality of extended hepatectomy for biliary cancer is still high, and the most common cause of death is hepatic failure; therefore, preoperative biliary drainage is desirable in patients who are to undergo extended hepatectomy. CQ 2. What procedures are appropriate for preoperative biliary drainage? There are three methods of biliary drainage: percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD) or endoscopic retrograde biliary drainage (ERBD), and surgical drainage. ERBD is an internal drainage method, and PTBD and ENBD are external methods. However, there are no reports of comparisons of preoperative biliary drainage methods using randomized controlled trials (RCTs). Thus, at this point, a method should be used that can be safely performed with the equipment and techniques available at each facility. CQ 3. Which is better, unilateral or bilateral biliary drainage, in malignant hilar obstruction? Unilateral biliary drainage of the future remnant hepatic lobe is usually enough even when intrahepatic bile ducts are separated into multiple units due to hilar malignancy. Bilateral biliary drainage should be considered in the following cases: those in which the operative procedure is difficult to determine before biliary drainage; those in which cholangitis has developed after unilateral drainage; and those in which the decrease in serum bilirubin after unilateral drainage is very slow. CQ 4. What is the best treatment for postdrainage fever? The most likely cause of high fever in patients with biliary drainage is cholangitis due to problems with the existing drainage catheter or segmental cholangitis if an undrained segment is left. In the latter case, urgent drainage is required. CQ 5. Is bile culture necessary in patients with biliary drainage who are to undergo surgery? Monitoring of bile cultures is necessary for patients with biliary drainage to determine the appropriate use of antibiotics during the perioperative period. CQ 6. Is bile replacement useful for patients with external biliary drainage? Maintenance of the enterohepatic bile circulation is vitally important. Thus, preoperative bile replacement in patients with external biliary drainage is very likely to be effective when highly invasive surgery (e.g., extended hepatectomy for hilar cholangiocarcinoma) is planned.     

Operable malignant jaundice: To stent or not to stent before the operation?

Traditionally, pre-operative biliary drainage (PBD) was believed to improve multi-organ dysfunction, and for this reason, was practiced worldwide. Over the last decade, this concept was challenged by many reports, including meta-analyses that showed no difference in morbidity and mortality between surgery with, and surgery without PBD, in operable malignant jaundice. The main disadvantages of PBD are seen to be the additional cost of the procedure itself, and the need for longer hospitalization. In addition, many studies showed the significance of specific complications resulting from PBD, such as recurrent jaundice, cholangitis, pancreatitis, cutaneous fistula, and bleeding. However, the results of these studies remain inconclusive as to date there has been no perfect study that equally randomized comparable patients according to the level of obstruction and technique used for PBD. Generally, endoscopic stent insertion (ES) is preferred for common duct obstruction, whereas endoscopic nasobiliary drainage and percutaneous biliary drainage is reserved for hilar obstruction, since ES in hilar block confers a high rate of cholangitis. Although, there is no guideline which either supports or refutes this approach, certain subgroups of patients, including those with symptomatic jaundice, cholangitis, impending renal failure, hilar block requiring preoperative portal vein embolization, and those who need pre-operative neoadjuvant therapy, are suitable candidates for PBD.     

Role of ciprofloxacin in patients with cholestasis after endoscopic retrograde cholangiopancreatography

AIM To determine the role of ciprofloxacin in reducing cholangitis in cholestatic patients with adequate biliary drainage after endoscopic retrograde cholangiopancreatography (ERCP).METHODS A randomized, controlled trial was performed in 48 cholestatic patients at Rajavithi Hospital (Tertiary Referral Center for ERCP 600 cases per year). All the 48 patients received 200 mg ciprofloxacin intravenous injection for 30 min before starting any procedures, and then were randomly divided in two groups. Twenty-two patients in study group continually received ciprofloxacin until 48 h after ERCP. Causes of biliary obstruction, bacteriology of bile and blood (in cholangitis) and clinical cholangitis were recorded.RESULTS Forty-eight patients were enrolled and divided into continuous ciprofloxacin treatment group (n = 22) and discontinuous ciprofloxacin treatment group (n = 26). During ERCP, stones were found in 22 patients,malignant diseases in 24 patients and other pathologic lesions in 5 patients. One (4.5%) of the 22 patients who received ciprofloxacin and 2 (6.3%) of the 26 patients who discontinued ciprofloxacin after ERCP developed cholangitis (relative risk = 0.71; 95% CI = 0.14-3.65;P = 0.88). Bacterobilia was found in 27 (56.3%) out of 48 patients. E. coli and Streptococcus viridans were the most common organisms.CONCLUSION Continual use of ciprofloxacin in patients with cholestasis after adequate biliary drainage procedures plays no role in reducing cholangitis.     

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。