Percutaneous transhepatic cholangioscopy and lithotripsy in treating difficult biliary ductal stones: Two case reports

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP) is preferred for managing biliary obstruction in patients with bilio-enteric anastomotic strictures(BEAS) and calculi. In patients whose duodenal anatomy is altered following upper gastrointestinal(UGI) tract surgery, ERCP is technically challenging because the biliary tree becomes difficult to access by per-oral endoscopy.Advanced endoscopic therapies like balloon-enteroscopy or rendevous-ERCP may be considered but are not always feasible. Biliary sepsis and comorbidities may also make these patients poor candidates for surgical management of their biliary obstruction.CASE SUMMARY We present two 70-year-old caucasian patients admitted as emergencies with obstructive cholangitis. Both patients had BEAS associated with calculi that were predominantly extrahepatic in Patient 1 and intrahepatic in Patient 2. Both patients were unsuitable for conventional ERCP due to surgically-altered UGl anatomy. Emergency biliary drainage was by percutaneous transhepatic cholangiography(PTC) in both cases and after 6-weeks' maturation, PTC tracts were dilated to perform percutaneous transhepatic cholangioscopy and lithotripsy(PTCSL) for duct clearance. BEAS were firstly dilated fluoroscopically,and then biliary stones were flushed into the small bowel or basket-retrieved under visualization provided by the percutaneously-inserted video cholangioscope. Lithotripsy was used to fragment impacted calculi, also under visualization by video cholangioscopy. Satisfactory duct clearance was achieved in Patient 1 after one PTCSL procedure, but Patient 2 required a further procedure to clear persisting intrahepatic calculi. Ultimately both patients had successful stone clearance confirmed by check cholangiograms.CONCLUSION PTCSL offers a pragmatic, feasible and safe method for biliary tract clearance when neither ERCP nor surgical exploration is suitable.

Retrospective cohort study of statin therapy effect on resected colorectal liver metastases

BACKGROUND Above and beyond their role in cardiovascular risk reduction,statins appear to have a chemopreventive role in some gastro-intestinal cancers.In the quest for new chemopreventive agents,some existing established drugs such as statins have shown potential for re-purposing as chemoprevention.Probing existing drugs,whose pharmacodynamics are familiar,for novel beneficial effects offers a more cost-effective and less time-consuming strategy than establishing brand new drugs whose pharmacodynamic profile is unfamiliar.Observational studies show statins decrease the risk of developing colorectal cancer but there are no published studies exploring the potential impact of statins on carcinogenesis in colorectal liver metastases(CRLM).AIM To evaluate impact of statins on outcomes of CRLM resection,and secondarily to assess if statins influence CRLM histo-pathology.METHODS We conducted a retrospective cohort study of patients operated for CRLM over a 13-year period from 2005 to 2017.Patients were identified from a prospective database maintained in our Tertiary care hospital.All 586 patients included the study had undergone resection of CRLM following discussion at multidisclipinary team meeting,some patients requiring neoadjuvant chemotherapy to downstage CRLM prior to surgery.We analysed patient demographics,operative details,CRLM histopathology,Index of Deprivation,neutrophil-to-lymphocyte ratio,platelet-to-lymphocyte ratio and chemotherapy use in relation to clinical outcome.Statistics were performed using SPSS version 16.0;significance taken at 5%.RESULTS Liver resection for CRLM was undertaken in 586 patients at a median age of 68(range 19 to 88)years.Statin therapy was used by 181 patients.Median follow-up time was 23(range 12-96)mo and further colorectal cancer metastases developed in 267 patients.A total of 131 patients died.Multi-variate analysis identified 6 independent predictors of poorer disease-free survival:Synchronous presentation,multiple tumours,tumour size≥5 cm,moderate-severe steatosis,peri-neural invasion,and R1-resection margin.Poorer overall survival was significantly associated with neo-adjuvant chemotherapy,major hepatectomy,peri-neural invasion and R1-resection margin.Neither histo-pathological nor radiological traits of CRLM were affected by statins,and,there was no demonstrable effect of statin therapy on patient outcomes.CONCLUSION Statin therapy does not affect patient survival following liver resection for CRLM.We postulate the reason for this key finding is that statins do not modulate tumour biology of CRLM.