Background and study aims: Endoscopic biliary drainage is an established mode of treatment for acute cholangitis. We compared the safety and efficacy of nasobiliary drain (NBD) placement and stent placement for biliar...Background and study aims: Endoscopic biliary drainage is an established mode of treatment for acute cholangitis. We compared the safety and efficacy of nasobiliary drain (NBD) placement and stent placement for biliary drainage in patients with acute cholangitis. Patients and methods: We recruited a total of 150 patients with severe cholangitis who required endoscopic biliary drainage. Patients were randomized to have either a 7-Fr NBD or a 7-Fr straight flap stent placed during endoscopy. Outcome measures included complications related to endoscopic retrograde cholangiopancreatography (ERCP) and the clinical outco- me. Results: Of the 150 patients, 75 were randomized to the NBD group and 75 to the stent group. The most common causes of biliary obstruction were common bile duct stones (n = 102) and biliopancreatic malignancies (n = 37). The site of the biliary obstruction was predominantly found to be the lower part of common bile duct in both the NBD group (n = 58) and the stent group (n = 59). Indications for biliary drainage were: a fever of > 100.4°F (n = 140), hypotension (n = 23), peritonism (n = 40), impaired consciousness (n = 29), and failure to improve with conservative management (n = 45). Biliary drainage was achieved in 147 patients. Abdominal pain, fever, jaundice, hypotension, peritonism and altered sensorium improved after a median period of 2 days in both groups. Leukocyte counts became normal after a median time of 7 days in the NBD group and 6 days in the stent group. There were no ERCP-related complications. There were no instances of displacement or kinking of an NBD, occlusion of an NBD or stent, or of stent migration. Four patients died (two in the NBD group and two in the stent group) as a result of uncontrolled cholangitis after 1, 2, 4, and 6 days of biliary drainage. The success rates of biliary drainage in cholangitis were not affected by the type of endoprosthesis used (72/74 for NBD patients vs. 71/73 for stent patients), the etiology of the biliary obstruction (110/112 for benign obstruction vs. 33/35 for malignant obstruction), or the site of the biliary obstruction (28/30 for upper common bile duct obstruction vs. 115/117 for obstruction at the lower end of common bile duct). Conclusions: Biliary drainage by nasobiliary drain and drainage by stent are equally safe and effective treatments for patients with severe cholangitis.展开更多
Background and Study Aims:The formation of a communication between liver abscesses or cysts and intrahepatic bile ducts is an uncommon cause of significant bile leak.Surgical management of biliary fistulas is associat...Background and Study Aims:The formation of a communication between liver abscesses or cysts and intrahepatic bile ducts is an uncommon cause of significant bile leak.Surgical management of biliary fistulas is associated with high morbidity and mortality.We performed a prospective study of endoscopic management of this type of biliary fistula.Patients and Methods:We studied 26 patients who had either liver abscesses or hepatic cysts that had ruptured into the intrahepatic bile ducts.The presence of a biliary fistula was suspected by jaundice and/or by the appearance of bile in percutaneous drainage effluent from a liver abscess and was confirmed by endoscopic retrograde cholangiopancreatography.Once the route of the fistula between the liver abscess or cyst and the intrahepatic bile duct had been defined by cholangiography,patients underwent treatment by sphincterotomy,and either biliary stenting or nasobiliary drainage.Nasobiliary drains or biliary stents(both 7 Fr)were placed according to standard techniques.Nasobiliary drains were removed when bile leakage stopped and closure of the fistula was confirmed by cholangiography;stents were removed after an interval of 4-6 weeks.Results:Of a total of 525 patients with hepatic abscesses or cysts who were seen over a 5-year period,there were 26 patients who developed a demonstrable communication between liver abscesses(n = 20;16 amebic,four pyogenic)or hydatid cysts(n = 6)and intrahepatic bile ducts(right intrahepatic bile ducts in 22 patients,left intrahepatic bile ducts in four patients).We performed either sphincterotomy with insertion of a nasobiliary drain(n = 20)or sphincterotomy with biliary stenting(n = 6).The fistulas healed in all patients after a mean time of 4 days(range 2-20 days)after endoscopic treatment.We were able to remove the nasobiliary drainage catheters and stents 6-34 days after their placement.Conclusions:In this case series,endoscopic therapy appears to be an effective mode of treatment for biliary fistulas complicating liver abscesses and cysts.展开更多
文摘Background and study aims: Endoscopic biliary drainage is an established mode of treatment for acute cholangitis. We compared the safety and efficacy of nasobiliary drain (NBD) placement and stent placement for biliary drainage in patients with acute cholangitis. Patients and methods: We recruited a total of 150 patients with severe cholangitis who required endoscopic biliary drainage. Patients were randomized to have either a 7-Fr NBD or a 7-Fr straight flap stent placed during endoscopy. Outcome measures included complications related to endoscopic retrograde cholangiopancreatography (ERCP) and the clinical outco- me. Results: Of the 150 patients, 75 were randomized to the NBD group and 75 to the stent group. The most common causes of biliary obstruction were common bile duct stones (n = 102) and biliopancreatic malignancies (n = 37). The site of the biliary obstruction was predominantly found to be the lower part of common bile duct in both the NBD group (n = 58) and the stent group (n = 59). Indications for biliary drainage were: a fever of > 100.4°F (n = 140), hypotension (n = 23), peritonism (n = 40), impaired consciousness (n = 29), and failure to improve with conservative management (n = 45). Biliary drainage was achieved in 147 patients. Abdominal pain, fever, jaundice, hypotension, peritonism and altered sensorium improved after a median period of 2 days in both groups. Leukocyte counts became normal after a median time of 7 days in the NBD group and 6 days in the stent group. There were no ERCP-related complications. There were no instances of displacement or kinking of an NBD, occlusion of an NBD or stent, or of stent migration. Four patients died (two in the NBD group and two in the stent group) as a result of uncontrolled cholangitis after 1, 2, 4, and 6 days of biliary drainage. The success rates of biliary drainage in cholangitis were not affected by the type of endoprosthesis used (72/74 for NBD patients vs. 71/73 for stent patients), the etiology of the biliary obstruction (110/112 for benign obstruction vs. 33/35 for malignant obstruction), or the site of the biliary obstruction (28/30 for upper common bile duct obstruction vs. 115/117 for obstruction at the lower end of common bile duct). Conclusions: Biliary drainage by nasobiliary drain and drainage by stent are equally safe and effective treatments for patients with severe cholangitis.
文摘Background and Study Aims:The formation of a communication between liver abscesses or cysts and intrahepatic bile ducts is an uncommon cause of significant bile leak.Surgical management of biliary fistulas is associated with high morbidity and mortality.We performed a prospective study of endoscopic management of this type of biliary fistula.Patients and Methods:We studied 26 patients who had either liver abscesses or hepatic cysts that had ruptured into the intrahepatic bile ducts.The presence of a biliary fistula was suspected by jaundice and/or by the appearance of bile in percutaneous drainage effluent from a liver abscess and was confirmed by endoscopic retrograde cholangiopancreatography.Once the route of the fistula between the liver abscess or cyst and the intrahepatic bile duct had been defined by cholangiography,patients underwent treatment by sphincterotomy,and either biliary stenting or nasobiliary drainage.Nasobiliary drains or biliary stents(both 7 Fr)were placed according to standard techniques.Nasobiliary drains were removed when bile leakage stopped and closure of the fistula was confirmed by cholangiography;stents were removed after an interval of 4-6 weeks.Results:Of a total of 525 patients with hepatic abscesses or cysts who were seen over a 5-year period,there were 26 patients who developed a demonstrable communication between liver abscesses(n = 20;16 amebic,four pyogenic)or hydatid cysts(n = 6)and intrahepatic bile ducts(right intrahepatic bile ducts in 22 patients,left intrahepatic bile ducts in four patients).We performed either sphincterotomy with insertion of a nasobiliary drain(n = 20)or sphincterotomy with biliary stenting(n = 6).The fistulas healed in all patients after a mean time of 4 days(range 2-20 days)after endoscopic treatment.We were able to remove the nasobiliary drainage catheters and stents 6-34 days after their placement.Conclusions:In this case series,endoscopic therapy appears to be an effective mode of treatment for biliary fistulas complicating liver abscesses and cysts.
