Malignant biliary obstruction due to metastatic non-hepatopancreato-biliary cancer

Malignant biliary obstruction generally results from primary malignancies of the pancreatic head,bile duct,gallbladder,liver,and ampulla of Vater.Metastatic lesions from other primaries to these organs or nearby lymph nodes are rarer causes of biliary obstruction.The most common primaries include renal cancer,lung cancer,gastric cancer,colorectal cancer,breast cancer,lymphoma,and melanoma.They may be difficult to differentiate from primary hepato-pancreatobiliary cancer based on imaging studies,or even on biopsy.There is also no consensus on the optimal method of treatment,including the feasibility and effectiveness of endoscopic intervention or surgery.A thorough review of the literature on pancreato-biliary metastases and malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer is presented.The diagnostic modality and clinical characteristics may differ significantly depending on the type of primary cancer.Different primaries also cause malignant biliary obstruction in different ways,including direct invasion,pancreatic or biliary metastasis,hilar lymph node metastasis,liver metastasis,and peritoneal carcinomatosis.Metastasectomy may hold promise for some types of pancreato-biliary metastases.This review aims to elucidate the current knowledge in this area,which has received sparse attention in the past.The aging population,advances in diagnostic imaging,and improved treatment options may lead to an increase in these rare occurrences going forward.

Relationship between entero-hepatic bile acid circulation and interdigestive migrating myoelectrical activity in rats

AIM： To investigate the effects of entero-hepatic bile add circulation on the inter-digestive migrating myoelectrical complex （MMC） in rats. METHODS： Thirty-two rats were divided into four groups. Three pairs of bipolar silver electrodes were chronically implanted in the antrum, duodenum and jejunum. Three groups of Uhem were ligatecl around the upper part of common bile duct （CBD）. The experiments were performed in consdous and fasting state. The gastrointestinal myoelectrical activity was recorded. Ursodeoxycholic acid （UDCA） and saline were then perfused into stomachs of two groups with CBD obstruction and the effects of them on the MMC were observed. RESULTS： A typical pattern of MMC was observed in normal fasting rats. MMC of antral and duodenal origin disappeared temporarily in earlier stage of CBD obstruction. While MMC of jejunum origin appeared. increased MMC cycle duration was seen after 4 d in rats with CBD obstruction. The MMC after CBD obstruction was characterized by an increased duration of phase Ⅱ-like activity and decreased duration of phase Ⅰ ＆ Ⅲ activity. Perfusion into stomachs with UDCA resulted in a shorter MMC cycle duration and a longer duration of phase III of duodenal origin compared to the normal group. CONCLUSION： Entero-hepatic bile add drculation initiates inter-digestive MMC of duodenal origin.

Hemophagocytic lymphohistiocytosis with jaundice as first manifestation:A case report

BACKGROUND Hemophagocytic lymphohistiocytosis(HLH)is a rare but life-threatening condition.It is an immune-mediated disease that has a wide range of causes,elicits a hyperinflammatory response,and results in multiple organ damage.Clinical presentations vary,and in some cases,jaundice occurs as the first symptom.CASE SUMMARY We report the case of a 71-year-old female patient who presented with jaundice.She was admitted to our hospital because of the occurrence of“jaundice for half a month”,and upon examination,obstructive jaundice with choledocholithiasis and gallstones was suggested.Cholecystectomy and choledocholithotomy were performed.However,the jaundice did not improve after surgery.We found splenomegaly,cytopenia,hypertriglyceridemia,hypofibrinogenemia,and elevated ferritin.Bone marrow biopsy revealed hemophagocytosis.Later,cardiac arrest occurred when she returned 3 wk after the surgery.We considered that HLH was triggered by septic shock.The patient’s condition deteriorated rapidly,with multiple organ dysfunction and severe gastrointestinal bleeding.Corticosteroid therapy and symptomatic treatment failed to save her life.CONCLUSION Jaundice rarely presents as the first symptom in HLH patients.The HLH in this case was triggered by septic shock with jaundice as the first symptom.Clinicians should try hard to reduce missed diagnoses and misdiagnoses.

Endoscopic ultrasound-guided biliary drainage

Endoscopic ultrasound(EUS)-guided biliary drainage has emerged as a minimally invasive alternative to percutaneous and surgical interventions for patients with biliary obstruction who had failed endoscopic retrograde cholangiopancreatography(ERCP).EUSguided biliary drainage has become feasible due to the development of large channel curvilinear therapeutic echo-endoscopes and the use of real-time ultrasound and fluoroscopy imaging in addition to standard ERCP devices and techniques.EUS-guided biliary drainage is an attractive option because of its minimally invasive,single step procedure which provides internal biliary decompression.Multiple investigators have reported high success and low complication rates.Unfortunately,high quality prospective data are still lacking.We provide detailed review of the use of EUS for biliary drainage from the perspective of practicing endoscopists with specific focus on the technical aspects of the procedure.

Endoscopic ultrasound-guided choledochoduodenostomies with fully covered self-expandable metallic stents

AIM:To investigate the long-term outcomes of endoscopic ultrasound-guided choledochoduodenostomy(EUS-CDS) with a fully covered self-expandable metallic stent(FCSEMS).METHODS:From April 2009 to August 2010,15 patients with distal malignant biliary obstructions who were candidates for alternative techniques for biliary decompression due to a failed endoscopic retrograde cholangiopancreatography(ERCP) were included.These 15 patients consisted of 8 men and 7 women and had a median age of 61 years(range:30-91 years).The underlying causes of the distal malignant biliary obstruction were pancreatic cancer(n = 9),ampulla of Vater cancer(n = 2),renal cell carcinoma(n = 1),advanced gastric cancer(n = 1),lymphoma(n = 1),and duodenal cancer(n = 1).RESULTS:The technical success rate of EUS-CDS with an FCSEMS was 86.7%(13/15),and functional success was achieved in 100%(13/13) of those cases.In two patients,the EUS-CDS failed because an FCSEMS with a delivery device could not be passed into the common bile duct.The mean duration of stent patency was 264 d.Early adverse events developed in three patients(3/13,23.1%),including self-limited pneumoperitoneum in two patients and cholangitis requiring stent reposition in one patient.During the follow-up period(median:186 d,range:52-388 d),distal stent migration occurred in four patients(4/13,30.8%).In 3 patients,the FCSEMS could be reinserted through the existing choledochoduodenal fistula tract.CONCLUSION:EUS-CDS with an FCSEMS is technically feasible and can lead to effective palliation of distal malignant biliary obstructions after failed ERCP.

Endoscopic ultrasound-guided biliary drainage-current status and future perspectives

Endoscopic retrograde cholangiopancreatography(ERCP)with stenting is the treatment modality of choice for patients with benign and malignant bile duct obstruction.ERCP could fail in cases of duodenal obstruction,duodenal diverticulum,ampullary neoplastic infiltration or surgically altered anatomy.In these cases percutaneous biliary drainage(PTBD)is traditionally used as a rescue procedure but is related to high morbidity and mortality and lower quality of life.Endoscopic ultrasound-guided biliary drainage(EUS-BD)is a relatively new interventional procedure that arose due to the development of curvilinear echoendoscope and the various endoscopic devices.A large amount of data is already collected that proves its efficacy,safety and ability to replace PTBD in cases of ERCP failure.It is also possible that EUS-BD could be chosen as a first-line treatment option in some clinical scenarios in the near future.Several EUS-BD techniques are developed EUS-guided transmural stenting,antegrade stenting and rendezvous technique and can be personalized depending on the individual anatomy.EUS-BD is normally performed in the same session from the same endoscopist in case of ERCP failure.The lack of training,absence of enough dedicated devices and lack of standardization still makes EUS-BD a difficult and not very popular procedure,which is related to life-threatening adverse events.Developing training models,dedicated devices and guidelines hopefully will make EUS-BD easier,safer and well accepted in the future.This paper focuses on the technical aspects of the different EUS-BD procedures,available literature data,advantages,negative aspects and the future perspectives of these modalities.