Biliary drainage for obstructive jaundice caused by unresectable hepatocellular carcinoma: the endoscopic versus percutaneous approach

BACKGROUND: For palliative treatment of the obstructive jaundice associated with unresectable hepatocellular carcinoma (HCC), percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde biliary drainage (ERBD) has been performed. PTBD is preferred as an initial procedure. Little is known about the better option for patients with obstructive jaundice caused by unresectable HCC. METHODS: Sixty patients who had received ERBD or PTBD for the palliative treatment of obstructive jaundice caused by unresectable HCC between January 2006 and May 2010 were included in this retrospective study. Successful drainage, drainage patency, and the overall survival of patients were evaluated. RESULTS: Univariate analysis revealed that the overall frequency of successful drainage was higher in the ERBD group (22/29, 75.9%) than in the PTBD group (15/31, 48.4%) (P=0.029); but multivariate analysis showed marginal significance (P=0.057). The duration of drainage patency was longer in the ERBD group than in the PTBD group (82 vs 37 days, respectively, P=0.020). Regardless of what procedure was performed, the median survival time of patients who had a successful drainage was much longer than that of the patients who did not have a successful drainage (143 vs 38 days, respectively, P<0.001).CONCLUSION: Besides PTBD, ERBD may be used as the initial treatment option to improve obstructive jaundice in patients with unresectable HCC if there is a longer duration of drainage patency after a successful drainage.

Application of endoscopic nasobiliary cutting in the treatment of hilar cholangiocarcinoma

Objective The aim of the study was to study the clinical efficacy and prognosis of endoscopicallycutting the nasobiliary duct and leaving its residual segment as a biliary stent in the treatment of hilarcholangiocarcinoma (HC).Methods The clinical data of 55 patients with HC treated by endoscopic biliary drainage at theGastrointestinal Endoscopy Center of our hospital (Renmin Hospital of Wuhan University, China) fromAugust 2017 to August 2019 were retrospectively analyzed. According to different drainage schemes,patients were divided into the endoscopic nasobiliary cutting group (n = 26) and the endoscopic retrogradebiliary drainage (ERBD) group (n = 29). The postoperative liver function indexes, incidence of postoperativecomplications, median patency period of stents, and median survival time of patients were comparedbetween the two groups.Results Liver function indexes (total bilirubin, direct bilirubin, alanine aminotransferase, aspartateaminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase) were significantly decreased in55 patients a week postoperaticely (P < 0.05), and decreases in liver function indexes in the endoscopicnasobiliary cutting group were more significant than those in the ERBD group (P < 0.05). The incidenceof biliary tract infection in the endoscopic nasobiliary cutting group was significantly lower than that in theERBD group (15.40% vs. 41.4%, P < 0.05). In the endoscopic nasobiliary cutting subgroups, there were 1and 3 cases of biliary tract infection in the gastric antrum cutting group (n = 21) and duodenal papilla cuttinggroup (n = 5), respectively, and 0 cases and 2 cases of displacement, respectively;there was a statisticallysignificant difference in terms of complications between the two subgroups (P < 0.05). The median patencyperiod (190 days) and median survival time (230 days) in the nasobiliary duct cutting group were higherthan those (169 days and 202 days) in the ERBD group, but there was no significant difference (P > 0.05).Conclusion The nasobiliary duct was cut by using endoscopic scissors in Stage II after the bile was fullydrained through the nasobiliary duct. The residual segment could still support the bile duct and drain bile.The reduction of jaundice and the recovery of liver enzymes were significant, and the incidence of biliarytract infection was low. Cutting off the nasobiliary duct at the duodenal papilla results in a higher incidenceof biliary tract infection, and the residual segment of the nasobiliary duct is more likely to be displaced.Endoscopic nasobiliary-cutting drainage is an effective, simple, and safe method to reduce jaundice in thepalliative treatment of HC.

Successful endoscopic procedures for intraductal papillary neoplasm of the bile duct:A case report

Attention has recently been focused on biliary papillary tumors as the novel disease entity intraductal papillary neoplasm of the bile duct(IPNB),which consists of papillary proliferation of dysplastic biliary epithelium.As even benign papillary tumors are considered as premalignant,some investigators recommend aggressive surgical therapy for IPNB,although no guidelines are available to manage this disease.Few reports have described long-term follow-up of patients with benign IPNB without radical resection.If patients with IPNB who are treated only with endoscopic procedures are noted,clinical profiles and alternative therapies other than resection may be recommended.We report the case of a patient who experienced repetitive cholangitis for 10 years and was finally diagnosed with IPNB.Radical resection could not be recommended because of the age of the patient,therefore,endoscopic sphincterotomy was performed.Although an endoscopic retrograde biliary drainage catheter was placed several times for repetitive cholangitis,the patient has done well during follow-up.Our case may offer insights into the natural course and management decisions for the novel disease entity of IPNB.

Palliative surgery for hilar cholangiocarcinoma

OBJECTIVE: To evaluate the results of palliative surgical treatment of hilar cholangiocarcinoma in terms of quality of life, survival period and cholangitis rate. MFTHODS: The clinical data on 232 patients with hilar cholangiocarcinoma in the last 22 years were analyzed retrospectively. Palliative operations included extrahepatic or intrahepatie choledochojejunostomy (123 patients), bridge internal drainage (15), endoscopic biliary drainage (49), percutaneous transhepatic biliary drainage or celiotomy biliary drainage (29), and exploratory celiotomy external drainage (16). RESULTS: In this series, the operative mortality rate was 9.1%, and no significant difference was observed between groups. The rate of cholangitis after operation was significantly lower in Roux-en-Y choledochojejunostomy group (16.2%) and bridge internal drainage group (15.4%) than in internal drainage group (35.5%, P<0.01), including percutaneous transhepatic biliary drainage (PTBD), endoscopic retrograde biliary drainage (ERBD), and celiotomy (or PTBD) external biliary drainage group (39.1%, P<0.01). No significant difference in survival was observed between the Roux-en-Y choledcthojejunostomy group (9.3±1.8 months) and PTBD (or ERBD) internal drainage group (8.7±2.2 months), but the survivals of the above groups were significantly longer than those of the bridge internal drainage group (6.5±1.7 months, P<0.05) and celiotomy (or PTBD) external biliary drainage group (4.4±2.1 months, P<0.01). CONCLUSIONS: In unresectable cholangiocarcinomas, either operative bilioenteric bypass or percutaneous transhepatic biliary drainage can achieve significant palliation. Roux-en-Y choledochojejunostomy is the best choice for palliative operation. The use of U-tube is recommended for internal radiation therapy.