Efficacy and safety of percutaneous transhepatic biliary radiofrequency ablation in patients with malignant obstructive jaundice

BACKGROUND Percutaneous transhepatic cholangiodrainage(PTCD)and endoscopic retrograde cholangiopancreatography/endoscopic nasobiliary drainage are the most common clinical procedures for jaundice control in patients with unresectable malignant obstructive jaundice,yet the safety and effect of endobiliary radiofrequency ablation(EB-RFA)combined PTCD is rarely reported,in this article,we report our experience of EB-RFA combined PTCD in such patients.AIM To retrospectively study the efficacy and safety of EB-RFA combined PTCD in patients with unresectable malignant obstructive jaundice.METHODS Patients with unresectable malignant obstructive jaundice treated with EB-RFA under PTCD were selected,the bile ducts of the right posterior lobe was selected as the target bile ducts in all cases.The general conditions of all patients,preoperative tumour markers,total bilirubin(TBIL),direct bilirubin(DBIL),albumin(ALB),alkaline phosphatase(ALP),and glutamyl transferase(GGT)before and on the 7th day after the procedure,as well as perioperative complications,stent patency time and patient survival were recorded.RESULTS All patients successfully completed the operation,TBIL and DBIL decreased significantly in all patients at the 7th postoperative day(P=0.009 and 0.006,respectively);the values of ALB,ALP and GGT also decreased compared with the preoperative period,but the difference was not statistically significant.Perioperative biliary bleeding occurred in 2 patients,which was improved after transfusion of blood and other conservative treatments,pancreatitis appeared in 1 patient after the operation,no serious complication and death happened after operation.Except for 3 patients with loss of visits,the stent patency rate of the remaining 14 patients was 100%71%and 29%at the 1^(st),3^(rd),and 6^(th)postoperative months respectively,with a median survival of 4 months.CONCLUSION EB-RFA under PTCD in patients with unresectable malignant obstructive jaundice has a satisfactory therapeutic effect and high safety,which is worthy of further clinical practice.

Advances in minimally invasive treatment of malignant obstructive jaundice

Malignant obstructive jaundice(MOJ)encompasses a range of diseases stemming from malignant tumors such as cholangiocarcinoma,pancreatic cancer,and primary liver cancer,among others,which cause obstruction in both intra-and extra-hepatic bile ducts.This obstruction may lead to elevated bilirubin levels,hepatic function impairment,and a low rate of successful surgical resection in clinical settings.There are various minimally invasive treatment options for MOJ,including endoscopic biliary drainage,ultrasound-guided procedures,and percutaneous biliary tract puncture drainage.

Endoscopic ultrasound-guided biliary drainage vs percutaneous transhepatic bile duct drainage in the management of malignant obstructive jaundice

BACKGROUND Malignant obstructive jaundice(MOJ)is a condition characterized by varying degrees of bile duct stenosis and obstruction,accompanied by the progressive development of malignant tumors,leading to high morbidity and mortality rates.Currently,the two most commonly employed methods for its management are percutaneous transhepatic bile duct drainage(PTBD)and endoscopic ultrasound-guided biliary drainage(EUS-BD).While both methods have demonstrated favorable outcomes,additional research needs to be performed to determine their relative efficacy.To compare the therapeutic effectiveness of EUS-BD and PTBD in treating MOJ.METHODS This retrospective analysis,conducted between September 2015 and April 2023 at The Third Affiliated Hospital of Soochow University(The First People’s Hospital of Changzhou),involved 68 patients with MOJ.The patients were divided into two groups on the basis of surgical procedure received:EUS-BD subgroup(n=33)and PTBD subgroup(n=35).Variables such as general data,preoperative and postoperative indices,blood routine,liver function indices,myocardial function indices,operative success rate,clinical effectiveness,and complication rate were analyzed and compared between the subgroups.RESULTS In the EUS-BD subgroup,hospital stay duration,bile drainage volume,effective catheter time,and clinical effect-iveness rate were superior to those in the PTBD subgroup,although the differences were not statistically significant(P>0.05).The puncture time for the EUS-BD subgroup was shorter than that for the PTBD subgroup(P<0.05).Postoperative blood routine,liver function index,and myocardial function index in the EUS-BD subgroup were significantly lower than those in the PTBD subgroup(P<0.05).Additionally,the complication rate in the EUS-BD subgroup was lower than in the PTBD subgroup(P<0.05).CONCLUSION EUS-BD may reduce the number of punctures,improve liver and myocardial functions,alleviate traumatic stress,and decrease complication rates in MOJ treatment.

Effect of preoperative biliary drainage on malignant obstructive jaundice:A meta-analysis

AIM: To evaluate the effect of preoperative biliary drainage (PBD) on obstructive jaundice resulting from malignant tumors. METHODS: According to the requirements of Cochrane systematic review, studies in the English language were retrieved from MEDLINE and Embase databases from 1995 to 2009 with the key word "preoperative biliary drainage". Two reviewers independently screened the eligible studies, evaluated their academic level and extracted the data from the eligible studies confirmed by cross-checking. Data about patients with and without PBD after resection of malignant tumors were processed for meta-analysis using the Stata 9.2 software, including postoperative mortality, incidence of postoperative pancreatic and bile leakage, abdominal abscess, delayed gastric emptying and incision infection.RESULTS: Fourteen retrospective cohort studies involving 1826 patients with malignant obstructive jaundice accorded with our inclusion criteria, and were included in meta-analysis. Their baseline characteristics were comparable in all the studies. No significant difference was found in combined risk ratio (RR) of postoperative mortality and incidence of pancreatic and bile leakage, abdominal abscess, delayed gastric emptying between patients with and without PBD. However, the combined RR for the incidence of postoperative incision infection was improved better in patients with PBD than in those without PBD (P < 0.05). CONCLUSION: PBD cannot significantly reduce the post-operative mortality and complications of malignant obstructive jaundice, and therefore should not be used as a preoperative routine procedure for malignant obstructive jaundice.

Effect of postoperative early enteral nutrition on clinical outcomes and immune function of cholangiocarcinoma patients with malignant obstructive jaundice

BACKGROUND Most cholangiocarcinoma patients with malignant obstructive jaundice(MOJ)have varying degrees of malnutrition and immunodeficiency preoperatively.Therefore,perioperative nutritional support has important clinical significance in the treatment of cholangiocarcinoma.AIM To investigate the effects of postoperative early enteral nutrition(EEN)on immunity function and clinical outcomes of cholangiocarcinoma patients with MOJ.METHODS This prospective clinical study included 60 cholangiocarcinoma patients with MOJ who underwent surgery.The patients were randomly divided into an experimental group and a control group according to the nutrition support modes.The control group received postoperative total parenteral nutrition(TPN),whereas the experimental group received postoperative EEN and parenteral nutrition(PN;EEN+PN).The clinical outcomes,postoperative immune function,incidences of surgical site infection and bile leakage,intestinal function recovery time,average hospitalization days,and hospitalization expenses of the two groups were assessed on postoperative days(PODs)1,3,and 7.RESULTS The CD3+T,CD4+T,CD8+T,and CD4+T/CD8+T cell count and the immunoglobulin(Ig)G,IgM,and IgA levels in the EEN+PN group were significantly higher than those in the TPN group on PODs 3 and 7(P<0.05),whereas no significant differences in the CD3+T,CD4+T,CD8+T,and CD4+T/CD8+T cell counts and IgG,IgM,and IgA levels before operation and on POD 1 were found between the two groups(P>0.05).The intestinal function recovery time and postoperative hospital stay were shorter(P<0.001 for both)in the EEN+PN group than in the TPN group.The hospitalization expenses of the EEN+PN group were lower than those of the TPN group(P<0.001).However,the incidence of abdominal distension was higher than in the EEN+PN group than in the TPN group(P<0.05).The incidence rates of biliary leakage and surgical site infection were not significantly different between the two groups(P>0.05).CONCLUSION A postoperative EEN program could reduce the incidence of postoperative complications and improve the clinical outcomes and immune functions of cholangiocarcinoma patients with MOJ and is thus beneficial to patient recovery.

Biliary stent combined with iodine-125 seed strand implantation in malignant obstructive jaundice

BACKGROUND Malignant obstructive jaundice is mainly caused by cholangiocarcinoma.Only a few patients are indicated for surgical resection,and the 3-year survival rate is<50%.For patients who are not eligible for surgery,biliary stent placement can relieve biliary obstruction and improve liver function and quality of life.However,restenosis after biliary stents has a poor prognosis and is a clinical challenge.Biliary stent combined with iodine-125(125I)seed implantation can prolong stent patency and improve survival.AIM To evaluate the safety and efficacy of biliary stent combined with 125I seed strand implantation in malignant obstructive jaundice.METHODS We enrolled 67 patients between January 2016 and June 2018 with malignant obstructive jaundice and randomized them into a biliary stent combined with 125I seed strand treatment(combined)group(n=32)and biliary stent(control)group(n=35).All patients underwent enhanced computed tomography and magnetic resonance imaging and were tested for biochemical and cancer markers.Twelve patients underwent pathological examination before surgery.All patients were followed up by telephone or clinical visit.Postoperative liver function improvement,postoperative complications,stent patency time,and survival time were compared between the two groups.Prognostic risk factors were evaluated.RESULTS Technical success was achieved in all patients in both groups.Postoperative liver function improved significantly in all patients(total bilirubin,direct bilirubin,alanine aminotransferase,and aspartate aminotransferase decreased significantly in all patients,the P values were less than 0.05).There was no significant difference in preoperative or postoperative indexes between the two groups for changes in total bilirubin(P=0.147),direct bilirubin(P=0.448),alanine aminotransferase(P=0.120),and aspartate aminotransferase(P=0.387)between the two groups.The median stent patency time of the combined group was 9.0±1.4 mo[95%confidence interval(CI):6.3-11.8 mo],which was significantly longer than the that of the control group(6.0±0.3 mo,95%CI:5.5-6.5 mo,P=0.000).The median survival time of the combined group was 11.0±1.4 mo(95%CI:8.2-13.7 mo),which was significantly longer than that of the control group(7.0±0.3 mo,95%CI:6.4-7.6 mo,P=0.000).Location of obstruction and number of stents were independent risk factors affecting prognosis.CONCLUSION Biliary stent combined with 125I seed strand implantation is safe and effective in malignant obstructive jaundice and improves stent patency time and median survival time.

Surgical mortality in patients with malignant obstructive jaundice: a multivariate discriminant analysis

OBJECTIVE: To estimate the operative mortality in patients with malignant obstructive jaundice. METHODS: Twelve risk factors were analyzed using multivariate discriminant analysis in 90 patients who had been operated on. RESULTS: Operative mortality was significantly related to the following factors: age, duration of jaundice, packed RBC volume, white blood cell count and concentration of blood urine nitrogen; it was not significantly related to diseases and types of operation. The following formula was obtained: packed RBC volume×0.09954-age×0. 04018-blood urine nitrogen×0. 23693-duration of jaundice× 2. 07388-WBC count×0. 21118+5. 26593. With this formula, an operative mortality of 77. 8% was predicted. CONCLUSION: With a positive value from the formula, the patient should be operated on; otherwise non-operative treatment is advocated.

Percutaneous biliary stent combined with brachytherapy using 125I seeds for treatment of unresectable malignant obstructive jaundice:A meta-analysis

BACKGROUND Malignant obstructive jaundice(MOJ)is a common pathologic manifestation of malignant biliary obstruction.Recently,several clinical trials have explored the clinical effectiveness of intraluminal^(125)I seed-based brachytherapy for MOJ patients,and various outcomes have been reported.AIM To assess the efficacy and safety of percutaneous biliary stents with^(125)I seeds compared to conventional metal stents in patients with unresectable MOJ.METHODS A systematic search of English-language databases(PubMed,Embase,Cochrane Library,and Web of Science)was performed to identify studies published prior to June 2020 that compared stents with or without^(125)I seeds in the treatment of unresectable MOJ.The outcomes analyzed included primary outcomes(stent patency and overall survival)and secondary outcomes(complications and liver function parameters).RESULTS Six randomized controlled trials and four retrospective studies involving 875 patients were eligible for the analysis.Of the 875 included patients,404 were treated with^(125)I seed stents,while 471 were treated with conventional stents.Unadjusted pooled analysis demonstrated that compared to conventional stents,^(125)I seed stents extended the stent patency time[hazard ratio(HR)=0.36,95%confidence interval(CI)=0.28-0.45,P<0.0001]and overall survival period(HR=0.52,95%CI=0.42–0.64,P<0.00001).Subgroup analyses based on the type of^(125)I seed stent and type of study design showed consistent results.However,there were no significant differences in the occurrence of total complications[odds ratio(OR)=1.12,95%CI=0.75-1.67,P=0.57],hemobilia(OR=1.02,95%CI=0.45-2.3,P=0.96),pancreatitis(OR=1.79,95%CI=0.42-7.53,P=0.43),cholangitis(OR=1.13,95%CI=0.60-2.13,P=0.71),or pain(OR=0.67,95%CI=0.22-2,P=0.47).In addition,there were no reductions in the levels of serum indices,including total bilirubin[mean difference(MD)=10.96,95%CI=-3.56-25.49,P=0.14],direct bilirubin(MD=7.37,95%CI=-9.76-24.5,P=0.4),alanine aminotransferase(MD=7.52,95%CI=-0.71-15.74,P=0.07),and aspartate aminotransferase(MD=-4.77,95%CI=-19.98-10.44,P=0.54),after treatment.Publication bias was detected regarding the outcome overall survival;however,the conclusions were not changed after the adjustment.CONCLUSION Placement of stents combined with brachytherapy using^(125)I seeds contributes to a longer stent patency and higher overall survival than placement of conventional stents without extra complications or severe liver damage.Thus,it can be considered an effective and safe treatment for unresectable MOJ.

Obstructive jaundice caused by secondary pancreatic tumor from malignant solitary fibrous tumor of pleura:A case report

A 77-year-old man on systemic chemotherapy against postoperative bilateral multiple lung metastases of malignant solitary fibrous tumor of the pleura suffered from pruritus and jaundice. Blood examination showed elevated levels of hepatobiliary enzymes. Abdominal computed tomography showed a tumor with peripheral enhancement in the pancreatic head, accompanied with the dilatation of intra- and extra-hepatic bile ducts. He was diagnosed as having obstructive jaundice caused by a pancreatic head tumor. The pancreatic head tumor was presumably diagnosed as the metastasis of malignant solitary fibrous tumor of the pleura, because the findings on the pancreatic head tumor on abdominal CT were similar to those on the primary lung lesion of malignant solitary fibrous tumor of the pleura. The pancreatic tumor grew rapidly after the implantation of metallic stent in the inferior part of the common bile duct. The patient died of lymphangitis carcinomatosa of the lungs. Autopsy revealed a tumor that spread from the pancreatic head to the hepatic hilum. Microscopically, spindle-shaped cells exhibiting nuclear atypicality or division together with collagen deposition were observed. Immunohistochemically the pancreatic head tumor cells were negative for staining of α-smooth muscle actin （α-SMA） or CD117, but positive for vimentin, CD34 and CD99. These findings are consistent with those on malignant solitary fibrous tumor of the pleura. We report the first case of obstructive jaundice caused by a secondary pancreatic tumor from malignant solitary fibrous tumor of the pleura.

^(18)F-FDG PET/CT in differentiating malignant from benign origins of obstructive jaundice

BACKGROUND： The various origins of obstructive jaundice make the diagnosis of the disease difficult. This study was undertaken to evaluate the role of 18F-FDG PET/CT in differentiating malignant from benign origins of obstructive jaundice and to quantify the added value of 18F-FDG PET/CT over conventional imaging（enhanced CT and/or MRI）.METHODS： Eighty-five patients with obstructive jaundice who underwent 18F-FDG PET/CT within 2 weeks after enhanced CT and/or MRI were reviewed retrospectively. All 18F-FDG PET/CT images were independently evaluated by 2 nuclear medicine physicians who were unaware of other imaging data; differences were resolved by consensus of the physicians. All conventional imaging interpretations, according to the medical records, were reviewed by 2 radiologists to determine the potential value. Final diagnoses were based on histological or surgical findings.RESULTS： Sixty-six patients were diagnosed with malignancies, and 19 patients with benign lesions. The maximum standardized uptake values for malignant and benign lesions causing biliary obstruction were 8.2±4.4 and 4.0±5.0, respectively（P〈0.05）. The sensitivity, specificity, and overall accuracy for differentiating malignant from benign origins with 18F-FDG PET/CT were 86.4%（57/66）, 73.7%（14/19）, and 83.5%（71/85）, respectively. 18F-FDG PET/CT in conjunction with conventional imaging changed the sensitivity, specificity, and overall accuracy of conventional imaging alone from 75.8%（50/66） to 95.5%（63/66）（P〈0.05）, 68.4%（13/19） to 57.9%（11/19）（P〉0.05）, and 74.1%（63/85） to 87.1%（74/85）（P〈0.05）, respectively.CONCLUSIONS： 18F-FDG PET/CT is of great value in differentiating malignant from benign origins of obstructive jaundice and is a useful adjuvant to conventional imaging. 18F-FDG PET/CT should be recommended for further etiological clarification.

Endoscopic Ultrasound-Guided Biliary Drainage with a Fully Covered Self-Expandable Metal Stent for Malignant Obstructive Jaundice

Objective: To study the therapeutic effect of Endoscopic ultrasound-guided biliary drainage (EUS-BD) with a nitinol fully covered self-expandable metal stent in patients with malignant obstructive jaundice when endoscopic retrograde cholangiopancreatography (ERCP) fails. Methods: From January 2016 January 2018, all patients with malignant obstructive jaundice during hospitalization underwent EUS-guided biliary drainage with a nitinol fully covered self-expandable metal stent, and the operation success rate, the clinical success rate, complications, length of hospital stay and survival time were observed. Results: Of 36 patients, 34 cases had successful operation;the operation success rate was 94.44% (34/36). The clinical success rate was 88.89% (32/36). Hemobilia occurred in 1, acute cholangitis in 1, and bile peritonitis in 1;improved after conservative treatment, the complication rate is 8.33% (3/36). Hospital stay and survival time was 21.54 ± 4.73 days and 220.54 ± 54.76 days, respectively. Conclusion: EUS-BD with a nitinol fully covered self-expandable metal stent may be a feasible and effective treatment option in patients with malignant biliary obstruction when ERCP fails.

Effects of Danshen Injection on the Malignant Obstructive Jaundice in the SD Rat Model

To observe the effects of Danshen on the growth of hepatocellular carcinoma in the SD rats, a model of malignant obstructive jaundice was established by inoculation of transplanted tumor into the hepatic portal with the walker-256 hepatocarcine line, which resulted in the obstruction by the infiltration and metastasis of hepatocellular carcinoma. SD rats were divided into 4 groups： the rats were treated by 0.9 % NS （n=24, control group）, inosine＋vitamin C （n=40, InV group）, Danshen （n=40, DS group） and 5-FU （n=40, 5-FU group）, respectively. The liver function, morphological changes and the expressions of PCNA, VEGF and ICAM-1 in carcinoma foci, peri-carcinoma tissues, adjacent lobe （left-internal lobe） and lung tissues were observed after the treatment with the 4 agents. Our results showed that the protective effect of Danshen on liver function was significantly better than that of NS and 5-FU （P〈0.01）. No significant difference in protective effect was observed between DS group and lnV group （P〉0.05）. Danshen also provided protective effect on the morphological damage of liver caused by obstructive jaundice. The rates of carcinoma-inhibition and metastasis inhibition were significantly higher than those of NS and inosine＋vitamin C （P〈0.01）. No significant difference in this regard existed between DS group and 5-FU group （P〉0.05）. The expressions of PCNA,VEGF and ICAM-1 PCNA, VEGF and ICAM-1 in carcinoma foci, peri-carcinoma tissues, adjacent lobe （left-internal lobe） and lung tissues were lower than those in control group and InV group, with the differences being significant （P〈0.01）. No significant differences were found between DS group and 5-FU group in the expression levels of PCNA and VEGF （P〉0.05） but ICAM-1 （P〈0.05）. It is concluded that Danshen injection not only has protective effects on liver injury caused by obstructive jaundice, but can inhibit the proliferation and growth of hepatocarcinoma, interfere with the vascularization of tumors, prevent recurrence and metastasis of hepatocarcineoma.

Changes over time in treatment for obstructive jaundice

This editorial discusses an article by Peng et al.This study reviewed the efficacy and safety of a new approach for treating obstructive jaundice.Although the pathophysiology of obstructive jaundice has not yet been fully elucidated,pro-gress has been made in its management.There are two aspects of obstructive jaundice:Cholestatic status and absence of bile in the intestinal lumen.Internal biliary drainage resolved both the conditions.Clinically,endoscopic retrograde biliary drainage(ERBD)has replaced percutaneous transhepatic biliary drainage,and ERBD is transitioning to endoscopic ultrasound guided biliary drainage.This editorial briefly explains the mechanism and treatment of obstructive jaundice and the prospects of this new internal biliary drainage technique.

Pathophysiological consequences of obstructive jaundice and perioperative management

Background: Obstructive jaundice is a common problem in daily clinical practice. Understanding completely the pathophysiological changes in obstructive jaundice remains a challenge for planning current and future management.Data sources: A Pub Med was searched for relevant articles published up to August 2016. The effect of obstructive jaundice on proinflammatory cytokines, coagulation status, hemodynamics and organ functions were evaluated.Results: The effects of obstructive jaundice included biliary tree, the hepatic cell and liver function as well as systemic complications. The lack of bile in the gut, the disruption of the intestinal mucosal barrier,the increased absorption of endotoxin and the subsequent endotoxemia cause proinflammatory cytokine production(TNF-α, IL-6). Bilirubin induces systemic inflammatory response syndrome which may lead to multiple organ dysfunction syndrome. The principal clinical manifestations include hemodynamic instability and acute renal failure, cardiovascular suppression, immune compromise, coagulation disorders,nutritional impairment, and wound healing defect. The proper management includes full replacement of water and electrolyte deficiency, prophylactic antibiotics, lactulose, vitamin K and fresh frozen plasma,albumin and dopamine. The preoperative biliary drainage has not been indicated in overall, but only in a few selected cases.Conclusion: The perioperative management is an essential measure in improving the outcome after the appropriate surgical operation in jaundiced patients especially those with malignancy.

Obstructive jaundice in Iran:factors affecting early outcome

BACKGROUND:Understanding any factors which influence the morbidity and mortality in patients with obstructive jaundice in each society will better guide appropriate management and lead to improved survival This study aimed to assess baseline etiologies,clinical manifestations,diagnostic results,and morbidity and mortality related to obstructive jaundice in Iranian patients. METHODS:The hospital recorded files of 133 patients with the final diagnosis of obstructive jaundice who had been admitted to the Taleqhani Hospital in Tehran between January 2001 and September 2004 were reviewed. RESULTS:The most common etiologies of obstructive jaundices were neoplasia and then common bile duct stone in the two genders.The results of ultrasonography were positive in less than half of the patients.However,the most positive results were related to endoscopic retrograde cholangiopancreatography(ERCP).The in-hospital mortality rate in patients less than 50 years old and elderly patients was 0%and 6.76%,respectively.The in-hospital morbidity rate was 2.25%and 7.51%,respectively in both patients and it was commonly related to infection of ulcer (44.46%),pneumonia(14.75%),myocardial infarction (14.75%),and subdiaphragmatic abscess(11.29%).In patients with a diagnosis of benign obstruction,only one patient died of severe sepsis.In malignant group preoperative characteristics,such as weight loss(P=0.015) and serum bilirubin concentration more than 16 mg/dl and postoperative complications,such as sepsis(P<0.001) cardiac arrest(P<0.001),and hepatic coma(P<0.001)were main predictors for the in-hospital mortality rate.CONCLUSION:Although the mortality and morbidity of obstructive jaundice in our study are less than those in other studies,the determination of preoperative clinical and laboratory indices and postoperative complications of patients is needed for the control of mortality and morbidity rate.

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.

Protective effects of intravenous anesthetics on kidney tissue in obstructive jaundice

AIM: To evaluate the protective effects on kidney tissue of frequently used intravenous anesthetics (ketamine, propofol, thiopental, and fentanyl) in rats with obstructive jaundice.

Pathophysiology of increased intestinal permeability in obstructive jaundice

Despite advances in preoperative evaluation and postoperative care, intervention, especially surgery, for relief of obstructive jaundice still carries high morbidity and mortality rates, mainly due to sepsis and renal dysfunction. The key event in the pathophysiology of obstructive jaundice-associated complications is endotoxemia of gut origin because of intestinal barrier failure. This breakage of the gut barrier in obstructive jaundice is multi-factorial, involving disruption of the immunologic, biological and mechanical barrier. Experimental and clinical studies have shown that obstructive jaundice results in increased intestinal permeability. The mechanisms implicated in this phenomenon remain unresolved, but growing research interest during the last decade has shed light in our knowledge in the field. This review summarizes the current concepts in the pathophysiology of obstructive jaundice-induced gut barrier dysfunction, analyzing pivotal factors, such as altered intestinal tight junctions expression, oxidative stress and imbalance of enterocyte proliferation and apoptosis. Clinicians handling patients with obstructive jaundice should not neglect protecting the intestinal barrier function before, during and after intervention for the relief of this condition, which may improve their patients’ outcome.

Obstructive jaundice due to hepatobiliary cystadenoma or cystadenocarcinoma

Hepatobiliary cystadenomas (HBC) and cystadenocarci- nomas are rare cystic lesions. Most patients with these lesions are asymptomatic, but presentation with ob- structive jaundice may occur. The first patient presented with intermittent colicky pain and recurrent obstructive jaundice. Imaging studies revealed a polypoid lesion in the left hepatic duct. The second patient had recurrent jaundice and cholangitis. Endoscopic retrograde cholan- giopancreatography (ERCP) showed a cystic lesion at the confluence of the hepatic duct. In the third patient with intermittent jaundice and cholangitis, cholangioscopy re- vealed a papillomatous structure protruding into the left bile duct system. In the fourth patient with obstructive jaundice, CT-scan showed slight dilatation of the intrahe- patic bile ducts and dilatation of the common bile duct of 3 cm. ERCP showed filling of a cystic lesion. All patients underwent partial liver resection, revealing HBC in the specimen. In the fifth patient presenting with obstructive jaundice, ultrasound examination showed a hyperecho- genic cystic lesion centrally in the liver. The resection specimen revealed a hepatobiliary cystadenocarcinoma. HBC and cystadenocarcinoma may give rise to obstruc- tive jaundice. Evaluation with cross-sectional imaging techniques is useful. ERCP is a useful tool to differentiate extraductal from intraductal obstruction.

Profile of hepatocyte apoptosis and bile lakes before and after bile duct decompression in severe obstructive jaundice patients

BACKGROUND:Excessive hepatocyte apoptosis and bile lakes in severe obstructive jaundice might impair liver functions.Although decompression of the bile duct has been reported to improve liver functions in animal studies,the mechanism of obstruction differs from that in humans.This study aimed to determine the profiles of hepatocyte apoptosis and bile lakes following bile duct decompression in patients with severe obstructive jaundice in the clinical setting.METHODS:We conducted a 'before and after study' on severe obstructive jaundice patients as a model of inhibition of the excessive process by bile duct decompression.Specimens of liver biopsies were taken before and after decompression of the bile duct and then stained by terminal deoxynucleotide transferase-mediated dUTP nick end-labeling(TUNEL) to identify hepatocyte apoptosis and by hematoxilin-eosin(HE) to identify bile lakes.All measurements were independently done by 2 observers.RESULTS:Twenty-one severe obstructive jaundice patients were included.In all patients,excessive hepatocyte apoptosis and bile lakes were apparent.After decompression,the hepatocyte apoptosis index decreased from 53.1(SD 105) to 11.7(SD 13.6)(P<0.05),and the bile lakes from 23.6(SD 14.8) to 10.9(SD 6.9)(P<0.05).CONCLUSION:Bile duct decompression improves hepatocyte apoptosis and bile lakes in cases of severe obstructive jaundice,similar to the findings in animal studies.