Current Status and Perspectives of External Versus Internal Pancreatic Duct Drainage during the Learning Curve of Laparoscopic Pancreaticoduodenectomy

Objectives: To summarize the current status and outlook of pancreatic duct drainage in the learning curve period of laparoscopic pancreaticoduodenectomy (LPD). Methods: By searching the literature related to the efficacy analysis of internal versus external pancreatic duct drainage in pancreaticoduodenectomy (OPD) and the learning curve period of laparoscopic pancreaticoduodenectomy in recent years at home and abroad and making a review. Results: Because of the complexity of the LPD surgical procedure, the high technical requirements and the high complication rate, it is necessary for the operator and his/her team to carry out a certain number of cases to pass through the learning curve in order to have a basic mastery of the procedure. In recent years, more and more pancreatic surgeons have begun to promote and use pancreatic duct drains. However, no consensus conclusion has been reached on whether to choose internal or external drainage for pancreatic duct placement and drainage in LPD. Conclusions: Intraoperative application of pancreatic duct drainage reduces the incidence of pancreatic fistula during the learning curve of laparoscopic pancreaticoduodenectomy. However, external pancreatic duct drainage and internal pancreatic duct drainage have both advantages and disadvantages, so when choosing the drainage method, one should choose the appropriate drainage method in conjunction with one’s own conditions, so as to reduce the incidence of complications.

Internal compared with external drainage of pancreatic duct during pancreaticoduodenectomy: a retrospective study

Objective： To compare internal with external drainage of the pancreatic duct during pancreaticoduodenectomy with regard to the incidence of postoperative pancreatic fistula （POPF） and other complications. Methods： We retrospectively analyzed 316 patients who underwent pancreaticoduodenectomy with a placed drainage tube （external, n=128; internal, n=188） in the pancreatic duct from 1 January 1999 to 31 December 2011 in Tianjin Third Central Hospital of China. The incidence of POPF and some other complications were compared. Results： There was no difference in the incidence rates of POPF between those given an internal or external drainage tube （P=0.788）, but POPF was more severe in the former （P=0.014）. Intraperitoneal bleeding rate was also higher in the patients with internal drainage （P=0.040）, but operative time and postoperative hospitalization were longer in those with external drainage （P=0.002 and P=0.007, respectively）. There was no difference between the groups with regard to the incidence rates of gastrointestinal bleeding, delayed gastric emptying, pulmonary infection, or incision infection and in-hospital mortality. Conclusions： External drainage of the pancreatic duct during pancreaticoduodenectomy can decrease the severity of POPF, but operative time and postoperative hospitalization will be extended.

Laparoscopic pancreatic duct incision and stone removal and T-type tube drainage for pancreatic duct stone: A case report and review of literature

To study a more micro-invasive procedure for patients having pancreatic duct stones(PDS).Till now,there has been no report of laparoscopic pancreatic duct incision and stone removal and T-type tube drainage for PDS in the English literature.An 82-year-old man suffered from subxiphoid pain associated with a dilated pancreatic duct(7 mm)containing one stone,but without a mass in the head of the pancreas.Laparoscopic pancreatic duct incision,stone removal,and T-type tube drainage were successfully performed without intraoperative or postoperative complications.An uneventful operation was performed with laparoscopically completed procedures in 160 min.The intraoperative loss of blood was around 50 mL.After patient a discharge on day 11,complete relief from the subxiphoid pain was reported at a follow-up visit 15 mo later.Laparoscopic pancreatic duct incision with stone removal and T-type tube drainage is applicable in carefully selected patients and can be effectively and safely used for the treatment of the abdominal pain of chronic pancreatitis.

Effect of preoperative biliary drainage on surgical results after pancreaticoduodenectomy in patients with distal common bile duct cancer:Focused on the rate of decrease in serum bilirubin

AIM: To examine if the rate of decrease in serum bilirubin after preoperative biliary drainagecan be used as a predicting factor for surgical complications and postoperative recovery after pancreaticoduodenectomy in patients with distal common bile duct cancer.METHODS: A retrospective study was performed in 49 consecutive patients who underwent pancrea-ticoduodenectomy for distal common bile duct cancer. Potential risk factors were compared between the complicated and uncomplicated groups. Also, the rates of decrease in serum bilirubin were compared pre- and postoperatively. RESULTS: Preoperative biliary drainage (PBD) was performed in 40 patients (81.6%). Postoperative morbidity and mortality rates were 46.9% (23/49) and 6.1% (3/49), respectively. The presence or absence of PBD was not different between the complicated and uncomplicated groups. In patients with PBD, neither the absolute level nor the rate of decrease in serum bilirubin was significantly different. Patients with rapid decrease preoperatively showed faster decrease during the first postoperative week (5.5 ± 4.4 μmol/L vs -1.7 ± 9.9 μmol/L, P = 0.004).CONCLUSION: PBD does not affect the surgical outcome of pancreaticoduodenectomy in patients with distal common bile duct cancer. There is a certain group of patients with a compromised hepatic excretory function, which is represented by the slow rate of decrease in serum bilirubin after PBD.

Benefits of endoscopic gallbladder stenting following percutaneous transhepatic gallbladder drainage

BACKGROUND Endoscopic transpapillary gallbladder drainage is challenging because of the complexity of the procedure and high incidence of adverse events(AEs).To overcome these problems,endoscopic gallbladder stenting(EGBS)after percutaneous transhepatic gallbladder drainage(PTGBD)can be effective,as it mitigates inflammation and adhesion.AIM To examine the benefits of EGBS after PTGBD to assess its efficacy and impact on AEs.METHODS We retrospectively analyzed data from 35 patients who underwent EGBS after PTGBD at a single center between January 2016 and December 2023.The primary outcomes were technical success and AEs,and the rate of recurrent cholecystitis was evaluated.In addition,the reasons for the failure of the procedure were identified.RESULTS Among the 35 patients,the technical success rate was 77.1%and the final contrast of the cystic duct was successful in 97.1%of patients.The incidence of early AEs was relatively low(11.4%),with no instances of cystic duct perforation.The rate of recurrent cholecystitis was 3.7%,and no other biliary events were observed.CONCLUSION EGBS after PTGBD may be significantly beneficial,with a substantial success rate and minimal AEs in both short-and long-term follow-ups.

Role of endoscopic ultrasound-guided biliary drainage for palliation of malignant biliary obstruction

Endoscopic ultrasound-guided biliary drainage(EUS-BD)directs bile flow into the digestive tract and has been mostly used in patients with malignant biliary obstruction(MBO)where endoscopic retrograde cholangiopancreatography-guided biliary drainage was unsuccessful or was not feasible.Lumen apposing metal stents(LAMS)are deployed during EUS-BD,with the newer electrocautery-enhanced LAMS reducing procedure time and complication rates due to the inbuilt cautery at the catheter tip.EUS-BD with electrocautery-enhanced LAMS has high technical and clinical success rates for palliation of MBO,with bleeding,cholangitis,and stent occlusion being the most common adverse events.Recent studies have even suggested comparable efficacy between EUS-BD and endosc-opic retrograde cholangiopancreatography as the primary approach for distal MBO.In this editorial,we commented on the article by Peng et al published in the recent issue of the World Journal of Gastrointestinal Surgery in 2024.

Percutaneous transhepatic cholangial drainage-guided methylene blue for fistulotomy using dual-knife for bile duct intubation: A case report

BACKGROUND Difficult bile duct intubation is a big challenge for endoscopists during endoscopic retrograde cholangiopancreatography(ERCP)procedure.We report a case of percutaneous transhepatic cholangial drainage(PTCD)-guided methylene blue for fistulotomy using dual-knife for bile duct intubation.CASE SUMMARY A 50-year-old male patient had developed obstructive jaundice,and ERCP procedure need to be performed to treat the obstructive jaundice.But intubation cannot be performed if the duodenal papilla cannot be identified because of previous surgery for a perforated descending duodenal diverticulum.We used PTCD-guided methylene blue to identify the intramural common bile duct before dual-knife fistulotomy,and bile duct intubation was successfully completed.CONCLUSION The method that combing methylene blue and dual-knife fistulotomy to achieve bile duct intubation during difficult ERCP is safe and effective.

Optimal biliary drainage for inoperable Klatskin's tumor based on Bismuth type

AIM： To investigate differences in the effects of biliary drainage procedures in patients with inoperable Klatskin＇s tumor based on Bismuth type, considering endoscopic retrograde biliary drainage （ERBD）, external percutaneous transhepatic biliary drainage （EPTBD） and internal biliary stenting via the PTBD tract （IPTBD）. METHODS： The initial success rate, cumulative patency rate, and complication rate were compared retrospectively, according to the Bismuth type and ERBD, EPTBD, and IPTBD. Patency was defined as the duration for adequate initial bile drainage or to the point of the patient＇s death associated with inadequate drainage. RESULTS： One hundred thirty-four patients （93 men, 41 women; 21 Bismuth type Ⅱ, 47Ⅲ, 66 Ⅳ; 34 ERBD, 66 EPTBD, 34 IPTBD） were recruited. There were no differences in demographics among the groups. Adequate initial relief of jaundice was achieved in 91% of patients without a significant difference in the results among different procedures or Bismuth types. The cumulative patency rates for ERBD and IPTBD were better than those for EPTBD with Bismuth type Ⅲ. IPTBD provided an excellent response for Bismuth type IV. However, there was no difference in the patency rate among drainage procedures for Bismuth type Ⅱ. Procedure-related cholangitis occurred less frequently with EPTBD than with ERBD and IPTBD. CONCLUSION： ERBD is recommended as the firstline drainage procedure for the palliation of jaundice in patients with inoperable Klatskin＇s tumor of Bismuth type Ⅱ or Ⅲ, but IPTBD is the best option for Bismuth type Ⅳ.

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 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.

Current surgical treatment for bile duct cancer

Since extrahepatic bile duct cancer is difficult to diagnose and to cure, a safe and radical surgical strategy is needed. In this review, the modes of infiltration and spread of extrahepatic bile duct cancer and surgical strategy are discussed. Extended hemihepatectomy, with or without pancreatoduodenectomy （PD）, plus extrahepatic bile duct resection and regional lyrnphadenectomy has recently been recognized as the standard curative treatment for hilar bile duct cancer. On the other hand, PD is the choice of treatment for middle and distal bile duct cancer. Major hepatectomy concomitant with PD （hepatopancreatoduodenectomy） has been applied to selected patients with widespread tumors. Preoperative biliary drainage （BD） followed by portal vein embolization （PVE） enables major hepatectomy in patients with hilar bile duct cancer without mortality. BD should be performed considering the surgical procedure, especially, in patients with separated intrahepatic bile ducts caused by hilar bile duct cancer. Right or left trisectoriectomy are indicated according to the tumor spread and biliary anatomy. As a result, extended radical resection offers a chance for cure of hilar bile duct cancer with improved resectability, curability, and a 5-year survival rate of 40%. A 5-year survival rate has ranged from 24% to 39% after PD for middle and distal bile duct cancer.

A comparison between monocanalicular and pushed monocanalicular silicone intubation in the treatment of congenital nasolacrimal duct obstruction

AIM: To compare the success rate of monocanalicular versus pushed monocanalicular silicone intubation(PMCI)of the nasolacrimal duct for congenital nasolacrimal duct obstruction(CNLDO).METHODS: In a prospective randomized clinical trial 53 eyes of 49 patients with CNLDO underwent either monocanalicular silicone intubation(MCI)(n =28 eyes) or PMCI(n =25 eyes). All procedures were performed by 1oculoplastic surgeon. Treatment success was defined as the complete resolution of epiphora at 3mo after tube removal.RESULTS: The surgical outcome was assessed in 20 eyes with MCI and 20 eyes with PMCI. The mean age of treatment was 26.25 ±10.08mo(range, 13-49mo) for MCI and 26.85±12.25mo(range, 16-68mo) for PMCI. Treatment success was achieved in 18 of 20 eyes(90.0%) in the MCI group compared with 10 of 20 eyes(50%) in the PMCI group(P =0.01). In the PMCI group, the tube loss(30%)was greater than the MCI group(5%), however the differences between the 2 groups proved to be not significant(P =0.91).CONCLUSION: Our results indicate that MCI has higher success rate in CNLDO treatment compared with PMCI in this small series of patients.

Iatrogenic bile duct injuries:Etiology,diagnosis and management

Iatrogenic bile duct injuries (IBDI) remain an important problem in gastrointestinal surgery. They are most frequently caused by laparoscopic cholecystectomy which is one of the commonest surgical procedures in the world. The early and proper diagnosis of IBDI is very important for surgeons and gastroenterologists, because unrecognized IBDI lead to serious complications such as biliary cirrhosis, hepatic failure and death. Laboratory and radiological investigations play an important role in the diagnosis of biliary injuries. There are many classifications of IBDI. The most popular and simple classification of IBDI is the Bismuth scale. Endoscopic techniques are recommended for initial treatment of IBDI. When endoscopic treatment is not effective, surgical management is considered. Different surgical reconstructions are performed in patients with IBDI. According to the literature, Roux- en-Y hepaticojejunostomy is the most frequent surgical reconstruction and recommended by most authors. In the opinion of some authors, a more physiological and equally effective type of reconstruction is end- to-end ductal anastomosis. Long term results are the most important in the assessment of the effectiveness of IBDI treatment. There are a few classifications for the long term results in patients treated for IBDI; the Terblanche scale, based on clinical biliary symptoms, is regarded as the most useful classification. Proper diagnosis and treatment of IBDI may avoid many serious complications and improve quality of life.

Non-surgical treatment of post-surgical bile duct injury: Clinical implications and outcomes

AIM: To investigate the prognostic factors determining the success rate of non-surgical treatment in the management of post-operative bile duct injuries (BDIs).

Endoscopic ultrasound guided biliary and pancreatic duct interventions

When endoscopic retrograde cholangio-pancreatog-raphy fails to decompress the pancreatic or biliary system, alternative interventions are required. In this situation, endosonography guided cholangio-pancrea-tography(ESCP), percutaneous radiological therapy or surgery can be considered. Small case series reporting the initial experience with ESCP have been superseded by comprehensive reports of large cohorts. Although these reports are predominantly retrospective, they demonstrate that endoscopic ultrasound(EUS) guided biliary and pancreatic interventions are associated with high levels of technical and clinical success. The proce-dural complication rates are lower than those seen with percutaneous therapy or surgery. This article describes and discusses data published in the last five years relat-ing to EUS-guided biliary and pancreatic intervention.

Endoscopic ultrasound-guided pancreaticogastrostomy for symptomatic pancreatic duct obstruction caused by migrated pancreatic stent

Endoscopic pancreatic stenting has been widely used in various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been recognized. Especially, proximal stent migration presents a serious condition because of subsequent pancreatic duct obstruction, impaired drainage, ductal dilation, and pancreatic pain. Although endoscopic retrieval is the preferred treatment for proximally migrated pancreatic stents, it is not always successful, resulting in conversion to surgery. To date, endoscopic ultrasound-guided pancreatic duct drainage(EUS-PD) has never been reported for treatment of pancreatic duct obstruction caused by proximally migrated pancreatic stent. We herein describe a case of pancreatic duct rupture and obstruction caused by proximally migrated pancreatic stent that was successfully treated by EUS-guided pancreaticogastrostomy while keeping the former stent in situ after failed endoscopic retrograde cholangiopancreatography. We believe that this report adds to the increasing evidence of symptomatic pancreatic duct obstruction being successfully treated by EUS-PD.

Spontaneous healing after conservative treatment of isolated grade IV pancreatic duct disruption caused by trauma:A case report

BACKGROUND Trauma is a common cause of pancreatic duct disruption.Surgical treatment is recommended in current clinical guidelines for adult pancreatic injury because non-surgical treatments have higher risks of serious complications or even death compared with surgical treatment.CASE SUMMARY A 22-year-old woman was admitted to Tiantai People’s Hospital of Zhejiang Province after 1-h duration of abdominal pain and distension following trauma.The diagnosis was“traumatic pancreatic rupture”.The patient’s symptoms were not severe,her vital signs were stable,and signs of peritonitis were not obvious.Therefore,conservative treatment could be considered,with the possibility of emergency surgery if necessary.After 2 mo of conservative treatment with duct drainage,the pancreatic duct healed spontaneously with no significant complications.CONCLUSION We report a case of pancreatic duct disruption in the head and neck caused by trauma that was treated conservatively and healed spontaneously,providing a new choice for clinical practice.For isolated pancreatic injury with rupture of the pancreatic duct in the head and neck,conservative treatment under close observation is feasible.

Biliary metal stents should be placed near the hilar duct in distal malignant biliary stricture patients

BACKGROUND Endoscopic biliary drainage using a self-expandable metallic stent(SEMS)has been widely performed to treat distal malignant biliary obstruction(DMBO).However,the optimal position of the stent remains unclear.AIM To determine the ideal position for SEMS placement.METHODS In total,135 DMBO patients underwent SEMS(uncovered or covered)placement over a ten-year period.A total of 127 patients with biliary obstruction between the junction of the cystic duct and Vater’s papilla were enrolled.An SEMS was placed through the upper common bile duct 2 cm from the biliary hilar duct in 83 patients(Hilar group)or near the top of the biliary obstruction in 44 patients(Lower group).Technical and functional success,adverse events,and risk factors for SEMS dysfunction were evaluated.RESULTS The stent patency period was significantly longer in the Hilar group than in the Lower group(P value<0.01).In multivariate analysis,the only statistically significant risk factor for SEMS dysfunction was being in the Lower group(hazard ratio:9.94,95%confidence interval:2.25–44.0,P<0.01).CONCLUSION A longer patency period was achieved by positioning the SEMS near the biliary hilar duct.

术前不同减黄策略对胰腺癌手术疗效及预后的影响研究

目的 观察术前不同减黄策略对胰腺癌患者手术疗效及预后的影响。方法 本研究为前瞻性研究,以郑州大学第一附属医院2021年1月至2022年12月收治的119例胰腺癌患者为研究对象,基于随机、对照原则,采用电脑分组法将入组患者分为A组(60例)、B组(59例),A组术前采用内镜下逆行胆管引流术(ERBD)治疗,B组术前采用经皮肝胆管穿刺引流术(PTBD)治疗,所有患者术后开展为期1年随访,比较2组患者的肝功能、凝血功能、营养状态、并发症发生、治疗及远期生存情况。结果 在不同术前减黄策略下,A组患者的丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、总胆红素(TBil)分别为(35±5)U/L、(35±5)U/L、(15±3)μmol/L,均低于B组[(39±5)U/L、(38±5)U/L、(18±3)μmol/L];A组患者的活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、凝血时间(TT)分别为(28±5)s、(11±3)s、(17±3)s,均低于B组[(32±5)s、(13±3)s、(19±3)s];A组患者的血红蛋白(Hb)、总蛋白(TA)、白蛋白(ALB)分别为(118±20)g/L、(66±10)g/L、(45±10)g/L,均高于B组[(104±20)g/L、(60±10)g/L、(40±10)g/L];A组患者的并发症发生率6.7%(4/60)低于B组20.3%(12/59);A组患者的减黄时间、住院时间、30 d内死亡率分别为(14±3)d、(35±5)d、1.7%(1/60),均低于B组[(17±3)d、(39±5)d、15.2%(9/59)];中位无进展生存期(PFS)、中位总生存期(OS)分别为(10.2±2.2)月、(11.5±3.2)月,均高于B组[(8.3±1.3)月、(9.4±2.2)月](P<0.05)。结论 术前实施ERBD能有效改善胰腺癌患者的肝功能、凝血功能及营养状态,对加快患者康复进程、降低并发症发生风险并延长生存周期均有积极意义。

LCBDE术中一期缝合与T管引流的术后胆漏发生率比较

目的比较腹腔镜胆总管探查术中(LCBDE)行一期缝合和T管引流的术后胆漏发生率,并分析术后胆漏的危险因素。方法回顾性分析2015年1月至2022年11月于温州医科大学附属第一医院行LCBDE的患者资料,分为一期缝合组和T管引流组,采用Logistic多因素回归分别分析两组发生胆漏的危险因素。对两组中有肝内结石、上段胆总管结石、最大结石直径、体温最高值和中性粒细胞百分比5项指标进行倾向性评分匹配(PSM)后,比较两组胆漏发生率。结果共纳入患者1052例,其中143例患者发生术后胆漏,发生率为13.5%。Logistic多因素回归分析显示年龄>60岁为一期缝合组(n=506)胆漏的危险因素(OR=2.242,95%CI 1.300-4.038,P=0.005),主刀医师实施LCBDE少于10例为T管引流组(n=546)胆漏的危险因素(OR=3.525,95%CI 1.469-7.996,P=0.003)。经PSM成功匹配383对患者,一期缝合组胆漏发生率较T管引流组高[15.1%(58/383)vs 9.9%(38/383),P=0.029]。结论患者年龄>60岁是行LCBDE术中一期缝合后发生胆漏的独立危险因素,医师经验不足(主刀医师实施LCBDE少于10例)是行留置T管后发生胆漏的独立危险因素。相较于一期缝合,留置T管引流可以降低LCBDE术后胆漏的发生率。