Change and significance of T-cell subsets and TNF-α in patients with advanced malignant obstructive jaundice treated by percutaneous transhepatic biliary external and internal drainage

The aim of this article was to study the influence of immunity function of advanced malignant obstructive jaundice(MOJ)treated by percutaneous transhepatic biliary external and internal drainage.Ninety-six cases of MOJ were divided into two groups according to the different ways of biliary drainage.Fifty-two external drainage tubes were placed in 41 cases of percutaneous transhepatic biliary exter-nal drainage group and 66 metal stents were placed in 55 cases of percutaneous transhepatic biliary internal drainage group.Liver function,serum TNF-α and cellular function were examined one day before operation and one week after operation and liver function was re-examined two weeks after operation,in order to observe the change and analyze the association among them and compare with the control group.All patients’conditions were improved after operation.In the percutaneous transhepatic biliary external and internal drainage groups,the total level of bilirubin decreased from(343.54±105.56)μmol/L and(321.19±110.50)μmol/L to(290.56±103.46)μmol/L and(283.72±104.95)μmol/L after operation respectively,which were significantly lower than pre-operation(P<0.05),but there was no significant difference between the two groups(P>0.05).Serum alanine aminotransferase(ALT)of all patients one week after opera-tion was significantly lower than that before operation.TNF-a in percutaneous transhepatic biliary external and internal groups decreased from(108.58±19.95)pg/mL,(109.98±16.24)pg/mL of pre-operation to(104.32±19.59)pg/mL,(83.92±13.43)pg/mL of post-operation respectively,there was notable improvement(P<0.01)in internal drainage group after operation.Patients’serum CD4,CD3 and CD4/CD8 were notably increased,but CD8 was notably decreased(P<0.05).There was no difference in external drainage group(P>0.05).There was a significant difference between the two groups.Serum TNF-α and ALT had positive correlation.Percutaneous transhepatic biliary internal or external drain-age was an effective and important method to treat MOJ.Patients’immune function was weak when they suffered MOJ,but body’s cellular immune function can be notably improved after internal biliary drainage.

Endoscopic management of gastrointestinal leaks and fistulae: Whatoption do we have?

Gastrointestinal leaks and fistulae are serious, potentially life threateningconditions that may occur with a wide variety of clinical presentations. Leaks aremostly related to post-operative anastomotic defects and are responsible for animportant share of surgical morbidity and mortality. Chronic leaks and longstanding post-operative collections may evolve in a fistula between twoepithelialized structures. Endoscopy has earned a pivotal role in the managementof gastrointestinal defects both as first line and as rescue treatment. Endotherapyis a minimally invasive, effective approach with lower morbidity and mortalitycompared to revisional surgery. Clips and luminal stents are the pioneer ofgastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closuredevices and techniques, such as endoscopic internal drainage, suturing systemand vacuum therapy, has broadened the indications of endoscopy for themanagement of GI wall defect. Although several endoscopic options are currentlyused, a standardized evidence-based algorithm for management of GI defect isnot available. Successful management of gastrointestinal leaks and fistulaerequires a tailored and multidisciplinary approach based on clinical presentation,defect features (size, location and onset time), local expertise and the availabilityof devices. In this review, we analyze different endoscopic approaches, which weselected on the basis of the available literature and our own experience. Then, weevaluate the overall efficacy and procedural-specific strengths and weaknesses ofeach approach.

Diagnosis and treatment for advanced hilar cholangiocarcinoma:experience of 24 cases

The aim of this paper is to evaluate the effi-cacy of the surgical treatment for advanced hilar cholan-giocarcinoma(CCA)in order to improve the resection rate and curative effect.A retrospective analysis was performed on the data of 24 patients who had under-gone surgical treatment for advanced hilar CCA.According to the Bismuth classification,there were four cases of type IIIa,six cases of type IIIb,and 14 cases of type IV.Based on the treatment approaches,these patients were divided into three groups:①Radical resection group:There were five cases(one type IIIa,three type IIIb,and one type IV).The tumor visible to the naked eyes was resected thoroughly and the cut mar-gin was free of tumor by microscopic examination.Then,Roux-en-Y hepatico-jejunal anastomosis was per-formed to restore the bile flow.②Palliative resection group:There were 11 cases.The bile flow was restored by Roux-en-Y hepatico-jejunal anastomosis directly in five cases(two type IIIa,three type IIIb)and by internal drainage through a hepatico-jejunal bridge in the other six cases(one type IIIa,five type IV).③Simple internal biliary drainage group:There were eight cases of type IV,including three cases with the internal drainage through hepatico-jejunal bridge by laparotomy,three cases with endoscopic retrograde biliary drainage(ERBD),two cases with percutaneous transhepatic biliary drainage(PTBD).The rate of radical resection was 20.8%and the overall resection rate was 66.7%.All of the 24 patients were fol-lowed-up.The cumulative surviving rates were significantly different among these three groups(Log-rank x2=17.56,P=0.0002).For advanced hilar CCA,the best choice of treatment is radical resection.If radical resection is impractical,palliative resection combined with partial hepatectomy can significantly prolong the survival time.Internal drainage through a hepatico-jejunal bridge can enhance the surgical resection rate and decrease the occur-rence rate of postoperative biliary leakage.