BACKGROUND: Significant bile leak as an uncommon complication after biliary tract surgery may constitute a serious and difficult management problem. Surgical management of biliary fistulae is associated with high morb...BACKGROUND: Significant bile leak as an uncommon complication after biliary tract surgery may constitute a serious and difficult management problem. Surgical management of biliary fistulae is associated with high morbidity and mortality. Biliary endoscopic procedures have become the treatment of choice for management of biliary Gstulae. METHODS: Ninety patients presented with bile leaks after cholecystectomy ( open cholecystectomy in 45 patients, cholecystectomy with common bile duct exploration in 20 and laparoscopic cholecystectomy in 25). The presence of bile leaks was confirmed by ERCP and the appearance of bile in percutaneous drainage of abdominal collections. Of the 90 patients with postoperative bile leaks, 18 patients had complete transaction of the common bile duct by ERCP and were subjected to bilioenteric anastomosis. In the remaining patients after cholangiography and localization of the site of bile leaks. therapeutic procedures like sphinctero-tomy, biliary stenting and nasobiliary drainage ( NBD ) were performed. If residual stones were seen in the common bile duct, sphincterotomy was followed by stone extraction using dormia basket. Nasobiliary drain or stents of 7F size were placed according to the standard techniques. The NBD was removed when bile leak stopped and closure of the fistula confirmed cholangiographically. The stents were removed after an interval of 6-8 weeks. RESULTS: Bile leaks in 72 patients occurred in the cystic duct (38 patients), the common bile duct (30 ), and the right hepatic duct (4). Of the 72 patients with post-operative bile leak, 24 had associated retained common bile duct stones and 1 had ascaris in common bile duct. All the 72 patients were subjected to therapeutic procedures including sphincterotomy with stone extraction followed by biliary stenting (24 patients), removal of ascaris and biliary stenting (1), sphincterotomy with biliary stenting (18), sphincterotomy with NBD (12), biliary stenting alone (12), and NBD alone (5). Bile leaks stopped in all patients at展开更多
AIM:To evaluate the effect of photodynamic therapy (PDT) on metal stent patency in patients with unresectable hilar cholangiocarcinoma (CC). METHODS:This was a retrospective analysis of patients with hilar CC referred...AIM:To evaluate the effect of photodynamic therapy (PDT) on metal stent patency in patients with unresectable hilar cholangiocarcinoma (CC). METHODS:This was a retrospective analysis of patients with hilar CC referred to our institution from December, 1999 to January, 2011. Out of 232 patients, thirty-three patients with unresectable hilar CC were treated. Eighteen patients in the PDT group were treated with uncovered metal stents after one session of PDT. Fifteen patients in the control group were treated with metal stents alone. Porfimer sodium (2 mg/kg) was administered intravenously to PDT patients. Fortyeight hours later, PDT was administered using a diffusing fiber that was advanced across the tumor by either endoscopic retrograde cholangiopancreatography or percutaneous cholangiography. After performance of PDT, uncovered metal stents were inserted to ensure adequate decompression and bile drainage. Patient survival rates and cumulative stent patency were calculated using Kaplan-Meier analysis with the log-rank test. RESULTS:The PDT and control patients were comparable with respect to age, gender, health status, pretreatment bilirubin, and hilar CC stage. When compared to control, the PDT group was associated with significantly prolonged stent patency (median 244 ± 66 and 177 ± 45 d, respectively, P = 0.002) and longer patient survival (median 356 ± 213 and 230 ± 73 d, respectively, P = 0.006). Early complication rates were similar between the groups (PDT group 17%, control group 13%) and all patients were treated conservatively. Stent malfunctions occurred in 14 PDT patients (78%) and 12 control patients (80%). Of these 26 patients, twenty-two were treated endoscopically and four were treated with external drainage. CONCLUSION:Metal stenting after one session of PDT may be safe with acceptable complication rates. The PDT group was associated with a significantly longer stent patency than the control group in patients with unresectable hilar CC.展开更多
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 ...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.展开更多
AIM:To compare efficacy and complications of par-tially covered self-expandable metal stent(pcSEMS)to plastic stent(PS)in patients treated for malignant,infrahilar biliary obstruction.METHODS:Multicenter prospective r...AIM:To compare efficacy and complications of par-tially covered self-expandable metal stent(pcSEMS)to plastic stent(PS)in patients treated for malignant,infrahilar biliary obstruction.METHODS:Multicenter prospective randomized clinical trial with treatment allocation to a pcWallstent(SEMS)or a 10 French PS.Palliative patients aged≥18,for infrahilar malignant biliary obstruction and a Karnofsky performance scale index>60%from 6 participating North American university centers.Primary endpoint was time to stent failure,with secondary outcomes of death,adverse events,Karnofsky performance score and short-form-36 scale administered on a three-monthly basis for up to 2 years.Survival analyses were performed for stent failure and death,with Cox proportional hazards regression models to determine significant predictive characteristics.RESULTS:Eighty-five patients were accrued over 37mo,42 were randomized to the SEMS group and 83patients were available for analyses.Time to stent failure was 385.3±52.5 d in the SEMS and 153.3±19.8 d in the PS group,P=0.006.Time to death did not differ between groups(192.3±23.4 d for SEMS vs211.5±28.0 d for PS,P=0.70).The only significant predictor was treatment allocation,relating to the time to stent failure(P=0.01).Amongst other measured outcomes,only cholangitis differed,being more common in the PS group(4.9%vs 24.5%,P=0.029).The small number of patients in follow-up limits longitudinal assessments of performance and quality of life.From an initially planned 120 patients,only 85 patients were recruited.CONCLUSION:Partially covered SEMS result in a longer duration till stent failure without increased complication rates,yet without accompanying measurable benefits in survival,performance,or quality of life.展开更多
AIM To evaluate the feasibility of repairing a common bile duct defect with a decellularized ureteral graft in a porcine model.METHODS Eighteen pigs were randomly divided into three groups. An approximately 1 cm segme...AIM To evaluate the feasibility of repairing a common bile duct defect with a decellularized ureteral graft in a porcine model.METHODS Eighteen pigs were randomly divided into three groups. An approximately 1 cm segment of the common bile duct was excised from all the pigs. The defect was repaired using a 2 cm long decellularized ureteral graft over a T-tube(T-tube group, n = 6) or a silicone stent(stent group, n = 6). Six pigs underwent bile duct reconstruction with a graft alone(stentless group). The surviving animals were euthanized at 3 mo. Specimens of the common bile ducts were obtained for histological analysis.RESULTS The animals in the T-tube and stent groups survived until sacrifice. The blood test results were normal in both groups. The histology results showed a biliary epithelial layer covering the neo-bile duct. In contrast, all the animals in the stentless group died due to biliary peritonitis and cholangitis within two months post-surgery. Neither biliary epithelial cells nor accessory glands were observed at the graft sites in the stentless group.CONCLUSION Repair of a common bile duct defect with a decellularized ureteral graft appears to be feasible. A T-tube or intraluminal stent was necessary to reduce postoperative complications.展开更多
AIM To investigate whether an uncovered self-expandable metal stent(UCSEMS) with a large diameter could prevent recurrent biliary obstruction(RBO).METHODS Thirty-eight patients with malignant biliary obstruction under...AIM To investigate whether an uncovered self-expandable metal stent(UCSEMS) with a large diameter could prevent recurrent biliary obstruction(RBO).METHODS Thirty-eight patients with malignant biliary obstruction underwent treatment with an UCSEMS with a 14-mm diameter(Niti-S 14). Retrospectively, we evaluated technical and functional success rate, RBO rate, time to RBO, survival time, and adverse events in these patients.RESULTS Stent placement success and functional success were achieved in all patients. Two patients(5.3%) had RBO due to tumor ingrowth or overgrowth. The median time to RBO was 190(range, 164-215) d. The median survival time was 120(range, 18-502) d. The 6-mo non-RBO rate was 91%. Other adverse events other than RBO occurred as follows: Acute cholecystitis, post-ERCP pancreatitis, hemobilia, and fever without exacerbation of liver injury, and liver abscess in 4(10.3%), 3(7.9%), 2(5.3%), 1(2.6%), and 1(2.6%), respectively. Migration of the stents was not observed.CONCLUSION Niti-S 14 is considered to be a preferable metal stent because of a low rate of RBO with no migration.展开更多
BACKGROUND Pancreatic adenoma can potentially transform into adenocarcinoma, so it is recommended to be resected surgically or endoscopically. Endoscopic papillectomy is one of the main treatments for papillary adenom...BACKGROUND Pancreatic adenoma can potentially transform into adenocarcinoma, so it is recommended to be resected surgically or endoscopically. Endoscopic papillectomy is one of the main treatments for papillary adenoma, and bleeding, perforation, and pancreatitis are the most frequent and critical adverse events that restrict its wider use. There is no standard procedure for endoscopic papillectomy yet. The procedure is relevant to postoperative adverse events.AIM To reduce the postoperative adverse event rates and improve patients' postoperative condition, we developed a standard novel procedure for endoscopic papillectomy.METHODS The novel endoscopic papillectomy had two main modifications based on the conventional method: The isolation of bile from pancreatic juice with a bile duct stent and wound surface protection with metal clips and fibrin glue. We performed a single-center retrospective comparison study on the novel and conventional methods to examine the feasibility of the novel method for reducing postoperative adverse events.RESULTS A total of 76 patients, of whom 23 underwent the novel procedure and 53 underwent the conventional procedure, were retrospectively evaluated in this study. The postoperative bleeding and pancreatitis rates of the novel method were significantly lower than those of the conventional method(0 vs 20.75%, P = 0.028, and 17.4% vs 41.5%, P = 0.042, respectively). After applying the novel method, the most critical adverse event, perforation, was entirely prevented, compared to a prevalence of 5.66% with the conventional method. Several postoperative symptoms, including fever, rapid pulse, and decrease in hemoglobin level, were significantly less frequent in the novel group(P = 0.042, 0.049, and 0.014, respectively). Overall, the total adverse event rate of the novel method was lower(0 vs 24.5%, P = 0.007) than that of the conventional method.CONCLUSION Patients who underwent the novel procedure had lower postoperative adverse event rates. This study demonstrates the potential effic展开更多
In this case report we present an elderly patient who was referred to our hospital with recurrent episodes of cholangitis that persisted after placement of fi ve metal stents for a distal common bile duct(CBD) stenosi...In this case report we present an elderly patient who was referred to our hospital with recurrent episodes of cholangitis that persisted after placement of fi ve metal stents for a distal common bile duct(CBD) stenosis.All metal stents were endoscopically removed from the CBD by forceps after balloon dilatation of the papilla.A profoundly dilated CBD with sludge and concrements was seen.To ensure adequate bile drainage an enteral metal stent was inserted in the CBD.This case shows that proximally migrated uncovered metal stents in the CBD can be safely removed endoscopically under certain circumstances.We suggest that in the case of a CBD drainage problem due to an extremely dilated CBD,placement of an enteral metal stent in the CBD could be considered,especially in patients who are unfi t for surgery.展开更多
BACKGROUND:Endoscopic retrograde cholangiopancrea-tography(ERCP)is widely used to manage post-cholecystectomy bile leaks.However,the best endoscopic intervention remains controversial.We investigated the success of a ...BACKGROUND:Endoscopic retrograde cholangiopancrea-tography(ERCP)is widely used to manage post-cholecystectomy bile leaks.However,the best endoscopic intervention remains controversial.We investigated the success of a 7 French double pigtail stent following sphincterotomy in the management of such bile leaks. METHODS:Between July 1998 and June 2008,48 patients were referred for ERCP for presumed post-cholecystectomy bile leaks.Leaks were confirmed at ERCP and managed by a combination of sphincterotomy and stent insertion unless contraindicated. RESULTS:Bile duct cannulation was successful in 44(91.7%)patients.A leak of the cystic duct was demonstrated in 19(43.2%)patients,the duct of Luschka in 11(25.0%),and the common hepatic duct in 5 (11.4%).Complete transection of the common bile duct occurred in 4 patients.The remaining patients had no cholangiographic evidence of a leak.Sphincterotomy was performed in 34 patients.A 7 French double pigtail plastic stent was placed in all 35 patients with cholangiographic evidence of a bile leak.No bile leaks were demonstrated at a follow-up of 8-16 weeks and all stents were removed successfully. CONCLUSION:The combination of sphincterotomy and insertion of a 7 French double pigtail stent results in excellent outcomes in the management of post-cholecystectomy bile leaks.展开更多
Background It is difficult and time-consuming for carrying out conventional hand-sewn bilioenteric anastomosis, especially for small bile duct anastomosis and laparoscopic procedure. In order to simplify it, we have d...Background It is difficult and time-consuming for carrying out conventional hand-sewn bilioenteric anastomosis, especially for small bile duct anastomosis and laparoscopic procedure. In order to simplify it, we have developed a novel procedure of sutureless bilioenteric anastomosis with an intraluminal degradable stent. This study aimed to evaluate the feasibility and safety of this technique with cholangioduodenostomy in dog model. Methods A patent intraluminal degradable stent tube for sutureless choledochoduodenostomy in dog model was made with polylactic acid in diameter of 3 mm or 4 mm. Thirty-eight dogs were randomly divided into to a stent group （SG, n=20） and a control group （CG, n=18）. Dogs in the SG underwent sutureless choledochoduodenostomy with intraluminal stent, while the CG underwent conventional choledochoduodenostomy （single layer discontinuous anastomosis with absorbable suture）. Dogs of each group were divided into 4 subgroups according to time of death （1,3, 6, and 12 months postoperatively） to evaluate the healing of anastomosis. Operation time, intraoperative tolerance pressure of anastomosis, rate of postoperative bile leakage, bursting pressure of anastomosis were compared between the two groups. Anastomosis tissue was observed afterwards by pathology evaluation, hydroxyproline content, serum bilirubin, liver enzyme level and magnetic resonance cholangio-pancreatography （MRCP） to assess the stricture. Results All procedures were completed successfully. The surgical time of the SG was significantly less than the CG （SG： （19.2±4.3） minutes, vs. CG： （29.2±7.1） minutes, P=0.000）. One bile leakage was occurred in either group. No significant difference of intraoperative tolerance pressure of anastomosis, rate of bile leakage and postoperative bursting pressure of anastomosis, anastomotic stricture, hydroxyproline content, serum bilirubin and liver enzyme level was found between the two groups. MRCP showed no anastomosis stricture and obstruction during mon展开更多
Objective： To evaluate the effect of a new-type sutureless magnetic bilioenteric anastomosis stent that was used to reconstruct the bilioenteric continuity （primarily under the circumstances of severe inflammation a...Objective： To evaluate the effect of a new-type sutureless magnetic bilioenteric anastomosis stent that was used to reconstruct the bilioenteric continuity （primarily under the circumstances of severe inflammation after acute bile duct injury in dogs ）. Methods： Establishing an animal model of acute bile duct injury with severe inflammation and bile peritonitis in dogs. The newtype sutureless magnetic bilioenteric anastomosis stent was used to reconstruct the bilioenteric continuity primarily. Results： The experiment group anastomosis healed well with a mild local inflammation reaction, and the collagen lined up in order without the occurrence of observable bile leakage and infection. Conclusion： It was safe and feasible to use the new-type anastomosis stent to reconstruct the bilioenteric continuity primarily under the circumstances of severe inflammation after acute bile duct injury in dogs.展开更多
BACKGROUND Breast cancer is the most common tumor in women,and about one-third of cases develop metastatic disease.However,metastatic breast cancer rarely invades the common bile duct(CBD)directly without involving th...BACKGROUND Breast cancer is the most common tumor in women,and about one-third of cases develop metastatic disease.However,metastatic breast cancer rarely invades the common bile duct(CBD)directly without involving the liver,and involvement of the gastrointestinal tract is rare.Cases of such metastases pose a particular diagnostic challenge.CASE SUMMARY A 55-year-old female presented to the Department of Gastroenterology with complaint of a 2 mo history of right upper abdominal pain accompanied by pain in the right back,aggravated after eating greasy diet.The patient had received a diagnosis of breast cancer 3 years prior.Physical examination showed obvious superficial protuberant erythema on the left neck and chest skin,with slight tenderness and burning sensation.Endoscopic retrograde cholangiopancreatography showed an obstruction at the end of the CBD.Histopathology of the CBD and symptomatic skin biopsies showed positivity for cytokeratin 7 and trans-acting T-cell-specific transcription factor breast cancer biomarkers.A cancer embolus was also found in the skin vasculature.Accordingly,the diagnosis of breast cancer metastases to the skin and biliary ducts was made.A plastic biliary sent was placed,which relieved the right upper abdominal pain and protected against unnecessary hepatectomy surgery.CONCLUSION Although rare,biliary metastasis should be considered in patients with bile duct stenosis and a history of breast cancer.展开更多
BACKGROUND Conventional endoscopic papillectomy(EP)is safe and effective for the treatment of small papilla adenoma to even large laterally spreading tumors of duodenum lesions.As reported by some existing studies,tem...BACKGROUND Conventional endoscopic papillectomy(EP)is safe and effective for the treatment of small papilla adenoma to even large laterally spreading tumors of duodenum lesions.As reported by some existing studies,temporarily placing a prophylactic stent in the pancreatic and bile duct can lower the risk of this perioperative complication.AIM To evaluate the usefulness,convenience,safety,and short-term results of a novel autorelease bile duct supporter after EP procedure,especially the effectiveness in preventing EP.METHODS A single-center comparison study was conducted to verify the feasibility of the novel method.After EP,a metallic endoclip and human fibrin sealant kit were applied for protection.The autorelease bile duct supporter fell into the duct segment and the intestinal segment.Specifically,the intestinal segment was extended by nearly 5 cm as a bent coil.The bile was isolated from the pancreatic juice using an autorelease bile duct supporter,which protected the wound surface.The autorelease bile duct supporter fell off naturally and arrived in colon nearly 10 d after the operation.RESULTS En bloc endoscopic resection was performed in 6/8 patients(75%),and piecemeal resection was performed in 2/8 of patients(25%).None of the above patients were positive for neoplastic lymph nodes or distant metastasis.No cases of mortality,hemorrhage,delayed perforation,pancreatitis,cholangitis or duct stenosis with the conventional medical treatment were reported.The autorelease bile duct supporter in 7 of 8 patients fell off naturally and arrived in colon 10 d after the operation.One autorelease bile duct supporter was successfully removed using forceps or snare under endoscopy.No recurrence was identified during the 8-mo(ranging from 6-9 mo)follow-up period.CONCLUSION In brief,it was found that the autorelease bile duct supporter could decrease the frequency of procedure-associated complications without second endoscopic retraction.Secure closure of the resection wound with clips and fibrin glue were indicated to be 展开更多
AIM: To present a case of methicillin-resistant Staphylococcus aureus (MRSA) infection following bile duct stenting in a patient with malignant biliary obstruction.METHODS: A 78-year-old male patient was admitted to a...AIM: To present a case of methicillin-resistant Staphylococcus aureus (MRSA) infection following bile duct stenting in a patient with malignant biliary obstruction.METHODS: A 78-year-old male patient was admitted to a community hospital with progredient painless jaundice lasting over two weeks, weight loss and sweating at night.Whether a stent should be implanted pre-operatively in jaundiced patients or whether these patients should directly undergo surgical resection, was discussed.RESULTS: ERC and a biopsy from the papilla of Vater revealed an adenocarcinoma. In addition, a 7-Ch plastic stent was placed into the common bile duct. Persistent abdominal pain, increasing jaundice, weakness and indigestion led to the transfer of the patient to our hospital.A pylorus-preserving pancreatoduodenectomy wasperformed. Intraoperatively, bile leaked out of the transected choledochus andthe stent was found to be dislocated in the duodenum. A smear of the bile revealed an infection with MRSA, leading to post-operative isolation of the patient.CONCLUSION:As biliary stents can cause severe infection of the bile, the need for pre-operative placement of biliary stents should be carefully evaluated in each individual case.展开更多
文摘BACKGROUND: Significant bile leak as an uncommon complication after biliary tract surgery may constitute a serious and difficult management problem. Surgical management of biliary fistulae is associated with high morbidity and mortality. Biliary endoscopic procedures have become the treatment of choice for management of biliary Gstulae. METHODS: Ninety patients presented with bile leaks after cholecystectomy ( open cholecystectomy in 45 patients, cholecystectomy with common bile duct exploration in 20 and laparoscopic cholecystectomy in 25). The presence of bile leaks was confirmed by ERCP and the appearance of bile in percutaneous drainage of abdominal collections. Of the 90 patients with postoperative bile leaks, 18 patients had complete transaction of the common bile duct by ERCP and were subjected to bilioenteric anastomosis. In the remaining patients after cholangiography and localization of the site of bile leaks. therapeutic procedures like sphinctero-tomy, biliary stenting and nasobiliary drainage ( NBD ) were performed. If residual stones were seen in the common bile duct, sphincterotomy was followed by stone extraction using dormia basket. Nasobiliary drain or stents of 7F size were placed according to the standard techniques. The NBD was removed when bile leak stopped and closure of the fistula confirmed cholangiographically. The stents were removed after an interval of 6-8 weeks. RESULTS: Bile leaks in 72 patients occurred in the cystic duct (38 patients), the common bile duct (30 ), and the right hepatic duct (4). Of the 72 patients with post-operative bile leak, 24 had associated retained common bile duct stones and 1 had ascaris in common bile duct. All the 72 patients were subjected to therapeutic procedures including sphincterotomy with stone extraction followed by biliary stenting (24 patients), removal of ascaris and biliary stenting (1), sphincterotomy with biliary stenting (18), sphincterotomy with NBD (12), biliary stenting alone (12), and NBD alone (5). Bile leaks stopped in all patients at
文摘AIM:To evaluate the effect of photodynamic therapy (PDT) on metal stent patency in patients with unresectable hilar cholangiocarcinoma (CC). METHODS:This was a retrospective analysis of patients with hilar CC referred to our institution from December, 1999 to January, 2011. Out of 232 patients, thirty-three patients with unresectable hilar CC were treated. Eighteen patients in the PDT group were treated with uncovered metal stents after one session of PDT. Fifteen patients in the control group were treated with metal stents alone. Porfimer sodium (2 mg/kg) was administered intravenously to PDT patients. Fortyeight hours later, PDT was administered using a diffusing fiber that was advanced across the tumor by either endoscopic retrograde cholangiopancreatography or percutaneous cholangiography. After performance of PDT, uncovered metal stents were inserted to ensure adequate decompression and bile drainage. Patient survival rates and cumulative stent patency were calculated using Kaplan-Meier analysis with the log-rank test. RESULTS:The PDT and control patients were comparable with respect to age, gender, health status, pretreatment bilirubin, and hilar CC stage. When compared to control, the PDT group was associated with significantly prolonged stent patency (median 244 ± 66 and 177 ± 45 d, respectively, P = 0.002) and longer patient survival (median 356 ± 213 and 230 ± 73 d, respectively, P = 0.006). Early complication rates were similar between the groups (PDT group 17%, control group 13%) and all patients were treated conservatively. Stent malfunctions occurred in 14 PDT patients (78%) and 12 control patients (80%). Of these 26 patients, twenty-two were treated endoscopically and four were treated with external drainage. CONCLUSION:Metal stenting after one session of PDT may be safe with acceptable complication rates. The PDT group was associated with a significantly longer stent patency than the control group in patients with unresectable hilar CC.
基金Supported by The 2012 Inje University Research Grant
文摘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.
基金Supported by Research Funding from Boston Scientific Inc to Barkun ANResearch Funding from Cook Endoscopy to Branch MSResearch Funding from Pentax Corp to Kowalski TE
文摘AIM:To compare efficacy and complications of par-tially covered self-expandable metal stent(pcSEMS)to plastic stent(PS)in patients treated for malignant,infrahilar biliary obstruction.METHODS:Multicenter prospective randomized clinical trial with treatment allocation to a pcWallstent(SEMS)or a 10 French PS.Palliative patients aged≥18,for infrahilar malignant biliary obstruction and a Karnofsky performance scale index>60%from 6 participating North American university centers.Primary endpoint was time to stent failure,with secondary outcomes of death,adverse events,Karnofsky performance score and short-form-36 scale administered on a three-monthly basis for up to 2 years.Survival analyses were performed for stent failure and death,with Cox proportional hazards regression models to determine significant predictive characteristics.RESULTS:Eighty-five patients were accrued over 37mo,42 were randomized to the SEMS group and 83patients were available for analyses.Time to stent failure was 385.3±52.5 d in the SEMS and 153.3±19.8 d in the PS group,P=0.006.Time to death did not differ between groups(192.3±23.4 d for SEMS vs211.5±28.0 d for PS,P=0.70).The only significant predictor was treatment allocation,relating to the time to stent failure(P=0.01).Amongst other measured outcomes,only cholangitis differed,being more common in the PS group(4.9%vs 24.5%,P=0.029).The small number of patients in follow-up limits longitudinal assessments of performance and quality of life.From an initially planned 120 patients,only 85 patients were recruited.CONCLUSION:Partially covered SEMS result in a longer duration till stent failure without increased complication rates,yet without accompanying measurable benefits in survival,performance,or quality of life.
基金Supported by National Natural Science Foundation of China,No.30972923
文摘AIM To evaluate the feasibility of repairing a common bile duct defect with a decellularized ureteral graft in a porcine model.METHODS Eighteen pigs were randomly divided into three groups. An approximately 1 cm segment of the common bile duct was excised from all the pigs. The defect was repaired using a 2 cm long decellularized ureteral graft over a T-tube(T-tube group, n = 6) or a silicone stent(stent group, n = 6). Six pigs underwent bile duct reconstruction with a graft alone(stentless group). The surviving animals were euthanized at 3 mo. Specimens of the common bile ducts were obtained for histological analysis.RESULTS The animals in the T-tube and stent groups survived until sacrifice. The blood test results were normal in both groups. The histology results showed a biliary epithelial layer covering the neo-bile duct. In contrast, all the animals in the stentless group died due to biliary peritonitis and cholangitis within two months post-surgery. Neither biliary epithelial cells nor accessory glands were observed at the graft sites in the stentless group.CONCLUSION Repair of a common bile duct defect with a decellularized ureteral graft appears to be feasible. A T-tube or intraluminal stent was necessary to reduce postoperative complications.
文摘AIM To investigate whether an uncovered self-expandable metal stent(UCSEMS) with a large diameter could prevent recurrent biliary obstruction(RBO).METHODS Thirty-eight patients with malignant biliary obstruction underwent treatment with an UCSEMS with a 14-mm diameter(Niti-S 14). Retrospectively, we evaluated technical and functional success rate, RBO rate, time to RBO, survival time, and adverse events in these patients.RESULTS Stent placement success and functional success were achieved in all patients. Two patients(5.3%) had RBO due to tumor ingrowth or overgrowth. The median time to RBO was 190(range, 164-215) d. The median survival time was 120(range, 18-502) d. The 6-mo non-RBO rate was 91%. Other adverse events other than RBO occurred as follows: Acute cholecystitis, post-ERCP pancreatitis, hemobilia, and fever without exacerbation of liver injury, and liver abscess in 4(10.3%), 3(7.9%), 2(5.3%), 1(2.6%), and 1(2.6%), respectively. Migration of the stents was not observed.CONCLUSION Niti-S 14 is considered to be a preferable metal stent because of a low rate of RBO with no migration.
基金Supported by National Key R and D Program of China,No. 2016YFC1303601。
文摘BACKGROUND Pancreatic adenoma can potentially transform into adenocarcinoma, so it is recommended to be resected surgically or endoscopically. Endoscopic papillectomy is one of the main treatments for papillary adenoma, and bleeding, perforation, and pancreatitis are the most frequent and critical adverse events that restrict its wider use. There is no standard procedure for endoscopic papillectomy yet. The procedure is relevant to postoperative adverse events.AIM To reduce the postoperative adverse event rates and improve patients' postoperative condition, we developed a standard novel procedure for endoscopic papillectomy.METHODS The novel endoscopic papillectomy had two main modifications based on the conventional method: The isolation of bile from pancreatic juice with a bile duct stent and wound surface protection with metal clips and fibrin glue. We performed a single-center retrospective comparison study on the novel and conventional methods to examine the feasibility of the novel method for reducing postoperative adverse events.RESULTS A total of 76 patients, of whom 23 underwent the novel procedure and 53 underwent the conventional procedure, were retrospectively evaluated in this study. The postoperative bleeding and pancreatitis rates of the novel method were significantly lower than those of the conventional method(0 vs 20.75%, P = 0.028, and 17.4% vs 41.5%, P = 0.042, respectively). After applying the novel method, the most critical adverse event, perforation, was entirely prevented, compared to a prevalence of 5.66% with the conventional method. Several postoperative symptoms, including fever, rapid pulse, and decrease in hemoglobin level, were significantly less frequent in the novel group(P = 0.042, 0.049, and 0.014, respectively). Overall, the total adverse event rate of the novel method was lower(0 vs 24.5%, P = 0.007) than that of the conventional method.CONCLUSION Patients who underwent the novel procedure had lower postoperative adverse event rates. This study demonstrates the potential effic
文摘In this case report we present an elderly patient who was referred to our hospital with recurrent episodes of cholangitis that persisted after placement of fi ve metal stents for a distal common bile duct(CBD) stenosis.All metal stents were endoscopically removed from the CBD by forceps after balloon dilatation of the papilla.A profoundly dilated CBD with sludge and concrements was seen.To ensure adequate bile drainage an enteral metal stent was inserted in the CBD.This case shows that proximally migrated uncovered metal stents in the CBD can be safely removed endoscopically under certain circumstances.We suggest that in the case of a CBD drainage problem due to an extremely dilated CBD,placement of an enteral metal stent in the CBD could be considered,especially in patients who are unfi t for surgery.
文摘BACKGROUND:Endoscopic retrograde cholangiopancrea-tography(ERCP)is widely used to manage post-cholecystectomy bile leaks.However,the best endoscopic intervention remains controversial.We investigated the success of a 7 French double pigtail stent following sphincterotomy in the management of such bile leaks. METHODS:Between July 1998 and June 2008,48 patients were referred for ERCP for presumed post-cholecystectomy bile leaks.Leaks were confirmed at ERCP and managed by a combination of sphincterotomy and stent insertion unless contraindicated. RESULTS:Bile duct cannulation was successful in 44(91.7%)patients.A leak of the cystic duct was demonstrated in 19(43.2%)patients,the duct of Luschka in 11(25.0%),and the common hepatic duct in 5 (11.4%).Complete transection of the common bile duct occurred in 4 patients.The remaining patients had no cholangiographic evidence of a leak.Sphincterotomy was performed in 34 patients.A 7 French double pigtail plastic stent was placed in all 35 patients with cholangiographic evidence of a bile leak.No bile leaks were demonstrated at a follow-up of 8-16 weeks and all stents were removed successfully. CONCLUSION:The combination of sphincterotomy and insertion of a 7 French double pigtail stent results in excellent outcomes in the management of post-cholecystectomy bile leaks.
基金This study was supported by grants from the National Natural Science Foundation of China （No. 30772132）, the Natural Science Foundation of Zhejiang Province （No. Y206154, No.Y208511） and the Hi-tech Research and Development Program of China （863 Program No. 2007AA02Z446）.
文摘Background It is difficult and time-consuming for carrying out conventional hand-sewn bilioenteric anastomosis, especially for small bile duct anastomosis and laparoscopic procedure. In order to simplify it, we have developed a novel procedure of sutureless bilioenteric anastomosis with an intraluminal degradable stent. This study aimed to evaluate the feasibility and safety of this technique with cholangioduodenostomy in dog model. Methods A patent intraluminal degradable stent tube for sutureless choledochoduodenostomy in dog model was made with polylactic acid in diameter of 3 mm or 4 mm. Thirty-eight dogs were randomly divided into to a stent group （SG, n=20） and a control group （CG, n=18）. Dogs in the SG underwent sutureless choledochoduodenostomy with intraluminal stent, while the CG underwent conventional choledochoduodenostomy （single layer discontinuous anastomosis with absorbable suture）. Dogs of each group were divided into 4 subgroups according to time of death （1,3, 6, and 12 months postoperatively） to evaluate the healing of anastomosis. Operation time, intraoperative tolerance pressure of anastomosis, rate of postoperative bile leakage, bursting pressure of anastomosis were compared between the two groups. Anastomosis tissue was observed afterwards by pathology evaluation, hydroxyproline content, serum bilirubin, liver enzyme level and magnetic resonance cholangio-pancreatography （MRCP） to assess the stricture. Results All procedures were completed successfully. The surgical time of the SG was significantly less than the CG （SG： （19.2±4.3） minutes, vs. CG： （29.2±7.1） minutes, P=0.000）. One bile leakage was occurred in either group. No significant difference of intraoperative tolerance pressure of anastomosis, rate of bile leakage and postoperative bursting pressure of anastomosis, anastomotic stricture, hydroxyproline content, serum bilirubin and liver enzyme level was found between the two groups. MRCP showed no anastomosis stricture and obstruction during mon
基金The study was supported by science and technology project founda-tion of Shanxi Province of China. (2005K11-G4)
文摘Objective： To evaluate the effect of a new-type sutureless magnetic bilioenteric anastomosis stent that was used to reconstruct the bilioenteric continuity （primarily under the circumstances of severe inflammation after acute bile duct injury in dogs ）. Methods： Establishing an animal model of acute bile duct injury with severe inflammation and bile peritonitis in dogs. The newtype sutureless magnetic bilioenteric anastomosis stent was used to reconstruct the bilioenteric continuity primarily. Results： The experiment group anastomosis healed well with a mild local inflammation reaction, and the collagen lined up in order without the occurrence of observable bile leakage and infection. Conclusion： It was safe and feasible to use the new-type anastomosis stent to reconstruct the bilioenteric continuity primarily under the circumstances of severe inflammation after acute bile duct injury in dogs.
基金Top-level Clinical Discipline Project of Shanghai Pudong,No.PWYgf2018-04.
文摘BACKGROUND Breast cancer is the most common tumor in women,and about one-third of cases develop metastatic disease.However,metastatic breast cancer rarely invades the common bile duct(CBD)directly without involving the liver,and involvement of the gastrointestinal tract is rare.Cases of such metastases pose a particular diagnostic challenge.CASE SUMMARY A 55-year-old female presented to the Department of Gastroenterology with complaint of a 2 mo history of right upper abdominal pain accompanied by pain in the right back,aggravated after eating greasy diet.The patient had received a diagnosis of breast cancer 3 years prior.Physical examination showed obvious superficial protuberant erythema on the left neck and chest skin,with slight tenderness and burning sensation.Endoscopic retrograde cholangiopancreatography showed an obstruction at the end of the CBD.Histopathology of the CBD and symptomatic skin biopsies showed positivity for cytokeratin 7 and trans-acting T-cell-specific transcription factor breast cancer biomarkers.A cancer embolus was also found in the skin vasculature.Accordingly,the diagnosis of breast cancer metastases to the skin and biliary ducts was made.A plastic biliary sent was placed,which relieved the right upper abdominal pain and protected against unnecessary hepatectomy surgery.CONCLUSION Although rare,biliary metastasis should be considered in patients with bile duct stenosis and a history of breast cancer.
基金Supported by National Key R&D Program of China,No. 2016YFC1303600
文摘BACKGROUND Conventional endoscopic papillectomy(EP)is safe and effective for the treatment of small papilla adenoma to even large laterally spreading tumors of duodenum lesions.As reported by some existing studies,temporarily placing a prophylactic stent in the pancreatic and bile duct can lower the risk of this perioperative complication.AIM To evaluate the usefulness,convenience,safety,and short-term results of a novel autorelease bile duct supporter after EP procedure,especially the effectiveness in preventing EP.METHODS A single-center comparison study was conducted to verify the feasibility of the novel method.After EP,a metallic endoclip and human fibrin sealant kit were applied for protection.The autorelease bile duct supporter fell into the duct segment and the intestinal segment.Specifically,the intestinal segment was extended by nearly 5 cm as a bent coil.The bile was isolated from the pancreatic juice using an autorelease bile duct supporter,which protected the wound surface.The autorelease bile duct supporter fell off naturally and arrived in colon nearly 10 d after the operation.RESULTS En bloc endoscopic resection was performed in 6/8 patients(75%),and piecemeal resection was performed in 2/8 of patients(25%).None of the above patients were positive for neoplastic lymph nodes or distant metastasis.No cases of mortality,hemorrhage,delayed perforation,pancreatitis,cholangitis or duct stenosis with the conventional medical treatment were reported.The autorelease bile duct supporter in 7 of 8 patients fell off naturally and arrived in colon 10 d after the operation.One autorelease bile duct supporter was successfully removed using forceps or snare under endoscopy.No recurrence was identified during the 8-mo(ranging from 6-9 mo)follow-up period.CONCLUSION In brief,it was found that the autorelease bile duct supporter could decrease the frequency of procedure-associated complications without second endoscopic retraction.Secure closure of the resection wound with clips and fibrin glue were indicated to be
文摘AIM: To present a case of methicillin-resistant Staphylococcus aureus (MRSA) infection following bile duct stenting in a patient with malignant biliary obstruction.METHODS: A 78-year-old male patient was admitted to a community hospital with progredient painless jaundice lasting over two weeks, weight loss and sweating at night.Whether a stent should be implanted pre-operatively in jaundiced patients or whether these patients should directly undergo surgical resection, was discussed.RESULTS: ERC and a biopsy from the papilla of Vater revealed an adenocarcinoma. In addition, a 7-Ch plastic stent was placed into the common bile duct. Persistent abdominal pain, increasing jaundice, weakness and indigestion led to the transfer of the patient to our hospital.A pylorus-preserving pancreatoduodenectomy wasperformed. Intraoperatively, bile leaked out of the transected choledochus andthe stent was found to be dislocated in the duodenum. A smear of the bile revealed an infection with MRSA, leading to post-operative isolation of the patient.CONCLUSION:As biliary stents can cause severe infection of the bile, the need for pre-operative placement of biliary stents should be carefully evaluated in each individual case.
