Percutaneous vs. endoscopic pre-operative biliary drainage in hilar cholangiocarcinoma - a systematic review and meta-analysis.

BACKGROUND: The strategy for preoperative management of biliary obstruction in hilar cholangiocarcinoma (HCCA) patients with regards to drainage by endoscopic (EBD) or percutaneous (PTBD) methods is not clearly defined. The aim of this study was to investigate the utility, complications and therapeutic efficacy of these methods in HCCA patients, with a secondary aim to assess the use of portal vein embolization (PVE) in patients undergoing drainage. METHODS: Studies incorporating HCCA patients undergoing biliary drainage prior to curative resection were included (EMBASE and Medline databases). Analyses included baseline drainage data, procedure-related complications and efficacy, post-operative parameters, and meta-analyses where applicable. RESULTS: Fifteen studies were included, with EBD performed in 536 patients (52%). Unilateral drainage of the future liver remnant was undertaken in 94% of patients. There was a trend towards higher procedure conversion (RR 7.36, p = 0.07) and cholangitis (RR 3.36, p = 0.15) rates in the EBD group. Where specified, 134 (30%) drained patients had PVE, in association with a major hepatectomy in 131 patients (98%). Post-operative hepatic failure occurred in 22 (11%) of EBD patients compared to 56 (13%) of PTBD patients, whilst median 1-year survival in these groups was 91% and 73%, respectively. DISCUSSION: The accepted practice is for most jaundiced HCCA patients to have preoperative drainage of the future liver remnant. EBD may be associated with more immediate procedure-related complications, although it is certainly not inferior compared to PTBD in the long term.

Anatomic Variations of the Floor of the Third Ventricle: An Endoscopic Study.

OBJECTIVE: Anatomical variations of the floor of the third ventricle are common in hydrocephalic patients and can significantly affect outcomes of endoscopic third ventriculostomy (ETV). We sought to categorize variations in third ventricle anatomy and to discuss the implications of these variations for ETV. METHODS: Intraoperative videos and pictures of 50 patients who underwent ETV between April 2001 and August 2010 were reviewed. Twenty-seven patients with clearly demonstrable third ventricular floors that satisfied our criteria were selected for the study. RESULTS: Images of variations were organized into the following categories: 1) thinned floor, 2) thickened floor, 3) partially effaced floor, 4) ballooning/herniating floor, 5) small prepontine interval, 6) narrowed third ventricle, and 7) other significant anomalies. CONCLUSIONS: The third ventricle is a common site for anatomical variations in hydrocephalic patients. A good knowledge of these variations is essential before performing ETV, because they have the potential to increase operative risk.