Current status of preoperative endoscopic biliary drainage for distal and hilar biliary obstruction.

The purpose of preoperative biliary drainage (PBD) is to reduce complications during the perioperative period. The extrahepatic bile duct comprises distal and hilar bile ducts and assessing the need for PBD must be considered separately for each duct, as surgical procedures and morbidities vary. The representative disease-causing distal bile duct obstruction is pancreatic cancer. A randomized controlled trial has revealed that PBD carries the risk of recurrent cholangitis and pancreatitis before surgery, thus eliminating the need for PBD when early surgery is feasible. However, neoadjuvant therapy has seen a rise in recent years, resulting in longer preoperative waiting periods and an increased demand for PBD. In such cases, metal stents are preferable to plastic stents due to their lower stent occlusion rates. When endoscopic transpapillary biliary drainage (EBD) is not viable, endoscopic ultrasound-guided biliary drainage may be a suitable substitute. In the hilar bile duct, the representative disease-causing obstruction is hilar cholangiocarcinoma. PBD's necessity has long been a subject of contention. In spite of earlier criticisms of routine PBD, recent views have emerged recommending PBD, particularly when major hepatectomy is required, to prevent postoperative liver failure. Given the risk of tumor seeding associated with percutaneous transhepatic biliary drainage, EBD is preferable. Nevertheless, as its shortcomings involve recurrent cholangitis until surgery due to stent or tube obstruction, it is necessary to seek out novel approaches to circumvent complications. In this review we summarize the current evidence for PBD in patients with distal and hilar biliary obstruction.

Secondary uncovered versus fully-covered metal stents for the management of occluded stent in unresectable distal malignant biliary obstruction.

INTRODUCTION: Self-expandable metallic stents (SEMS) have been widely placed for unresectable distal malignant biliary obstruction (UDMBO). However, the dysfunction rate is 19-40% and its treatment is controversial. We aimed asses the efficacy and safety of a secondary biliary stents (uncovered (UC) versus fully-covered (FC) stent) for the management of occluded SEMS. PATIENTS AND METHODS: Between 2015 and June 2023, 41 patients with UDMBO underwent secondary biliary stent placement as "stent-in-stent" (20 FCSEMS and 21 UCSEMS). The primary outcomes were technical and clinical success of SEMS placement. Secondary outcomes included adverse events (AEs), patency and survival. Patients were prospectively followed until death or loss of follow-up. RESULTS: Technical (100% vs 85.5%) and clinical (100% vs 95.2%) success rates were similar in FCSEMS and UCSEMS groups. The median follow-up period was 510 days (range 290-630). The median duration of stent patency of FCSEMS (220 days, IQR 137.5-442.5) was longer than UCSEMS (150 days, IQR 110-362.5) (P=0.395), although stent dysfunction within 6 months was not different between groups. Multivariate analysis indicated that sex (HR=0.909, 0.852-0.970), antitumor treatment (HR=0.248, 0.032-0.441), stent patency (HR=0.992, 0.986-0.998) and clinical success (HR=0.133, 0.026-0.690) were significant factors for overall survival. There were no remarkable differences in AEs. CONCLUSIONS: The placement of additional biliary stent using the stent-in-stent method is an effective and safe rescue treatment for patients with UDMBO and occluded stent. In addition, the use of FCSEMS compared UCSEMS has unclear benefits regarding stent patency and overall survival.

[Surgical treatment and prognostic factors in perihilar tumors]. / Khirurgicheskoe lechenie i faktory prognoza pri perikhilyarnoi opukholi.

OBJECTIVE: To study the results of surgical treatment in patients with perihilar tumors. MATERIAL AND METHODS: We analyzed 98 patients with perihilar tumors who underwent surgery. RESULTS: We prefer percutaneous transhepatic biliary drainage (n=58) for jaundice. Retrograde interventions were performed in 18 cases (20.5%), complications grade III-IV were more common (p=0.037) in the last group. Postoperative mortality was 12%. Complications developed in 81 patients (82.7%), grade ≥3 - in 39 (39.8%) cases. Portal vein resection (n=26) increased the incidence of complications grade ≥III (p=0.035) and portal vein thrombosis (p=0.0001). Chemotherapy after surgery was performed in 47 patients (48.0%), photodynamic therapy - in 7 (7.1%) patients. A 5-year overall survival was 28.1%, the median survival - 29 months. R2 resection and/or M1 stage (n=12) significantly worsened the prognosis and overall survival (16.5 vs. 31 months, p=0.0055). Lymph node (LN) lesion, microscopic status (R0 vs. R1) of resection margin, technique of decompression and isolated resection of extrahepatic bile ducts did not affect the prognosis, and we combined appropriate patients (n=72) for analysis. SI resection and excision of ≥6 lymph nodes were independent positive factors for disease-free survival (p=0.042 and p=0.007, respectively). Blood transfusion and high preoperative neutrophil-lymphocyte index (NLI ≥2.15) worsened overall (p=0.009 and p=0.002, respectively) and disease-free survival (p=0.002 and 0.007, respectively). The absence of adjuvant therapy worsened disease-free survival alone (p=0.024). CONCLUSION: SI liver resection, adequate lymph node dissection and adjuvant therapy should be used for perihilar tumors. Isolated resection of extrahepatic bile ducts is permissible in some cases. Blood transfusion and NLI ≥2.15 are independent negative prognostic factors.

Surgical site infection following pancreaticoduodenectomy in a referral cancer center in Mexico.

BACKGROUND: Pancreaticoduodenectomy is the standard treatment for resectable periampullary cancer. Surgical site infections (SSI) are common complications with increased morbidity. The study aimed to describe the prevalence, risk factors, microbiology, and outcomes of SSI among patients undergoing pancreaticoduodenectomy. METHODS: We conducted a retrospective study in a referral cancer center between January 2015 and June 2021. We analyzed baseline patient characteristics and SSI occurrence. Culture results and susceptibility patterns were described. Multivariate logistic regression was used to determine risk factors, proportional hazards model to evaluate mortality, and Kaplan-Meier analysis to assess long-term survival. RESULTS: A total of 219 patients were enrolled in the study; 101 (46%) developed SSI. Independent factors for SSI were diabetes mellitus, preoperative albumin level, biliary drainage, biliary prostheses, and clinically relevant postoperative pancreatic fistula. The main pathogens were Enterobacteria and Enterococci. Multidrug-resistance rate in SSI was high but not associated with increased mortality. Infected patients had higher odds of sepsis, longer hospital stay and intensive care unit stay, and readmission rate. Neither 30-day mortality nor long-term survival was significantly different between infected and non-infected patients. CONCLUSIONS: SSI prevalence among patients undergoing pancreaticoduodenectomy was high and largely caused by resistant microorganisms. Most risk factors were related to preoperative instrumentation of the biliary tree. SSI was associated with greater risk of unfavorable outcomes; however, survival was unaffected.

Endoscopic Nasobiliary Drainage Comparable with Endoscopic Biliary Stenting as a Preoperative Drainage Method for Malignant Hilar Biliary Obstruction: A Multicenter Retrospective Study.

INTRODUCTION: Preoperative endoscopic biliary drainage (PEBD) for malignant hilar biliary obstruction (MHBO) is widely accepted. Recent PEBD consists of endoscopic nasobiliary drainage (ENBD), conventional endoscopic biliary stenting (CEBS) with plastic stents across the papilla, and endoscopic biliary inside stenting (EBIS) with plastic stents above the papilla, while ENBD is the primary procedure in Asian countries. Thus, we aimed to compare the efficacy of ENBD with those of CEBS and EBIS as a means of PEBD for MHBO. METHODS: We retrospectively identified patients with MHBO who underwent upfront surgery between January 2011 and December 2018 in a multicenter setting. The outcome measures were cumulative dysfunction of PEBD, risk factors for PEBD dysfunction, and adverse events. RESULTS: We analyzed a total of 219 patients, comprising 163 males (74.4%); mean age, 69.7 (±7.6) years; Bismuth-Corlette (BC) classification I, II, IIIa, IIIb, and IV in 68, 49, 43, 30, and 29 patients, respectively; and diagnosis of hilar cholangiocarcinoma and gallbladder cancer in 188 and 31 patients, respectively. PEBD procedures were performed in 160 patients with ENBD, 31 patients with CEBS, and 28 patients with EBIS. PEBD dysfunction occurred in 58 patients (26.5%), and the cumulative dysfunction rates were not significantly different among PEBD methods (p = 0.60). Multivariate analysis showed that BC-IV was significantly associated with the occurrence of PEBD dysfunction (hazard ratio = 2.10, p = 0.02). The adverse event rates were not significantly different among PEBD groups (p = 0.70). CONCLUSION: ENBD as a means of PEBD for MHBO is comparable with CEBS and EBIS in rates of dysfunction and adverse events.

Stent placement above the sphincter of Oddi is a useful option for patients with inoperable malignant hilar biliary obstruction.

BACKGROUND AND AIMS: Endoscopic biliary drainage (EBD) is essential for the management of malignant hilar biliary obstruction (MHBO). We prospectively evaluated the efficacy and safety of "inside-stent" therapy, where a plastic stent is placed above the sphincter of Oddi without endoscopic sphincterotomy, in patients with inoperable MHBO. METHODS: This study was a multicenter, single-blinded, randomized controlled trial at three centers. Patients with inoperable MHBO were enrolled in this study, and randomly assigned to receive an inside-stent or conventional-stent therapy. The primary endpoint was cumulative stent patency of the initial stent. The secondary endpoints were second stent patency, technical and clinical success rate, adverse events, re-intervention rate, and overall patient survival. RESULTS: Forty-three patients were randomly assigned to the inside-stent group (n = 21) or the conventional-stent group (n = 22). The median cumulative stent patency of the initial stent was 123 days in the inside-stent group and 51 days in the conventional-stent group (P = .031). For patients with the initial stent dysfunction in the conventional-stent group, the inside-stent was placed as a second stent, and its patency was significantly longer than that of the initial stent (P = .0001). The technical and clinical success rate, re-intervention rate, second stent patency, adverse events, and survival probability did not differ between the groups. CONCLUSIONS: Inside-stent therapy appears to be useful not only as an initial stent but also as a second stent for patients with inoperable MHBO. TRIAL REGISTRATION NUMBER: UMIN000004587.

Endoscopic biliary drainage using a 4-Fr catheter for biliary obstruction: a pilot study.

INTRODUCTION: Stent or endoscopic nasobiliary drainage (ENBD) catheter placement for a tight, complicated biliary stricture is still technically challenging. A thin, 4-Fr ENBD catheter (4-Fr catheter) has been developed to overcome this difficulty. The study aimed to evaluate the feasibility of the 4-Fr catheter for endoscopic biliary drainage (EBD). MATERIAL AND METHODS: We performed a retrospective review of 51 patients who underwent EBD with the 4-Fr catheter because placement of a conventional drainage catheter (CDC) had failed. RESULTS: The success rate of 4-Fr catheter placement was 96.1% (49/51). The median patency period of the catheter was 114 days (95% CI, 53-200). Among the 49 patients with successful placement of the catheter, adverse events occurred in five (10.2%) patients: post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), two patients; catheter dislocation, one patient; and kinking of the 4-Fr catheter, two patients. Both cases of PEP improved with conservative treatment, but all cases of catheter dislocation and kinking required reintervention with a 4-Fr catheter. Forty-three (87.8%) patients achieved clinical remission after EBD with a 4-Fr catheter. CONCLUSIONS: The newly developed 4-Fr catheter is safe and feasible for EBD in patients in whom CDC placement is difficult due to a tight, complicated biliary stricture.

Negative prognostic outcomes of percutaneous transhepatic biliary drainage in distal cholangiocarcinoma: a retrospective analysis using propensity score matching.

BACKGROUND: The efficacy of different types of preoperative biliary drainage for cholangiocarcinoma has been debated over the past two decades. Controversy concerning the use of percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary drainage (EBD) still exists. This study aimed to compare the long-term outcomes between PTBD and EBD in patients with distal cholangiocarcinoma. METHODS: Data of patients diagnosed with distal cholangiocarcinoma who underwent preoperative PTBD or EBD from January 1999 to December 2017 were analyzed retrospectively. Post-surgical outcomes, including the incidence of post-operative complications, peritoneal metastasis, disease-free survival, and overall survival, were analyzed. Survival analyses were also performed after propensity score matching in the PTBD and EBD groups. RESULTS: The incidence of post-operative complications was similar in both groups. The 5-year estimated cumulative incidences for peritoneal metastasis were 14.7% and 7.2% in the PTBD and EBD groups, respectively (p = 0.192). The 5-year disease-free survival rates were 23.7% and 47.3% in the PTBD and EBD groups, respectively (p = 0.015). In the multi-variate analysis for overall survival, PTBD was an independent poor prognostic factor. The 5-year overall survival rates were 35.9% and 56.3% in the PTBD and EBD groups, respectively (hazard ratio 1.85, confidence interval 1.05-3.26, p = 0.035). The results after propensity score matching indicated a poorer prognosis in the PTBD group, with a 5-year survival rate of 35.9% in the PTBD group vs 56.0% in the EBD group (p = 0.044). CONCLUSION: PTBD should be considered as a negative prognostic factor in distal cholangiocarcinoma patients.

Endoscopic stent placement above the sphincter of Oddi for biliary strictures after living donor liver transplantation.

BACKGROUND: Endoscopic balloon dilation and/or plastic stent placement has been a standard method for treating biliary strictures complicated post living donor liver transplantation (LDLT). The strictures may be refractory to endoscopic treatment and require long-term stent placement. However, consensus on the optimal period of the stent indwelling and usefulness of the inside stent does not exist. METHODS: We evaluated the long-term efficacy of stent treatment in patients with biliary stricture post LDLT. In addition, we compared the stent patency between inside stent and conventional outside stent. RESULTS: A total of 98 ERC sessions (median 6: range 1-14) performed on 16 patients receiving endoscopic treatment for biliary strictures post LDLT with duct-to-duct biliary reconstruction were analyzed. Biliary strictures successfully treated in 14 patients (88%) included 7 patients (44%) showing improvement of biliary strictures with repeated endoscopic stent placement. Stent replacement was carried out every 6 to 12 months for the remainder 7 patients (44%). Biliary stents were placed in 87 sessions (77 inside sessions and 10 outside sessions). Stent migration occurred 13 times (16%) and none of the inside stent sessions and the outside stent sessions, respectively. Median patency of inside stent and outside stent were 222 days (range; 8-1736) and 99 days (range; 7-356), respectively. The stent occlusion was significantly less in inside stent than in outside stent (p < 0.001). Stone formation was observed in 14 (18%) of the inside stent and 3 (30%) of the outside stent. Biliary stones were small and successfully removed endoscopically. CONCLUSIONS: The endoscopic treatment using inside stent was useful in the management of biliary strictures after LDLT.

Oncologic effects of preoperative biliary drainage in resectable hilar cholangiocarcinoma: Percutaneous biliary drainage has no adverse effects on survival.

BACKGROUND AND OBJECTIVES: The objective of the current study was to define long-term survival of patients with resectable hilar cholangiocarcinoma (HCCA) after preoperative percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary drainage (EBD). METHODS: Between 2000 and 2014, 240 patients who underwent curative-intent resection for HCCA were identified at 10 major hepatobiliary centers. Postoperative morbidity and mortality, as well as disease-specific survival (DSS) and recurrence-free survival (RFS) were analyzed among patients. RESULTS: The median decrease in total bilirubin levels after biliary drainage was similar comparing PTBD (n = 104) versus EBD (n = 92) (mg/dL, 4.9 vs 4.9, P = 0.589) before surgery. There was no difference in baseline demographic characteristics, type of surgical procedure performed, final AJCC tumor stage or postoperative morbidity among patients who underwent EBD only versus PTBD (all P > 0.05). Patients who underwent PTBD versus EBD had a comparable long-term DSS (median, 43.7 vs 36.9 months, P = 0.802) and RFS (median, 26.7 vs 24.0 months, P = 0.571). The overall pattern of recurrence relative to regional or distant disease was also the same among patients undergoing PTBD and EBD (P = 0.669) CONCLUSIONS: Oncologic outcomes including DSS and RFS were similar among patients who underwent PTBD versus EBD with no difference in tumor recurrence location.

Current strategies for endoscopic management of acute cholangitis.

BACKGROUND AND AIM: At the pancreatobiliary session of Endoscopic Forum Japan (EFJ) 2016, current strategies for the endoscopic management of acute cholangitis were discussed. The topics consisted of two major parts, namely endoscopic management of acute cholangitis caused by common bile duct stones (CBDS) and biliary stent occlusion. METHODS: Endoscopists from nine Japanese high-volume centers along with two overseas centers participated in the questionnaires and discussion. RESULTS: Strategies for management of cholangitis due to CBDS were agreed upon, and the clinical guideline of acute cholangitis (Tokyo guidelines 2013) was accepted. The best timing for drainage in Grade 2 (moderate) cholangitis urgent or early (<24 h) was inconclusive, and more data is required on this issue. Another controversy was the feasibility of one step stone extraction in the patient with cholangitis vs stone removal after the cholangitis had resolved. There were various opinions with regards to the management of acute cholangitis due to stent occlusion, and the strategies differed according to the stricture location (distal or hilar) and stent type initially placed (Covered or uncovered metal stent). CONCLUSION: Strategies for management of cholangitis caused by CBD stones are well established according to the TG13. More evidence is required before further recommendations can be made with regards to cholangitis due to stent occlusion. We aim to clarify this in the near future with questionnaires and consensus from experts.

Management of acute cholangitis as a result of occlusion from a self-expandable metallic stent in patients with malignant distal and hilar biliary obstructions.

Acute cholangitis as a result of common bile duct stones can be managed; however, cholangitis caused by occlusion with a biliary self-expandable metallic stent (SEMS) in patients with an unresectable malignant biliary obstruction has not been fully discussed. The acute cholangitis clinical guidelines (Tokyo Guidelines 2013) recommend following the same procedure as that used for cholangitis; however, the patient's condition, including performance status, tumor extension or staging, and prognosis must be considered. Most physicians manage cholangitis from a SEMS occlusion using a two-step procedure. They insert endoscopic drainage with a plastic stent or insert a nasobiliary drainage tube, which does not exacerbate sepsis. Addition or replacement of a biliary SEMS is required in many cases depending on the cause of the occlusion. Tumor ingrowth through the stent mesh is common in uncovered SEMS and requires placement of another stent in an in-stent method. However, covered SEMS tends to be occluded by sludge, so it must be replaced because of the bacterial biofilm that forms on the covering membrane. The location of the biliary stricture (hilar or distal) should also be considered. Strategies for managing cholangitis as a result of occlusion by a biliary SEMS remain controversial, so prospective clinical trials are needed.

Endoscopic management of acute cholangitis according to the TG13.

The Tokyo Guidelines 2013 (TG13) recommend that endoscopic drainage should be the first-choice treatment for biliary decompression in patients with acute cholangitis. Timing of biliary drainage for acute cholangitis should be based on the severity of the disease. For patients with severe acute cholangitis, appropriate organ support and urgent biliary drainage are needed. For patients with moderate acute cholangitis, early biliary drainage is needed. For patients with mild acute cholangitis, biliary drainage is needed when initial treatment such as antimicrobial therapy is ineffective. There are three methods of biliary drainage: endoscopic drainage, percutaneous transhepatic drainage, and surgical drainage. Endoscopic drainage is less invasive than the other two drainage methods. The drainage method (endoscopic nasobiliary drainage and stenting) depends on the endoscopist's preference but endoscopic sphincterotomy should be selected rather than endoscopic papillary balloon dilation from the aspect of procedure-related complications. In the TG13, balloon enteroscopy-assisted and endoscopic ultrasound-guided biliary drainages have been newly added as specific drainage methods. Recent studies have demonstrated their usefulness and safety. These drainage methods will become more widespread in the future.

Comparison of percutaneous transhepatic biliary drainage and endoscopic biliary drainage in the management of malignant biliary tract obstruction: a meta-analysis.

BACKGROUND AND AIM: To compare percutaneous transhepatic biliary drainage (PTBD) and endoscopic biliary drainage (EBD) for management of malignant biliary tract obstruction (MBTO). METHODS: PubMed, Google Scholar, and the Cochrane database were searched to 31 December 2013. Main outcome measurements were therapeutic success rate, 30-day mortality rate, overall complications, cholangitis, and pancreatitis. RESULTS: Eight studies (five retrospective and three randomized controlled trials) were included in the meta-analysis with a total of 692 participants. Combined odds ratio (OR) = 2.18 revealed no significant difference in therapeutic success between PTBD and EBD (95% confidence interval [CI] = 0.73-6.47, P = 0.162). However, after excluding two studies that appeared to be outliers, PTBD exhibited a better therapeutic success rate than EBD (pooled OR = 4.45, 95% CI = 2.68-7.40, P < 0.001). Patients who underwent PTBD were 0.55 times as likely to have cholangitis as those who underwent EBD, whereas the overall complication rate, pancreatitis rate, and 30-day mortality were similar between the two procedures. CONCLUSIONS: PTBD may be associated with a better therapeutic success rate and lower incidence of cholangitis than EBD, but the overall complication rate, pancreatitis rate, and 30-day mortality of the two procedures are similar.

3-Fr microcatheter-assisted endoscopic ultrasound-guided rendezvous technique with a 22-gauge needle and a 0.018-inch guidewire for difficult biliary cannulation.

Endoscopic ultrasound-guided rendezvous with a 22-gauge needle and a 0.018-inch guidewire, assisted by a 3-Fr microcatheter, effectively addresses challenges in biliary cannulation, improving guidewire manipulation and reducing risks of injury and leakage. Natsume and colleagues describe the successful extraction of common bile duct stones to demonstrate the efficacy of this technique.

Prophylactic endoscopic transpapillary gallbladder stenting to prevent acute cholecystitis induced after metallic stent placement for malignant biliary strictures: a retrospective study in Japan.

BACKGROUND/AIMS: Endoscopic biliary drainage using self-expandable metallic stents (SEMSs) for malignant biliary strictures occasionally induces acute cholecystitis (AC). This study evaluated the efficacy of prophylactic gallbladder stents (GBS) during SEMS placement. METHODS: Among 158 patients who underwent SEMS placement for malignant biliary strictures between January 2018 and March 2023, 30 patients who attempted to undergo prophylactic GBS placement before SEMS placement were included. RESULTS: Technical success was achieved in 21 cases (70.0%). The mean diameter of the cystic duct was more significant in the successful cases (6.5 mm vs. 3.7 mm, p<0.05). Adverse events occurred for 7 patients (23.3%: acute pancreatitis in 7; non-obstructive cholangitis in 1; perforation of the cystic duct in 1 with an overlap), all of which improved with conservative treatment. No patients developed AC when the GBS placement was successful, whereas 25 of the 128 patients (19.5%) without a prophylactic GBS developed AC during the median follow-up period of 357 days (p=0.043). In the multivariable analysis, GBS placement was a significant factor in preventing AC (hazard ratio, 0.61; 95% confidence interval, 0.37-0.99; p=0.045). CONCLUSIONS: GBS may contribute to the prevention of AC after SEMS placement for malignant biliary strictures.

Optimal liver drainage rate for survival in patients with unresectable malignant hilar biliary obstruction using 3D-image volume analyzer.

Background: Drainage exceeding 50% of total liver volume is a beneficial prognostic factor in patients with unresectable malignant hilar biliary obstruction (UMHBO). However, it is unclear what threshold percentage of total liver volume drained ('liver drainage rate') significantly improves survival in patients with UMHBO who received systemic chemotherapy. Objectives: We aimed to assess the optimal liver drainage rate that improves survival in patients with UMHBO receiving chemotherapy using a three-dimensional (3D)-image volume analyzer. Design: This study was a single-center retrospective cohort study. Methods: Data from 90 patients with UMHBO who received chemotherapy after endoscopic biliary drainage using metal stents at Okayama University Hospital from January 2003 to December 2020 were reviewed. The liver drainage rate was calculated by dividing the drained liver volume by the total liver volume using a 3D-image volume analyzer. The primary endpoint was overall survival by liver drainage rate. The secondary endpoints were time to recurrent biliary obstruction (TRBO) and prognostic factors. Results: The median total liver volume was 1172 (range: 673-2032) mL, and the median liver drainage rate was 83% (range: 50-100). Overall survival was 376 (95% CI: 271-450) days, and patients with >80% drainage (n = 67) had significantly longer survival than those with <80% drainage (n = 23) (450 days versus 224 days, p = 0.0033, log-rank test). TRBO was 201 (95% CI: 155-327) days and did not differ significantly by liver drainage rate. Multivariate Cox proportional hazards regression analysis revealed >80% liver drainage [hazard ratio (HR): 0.35, 95% CI: 0.20-0.62, p = 0.0003] and hilar cholangiocarcinoma (HR: 0.30, 95% CI: 0.17-0.50, p < 0.0001) as significant prognostic factors. Conclusion: In patients with UMHBO scheduled for chemotherapy, >80% drainage is associated with improved survival. Further prospective multicenter studies are needed to verify the results of this study. Trail registration: Okayama University Hospital, IRB number: 2108-011.

Laparoscopic cholecystectomy after transcatheter arterial embolisation for haemobilia due to a pseudoaneurysm in the gallbladder: A case report.

Pseudoaneurysms of the cystic artery are a rare but significant complication of acute cholecystitis. Laparoscopic cholecystectomy may be a safe alternative to open cholecystectomy in such cases. We report the case of a female patient in her seventies, who presented with anaemia, jaundice, and hepatic dysfunction during hospitalisation for right knee pyogenic arthritis. The patient had no pain in the right upper quadrant. Her serum haemoglobin level was 6.5 g/dL, and upper gastrointestinal endoscopy revealed no abnormalities. Six days later, jaundice worsened, and endoscopic retrograde cholangiopancreatography revealed bloody bile. An endoscopic biliary drainage tube was inserted at the discretion of the gastroenterology department. Contrast-enhanced computed tomography revealed a haematoma in the gallbladder and a pseudoaneurysm in the lateral wall of the gallbladder. On the same day, the endoscopic biliary drainage tube was replaced with an endoscopic nasobiliary drainage tube, which indicated the degree of haemorrhage and enabled lavage of the lumen in cases of obstruction. The next day, angiography revealed a pseudoaneurysm of the deep branch of the cystic artery and coil embolisation was performed at the periphery of the cystic artery. Uninterrupted laparoscopic cholecystectomy was performed. Although laparoscopic cholecystectomy is difficult when bleeding is uncontrolled, it was safely performed following haemostasis using transcatheter arterial embolisation. Laparoscopic cholecystectomy is feasible in haemodynamically stable patients with cystic artery pseudoaneurysms after transcatheter arterial embolisation.

Endoscopic Treatment of Malignant Hilar Biliary Obstruction.

Stent implantation is an effective approach for palliative treatment of Bismuth-Corlette type III-IV malignant hilar biliary obstructions (MHBOs). In this article, we reviewed the currently used access methods for biliary stent placement (percutaneous transhepatic biliary drainage, endoscopic biliary drainage, endosonography guided biliary drainage), the available stent types (plastic stent, self-expanding metallic stent, full cover self-expanding metallic stent, radioactive self-expanding metallic stent), major approaches (unilateral, bilateral) and deployment methods (stent-in-stent, stent-by-stent). Finally, this review gives an outlook on perspectives of development in stenting and other palliative methods in MHBO.

Comparison of Bilateral and Trisegment Drainage in Patients with High-Grade Hilar Malignant Biliary Obstruction: A Multicenter Retrospective Study.

Background/Aims: Bilateral endoscopic drainage with self-expanding metallic stent (SEMS) can be used to effectively manage hilar malignant biliary obstruction. However, the benefits of using a trisegment drainage method remain unknown. Methods: This study retrospectively reviewed the data of 125 patients with Bismuth type IIIa or IV unresectable malignant strictures who underwent bilateral endoscopic drainage using SEMSs at four tertiary centers. The patients were divided into the bilateral and trisegment drainage groups for comparison. The primary endpoint was stent patency and the secondary endpoints were technical success, technical and clinical success of reintervention, and overall survival. Results: The technical success rates of the bilateral and trisegment drainage groups were 95% (34/36) and 90% (80/89) (p=0.41), respectively, with median stent patency durations of 226 and 170 days (p=0.26), respectively. Although the technical success of reintervention was not significantly different between the two groups (p=0.51), the clinical success rate of reintrvention was significantly higher in the trisegment drainage group (73% [11/15] vs 96% [47/49], p=0.009). The median survival times were 324 and 323 days in the bilateral and trisegment drainage groups, respectively (p=0.72). Multivariate Cox hazards model revealed no stent patency-associated factor; however, chemotherapy was associated with longer survival. Conclusions: Although no significant difference was noted with respect to stent patency, significantly higher clinical success rates were achieved with reintervention using the trisegment drainage method than using the bilateral drainage method alone.