Endoscopic sump syndrome secondary to EUS-guided choledocho-duodenostomy with a lumen-apposing metal stent.

Sump syndrome (SS) is associated with choledocho-duodenostomy (CDD) dysfunction, which occurs due to accumulation of detritus, biliary mud and food remains in the suprapapillary distal common bile duct. The prevalence is low after CDD. Currently, biliary drainage endoscopic ultrasound (EUS)-guided with a lumen-apposing metal stent (LAMS) is a new minimally invasive alternative for biliary stenosis for patients in whom endoscopy retrograde cholangial-pancreatography (ERCP) is not feasible. CDD via EUS-guided LAMS is increasing. Thus, SS has become a potential associated complication that was previously unreported in the literature.

EUS-guided Choledochoduodenostomy Versus Hepaticogastrostomy: A Systematic Review and Meta-analysis.

BACKGROUND AND AIMS: Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternative in cases of endoscopic retrograde cholangiopancreatography (ERCP) failure. Two types of EUS-BD methods for achieving biliary drainage when ERCP fails are choledochoduodenostomy (CDS) or hepaticogastrostomy (HGS). However, there is no consensus if one approach is better than the other. Therefore, we conducted a systematic review and meta-analysis to evaluate these 2 main EUS-BD methods. METHODS: We searched MEDLINE, Embase, Scopus, Cochrane database, LILACS from inception through April 8, 2017, using the following search terms in various combinations: biliary drainage, biliary stent, transluminal biliary drainage, choledochoduodenostomy, hepaticogastrostomy, endoscopic ultrasound-guided biliary drainage. We selected studies comparing CDS and HGS in patients with malignant biliary obstruction with ERCP failure. Pooled odds ratio (OR) were calculated for technical success, clinical success, and adverse events and difference of means calculated for duration of procedure and survival after procedure. RESULTS: A total of 10 studies with 434 patients were included in the meta-analysis: 208 underwent biliary drainage via HGS and the remaining 226 via CDS. The technical success for CDS and HGS was 94.1% and 93.7%, respectively, pooled OR=0.96 [95% confidence interval (CI)=0.39-2.33, I=0%]. Clinical success was 88.5% in CDS and 84.5% in HGS, pooled OR=0.76 (95% CI=0.42-1.35, I=17%). There was no difference for adverse events OR=0.97 (95% CI=0.60-1.56), I=37%. CDS was about 2 minutes faster with a pooled difference in means of was -2.69 (95% CI=-4.44 to -0.95). CONCLUSION: EUS-CDS and EUS-HGS have equal efficacy and safety, and are both associated with a very high technical and clinical success. The choice of approach may be selected based on patient anatomy.

Analysis of the reversibility of biliary cirrhosis in young rats submitted to biliary obstruction.

BACKGROUND/PURPOSE: Biliary atresia and other liver biliary obstructions are relevant conditions in pediatric surgery due to their progression to biliary cirrhosis and indication for liver transplantation. It is known that the period during which biliary obstruction persists determines the development of cirrhosis and its reversibility after a biliary drainage procedure. However, no time or histological markers of biliary cirrhosis reversibility have been established. MATERIALS AND METHODS: One hundred and twenty-nine young Wistar rats underwent surgery for ligation of the common bile duct and were maintained until 8weeks. A part of these animals was submitted to biliary drainage surgery at 2, 3, 4, 5, or 6weeks after the initial procedure. After cyst formation at the site of obstruction, cyst-jejunal anastomosis was performed to restore bile flow. After biliary obstruction and drainage, liver samples were collected for histological and molecular analysis of the genes responsible for collagen deposition and fibrosis. RESULTS: The mortality rates were 39.8% and 56.7% after the first and second procedures, respectively. Ductular proliferation (p=0.001) and collagen deposition increased according to the period under obstruction (p=0.0001), and both alterations were partially reduced after biliary drainage. There were no significant differences in the values of desmin and α-actin according to the period during which the animal remained with biliary obstruction (p=0.09 and p=0.3, respectively), although increased values of transforming growth factor beta 1 (TGFß1) occurred after 8weeks (p=0.000). Desmin levels decreased, and α-actin and TGFß1 levels increased according to the period under obstruction. The molecular alterations were partially reversed after biliary drainage. CONCLUSIONS: The histologic and molecular changes in the liver parenchyma promoted by biliary obstruction in the young animal can be partially reversed by a biliary drainage procedure.

Fístula coledocoduodenal / Choledochoduodenal fistula

La fistulas biliares internas son consideras una complicación poco frecuente de las enfermedad biliar y aún más raras del ulcus duodenal. Constituyen un hallazgo ocasional durante la colangiografía retrograda endoscópica durante el estudio de la enfermedad biliar recurrente. Se relaciona principalmente con la litiasis vesicular complicada. Puede afectar hasta un 2 por ciento del total de los pacientes con enfermedad biliar y se asocia a una mayor incidencia de carcinoma de este sistema. La localización más habitual es entre la vesícula y el duodeno (colecistoduodenal) en un 72 - 80 por ciento de los casos. La coledocoduodenal -la cual se relaciona con el caso a reportar- es de las menos frecuentes, la cual se encuentra solo en 3-5 por ciento. Se presenta a un paciente masculino de 44 años, operado hace 26 años de úlcera duodenal perforada. En octubre de 2015 debutó con íctero ligero, coluria y dolor en hipocondrio derecho, que impresionó hepatitis toxica, cuadro que recurrió en varias ocasiones. Durante el estudio realizado en su última crisis, se halló una fístula coledocoduodenal, se remitió a nuestro centro para tratamiento quirúrgico. Debido a lo infrecuente del caso, se decidió realizar revisión de la literatura actual y su presentación(AU)

Internal biliary fistulas are considered a rare complication of biliary disease and even rarer of duodenal ulcers. They are an occasional finding during endoscopic retrograde cholangiography during the study of recurrent biliary disease. It is mainly related to complicated vesicular lithiasis. It can affect up to 2 percent of all patients with biliary disease and is associated with a higher incidence of carcinoma in this system. The most common localization is between the gallbladder and the duodenum (cholecystoduodenal) in 72-80 percent of cases. The choledocoduodenal type, related to the case to be reported, is the least frequent, which is found in 3-5 percent of the cases. A case is presented of a 44-year-old male patient, operated 26 years ago for perforated duodenal ulcer. In October 2015, the patient debuted with light icterus, choluria and pain to the right hypochondrium, which seemed to be toxic hepatitis, a clincal frame that relapsed in several occasions. During the study performed in his last crisis, a choledochoduodenal fistula was found and he was referred to our center for surgical treatment. Due to the infrequent case, it was decided to review the current literature and its presentation(AU)

[Endoscopic ultrasound-guided choledocho-duodenostomy in advanced pancreatic cancer with duodenal obstruction]. / Colédoco-duodenostomía guiada por ecoendoscopía en cáncer de páncreas avanzado con obstrucción duodenal.

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the first-approach for biliary drainage. In cases of ERCP failure, patients are usually referred for percutaneous transhepatic biliary drainage or surgical biliary bypass. In the last decade, the indications of endoscopic ultrasound (EUS) in the management of patients with pancreatic cancer have increased, and numerous cases of EUS-guided biliary drainage have been reported in patients with failures during the ERCP. Our goal is to report a patient with locally advanced pancreatic cancer who presented with painless jaundice and cholestasis with biliary and duodenal obstruction. A EUS-guided choledochoduodenostomy was performed by placement of a self-expanding metal stent.

Colédoco-duodenostomía guiada por ecoendoscopia en cáncer de páncreas avanzado con obstrucción duodenal / Endoscopic ultrasound-guided choledocho-duodenostomy in advanced pancreatic cancer with duodenal obstruction

La colangiopancreatografía retrógrada endoscópica (CPRE) se considera el tratamiento de primera línea para el drenaje biliar en pacientes con cáncer de páncreas. En los casos de fracaso por CPRE, generalmente se realiza un drenaje biliar transparietohepático o una derivación biliar quirúrgica. En la última década, las indicaciones y la utilidad de la ecoendoscopia en pacientes con cáncer de páncreas han ido creciendo, y se han informado numerosos casos de drenajes biliares guiados por ecoendoscopia como una alternativa al drenaje biliar percutáneo o quirúrgico en fracasos en la CPRE. Nuestro objetivo es comunicar un caso con cáncer de páncreas localmente avanzado que se presentó con ictericia indolora y síndrome coledociano con obstrucción biliar y duodenal, en el que se realizó una colédoco-duodenostomía guiada por ecoendoscopia mediante la colocación de una prótesis metálica autoexpandible.

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the first-approach for biliary drainage. In cases of ERCP failure, patients are usually referred for percutaneous transhepatic biliary drainage or surgical biliary bypass. In the last decade, the indications of endoscopic ultrasound (EUS) in the management of patients with pancreatic cancer have increased, and numerous cases of EUS-guided biliary drainage have been reported in patients with failures during the ERCP. Our goal is to report a patient with locally advanced pancreatic cancer who presented with painless jaundice and cholestasis with biliary and duodenal obstruction. A EUS-guided choledochoduodenostomy was performed by placement of a self-expanding metal stent.

[Laparoscopic choledochoduodenostomy as an optional treatment choledocholithiasis]. / Coledocoduodenoanastomosis laparoscópica como opción terapéutica en coledocolitiasis compleja.

INTRODUCTION: Choledochoduodenostomy is indicated for unsolved choledocholithiasis and biliary malignant or benign stenosis. This surgical procedure has been feared for its potential complications. This article shows our initial experience with this laparo-endoscopic approach. METHODS: We performed laparoscopic choledochoduodenoastomy in seven elderly patients with recurrent or unsolved choledocholithiasis. Additionally, laparo-endoscopic extraction of gallstones was performed in necessary cases. We gathered and analyzed the demographic data, diagnostic proofs and follow up of the patients. RESULTS: Average age of patients was 71 years, with 57.1% of women in our population. Main omorbidities of our patients included obesity in 71.4%, diabetes mellitus type 2 in 57.4%, and arterial hypertension in 42.85%. Patients had in average 2.7 previous episodes of choledocholithiasis and/or cholangitis and the average diameter of the removed stones was 22.6 mm. Average follow-up was 155 days (range 28 to 420). DISCUSSION: Laparoscopic chooledochoduodenostomy has proved to be safe, effective and be superior to open surgery, as long as an appropriate selection of patients is performed and surgeons with experience on laparoscopic techniques are available. All these factors reduce the long-term complications with which this surgical procedure has been related. CONCLUSIONS: Laparoscopic choledochoduodenostomy is an option for the definitive surgical treatment of "difficult choledocholithiasis" in elderly patients with multiple comorbidities; it also offers the advantages of the minimally invasive approaches.

Endoscopic ultrasound-guided choledochoduodenostomy and duodenal stenting in patients with unresectable periampullary cancer: one-step procedure by using linear echoendoscope.

OBJECTIVE: Describe a case series of endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CD) associated with duodenal self-expandable metal stents (SEMS) placement using solely the linear echoendoscope in seven patients with obstructive jaundice and duodenal obstruction due to unresectable periampullary cancer. MATERIAL AND METHODS: EUS-CD in the first portion of the duodenum, associated with duodenal SEMS placement was performed in seven patients with unresectable periampullary cancer with obstructive jaundice and invasive duodenal obstruction. Laboratory tests and clinical follow-up were performed until patient's death. The procedure was performed by an experienced endoscopist under conscious sedation. The puncture position was chosen based on EUS evaluation, at the common bile duct (CBD) above the tumor, through the distal part of the duodenal bulb. After that, the needle was withdrawn and a wire-guided needle knife was used to enlarge the site puncture in the duodenal wall. Then, a partially covered SEMS was passed over the guide, through the choledochoduodenal fistula. Duodenal SEMS placement was performed during the same endoscopic procedure. RESULTS: The procedure was performed in seven patients, ranging between 34 and 86 years. Technical success of EUS-CD, by the stent placement, occurred in 100% of the cases. There were no early complications. Duodenal SEMS placement was effective in 100% of the cases that remained alive after a follow-up of 7 and 30 days. CONCLUSION: The results suggest therapeutic EUS one-step procedure drainage as an alternative for these patients, with good clinical success, feasible technique and safety.

Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: endoscopic ultrasonography-guided choledochoduodenostomy versus percutaneous drainage.

BACKGROUND: Endoscopic retrograde cholangiopancreatography may fail because of malignant involvement of the second portion of the duodenum and the major papilla. Alternatives include percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. Endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CD) has been reported as an alternative. OBJECTIVE: To prospectively compare EUS-CD and PTBD in patients with unresectable malignant biliary obstruction. DESIGN: Prospective and randomized study. SETTING: Tertiary center. MAIN OUTCOME MEASUREMENTS: Success and efficacy comparison EUS-CD with PTBD. RESULTS: Twenty-five subjects were randomized (13 EUS-CD and 12 PTBD). Mean age was 67 years (SD, 11.9). The 2 groups were similar before intervention in terms of quality of life [EUS-CD (58.3) vs. PTBD (57.8); P=0.78], total bilirubin (16.4 vs. 17.2; P=0.7), alkaline phosphatase (539 vs. 518; P=0.7), and gamma-glutamyl transferase (554.3 vs. 743.5; P=0.56). All procedures were technically and clinically successful in both groups. At 7-day follow-up there was a significant reduction in total bilirubin in both the groups (EUS-CD, 16.4 to 3.3; P=0.002 and PTBD, 17.2 to 3.8; P=0.01), although no difference was noted comparing the 2 groups (EUS-CD to PTBD; 3.3 vs. 3.8; P=0.2). There was no difference between the complication rates in the 2 groups (P=0.44), EUS-CD (2/13; 15.3%) and PTBD (3/12; 25%). Costs were similar in the 2 groups also ($5673-EUS-CD vs. $7570-PTBD; P=0.39). LIMITATIONS: Small sample size and single center study. CONCLUSIONS: EUS-CD can be an effective and safe alternative to PTBD with similar success, complication rate, cost, and quality of life.

Influence of biliary anastomosis on recovery from secondary biliary cirrhosis.

OBJECTIVE: The influence of choledochoduodenostomy and choledochojejunostomy on the repair of hepatic lesions secondary to biliary obstruction is not well known. The aim of the present study was to compare the effects of choledochoduodenostomy and choledochojejunostomy on the recovery of these lesions in rats with biliary obstruction. METHODS: Rats subjected to 4 weeks of biliary obstruction underwent choledochoduodenostomy (n=10) or choledochojejunostomy (n=10). The following variables were measured: total bilirubin, alkaline phosphatase, aminotransferases, and albumin. Hepatic mitochondrial energy metabolism was evaluated by calculating the respiratory control ratio and the oxidative phosphorylation index. Hepatic morphometry was used to estimate the mass of the hepatocytes, bile ducts, and fibrosis, as well as the hepatic stellate cell count. RESULTS: After choledochoduodenostomy and choledochojejunostomy, there was a regression in cholestasis and a reduction in the oxidative phosphorylation index. However, the total bilirubin, alkaline phosphatase, albumin, and respiratory control ratio values improved only after choledochojejunostomy. The mass of the liver, spleen, and fibrosis was reduced after both choledochoduodenostomy and choledochojejunostomy, but the number of hepatic stellate cells increased. After choledochojejunostomy, the hepatic mass recovered completely, and the spleen mass was significantly reduced compared with that after choledochoduodenostomy. After both choledochoduodenostomy and choledochojejunostomy, enterobiliary reflux, biliary contamination, and an exacerbation in hepatic inflammation developed. CONCLUSION: Choledochojejunostomy was more effective than choledochoduodenostomy, but both techniques induced enterobiliary reflux and biliary contamination, which may explain the maintenance of hepatic alterations, especially after choledochoduodenostomy.

[Endoscopic ultrasound-guided choledochoduodenostomy for relieving malignant distal biliary obstruction]. / Coledocoduodenostomía guiada por Ultrasonido Endoscópico para la paliación de la obstrucción biliar distal maligna.

Ultrasound-guided biliary drainage is a new and effective method for relieving obstructive lesions of the biliary tract. In the hands of experienced operators, ultrasound-guided diversion of the mid portion of the common bile duct and the duodenal bulb is a feasible strategy for the relief of jaundice secondary to distal obstruction (distal bile duct tumors, pancreatic head cancer, or major duodenal papillary tumor), with low morbidity and mortality rates. The technical aspects of the procedure and its indications are reviewed herein, emphasizing its performance in institutions equipped with experienced personnel adhering to strict study protocols.

EUS-guided biliary drainage: a review article.

CONTEXT: To demonstrate a comprehensive review of published articles regarding EUS-guided biliary drainage. METHODS: Review of studies regarding EUS-guided biliary drainage including case reports, case series and previous reviews. RESULTS: EUS-guided hepaticogastrostomy, choledochoduodenostomy and choledochoantrostomy are advanced procedures on biliary and pancreatic endoscopy and together make up the echo-guided biliary drainage. Hepaticogastrostomy is indicated in cases of hilar obstruction, while the procedure of choice is choledochoduodenostomy in distal lesions. Both procedures must be done only after unsuccessful ERCP. The indication of these procedures must be made under a multidisciplinary view while sharing information with the patient or legal guardian. CONCLUSION: Hepaticogastrostomy and choledochoduodenostomy are feasible when performed by endoscopists with expertise in biliopancreatic endoscopy and advanced echo-endoscopy and should be performed currently under rigorous protocol in educational institutions.

Colecistitis aguda en paciente con situs inversus totalis / Acute cholecystitis in a patient with situs inversus totalis

El objetivo del presente reporte es dar a conocer un caso de situs inversus y colecistitis aguda diagnosticado y tratado en el Hospital Al Wahda Mabar Thamar de Yemen. Paciente de sexo femenino, de 50 años, con dolor en epigastrio después de la ingestión de alimentos grasos. Dos días antes de su ingreso incrementa su intensidad y se mantiene en hipocondrio izquierdo, y además, presenta vómitos. Utilizando antibioticoterapia perioperatoria, se realiza incisión subcostal izquierda, y se encuentra colecistitis aguda con dilatación moderada del colédoco. Se realiza colecistectomía y coledocotomía, con buena evolución posoperatoria(AU)

The objective of present paper is to present a case of situs inversus and cholecystitis diagnosed and treated in the Al Wahda Mabar Thamar Hospital of Yemen. A female patient aged 50 with epigastric pain after ingestion of fatty foods; two days before its admission increase its intensity and remains in left hypochondrium and also vomiting. With the use of perioperative antibiotic-therapy, a left subcostal incision is made detecting an acute cholecystitis with a choledochal slight dilatation. A cholecystectomy and choledochotomy with a good postoperative evolution were performed(AU)

Endoscopy Ultra- Sonography -guided biliary drainage in the surgical -endoscopy era.

BACKGROUND: US-guided hepatico - gastrostomy, choledocho-duodenostomy and choledocho-antrostomy are advanced procedures on biliary and pancreatic endoscopy and together make up the echo-guided biliary drainage. Hepatico - gastrostomy is indicated in cases of hiliar obstruction, while the procedure of choice is choledocho - duodenostomy in distal lesions. Both procedures must be done only after unsuccessful ERCP. AIMS: To clarify to the readers about indication of these procedures, they must be made under a multidisciplinary view while sharing information with the patient or legal guardian. METHODS: All series cases report and selected cohort studies were selected according to the DDTS system in which key words were EUS biliary drainage, choledocho-duodenostomy, hepatico-gastrostomy, EUS, palliation and pancreatic biliary advanced cancer. RESULTS: Separately it was stated definition on the EUS biliary drainage procedures and it includes the techniques details and critical analysis. CONCLUSION: Hepatico- gastrostomy and Choledocho- duodenostomy are feasible when performed by endoscopists with expertise in bilio pancreatic endoscopy and advanced echo-endoscopy and should be performed currently under rigorous protocol in educational institutions.

EUS-guided choledochoduodenostomy for biliary drainage in unresectable pancreatic cancer: a case series.

CONTEXT: Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice for biliary decompression in patients with unresectable pancreatic cancer. However, it may be unsuccessful in 3 to 10% of cases. When ERCP is unsuccessful, the usual alternatives are percutaneous transhepatic biliary drainage or surgery. Recently, several authors have reported the use of EUS-guided biliary drainage in patients with malignant biliary obstructions, with acceptable success and complication rates. We describe three cases of unresectable pancreatic cancer associated with obstructive jaundice, treated by EUS-guided biliary drainage. CASE REPORT: Three patients with unresectable pancreatic cancer, associated with obstructive jaundice, were included. ERCP was unsuccessful because of complete tumor obstruction of the distal common bile duct and papilla invasion. An EUS-guided rendezvous maneuver was attempted, without success. Then, EUS-guided choledochoduodenostomy, with a partially covered self-expanding metal stent, was performed in the same procedure. There were no early complications and the procedure was also clinically effective in relieving jaundice in all cases. CONCLUSIONS: EUS-guided biliary drainage is a feasible alternative to percutaneous transhepatic biliary drainage or surgery in unresectable pancreatic cancer with obstructive jaundice when ERCP fails. However, the development of new specific instruments and studies comparing this procedure with percutaneous transhepatic biliary drainage and surgery are needed.

Exploración laparoscópica de la vía biliar y manejo actual de la coledocolitiasis: análisis de los primeros 30 casos / Laparoscopic common bile duct exploration and current management of choledocholithiasis

Se trata de un estudio descriptivo, prospectivo, longitudinal que incluyó a 30 pacientes que consultaron con indicaciones de exploración laparoscópica de la vía biliar. Se describe la técnica utilizada para la exploración transcística y por coledocotomía, tanto con guía fluoroscópica como el uso del coledocoscopio. Se estudiaron las variables, efectividad, conversión, tiempo quirúrgico, complicaciones tiempo de hospitalización, litiasis residual. La exploración laparoscópica de la vía biliar fue efectiva en el 84% de los casos. Las causas de conversión fueron cálculos enclavados y cálculos intrahepáticos. El 32% de los casos se resolvió por la vía transcística , mientras que el resto (68%) se resolvió mediante coledocotomía. La morbilidad asociada la técnica fue de 6,6% dada por diarrea postoperatoria y biliperitoneo luego del retiro del tubo en “t”. El tiempo promedio de hospitalización fue de 3,5 días. Sin casos reportados de litiasis residual. La exploración laparoscópica de la vía biliar (ELVB) es una alternativa terapéutica segura y efectiva en el tratamiento de la obstrucción de la vía biliar principal por cálculos. Sin embargo, queda claro que el éxito del procedimiento depende del dominio de técnicas endoscópicas y laparoscópicas avanzadas y la disponibilidad de recursos tecnológicos de primera.

Report the experience in laparoscopic common bile duct exploration in the Surgery Department III of the Hospital Universitario de Caracas. Descriptive, prospective, longitudinal study of patients admitted with indication of laparoscopic common bile duct exploration. We describe the transcystic approach and choledochotomy technique, using fluoroscopic guidance or choledochoscope. Success rate, conversion, operative time, complications, length of stay and residual lithiasis were studied. Laparoscopic common bile exploration was successful in 84% of the patients. Conversión causes were embedded stones and intrahepatic lithiasis. Transcystic approach was used in 32% of the cases and choledochotomy was performed in 68% of the patients. Morbidity rate was 6,6% due to diarrhea and biliary peritonitis after "t" tube removal. Median length of stay was 3,5 days. No cases of residual stones were reported. Laparoscopic common bile duct exploration is a safe and effective procedure in patients with common bile duct obstruction due to choledocholithiasis However, the success rate is in relation with endoscopic and advanced laparoscopic techniques mastery and technologic resources availability.

Proposal of a new technique for bile duct reconstruction after iatrogenic injury: study in dogs and review of the literature / Reconstrução da via biliar após lesão iatrogênica, proposta de nova técnica. Estudo em cães e revisão da literatura

PURPOSE: Interposition of a jejunal tube between the common bile duct and duodenum. METHODS: Five adult mongrel dogs of both sexes, weighing on average 22.3 kg (18 to 26.5 kg), were used. Obstructive jaundice was induced by ligation of the distal common bile duct. After one week, a 2.5-cm long jejunal tube was fabricated from a segment of the loop removed 15 cm from the Treitz angle and interposed between the common bile duct and duodenum. RESULTS: The animals presented good clinical evolution and no complications were observed. After 6 weeks, complete integration was noted between the bile duct mucosa, tube and duodenum and a significant reduction in total bilirubin and alkaline phosphatase was observed when compared to the values obtained one week after ligation of the common bile duct. CONCLUSION: The jejunal tube interposed between the dilated bile duct and duodenum showed good anatomic integration and reduced total bilirubin and alkaline phosphatase levels in the animals studied.(AU)

OBJETIVO: Interposição de um tubo de jejuno entre o colédoco e o duodeno. MÉTODOS: Foram utilizados cinco cães adultos, sem raça definida, de ambos os sexos, com peso médio de 22,3 Kg (18 e 26,5 Kg). Após provocar icterícia obstrutiva pela ligadura do colédoco distal, após uma semana, praticou-se confecção do tubo de jejuno de 2,5 cm de extensão, que foi realizado com um segmento de alça retirado a 15 cm do ângulo de Treitz e a interposição do tubo entre o colédoco e o duodeno. RESULTADOS: Os animais tiveram boa evolução clínica e não apresentaram complicações. Notou-se total integração entre a mucosa da via biliar, do tubo e do duodeno e redução significativa dos valores da bilirrubina total e da fosfatase alcalina após seis semanas, quando comparado com os valores após uma semana de ligadura do colédoco. CONCLUSÃO: O tubo de jejuno interposto entre a via biliar dilatada e o duodeno, apresentou boa integração anatômica e reduziu os níveis de bilirrubina total e fosfatase alcalina dos animais estudados.(AU)

Surgery or endoscopy for palliation of biliary obstruction due to metastatic pancreatic cancer.

BACKGROUND AND AIMS: Both endoscopic and surgical drainage procedures are effective palliative methods for malignant biliary obstruction. Surgical drainage is still preferred in developing countries due to the high cost of procuring metal biliary stents. The aim of this study was to evaluate the quality of life and the cost of care in patients with metastatic pancreatic cancer after endoscopic biliary drainage and surgical drainage. PATIENTS AND METHODS: This is a prospective, randomized controlled trial conducted in a tertiary referral center in Brazil. Patients with biliary obstruction due to metastatic pancreatic cancer and liver metastasis, but without gastric outlet obstruction, were included in the study. Endoscopic biliary drainage with the insertion of a metal stent into the bile duct was compared with the surgical drainage procedure (choledochojejunostomy and gastrojejunostomy). Quality of life was assessed before, and 30 days, 60 days, and 120 days after the drainage procedure. The cost of drainage procedure, cost during the first 30 days and the total cost from drainage procedure to death were calculated. RESULTS: Of the 273 patients with pancreatic malignancy seen at our hospital between July 2001 and October 2004, 35 patients were eligible for the study, and 30 agreed to participate in the study. Both surgical and endoscopic drainage procedures were successful, without any mortality in the first 30 days. The cost of biliary drainage procedure (US dollars 2,832 +/- 519 vs 3,821 +/- 1,181, p= 0.031), the cost of care during the first 30 days after drainage (US dollars 3,122 +/- 877 vs 6,591 +/- 711, p= 0.001), and the overall total cost of care that included initial care and subsequent interventions and hospitalizations until death (US dollars 4,271+/- 2,411 vs 8,321 +/- 1,821, p= 0.0013) were lower in the endoscopy group compared with the surgical group. In addition, the quality of life scores were better in the endoscopy group at 30 days (p= 0.042) and 60 days (p= 0.05). There was no difference between the two groups in complication rate, readmissions for complications, and duration of survival. CONCLUSIONS: Endoscopic biliary drainage is cheaper and provides better quality of life in patients with biliary obstruction and metastatic pancreatic cancer.

Prospective randomized study of T-tube versus biliary stent for common bile duct decompression after open choledocotomy.

The T-tube has been the alternative of choice for decompression following common bile duct (CBD) exploration. The development of laparoscopic surgery has suggested using a biliary stent as an alternative to the T-tube following choledochotomy. The purpose of this prospective randomized study was to compare clinical results obtained from patients who underwent open CBD exploration using a biliary stent versus those from patients with a T-tube for decompression. Between September 2000 and June 2002 a total of 81 patients were randomly assigned to a biliary stent or a T-tube as the decompression method following choledochotomy. An open CBD exploration was performed when CBD stones were suspected, in both elective and emergency settings. The length of the postoperative hospital stay was 6.8 +/- 4.7 days for patients with the T-tube and of 5.2 +/- 3.3 days for, patients with the biliary stent (p = 0.19). Postoperative complications were observed in 13 patients (30%) with the T-tube and in 4 patients (11%) with the biliary stent (p = 0.03). One patient with a biliary stent was reoperated because of an intraabdominal abscess, and another patient was reoperated because of biliary peritonitis following T-tube removal. Three patients (7%) with a biliary stent and one patient (3%) with a T-tube were rehospitalized. There were no deaths. The T-tube and biliary stent were removed 27.1 +/- 10.8 days and 34.9 +/- 12.9 days after surgery, respectively (p = 0.24). The biliary stent is a safe alternative to the T-tube as a biliary decompression method following an open CBD exploration.