Perioperative outcomes after open biliary bypass for malignant biliary obstruction (MBO) in resource-limited setups; a multicenter prospective cohort study, 2023.

INTRODUCTION: Obstructive jaundice is the most common symptom of malignant diseases of the extrahepatic biliary system and necessitates either non-operative or operative biliary bypass. Because of percutaneous and endoscopic approaches, the use of palliative surgical procedures has decreased in recent years. However, in resource-limited situations, open biliary bypasses remain a viable option. This study aimed to identify factors associated with adverse perioperative outcomes following open biliary bypass. METHODS: From June 2022 to May 2023, 69 patients underwent open biliary bypass for malignant biliary obstruction. Postoperative morbidity and mortality within 30 days of surgery were assessed. A Kaplan-Meier was used for categorical variables, and a log-rank test was used to determine the statistically significant difference between variables. A Cox regression analysis was conducted to identify factors associated to time to develop complications. RESULTS: The hazard of developing complications among those with preoperative cholangitis was 2.49 times higher than those without preoperative cholangitis (HR 2.49, 95% CI [1.06, 5.84]). For every hour increment in the length of surgery, the hazard of getting complications increased by 2.47 times (HR 2.47, 95% CI [1.28, 4.77]). As serum bilirubin increased by 1 mg/dl, the hazard of developing complications increased by 14% (HR 1.14, 95% CI [1.03, 1.17]). CONCLUSION: Patients who had long operation times, preoperative cholangitis, and elevated total bilirubin levels are at increased risk for poor perioperative outcomes. Clinicians may use these results to optimize these patients to decrease their elevated risk of serious morbidity and mortality.

[Preliminary clinical application of novel magnetic navigation and ultrasound-guided percutaneous transhepatic cholangiography drainage through the right liver duct for malignant obstructive jaundice].

Objective: To analyze the clinical application value of a novel magnetic navigation ultrasound (MNU) combined with digital subtraction angiography (DSA) dual-guided percutaneous transhepatic biliary drainage (PTCD) through the right hepatic duct for the treatment of malignant obstructive jaundice. Methods: Randomized controlled trial. The clinical data of 64 patients with malignant obstructive jaundice requiring PTCD through the right hepatic duct at the Hepatobiliary Center of the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province People's Hospital) from December 2018 to December 2021 were retrospectively analyzed. The MNU group (n=32) underwent puncture guided by a novel domestic MNU combined with DSA, and the control group (n=32) underwent puncture guided by traditional DSA. The operation time, number of punctures, X-ray dose after biliary stenting as shown by DSA, patients' tolerance of the operation, success rate of the operation, pre- and post-operative total bilirubin, and incidence of postoperative complications were compared between the two groups. Results: The operation time of the MNU group was significantly shorter than that of the control group [(17.8±7.3) vs. (31.6±9.9) min, t=-6.35,P=0.001]; the number of punctures in the MNU group was significantly lower [(1.7±0.6) vs. (6.3±3.9) times, t=-6.59, P=0.001]; and the X-ray dose after biliary stenting as shown by DSA in the MNU group was lower than that in the control group [(132±88) vs. (746±187) mGy, t=-16.81,P<0.001]; Five patients in the control group were unable to tolerate the operation, and two stopped the operation, however all patients in the MNU group could tolerate the operation, and all completed the operation, with a success rate of 100% (32/32) in the MNU group compared to 93.8%(30/32) in the control group; the common complications of PTCD were biliary bleeding and infection, and the incidence of biliary bleeding (25.0%, 8/32) and infection (18.8%, 6/32) in the MNU group was significantly lower than that in the control group, 53.1% (17/32) and 28.1% (9/32), respectively. Conclusion: Magnetic navigation ultrasound combined with DSA dual-guided PTCD through the right biliary system for the treatment of malignant obstructive jaundice is safe and feasible.

[Endoscopic stenting for malignant pancreatobiliary strictures]. / Endoskopicheskoe stentirovanie pri opukholevykh strikturakh pankreatobiliarnoi zony.

OBJECTIVE: To improve the outcomes in patients with malignant obstructive jaundice using intraluminal stenting. MATERIAL AND METHODS: The present study included 62 patients with clinical symptoms of malignant obstructive jaundice. In the main group, we performed biliary stenting with self-expanding multi-perforated stents (Hanarostent Multi-hole Biliary). Microscopic perforations of these stents prevent migration and reduce the risk of blocking the cystic and main pancreatic ducts. In the control group, stenting was performed with fully and partially covered self-expanding stents. RESULTS: Lower incidence of obstructive cholecystitis and acute pancreatitis in the main group was associated with multiperforated stents reducing the risk of blocking the main pancreatic and cystic ducts. CONCLUSION: In our study, multiperforated stents excluded migration and reduced the incidence of complications (acute cholecystitis from 11.5 to 3.8%, acute pancreatitis from 15.3 to 7.7%).

Preoperative endoscopic ultrasound-guided biliary drainage for primary drainage in obstructive jaundice.

INTRODUCTION: Endoscopic transpapillary approach by endoscopic retrograde cholangiopancreatography (ERCP) is the established technique for preoperative biliary drainage (PBD). Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been reported to be a useful alternative technique after ERCP fail. However, the optimal strategy remain controversial. AREA COVERED: This review summarizes the literature on EUS-BD techniques for PBD with a literature search using PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials database between 2000 and 2023 using keywords for 'preoperative biliary drainage' and all types of EUS-BD techniques. EXPERT OPINION: As there is no consensus on the optimal EUS-BD technique for PBD, selection of the EUS-BD approach depends on the patient's condition, the biliary obstruction site, the anastomosis after surgical intervention, and the preference of the endoscopist. However, we consider that EUS-HGS using a dedicated plastic stent may have some advantages in the adverse impact of surgical procedure because the location where the fistula is created by EUS-HGS is away from the site of the surgical procedure. Although there remain many issues that require further investigation, EUS-BD can be a feasible and safe alternative method of PBD for malignant biliary obstruction after ERCP fail.

[Minimally invasive technologies of lithotripsy and antegrade hydraulic lithoextraction in complex treatment of choledocholithiasis]. / Primenenie mini-invazivnykh tekhnologii litotripsii i antegradnoi gidravlicheskoi litoekstraktsii v kompleksnom lechenii bol'nykh kholedokholitiazom.

OBJECTIVE: To evaluate the effectiveness of minimally invasive technologies of lithotripsy and hydraulic antegrade lithoextraction in complex treatment of choledocholithiasis. MATERIAL AND METHODS: In the main group, 74 patients with choledocholithiasis underwent complex treatment with minimally invasive lithotripsy and hydraulic antegrade lithoextraction. In the control group, 177 patients with choledocholithiasis complicated by obstructive jaundice underwent complex treatment without minimally invasive lithotripsy and hydraulic antegrade lithoextraction. RESULTS: Both groups were characterized by significant decrease of serum bilirubin, markers of cytolysis and cholestasis with regression of clinical manifestations of obstructive jaundice. At the same time, early and delayed postoperative complications were significantly more common in the control group. Most of these complications accounted for interventions through laparotomy such as external drainage of the common bile duct and hepaticojejunostomy. There were no similar procedures in the main group due to the use of minimally invasive technologies of lithotripsy and antegrade hydraulic lithoextraction. CONCLUSION: Minimally invasive lithotripsy and antegrade hydraulic lithoextraction are safe alternatives to traditional methods of lithoextraction and can be recommended in case of ineffective laparoscopic and retrograde endoscopic lithoextraction.

[Endoscopic treatment of obstructive jaundice in patients with Klatskin tumor]. / Endoskopicheskoe lechenie patsientov s mekhanicheskoi zheltukhoi pri opukholi Klatskina.

OBJECTIVE: To improve treatment outcomes in patients with Klatskin tumor and obstructive jaundice by using of endoscopic bilioduodenal stenting. MATERIAL AND METHODS: There were 1904 transpapillary interventions between August 2017 and February 2022. Endoscopic bilioduodenal stenting was performed in 250 patients including 25 (10%) ones with Klatskin tumor. RESULTS: Bilioduodenal plastic and self-expanding stents were installed in 19 (76%) and 6 (24%) patients, respectively. In Klatskin tumor type I, 11 patients (44%) underwent bilioduodenal stenting of common hepatic duct with plastic stent; 5 (20%) patients with Klatskin tumor type II received self-expanding stents. In case of tumor type IIIA, 3 (12%) patients underwent stenting of the right lobar duct with plastic stent. Four (16%) patients with Klatskin tumor type III B underwent stenting of the left lobar duct. Two 2 (8%) patients with Klatskin tumor type IV underwent bilateral bilioduodenal stenting with plastic and bifurcation self-expanding stents. Peroral cholangioscopy using the SpyGlass DS system was performed in 4 (16%) patients. No intraoperative complications were identified. One (4%) patient developed gastrointestinal bleeding in 2 postoperative days after retrograde intervention that did not require surgery. Moreover, 1 (4%) patient with distal dislocation of plastic bilioduodenal stent required redo bilioduodenal stenting. Three (12%) patients died from multiple organ failure despite adequate biliary decompression, and 22 (88%) patients were discharged in 8±5 days after retrograde intervention. CONCLUSION: Bilioduodenal stenting as minimally invasive and physiological method was highly effective for obstructive jaundice in patients with Klatskin tumor. Peroral cholangioscopy using the SpyGlass system provides effective and safe direct visualization of the biliary tract, as well as biopsy for morphological verification and prescription of chemotherapy in patients with intraductal growth of tumor.

[Hemobilia as a sign of arterio-biliary fistula]. / Gemobiliya kak proyavlenie arteriobiliarnoi fistuly.

Hepatic artery aneurysms (HAA) are rare (20% of all visceral arteries). Most often, HAAs are asymptomatic and detected at autopsy. However, their ruptures and/or bleeding following pressure ulcers in visceral gastrointestinal organs are a significant clinical and diagnostic problem. We present 2 patients with obstructive jaundice and hemobilia. Diagnostics revealed aneurysm of the right hepatic artery with arterio-biliary fistula. Life-threatening hemobilia is a consequence of HAA rupture into biliary system. Endovascular approach is preferable for HAA without clinical manifestations. Awareness of this disease is important for early detection and active surgical intervention before possible complications.

Cytochrome P450 3A4 activity and genetic variants as predictors of liver failure in patients with obstructive jaundice.

Liver failure in patients with obstructive jaundice is a significant contributor to mortality within this patient cohort. The exact mechanism and triggers of this occurrence are yet to be fully understood. With this in mind, our study aimed to assess the correlation between the urinary 6 ß-OHC/C ratio and various biochemical parameters of liver function. Furthermore, we conducted genotyping of CYP3A4*22 (rs35599367), CYP3A5*3 (rs776746) polymorphic markers to investigate the potential effects of their variants on the probability of liver failure in obstructive jaundice. Our study included 75 patients diagnosed with severe obstructive jaundice. All test subjects underwent functional liver tests, and control blood tests were administered on the seventh day following biliary decompression. Patients were categorized into two groups: group 1 - patients without liver failure (n = 60) and group 2 - patients with liver failure (n = 15). Laboratory indexes such as 6 ß -OHC concentration and 6 ß- OHC/cortisol ratio can serve as significant predictors of liver failure in patients with moderate and severe degree obstructive jaundice after biliary decompression. Based on the study of "wild" and polymorphic variants of CYP3A4*22 (CC and CT) and polymorphism of CYP3A5*3A6986G (GG, GA, AA), it was discovered that liver failure in the CYP3A4*22 variant may be associated with the CC genotype, and in the CYP3A5*3 variant - with the GA genotype. Hence, the determination of 6ß- OHC concentration and 6ß- OHC/C ratio, as well as the analysis of polymorphic and "wild" variants of CYP3A4*22 (CC and CT) and CYP3A5*3 polymorphism A6986G (GG, GA, AA), may play a crucial role in predicting liver failure in patients with obstructive jaundice.

Bending the distal tip of a guidewire aids in cannulation of an occluded uncovered biliary metal stent.

Biliary metal stent implantation is an effective treatment for malignant obstructive jaundice. But it's well known that stents put in for a long time can become occluded and cause jaundice and cholangitis. At this time, endoscopic intervention is usually required to replace the stent or re-insert the stent. Re-cannulation for metal stent occlusion is challenging because the guide wire may pass through the side holes of the uncovered metal stents, resulting in prolonged surgical time and exposure to radiation. Here we present a small tip that may help endoscopists complete the re-cannulation of an uncovered metal stent in a very short time.

PALLIATIVE SURGICAL TREATMENT OF PATIENTS WITH UNRESECTABLE CANCER OF THE HEAD OF THE PANCREAS COMPLICATED BY MECHANICAL JAUNDICE.

OBJECTIVE: The aim: To improve the results of palliative surgical treatment of patients with unresectable cancer of the head of the pancreas, complicated by obstructive jaundice, disturbances of evacuation from the stomach, cancerous pancreatitis by improving surgical tactics and techniques of surgical interventions.. PATIENTS AND METHODS: Materials and methods: There were 277 patients with unresectable cancer of the head of the pancreas participated in the study, who were divided into control (n=159) and main (n=118) groups depending on treatment tactics. RESULTS: . Results: The operation of choice in the surgical treatment of patients with unresectable cancer of the head of the pancreas, complicated by obturation of the biliary system and duodenum with a high surgical risk is endoscopic stenting of the bile ducts and duodenum with nitinol stents, which is accompanied by a decrease in the frequency of postoperative complications from 72.7 to 29.6% (χ2=5.8, 95% CI 8.26-65.39, p=0.01), mortality from 36.4% to 0.0% (χ2=10.69, 95% CI 11.8- 64.65, p=0.001). The patient's formation of biliodigestive and prophylactic gastrodigestive anastomosis is an effective and safe procedure, which, in comparison with only biliodigestive shunting, reduces the frequency of postoperative complications by 16.2% (χ2=6.61, 95% CI 3.69-30.89, p=0.01), improves quality of life and prevents repeated surgical operations to restore evacuation from the stomach. CONCLUSION: Conclusions: The use of the proposed surgical tactics and technique of surgical interventions in patients with unresectable cancer of the head of the pancreas, complicated by obstructive jaundice, disturbances of evacuation from the stomach, cancerous pancreatitis made it possible to reduce the frequency of complications by 9.3% (χ2=3.94, 95% CI 0.09-17.86, p=0.04) and fatal cases by 5.8% (χ2=4.5, 95% CI 0.42-12.72, p=0.03).

Prophylactic Administration with Methylene Blue Improves Hemodynamic Stabilization During Obstructive Jaundice-Related Diseases' Operation: a Blinded Randomized Controlled Trial.

OBJECTIVES: Patients with obstruction jaundice are at a high risk of hypotension and need high volume of fluids and a high dose of catecholamine to maintain organ perfusion during operation procedure. All these likely contribute to high perioperative morbidity and mortality. The aim of the study is to evaluate the effects of methylene blue on the hemodynamics in patients undergoing surgeries associated with obstructive jaundice. DESIGN: A prospective, randomized, and controlled clinical study. SETTING: The enrolled patients randomly received 2 mg/kg of methylene blue in saline or saline (50 ml) before anesthesia induction. The primary outcome was the frequency and dose of noradrenaline administration to maintain mean arterial blood pressure over 65 mmHg or > 80% of baseline, and systemic vascular resistance (SVR) over 800 dyne/s/cm5 during operation. The secondary outcomes were liver and kidney functions, and ICU stay. PATIENTS: Seventy patients were enrolled in the study and randomly assigned to receive either methylene blue or control (n = 35/group). RESULTS: Fewer patients received noradrenaline in the methylene blue group when compared with the control group (13/35 vs 23/35, P = 0.017), and the noradrenaline dose administrated during operation was reduced in the methylene blue group when compared with the control group (0.32 ± 0.57 mg vs 1.787 ± 3.51 mg, P = 0.018). The blood level of creatinine, glutamic oxalacetic transaminase, and glutamic-pyruvic transaminase after the operation was reduced in the methylene blue group when compared with the control group. CONCLUSIONS: Prophylactic administration of methylene blue before operation associated with obstructive jaundice improves hemodynamic stability and short-term prognosis. QUESTION: Methylene blue use prevented refractory hypotension during cardiac surgery, sepsis, or anaphylactic shock. It is still unknown that methylene blue on the vascular hypo-tone associated with obstructive jaundice. FINDINGS: Prophylactic administration with methylene blue improved peri-operative hemodynamic stability, and hepatic and kidney function on the patients with obstructive jaundice. MEANINGS: Methylene blue is a promising and recommended drug for the patients undergoing the surgeries of relief obstructive jaundice during peri-operation management.

Prognostic effects of different malignant obstructive jaundice sites on percutaneous biliary intervention: A retrospective controlled study.

Purpose: To compare the survival prognosis of percutaneous transhepatic biliary stenting (PTBS) in the treatment of malignant obstructive jaundice (MOJ) at different horizontal sites. Methods: A total of 120 patients with MOJ who underwent biliary stenting were retrospectively included and analyzed and divided into the high-position group (36 patients), middle-position group (43 patients), and low-position group (41 patients) according to biliary obstruction plane by biliary anatomy. Kaplan-Meier curves were used to test for differences in the overall survival (OS), risk assessment of death and potential risk factors for 1-year survival were analyzed using multifactorial Cox regression. Results: The median survival of the high-, middle-, low-position groups were 16, 8.6, and 5.6 months, with a statistically significant difference (P = 0.017). The 1-year survival rate was 67.6%, 41.9%, and 41.5% in the high-, middle-, low-position groups (P < 0.05), and the 1-year risk of death was 2.35 and 2.93 times higher in the medium- and low-position groups, respectively. The incidences of the main complications were 25%, 48.8%, and 65.9% in the high-, middle-, and low-position groups, respectively, (P = 0.002). While the differences in median stent patency were not statistically significant (P > 0.05) in the groups, alanine transaminase, aspartate transaminase, and total bilirubin levels decreased gradually in each group at 1 month and 3 months after interventional therapy (P < 0.001), while there was no significant difference in the decrease between the groups. Conclusions: Different levels of biliary obstruction in patients with MOJ affect survival, especially at 1 year, where high obstruction treated with PTBS has a low incidence of complications and a low risk of death.

SURGICAL APPROACH FOR TREATMENT OF OBSTRUCTIVE JAUNDICE IN PATIENTS OF DIFFERENT AGE GROUPS.

OBJECTIVE: The aim: Assessment of the effectiveness of using minimally invasive and open methods of bile duct decompression for treatment of obstructive jaundice (OJ) by comparing complications in patients of di!erent age groups. PATIENTS AND METHODS: Materials and methods: We analyzed the results of surgical treatment of 250 patients with OJ. The patients were assigned to two groups: Group I (n = 100) consisting of young and middle-age patients, and Group II (n = 150) consisting of elderly, senile and long-living patients. The average age was 52 ± 6.0 years. RESULTS: Results: 62 (24.8%) Group I patients and 74 (29.6%) Group II patients were submitted to minimally invasive surgical interventions. 38 (15.2%) Group I patients and 76 (30.4%) Group II patients were submitted to open surgical interventions. Complications after minimally invasive surgery (n = 62) in Group I patients were observed in 2 (3.2%) cases, and in 4 (10.5%) cases after open surgeries (n = 38). Complications following minimally invasive interventions (n = 74) in Group II patients were registered in 5 (6.8%) cases, and in 9 (11.8%) cases following open operations (n = 76). 2 (2.6%) Group II patients died for transmural myocardial infarction. CONCLUSION: Conclusions: The use of minimally invasive surgical interventions for treatment of young and middle-aged OJ patients compared to patients of older age groups makes it possible to reduce the frequency of complications by 2.1 times, which is a statistically signi"cant (p <0.05). The frequency of complications after open surgical interventions of bile ducts in patients of di!erent age groups is not statistically signi"cant (p >0.05).

A novel ameliorated rat model of reversible obstructive jaundice. / ä¸€ç§æ–°åž‹æ”¹è‰¯å¼å¯é€†æ€§æ¢—é˜»æ€§é»„ç–¸å¤§é¼ æ¨¡åž‹çš„å»ºç«‹.

Obstructive jaundice is a common clinical symptom generally caused by bile duct stones, inflammatory hyperplasia, and tumors. It is characterized by hyperbilirubinemia and may trigger a variety of complications such as hypotension, kidney injury, endotoxemia, multiple organ dysfunction syndrome, and even death (Pavlidis and Pavlidis, 2018; Liu et al., 2021). Relieving bile duct obstruction and providing adequate drainage have been considered as the most effective therapies for obstructive jaundice. However, it has not yet been established whether it is beneficial to treat affected patients by pre-operative biliary drainage (Blacker et al., 2021). Moreover, the pathophysiological changes or mechanisms associated with the reversal of organ function following the relief of bile-duct obstruction are unclear (Huang et al., 2004). Therefore, it is necessary to establish an experimental model of reversible obstructive jaundice to simulate biliary drainage in clinical practice.

CHANGES ANALYSIS OF THE HEPATOCYTE APOPTOSIS MARKERS LEVELS IN MALIGNANT OBSTRUCTIVE JAUNDICE COMPLICATED BY CHOLANGITIS.

OBJECTIVE: The aim: To evaluate changes in the levels of hepatocyte apoptosis markers in malignant obstructive jaundice (MOJ) depending on the performance of preoperative biliary decompression (PBD) and the severity degree of primary ascending cholangitis (PAC). PATIENTS AND METHODS: Materials and methods: 136 patients with MOJ complicated by cholangitis were included in the study: group A (n=84) - patients who underwent PBD; group B (n=52) - patients without PBD. The level of CASP3 and Bcl-2 (Human Bcl-2(B-cell Leukemia/Lymphoma 2) in blood serum and bile was assessed according to the principle of Sandwich-ELISA. Material collection for research was performed at the PBD stage and intraoperatively. RESULTS: Results: Comparative analysis of CASP3 levels in patients of the study groups revealed that the level of this indicator in the blood and bile of group A patients was statistically significantly higher compared to group B, p=0,004 and p<0,001, respectively. There was no statistically significant difference between the study groups in the intraoperative levels of blood serum Bcl-2 (p=0,786) and bile Bcl-2 (p=0,439). The presence of a correlation between apoptosis markers in group A patients with I and II degree of PAC at the time of PBD and the main surgical intervention was determined: blood serum CASP3 - r=0,733, p<0,001 and r=0,753, p<0,001; bile CASP3 - r=0,716, p<0,001 and r=0,792, p<0,001; blood serum Bcl-2 - r=0,609, p<0,001 and r=0,495, p=0,002; bile Bcl-2- r=0,744, p<0,001 and r=0,497, p=0,002, respectively. Binary logistic regression analysis showed that the development of grade I and II PAC did not relate with the levels of apoptosis markers (p>0.05). Linear regression analysis revealed a correlation between the levels of Bcl-2 in bile during PBD and intraoperatively in group A patients with moderate grade OJ (R2=0,547, p<0,001) and between the levels of CASP3 in blood serum (R2=0,614, p<0,001), CASP3 in bile (R2=0,603, p<0,001), Bcl-2 in blood serum (R2=0,484, p<0,001) and Bcl-2 in bile (R2=0,485, p<0,001) in PBD and intraoperatively in patients with severe grade OJ. A statistically significant difference in the levels of Bcl-2 in blood serum (p<0,001) and Bcl-2 in bile (p=0,016) was found when comparing apoptosis markers in patients with moderate grade OJ of the study groups. Binary logistic analysis showed that the performance of PBD had a significant (reducing) effect on CASP3 levels in blood serum and bile taken intraoperatively in study groups patients with moderate grade OJ (R2= 0,292, p<0,001; R2= 0,184, p<0,001). CONCLUSION: Conclusions: Prolonged OJ leads to the pathological apoptosis process. The performance of PBD statistically significantly reduces the level of CASP3 in blood serum and bile, which is confirmed by further determination intraoper¬atively in patients with OJ complicated by PAC, p<0,001. Staged surgical intervention with the performance of PBD according to clear indications is a necessary treatment strategy in patients with MOJ complicated by cholangitis.

Clinical Outcomes of EUS-Guided Choledochoduodenostomy for Biliary Drainage in Unresectable Pancreatic Cancer: A Case Series.

Introduction. Pancreatic ductal adenocarcinoma (PDA) is associated with poor prognosis and 98% loss-of-life expectancy. 80% of patients with PDA are unfit for radical surgery. In those cases, emphasis is set on management of cancer-related symptoms, among which obstructive jaundice is most common. Endoscopic ultrasound-guided biliary drainage (EUS-BD) emerges as a valid alternative to the well-accepted methods for treatment of biliary obstruction. Patient Selection. Five consecutive patients with unresectable pancreatic malignancy, were subjected to EUS-BD, particularly EUS-guided choledochoduodenostomy (EUS-CDS). Ethics. Oral and written informed consent was obtained in all cases prior procedure. Technique. EUS-guided puncture of the common bile duct was performed, followed by advancement of a guidewire to the intrahepatic bile ducts. After dilation of the fistulous tract with a cystotome, a fully covered self-expandable metal stent was inserted below the hepatic confluence and extending at least 3 cm in the duodenum. Technical and clinical success was achieved in four patients without adverse events. In one patient procedure failed due to dislocation of the guidewire, with consequent biliary leakage requiring urgent surgery. Recovery was uneventful with no further clinical sequelae and there was no mortality associated with procedure. Discussion. Introduced in 2001, EUS-guided biliary drainage has become an accepted option for treatment of obstructive jaundice. According to recent guidelines published by European Society of Gastrointestinal Endoscopy (ESGE) in 2022, EUS-CDS is a preferred modality to percutaneous transhepatic biliary drainage (PTBD) and surgery in patients with failed ERCP, with comparable efficiency and better safety profile, which is supported by our experience with the procedure. Conclusions. Our case series suggests that EUS-CDS is an excellent option for palliative management of malignant distal biliary obstruction, emphasizes on the importance of adequate technique and experience for the technical success, and urges the need for future research on establishing the best choice for guidewire and dilation device.

Comparison of Efficacy and Safety between Endoscopic Retrograde Cholangiopancreatography and Percutaneous Transhepatic Cholangial Drainage for the Treatment of Malignant Obstructive Jaundice: A Systematic Review and Meta-Analysis.

BACKGROUND: At present, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangial drainage (PTCD) are frequently used for reducing malignant obstructive jaundice (MOJ). However, it is controversial as to which method is superior in terms of efficacy and safety. OBJECTIVES: The aim of this study was to compare the safety, feasibility, and clinical benefits of ERCP and PTCD in matched cases of MOJ. METHODS: The Web of Science, Cochrane, PubMed, and CNKI databases were searched systematically to identify studies published between January 2000 and December 2019, without language restrictions, that compared ERCP and PTCD in patients with MOJ. The primary outcome was the success rate for each procedure. The secondary outcomes were the technical success rate, serum total bilirubin level, length of hospital stay, hospital expense, complication rate, and survival. This meta-analysis was performed using Review Manager 5.3. RESULTS: Sixteen studies met the inclusion criteria, including 1,143 cases of ERCP and 854 cases of PTCD. The analysis demonstrated that jaundice remission in PTCD was equal to that in ERCP (mean difference [MD], 1.19; 95% confidence interval [CI]: -0.56 to -2.93; p = 0.18). However, the length of hospital stay in the ERCP group was 3.03 days shorter than that in the PTCD group (MD, -2.41; 95% CI: -4.61 to -0.22; p = 0.03). ERCP had a lower rate of postoperative complications (odds ratio, 0.66; 95% CI: 0.42-1.05); however, the difference was not significant (p = 0.08). ERCP was also more cost-efficient (MD, -5.42; 95% CI: -5.52 to -5.32; p < 0.01). Further, we calculated the absolute mean of hospital stay (ERCP:PTCD = 8.73:12.95 days), hospital expenses (ERCP:PTCD = 5,104.13:5,866.75 RMB), and postoperative complications (ERCP:PTCD = 11.2%:9.1%) in both groups. CONCLUSION: For remission of MOJ, PTCD and ERCP had similar clinical efficacy. Each method has its own strengths and weaknesses. Considering that ERCP had a lower rate of postoperative complications, shorter hospital stay, and higher cost efficiency, ERCP may be a superior initial treatment choice for MOJ.