Contemporary practice and perception of autologous blood salvage in hepato-pancreatico-biliary operations: an international survey.

BACKGROUND: This study aimed to assess contemporary knowledge, attitudes and behaviors around transfusion of intraoperative salvaged blood (sRBCt) during hepato-pancreatico-biliary (HPB) operations. Findings are meant to inform the design of future studies that address provider concerns to change behaviors and improve patient outcomes. METHODS: A survey was designed and assessed for relevance, readability and content, and distributed to an international audience of surgeons performing HPB operations. RESULTS: The 237 respondents were predominantly distributed across North America (37.55%), Europe (27.43%) and Asia (19.83%). Roughly one-half (52.74%) of respondents had used sRBCt in HPB surgery before. Transplantation surgeons were more likely than HPB surgeons to have previously used sRBCt [odds ratio = 5.18 (95% CI 1.89-14.20)]. More respondents believed sRBCt was safe for non-cancer versus cancer operations (68.57% vs. 24.17%, p < 0.0001). Less than half (45.71%) of respondents believed that sRBCt was safe in clean-contaminated fields. Most did not utilize preoperative strategies to avoid donor transfusion. CONCLUSION: Practices related to sRBCt in HPB operations vary widely and there is no consensus on its use. Concerns seem primarily related to cancer-specific and infectious outcomes. While further studies are pursued, surgeons may increase their utilization of preoperative strategies to boost hemoglobin levels for at risk patients.

BISCIT: Biliary interventions in critically ill patients with secondary sclerosing cholangitis-a study protocol for a multicenter, randomized, controlled parallel group trial.

BACKGROUND: Progress of cholangitis to cholangiosepsis is a frequent observation in patients with secondary sclerosing cholangitis in critically ill patients (SSC-CIP). Adequate biliary drainage may reduce episodes of cholangiosepsis and therefore stabilize liver function and improve survival. The primary objective of the BISCIT study is to demonstrate that scheduled biliary interventions will reduce incidence of cholangiosepsis, liver transplantation, or death in patients with SSC-CIP. METHODS: A total of 104 patients will be randomized at ten study sites. Patients with SSC-CIP, confirmed by endoscopic retrograde cholangiography (ERC), will be randomized 1:1 either in the intervention group which will be treated with scheduled biliary interventions (i.e., therapeutic ERC) every 8 weeks for 6 months or in the control group which will receive standard of care. The randomization will be stratified by center. The composite primary efficacy endpoint is defined as (1) occurrence of death, (2) necessity of liver transplantation, or (3) occurrence of cholangiosepsis within 6 months following randomization. DISCUSSION: Prospective evaluation of endoscopic treatment procedures is urgently needed to establish an evidence-based therapeutic treatment algorithm in SSC-CIP. A positive trial result could change the current standard of care for patients with SSC-CIP. The results of this study will be disseminated through presentations at international congresses, workshops, and peer-reviewed publications. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov (NCT05396755, date of registration: May 31, 2022, last update: May 31, 2022).

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.

The management of thoracobiliary fistulas in children: a systematic review.

Thoracobiliary fistula (TBF) is a rare condition, in which an atypical communication between the bronchial tree and the biliary tree is present. A comprehensive literature search was conducted on Medline, Embase and Web of Science databases for studies reporting TBF in children. Data regarding patient demographics, site of fistula presentation, preoperative diagnostic procedures needed, and treatment modalities employed were extracted for further analysis. The study pool consisted of 43 studies incorporating 48 cases of TBF. The most frequent symptom was bilioptysis (67%), followed by dyspnea (62.5%), cough (37.5%) and respiratory failure (33%). Regarding the origin of fistula, the left hepatic duct was involved in 29 cases (60.4%), the right hepatic duct in 4 cases (8.3%), and the hepatic junction in 1 case (2%). Surgical management was employed in 46 patients (95.8%). Fistulectomy was performed in 40 patients (86.9%), lung lobectomy or pneumonectomy in 6 (13%), Roux en Y hepaticojejunostomy in 3 (6.5%), and decortication or drainage in 3 cases (6.5%). Three patients died (overall mortality 6.3%), while 17 patients suffered from postoperative complications (overall morbidity 35.4%). TBF in children is a rare but morbid entity which evolves as a result of congenital malformation in the majority of cases. Preoperative imaging of the biliothoracic communication and proper surgical treatment are the components of current management.

Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery.

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs easily when performing another operation for laparoscopic common bile duct exploration (LCBDE), which was once considered a relative contraindication. In view of the limitations of the current surgical technique, this study summarized the surgical approaches and crucial anatomical landmarks for reoperation for LCBDE. Four general surgical approaches were proposed to expose the common bile duct, including the ligamentum teres hepatis approach, the anterior hepatic duodenal ligament approach, the right hepatic duodenal ligament approach, and the hybrid approach. Additionally, this study highlighted seven crucial anatomical landmarks: the parietal peritoneum, the gastrointestinal serosa, the ligamentum teres hepatis, the inferior margin of the liver, the gastric antrum, the duodenum, and the hepatic flexure of the colon, which were helpful to safely separate abdominal adhesions and expose the common bile duct. Moreover, to shorten the time of choledocholithotomy, a sequential method was innovatively applied for the removal of the stones in common bile duct. Mastering the above surgical approaches, including identifying crucial anatomical landmarks and adopting the sequential method will improve the safety of reoperation for LCBDE, shorten the operation time, promote the fast recovery of patients, reduce postoperative complications, and contribute to the popularization and application of this technique.

Complications of biliary stenting versus T-tube insertion after common bile duct exploration: A systematic review and meta-analysis.

BACKGROUND: Complications following the insertion T-tube or stent after common bile duct exploration (CBDE) remain problematic in nowadays surgical era. Based on our knowledge, we did not find any meta-analysis intentionally evaluating the complications between both groups. At this moment, we aimed to analyze and compare both procedures' complications, efficacy, efficiency, and feasibility. METHODS: We searched literature from four databases (EuroPMC, PubMed, Scopus, and ClinicalTrials.gov) up to June 2022 to compile the randomized controlled trials and pro-/retrospective cohort studies. Review Manager 5.4 was used to statistically analyze each outcome measured between biliary stenting and T-tube insertion. RESULTS: Sixteen studies with 1,080 patients (534 biliary stents and 546 T-tube) were included for qualitative and quantitative analysis. The pooled risk ratio (RR) of the overall postoperative complications rate was significantly lower in the biliary stent group compared to the T-tube group 0.43 [95% confidence interval (CI) 0.23-0.80, p = 0.007]. In terms of the operation time, length of hospital stay, and readmission rate was also decreased in stenting as biliary drainage over T-tube placement 1.02 minutes [95% CI -1.53, -0.52, p < 0.0001], 1.96 days [95% CI -2.63, -1.29, p < 0.00001], and RR 0.39 [95% CI 0.15-0.97, p = 0.04], respectively. CONCLUSIONS: Stenting as biliary drainage after CBDE was superior to T-tube insertion. A shorter operation time and hospital stay in biliary drainage resulted in a lower overall postoperative complication rate. Other influences, including the complexity and shorter learning curve, might also affect the superiority of biliary stenting.

Clinical Treatment of Perioperative Disseminated Intravascular Coagulation in Patients Who Underwent Gastrointestinal and Hepato-Biliary-Pancreatic Surgery.

BACKGROUND: It is unclear how effective recombinant thrombomodulin (rTM) treatment is in disseminated intravascular coagulation (DIC) during the perioperative period of gastrointestinal and hepato-biliary-pancreatic surgery. The current study aimed to evaluate the therapeutic outcomes of rTM for perioperative DIC. METHODS: We enrolled 100 consecutive patients diagnosed with perioperative DIC after gastrointestinal surgery, and hepato-biliary-pancreatic including emergency procedures, between January 2012 and May 2021. Patients received routine rTM treatment immediately after DIC diagnosis. Then, the DIC, Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were calculated and used for evaluation. The outcomes of rTM treatment and the predictors of survival were evaluated. RESULTS: The causative diseases of DIC were as follows: perforated peritonitis, n = 38; intestinal ischemia, n = 23; intra-abdominal abscess, n = 13; anastomotic leakage, n = 7; pneumonia, n = 7; cholangitis, n = 4; and others, n = 6. The 30-day mortality rate was 18.0%. There were significant differences in the platelet count (13.78 vs 10.41, P = .032) and the SOFA score (5.22 vs 9.89, P<.0001) at the start of DIC treatment between the survivor and non-survivor groups (day 0). The survivor group had a significantly lower DIC score (3.13 vs 4.93, P = .0006) and SOFA score (4.94 vs 12.14, P < .0001) and a higher platelet count (13.50 vs 4.34, P < .0001) than the non-survivor group on day 3. CONCLUSIONS: Comprehensive and systemic treatment is fundamentally essential for DIC, in which rTM may play an important role in the treatment of perioperative DIC.

Impact of large amount of intra-abdominal lavage on surveillance of surgical site infection after hepato-pancreato-biliary surgery: A prospective cohort study.

BACKGROUND/PURPOSE: In hepatobiliary and pancreatic (HBP) surgery, the role and significance of intra-abdominal lavage (IAL) for surgical site infection (SSI) is controversial. METHODS: This prospective study was performed between July 2020 and July 2022. A total of 150 patients, 10-L IAL was performed. The lavage fluid at 1-L, 5-L, and 10-L was subjected to bacterial culture examination. Risk factors for SSI were evaluated. RESULTS: Bacterial positivity rate significantly decreased as follows: 1-L, 36% (n = 54); 5-L, 27% (n = 41); 10-L, 23% (n = 35) (36% vs 23%, p = .001). Patients with positive lavage fluid culture at 10-L had significantly higher incidence of both incisional (37% vs 6%, p < .01) and organ/space (54% vs 3%, p < .01) SSI. Multivariate analysis revealed positivity for bacterial culture at 10-L as the strongest independent risk factor for incisional SSI (OR 13.0, 95% CI: 3.86-43.6, p < .01), followed by postoperative pancreatic fistula (OR 11.7, 95% CI: 3.03-45.6, p < .01). Likewise, in organ/space SSI, positivity for bacterial culture at 10-L was the strongest independent risk factor (OR 48.9, 95% CI:12.1-197.7, p < .01), followed by digestive reconstruction (OR 5.20, 95% CI: 1.45-18.6, p = .01). CONCLUSION: IAL decreased the intraperitoneal contamination rate in a volume-dependent manner and can be useful in the surveillance of SSI development in HBP surgery.

Hepatic subcapsular hematoma post-endoscopic retrograde cholangiopancreatography requiring embolization.

Endoscopic retrograde cholangiopancreatography (ERCP) placement of biliary stents is the procedure of choice for bile duct strictures. Complications of endoscopic retrograde cholangiopancreatography have a low incidence. Hepatic subcapsular hematoma is uncommon but potentially serious. It is caused by laceration of the bile duct with guidewire or biliary traction during the procedure. Initial management is conservative with supportive measures. In case of hemodynamic instability or superinfection, embolization of the affected branch or even surgery could be performed.

Postoperative anastomotic stricture following excision of choledochal cyst: a systematic review and meta-analysis.

PURPOSE: Postoperative anastomotic stricture (PAS) is a well-known complication after correcting choledochal cyst (CC). Although the exact cause of PAS is unknown, various risk factors, such as Todani classification type IV-A, hepaticoduodenostomy, and narrow anastomosis have been reported to be associated with PAS. As far as we know, there is no report with a cumulative analysis of such risk factors of PAS. This systematic review and meta-analysis aimed to investigate the risk factors of PAS following surgical correction of CC in children. METHODS: A systematic literature search for relevant articles was performed in four databases using the combinations of the following terms "Congenital biliary dilatation", "Congenital choledochal cyst", "Choledochal cyst", "Stenosis", "Stricture", and "Complication" for studies published between 1973 and 2022. The relevant cohorts of PAS were systematically searched for clinical presentation and outcomes. RESULTS: The search strategy identified 795 reports. Seventy studies met the defined inclusion criteria, reporting a total of 206 patients with PAS. There is no prospective study in this search. The incidence of PAS was 2.1%. The proportion of Todani classification of the patient with PAS was higher in type IV-A with significant difference (2.0% in type I and 10.1% in type IV-A (p = 0.001)). Fourteen studies reported a comparison between hepaticojejunostomy and hepaticoduodenostomy. There was no significant difference between the two groups (p = 0.36). Four studies reported the diameter of the anastomosis at the primary surgery. The mean diameter was 12.5 mm. Nine studies reported a comparison between laparoscopic surgery and open surgery. Pooled odds ratio of PAS did not show a statistical difference (p = 0.29). CONCLUSIONS: This study suggests that close careful follow-up is important in the patients with type IV-A of CC who underwent excision surgery, considering the possibility of PAS.

[Clinical effect of laparoscopic transcystic drainage combined with common bile duct exploration for the patients with difficult biliary stones].

OBJECTIVE: To explore the feasibility and efficacy of laparoscopic transcystic drainage and common bile duct exploration in the treatment of patients with difficult biliary stones. METHODS: Between April 2020 and December 2021, eighteen patients with difficult biliary stones received laparoscopic transcystic drainage (C-tube technique) and common bile duct exploration. The clinical characteristics and outcomes were retrospectively collected. The safety and effectiveness of laparoscopic transcystic drainage and common bile duct exploration were analyzed. RESULTS: Among the eighteen patients with difficult biliary stones, thirteen patients received traditional laparoscopic transcystic drainage, and the remaining five received modified laparoscopic transcystic drainage. The mean surgical duration were (161±59) min (82-279 min), no bile duct stenosis or residual stone was observed in the patients receiving postoperative cholangiography via C-tube. The maximum volume of C-tube drainage was (500±163) mL/d (180-820 mL/d). Excluding three patients with early dislodgement of C-tube, among the fifteen patients with C-tube maintained, the median time of C-tube removal was 8 d (5-12 d). The duration of hospital stay was (12±3) d (7-21 d) for the 18 patients. Five C-tube related adverse events were observed, all of which occurred in the patients with traditional laparoscopic transcystic drainage, including two abnormal position of the C-tube, and three early dislocation of the C-tube. All the 5 adverse events caused no complications. Only one grade one complication occurred, which was in a patient with modified laparoscopic transcystic drainage. The patient demonstrated transient fever after C-tube removal, but there was no bile in the drainage tube and the subsequent CT examination confirmed no bile leakage. The fever spontaneously relieved with conservative observation, and the patient recovered uneventfully with discharge the next day. All the 18 patients were followed up for 1-20 months (median: 9 months). Normal liver function and no recurrence of stone were detected with ultrasonography or magnetic resonance cholangiopancreatography (MRCP). CONCLUSION: Laparoscopic transcystic drainage combined with common bile duct exploration is safe and feasible in the treatment of patients with difficult biliary stones. The short-term effect is good. Modified laparoscopic transcystic drainage approach may reduce the incidence of C-tube dislocation and bile leak.

Estimation of Physiologic Ability and Surgical Stress (E-PASS) Predicts Postoperative Major Complications After Hepato-Pancreato Biliary Surgery in the Elderly.

BACKGROUND: As society ages, an increasing number of elderly patients require hepato-pancreato-biliary (HPB) surgery. We investigated the risk factors for complications in elderly patients undergoing HPB surgery using surgical risk scoring models. METHODS: We retrospectively investigated 184 elderly patients (≥ 65 years old) who underwent HPB surgery, including the liver, pancreas, bile duct, and/or gallbladder resection, with exemption to simple cholecystectomy between January 2017 and December 2019. The surgical risk scoring models used included the Estimation of Physiological Ability and Surgical Stress (E-PASS), Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), and Geriatric 8 (G8). We evaluated the correlations between the scores and severe complications. Complications were classified as severe (Clavien-Dindo classification [C-D] ≥ III) or non-severe (C-D ≤ II). RESULTS: Complications occurred in 78 patients (24 C-D ≥ III, 54 C-D ≤ II). Preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) were significantly higher in patients with C-D ≥ IIIa than in those with C-D ≤ II. Multiple logistic regression analysis revealed that PRS (P = 0.01) and SSS (P = 0.04) were independent predictive factors for severe complications. However, the POSSUM and G8 models showed no significant correlations to severe complications. CONCLUSION: E-PASS is a useful model for predicting complications in elderly patients undergoing HPB surgery.

The safety and feasibility of laparoscopic approach for the management of intrahepatic and extrahepatic bile duct stones in patients with prior biliary tract surgical interventions.

The purpose of this study was to compare the efficacy and safety of laparoscopic and open reoperation for intrahepatic and extrahepatic bile duct stones patients with previous biliary tract surgical procedures. The clinical data were retrospectively analyzed of intrahepatic and extrahepatic bile duct stones patients with previous biliary tract surgical procedures who underwent reoperation in the Second General Surgery Department of China Medical University from January 2012 to February 2018. 44 eligible cases were selected. In accordance with the surgical procedures, they were divided into a laparoscopy group (n = 23) and an open surgery group (n = 21). No statistically significant differences were found in the preoperative general clinical data between the two group. Two patients in the laparoscopy group were converted to open surgery. Comparisons between the two groups showed that the intraoperative blood loss [90.87 ± 62.95 (ml) vs. 152.38 ± 118.82 (ml)], the proportion of postoperative analgesia [10/23 (43.5%) vs. 16/21 (76.2%)], and the length of stay [7.19 ± 5.32 (d) vs. 11.00 ± 4.66 (d)] in the laparoscopy group were significantly lower than those in the open surgery group (P < 0.05). Laparoscopic biliary reoperation for intrahepatic and extrahepatic bile duct stones was feasible. Compared with open surgery, laparoscopic surgery has the advantages of less bleeding, a shorter postoperative length of stay, and a lower rate of additional postoperative analgesia.

Long-term outcomes of surgical approaches for bilateral hepatolithiasis: A real-world six-decade experience at a single center.

BACKGROUND: Bilateral hepatolithiasis is an intractable disease and repeated attacks of acute cholangitis seriously threaten patient health. The surgical approaches evolve along with gradually greater understanding of its pathophysiology. METHODS: This is a retrospective cohort study for bilateral hepatolithiasis from January 1958 to December 2018. Before May 1993 (Group A, n = 70), three surgical approaches were adopted: 37 patients with common bile duct exploration (CBDE), 29 with choledochoenterostomy (CE) and four with partial hepatectomy (PH). After June 1993 (Group B, n = 150), 101 patients underwent Oddi sphincter-preserved cholangioplasty with hepatico-subcutaneous stoma (OSPCHS), and 16 with CBDE, 21 with CE, 12 with PH. The perioperative and long-term outcomes were compared. RESULTS: After 1993, the cholangitis recurrence rate significantly decreased from 49.2% to 20.9%, and the stone recurrence rate from 76.3% to 37.1% (both P < .001). Also, the stone-/cholangitis-free durations were prolonged significantly (median: 50.8 vs 26.4/49.6 vs 16.2 months, both P < .001). Preoperative cholangitis was an independent risk factor for stone recurrence (hazard ratio [HR] = 1.863, P = .018), and residual stone for cholangitis recurrence (HR = 2.838, P < .001). OSPCHS and PH were protective surgical approaches for recurrent stone (CBDE: reference; OSPCHS: HR = .469, P = .016, PH: HR = .219, P = .018) and cholangitis (CBDE: reference; OSPCHS: HR = .421, P = .010, PH: HR = .283, P = .093). CONCLUSIONS: For bilateral hepatolithiasis, the management should focus on hepatobiliary lesion eradication and Oddi sphincter function preservation.

Long-term outcomes and predictors of adverse events of EUS-guided hepatico-gastrostomy for malignant biliary obstruction: Multicenter, retrospective study.

BACKGROUND AND AIMS: Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) may be a feasible and useful alternative in patients with malignant biliary obstruction (MBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). To date, the risk factors for adverse events (AEs) and long-term outcomes of EUS-HGS have not been fully explored according to stent type. Therefore, we evaluated potential risk factors for AEs and long-term outcomes of EUS-HGS. METHODS: In total, 120 patients who underwent EUS-HGS were retrospectively reviewed. A multivariate analysis through Cox proportional hazard and logistic regression model was used to identify the risk factors for stent dysfunction and AEs, respectively. Stent patency and patient survival were evaluated using Kaplan-Meier plots with a log-rank test for each stent. RESULTS: The technical and clinical success rates were 96.2% (102/106) and 83.0% (88/106). The median duration of stent patency was longer in self-expandable metal stents (SEMS) compared to plastic stents (PS) (158 vs. 108 days). Kaplan-Meier analysis indicated that the type of stent was not associated with stent patency (Hazard ratios [HR] 0.997, 95% confidence interval [CI] [0.525-1.896]) or overall survival. In addition, multivariate analysis indicated that hilar MBO significantly associated with stent dysfunction (HR, 2.340; 95% CI, 1.028-5.326, p = 0.043) and late AEs. CONCLUSIONS: Given the lower incidence of AEs and better long-term outcomes of EUS-HGS, it can be considered a safe alternative to ERCP or percutaneous approaches regardless of which stent is used. Furthermore, hilar MBO was established as a potential risk factor for stent dysfunction and late AEs.

Endoscopic Ultrasound-guided Hepaticogastrostomy in a Seven-year-old Girl.

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective biliary drainage procedure in adult cases with difficult biliary access. However, there have been no reports on this procedure being used in pediatric cases. We successfully performed EUS-HGS in a pediatric case with a surgically altered anatomy. A standard convex-type echoendoscope and standard devices were used, and there were no device-related complications. The benefit of EUS-HGS for pediatric patients was avoidance of a percutaneous tube, which is difficult to maintain in active children. The accumulation of further cases and performance of a prospective study are warranted to standardize and expand the experience with this procedure.

Long-Term Outcomes of Patients With Progressive Familial Intrahepatic Cholestasis After Biliary Diversion.

OBJECTIVES: Progressive familial intrahepatic cholestasis is a heterogeneous group of genetic disorders characterized by disrupted bile homeostasis. Patients with this disease typically present with cholestasis and pruritus early in life and often progress to end-stage liver disease. The clinical symptoms that patients with progressive familial intrahepatic cholestasis encounter are usually refractory to medical treatment. Although the effects of biliary diversion surgery on native liver survival are not exactly known, this procedure may provide a positive impact on pruritus and laboratory parameters in these patients. MATERIALS AND METHODS: We retrospectively evaluated the clinical and laboratory characteristics of patients with progressive familial intrahepatic cholestasis who underwent partial external biliary diversion between 2002 and 2020 at our center. Diagnosis of progressive familial intrahepatic cholestasis was made by clinical, biochemical, and histopathological characteristics as well as genetic testing. RESULTS: Nine patients were included in the study. Five patients required liver transplant during follow-up, with 4 having liver transplant as a result of endstage liver disease (median interval of 5 years). In 1 patient, partial external biliary diversion was performed 1.5 years after liver transplant for severe diarrhea, metabolic acidosis, and hepatic steatosis. Four patients did not require liver transplant during follow-up (median follow-up time of 7.6 years). Pruritus responded well to partial external biliary diversion in all patients. Among laboratory values evaluated 6 months after biliary diversion, only albumin showed significant improvement. CONCLUSIONS: Partial external biliary diversion had favorable results on long-term follow-up. This procedure can provide the relief of pruritus and delay the requirement for liver transplant in patients with progressive familial intrahepatic cholestasis. In our view, partial external biliary diversion should be considered the first-line surgical management for patients with this disease.

Biliary metal stents should be placed near the hilar duct in distal malignant biliary stricture patients.

BACKGROUND: Endoscopic biliary drainage using a self-expandable metallic stent (SEMS) has been widely performed to treat distal malignant biliary obstruction (DMBO). However, the optimal position of the stent remains unclear. AIM: To determine the ideal position for SEMS placement. METHODS: In total, 135 DMBO patients underwent SEMS (uncovered or covered) placement over a ten-year period. A total of 127 patients with biliary obstruction between the junction of the cystic duct and Vater's papilla were enrolled. An SEMS was placed through the upper common bile duct 2 cm from the biliary hilar duct in 83 patients (Hilar group) or near the top of the biliary obstruction in 44 patients (Lower group). Technical and functional success, adverse events, and risk factors for SEMS dysfunction were evaluated. RESULTS: The stent patency period was significantly longer in the Hilar group than in the Lower group (P value < 0.01). In multivariate analysis, the only statistically significant risk factor for SEMS dysfunction was being in the Lower group (hazard ratio: 9.94, 95% confidence interval: 2.25-44.0, P < 0.01). CONCLUSION: A longer patency period was achieved by positioning the SEMS near the biliary hilar duct.