Modern approaches to the treatment of mechanical jaundice on the background of malignant damage of the pancreatobiliary zone

Aim. To study the role of tumors of the pancreatobiliary zone in the development of obstructive jaundice. To evaluate the effectiveness of endoscopic methods of diagnosis and treatment of this pathology. Materials and methods. The study is based on the results of the activities of JSC “MSU Neftyanik” in Tyumen for 2011-2020. During this period, 1284 patients with obstructive jaundice were admitted for emergency indications. Of this number, 181 patients had signs of cancerous lesions of the organs of the pancreatobiliary zone. The results obtained were used to evaluate effective endoscopic methods of diagnosis and treatment of patients in this group. Results. Malignant lesion of the pancreatobiliary zone is 14.3% of all cases of emergency treatment of patients with obstructive jaundice. The main cause is cancer of the pancreas, cancer of the bile ducts, as well as cancer of the large duodenal papilla and compression of the bile ducts “from the outside”. Performing emergency duodenoscopy on the first day after admission of patients made it possible to accurately verify the cancerous nature of the disease in the vast majority of patients. The most effective method for the relief of biliary hypertension syndrome in this group is bile duct stenting. Despite the varied nature of the cancer lesion, effective stenting was achieved in 71.3% of patients. If it is technically impossible to carry out stenting, minimally invasive puncture catheterization of the intrahepatic bile ducts is performed. Conclusion. Currently, cancer of the pancreatobiliary zone was established in every 5-7 patients with obstructive jaundice. Emergency duodenoscopy and ERCH is an effective diagnostic method that allows you to verify the “cancerous” nature of jaundice with a probability close to 100%. The most effective method of bile duct decompression in this group of patients is endoscopic transpapillary stenting.

When Is It Safe to Proceed With Pancreaticoduodenectomy Without Biliary Decompression?

Background An absolute bilirubin level where preoperative biliary decompression (PBD) is indicated before pancreaticoduodenectomy has been elusive. Our goal was to identify a total bilirubin level whereby biliary decompression provides clear benefit, despite associated expenses and potential complications. Materials and Methods We reviewed a prospectively collected database of patients undergoing pancreaticoduodenectomy at the Vidant Medical Center between 2007 and 2016. Patients were arbitrarily subdivided into 3 groups based on presenting bilirubin level (≤10 mg/dL, 10.1-14.9 mg/dL, and ≥15 mg/dL) to determine the presence of overall complications, severe complications (Clavien-Dindo classification ≥3), prolonged length of stay (>1 SD), readmissions, or mortality. Results Common bile duct stenting independently predicted a higher incidence of complications in patients presenting with bilirubin ≤10 mg/dL ( P = .03) vs. those patients going directly to surgery. No differences were observed for patients with bilirubin between 10.1 mg/dL and 14.9 mg/dL. Biliary decompression in patients with bilirubin ≥15 mg/dL independently predicted fewer overall (73.8% vs. 100%, P = .0082) and less severe complications (14.3% vs. 44.5%, P = .03) and lower readmission rates (15.8% vs. 55.6%, P = .03) vs. those going directly to surgery. Patients not undergoing biliary decompression underwent pancreaticoduodenectomy sooner than those decompressed (4.7 days vs. 17.2 days, P = .01). Discussion All patients presenting with bilirubin ≥15 mg/dL should undergo PBD, while those with bilirubin ≤10 mg/dL should forego stent placement to avoid stent-related complications. The decision to stent between 10.1 and 14.9 mg/dL should be made on a case-by-case basis keeping in mind timeliness to definitive cancer treatment.

Adding ursodeoxycholic acid to the endoscopic treatment and common bile duct stenting for large and multiple biliary stones: Will it improve the outcomes?

Background The role of common bile duct (CBD) stenting in the establishment of bile stream in the elderly patients and the ones who are not good candidates for surgery due to not responding to treatments was well documented in previous studies. The current study aimed at investigating the effect of adding Ursodeoxycholic acid (UDCA) to CBD stenting alone in order to reduce the size of large and multiple CBD stones. Methods Clinical outcomes including success rates in CBD stones clearance, incidence of pancreatitis, perforation, bleeding, as well as, decrease in size of stones and liver enzymes after a two-month period were assessed in the UDCA + CBD stenting group. Results A total of 64 patients referring to Shahid Beheshti Hospital in Qom, Iran with multiple or large CBD stones (above three or larger than 15 mm) received standard endoscopic therapies and UDCA + CBD stenting (group B) and controls only received standard endoscopic therapies with only CBD stenting (group A). The mean reduction in the size of stones in group B was significantly higher than that of group A (3.22 ± 1.31 vs 4.09 ± 1.87 mm) (p = 0.034). There was no difference in the incidence rate of complications including pancreatitis, cholangitis, bleeding, and perforation between the two groups (P > 0.05). Conclusion Adding UDCA to CBD stenting, due to decrease in the stone size and subsequently facilitation of the stones outlet, can be considered as the first-line treatment for patients with large and multiple CBD stones. Also, in the cases with large or multi stones may be effective in reducing size and subsequently stone retrieval. Trial registry The study protocol was approved by the Ethics Committee of Qom University of Medical Sciences (ethical code: IR.MUQ.REC.1397.075); the study was also registered in the Iranian Registry of Clinical Trials (No. IRCT20161205031252N8). This study adheres to CONSORT guidelines.

Role of biliary drainage before pancreatoduodenectomy in treatment periampullary cancer

Introduction: Many studies show that biliary drainage prior to pancreatoduodenectomy increases the risk of biliarys bacterial infection. Our studys question: How does biliary drainage through ERCP before pancreatoduodenectomy affect the rate of post-operation infection? Materials and Methods: Prospective cohort study. All cases of periampullary cancer were scheduled to be performed standardize pancreatoduodenectomy from September 1st, 2018 to May 1st, 2019, at Cho Ray Hospital. Results: During the period of study, there were 38 cases that achieved criteria. There were 19 cases of ERCP with stenting before surgery, accounting for 50%, 19 cases of non-preoperative biliary drainage (accounting for 50%). The rate of positive culture with bacteria is common in patients with biliary tract stenting prior to surgery, the difference is statistically significant (p = 0.01). The incidence of surgical site infection is common among patients with biliary tract drainage prior to surgery and positive bile culture results for bacteria, but the difference is not statistically significant (p = 0.068). Conclusions: Biliary infection in patients with pancreatoduodenectomy treating periampullary cancer accounted for 60.5%. Bile duct stenting prior to surgery increases the risk of biliary tract infections and changes the type of bacteria in bile fluid. Keywords: Bilary drainage, pancreatoduodenectomy. Tóm tắt Đặt vấn đề: Dẫn lưu đường mật trước phẫu thuật cắt khối tá tụy làm tăng nguy cơ nhiễm khuẩn dịch mật. Câu hỏi nghiên cứu chúng tôi: ERCP dẫn lưu đường mật trước phẫu thuật ảnh hưởng thế nào đến tỉ lệ nhiễm trùng sau phẫu thuật cắt khối tá tụy. Phương pháp nghiên cứu: Nghiên cứu tiến cứu, mô tả hàng loạt ca. Thời gian từ 01 tháng 9 năm 2018 đến 01 tháng 5 năm 2019, các trường hợp cắt khối tá tụy thỏa tiêu chuẩn chọn bệnh tại Bệnh viện Chợ Rẫy. Kết quả: Có 38 trường hợp thỏa tiêu chuẩn chọn mẫu. Nghiên cứu ghi nhận có 19 trường hợp ERCP đặt stent dẫn lưu đường mật trước mổ (chiếm 50%), 19 trường hợp không dẫn lưu đường mật trước mổ (chiếm 50%). Tỉ lệ cấy dương tính với vi khuẩn thường gặp ở nhóm người bệnh có đặt stent dẫn lưu đường mật trước mổ, có ý nghĩ thống kê (p = 0,01). Tỉ lệ nhiễm khuẩn vết mổ thường gặp ở nhóm bệnh có đặt dẫn lưu đường mật trước mổ, sự khác biệt không có ý nghĩa thống kê (p = 0,068). Kết luận: Nhiễm khuẩn dịch mật sau phẫu thuật cắt khối tá tụy chiếm 60,5%. Đặt stent dẫn lưu đường mật trước mổ làm tăng nhiễm khuẩn dịch mật và làm thay đổi chủng vi khuẩn trong dịch mật.

Pancreatitis and Biliary Obstruction Secondary to Duodenal Metastasis from Rapidly Progressing Lung Adenocarcinoma Treated with Common Bile Duct Stenting

Non-small cell lung cancer (NSCLC) is characterised by diffuse metastases, with common sites being the brain, liver, bones, and adrenal glands. Small bowel metastasis from NSCLC is a rare phenomenon, particularly in patients with an adenocarcinoma histology. We report the case of a 56-year-old lung adenocarcinoma patient with a duodenal metastasis diagnosed on FDG/PET-CT and confirmed on duodenal biopsy. Although initially asymptomatic, he subsequently presented with obstructive jaundice secondary to rapid local disease progression at the duodenal metastasis, requiring endoscopic intervention for biliary drainage. He was commenced on single agent pembrolizumab, with disease response on subsequent follow-up. This case highlights a rare case of gastrointestinal metastasis from NSCLC requiring endoscopic intervention due to rapid progression of the disease at the site of metastasis.