Infectious Complications after Different Percutaneous External-Internal Biliary Drainage Techniques for Malignant Jaundice

Purpose: Analysis of infectious complications incidence in different types of percutaneous externalinternal biliary drainage in patients with obstructive jaundice of tumor genesis.Material and methods: The results of using antegrade external-internal drainage of the biliary tree in transpapillary and suprapapillary variants in 110 patients were analyzed. External-internal biliary drainage was performed in stages, after percutaneous transhepatic cholangiostomy or involuntarily primary with proximal obstruction of the biliary tree with bile duct segregation if it is impossible to form a fixing element of drainage proximal to the obstruction zone.Results: In the first group, transpapillary external-internal drainage was performed in 30 patients with peripapillary tumor obstruction. Of the 26 patients with proximal obstruction, suprapapillary external-internal drainage was performed in 8 patients, transpapillary — in 18 patients. Postmanipulation cholangitis in the first group occurred in 16 cases (28.6 %), liver abscesses developed 4 cases (7.1 %). In the second group, among 30 patients with transpapillary drainage on the background of peripapillary tumor obstruction, signs of acute cholangitis developed in 4 cases. Cholangitis was stopped by timely transfer of external-internal drainage to external. Among 24 patients with proximal obstruction of the biliary tree, suprapapillary external-internal drainage without complications was performed in 18 cases, transpapillary in 6 patients with the proximal block without disconnecting of the biliary tree. Acute cholangitis developed in 2 cases. Patients of the second group had no liver cholangigenic abscesses. There were no cases of hospital mortality in both groups.Conclusion: Factors in the development of postmanipulation cholangitis and liver abscesses during external-internal drainage of the biliary tree against the background of its tumor obstruction are the transpapillary position of endobiliary drainage with duodeno-biliary reflux in persistent biliary hypertension. In the case of suprapapillary location of the working end of external-internal drainage during antegrade drainage of the proximal tumor obstruction of the biliary tree with dissociation, the risk of postmanipulation cholangitis in non-drained liver segments is minimal. In the event of post-manipulation cholangitis in the case of transpapillary drainage of the biliary tree, a temporary transformation of external-internal drainage into external cholangiostomy is necessary.

Endoscopic transmural drainage is associated with improved outcomes in disconnected pancreatic duct syndrome: a systematic review and meta-analysis

Background Disconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis in the neck and body of the pancreas often manifesting as persistent pancreatic fluid collection (PFC) or external pancreatic fistula (EPF). This systematic review and pairwise meta-analysis aimed to review the definitions, clinical presentation, intervention, and outcomes for DPDS. Methods The PubMed, EMBASE, MEDLINE, and SCOPUS databases were systematically searched until February 2020 using the PRISMA framework. A meta-analysis was performed to assess the success rates of endoscopic and surgical interventions for the treatment of DPDS. Success of DPDS treatment was defined as long-term resolution of symptoms without recurrence of PFC, EPF, or pancreatic ascites. Results Thirty studies were included in the quantitative analysis comprising 1355 patients. Acute pancreatitis was the most common etiology (95.3%, 936/982), followed by chronic pancreatitis (3.1%, 30/982). DPDS commonly presented with PFC (83.2%, 948/1140) and EPF (13.4%, 153/1140). There was significant heterogeneity in the definition of DPDS in the literature. Weighted success rate of endoscopic transmural drainage (90.6%, 95%-CI 81.0–95.6%) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7–77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical intervention, which were 82% (weighted 95%-CI 68.6–90.5) and 87.4% (95%-CI 81.2–91.8), respectively (P = 0.389). Conclusions Endoscopic transmural drainage was superior to transpapillary drainage for the management of DPDS. Endoscopic and surgical interventions had comparable success rates. The significant variability in the definitions and treatment strategies for DPDS warrant standardisation for further research.

The Role of Endoscopic Transpapillary Stenting of the Main Pancreatic Duct during the Endoscopic Treatment of Pancreatic Fluid Collections

Endotherapy is a recognized, widely available, and minimally invasive treatment method for pancreatic fluid collections (PFCs) formed in the course of acute pancreatitis (AP). The use of endoscopic techniques in the treatment of main pancreatic duct (MPD) disruption due to AP remains unclear. In this article, a comprehensive review of current literature referencing our observations was performed to identify publications on the role of MPD stenting in patients undergoing endoscopic drainage of PFCs resulting from AP. In this paper, we attempt to clarify this most controversial aspect of endotherapy for PFCs based on existing knowledge and our own experience regarding the endoscopic treatment of AP sequelae. Endoscopic retrograde pancreatography should be performed in all patients undergoing endoscopic drainage of walled-off pancreatic necrosis to assess the integrity of the main pancreatic duct and to implement endotherapy if pancreatic duct disruption is detected. Passive transpapillary drainage is an effective method for treating MPD disruption in the course of necrotizing AP and is one of the key components of endoscopic therapy for local pancreatic necrosis. Conversely, in patients with pancreatic pseudocysts, passive transpapillary drainage reduces the effectiveness of endoscopic treatment and should not be used even in cases of MPD disruption during transmural drainage of pancreatic pseudocysts. In conclusion, the use of transpapillary drainage should depend on the type of the PFC. This conclusion is of great clinical importance, as it can help improve the results of pancreatic endotherapy for fluid collections resulting from AP.

Endoscopic Transmural Drainage is Associated With Improved Outcomes in Disconnected Pancreatic Duct Syndrome: A Systematic Review and Meta-analysis

BackgroundDisconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis in the neck and body of the pancreas often manifesting as persistent pancreatic fluid collection (PFC) or external pancreatic fistula (EPF). This systematic review and pairwise meta-analysis aim to review the definitions, clinical presentation, intervention, and outcomes for DPDS. MethodsThe PubMed, EMBASE, MEDLINE, and SCOPUS databases were systematically searched until February 2020 using the PRISMA framework. A meta-analysis was performed to assess the success rates of endoscopic and surgical interventions for the treatment of DPDS. Success of DPDS treatment was defined as long-term resolution of symptoms without recurrence of PFC, EPF, or pancreatic ascites.ResultsThirty studies were included in the quantitative analysis comprising 1355 patients. Acute pancreatitis was the most common etiology (95.2%, 918/964), followed by chronic pancreatitis (3.1%, 30/964). DPDS commonly presented with PFC (77.3%,728/942) and EPF (18.6%, 175/942). There was significant heterogeneity in the definition of DPDS in the literature. Weighted success rate of endoscopic transmural drainage (90.6%, 95%-CI: 81.0-95.6%) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7-77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical intervention, which were 82% (weighted 95%-CI 68.6-90.5) and 87.4% (95%-CI 81.2-91.8), respectively (P=0.389). Conclusions Endoscopic transmural drainage was superior to transpapillary drainage for the management of DPDS. Endoscopic and surgical interventions had comparable success rates. The significant variability in the definitions and treatment strategies for DPDS warrant standardisation for further research.

Timing of the termination of mechanical jaundice after antegrade and retrograde decompressive surgeries in mechanical jaundice of various genesis

Aim: to determine in a comparative aspect the effectiveness of various minimally invasive decompressive operations in mechanical jaundice of different genesis. Materials and methods. In 135 patients with mechanical jaundice, the rate of bile duct resolution after cholecystostomy and percutaneous cholangiostomy was studied on the background of pancreatic head tumor. In 643 patients with obstructive bile duct disease in cholelithiasis, timing of the termination of jaundice after minimally invasive retrograde (endoscopic papillosphincterotomy (EPT) and EPT with transpapillary drainage) and percutaneous antegrade (cholecystostomy and cholangiostomy) of decompressive operations was studied. Result. Upon cholelithiasis and hyperbilirubinemia less than 100 μmol/l, jaundice is terminated after both variants of retrograde decompression within 3–5 days, antegrade interventions increase these terms by half. Comparison of retrograde and antegrade decompressive surgeries in mechanical jaundice of medium and severe degree on the background of cholelithiasis indicates that the rate of termination of bile stasis is the highest after EPT with transpapillary drainage. Isolated EPT and percutaneous cholangiostoma with medium-grade gallstones increase the duration of jaundice termination by an average of one week. Upon hyperbilirubinemia more than 200 μmol/l, cholangiostomy is not worse than transpapillary drainage. The longest termination period of obstructive jaundice (28–30 days) is observed after superimposition of microcholecystostoma. In patients with jaundice of a mild degree of tumor genesis, no differences in the results were revealed after both variants of percutaneous decompression. Upon hyperbilirubinemia above 100 μmol/l, when cholangio- and cholecystostomy were compared, a higher rate of decrease in serum bilirubin was observed after percutaneous interventions with a cholecystostomy. Conclusion. At all severity levels of mechanical jaundice on the background of cholelithiasis, the best way of decompression is endoscopic papillotomy with transpapillary drainage. In obturation bile stasis upon the pancreatic head tumor, the best decompressive effect is observed after percutaneous cholecystoostomy.