Table 4 - uploaded by Hiroshi Kawakami
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The controversy over whether and how to perform preoperative biliary drainage (PBD) in patients with hilar cholangiocarcinoma (HCA) remains unsettled. Arguments against PBD before pancreatoduodenectomy have recently been gaining momentum. However, the complication-related mortality rate is as high as 10% for patients with HCA who have undergone maj...
Context in source publication
Context 1
... were classified by tumor type as Bismuth type II (n = 8), IIIa (n = 5), IIIb (n = 1), and IV (n = 10). Factors that necessitated the use of two ENBD tubes were: bilateral SC (n = 9), contralateral SC (n = 9), ipsilateral SC (n = 3), and other (n = 3; Table 4). All patients had successful insertion of both ENBD tubes (diameter range 5-7 Fr, a pair of 5-Fr tubes, a pair of 5-and 6-Fr tubes, or a pair of 5- and 7-Fr tubes). ...
Citations
... Endoscopic nasobiliary drainage (ENBD) and percutaneous transhepatic biliary drainage (PTBD) were performed in 51.3% and 35.5% of the patients in the previous study and 80% and 4.0% in this study, respectively. Based on the study by Kawakami et al. in 2011, this was thought to be because ENBD became the first choice for biliary drainage at our institution [25]. The difference in results between the present and past studies may have been due to the changes in preoperative management. ...
... Endoscopic nasobiliary drainage (ENBD) and percutaneous transhepatic biliary drainage (PTBD) were performed in 51.3% and 35.5% of the patients in the previous study and 80% and 4.0% in this study, respectively. Based on the study by Kawakami et al. in 2011, this was thought to be because ENBD became the first choice for biliary drainage at our institution [25]. The difference in results between the present and past studies may have been due to the changes in preoperative management. ...
Purpose
Recently, systemic inflammatory responses (SIR) have been shown to play a pivotal role in the development and progression of cancer. We previously reported that four factors, serum carcinoembryonic antigen (> 7 ng/dL), serum albumin (< 3.5 g/dL), C-reactive protein (> 0.5 mg/dL), and platelet-lymphocyte ratio (PLR; > 150), were independent prognostic factors after perihilar cholangiocarcinoma (PHCC) surgery. We also advocated a prognosis predictive preoperative prognostic score (PPS) using these four factors and showed that PPS could predict patients’ prognosis on survival. This retrospective study sought to validate preoperatively available prognostic factors for survival after major hepatectomy as reported previously, including PPS for PHCC.
Methods
We retrospectively validated our PPS score and reported SIR scoring systems using the data of 125 consecutive patients who underwent PHCC surgery from January 2010 to November 2020.
Results
PPS was an independent preoperative prognostic factors for survival. The T and N categories were independent prognostic factors. Other SIR scores were not independent preoperative factors in the univariate analysis. Among SIR scores, only the PPS was found to be associated with OS and disease-free survival. The PPS was also associated with histopathological factors (T and N categories).
Conclusion
PPS could be useful in predicting long-term survival after PHCC and may be a more useful scoring system than other SIR systems.
... Usually, the incidence of cholangitis after endoscopic drainage is up to 28.8%, while the incidence of pancreatitis is up to 20.1% [4]. Many surgeons prefer to use percutaneous transhepatic biliary drainage (PTBD) to reduce jaundice, because it's reported to cause lower incidence of postoperative cholangitis and pancreatitis [5], especially for those patients who are likely to undergo radical surgery. Although the incidence of cholangitis after PTBD is relatively low, it has been reported that PTBD might lead to needle-tract metastasis and thus affect long-term prognosis [6]. ...
... Post-ERCP cholangitis is the major problem in endoscopic biliary drainage for patients with hilar biliary cancer, which occurs in 10-60% of cases [5,15]. Inadequate drainage and contrast media injection under hilar biliary duct are one of the major causes of post-ERCP cholangitis [16,17]. ...
Background and aims
ERCP-guided biliary drainage (ERCP-BD) is a standard treatment for malignant biliary obstruction. For the drainage of hilar cholangiocarcinoma (HCCA), ERCP-BD has always been controversial due to the high incidence of postoperative cholangitis. In this study, we used a 3-D reconstruction technology (IQQA®-liver) to provide an accurate spatial conformation between tumors and bile ducts, and significantly reduced the incidence of cholangitis.
Methods
A total of 12 patients with HCCA were included in this study during 2017–2018. All patients underwent thin-layer CT scan and MRCP before ERCP-BD to identify the obstruction site and tumor location. The 3-D imaging system was used to accurately locate the tumors and bile ducts. Based on it, we selected the appropriate drainage of hepatic lobes. Intraoperative air cholangiography and nasobiliary drainage were performed, and nasojejunal tubes were placed for external biliary recycle.
Results
All patients underwent successful ERCP procedure and were placed with nasobiliary drainage. One patient also underwent plastic biliary stent implantation. Intraoperative, 4 patients were placed with pancreatic duct stents and 3 patients underwent small endoscopic sphincterotomy (EST). After ERCP, 1 patient presented with mild pancreatitis and cholangitis. No patients received additional percutaneous transhepatic biliary drainage (PTBD) due to insufficient drainage. Except two patients, the remaining patients received radical surgical treatment.
Conclusion
The 3-D reconstruction assisted precision ERCP-BD is a safe and effective method, it can reduce the risk of post-ERCP cholangitis in HCCA patients. Precision ERCP-BD might be justified as a routine procedure for HCCA patients with hyperbilirubinemia.
... In addition, in a retrospective study of patients undergoing PTBD or ERBD, the PTBD group had significantly higher hepatic metastasis, more wound infections, and lower OS [100]. Sasahira et al [106] found that ENBD was associated with much less dysfunction than EBS in MBO. However, ENBD may not be suitable for long-term preoperative cure because of its impact on patient quality of life and disruptions in the enterohepatic circulation of bile salts [107]. ...
Borderline resectable pancreatic cancer (BRPC) is a complex clinical entity with specific biological features. Criteria for resectability need to be assessed in combination with tumor anatomy and oncology. Neoadjuvant therapy (NAT) for BRPC patients is associated with additional survival benefits. Research is currently focused on exploring the optimal NAT regimen and more reliable ways of assessing response to NAT. More attention to management standards during NAT, including biliary drainage and nutritional support, is needed. Surgery remains the cornerstone of BRPC treatment and multidisciplinary teams can help to evaluate whether patients are suitable for surgery and provide individualized management during the perioperative period, including NAT responsiveness and the selection of surgical timing.
... Furthermore, compared with conventional stents, endoscopic nasobiliary drainage can be used to monitor the amount and nature of bile [10] and is less likely to cause cholangitis [8,11]. However, endoscopic nasobiliary drainage is inferior in that it causes more patient suffering and impaired enterohepatic circulation of bile [3,12,13]. ...
... In the diagnosis of PHCC, contrast-enhanced multidetectorrow computed tomography should be conducted after hematological examination and abdominal ultrasonography, enabling accurate tumor staging [3]. Based on this assessment, PBD should be performed in jaundiced patients who are scheduled for major hepatectomy [11,12,28,29] because mortality remains high in this setting, mainly due to liver failure [3]. Also, because it is estimated that the risk of developing de novo malignancies after liver transplantation is high [30], it is expected that PBD will be performed more frequently in such patients in the future. ...
Background:
There is a need for a more tolerable preoperative biliary drainage (PBD) method for perihilar cholangiocarcinoma (PHCC). In recent years, inside stents (ISs) have attracted attention as a less suffering PBD method. Few studies have compared IS with a fully covered self-expandable metallic stent (FCSEMS) as PBD for resectable PHCC. The aim of this study is to compare them.
Methods:
This study involved 86 consecutive patients (IS: 51; FCSEMS: 35). The recurrent biliary obstruction (RBO) rate until undergoing surgery or being diagnosed as unresectable, time to RBO, factors related to RBO, incidence of adverse events related to endoscopic retrograde cholangiography, and postoperative complications associated with each stent were evaluated retrospectively.
Results:
There was no significant difference between the two groups in the incidence of adverse events after stent insertion. After propensity score matching, the mean (SD) time to RBO was 37.9 (30.2) days in the IS group and 45.1 (35.1) days in the FCSEMS group, with no significant difference (P=0.912, log-rank test). A total of 7/51 patients in the IS group and 3/35 patients in the FCSEMS group developed RBO. The only risk factor for RBO was bile duct obstruction of the future excisional liver lobe(s) due to stenting (HR 29.8, P=0.008) in the FCSEMS group, but risk factors could not be indicated in the IS group. There was no significant difference in the incidence of bile leakage or liver failure. In contrast, pancreatic fistula was significantly more common in the FCSEMS group (13/23 patients) than in the IS group (3/28 patients) (P < 0.001), especially in patients who did not undergo pancreatectomy (P=0.001).
Conclusions:
As PBD, both IS and FCSEMS achieved low RBO rates. Compared with FCSEMS, IS shows no difference in RBO rate, is associated with fewer postoperative complications, and is considered an appropriate means of PBD for resectable PHCC. This trail is registered with UMIN000025631.
... Furthermore, compared with conventional stents, endoscopic nasobiliary drainage can be used to monitor the amount and nature of bile 9 and is less likely to cause cholangitis 7,10 . However, endoscopic nasobiliary drainage is inferior in that it causes more patient suffering and impaired enterohepatic circulation of bile 3,11,12 . Thus, it is necessary to explore methods of preoperative biliary drainage (PBD) other than conventional stent and endoscopic nasobiliary drainage. ...
... In the diagnosis of PHCC, contrast-enhanced multidetector row computed tomography should be conducted after hematological examination and abdominal ultrasonography, enabling accurate tumor staging 3 . Based on this assessment, PBD should be performed in jaundiced patients who are scheduled for major hepatectomy 10,11,27,28 because mortality remains high in this setting, mainly due to liver failure 3 . ...
Background
There is a need for a more tolerable preoperative biliary drainage (PBD) method for perihilar cholangiocarcinoma (PHCC). In recent years, inside stents (ISs) have attracted attention as a less suffering PBD method. Few studies have compared IS with a fully covered self-expandable metallic stent (FCSEMS) as PBD for resectable PHCC. The aim of this study is to compare them.
Methods
This study involved 87 consecutive patients (IS: 51, FCSEMS: 36). The recurrent biliary obstruction (RBO) rate until undergoing surgery or being diagnosed as unresectable, time to RBO, factors related to RBO, incidence of adverse events related to endoscopic retrograde cholangiography and postoperative complications associated with each stent were evaluated retrospectively.
Results
There was no significant difference between the two groups in the incidence of adverse events after stent insertion. The mean (s.d.) time to RBO was 40.0 (28.1) days in the IS group and 52.0 (45.5) days in the FCSEMS group, with no significant difference (P=0.384). A total of 7/51 patients in the IS group and 3/36 patients in the FCSEMS group developed RBO. The only risk factor for RBO was bile duct obstruction of the future excisional liver lobe(s) due to stenting (HR 0.033, P=0.006) in the FCSEMS group, but risk factors could not be indicated in the IS group. Regarding postoperative complications, there was no significant difference in the incidence of bile leakage or liver failure. In contrast, pancreatic fistula was significantly more common in the FCSEMS group (13/24 patients) than in the IS group (3/28 patients) (P=0.001), especially in patients who did not undergo pancreatectomy (P=0.001).
Conclusions
As PBD for PHCC, both IS and FCSEMS achieved low RBO rates. In contrast, the incidence of postoperative pancreatic fistula was higher with FCSEMS. Thus, IS, which can be inserted easily, is considered an optimal approach as PBD for resectable PHCC.
clinical trial registration number: UMIN000025631
... If the preoperative waiting period is short, ENBD is associated with less dysfunction as compared to EBS. 37 However, it may not be suitable for long-term preoperative treatment in terms of the patient's quality of life and disruption of the enterohepatic circulation of bile salts. 38 Therefore, when PBD is performed, EBS is commonly used; the stents used can be broadly divided into PS and SEMS (Fig. 2). When assessing stent patency, it is advisable to assess for recurrent biliary obstruction (RBO), which includes stent occlusion and migration. ...
Obstructive jaundice is a major symptom of pancreatic head cancer, and although its amelioration is required before scheduling chemotherapy, the decision to perform biliary drainage for resectable pancreatic cancer has remained controversial. In recent years, the effectiveness of neoadjuvant therapy for pancreatic cancer has been reported. Preoperative biliary drainage has become increasingly necessary, making the choice of stent an important one; thus, the longer the waiting period extends through neoadjuvant chemotherapy, the more durable stents—such as self-expandable metallic stents, rather than plastic stents—would be desired as an option. Still, there is insufficient evidence regarding surgical outcomes and long-term prognosis, and further confirmatory studies are needed. Through this review, we aim to provide an update on the characteristics of biliary stents and preoperative biliary drainage for potentially resectable pancreatic cancer.
... EBS is typically reserved for low bile duct obstructions, with the obstruction usually occurring below the common hepatic duct, as PHC often cannot be adequately drained via EBS techniques. Additionally, EBS is associated with a high incidence of cholangitis secondary to stent occlusion, 32 which can result in sepsisrelated morbidity, delayed surgical resection, or require additional procedures. It is also difficult to endoscopically target a specific area of the liver for drainage, risking leaving parts of the biliary tree undrained. ...
Perihilar cholangiocarcinoma (PHC) is a rare tumor that requires surgical resection for a potential cure. The role of preoperative biliary drainage has long been debated, given its treatment of biliary sepsis and decompression of the future liver remnant (FLR), but high procedure-specific morbidity. The indications, methods, and outcomes for preoperative biliary drainage are discussed to serve as a guide for perioperative management of patients with resectable PHC. Multiple studies from the literature related to perihilar cholangiocarcinoma, biliary drainage, and management of the FLR were reviewed. Commonly employed preoperative biliary drainage includes endoscopic biliary stenting and percutaneous transhepatic biliary drainage. Drainage of the FLR remains controversial, with most experts recommending drainage of the only in patients with an FLR <50%. Biliary drainage for resectable PHC requires a patient-specific approach with careful determination of the FLR and balancing of potential morbidity with the benefits of drainage.
... Other complications include perforation (up to 1.7%) and additional PTBD may be required in 10% to 12.8% of cases. Effective unilateral ENBD can be achieved in 59.1% to 95% of cases [16][17][18][19][20][21]. ...
... Post-ERCP pancreatitis can cause abandonment of curative resection in severe cases. When patients Bile replacement (Q6-7): Bile replacement during external biliary drainage helps restore intestinal barrier function in patients with biliary obstruction, similar to that of internal drainage, and can also prevent gut-derived bacterial translocation and, in turn, reduce the incidence of postoperative septic complications [27] Bile culture (Q9-10): Perioperative surveillance bile culture is useful for the perioperative selection of appropriate antibiotics because of the high likelihood that micro-organisms isolated from infected sites are identical to those isolated from bile develop a fever after EBS placement, differential diagnosis of whether it is due to cholangitis in the drained area or the undrained area is difficult as bile color or output cannot be checked [16][17][18][19][20][21]. PTBD is an invasive procedure [22]. ...
... Other complications include perforation (up to 1.7%) and additional PTBD may be required in 10% to 12.8% of cases. Effective unilateral ENBD can be achieved in 59.1% to 95% of cases [16][17][18][19][20][21]. ...
... Post-ERCP pancreatitis can cause abandonment of curative resection in severe cases. When patients Bile replacement (Q6-7): Bile replacement during external biliary drainage helps restore intestinal barrier function in patients with biliary obstruction, similar to that of internal drainage, and can also prevent gut-derived bacterial translocation and, in turn, reduce the incidence of postoperative septic complications [27] Bile culture (Q9-10): Perioperative surveillance bile culture is useful for the perioperative selection of appropriate antibiotics because of the high likelihood that micro-organisms isolated from infected sites are identical to those isolated from bile develop a fever after EBS placement, differential diagnosis of whether it is due to cholangitis in the drained area or the undrained area is difficult as bile color or output cannot be checked [16][17][18][19][20][21]. PTBD is an invasive procedure [22]. ...
... For patients who had major hepatectomy, ENBD was recommended for biliary drainage to save the liver function due to its more sufficient potency and less preoperative cholangitis compared to endoscopic retrograde biliary drainage (ERBD). [33,34] Complete preoperative drainage of the FLR (future liver remnant) segments corelates with lower postoperative mortality in patients with an FLR volume below 50%. By contrast, there is lack of evidence to support preoperative biliary drainage in the presence of an FLR volume above 50%. ...
Background:
The aim of this study was to compare the clinical outcomes between patients with preoperative cholangitis and noncholangitis patients to determine whether the preoperative cholangitis would be able to serve as an independent predictive factor on hilar cholangiocarcinoma (HCC) outcomes.
Methods:
A systematic literature search for reported preoperative cholangitis in patients with hilar cholangiocarcinoma was performed in 4 databases: PubMed, Web of Science, Embase, and the Cochrane Library, published from 1979 to 2017.
Results:
In total, the initial search identified 1228 articles. Of these studies only 9 studies met the inclusion criteria and were included in this analysis. Differences between preoperative cholangitis existing and noncholangitis patients were observed in terms of mortality (RR = 2.29; 95% CI = 1.48-3.52; P = .0002), overall morbidity (RR = 1.15;95% CI = 1.00-1.32; P = .04), Liver failure (RR = 1.15;95% CI = 1.00-1.32; P = .04), Infection (RR = 1.52;95% CI = 1.16-2.00; P = .003), sepsis (RR = 2.40;95% CI = 1.25-4.5; P = .008).
Conclusions:
The results lend support to the notion that in hilar cholangiocarcinoma patients, the existence of preoperative cholangitis is statistically associated with the higher postoperative mortality and morbidity. Also that it increases the risk of liver failure and infection. therefore, it is very important to properly control the preoperative cholangitis before surgery.
