IT IS NOT ALWAYS A CHOLANGIOCARCINOMA: UNUSUAL PERITONEAL CARCINOMATOSIS REVEALING GASTRIC ADENOCARCINOMA

In more than 85% of cases, gastric cancer is discovered at an advanced stage. Malignant biliary obstruction is an uncommon complication of gastric cancer, this case report presents a case of a peritoneal carcinomatosis causing biliary obstruction with radiographic dilatation, mimicking cholangiocarcinoma, and secondary to gastric adenocarcinoma. The imaging investigation had decisive roles in the diagnosis and differential diagnosis of the malignant jaundice predominated by periductal infiltrating cholangiocarcinoma, this pattern of cholangiocarcinoma, is frequently found in perihilar cholangiocarcinoma, it typically shows marked dilatation on imaging of the biliary tree proximal to the tumoral lesion.

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.

Infection of the biliary tract during palliative drainage in patients with hilar malignant jaundice

Background. Hilar malignant biliary obstruction in about 80 % of patients is not subject to radical treatment. Percutaneous transhepatic biliary drainage (PTBD) eliminates jaundice syndrome but is associated with bile loss. External-internal drainage is intended to eliminate this disadvantage, however, the balance between its benefits and the risk of complications, in particular cholangitis, has not yet been determined. The aim was to compare the rate of cholangitis and survival after percutaneous transhepatic biliary drainage and external-internal suprapapillary drainage treatment in patients with hilar malignant jaundice. Materials and methods. Fifty patients with hilar malignant jaundice were prospectively examined. Patients who underwent percutaneous transhepatic biliary drainage were included in the PTBD group (n = 24); patients who underwent external-internal suprapapillary biliary drainage (EISBD) treatment were included in the EISBD group (n = 26). The endpoints of the study were the rate of cholangitis, cholangitis duration index (number of cholangitis-days per 100 patient-days in a group), and cumulative survival. Results. Cholangitis during the entire follow-up period occurred in 7 (14.0 %) patients: in 3 (11.5 %) patients in the EISBD group, in 4 (16.7 %) patients in the PTBD group; p = 0.602. Taking into account the census data (patients who died during this period), the difference in the cumulative frequency of cholangitis was more significant (25.6 % in the EISBD group, 49.1 % in the PTBD group); p = 0.142. The average time of the onset of cholangitis from the beginning of the operation was 68.8 ± 14.7 days in the PTBD group, 90.7 ± 42.0 days in the EISBD group; p = 0.601. In the EISBD group, the cholangitis duration index was less than in the PTBD group: 0.46 versus 1.4 cholangitis-days per 100 patient-days, respectively, p = 0.001. Patients of the EISBD group had a greater cumulative survival rate compared with the PTBD group: the median survival was 90 days (95% CI: 70.0–109.9 days) and 75 days (95% CI: 51.1–98.9 days), respectively; p = 0.033. Conclusions. For palliative management of hilar malignant jaundice, EISBD treatment should be the priority over PTBD treatment.

153 Staging Laparoscopy in Bilio-Pancreatic Malignancies Compared To Radiological Staging: A Comparative Study

Introduction The study was to compare the accuracy of laparoscopy in staging and selecting patients diagnosed with malignant obstructive jaundice, to the traditional investigation. Method a prospective study conducted in the period between September 2017 and December 2018.30 patients, having malignant jaundice, were divided into two groups for cancer staging to assess their resectability and operability. Staging of 15 patients in group A was limited to conventional diagnostic methods, while 15 patients were in group B,where Laparoscopy was added. Results Results showed that the accuracy of routine investigations in staging was 73%, while that of laparoscopy was 93%.The number of cases under staged by imagings were 8 cases(these were 3 in Group A and 5 in group B) thus they were diagnosed as operable. On the other hand, just 1 case was misdiagnosed by the laparoscopy. Regarding the morbidity and mortality, there were variable complications among those who had unrequired laparotomies including one mortality case.on the other side,the incidence of complications were markedly decreased in group B,with no mortality incidence. Conclusions Diagnostic laparoscopy has a crucial role in staging people with malignant jaundice and may decrease the rate of unnecessary laparotomy in people found to have resectable disease by conventional imagings.

Lumen-apposing metal stent through the meshes of duodenal metal stents for palliation of malignant jaundice

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard procedure for malignant jaundice palliation; however, it can be challenging when a duodenal self-expandable metal stent (SEMS) is already in place. Patients and methods The primary aim of our study was to evaluate the technical feasibility of the placement of a lumen apposing metal stent (LAMS) through the mesh (TTM) of duodenal stents. The secondary aims were to evaluate clinical outcomes and adverse events (AEs) related to the procedures. Results Data from 23 patients (11 F and 12 M; mean age: 69.5 ± 11 years old) were collected. In 17 patients (73.9 %) TTM LAMS placement was performed as first intention, while in six patients (26.1 %) it was performed after a failed ERCP. Thirteen patients (56.5 %) underwent the procedure due to advanced pancreatic head neoplasia. One technical failure was experienced (4.3 %). The TTM LAMS placement led to a significant decrease in the serum levels of bilirubin, ALP, GGT, WBC and CRP. No cases of duodenal SEMS occlusion occurred and no other AEs were observed during the follow-up. Conclusions Concomitant malignant duodenal and biliary obstruction is a challenging condition. Palliation of jaundice using TTM LAMS in patients already treated with duodenal stent is associated to promising technical and clinical outcomes.