Current Status of Endoscopic Biliary Drainage in Patients with Distal Malignant Biliary Obstruction

Distal malignant biliary obstruction is caused by various malignant diseases that require biliary drainage. In patients with operable situations, preoperative biliary drainage is required to control jaundice and cholangitis until surgery. In view of tract seeding, endoscopic biliary drainage is the first choice. Since neoadjuvant therapies are being developed, the time to surgery is increasing, especially in pancreatic cancer cases. Therefore, it requires long stent patency. Recently, preoperative biliary drainage using self-expandable metal stents has been reported as a useful modality to secure long stent patency. In patients with unresectable distal malignant biliary obstruction, self-expandable metal stent is the first choice for maintaining long stent patency. Although there are many comparison studies between a covered and an uncovered self-expandable metal stent, their use is still controversial. Recently, endoscopic ultrasound-guided biliary drainage has been performed as an alternative treatment. The clinical success and stent patency are favorable. We should take into consideration that both endoscopic retrograde cholangiopancreatography-guided biliary drainage and endoscopic ultrasound-guided biliary drainage have advantages and disadvantages and chose the drainage method depending on the patient’s situation or the expertise of the endoscopist. Here, we discuss the current status of endoscopic biliary drainage in patients with distal malignant biliary obstruction.

Outcome of loop cholecystojejunostomy as a palliative procedure in unresectable distal malignant biliary obstruction

Background: Up to 70-80% of patients with malignant biliary obstruction seek medical attention only at unresectable stage. Though R0 resection is the therapeutic modality, surgical palliation has a definite role for securing biliary bypass. Hepatico (choledocho) jejunostomy and cholecystojejunostomy are the procedures of choice. As loop CCJ is technically simple to perform as well as having less operating time and blood loss;anappealing choice. Aim of the current study was to assess the outcome of loop CCJ as a palliative procedure in unresectable distal malignant biliary obstruction.Methods: 25 patients who underwent loop CCJ for radiologically and histopathologically proven unresectable distal malignant biliary obstruction in GMC, Thiruvananthapuram, were studied for a period from 1st January 2015 to 31st December 2016. Each patient was followed up for 6 months post operatively for the occurrence of cholangitis, relief from pruritus, number of hospitalization, duration of hospital stay, postoperative 30 day mortality and life span. Pre and postoperative serum bilirubin were studied using paired t test. Palliative surgery outcome score was calculated to assess the outcome.Results: Serum bilirubin levels were significantly reduced postoperatively. Mean pre and post-operative total bilirubin values were 15.10±1.65 (mg/dl) and 4.30±3.04 (mg/dl) respectively with p<0.001. 80% had relief of pruritus and 96% were free of cholangitis 76% had a PSOS more than 0.7.Conclusions: Loop CCJ has acceptable outcome as a palliative option for surgical bypass to relieve jaundice, pruritus in patients with unresectable distal malignant biliary obstruction with a good PSOS. This procedure is technically simpler and having fewer incidences of post-operative cholangitis, pruritus, post-operative hospital stays as well as 30 day mortality.

Optimal timing of endoscopic retrograde cholangiopancreatography for acute cholangitis associated with distal malignant biliary obstruction

Background There is a lack of studies regarding the optimal timing for endoscopic retrograde cholangiopancreatography (ERCP) in patients with cholangitis caused by distal malignant biliary obstruction (MBO). This study aims to investigate the optimal timing of ERCP in patients with acute cholangitis associated with distal MBO with a naïve papilla. Methods A total of 421 patients with acute cholangitis, associated with distal MBO, were enrolled for this study. An urgent ERCP was defined as being an ERCP performed within 24 h following emergency room (ER) arrival, and early ERCP was defined as an ERCP performed between 24 and 48 h following ER arrival. We evaluated both 30-day and 180-day mortality as primary outcomes, according to the timing of the ERCP. Results The urgent ERCP group showed the lowest 30-day mortality rate (2.2%), as compared to the early and delayed ERCP groups (4.3% and 13.5%) (P < 0.001). The 180-day mortality rate was lowest in the urgent ERCP group, followed by early ERCP and delayed ERCP groups (39.4%, 44.8%, 60.8%; P = 0.006). A subgroup analysis showed that in both the primary distal MBO group, as well as in the moderate-to-severe cholangitis group, the urgent ERCP had significantly improved in both 30-day and 180-day mortality rates. However, in the secondary MBO and mild cholangitis groups, the difference in mortality rate between urgent, early, and delayed ERCP groups was not significant. Conclusions In patients with acute cholangitis associated with distal MBO, urgent ERCP might be helpful in improving the prognosis, especially in patients with primary distal MBO or moderate-to-severe cholangitis.

Requirement of Biliary Decompression Prior to Pancreatoduodenectomy for Distal Malignant Biliary Obstruction

The role of biliary decompression prior to definitive surgery in patient with distal malignant obstruction remains controversial.Many authors put their views in favor; because of improvement of liver functions and reticulo-endothelial function after decompression resulting in uneventful postoperative outcome and many others are against because of increase the risk of postoperative morbidity and mortality. We found the patients who underwent prior biliary decompression had unusual development of organisms in their bile which are found frequently resistant to usual antibiotics and most of them developed postoperative complications. Several other studies concluded in between that preoperative drainage should be performed in selected patients; delaying of surgery for any cause, presence of severe cholangitis, severe jaundice and poor nutrition and where hepatic resection is required along with pancreatoduodenectomy. We therefore concluded that biliary decompression should not routinely be performed except in special situations in patients with distal malignant biliary obstructionbefore pancreatoduodenectomy. Journal of Surgical Sciences (2020) Vol. 24 (2) : 66-69