Tumors of the pancreas,the ampulla of Vater,and the extrahepatic and intrahepatic bile ducts have significant histological similarities due to the common embryonic origin of the pancreatobiliary system.This obviates t...Tumors of the pancreas,the ampulla of Vater,and the extrahepatic and intrahepatic bile ducts have significant histological similarities due to the common embryonic origin of the pancreatobiliary system.This obviates the need for discovery of biomarkers with diagnostic and prognostic value for these tumors.Mucins,especially MUC-1,-2,-4 and-5AC,are important candidates for developing into such reliable biomarkers.Increased expression of MUC1 occurs in pancreatic ductal adenocarcinomas and is associated with increased degrees of dysplasia in pancreatic intraepithelial neoplasia(Pan IN).Positive expression of MUC2 in intraductal papillary mucinus neoplasms(IPMN) of the intestinal type indicates high potential progression to invasive carcinoma with de novo expression of MUC1,while absence of MUC2 expression in IPMNs of gastric type implies low potential to malignant evolution.De novo MUC4 expression correlates to the severity of dysplasia in Pan IN and is associated with a poor prognosis in patients with pancreatic ductal adenocarcinomas.In biliary intraepithelial neoplasia(Bil IN),increased expression of MUC1 is associated with higher degrees of dysplasia.Intrahepatic cholangiocarcinomas(ICC) are characterized by increased expression of all glycoforms of MUC1.Positive MUC2 expression in intraductal papillary neoplasm of the bile ducts(IPNB) of the intestinal type indicates high malignant potential with de novo expression of MUC1 in the invasive element.Absent MUC2 expression in any degree of Bil IN may prove useful in differentiating them from IPNB.De novo expression of MUC4 is associated with poor prognosis in patients with ICC or carcinoma of the extrahepatic bile ducts(EHBDC).High de novo expression of MUC5 AC is found in all degrees of Bil IN and all types of IPNB and ICC.The MUC5 AC is useful in the detection of neoplastic lesions of the bile duct at an early stage.Increased expression of mucin MUC1 in carcinoma of the ampulla of Vater associated with unfavorable behavior of the tumor,such as lymph node metastasis,infiltration of the pancreas and duodenum,advanced TNM classification and worse prognosis.Patients withintra-ampullary papillary-tubular neoplasm(IAPN) of the pancreatobiliary immunophenotype did not show MUC2,while those of the intestinal immunophenotype are MUC2 positive.The expression of MUC4 is associated with poor prognosis in patients with carcinoma of the ampulla of Vater favoring metastasis and making them resistant to apoptosis.Moreover,it appears that MUC4 positivity correlates with recurrence of the tumor.Expression of MUC5 AC is associated with the invasive potential of the tumor.展开更多
Over the last decade, endoscopic ultrasound-guided biliary drainage(EUS-BD)has evolved into a widely accepted alternative to the percutaneous approach in cases of biliary obstruction with failed endoscopic retrograde ...Over the last decade, endoscopic ultrasound-guided biliary drainage(EUS-BD)has evolved into a widely accepted alternative to the percutaneous approach in cases of biliary obstruction with failed endoscopic retrograde cholangiopancreaticography(ERCP). The available evidence suggests that, in experienced hands, EUS-BD might even replace ERCP as the first-line procedure in specific situations such as malignant distal bile duct obstruction. The aim of this review is to summarize the available data on EUS-BD and propose an evidence-based algorithm clarifies the role of the different EUS-BD techniques in the management of benign and malignant biliary obstructive disease.展开更多
BACKGROUND Endoscopic ultrasound(EUS)has evolved from a diagnostic tool to a management technique for various gastroenterological conditions,including biliary strictures.AIM To summarize the current evidence on EUS’s...BACKGROUND Endoscopic ultrasound(EUS)has evolved from a diagnostic tool to a management technique for various gastroenterological conditions,including biliary strictures.AIM To summarize the current evidence on EUS’s role in diagnosing and managing biliary strictures.METHODS Two independent reviewers searched five electronic databases(PubMed,CENTRAL,Science Direct,Google Scholar,and EMBASE)for articles published up to January 2025.Included articles met specific criteria,and statistical software was used to analyze reported outcomes.RESULTS Of 935 articles,19 met the inclusion criteria.Ten articles focused on diagnostic EUS,while nine focused on EUSguided therapeutic interventions.EUS fine-needle aspiration demonstrated superior sensitivity[0.43-1.00;95%confidence interval(CI):0.24-1.00]compared to conventional techniques(0.36-0.96;95%CI:0.19-0.99)for diagnosing malignant biliary strictures.Both EUS-fine-needle aspiration and conventional methods exhibited high specificity,with most achieving 100%specificity.EUS-guided interventions showed significantly higher clinical success rates than control interventions(odds ratio=2.89;95%CI:1.22-6.84;P=0.02).No significant difference was observed in technical success rates(odds ratio=0.97;95%CI:0.30-3.16;P=0.96).CONCLUSION EUS is a promising tool for diagnosing and managing biliary strictures.Combining EUS-guided and conventional interventions improves diagnostic performance.Further research is needed to investigate the feasibility and use of EUS-guided interventions in this field.展开更多
Perihilar cholangiocarcinoma(pCCA)and intrahepatic cholangiocarcinoma(iCCA)are highly malignant neoplasms with a 5-year overall survival rate of approximately 30%[1,2].Surgical resection remains the only potentially c...Perihilar cholangiocarcinoma(pCCA)and intrahepatic cholangiocarcinoma(iCCA)are highly malignant neoplasms with a 5-year overall survival rate of approximately 30%[1,2].Surgical resection remains the only potentially curative treatment,yet only one-fifth of patients are eligible for resection at initial diagnosis[3].Threedimensional(3D)reconstruction technology provides precise preoperative visualization of complex hilar anatomy,significantly enhancing surgical planning and outcomes[4].Recent advances in 3D reconstruction technology have enhanced preoperative planning by providing precise anatomical mapping of tumor-vessel relationships and biliary variations[4,5].Therefore,this report describes a case of left iCCA successfully resected with biliary reconstruction guided by 3D visualization.展开更多
Endoscopic retrograde cholangiopancreatography(ERCP)in patients with surgically altered anatomy remains a challenging field in therapeutic endoscopy due to the complex anatomical reconstructions that limit access to t...Endoscopic retrograde cholangiopancreatography(ERCP)in patients with surgically altered anatomy remains a challenging field in therapeutic endoscopy due to the complex anatomical reconstructions that limit access to the biliary tree.Over the past two decades,device-assisted enteroscopy(DAE),including singleballoon,double-balloon,and motorized spiral enteroscopy,has expanded the feasibility of ERCP in this population,with overall technical success rates generally reported between 70%and 90%.Nevertheless,these techniques are technically demanding,time-consuming,and frequently affected by limited reach and unstable positioning.More recently,interventional endoscopic ultrasound(EUS)-guided procedures have emerged as highly effective alternatives,significantly improving clinical outcomes in selected patients,particularly in those with long-limb Roux-en-Y reconstructions where conventional methods are less effective.Percutaneous transhepatic biliary drainage continues to represent a valuable salvage option when endoscopic approaches fail,though it is associated with a greater burden of reinterventions and adverse events.This minireview provides a comprehensive overview of the main endoscopic strategies for biliary drainage in altered anatomy,focusing on technical considerations,efficacy,and safety profiles of DAE-assisted ERCP,EUS-guided interventions,and motorized systems.The evolving landscape of biliary drainage in this setting highlights the need for tailored treatment strategies,multidisciplinary collaboration,referral to high-volume centers,and further prospective studies to refine patient selection and optimize clinical outcomes.展开更多
The operation of the biliary system is usually employed for liver, gallbladder or pancreatic diseases. Most benign cases are cholelithiasisinduced cholecystitis and choledochitis, while malignant ones mainly include g...The operation of the biliary system is usually employed for liver, gallbladder or pancreatic diseases. Most benign cases are cholelithiasisinduced cholecystitis and choledochitis, while malignant ones mainly include gallbladder cancers, cholangiocarcinoma orcarcinoma of the head of the pancreas.展开更多
BACKGROUND Endoscopic drainage remains the treatment of choice for unresectable or inoperable malignant distal biliary obstruction(MDBO).AIM To compare the safety and efficacy of plastic stent(PS)vs self-expanding met...BACKGROUND Endoscopic drainage remains the treatment of choice for unresectable or inoperable malignant distal biliary obstruction(MDBO).AIM To compare the safety and efficacy of plastic stent(PS)vs self-expanding metal stent(SEMS)placement for treatment of MDBO.METHODS This meta-analysis was developed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.A comprehensive search was performed in MEDLINE,Cochrane,Embase,Latin American and Caribbean Health Sciences Literature,and grey literature to identify randomized clinical trials(RCTs)comparing clinical success,adverse events,stent dysfunction rate,reintervention rate,duration of stent patency,and mean survival.Risk difference(RD)and mean difference(MD)were calculated and heterogeneity was assessed with I2 statistic.Subgroup analyses were performed by SEMS type.RESULTS Twelve RCTs were included in this study,totaling 1005 patients.There was no difference in clinical success(RD=-0.03,95%confidence interval[CI]:-0.01,0.07;I 2=0%),rate of adverse events(RD=-0.03,95%CI:-0.10,0.03;I2=57%),and mean patient survival(MD=-0.63,95%CI:-18.07,19.33;I2=54%)between SEMS vs PS placement.However,SEMS placement was associated with a lower rate of reintervention(RD=-0.34,95%CI:-0.46,-0.22;I2=57%)and longer duration of stent patency(MD=125.77 d,95%CI:77.5,174.01).Subgroup analyses revealed both covered and uncovered SEMS improved stent patency compared to PS(RD=152.25,95%CI:37.42,267.07;I2=98%and RD=101.5,95%CI:38.91,164.09;I2=98%;respectively).Stent dysfunction was higher in the covered SEMS group(RD=-0.21,95%CI:-0.32,-0.1;I²=205%),with no difference in the uncovered SEMS group(RD=-0.08,95%CI:-0.56,0.39;I²=87%).CONCLUSION While both stent types possessed a similar clinical success rate,complication rate,and patient-associated mean survival for treatment of MDBO,SEMS were associated with a longer duration of stent patency compared to PS.展开更多
AIM: To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction.METHODS: A systematic review of randomized clinical trials(RCT) was conducted, with the last up...AIM: To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction.METHODS: A systematic review of randomized clinical trials(RCT) was conducted, with the last update on March 2015, using EMBASE, CINAHL(EBSCO), MEDLINE, LILACS/CENTRAL(BVS), SCOPUS, CAPES(Brazil), and gray literature. Information of the selected studies was extracted in sight of six outcomes: primarily regarding dysfunction, complication and reintervention rates; and secondarily costs, survival, and patency time. The data about characteristics of trial participants, inclusion and exclusion criteria and types of stents were also extracted. The bias was mainly assessed through the JADAD scale. This meta-analysis was registered in the PROSPERO database by the number CRD42014015078. The analysis of the absolute risk of the outcomes was performed using the software Rev Man, by computing risk differences(RD) of dichotomous variables and mean differences(MD) of continuous variables. Data on RD and MD for each primary outcome were calculated using the MantelHaenszel test and inconsistency was qualified and reported in χ2 and the Higgins method(I2). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. Student's t-test was used for the comparison of weighted arithmetic means regarding secondary outcomes.RESULTS: Initial searching identified 3660 studies; 3539 were excluded through title, repetition, and/or abstract, while 121 studies were fully assessed and were excluded mainly because they did not compare self-expanding metal stents(SEMS) and plastic stents(PS), leading to thirteen RCT selected, with 13 articles and 1133 subjects meta-analyzed. The mean age was 69.5 years old, that were affected mostly by bile duct(proximal) and pancreatic tumors(distal). The preferred SEMS diameter used was the 10 mm(30 Fr) and the preferred PS diameter used was 10 Fr. In the metaanalysis, SEMS had lower overall stent dysfunction compared to PS(21.6% vs 46.8%, P < 0.00001) and fewer re-interventions(21.6% vs 56.6%, P < 0.00001), with no difference in complications(13.7% vs 15.9%, P = 0.16). In the secondary analysis, the mean survival rate was higher in the SEMS group(182 d vs 150 d, P < 0.0001), with a higher patency period(250 d vs 124 d, P < 0.0001) and a lower cost per patient(4193.98 vs 4728.65 Euros, P < 0.0985).CONCLUSION: SEMS are associated with lower stent dysfunction, lower re-intervention rates, better survival, and higher patency time. Complications and costs showed no difference.展开更多
BACKGROUND Whether to use a T-tube for biliary anastomosis during orthotopic liver transplantation(OLT)remains a debatable question.Some surgeons chose to use a T-tube because they believed that it reduces the inciden...BACKGROUND Whether to use a T-tube for biliary anastomosis during orthotopic liver transplantation(OLT)remains a debatable question.Some surgeons chose to use a T-tube because they believed that it reduces the incidence of biliary strictures.Advances in surgical techniques during the last decades have significantly decreased the overall incidence of postoperative biliary complications.Whether using a T-tube during OLT is still associated with the reduced incidence of biliary strictures needs to be re-evaluated.AIM To provide an updated systematic review and meta-analysis on using a T-tube during adult OLT.METHODS In the electronic databases MEDLINE,PubMed,Scopus,ClinicalTrials.gov,the Cochrane Library,the Cochrane Hepato-Biliary Group Controlled Trails Register,and the Cochrane Central Register of Controlled Trials,we identified 17 studies(eight randomized controlled trials and nine comparative studies)from January 1995 to October 2020.The data of the studies before and after 2010 were separately extracted.We chose the overall biliary complications,bile leaks or fistulas,biliary strictures(anastomotic or non-anastomotic),and cholangitis as outcomes.Odds ratios(ORs)with 95%confidence intervals(CIs)were calculated to describe the results of the outcomes.Furthermore,the test for overall effect(Z)was used to test the difference between OR and 1,where P≤0.05 indicated a significant difference between OR value and 1.RESULTS A total of 1053 subjects before 2010 and 1346 subjects after 2010 were included in this meta-analysis.The pooled results showed that using a T-tube reduced the incidence of postoperative biliary strictures in studies before 2010(P=0.012,OR=0.62,95%CI:0.42-0.90),while the same benefit was not seen in studies after 2010(P=0.60,OR=0.76,95%CI:0.27-2.12).No significant difference in the incidence of overall biliary complications(P=0.37,OR=1.41,95%CI:0.66-2.98),bile leaks(P=0.89,OR=1.04,95%CI:0.63-1.70),and cholangitis(P=0.27,OR=2.00,95%CI:0.59-6.84)was observed between using and not using a T-tube before 2010.However,using a T-tube appeared to increase the incidence of overall biliary complications(P=0.049,OR=1.49,95%CI:1.00-2.22),bile leaks(P=0.048,OR=1.91,95%CI:1.01-3.64),and cholangitis(P=0.02,OR=7.21,95%CI:1.37-38.00)after 2010.A random-effects model was used in biliary strictures(after 2010),overall biliary complications(before 2010),and cholangitis(before 2010)due to their heterogeneity(I2=62.3%,85.4%,and 53.6%,respectively).In the sensitivity analysis(only RCTs included),bile leak(P=0.66)lost the significance after 2010 and a random-effects model was used in overall biliary complications(before 2010),cholangitis(before 2010),bile leaks(after 2010),and biliary strictures(after 2010)because of their heterogeneity(I2=92.2%,65.6%,50.9%,and 80.3%,respectively).CONCLUSION In conclusion,the evidence gathered in our updated meta-analysis showed that the studies published in the last decade did not provide enough evidence to support the routine use of T-tube in adults during OLT.展开更多
Biliary atresia(BA), a chronic progressive cholestatic disease of infants, is the leading cause for liver transplant in children, especially in patients under two years of age. BA can be successfully treated with the ...Biliary atresia(BA), a chronic progressive cholestatic disease of infants, is the leading cause for liver transplant in children, especially in patients under two years of age. BA can be successfully treated with the Kasai portoenterostomy; however most patients still require a liver transplant, with up to one half of BA children needing a transplant by age two. In the current pediatric end-stage liver disease system, children with BA face the risk of not receiving a liver in a safe and timely manner. In this review, we discuss a number of possible solutions to help these children. We focus on two general approaches:(1) preventing/delaying need for transplantation, by optimizing the success of the Kasai operation; and(2) expediting transplantation when needed, by performing techniques other than the standard deceased-donor, whole, ABO-matched organ transplant.展开更多
BACKGROUND Bilateral vs unilateral biliary stenting is used for palliation in malignant biliary obstruction.No clear data is available to compare the efficacy and safety of bilateral biliary stenting over unilateral s...BACKGROUND Bilateral vs unilateral biliary stenting is used for palliation in malignant biliary obstruction.No clear data is available to compare the efficacy and safety of bilateral biliary stenting over unilateral stenting.AIM To assess the efficacy and safety of bilateral vs unilateral biliary drainage in inoperable malignant hilar obstruction.METHODS PubMed,Embase,Scopus,and Cochrane databases,as well as secondary sources(bibliographic review of selected articles and major GI proceedings),were searched through January 2019.The primary outcome was the re-intervention rate.Secondary outcomes were a technical success,early and late complications,and stent malfunction rate.Pooled odds ratio(OR)and 95%confidence interval(CI)were calculated for each outcome.RESULTS A total of 9 studies were included(2 prospective Randomized Controlled Study,5 retrospective studies,and 2 abstracts),involving 782 patients with malignant hilar obstruction.Bilateral stenting had significantly lower re-intervention rate compared with unilateral drainage(OR=0.59,95%CI:0.40-0.87,P=0.009).There was no difference in the technical success rate(OR=0.7,CI:0.42-1.17,P=0.17),early complication rate(OR=1.56,CI:0.31-7.75,P=0.59),late complication rate(OR=0.91,CI:0.58-1.41,P=0.56)and stent malfunction(OR=0.69,CI:0.42-1.12,P=0.14)between bilateral and unilateral stenting for malignant hilar biliary strictures.CONCLUSION Bilateral biliary drainage had a lower re-intervention rate as compared to unilateral drainage for high grade inoperable malignant biliary strictures,with no significant difference in technical success,and early or late complication rates.展开更多
Endoscopic ultrasound(EUS)-guided biliary drainage is accepted as a less invasive,alternative treatment for patients in whom endoscopic retrograde cholangiopancreatography has failed. Most patients with malignant hila...Endoscopic ultrasound(EUS)-guided biliary drainage is accepted as a less invasive,alternative treatment for patients in whom endoscopic retrograde cholangiopancreatography has failed. Most patients with malignant hilar obstruction undergo EUSguided hepaticogastrostomy. The authors present the case of a 77-year-old man with advanced hilar cholangiocarcinoma who had undergone a rouxen-Y hepaticojejunostomy several months prior. He developed progressive jaundice and a low-grade fever that persisted for one week. The enteroscopic-assisted endoscopic retrograde cholangiopancreatography failed,thus the patient was scheduled for EUS-guided biliary drainage. In order to obtain adequate drainage,both intrahepatic systems were drained. This report describes the technique used for bilateral drainage via a transgastric approach. Currently,only a few different techniques for EUS-guided right system drainage have been reported in the literature. This case demonstrates that bilateral EUS-guided biliary drainage is feasible and effective in patients with hilar cholangiocarcinoma,and thus can be used as an alternative to percutaneous biliary drainage.展开更多
BACKGROUND Percutaneous transhepatic cholangiography is a diagnostic and therapeutic procedure that involves inserting a needle into the biliary tree,followed by the immediate insertion of a catheter.Endoscopic ultras...BACKGROUND Percutaneous transhepatic cholangiography is a diagnostic and therapeutic procedure that involves inserting a needle into the biliary tree,followed by the immediate insertion of a catheter.Endoscopic ultrasound-guided biliary drainage(EUS-BD)is a novel technique that allows BD by echoendoscopy and fluoroscopy using a stent from the biliary tree to the gastrointestinal tract.AIM To compare the technical aspects and outcomes of percutaneous transhepatic BD(PTBD)and EUS-BD.METHODS Different databases,including PubMed,Embase,clinicaltrials.gov,the Cochrane library,Scopus,and Google Scholar,were searched according to the guidelines for Preferred Reporting Items for Systematic reviews and Meta-Analyses to obtain studies comparing PTBD and EUS-BD.RESULTS Among the six studies that fulfilled the inclusion criteria,PTBD patients underwent significantly more reinterventions(4.9 vs 1.3),experienced more postprocedural pain(4.1 vs 1.9),and experienced more late adverse events(53.8%vs 6.6%)than EUS-BD patients.There was a significant reduction in the total bilirubin levels in both the groups(16.4-3.3μmol/L and 17.2-3.8μmol/L for EUSBD and PTBD,respectively;P=0.002)at the 7-d follow-up.There were no significant differences observed in the complication rates between PTBD and EUSBD(3.3 vs 3.8).PTBD was associated with a higher adverse event rate than EUSBD in all the procedures,including reinterventions(80.4%vs 15.7%,respectively)and a higher index procedure(39.2%vs 18.2%,respectively).CONCLUSION The findings of this systematic review revealed that EUS-BD is linked with a higher rate of effective BD and a more manageable procedure-related adverse event profile than PTBD.These findings highlight the evidence for successful EUS-BD implementation.展开更多
BACKGROUND Biliary drainage,either by the stent-in-stent(SIS)or side-by-side(SBS)technique,is often required when treating a malignant hilar biliary obstruction(MHBO).Both methods differ from each other and have disti...BACKGROUND Biliary drainage,either by the stent-in-stent(SIS)or side-by-side(SBS)technique,is often required when treating a malignant hilar biliary obstruction(MHBO).Both methods differ from each other and have distinct advantages.AIM To compare both techniques regarding their efficacy and safety in achieving drainage of MHBO.METHODS A comprehensive search of multiple electronic databases(MEDLINE,Embase,LILACS,BIREME,Cochrane)was conducted and grey literature from their inception until December 2020 with no restrictions regarding the year of publication or language,since there was at least an abstract in English.The included studies compared SIS and SBS techniques through endoscopic retrograde cholangiopancreatography.Outcomes analyzed included technical and clinical success,early and late adverse events(AEs),stent patency,reintervention,and procedure-related mortality.RESULTS Four cohort studies and one randomized controlled trial evaluating a total of 250 patients(127 in the SIS group and 123 in the SBS group)were included in this study.There were no statistically significant differences between the two groups concerning the evaluated outcomes,except for stent patency,which was higher in the SIS compared with the SBS technique[mean difference(d)=33.31;95%confidence interval:9.73 to 56.90,I2=45%,P=0.006].CONCLUSION The SIS method showed superior stent patency when compared to SBS for achieving bilateral drainage in MHBO.Both techniques are equivalent in terms of technical success,clinical success,rates of both early and late AEs,reintervention,and procedure-related mortality.展开更多
BACKGROUND In the classic descriptions of the human liver,the common hepatic duct forms at the confluence of left and right hepatic ducts.Many authors have documented variations in the intra-hepatic ductal system,but ...BACKGROUND In the classic descriptions of the human liver,the common hepatic duct forms at the confluence of left and right hepatic ducts.Many authors have documented variations in the intra-hepatic ductal system,but to the best of our knowledge there has been no report on bile duct variations in Caribbean populations.AIM To evaluate the variations in bile duct anatomy using magnetic resonance cholangiography(MRC)in unselected patients at a major hepatobiliary referral centre in the Eastern Caribbean.Knowledge of the intra-hepatic biliary anatomy is important to optimize service delivery for any physician treating liver and biliary disorders.METHODS This study was carried out at a tertiary referral hospital for hepatobiliary diseases in the Eastern Caribbean.We retrospectively evaluated magnetic resonance cholangiograms in 152 consecutive patients at this facility over a two-year period from April 1,2017 to March 31,2019.Two consultant radiologists experienced in MRC interpretation reviewed all scans and described biliary anatomy according to the Huang’s classification.A systematic review of published studies was performed and relevant data were extracted in order to calculate the global prevalence of each biliary variant.The variants in our population were compared to the global population.RESULTS There were 152 MRCs evaluated in this study in 86 males and 66 females.There were 109(71.7%)persons with“classic”biliary anatomy(type A1)and variants were present in 43(28.3%)persons.There was no statistical relationship between the presence of anatomic variants and gender or ethnicity.We encountered the following variants:29(19.1%)type A2,7(4.6%)type A3,6(3.95%)type A4,0 type A5 and a single variant(quadrification)that did not fit the classification system.Compared to the global prevalence,our population had a significantly greater occurrence of A1 anatomy(71.7%vs 62.6%;P=0.0227)and A2 trifurcations(19.1%vs 11.5%;P=0.0069),but a significantly lower incidence of A3 variants(4.61%vs 11.5%;P=0.0047).CONCLUSION There are significant differences in intra-hepatic biliary anatomy in this unselected Eastern Caribbean population compared to global statistics.Specifically,persons of Caribbean descent have a greater incidence of Huang A2 trifurcations and a lower incidence of Huang A3 variants.展开更多
AIM To review the clinical impact of machine perfusion(MP) of the liver on biliary complications post-transplantation, particularly ischaemic-type biliary lesions(ITBL). METHODS This systematic review was performed in...AIM To review the clinical impact of machine perfusion(MP) of the liver on biliary complications post-transplantation, particularly ischaemic-type biliary lesions(ITBL). METHODS This systematic review was performed in accordance with the Preferred Reporting Systematic Reviews and MetaAnalysis(PRISMA) protocol. The following databases were searched: PubMed, MEDLINE and Scopus. The keyword "liver transplantation" was used in combination with the free term "machine perfusion". Clinical studies reporting results of transplantation of donor human livers following ex situ or in situ MP were analysed. Details relating to donor characteristics, recipients, technique of MP performed and post-operative biliary complications(ITBL, bile leak and anastomotic strictures) were critically analysed.RESULTS Fifteen articles were considered to fit the criteria for this review. Ex situ normothermic MP was used in 6 studies, ex situ hypothermic MP in 5 studies and the other 4 studies investigated in situ normothermic regional perfusion(NRP) and controlled oxygenated rewarming. MP techniques which have per se the potential to alleviate ischaemia-reperfusion injury: Such as hypothermic MP and NRP, have also reported lower rates of ITBL. Other biliary complications, such as biliary leak and anastomotic biliary strictures, are reported with similar incidences with all MP techniques. There is currently less clinical evidence available to support normothermic MP as a mitigator of biliary complications following liver transplantation. On the other hand, restoration of organ to full metabolism during normothermic MP allows assessment of hepatobiliary function before transplantation, although universally accepted criteria have yet to be validated.CONCLUSION MP of the liver has the potential to have a positive impact on post-transplant biliary complications, specifically ITBL, and expand extended criteria donor livers utilisation.展开更多
BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is a method used to decrease portal hypertension.Biliary stricture is the rarest of the complications associated with this procedure with only 12 cases pre...BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is a method used to decrease portal hypertension.Biliary stricture is the rarest of the complications associated with this procedure with only 12 cases previously reported in the literature.None of these cases have documented the resolution of biliary stenosis induced by a stent graft.The only curative solutions reported are liver transplantation or bypassing the stenosis with an artificial biliary tract using advanced endoscopic techniques.CASE SUMMARY This is the first reported case of biliary obstruction secondary to TIPS placement in a transplanted liver.In our patient,a portosystemic shunt was created to treat severe veno-occlusive liver graft disease manifesting itself primarily by fluid retention.A cholestatic liver lesion and cholangitis with abscesses developed due to a stent graft-induced stricture in the dorsal segment of the right hepatic duct and the stricture diminished following percutaneous drainage.Endoscopic drainage was performed after unsuccessful removal of the percutaneous catheter resulting in a bilio-cutaneous fistula.Although the liver graft now functions well,the stricture remains refractory even after 44 mo of treatment.CONCLUSION Biliary strictures caused by TIPS in both transplanted and native livers seem refractory to endoscopic treatment.展开更多
Background: The outcomes and disease associations in pregnant women with primary biliary cholangitis(PBC) have not been largely explored. This study aimed to determine the level of evidence associated with maternal an...Background: The outcomes and disease associations in pregnant women with primary biliary cholangitis(PBC) have not been largely explored. This study aimed to determine the level of evidence associated with maternal and fetal outcomes and other disease associations in female patients with PBC. Data sources:: A comprehensive literature search was conducted. Maternal and fetal outcomes were obtained from patients with a previous, current or subsequent diagnosis of PBC. A random-effects model was employed, using odds ratios(ORs) with 95% confidence intervals(CIs). Results: Eleven studies, with 2179 female PBC patients were included. Pregnant women with PBC were significantly more likely to have a miscarriage(OR = 1.27, 95% CI: 1.02-1.58;P = 0.03), and a history of abortion(OR = 1.50, 95% CI: 1.09-2.07;P = 0.01), with absent heterogeneity( I 2 = 0%). PBC pregnant women were significantly more likely to deliver via vaginal birth(OR = 1.69, 95% CI: 1.33-2.14;P < 0.001) with low level heterogeneity( I^(2) < 0.001%). Patients had a statistically significant increased likelihood of lifetime smoking(OR = 1.95, 95% CI: 1.17-3.23;P = 0.01). Egger’s regression revealed no evidence of publication bias. Conclusions: This meta-analysis provides pooled evidence that a PBC pregnancy is associated with fetal morbidity and maternal lifestyle associations that may influence pregnancy outcomes. More studies are needed to establish disease associations that may directly affect pregnancy outcomes. These data are essential for clinicians managing these patients before, during or after pregnancy.展开更多
BACKGROUND Targeted therapy(TT)has resulted in controversial efficacy as first-line treatment for biliary tract cancer(BTC).More efficacy comparisons are required to clarify the overall effects of chemotherapy(CT)comb...BACKGROUND Targeted therapy(TT)has resulted in controversial efficacy as first-line treatment for biliary tract cancer(BTC).More efficacy comparisons are required to clarify the overall effects of chemotherapy(CT)combined with TT and CT alone on advanced BTC.AIM To conduct a meta-analysis of the available evidence on the efficacy of CT combined with TT for advanced BTC.METHODS The PubMed,EMBASE,ClinicalTrials,Scopus and Cochrane Library databases were systematically searched for relevant studies published from inception to August 2022.Only randomized clinical trials(RCTs)including comparisons between the combination of gemcitabine-based CT with TT and CT alone as firstline treatment for advanced BTC were eligible(PROSPERO-CRD42022313001).The odds ratios(ORs)for the objective response rate(ORR)and hazard ratios(HRs)for both progression-free survival(PFS)and overall survival(OS)were calculated and analyzed.Subgroup analyses based on different targeted agents,CT regimens and tumor locations were prespecified.RESULTS Nine RCTs with a total of 1361 individuals were included and analyzed.The overall analysis showed a significant improvement in ORR in patients treated with CT+TT compared to those treated with CT alone(OR=1.43,95%CI:1.11-1.86,P=0.007)but no difference in PFS or OS.Similar trends were observed in the subgroup treated with agents targeting epidermal growth factor receptor(OR=1.67,95%CI:1.17-2.37,P=0.004)but not in the subgroups treated with agents targeting vascular endothelial growth factor receptor or mesenchymal-epithelial transition factor.Notably,patients who received a CT regimen of gemcitabine+oxaliplatin in the CT+TT arm had both a higher ORR(OR=1.75,95%CI:1.20-2.56,P=0.004)and longer PFS(HR=0.83,95%CI:0.70-0.99,P=0.03)than those in the CT-only arm.Moreover,patients with cholangiocarcinoma treated with CT+TT had significantly increased ORR and PFS(ORR,OR=2.06,95%CI:1.27-3.35,PFS,HR=0.79,95%CI:0.66-0.94).CONCLUSION CT+TT is a potential first-line treatment for advanced BTC that leads to improved tumor control and survival outcomes,and highlighting the importance of CT regimens and tumor types in the application of TT.展开更多
文摘Tumors of the pancreas,the ampulla of Vater,and the extrahepatic and intrahepatic bile ducts have significant histological similarities due to the common embryonic origin of the pancreatobiliary system.This obviates the need for discovery of biomarkers with diagnostic and prognostic value for these tumors.Mucins,especially MUC-1,-2,-4 and-5AC,are important candidates for developing into such reliable biomarkers.Increased expression of MUC1 occurs in pancreatic ductal adenocarcinomas and is associated with increased degrees of dysplasia in pancreatic intraepithelial neoplasia(Pan IN).Positive expression of MUC2 in intraductal papillary mucinus neoplasms(IPMN) of the intestinal type indicates high potential progression to invasive carcinoma with de novo expression of MUC1,while absence of MUC2 expression in IPMNs of gastric type implies low potential to malignant evolution.De novo MUC4 expression correlates to the severity of dysplasia in Pan IN and is associated with a poor prognosis in patients with pancreatic ductal adenocarcinomas.In biliary intraepithelial neoplasia(Bil IN),increased expression of MUC1 is associated with higher degrees of dysplasia.Intrahepatic cholangiocarcinomas(ICC) are characterized by increased expression of all glycoforms of MUC1.Positive MUC2 expression in intraductal papillary neoplasm of the bile ducts(IPNB) of the intestinal type indicates high malignant potential with de novo expression of MUC1 in the invasive element.Absent MUC2 expression in any degree of Bil IN may prove useful in differentiating them from IPNB.De novo expression of MUC4 is associated with poor prognosis in patients with ICC or carcinoma of the extrahepatic bile ducts(EHBDC).High de novo expression of MUC5 AC is found in all degrees of Bil IN and all types of IPNB and ICC.The MUC5 AC is useful in the detection of neoplastic lesions of the bile duct at an early stage.Increased expression of mucin MUC1 in carcinoma of the ampulla of Vater associated with unfavorable behavior of the tumor,such as lymph node metastasis,infiltration of the pancreas and duodenum,advanced TNM classification and worse prognosis.Patients withintra-ampullary papillary-tubular neoplasm(IAPN) of the pancreatobiliary immunophenotype did not show MUC2,while those of the intestinal immunophenotype are MUC2 positive.The expression of MUC4 is associated with poor prognosis in patients with carcinoma of the ampulla of Vater favoring metastasis and making them resistant to apoptosis.Moreover,it appears that MUC4 positivity correlates with recurrence of the tumor.Expression of MUC5 AC is associated with the invasive potential of the tumor.
文摘Over the last decade, endoscopic ultrasound-guided biliary drainage(EUS-BD)has evolved into a widely accepted alternative to the percutaneous approach in cases of biliary obstruction with failed endoscopic retrograde cholangiopancreaticography(ERCP). The available evidence suggests that, in experienced hands, EUS-BD might even replace ERCP as the first-line procedure in specific situations such as malignant distal bile duct obstruction. The aim of this review is to summarize the available data on EUS-BD and propose an evidence-based algorithm clarifies the role of the different EUS-BD techniques in the management of benign and malignant biliary obstructive disease.
文摘BACKGROUND Endoscopic ultrasound(EUS)has evolved from a diagnostic tool to a management technique for various gastroenterological conditions,including biliary strictures.AIM To summarize the current evidence on EUS’s role in diagnosing and managing biliary strictures.METHODS Two independent reviewers searched five electronic databases(PubMed,CENTRAL,Science Direct,Google Scholar,and EMBASE)for articles published up to January 2025.Included articles met specific criteria,and statistical software was used to analyze reported outcomes.RESULTS Of 935 articles,19 met the inclusion criteria.Ten articles focused on diagnostic EUS,while nine focused on EUSguided therapeutic interventions.EUS fine-needle aspiration demonstrated superior sensitivity[0.43-1.00;95%confidence interval(CI):0.24-1.00]compared to conventional techniques(0.36-0.96;95%CI:0.19-0.99)for diagnosing malignant biliary strictures.Both EUS-fine-needle aspiration and conventional methods exhibited high specificity,with most achieving 100%specificity.EUS-guided interventions showed significantly higher clinical success rates than control interventions(odds ratio=2.89;95%CI:1.22-6.84;P=0.02).No significant difference was observed in technical success rates(odds ratio=0.97;95%CI:0.30-3.16;P=0.96).CONCLUSION EUS is a promising tool for diagnosing and managing biliary strictures.Combining EUS-guided and conventional interventions improves diagnostic performance.Further research is needed to investigate the feasibility and use of EUS-guided interventions in this field.
基金supported by grants from the National Natural Science Foundation of China(82170412)Shanghai Municipal Science and Technology Commission Clinical Innovation Research Special Project(23Y11905400).
文摘Perihilar cholangiocarcinoma(pCCA)and intrahepatic cholangiocarcinoma(iCCA)are highly malignant neoplasms with a 5-year overall survival rate of approximately 30%[1,2].Surgical resection remains the only potentially curative treatment,yet only one-fifth of patients are eligible for resection at initial diagnosis[3].Threedimensional(3D)reconstruction technology provides precise preoperative visualization of complex hilar anatomy,significantly enhancing surgical planning and outcomes[4].Recent advances in 3D reconstruction technology have enhanced preoperative planning by providing precise anatomical mapping of tumor-vessel relationships and biliary variations[4,5].Therefore,this report describes a case of left iCCA successfully resected with biliary reconstruction guided by 3D visualization.
文摘Endoscopic retrograde cholangiopancreatography(ERCP)in patients with surgically altered anatomy remains a challenging field in therapeutic endoscopy due to the complex anatomical reconstructions that limit access to the biliary tree.Over the past two decades,device-assisted enteroscopy(DAE),including singleballoon,double-balloon,and motorized spiral enteroscopy,has expanded the feasibility of ERCP in this population,with overall technical success rates generally reported between 70%and 90%.Nevertheless,these techniques are technically demanding,time-consuming,and frequently affected by limited reach and unstable positioning.More recently,interventional endoscopic ultrasound(EUS)-guided procedures have emerged as highly effective alternatives,significantly improving clinical outcomes in selected patients,particularly in those with long-limb Roux-en-Y reconstructions where conventional methods are less effective.Percutaneous transhepatic biliary drainage continues to represent a valuable salvage option when endoscopic approaches fail,though it is associated with a greater burden of reinterventions and adverse events.This minireview provides a comprehensive overview of the main endoscopic strategies for biliary drainage in altered anatomy,focusing on technical considerations,efficacy,and safety profiles of DAE-assisted ERCP,EUS-guided interventions,and motorized systems.The evolving landscape of biliary drainage in this setting highlights the need for tailored treatment strategies,multidisciplinary collaboration,referral to high-volume centers,and further prospective studies to refine patient selection and optimize clinical outcomes.
文摘The operation of the biliary system is usually employed for liver, gallbladder or pancreatic diseases. Most benign cases are cholelithiasisinduced cholecystitis and choledochitis, while malignant ones mainly include gallbladder cancers, cholangiocarcinoma orcarcinoma of the head of the pancreas.
文摘BACKGROUND Endoscopic drainage remains the treatment of choice for unresectable or inoperable malignant distal biliary obstruction(MDBO).AIM To compare the safety and efficacy of plastic stent(PS)vs self-expanding metal stent(SEMS)placement for treatment of MDBO.METHODS This meta-analysis was developed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.A comprehensive search was performed in MEDLINE,Cochrane,Embase,Latin American and Caribbean Health Sciences Literature,and grey literature to identify randomized clinical trials(RCTs)comparing clinical success,adverse events,stent dysfunction rate,reintervention rate,duration of stent patency,and mean survival.Risk difference(RD)and mean difference(MD)were calculated and heterogeneity was assessed with I2 statistic.Subgroup analyses were performed by SEMS type.RESULTS Twelve RCTs were included in this study,totaling 1005 patients.There was no difference in clinical success(RD=-0.03,95%confidence interval[CI]:-0.01,0.07;I 2=0%),rate of adverse events(RD=-0.03,95%CI:-0.10,0.03;I2=57%),and mean patient survival(MD=-0.63,95%CI:-18.07,19.33;I2=54%)between SEMS vs PS placement.However,SEMS placement was associated with a lower rate of reintervention(RD=-0.34,95%CI:-0.46,-0.22;I2=57%)and longer duration of stent patency(MD=125.77 d,95%CI:77.5,174.01).Subgroup analyses revealed both covered and uncovered SEMS improved stent patency compared to PS(RD=152.25,95%CI:37.42,267.07;I2=98%and RD=101.5,95%CI:38.91,164.09;I2=98%;respectively).Stent dysfunction was higher in the covered SEMS group(RD=-0.21,95%CI:-0.32,-0.1;I²=205%),with no difference in the uncovered SEMS group(RD=-0.08,95%CI:-0.56,0.39;I²=87%).CONCLUSION While both stent types possessed a similar clinical success rate,complication rate,and patient-associated mean survival for treatment of MDBO,SEMS were associated with a longer duration of stent patency compared to PS.
文摘AIM: To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction.METHODS: A systematic review of randomized clinical trials(RCT) was conducted, with the last update on March 2015, using EMBASE, CINAHL(EBSCO), MEDLINE, LILACS/CENTRAL(BVS), SCOPUS, CAPES(Brazil), and gray literature. Information of the selected studies was extracted in sight of six outcomes: primarily regarding dysfunction, complication and reintervention rates; and secondarily costs, survival, and patency time. The data about characteristics of trial participants, inclusion and exclusion criteria and types of stents were also extracted. The bias was mainly assessed through the JADAD scale. This meta-analysis was registered in the PROSPERO database by the number CRD42014015078. The analysis of the absolute risk of the outcomes was performed using the software Rev Man, by computing risk differences(RD) of dichotomous variables and mean differences(MD) of continuous variables. Data on RD and MD for each primary outcome were calculated using the MantelHaenszel test and inconsistency was qualified and reported in χ2 and the Higgins method(I2). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. Student's t-test was used for the comparison of weighted arithmetic means regarding secondary outcomes.RESULTS: Initial searching identified 3660 studies; 3539 were excluded through title, repetition, and/or abstract, while 121 studies were fully assessed and were excluded mainly because they did not compare self-expanding metal stents(SEMS) and plastic stents(PS), leading to thirteen RCT selected, with 13 articles and 1133 subjects meta-analyzed. The mean age was 69.5 years old, that were affected mostly by bile duct(proximal) and pancreatic tumors(distal). The preferred SEMS diameter used was the 10 mm(30 Fr) and the preferred PS diameter used was 10 Fr. In the metaanalysis, SEMS had lower overall stent dysfunction compared to PS(21.6% vs 46.8%, P < 0.00001) and fewer re-interventions(21.6% vs 56.6%, P < 0.00001), with no difference in complications(13.7% vs 15.9%, P = 0.16). In the secondary analysis, the mean survival rate was higher in the SEMS group(182 d vs 150 d, P < 0.0001), with a higher patency period(250 d vs 124 d, P < 0.0001) and a lower cost per patient(4193.98 vs 4728.65 Euros, P < 0.0985).CONCLUSION: SEMS are associated with lower stent dysfunction, lower re-intervention rates, better survival, and higher patency time. Complications and costs showed no difference.
基金National Natural Science Foundation of China,No.81770491The Innovation Capacity Support Plan of Shaanxi Province,No.2020TD-040.
文摘BACKGROUND Whether to use a T-tube for biliary anastomosis during orthotopic liver transplantation(OLT)remains a debatable question.Some surgeons chose to use a T-tube because they believed that it reduces the incidence of biliary strictures.Advances in surgical techniques during the last decades have significantly decreased the overall incidence of postoperative biliary complications.Whether using a T-tube during OLT is still associated with the reduced incidence of biliary strictures needs to be re-evaluated.AIM To provide an updated systematic review and meta-analysis on using a T-tube during adult OLT.METHODS In the electronic databases MEDLINE,PubMed,Scopus,ClinicalTrials.gov,the Cochrane Library,the Cochrane Hepato-Biliary Group Controlled Trails Register,and the Cochrane Central Register of Controlled Trials,we identified 17 studies(eight randomized controlled trials and nine comparative studies)from January 1995 to October 2020.The data of the studies before and after 2010 were separately extracted.We chose the overall biliary complications,bile leaks or fistulas,biliary strictures(anastomotic or non-anastomotic),and cholangitis as outcomes.Odds ratios(ORs)with 95%confidence intervals(CIs)were calculated to describe the results of the outcomes.Furthermore,the test for overall effect(Z)was used to test the difference between OR and 1,where P≤0.05 indicated a significant difference between OR value and 1.RESULTS A total of 1053 subjects before 2010 and 1346 subjects after 2010 were included in this meta-analysis.The pooled results showed that using a T-tube reduced the incidence of postoperative biliary strictures in studies before 2010(P=0.012,OR=0.62,95%CI:0.42-0.90),while the same benefit was not seen in studies after 2010(P=0.60,OR=0.76,95%CI:0.27-2.12).No significant difference in the incidence of overall biliary complications(P=0.37,OR=1.41,95%CI:0.66-2.98),bile leaks(P=0.89,OR=1.04,95%CI:0.63-1.70),and cholangitis(P=0.27,OR=2.00,95%CI:0.59-6.84)was observed between using and not using a T-tube before 2010.However,using a T-tube appeared to increase the incidence of overall biliary complications(P=0.049,OR=1.49,95%CI:1.00-2.22),bile leaks(P=0.048,OR=1.91,95%CI:1.01-3.64),and cholangitis(P=0.02,OR=7.21,95%CI:1.37-38.00)after 2010.A random-effects model was used in biliary strictures(after 2010),overall biliary complications(before 2010),and cholangitis(before 2010)due to their heterogeneity(I2=62.3%,85.4%,and 53.6%,respectively).In the sensitivity analysis(only RCTs included),bile leak(P=0.66)lost the significance after 2010 and a random-effects model was used in overall biliary complications(before 2010),cholangitis(before 2010),bile leaks(after 2010),and biliary strictures(after 2010)because of their heterogeneity(I2=92.2%,65.6%,50.9%,and 80.3%,respectively).CONCLUSION In conclusion,the evidence gathered in our updated meta-analysis showed that the studies published in the last decade did not provide enough evidence to support the routine use of T-tube in adults during OLT.
文摘Biliary atresia(BA), a chronic progressive cholestatic disease of infants, is the leading cause for liver transplant in children, especially in patients under two years of age. BA can be successfully treated with the Kasai portoenterostomy; however most patients still require a liver transplant, with up to one half of BA children needing a transplant by age two. In the current pediatric end-stage liver disease system, children with BA face the risk of not receiving a liver in a safe and timely manner. In this review, we discuss a number of possible solutions to help these children. We focus on two general approaches:(1) preventing/delaying need for transplantation, by optimizing the success of the Kasai operation; and(2) expediting transplantation when needed, by performing techniques other than the standard deceased-donor, whole, ABO-matched organ transplant.
文摘BACKGROUND Bilateral vs unilateral biliary stenting is used for palliation in malignant biliary obstruction.No clear data is available to compare the efficacy and safety of bilateral biliary stenting over unilateral stenting.AIM To assess the efficacy and safety of bilateral vs unilateral biliary drainage in inoperable malignant hilar obstruction.METHODS PubMed,Embase,Scopus,and Cochrane databases,as well as secondary sources(bibliographic review of selected articles and major GI proceedings),were searched through January 2019.The primary outcome was the re-intervention rate.Secondary outcomes were a technical success,early and late complications,and stent malfunction rate.Pooled odds ratio(OR)and 95%confidence interval(CI)were calculated for each outcome.RESULTS A total of 9 studies were included(2 prospective Randomized Controlled Study,5 retrospective studies,and 2 abstracts),involving 782 patients with malignant hilar obstruction.Bilateral stenting had significantly lower re-intervention rate compared with unilateral drainage(OR=0.59,95%CI:0.40-0.87,P=0.009).There was no difference in the technical success rate(OR=0.7,CI:0.42-1.17,P=0.17),early complication rate(OR=1.56,CI:0.31-7.75,P=0.59),late complication rate(OR=0.91,CI:0.58-1.41,P=0.56)and stent malfunction(OR=0.69,CI:0.42-1.12,P=0.14)between bilateral and unilateral stenting for malignant hilar biliary strictures.CONCLUSION Bilateral biliary drainage had a lower re-intervention rate as compared to unilateral drainage for high grade inoperable malignant biliary strictures,with no significant difference in technical success,and early or late complication rates.
文摘Endoscopic ultrasound(EUS)-guided biliary drainage is accepted as a less invasive,alternative treatment for patients in whom endoscopic retrograde cholangiopancreatography has failed. Most patients with malignant hilar obstruction undergo EUSguided hepaticogastrostomy. The authors present the case of a 77-year-old man with advanced hilar cholangiocarcinoma who had undergone a rouxen-Y hepaticojejunostomy several months prior. He developed progressive jaundice and a low-grade fever that persisted for one week. The enteroscopic-assisted endoscopic retrograde cholangiopancreatography failed,thus the patient was scheduled for EUS-guided biliary drainage. In order to obtain adequate drainage,both intrahepatic systems were drained. This report describes the technique used for bilateral drainage via a transgastric approach. Currently,only a few different techniques for EUS-guided right system drainage have been reported in the literature. This case demonstrates that bilateral EUS-guided biliary drainage is feasible and effective in patients with hilar cholangiocarcinoma,and thus can be used as an alternative to percutaneous biliary drainage.
文摘BACKGROUND Percutaneous transhepatic cholangiography is a diagnostic and therapeutic procedure that involves inserting a needle into the biliary tree,followed by the immediate insertion of a catheter.Endoscopic ultrasound-guided biliary drainage(EUS-BD)is a novel technique that allows BD by echoendoscopy and fluoroscopy using a stent from the biliary tree to the gastrointestinal tract.AIM To compare the technical aspects and outcomes of percutaneous transhepatic BD(PTBD)and EUS-BD.METHODS Different databases,including PubMed,Embase,clinicaltrials.gov,the Cochrane library,Scopus,and Google Scholar,were searched according to the guidelines for Preferred Reporting Items for Systematic reviews and Meta-Analyses to obtain studies comparing PTBD and EUS-BD.RESULTS Among the six studies that fulfilled the inclusion criteria,PTBD patients underwent significantly more reinterventions(4.9 vs 1.3),experienced more postprocedural pain(4.1 vs 1.9),and experienced more late adverse events(53.8%vs 6.6%)than EUS-BD patients.There was a significant reduction in the total bilirubin levels in both the groups(16.4-3.3μmol/L and 17.2-3.8μmol/L for EUSBD and PTBD,respectively;P=0.002)at the 7-d follow-up.There were no significant differences observed in the complication rates between PTBD and EUSBD(3.3 vs 3.8).PTBD was associated with a higher adverse event rate than EUSBD in all the procedures,including reinterventions(80.4%vs 15.7%,respectively)and a higher index procedure(39.2%vs 18.2%,respectively).CONCLUSION The findings of this systematic review revealed that EUS-BD is linked with a higher rate of effective BD and a more manageable procedure-related adverse event profile than PTBD.These findings highlight the evidence for successful EUS-BD implementation.
文摘BACKGROUND Biliary drainage,either by the stent-in-stent(SIS)or side-by-side(SBS)technique,is often required when treating a malignant hilar biliary obstruction(MHBO).Both methods differ from each other and have distinct advantages.AIM To compare both techniques regarding their efficacy and safety in achieving drainage of MHBO.METHODS A comprehensive search of multiple electronic databases(MEDLINE,Embase,LILACS,BIREME,Cochrane)was conducted and grey literature from their inception until December 2020 with no restrictions regarding the year of publication or language,since there was at least an abstract in English.The included studies compared SIS and SBS techniques through endoscopic retrograde cholangiopancreatography.Outcomes analyzed included technical and clinical success,early and late adverse events(AEs),stent patency,reintervention,and procedure-related mortality.RESULTS Four cohort studies and one randomized controlled trial evaluating a total of 250 patients(127 in the SIS group and 123 in the SBS group)were included in this study.There were no statistically significant differences between the two groups concerning the evaluated outcomes,except for stent patency,which was higher in the SIS compared with the SBS technique[mean difference(d)=33.31;95%confidence interval:9.73 to 56.90,I2=45%,P=0.006].CONCLUSION The SIS method showed superior stent patency when compared to SBS for achieving bilateral drainage in MHBO.Both techniques are equivalent in terms of technical success,clinical success,rates of both early and late AEs,reintervention,and procedure-related mortality.
文摘BACKGROUND In the classic descriptions of the human liver,the common hepatic duct forms at the confluence of left and right hepatic ducts.Many authors have documented variations in the intra-hepatic ductal system,but to the best of our knowledge there has been no report on bile duct variations in Caribbean populations.AIM To evaluate the variations in bile duct anatomy using magnetic resonance cholangiography(MRC)in unselected patients at a major hepatobiliary referral centre in the Eastern Caribbean.Knowledge of the intra-hepatic biliary anatomy is important to optimize service delivery for any physician treating liver and biliary disorders.METHODS This study was carried out at a tertiary referral hospital for hepatobiliary diseases in the Eastern Caribbean.We retrospectively evaluated magnetic resonance cholangiograms in 152 consecutive patients at this facility over a two-year period from April 1,2017 to March 31,2019.Two consultant radiologists experienced in MRC interpretation reviewed all scans and described biliary anatomy according to the Huang’s classification.A systematic review of published studies was performed and relevant data were extracted in order to calculate the global prevalence of each biliary variant.The variants in our population were compared to the global population.RESULTS There were 152 MRCs evaluated in this study in 86 males and 66 females.There were 109(71.7%)persons with“classic”biliary anatomy(type A1)and variants were present in 43(28.3%)persons.There was no statistical relationship between the presence of anatomic variants and gender or ethnicity.We encountered the following variants:29(19.1%)type A2,7(4.6%)type A3,6(3.95%)type A4,0 type A5 and a single variant(quadrification)that did not fit the classification system.Compared to the global prevalence,our population had a significantly greater occurrence of A1 anatomy(71.7%vs 62.6%;P=0.0227)and A2 trifurcations(19.1%vs 11.5%;P=0.0069),but a significantly lower incidence of A3 variants(4.61%vs 11.5%;P=0.0047).CONCLUSION There are significant differences in intra-hepatic biliary anatomy in this unselected Eastern Caribbean population compared to global statistics.Specifically,persons of Caribbean descent have a greater incidence of Huang A2 trifurcations and a lower incidence of Huang A3 variants.
基金supported by the NIHR Birmingham Biomedical Research Centre at the University Hospitals Birmingham NHS Foundation Trustthe University of Birmingham
文摘AIM To review the clinical impact of machine perfusion(MP) of the liver on biliary complications post-transplantation, particularly ischaemic-type biliary lesions(ITBL). METHODS This systematic review was performed in accordance with the Preferred Reporting Systematic Reviews and MetaAnalysis(PRISMA) protocol. The following databases were searched: PubMed, MEDLINE and Scopus. The keyword "liver transplantation" was used in combination with the free term "machine perfusion". Clinical studies reporting results of transplantation of donor human livers following ex situ or in situ MP were analysed. Details relating to donor characteristics, recipients, technique of MP performed and post-operative biliary complications(ITBL, bile leak and anastomotic strictures) were critically analysed.RESULTS Fifteen articles were considered to fit the criteria for this review. Ex situ normothermic MP was used in 6 studies, ex situ hypothermic MP in 5 studies and the other 4 studies investigated in situ normothermic regional perfusion(NRP) and controlled oxygenated rewarming. MP techniques which have per se the potential to alleviate ischaemia-reperfusion injury: Such as hypothermic MP and NRP, have also reported lower rates of ITBL. Other biliary complications, such as biliary leak and anastomotic biliary strictures, are reported with similar incidences with all MP techniques. There is currently less clinical evidence available to support normothermic MP as a mitigator of biliary complications following liver transplantation. On the other hand, restoration of organ to full metabolism during normothermic MP allows assessment of hepatobiliary function before transplantation, although universally accepted criteria have yet to be validated.CONCLUSION MP of the liver has the potential to have a positive impact on post-transplant biliary complications, specifically ITBL, and expand extended criteria donor livers utilisation.
基金Supported by Czech Health Research Council,No.17-30281A.
文摘BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is a method used to decrease portal hypertension.Biliary stricture is the rarest of the complications associated with this procedure with only 12 cases previously reported in the literature.None of these cases have documented the resolution of biliary stenosis induced by a stent graft.The only curative solutions reported are liver transplantation or bypassing the stenosis with an artificial biliary tract using advanced endoscopic techniques.CASE SUMMARY This is the first reported case of biliary obstruction secondary to TIPS placement in a transplanted liver.In our patient,a portosystemic shunt was created to treat severe veno-occlusive liver graft disease manifesting itself primarily by fluid retention.A cholestatic liver lesion and cholangitis with abscesses developed due to a stent graft-induced stricture in the dorsal segment of the right hepatic duct and the stricture diminished following percutaneous drainage.Endoscopic drainage was performed after unsuccessful removal of the percutaneous catheter resulting in a bilio-cutaneous fistula.Although the liver graft now functions well,the stricture remains refractory even after 44 mo of treatment.CONCLUSION Biliary strictures caused by TIPS in both transplanted and native livers seem refractory to endoscopic treatment.
文摘Background: The outcomes and disease associations in pregnant women with primary biliary cholangitis(PBC) have not been largely explored. This study aimed to determine the level of evidence associated with maternal and fetal outcomes and other disease associations in female patients with PBC. Data sources:: A comprehensive literature search was conducted. Maternal and fetal outcomes were obtained from patients with a previous, current or subsequent diagnosis of PBC. A random-effects model was employed, using odds ratios(ORs) with 95% confidence intervals(CIs). Results: Eleven studies, with 2179 female PBC patients were included. Pregnant women with PBC were significantly more likely to have a miscarriage(OR = 1.27, 95% CI: 1.02-1.58;P = 0.03), and a history of abortion(OR = 1.50, 95% CI: 1.09-2.07;P = 0.01), with absent heterogeneity( I 2 = 0%). PBC pregnant women were significantly more likely to deliver via vaginal birth(OR = 1.69, 95% CI: 1.33-2.14;P < 0.001) with low level heterogeneity( I^(2) < 0.001%). Patients had a statistically significant increased likelihood of lifetime smoking(OR = 1.95, 95% CI: 1.17-3.23;P = 0.01). Egger’s regression revealed no evidence of publication bias. Conclusions: This meta-analysis provides pooled evidence that a PBC pregnancy is associated with fetal morbidity and maternal lifestyle associations that may influence pregnancy outcomes. More studies are needed to establish disease associations that may directly affect pregnancy outcomes. These data are essential for clinicians managing these patients before, during or after pregnancy.
基金Supported by China Academy of Medical Science Innovation Fund for Medical Sciences,CIFMS,No.2021-I2M-1-022-2021-S4.
文摘BACKGROUND Targeted therapy(TT)has resulted in controversial efficacy as first-line treatment for biliary tract cancer(BTC).More efficacy comparisons are required to clarify the overall effects of chemotherapy(CT)combined with TT and CT alone on advanced BTC.AIM To conduct a meta-analysis of the available evidence on the efficacy of CT combined with TT for advanced BTC.METHODS The PubMed,EMBASE,ClinicalTrials,Scopus and Cochrane Library databases were systematically searched for relevant studies published from inception to August 2022.Only randomized clinical trials(RCTs)including comparisons between the combination of gemcitabine-based CT with TT and CT alone as firstline treatment for advanced BTC were eligible(PROSPERO-CRD42022313001).The odds ratios(ORs)for the objective response rate(ORR)and hazard ratios(HRs)for both progression-free survival(PFS)and overall survival(OS)were calculated and analyzed.Subgroup analyses based on different targeted agents,CT regimens and tumor locations were prespecified.RESULTS Nine RCTs with a total of 1361 individuals were included and analyzed.The overall analysis showed a significant improvement in ORR in patients treated with CT+TT compared to those treated with CT alone(OR=1.43,95%CI:1.11-1.86,P=0.007)but no difference in PFS or OS.Similar trends were observed in the subgroup treated with agents targeting epidermal growth factor receptor(OR=1.67,95%CI:1.17-2.37,P=0.004)but not in the subgroups treated with agents targeting vascular endothelial growth factor receptor or mesenchymal-epithelial transition factor.Notably,patients who received a CT regimen of gemcitabine+oxaliplatin in the CT+TT arm had both a higher ORR(OR=1.75,95%CI:1.20-2.56,P=0.004)and longer PFS(HR=0.83,95%CI:0.70-0.99,P=0.03)than those in the CT-only arm.Moreover,patients with cholangiocarcinoma treated with CT+TT had significantly increased ORR and PFS(ORR,OR=2.06,95%CI:1.27-3.35,PFS,HR=0.79,95%CI:0.66-0.94).CONCLUSION CT+TT is a potential first-line treatment for advanced BTC that leads to improved tumor control and survival outcomes,and highlighting the importance of CT regimens and tumor types in the application of TT.
