Malignant obstructive jaundice often manifests clinically as yellowing of the skin and sclera, yellow urine, itching of the skin, white clay-like stools, mostly progressive aggravation and progressive wasting, failure, and in cases of combined infection, chills, fever, abdominal pain, and even shock symptoms. Treatment includes surgical radical resection and palliative surgical biliary anastomosis; interventions include endoscopic retrograde catheterization and drainage (ERCP) or percutaneous hepatic puncture and drainage (PTCD), and can be supplemented by stenting.
For early obstructive jaundice, surgical treatment is currently one of the most important treatment options. The main surgical procedures are excision of the lesion, removal of the combined stones, and bile duct diversion. However, malignant obstructive jaundice is mostly advanced when detected, and the surgery is very traumatic. Patients with moderate-to-severe obstructive jaundice often suffer from postoperative complications and mortality due to advanced age, tumor erosion, hypoproteinemia, hepatic and renal impairment, and malnutrition. Currently, interventional methods are used first to relieve obstructive jaundice, improve the general condition, further determine the tumor stage, help determine the surgical resection rate, reduce unnecessary surgical trauma, reduce postoperative complications, and play a pivotal role in selecting a treatment plan for obstructive jaundice.
Endoscopic retrograde cholangiography and stent placement
The pancreaticoduodenoscopy technique involves entering the duodenum through the mouth and stomach, observing the duodenal papilla, and performing endoscopic retrograde cholangiopancreatography (ERCP), which has evolved from an initial diagnostic technique to an endoscopic technique that integrates diagnosis and treatment.
This technique is a very good method to lift malignant biliary obstruction that cannot be removed by surgery, and it is less traumatic, faster recovery for patients after surgery, less physical requirements for patients, less interference from supervisors, no loss of bile causing bile loss syndrome, and internal drainage is in line with physiological conditions compared with external drainage, no discomfort caused by long-term tube, and no water and electrolyte disorders. In contrast, percutaneous hepatic puncture biliary drainage and nasobiliary drainage are external drainage, the catheter is easy to fill and fall off, and it is difficult to retain for a long time, and the large amount of bile outflow can lead to water-electrolyte disorders and digestive dysfunction, especially for obstructive jaundice caused by middle and late stage bile duct and pancreatic tumor, the application of duodenoscopy to place biliary stents has the effect of recently relieving biliary obstruction, relieving jaundice, improving liver function and prolonging patients’ lives. It is less invasive and risky, and easy for patients to tolerate.
The endoscopic treatment of cholangiocarcinoma is closely related to whether the patient has the opportunity to undergo surgery. If the patient can undergo surgery, the endoscopic treatment is mainly aimed at preoperative reduction of jaundice, and nasobiliary drainage tubes, plastic stents and retrievable stents can be placed.
If the patient is no longer amenable to surgical treatment, endoscopic treatment will be one of the palliative treatment methods and stents can be placed in the bile ducts, with longer patency times preferred, such as metal stents. If the patient’s survival time is about 1.5 years, the placement of metal stents is generally considered. The length of the stent is usually chosen to be about 2 cm beyond the tumor at both ends.
Endoscopic treatment of bile duct stones stones over 1.5cm are first lithotripsy, then stone extraction basket is used to extract stones, stones with diameter around 0.5cm can be directly extracted by balloon. The papillotomy is stopped with 1:10,000 epinephrine. However, there are still some patients in whom the lesion invades the papilla and the operation cannot be performed transduodenally or the patient cannot tolerate the position and discomfort of the operation and aborts this operation. In addition, sphincter of Oddisotomy (EST) has more complications, such as acute pancreatitis, gastrointestinal bleeding, gastrointestinal perforation, and local infection in the near future; and long-term complications such as recurrence of gallstones, duodenal papillary stenosis, cholangitis, cholecystitis, gallbladder cancer, recurrent acute pancreatitis and chronic pancreatitis, and liver abscess.
Percutaneous hepatic puncture for biliary drainage and treatment of obstructive jaundice
For obstructive jaundice, percutaneous hepatic puncture biliary drainage is currently one of the most commonly used treatments and has a wide range of indications for benign and malignant obstructive jaundice, high or low level obstructive jaundice as well as mild, moderate and severe obstructive jaundice and post-surgical biliary strictures and obstructive jaundice lesions. It is especially superior for high right or left intrahepatic bile ducts with both obstruction, severe obstructive jaundice, and after surgical procedures, requiring long-term bile drainage (such as malignant obstructive jaundice). Percutaneous hepatic puncture biliary drainage can drain the left and right intrahepatic bile ducts at the same time, and its yellowing and decompression are fast; internal or external drainage can also be performed, and internal drainage can avoid the loss of bile and other nutrients in addition to reducing yellowing, which is conducive to improving digestive function. Percutaneous hepatic puncture biliary drainage can be performed at the same time to biopsy the tumor tissue. Percutaneous hepatic puncture biliary drainage is simple, practical, relatively less invasive, with high success rate, significant and rapid efficacy, and can be done for long-term bile drainage. If the obstructed bile duct is placed with a biliary stent, the carrying drainage bag can be removed to reduce the psychological burden and inconvenience of life and improve the quality of life. Also for those who cannot be operated, combined with arterial cannulation chemoembolization or internal radiation therapy. Further obstructive jaundice can be prolonged survival or provide the opportunity for second-stage surgical resection. Currently, this treatment has become the ideal choice for palliative treatment of malignant obstructive jaundice.
The indications are broad, and bile duct obstruction in the hilar region and bile duct obstruction due to intrahepatic lesions are more suitable for interventional treatment by percutaneous transhepatic bile drainage, and those who fail by the endoscopic route can also be relieved of obstruction by this method. It is clinically estimated that about 20% of jaundice cases are treated by surgical reduction, about 20% of malignant obstructive jaundice patients are treated by endoscopic reduction, and percutaneous transhepatic percutaneous bile drainage accounts for about 60% of cases and is the most commonly used palliative treatment.
The costs of patients hospitalized for interventional treatment include: interventional procedure, material consumption, contrast, hospitalization, antibiotics, analgesics, albumin, diuretics, etc., and may be directed at the treatment of comorbidities such as pancreatitis and bile duct infection. It can be considered that interventional treatment to reduce yellowing is a more expensive treatment. In the Beijing area, for example, the overall cost is often in the range of 10-50,000 yuan, with an average of greater than 20,000 yuan. Medical insurance covers 50% of interventional consumables worth 500 RMB or more. After yellow reduction, patients still need to continue treatment, including tumor-specific treatment, anti-infection, supportive treatment, and management of complications. The total medical cost is often over $100,000. Therefore, appropriate treatment must be planned from the beginning to improve the efficacy ratio of treatment.
Surgical treatment
It is mainly applied to extrahepatic bile duct obstruction, and its advantage is that it can not only relieve jaundice but also remove the cause of obstruction, such as Whipple surgery, lithotripsy and T-tube drainage for pancreatic head cancer or periampullary cancer. In many cases, radical surgery is not suitable due to large lesions invading the surrounding blood vessels, or due to poor general condition of the patient, inclusions such as diabetes and cardiovascular disease, or advanced age.
For treatment, there are radical surgical resection and palliative surgical biliary-intestinal anastomosis.
Interventional treatment of obstructive jaundice due to malignant tumor compression
Jaundice is a clinical manifestation of yellow staining of sclera, skin, mucous membranes and body fluids caused by an increase in plasma bilirubin concentration when bilirubin metabolism is impaired. Bilirubin comes from aging red blood cells in the body, and its production, metabolism and excretion are closely related to the liver, and any disorder in any part of the process can lead to an increase in the concentration of bilirubin in the blood and cause jaundice.
In recent years, interventional treatment has been widely carried out in clinical practice because of its safety and minimally invasive effect. Interventional treatment of obstructive jaundice due to malignant tumor compression is generally performed in three steps:
I. Percutaneous hepatic perforated bile duct drainage (PTCD)
1. External drainage The percutaneous transhepatic perforated bile duct is first performed, and under the guidance of a guidewire, multiple lateral holes (the number and location of the lateral holes are determined by the puncture point and the site of obstruction) are placed.
The drainage tube with multiple side holes (the number and location of the side holes are determined by the puncture point and the site of obstruction) is placed into the dilated bile duct, and the head end of the catheter is placed above the obstruction to drain the bile outside the body, reduce the pressure in the biliary system, and relieve jaundice.
2.Internal drainage On the basis of external drainage, or under the guidance of a guidewire after puncture, the head end of the drainage catheter is directly placed in the bile duct or duodenum distal to the obstruction through the narrow obstruction area, and bile will flow into the bile duct at the lower end of the obstruction and into the duodenum through the side holes of the drainage catheter. Again, the number and location of the lateral holes must be determined by the site of the stricture. The purpose of internal drainage can be achieved by closing the drainage tube left outside the body. Internal drainage avoids the disadvantage of losing bile.
B. Percutaneous transhepatic endobiliary stent drainage (EMBE)
After 1-2 weeks of PTCD drainage, the symptoms and signs caused by jaundice have basically subsided, and the laboratory indexes have basically returned to normal, at this time, an endobiliary stent can be placed in the narrowed bile duct through the PTCD drainage tube to restore the natural biliary system. After the jaundice is clearly reduced, the stent can be replaced with an endobiliary stent.
Advantages of EMBE for obstructive jaundice.
①The percutaneous transhepatic biliary stent delivery catheter used is only about 3 mm in diameter, yet it can safely insert an 8-10 mm diameter metal endoprosthesis (EMS), thus causing little patient injury.
②EMS has good radial tension and can provide effective support to the bile duct wall, thus resisting external pressure on the bile duct and preventing the stent from shifting or falling out.
③The risk of bile sludge precipitation around the stent wire and the chance of biliary infection is low because the contact area between the stent and bile is small.
④The clearance of the stent is large, and the stent placed will not hinder the drainage of bile or pancreatic juice even if it crosses the bile duct branches or pancreatic duct.
(5) A second set of EMS can be placed inside the EMS, which can increase the tension of the stent and reduce the restenosis rate.
(6) EMS can be covered by epithelium at an early stage and become part of the bile duct wall.
(7) It is possible to perform internal drainage for some refractory intrahepatic bile duct obstruction in the past. However, some foreign scholars have different views on whether to place stents or not.
(3) Transarterial cannulation chemotherapy (TAC) or chemotherapy plus embolization (TACE)
If there is a clear tumor donor artery, the tumor donor artery will be super-selected by super-selected catheter and then embolized after perfusion chemotherapy. In this way, the tumor shrinks, the degree of bile duct stenosis is reduced, and the occurrence of restenosis is reduced.
Through the combination of clinical and radiological comprehensive imaging diagnosis and comprehensive interventional treatment, the malignant tumor compression leading to obstructive jaundice has significantly improved the quality of survival and prolonged survival time, especially in patients who cannot be operated.
Placement of internal and external drainage tubes for patients
To relieve the patient’s symptoms, the hepatology department performed percutaneous hepatic percutaneous biliary drainage under C-arm, which was very successful. At the same time, an internal drainage tube was placed into the duodenum, which not only relieved the patient’s bile duct pressure quickly, but also, the placed internal drainage tube was able to drain bile into the intestine and maintain the patient’s digestive function.
With the development of interventional medicine and the higher requirements of clinical work, the application field of digital subtraction angiography technology is also expanding, said Wang Zhiqing, director of hepatology department. While obstructive jaundice due to malignant tumors is lost to surgery, percutaneous hepatic puncture bile duct drainage biliary drainage is becoming more and more widely used in the clinic. Its purpose is to relieve the obstruction of the bile duct through the placed drainage tube, reduce or clear the jaundice, create conditions for further treatment and improve the patient’s general condition, improve the quality of life and prolong life. In some elderly high-risk patients with biliary obstruction due to unresectable malignant tumors, drainage can achieve a better palliative treatment effect.
Percutaneous hepatic percutaneous bile duct drainage under C-arm or ultrasound guidance is performed with a clear view of the bile duct and its surrounding tissues and organs. The whole puncture process is safe and visualized, the operation is flexible and convenient, and the success rate of puncture is significantly increased, while complications are greatly reduced.
Mastering the indications
Percutaneous hepatic percutaneous bile duct drainage has a wide range of indications. It is suitable for several situations: First, when bile duct obstruction caused by bile duct cancer, pancreatic cancer, common bile duct stones, etc. is accompanied by liver function impairment and severe jaundice, percutaneous percutaneous hepatic percutaneous bile duct drainage is often performed before surgery to avoid the loss of electrolytes caused by intubation and drainage after the first stage surgery, to improve the cure rate and reduce complications. Secondly, inoperable bile duct cancer, pancreatic cancer, hepatic portal metastases and other malignant lesions can reduce patient pain and prolong patient life. Third, as a preparation for decompression before balloon catheter dilation for benign bile duct strictures. Fourth, as an emergency measure for acute obstructive septic cholangitis, it can quickly reduce the intra-biliary pressure, improve clinical symptoms and get the patient out of danger quickly. Fifth, it can be used to reduce pressure through drainage and then perform lithotripsy through the catheter.