Obstructive jaundice can be due to a variety of causes, bile duct cancer, pancreatic head cancer, periampullary cancer, gallbladder cancer, primary hepatocellular carcinoma, hilar lymph node metastases, liver metastases and postoperative anastomotic stricture, bile duct wall necrosis, and stones. The main treatment methods currently used are, surgery, interventional therapy and transendoscopic treatment. In many cases, due to the large lesions invading the peripheral blood vessels, it is not suitable for radical surgery, or due to the patient’s poor general condition, diabetes, cardiovascular disease and other inclusions, advanced age and other reasons, the endoscopic insertion of nasobiliary drains or internal stents through the duodenal papilla is chosen to achieve the purpose of reducing yellow, but there are still some patients with lesions invading the papilla can not be operated through the duodenum or the patient can not However, there are still some patients with lesions invading the papilla that cannot be operated through the duodenum, or patients cannot tolerate the position and discomfort of the operation through the mouth and give up this operation. The drainage of more complicated bile duct obstruction has some limitations. The drainage catheter is easily dislodged within a short period of time. Bile duct obstruction in the hilar region and bile duct obstruction due to intrahepatic lesions are more suitable for interventional treatment by percutaneous transhepatic percutaneous bile drainage. Zhang Chunqing, Department of Gastroenterology, Shandong Provincial Hospital
I. Indications
1, inoperable malignant biliary occlusion
2, benign biliary occlusion that cannot be treated by repeated balloon dilatation
Contraindications
Same as PTBD
Self-expanding stents are preferred for the use of biliary stents.
Preoperative preparation
1.Prepare for intraoperative analgesia, epidural anesthesia or general anesthesia is feasible.
2. Atropine sulfate o.5mg can be given intramuscularly 30 minutes before surgery.
V. Operation method
1.Extrahepatic biliary tract occlusion.
(1) Determine the length of the stent by PTBD drainage tube imaging, usually a 10mm diameter stent is used, with the proximal end placed as close to the hepatic portal as possible.
(2) Superrigid exchange guide wire is passed over the stenotic segment and into the 12-finger intestine.
(3) The stent is placed after accurate positioning under a long sheath guide.
(4) The PTBD drainage catheter is placed again and imaging is performed to confirm the effect.
2.Hilar bile duct occlusion
The left and right intrahepatic bile ducts need to be placed into the biliary stent at the same time, and the side-by-side or end-to-side method can be used to release the occlusion of the left and right intrahepatic bile ducts at the same time
Caution.
①For obstruction below the jugular of the common bile duct, the distal end of the stent should not exceed the hepatopancreatic jugular sphincter to maintain the physiological function of the hepatopancreatic jugular sphincter and to reduce the chance of infection.
②For obstruction caused by tumor in the jugular abdomen and head of the pancreas, the distal end of the stent should cross over the stenotic segment.
③If one stent cannot completely cover the stenotic segment, a second stent can be placed, and the two stents should slightly overlap.
The first stent is placed from the right hepatic duct to the common hepatic duct, and then a guidewire is fed through the mesh to the duodenum from the left side, and the mesh is dilated with a balloon, and the second stent is placed from the left hepatic duct, and the front end is located in the common bile duct through the mesh. This placement method is called “Y” implantation, or a “Y” shaped stent can be created by placing two stents side by side in the common bile duct from the right without passing through the stent mesh, or by implanting a stent from the right hepatic duct to the left hepatic duct and then placing a stent from the right hepatic duct to the common bile duct, which is called “T “T” shaped implantation. Internal and external drainage is also established to facilitate the observation of the nature of the bile duct drainage. If the stent is clear through the drainage duct imaging, we can consider clamping the drainage tube and keep it for observation, and generally remove the drainage tube in 2-3 weeks.
Postoperative treatment
Bed rest; antibiotic treatment; 2 weeks of contrast review, if the stenosis site contrast through smoothly remove the PTBD catheter.
VII. Treatment effect
The success rate of surgery is close to 100%, and there is a lack of comparative studies on the long-term opening rate of different stents. For malignant biliary strictures, chemotherapy helps to maintain the long-term opening rate of stents.
Frequently asked questions about biliary stents
1.How to determine whether the patient is suitable for interventional yellowing treatment?
Karnofsky score ≥ 50, (needs a lot of help and requires medical treatment from time to time). For cases with a score of 20-40 again, the expected postoperative mortality rate is up to 50% or more, and should be discussed carefully and fully with the family to weigh the pros and cons and reach a consensus before implementation. Serum total bilirubin ≥ 60µmol/l (4mg/l); in ≥ 140µmol/l (8mg/l) must be treated for yellowness reduction. Intrahepatic bile duct dilatation, acute cholangitis.
2. Is external or internal drainage or internal and external drainage or metal endoprosthesis implantation used?
Interventional treatment when the patient is old and frail may shorten the operation time and reduce trauma. Single bile drainage is preferred. For multiple obstruction of intrahepatic bile ducts, two-branch drainage may be used. Immediate metal endoprosthesis implantation is not advocated when there is inflammation in the bile duct.
3.Timing of multi-branch drainage
When multiple intrahepatic bile duct obstruction occurs, in principle, multiple drainage is performed. However, according to the patient’s ability, 1-2 puncture drains can be selected first, and then multiple drains can be performed after the condition stabilizes. The second drainage is often placed after a week.
4.Timing of transbiliary endobiliary biopsy
It is often difficult to obtain pathological histological diagnosis for bile duct cancer that cannot be removed surgically. Percutaneous transhepatic percutaneous bile duct biopsy is an important examination tool. In elderly patients with severe disease, this examination should be avoided during the initial bile drainage, and then biopsy can be performed after the patient receives drainage and the condition is relieved, and metal stents can be implanted at the same time.
5.What kind of cases should be placed intra-biliary metal stents?
Generally, stents can be placed for both extrahepatic biliary obstruction and biliary obstruction in the hilar region. Placement of more than 3 stents should be avoided.
6. Treatment of drainage duct nonperfusion
Patients may develop fever and jaundice when external drains are not patent. If the drainage has been in place for more than 4 weeks, replacement of the drainage tube may be considered. If the time is short, use empty needle to draw the drainage tube. If it does not work, the catheter can be flushed with antibiotic saline (sensitive antibiotics or gentamicin, etc.), and postoperative bacteremia may occur.
7.The causes and treatment of abdominal pain in patients after drainage
The common reason is that the internal and external bile drains stimulate the sphincter of Oddis and cause spasm. Tumor invasion of the abdominal plexus and bile leakage causing limited peritonitis. Occasionally, local infection and abscess formation may occur, and bile duct infection is often combined with elevated leukocytes and bacteraemia.
8.Management of pancreatitis
Pancreatitis is one of the most common complications of PTBD with internal and external drainage, but it is mostly a mild edematous pancreatitis, manifested as a transient increase in pancreatic amylase. Abdominal pain or back pain, and malignant vomiting may be present. Fasting, pain relievers, antibiotics, and Sunnin may be given as treatment. Patients often return to normal within 2-5 days, and in individual cases with a longer duration of illness, abdominal CT should be done to understand whether there is exudative edema in the pancreas, and if necessary, gastrointestinal decompression can be placed. The cause of occurrence is unknown and is mostly related to irritation of the jugular abdomen by the drainage tube. In some cases, internal and external drains need to be changed to simple external drains to avoid continuous irritation of the jugular abdomen. If necessary, consult with a medical surgeon to seek advice on treatment.
9.When to replace the drainage tube and the replacement technique
After the drainage tube is placed, impurities such as debris and epithelial necrotic tissue in the bile and infected purulent material often cause the drainage tube to become incompetent, the drainage effect decreases, and jaundice and biliary tract infection occurs. Replacement of drainage tubes is often performed within 2-4 months. When replacing, it is often difficult to withdraw the old catheter because the old drainage catheter fixed wire is not easy to open, so the catheter should be cut before the insertion of the guidewire and then the replacement operation.
10.Stent restenosis
After implantation of bile duct stent, tumor growth, mucosal inflammatory edema, residual debris in bile and necrotic tissue can lead to intra-stent occlusion. In case of combined biliary tract inflammation, it is not advisable to place bile duct stent immediately. Bile drainage should be performed first and the infection should be controlled before stent implantation, otherwise restenosis may occur within a short period of time after stent implantation. To prevent tumor growth or bile duct endothelial hyperplasia from causing stenosis in the stent, after stent implantation, when the jaundice subsides to a total serum bilirubin ≤ 4 mg/dl (70 μmol/L), tumor-specific treatment should be used as much as possible: local intensity-modulated conformal radiotherapy or interventional perfusion chemotherapy. Inhibit tumor growth and endothelial proliferation.
11.Treatment of bile drainage bleeding
Bile drainage fluid is bloody bile or whole blood. A small amount of bloody bile may stop automatically after observation. A large amount of blood flow suggests active bleeding, the cause may be due to tumor tissue bleeding or bleeding from the punctal tract. In addition to administering drugs such as lithotripsy to stop bleeding from the punctal tract, the lateral hole of the drainage tube should be observed under fluoroscopy to see if it is completely in the bile duct, if part of the lateral hole is exposed in the punctal tract it should be corrected immediately. If the lateral hole is confirmed to be within the bile duct, the drainage tube can be closed for 24 hours on a trial basis. The patient’s blood pressure and hemoglobin drop should be closely monitored. If the blood pressure drops due to large amount of bleeding, blood volume supplementation and red blood cell input should be given.
12.What is the timing and method of treatment for tumor after drainage?
Generally speaking, radiotherapy is not recommended for hyperbilirubinemia. After the appearance of obstructive jaundice, appropriate measures should be taken immediately to reduce the yellowing, and PTBD is the commonly used technique to reduce the yellowing. Percutaneous percutaneous external bile drainage, internal and external drainage and internal drainage with metal endoprosthesis implantation are effective drainage methods. Patients often experience significant relief of skin pruritus within 24 hours of drainage. The jaundice gradually subsides. However, the rate of jaundice regression varies depending on the obstruction. Our experience suggests that the rate of jaundice regression is related to various factors, the longer the duration of jaundice, the slower the rate of jaundice reduction; the older the jaundice reduction, the slower the rate of jaundice reduction, the higher obstruction is slower than status obstruction, the combined bile duct infection is slower; the rate of jaundice reduction in poor liver function is slower; the rate of jaundice reduction due to intrahepatic disease is slower. It is generally believed that when jaundice subsides to 4 mg/dl, tumor-specific treatment is feasible. Local treatment is more meaningful than systemic chemotherapy. Local treatment mainly uses intensity-modulated conformal radiotherapy and drug local infusion chemotherapy. The use of in-stent brachytherapy after stent implantation can achieve better efficacy, and the main purpose is to inhibit the local growth rate of the tumor. Delaying stent opening time. As the drainage tube cannot tolerate the radiation, it should be replaced after the end of radiotherapy to prevent aging fracture.
13. Risks of interventional treatment in elderly patients with jaundice
The presence of obstructive jaundice requires interventional reduction of jaundice, and there is generally no age limit. However, special care should be taken in elderly patients over 70 years of age. In the early years of our work, the hospital mortality rate after intervention was as high as 24% in elderly people over 70 years of age due to factors such as poor immunity and weak compensatory capacity of the organism. Therefore, the correction of preoperative patient condition, the choice of anesthesia method, the timely management of postoperative complications, the basic principle of simplifying interventional treatment as much as possible and strong supportive treatment are the fundamental guarantee to reduce complications and mortality.
14.Principles of bile duct stent application, potential problems
Biliary stents should not exceed three in the same patient, and the more stents there are, the earlier restenosis appears. The timing of in-stent restenosis is often around six months after surgery. Multiple stents can lead to earlier restenosis. Metal stents should not be used during the acute phase of bile duct inflammation and should be placed after drainage to control infection. Metal stents cannot be moved or withdrawn after placement. Stents can often be repositioned within the stent after the development of in-stent stenosis. The stent should be placed across the pot belly with attention to the occurrence of pancreatitis, fasting after surgery, and blood tests for serum amylase after 6 hours, if there is an increase, appropriate treatment should be given. Retrograde flow of duodenal fluid into the bile duct increases the chance of biliary tract infection. In case of poor bile drainage by restenosis in the stent, fever and jaundice may appear, antibiotics should be given, and if necessary, re-PTBD drainage should be performed.
15.Treatment principles of benign biliary obstruction
Benign biliary obstruction should be treated with drainage, balloon dilation and drainage bile duct shaping
(1) Such as sclerosing cholangitis, first balloon dilatation and then drainage bile duct shaping, the so-called drainage bile duct shaping both from 8F to 10, 12, 14F drainage tube in order to replace once a month, and finally remove the drainage tube.
(2) For limited strictures caused by trauma or postoperative, ball dilation is the mainstay.
(3) For septic bile duct or cholecystitis drainage is the mainstay.
For congenital common bile duct cyst, surgery is the mainstay, and for combined suppuration, drainage is the mainstay.
16.Treatment principles of malignant biliary obstruction
Malignant bile duct obstruction should be placed on the basis of balloon dilation and stenting as much as possible. If there is difficulty in stenting, it can be drained first, and after jaundice is relieved, stenting can be considered on the basis of radiotherapy and chemotherapy.
(1) For the treatment of simple left or right branch or common bile duct obstruction, it is feasible to place stents by puncturing the left or right branch.
(2) For the involvement of the left and right hepatic duct bifurcations or both left and right hepatic ducts, stents should be placed by puncturing the left and right branches simultaneously.
(3) For patients with bifurcation of the left and right hepatic ducts or both left and right hepatic ducts, and with a large amount of ascites or partial resection of the right lobe of the liver, a T-stent should be placed by left branch puncture or a KISS stent should be placed by left branch puncture in conjunction with stent placement under ERCP.
(4) For patients with left and right hepatic duct bifurcation or both left and right hepatic ducts involved and partial resection of the left or square lobe of the liver has been performed, right branch puncture with T-stent placement or right branch puncture with ERCP sub-stent placement with KISS stent placement should be performed.
17. Conversation with patients and families, patient’s right to know
Interventional treatment with reduced yellowing is a high-risk treatment. The average in-hospital mortality rate is as high as 3-4%, and the mortality rate is higher than 20% in elderly people over 70 years old. Bleeding, infection, and liver and kidney failure are common causes of death. Families need to be made fully aware of this and it is necessary to reduce medical disputes afterwards.