Comparison of the Clinical Outcomes of Suprapapillary and Transpapillary Stent Insertion in Unresectable Cholangiocarcinoma with Biliary Obstruction.
- 作者列表："Shin J","Park JS","Jeong S","Lee DH
BACKGROUND AND AIMS:To prevent stent migration, transpapillary stent placement has been recommended for the endoscopic treatment of malignant hilar biliary stricture. However, recent studies have suggested that placement above the papilla achieves better results, because it is believed to prevent reflux and prolong stent patency. The aim of this study was to compare the efficacy and safety aspects of transpapillary and suprapapillary stent placement. In addition, the success rates of stent revision were evaluated. MATERIALS AND METHODS:The medical records of 73 patients with hilar cholangiocarcinoma who underwent endoscopic metal stent insertion between January 2005 and December 2015 were retrospectively reviewed. Patients were assigned by stent location to a suprapapillary (S group; N = 44) or a transpapillary (T group; N = 29) cohort. Clinical outcomes, stent patency, adverse events, and revision success rates were compared between the two study groups. RESULTS:Patency periods were similar in the two groups (S; 140 vs. T; 157 days; P = 0.732). Rates of stent obstruction in the S and T groups were 63.4% and 55.2%, respectively (P = 0.470). An adverse event occurred in 15 (20.5%) of total study subjects, with no significant intergroup difference. The endoscopic revision success rate was significantly higher in the T group (P = 0.01), and the time required for revision tended to be shorter in the T group. CONCLUSIONS:The effectiveness and safety of suprapapillary and transpapillary stent insertion were found to be similar, but the success rate of endoscopic revision was significantly higher for the T group. Therefore, we recommend that transpapillary stent placement be considered for patients with hilar cholangiocarcinoma and biliary obstruction.
背景与目的: 为防止支架移位，内镜下经乳头支架置入术已被推荐用于肝门部恶性胆道狭窄的治疗。然而，最近的研究表明，放置在乳头上方可以获得更好的效果，因为它被认为可以防止反流并延长支架的通畅性。本研究的目的是比较经乳头和乳头上支架置入的有效性和安全性。此外，评估了支架翻修的成功率。 材料与方法: 回顾性分析2005年1月至2015年12月期间73例肝门部胆管癌患者的内镜下金属支架置入术的临床资料。根据支架位置将患者分配到毛细血管上 (S组; N = 44) 或毛细血管上 (T组; N = 29) 队列。比较两组患者的临床结局、支架通畅性、不良事件和翻修成功率。 结果: 两组的通畅期相似 (S; 140对T; 157天; P = 0.732)。S组和T组的支架阻塞率分别为63.4% 和55.2% (p = 0.470)。不良事件发生在15名 (20.5%) 总研究受试者中，无显著组间差异。T组的内镜翻修成功率明显较高 (p = 0.01)，T组翻修所需时间趋于较短。 结论: 经乳头和乳头上支架置入的有效性和安全性相似，但T组的内镜翻修成功率明显较高。因此，我们建议肝门部胆管癌和胆道梗阻患者应考虑经乳头支架置入术。
METHODS:AIM:To investigate the value of contrast enhanced ultrasound with high resolution linear transducers (HF-CEUS) for differential diagnosis of focal fundal gallbladder (GB) wall thickening. METHODS:A total of 32 patients with incidentally detected focal fundal GB wall thickening were included. After conventional B mode ultrasound (BMUS) examinations, HF-CEUS were performed with a 7.5-12 MHz 9L4 linear transducer (S2000 HELX OXANA unit, Siemens). Two radiologists independently reviewed the HF-CEUS enhancement patterns to determine the differential features between malignancy and benignity with a five-point confidence scale. The diagnostic accuracy of BMUS and HF-CEUS for GB wall thickening was compared. The final gold standard was surgery with histological examination. RESULTS:Final diagnoses included GB adenocarcinoma (n = 16), adenomyomatosis (n = 12), Xanthogranulomatous (n = 2) and cholecystitis (n = 2). HF-CEUS features associated with GB adenocarcinoma including arterial phase inhomogeneous hyperenhancement, venous phase hypoenhancement and disruption of GB wall layer structure (P < 0.05). Two small (5 mm) liver metastasis were confirmed by HF-CEUS during the late phase liver sweep as hypoenhanced lesions. Nonenhanced Rokitansky-Aschoff sinuses were clearly observed in 83.3% focal adenomyomatosis. Overall sensitivity, specificity and accuracy for differentiation between malignant and benign focal fundal GB wall thickening of HF-CEUS and BMUS were 84.3% vs 53.1%, 90.6% vs 59.3% and 87.5% vs 56.2% (P < 0.005). CONCLUSIONS:CEUS performed with high frequency linear transducers could be a useful alternative in the differential diagnosis of focal fundal GB wall thickening on conventional ultrasound.
METHODS::Small-for-size graft (SFSG) syndrome after living donor liver transplantation (LDLT) is the dysfunction of a small graft, characterized by coagulopathy, cholestasis, ascites, and encephalopathy. It is a serious complication of LDLT and usually triggered by excessive portal flow transmitted to the allograft in the postperfusion setting, resulting in sinusoidal congestion and hemorrhage. Portal overflow injures the liver directly through nutrient excess, endothelial activation, and sinusoidal shear stress, and indirectly through arterial vasoconstriction. These conditions may be attenuated with portal flow modulation. Attempts have been made to control excessive portal flow to the SFSG, including simultaneous splenectomy, splenic artery ligation, hemi-portocaval shunt, and pharmacological manipulation, with positive outcomes. Currently, a donor liver is considered a SFSG when the graft-to-recipient weight ratio is less than 0.8 or the ratio of the graft volume to the standard liver volume is less than 40%. A strategy for transplanting SFSG safely into recipients and avoiding extensive surgery in the living donor could effectively address the donor shortage. We review the literature and assess our current knowledge of and strategies for portal flow modulation in LDLT.
METHODS:BACKGROUND:Seasonal variation in the occurrence of medical illnesses reflects the effect of the environment, provides insight into pathogenesis, and can assist health care administrators in allocating resources accordingly. Seasonal variation has been reported in various infectious and surgical diseases, but has been rarely studied in acute cholecystitis. Our objective was to study seasonal variation in acute cholecystitis at our institution. METHODS:We performed a retrospective analysis of patients who underwent cholecystectomy for acute cholecystitis from January 1988 to December 2018. Chi-square goodness-of-fit test was used to analyze seasonality of acute cholecystitis adjusting for variation in number of days between seasons. The number of days for seasons were taken as 92, 92, 91, and 90.25 for spring, summer, fall, and winter, respectively. RESULTS:Overall, 3924 patients underwent cholecystectomy for acute cholecystitis during the study period. The frequency of cholecystectomies performed varied between months (minimum February n = 259, maximum July n = 372, P < 0.001) and seasons (minimum winter n = 789, maximum summer n = 1101 P < 0.001). Age and gender distribution across months and seasons was similar (P > 0.05). CONCLUSIONS:Our findings confirm seasonal variation in occurrence of acute cholecystitis with summer season witnessing the most and the winter season encountering the least patients with acute cholecystitis. Validation of our findings through prospectively collected data at national level is the way forward.