Comparative Study Of Percutaneous Transhepatic Bile Drainage By One And Two Catheters In Patients With Malignant Hilar Biliary Strictures

BackgroundMalignant hilar biliary strictures(MHBS) is a common type of stricture of biliary tract,which occurs on the patients with primary tumor(hilar cholangiocarcinoma), adjacent tumor(such as hepatocellular carcinoma,gallbladder),or metastatic hilar lymphadenopathy(from lung cancer,breast cancer or gastrointestinal adenocarcinoma, and so on).Only approximate 40%of patients with hilar cholangiocarcinoma can be operated with a curative intent.Most patients with metastatic disease affecting the porta hepatis and invasive gallbladder or hepatocellular carcinoma causing hilar biliary strictures are not candidates for curative resection but for alleviative treatment. The tendency of many malignant tumors for intrahepatic extension and involvement of the biliary ducts may hinder adequate palliative drainage of large volumes of the liver.it is still controversial to establish method of drainage to this type of stricture.Chapter One:Comparison of the short-term effect of PTBD by one and two catheters in the typeⅡ～ⅣMHBSObjectiveTo compare the short-term effect of PTBD by one with two catheters in patients with typeⅡ～ⅣMHBS. Materials and methodsWe retrospectively analyzed the datas of 79 patients with typeⅡ～ⅣMHBS undergoing PTBD from January 2002 to May 2008 in Nanfang hospital,There were 47 men,32 women,32 to 86-year-old,with mean age 64.1±11.8 years.All the patients were performed CT or MRI examination to determine the extent of cholangiectasis, liver parenchyma invasion and the proportion of liver lobes.One catheter(group A)or two catheters(group B) were used for draining.The liver lobe with atrophy or parenchyma invasion was not choosed if one catheter was used.Group B included draining unilateral hepatic lobe by two catheters or metal stents,draining two isolated systems by one external drainage catheter passing through the strictures site between two intrahepatic bile ducts,and bilateral drainage.Internal/external drainage was performed if the guidewire could pass through the strictures in the procedure.Otherwise,external drainage would be performed temporarily until the inspissated bile had been discharged and the inflammatory edema of the bile duct had been relieved,then internal/external drainage catheters or metal stents would be inserted.A catheter should be inserted accompanying a metal stent to retain the puncture transfixation.One week later,the catheter could be extracted in the patient the cholangiography showed the metal stent was patent and dilated well.MHBS was classified according to Bismuth-Corlette categorization,The criterion of isolation in our practice is the situation in which cholangiography does not result in any opacification of the isolated system(s)or the situation in which isolated ducts are opacified with contrast during cholangiography,but can not be drained.All the patients were rechecked with cholangiography 1 week later to make certain the catheters were patent and in place.Drainage was defined as clinically effective if serum bilirubin decreased by greater than 30%and jaundice was palliated on follow-up visit.For patients in whom the serum bilirubin was not initially elevated, maintenance of a normal serum bilirubin was considered to indicate efficacy. Otherwise it was inefficient.Baseline characteristics data of the two groups were compared,including sex,mean age,type of hilar structure,the proportion of lobes,diagnosis,draining process(including external drainage,internal drainage, internal/external drainage),preoperative bilirubin level,preoperative liver function (Child score) and perioperative cholangitis.We divided the 79 patients intoⅡandⅢ～Ⅳtwo layers according to stricture classification and compared the influence of PTBD by one catheter with two catheters to the short-term effect,respectively.Results79 patients were included in our study.38 were drained by one catheter,including 22 men and 16 women,38 to 82-year-old,with mean age 64.4±11.9 years(group A). 41 were drained by two catheters,including 25 men and 16 women,32 to 86-year-old,with mean age 63.4±11.7 years(group B).In group A,the diagnosis was primary hilar cholangiocarcinoma in 34 patients,gallbladder cancer in 3 patients,and hepatocellular carcinoma in 1 patient.In group B,the diagnosis was primary hilar cholangiocarcinoma in 34 patients,gallbladder cancer in 1 patient,hepatocellular carcinoma in 1 patient,and Lymph node metastases in 5 patients.According to the Bismuth classification,typeⅡ,Ⅲa,Ⅲb,Ⅳstrictures was found in 22,4,8,4 patients in group A and 21,1,11,8 in group B respectively.CT or MRI displayed atrophie of left hepatic lobe in 14 patients in group A and 10 patients in group B respectively. External drainage,internal drainage,internal/external drainage was performed in 8,20,10 patients in group A and in 9,18,14 patients in group B.Group B included draining the right hepatic lobe by two internal/external catheters or metal instents in 3 patients,draining two isolated systems of the right lobe by a external drainage catheter passing through the strictures site between two intrahepatic bile ducts of the right hepatic lobe in 3 patients,and bilateral drainage in the other 35 patients.The preoperative total bilirubin was 16.6～634.5mmol/L,mean 262.4±158.7 mmol/L in group A and 51.0～548.0 mmol/L,mean 236.8±116.6 mmol/L in group B.Displace or occlusion of catheter was excluded by cholangiography 1 week later.PTBD was clinically effective in 59(73.8%) of the 79 patients,ineffective in 20(26.2%).15 of the 20 ineffective patients demonstrated a slow decline in serum bilirubin,which decreased by less than 30%in one week.3 patients showed a increase in serum bilirubin after PTBD.2 patients showed a significant decrease in serum bilirubin in 1 week but an ascendent tendency thereafter.2 typeⅢa strictures did not respond to initial PTBD by one catheter,yet did not respond to an additional PTBD.1 patient with ineffective drainage got an effective outcome after exchanging a 12F catheter.There were no statistically significant differences in the baseline characteristics such as sex (χ~2=0.078,P=0.780),mean age(t=0.239,P=0.812),type of hilar structure(χ~2 =1.244,P=0.537),the proportion of lobes(χ~2=1.446,P=0.229),diagnosis(χ~2=0.705, P=0.401),draining process(χ~2=0.718,P=0.698),preoperative bilirubin level (t=0.822,P=0.414),preoperative liver function(t=0.287,P=0.755)and perioperative cholangitis(χ~2=0.117,P=0.732) between the group A and B.There were no statistically significant differences in the short-term effect between the two different draining methods in both typeⅡand typeⅢ～Ⅳ(P value was 0.069 and 0.722 respectively).The layer OR value was 5.429 and 1.364,respectively.The 95% confidence interval of OR value was 0.995～29.606 and 0.316～5.892.Both included 1.There was no statistically significant difference in the OR value between the two different group(χ~2=1.498,P=0.221).There was no statistically significant difference in the short-term effect between the two different draining methods after excluding the contribution of the layer factor(χ~2=3.136,P=0.074).ConclusionThe short-term effect of PTBD to the patients with typeⅡ～ⅣMHBS is nothing to do with the use of one or two catheters(metal stents).Chapter Two:Comparison of cholangitis after PTBD by one and two catheters in the typeⅡ～ⅣMHBS.ObjectiveTo analyze the relationship of cholangitis after PTBD to the stricture type and drainage by one or two catheters(metal stents) in patients with typeⅡ～ⅣMHBS,and explore the method to anti-infective therapyMaterials and methodsWe reviewed the occurrence of cholangitis after PTBD in above 79 patients and compared the cholangitis after PTBD by one with two catheters(metal stents) after excluding the cholangitis caused by hemobilia and biopsy.The criteriors of cholangitis were recurring chills,fever or low temperature,T≥38.5℃,or≤36℃, WBC≥10X10~9/L,or NEU%≥75%,with positive bacterial culture,excluding infection resulted from other causes.The criterior of cholangitis after PTBD included cholangitis emerging after PTBD without preoperative cholangitis,persisting more than 24 hours after PTBD and having been exist but symptoms aggravated after PTBD with increase of WBC or NEU%.The baseline characteristics data such as sex,mean age,diagnosis,type of hilar structure,draining process(including exterior drainage,interior drainage and internal/external drainage),preoperative liver function(child score) and preoperative cholangitis of the two groups(group A designates drainage by one catheter or metal stent,group B designates drainage by two catheters or metal stents) were compared.The eligible patients were divided intoⅡandⅢ～Ⅳtwo groups according to Bismuth-Corlette categorization.We looked the stricture type as the layer factor and compared the rate of the cholangitis after PTBD of the two different draining methods.Meanwhile,we compared the rate of the cholangitis after PTBD of the two stricture type.All the patients with cholangitis after PTBD were performed bacterial culture and drug susceptibility test.Results4 complicating hemobilia and 1 performing biopsy should be eliminated from our study.22 of 74 patients(22/74,29.7%) experienced early cholangitis after PTBD,including 8 patients(8/42,19%) with typeⅡstricture and 14 patients(14/32, 43.8%) with typeⅢ～Ⅳstricture,13 patients(13/36,36.1%) in group A and 9 patients(9/38,23.7%) in group B.12 of 18(12/16,67%) with preoperative cholangitis were improved by PTBD and anti-infective therapy.6 were aggravated after PTBD(6/18,33%).16 of 56 patients without preoperative cholangitis presented cholangitis symptom after PTBD(16/56,28.6%).All the patients were improved by postoperative anti-infective therapy in the duration of hospital stay.There were no statistically significant differences in the baseline characteristics such as sex(χ~2 =0.037,P=0.848),meanage(t=0.206,P=0.838),diagnosis(χ~2=0.781,P=0.377),type of hilar structure(χ~2=0.542,P=0.462),draining process(χ~2=0.731,P=0.694),preoperative liver function(t=0.112,P=0.911)and preoperative cholangitis(χ~2=0.168,P=0.682)between group A and B.There was statistically significant differences(χ~2=5.305,P=0.021) in different stricture types.There were no statistically significant differences between the two groups in both typeⅡand typeⅢ～Ⅳ(P value was 0.7 and 0.178 respectively). The layer OR value was 0.6 and 0.375,respectively.The 95%confidence interval of OR value was 0.123～2.917 and 0.089～1.587.Both included 1.There was no statistically significant difference in the OR value between the two different groups(χ~2 =0.186,P=0.667).There was no statistically significant difference in the cholangitis after PTBD between the group A and B after excluding the contribution of the layer factor(χ2=2.028,P=0.154).The main pathogens of biliary infection were E.coli,Pseudomonas aeruginosa and Enterococcus.Gram-negative bacterium was relatively sensitive to cefoperazone/sulbactam,amikacin,imipenem and Meropenem. Gram-positive bacterium was relatively sensitive to cefoperazone/ sulbactam, furadantin,teicoplanin,vancomycin.There were not recurrent cholangitis after anti-infective therapy for 5 to 10 days.30-day mortality was zero.ConclusionWith regard to typeⅡ～ⅣMHBS,there is statistically differences between two different Bismuth-Corlette categorization but no statistically differences between drainage by one and two catheters or metal stents in the incidence of cholangitis after PTBD.