Mo1099 Cost-Effectiveness Analysis of Endoscopic Ultrasound-Guided Biliary Drainage (EGBD) Versus Percutaneous Transheptatic Biliary Drainage (PTBD) for Malignant Biliary Obstruction After Failed ERCP (original) (raw)
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Trauma Surgery & Acute Care Open, 2018
background Patients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making, biliary point-of-care ultrasound (POCUS) in the emergency department has emerged as a diagnostic tool. The purpose of this study is to analyze the usefulness of POCUS in predicting the need for surgical intervention in biliary disease. Methods A retrospective study of patients visiting the emergency department who received a biliary POCUS from December 1, 2016 to July 15, 2017 was performed. The physician interpretations of the biliary POCUS scans were collected, as well as data from the electronic health records including lab values, the subsequent use of diagnostic imaging, surgical consultation or intervention, and 28 days follow-up for representation or complication. results Two hundred and eighty-three patients were identified as having received biliary POCUS. Of the patients referred to general surgery who received biliary POCUS 43% received a cholecystectomy. For the outcome of cholecystectomy, the finding of gallstones on POCUS was 55% sensitive (95% CI 40% to 70%) and 92% specific (95% CI 87% to 95%). A sonographic Murphy's sign was 16% sensitive (95% CI 7% to 30%) but 95% specific (95% CI 92% to 97%) and, gallbladder wall thickness was 18% sensitive (95% CI 9% to 33%) and 98% specific (95% CI 95% to 99%). Patients who received POCUS but did not proceed to confirmatory radiology department imaging had a shorter length of stay (433 min ± 50 min vs. 309 min ± 30 min, P<0.001). Discussion Point-of-care biliary ultrasound performed by emergency physicians provides timely access to diagnostic information. Positive findings of gallstones and increased gallbladder wall thickness are highly predictive of the need for surgical intervention, and use of POCUS is associated with shorter ER visits. Level of evidence Retrospective cohort study, level III. Contributors RH, FM, RL, DT, and NP conceptualized, designed, supervised, and allocated resources for this research. JDV, JK, and FM completed the data collection. RH and JDV performed the statistical analysis. All authors contributed to the analysis of the results. All authors contributed to the writing of the final article text.
Preoperative Biliary Drainage in Patients with Obstructive Jaundice: History and Current Status
Journal of Gastrointestinal Surgery, 2009
Rationale Preoperative biliary drainage (PBD) has been introduced to improve outcome after surgery in patients suffering from obstructive jaundice due to a potentially resectable proximal or distal bile duct/pancreatic head lesion. In experimental models, PBD is almost exclusively associated with beneficial results: improved liver function and nutritional status; reduction of systemic endotoxemia; cytokine release; and, as a result, an improved immune response. Mortality was significantly reduced in these animal models. Human studies show conflicting results. Findings For distal obstruction, currently the "best-evidence" available clearly shows that routine PBD does not yield the appreciated improvement in postoperative morbidity and mortality in patients undergoing resection. Moreover, PBD harbors its own complications. However, most of the available data are outdated or suffer from methodological deficits. Conclusion The highest level of evidence for PBD to be performed in proximal obstruction, as well as over the preferred mode, is lacking but, nevertheless, assimilated in the treatment algorithm for many centers. Logistics and waiting lists, although sometimes inevitable, could be factors that might influence the decision to opt for PBD, as well as an extended diagnostic workup with laparoscopy (on indication) or scheduled preoperative chemotherapy.
A Stop-gap Procedure in the Management of High Risk Patients with Acute Biliary Tract Diseases
2018
Introduction: Acute biliary tract diseases constitute a major portion of gastrointestinal disorders throughout world and include acute cholecystitis and acute cholangitis. Study aimed to assess efficacy and safety of percutaneous cholecystostomy (PC) in high risk patients with acute biliary tract diseases. Material and methods: The study was carried-out in high risk patients unfit for general anaesthesia with acute calculous/ acalculous cholecystitis, empyema/mucocele gallbladder and patients having acute cholangitis with failed ERCP and PTC. The catheter position was established by a cholecystogram done postoperatively. Results: 36 patients underwent ultrasound guided PC. 66.7% (24) had empyema-gallbladder, 16.7% (6) had mucocele of gallbladder and 11.1% (4) patients were diagnosed as acute calcular cholecystitis 5.6% (2) patients had acute pyogenic cholangitis with failed ERCP. All the patients had atleast one uncontrolled comorbidiy and none was fit for general anaesthesia. The post-procedure hospital stay was 3 to 6 days. Rapid clinical and biochemical improvement was observed in all patients after the procedure. There was statistically significant pain relief and reduction in mean total leukocyte count within 48 hours of procedure. 32 out of 36 procedures were done via trans-peritoneal route. Bile cultures yielded growth of E Coli in 10 (28.8%) patients, klebsela in 8 (22.86%), pseudomonas aeruginosa in 6 (17.14%) and Proteus mirabilis in 11.43% of patients. No major complication was recorded in our study. Catheter was removed after a mean of 25.25 days. Conclusion: USG guided PC is a safe and effective stopgap procedure for treating high-risk patients with acute biliary tract diseases. Once the acute symptoms diminish or resolve, it should be followed by elective surgery.
Pancreatology, 2019
Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an important therapeutic modality in acute biliary pancreatitis (ABP) cases with cholangitis or ongoing common bile duct obstruction. Theoretically, inflammation of the surrounding tissues would result in a more difficult procedure. No previous studies examined this hypothesis. Objectives: ABP and acute cholangitis (AC) without ABP cases were compared to assess difficulty of ERCP. Methods: The rate of successful biliary access, advanced cannulation method, adverse events, cannulation and fluoroscopy time were compared in 240 ABP cases and 250 AC cases without ABP. Previous papillotomy, altered gastroduodenal anatomy, and cases with biliary stricture were excluded. Results: Significantly more pancreatic guidewire manipulation (adjusted odds ratio (aOR) 1.921 [1.241 e2.974]) and prophylactic pancreatic stent use (aOR 4.687 [2.415e9.098]) were seen in the ABP than in AC group. Average cannulation time in the ABP patients (248 vs. 185 s; p ¼ 0.043) were longer than in AC cases. No difference was found between biliary cannulation and adverse events rates. Conclusion: ERCP in ABP cases seem to be more challenging than in AC. Difficult biliary access is more frequent in the ABP cases which warrants the involvement of an experienced endoscopist.
Clinical & Experimental Hepatology, 2022
Aim of the study: Most of the malignancies leading to obstructive jaundice are diagnosed too late when they are already advanced and inoperable, with palliation being the only treatment option left. Due to progressing hyperbilirubinaemia with its consequent adverse effects, biliary drainage must be established even in advanced malignancies. This study aims to investigate and analyse factors that affect clinical outcomes of percutaneous trans-hepatic biliary drainage (PTBD) in patients with obstructive jaundice due to advanced inoperable malignancy, and identify potential predictors of patient survival. Study design: Observational retrospective cohort study. Material and methods: Baseline variables and clinical outcomes were evaluated in 108 consecutive patients treated with PTBD. The study's primary endpoints were significant bilirubin level decrease and survival rates. Secondary endpoints included periprocedural major and minor complication rates and catheter primary and secondary patency rates. Results: PTBD was technically successful and bile ducts were successfully drained in all 108 patients. Median serum bilirubin level, which was 282 (171-376) μmol/l before drainage, decreased significantly, to 80 (56-144) μmol/l, 15 days after stent placement (p < 0.001). Patient survival ranged from 3 to 597 days and the overall (median) survival time following PTBD was 168 days (90-302). The 1, 3, 6, 12 and 18-month survival rates were 96.3%, 75.9%, 48.1%, 8.3% and 1.9%, respectively. Multivariate analysis revealed that liver metastases and alkaline phosphatase were significantly associated with mortality. The overall complication rate was 9.3%. Conclusions: PTBD is a safe and effective method to relieve jaundice caused by advanced inoperable malignant disease. Careful patient selection is necessary when introducing PTBD in order to avoid invasive procedures in patients with a poor prognosis.
Materia Socio Medica, 2019
Introduction: Cancelling elective procedures on the day of surgery presents a constant problem in all higher-level medical facilities, and the research of causes, consequences and possible solutions is the duty of every facility in order to enhance the quality of healthcare services. Methods: This prospective study included all patients that were scheduled for surgery from March 2016 to November 2018 in the operating rooms at our Department of Surgery, including both performed and cancelled cases. Cases by different surgical departments (general surgery, gynecology, orthopedics, urology, plastic surgery, ophthalmology and otorhinolaryngology) were all included. Results: Out of 8201 planned elective procedures from March 2016 to November 2018 at the General Hospital "Abdulah Nakas", 7825 cases were performed and 376 cases (4.58%) were cancelled on the day of surgery. The most common reasons for cancelling a surgical procedure on the day of surgery were: lack of time to perform surgery, (33.51%), surgery cancelled due to medical/anesthetic reasons, (31.38%), surgical procedure cancelled by the surgeon on the day of surgery, (11.97%). Conclusion: This study has shown that the percentage of elective cases cancelled on the day of surgery at our institution stands at an acceptable 4.58%. The most common reasons for case cancellation on the day of surgery were identified. The majority of reasons for cancellation were avoidable, which means that appropriate steps could contribute to lowering the percentage of cancelled elective cases and an improved quality of healthcare services.
Journal of gastroenterology, 2010
Background We aimed to determine the relationship between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis, using the Japanese administrative database associated with the diagnosis procedure combination (DPC) system. Methods A total of 8698 patients with endoscopic biliary drainage were referred to 654 hospitals. We corrected patients’ data from the database to compare risk-adjusted length of stay (LOS) and drainage-related complications in relation to the hospital volume. Hospital volume was categorized into three groups based on number of cases during the study period: low-volume hospitals (LVHs; <16 cases), medium-volume hospitals (MVHs; 16–32 cases), and high-volume hospitals (HVHs; >32 cases). Results Significant variation in mean LOS was observed between hospital volume categories (26.8 ± 22.6 days in LVHs vs. 23.3 ± 21.5 days in MVHs vs. 19.7 ± 17.2 days in HVHs, P < 0.001). There was a significant difference with regard to complications of endoscopic biliary drainage (5.6% in LVHs vs. 4.3% in MVHs vs. 3.2% in HVHs, P < 0.001). Multiple linear regression analysis revealed that hospital volume was most significantly associated with a decrease in risk-adjusted LOS. The standardized coefficient of MVHs was −0.155, whereas that of HVHs was −0.802. Multiple logistic regression analysis showed that hospital volume decreased the relative risk of drainage-related complications. The odds ratio (OR) of MVHs was 0.764 [95% confidence interval (CI), 0.604–0.965], whereas the OR of HVHs was 0.561 (95% CI, 0.434–0.725). Conclusions There was a significant association between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis.
Therapeutic Biliary Endoscopy: Experience at a Service Hospital
Medical journal, Armed Forces India, 1998
Therapeutic Biliary Endoscopy (TBE) is becoming a popular mode of treatment for patients with obstructive jaundice. This paper highlights our early experience of TBE at Armed Forces Medical College and Command Hospital (SC), Pune with this mode of treatment. TBE was used as a primary therapeutic option in 46 patients with obstructive jaundice. The age of the patients ranged from 11 to 80 (mean and SD:45.5 ± 16) years and majority 29 (63%) were males. The cause of obstructive jaundice in these patients was choledocholithiasis (n=31), benign biliary stricture (n=8), post cholecystectomy recurrent stones (n=3), carcinoma of pancreas (n=3) and papillary stenosis (n-1). Endoscopic Sphincterotomy (ES) was technically successful in all the 46 patients and brought prompt symptomatic relief in 43 patients. Sixteen patients (34.8%) required additional drainage such as stenting or nasobiliary drain. In patients with choledocholithiasis, bile duct could be cleared of stones in 29 (93.5%) patien...
Alimentary Pharmacology and Therapeutics, 2002
This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The health intervention considered in the study was antibiotic prophylaxis performed prior to endoscopic retrograde cholangiopancreatography (ERCP) in patients with obstructive jaundice. Type of intervention Antibiotic prophylaxis. Economic study type Cost-effectiveness analysis. Study population The study population comprised patients older than 15 years of age, with obstructive jaundice, defined as total bilirubin greater or equal to 2.5 ml/dL or, in the absence of documented bilirubin, having frank jaundice documented by physical examination at the time of ERCP. Patients were excluded if they had received antibiotics other than single-dose prophylaxis during the 7 days prior to ERCP or had received antimicrobial drugs during or following ERCP based on ERCP findings or for a febrile illness other than biliary sepsis or cholangitis.