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As there are effective surgical and endoscopic methods to alleviate obstructive jaundice, medical palliation is typically only required as a temporizing measure prior to definitive palliation. Topical agents are generally ineffective for pruritus secondary to obstructive jaundice. Antihistamines are often the initial treatment modality and although there is little supportive evidence, the sedating effects of H1 antihistamines are often beneficial for nocturnal pruritus. Mirtazapine, a selective norepinephrine reuptake inhibitor with antihistaminic properties, as well as opioid receptor antagonists have been associated with improvement in pruritus secondary to malignant cholestasis. Cholestyramine, a bile acid sequestrant, is also occasionally administered, but is of minimal benefit as the duct obstruction results in little bile entering the gastrointestinal tract for binding and subsequent excretion.
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Nonoperative palliation of obstructive jaundice can involve either endoscopic biliary stent placement, typically by gastroenterology specialists or surgeons with advanced endoscopic skills, or percutaneous transhepatic biliary drainage catheter placement by interventional radiology. As percutaneous transhepatic biliary drainage is more invasive and painful, and has a higher complication rate, this procedure is reserved for clinical situations in which endoscopic stent placement is not an option. Malignant strictures of the mid to lower bile ducts are usually amenable to endoscopic drainage, while strictures involving the hilum can be more challenging and may require a percutaneous approach.
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ENDOSCOPIC BILIARY STENT PLACEMENT
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There are several randomized controlled trials comparing plastic endobiliary stents to surgical biliary bypass in patients with pancreatic cancer requiring palliation of obstructive jaundice.15 The risk of complications was higher in the surgical group but this was offset by a higher rate of recurrent biliary obstruction in the patients undergoing endoscopic plastic stent placement. These trials were included in a recent meta-analysis demonstrating a 40% decrease in complications but 19-fold increased risk of recurrent biliary obstruction with stent placement.15 Table 143-1 contains the prospective randomized trials comparing the two approaches with the corresponding outcomes. In addition, there are also several randomized controlled trials comparing self-expanding metallic stents (SEMS) to plastic stents, and a recent meta-analysis of these trials demonstrated that the risk of recurrent obstruction with SEMS was approximately half that of plastic stents.15,16 The obvious implication of these studies is that SEMS would likely improve upon the high risk of recurrent obstruction when compared to surgical bypass. A single randomized controlled trial of surgery compared to SEMS has been performed for patients with metastatic pancreatic cancer. Although limited by size (N = 30) and not inclusive of patients with locally advanced disease, the study demonstrated improved cost and quality-of-life scores at 60 days for patients undergoing endoscopic drainage.17
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Various recommendations for stent type have been suggested based on prognostication. As an example, the European Society of Gastrointestinal Endoscopy recommends that if patient life expectancy is shorter than 4 months, initial insertion of a plastic stent is most cost-effective, but if expected survival is longer than 4 months then initial insertion of a SEMS is more cost-effective.18 Importantly, self-expanding metallic stents do not necessarily preclude subsequent pancreaticoduodenectomy in patients ultimately considered candidates for resection. Although it is always prudent to involve the surgeon in discussions prior to endobiliary stent placement, a short-segment stent can typically be removed at the time of surgery and is often within the field of resection. There is also some debate as to the application of covered versus uncovered SEMS. The current standard of care for endoscopic stenting favors placement of uncovered SEMS, as randomized trials indicate that covered stents are associated with higher rates of migration and other adverse events without an associated increase in stent patency.19
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PERCUTANEOUS TRANSHEPATIC BILIARY CATHETER PLACEMENT
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Percutaneous transhepatic biliary drainage is most often performed by an interventional radiologist under conscious sedation with local anesthetic administration. Unilateral drainage is often sufficient to provide symptomatic palliation of obstructive jaundice. Technical decision making by the radiologist can include approaching the side with less disease or away from an atrophic hemi-liver. The right-sided approach may also benefit from an easier angle of catheter placement and avoidance of the fluoroscopic field, while the left-sided approach may be less painful and easier for the patient to manage than a right intercostal catheter. Technical details involve first confirming access to the bile ducts through aspiration of bile or through injection of contrast and performance of a percutaneous transhepatic cholangiogram. External drainage is performed when a catheter is placed above the site of obstruction and connected to gravity drainage. External drainage alone is not ideal as patients are prone to infections, dehydration, and electrolyte abnormalities. External–internal drainage is performed when a catheter is placed through the obstruction, and allows for at least some drainage of bile into the duodenum. Although external loss of bile can be improved through this approach, patients are still prone to developing cholangitis. Strictures that do not allow immediate external–internal drainage may require a period of external drainage and a second procedure to allow passage through the stricture. Finally, conversion to internal drainage is completed when an internal stent is placed through the stricture, allowing bile drainage into the duodenum, without the need for an external catheter. Another option when an internal–external catheter is in place is to perform a combined transhepatic and endoscopic procedure, also known as a rendezvous procedure. The rendezvous procedure allows for the endoscopist to place an endoscopic stent via a wire passed through the transhepatic catheter, which may allow for decreased risk of bleeding and bile leakage compared to transhepatic dilation for stent placement. Postprocedural care for patients undergoing transhepatic drainage procedures is important for surgeons, as patients undergoing interventional procedures are often placed on surgical inpatient services. Patients should be hospitalized for at least 24 hours following transhepatic drainage to monitor for complications, and catheters should be flushed with sterile saline every 12 to 24 hours.20 Patients should be well educated on the signs and symptoms of cholangitis including pain, fever, nausea/vomiting, and malaise, and should be informed that pericatheter leakage can indicate catheter occlusion.20 Complications of transhepatic catheter placement can include hemobilia, cholangitis, pancreatitis, pericatheter leakage, pneumothorax, and cholecystitis due to blockage of the cystic duct. Technical and drainage success rates are routinely reported as greater than 80% and mortality rates vary widely, depending on the indication for placement and patient functional status and comorbidities.
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Only a minority of patients with obstructive jaundice require surgical palliation. Potential surgical candidates include patients for whom an endoscopic approach is not possible, patients who live remote from endoscopic and interventional expertise, and patients with concomitant duodenal obstruction. Consideration should also incorporate prognosis and performance status. Local expertise can factor heavily into the risk–benefit analysis, as patients who fail an endoscopic attempt at palliation must be considered for an interventional percutaneous procedure that may require multiple procedures to drain both sides of the liver without a guarantee that the drain can be internalized. The debate regarding the optimal approach to palliation remains active as demonstrated by a recent meta-analysis of randomized trials revealing no significant difference in major complications or death between biliary stent placement and surgical bypass, albeit with significantly lower rates of recurrent biliary obstruction in the surgical bypass group.21 Regardless, the most frequent current indication for surgical palliation of biliary obstruction is the patient identified with unresectable disease at laparotomy. Roux-en-Y hepaticojejunostomy/choledochojejunostomy is the most widely accepted surgical technique, while cholecystojejunostomy and choledochoduodenostomy are infrequently performed due to concerns over ineffective palliation and recurrent jaundice with tumor progression. After cholecystectomy has been performed, the common bile/hepatic duct is dissected and transected. A 60-cm Roux-en-Y limb is created and an end to side hepaticojejunostomy is performed in an interrupted fashion with 4-0 absorbable suture. Other suitable options include a loop hepaticojejunostomy rather than a roux limb. Also, some authors elect to perform a side-to-side hepaticojejunostomy without dividing the bile duct. A loop gastrojejunostomy can be added to either approach if there are coexisting concerns regarding the presence or development of duodenal obstruction.
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Cholecystojejunostomy is frequently described in laparoscopic approaches to biliary bypass but is infrequently performed as an open operation due to the requirement for cystic duct patency. Although endoscopic studies of the hepatocystic junction suggest only half of patients with obstructive jaundice will be candidates based on cystic duct patency, recent case reports on laparoscopic cholecystojejunostomy have reported low rates of recurrent biliary obstruction.22,23 Perhaps the best evidence regarding this issue can be found from a study that utilized Surveillance, Epidemiology, and End Results (SEER) Medicare claims data and demonstrated that patients treated with a gallbladder bypass had a subsequent biliary intervention rate at 1 year of 7.5%, compared to 2.9% for patients treated with a bile duct bypass.24 The discrepancy in the rates of recurrent jaundice between the reports of open gallbladder bypass and newer reports of laparoscopic gallbladder bypass will need to be addressed prior to considering the laparoscopic approach a valid option. Similarly, choledochoduodenostomy is not routinely utilized for palliation due to concerns regarding recurrent jaundice with tumor progression. There are few studies comparing this approach to other forms of biliary bypass; however, small series suggest a low rate of recurrence and cholangitis.25,26