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ORIGINAL ARTICLE
Year : 2018  |  Volume : 14  |  Issue : 12  |  Page : 1158-1162

Percutaneous transhepatic cholangial drainage combined with percutaneous endoscopic jejunostomy for maintaining nutrition state in patients with advanced ampullary neoplasms


Department of General Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming 650101, Yunnan, China

Date of Web Publication11-Dec-2018

Correspondence Address:
Pengyuan Xu
Department of General Surgery, The Second Affiliated Hospital of Kunming Medical University, No. 374 Dianmian Avenue, Kunming 650101, Yunnan
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.199788

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 > Abstract 


Purpose: To investigate the role of percutaneous transhepatic cholangial drainage (PTCD) combined with percutaneous endoscopic jejunostomy (PEJ) in maintaining the nutrition state in patients with advanced ampullary neoplasms.
Materials and Methods: Sixty patients who suffered from advanced ampullary neoplasms and could not tolerate internal drainage operation or biliary stent placement were enrolled. After PTCD, PEJ was implemented, and then the enteral nutrient solution + bile were instilled through PEJ tube for enteral nutrition support. Before and 1, 2, 3, and 4 weeks after surgery, the body weight, bilirubin, liver function, nutritional status, and immunologic function indexes were detected and compared.
Results: All patients had successfully completed PTCD combined with PEJ, and no serious complication occurred. The body mass index of the patients from 4 weeks after surgery was significantly higher than before (P < 0.05). From 2 weeks, both serum total bilirubin and direct bilirubin levels were significantly lower than before (P < 0.05). From 1 week, both alanine aminotransferase and aspartate aminotransferase levels were significantly lower than before (P < 0.05); from 2 weeks, the level of gamma-glutamyl transferase was significantly lower than before (P < 0.05). From 1 week, the levels of albumin, transferrin, and prealbumin were significantly increased compared with before (P < 0.05), and serum CD3+ cell content, CD4+ cell content, and CD4+/CD8+ ratio were significantly improved compared with before (P < 0.05).
Conclusion: PTCD combined with PEJ is a safe and effective method for maintaining nutrition state in patients with advanced ampullary neoplasms.

Keywords: Ampullary neoplasms, nutrition, percutaneous endoscopic jejunostomy, percutaneous transhepatic cholangial drainage


How to cite this article:
Sun Y, Li W, Sun D, Li S, Xu Q, Li Y, Lin Y, Qi Y, Yang T, Su K, Cen Y, Chen X, Xu P. Percutaneous transhepatic cholangial drainage combined with percutaneous endoscopic jejunostomy for maintaining nutrition state in patients with advanced ampullary neoplasms. J Can Res Ther 2018;14, Suppl S5:1158-62

How to cite this URL:
Sun Y, Li W, Sun D, Li S, Xu Q, Li Y, Lin Y, Qi Y, Yang T, Su K, Cen Y, Chen X, Xu P. Percutaneous transhepatic cholangial drainage combined with percutaneous endoscopic jejunostomy for maintaining nutrition state in patients with advanced ampullary neoplasms. J Can Res Ther [serial online] 2018 [cited 2019 Sep 17];14:1158-62. Available from: http://www.cancerjournal.net/text.asp?2018/14/12/1158/199788




 > Introduction Top


The mass lesions of the ampulla of Vater represent <10% of pancreatic and periampullary tumors. Among these, carcinomas, adenomas, and neuroendocrine tumors are the most frequently recognized neoplasms.[1],[2] Malignant tumor of the ampulla of Vater is the second most common periampullary malignancy.[3] In most series, the resectability rate is higher, and the prognosis is better when carcinomas of the ampulla are compared to other periampullary pancreatic cancers. Due to factors such as obstructive jaundice and duodenal obstruction, it is difficult to improve or maintain the nutrition state of patients who suffer from advanced malignant tumor of the ampulla of Vater.[4]

Percutaneous transhepatic cholangial drainage (PTCD) is a classical minimally invasive operation method to relieve obstruction of biliary tract,[5],[6] but the patients treated by this operation will often lose large amount of digestive juice when obstruction of biliary tract is solved; hence, it is very hard to maintain the state of nutrition. Percutaneous endoscopic jejunostomy (PEJ) is one choice of setting up the path of enteral nutrition in patients with nutritional risk for long term. It has the advantages of minimal invasion, simple, and less complication, and the most important of all, it provides a path to carry out enteral nutrition that does not need to pass through upper gastrointestinal tract.[7] PEJ has been gradually used in nutrition support for some patients with upper gastrointestinal diseases.[8],[9] This study investigated the role of PTCD combined with PEJ in maintaining the nutrition state in patients with advanced ampullary neoplasms. The objective of the study was to provide a reference for further clinical application of PEJ combined with PTCD.


 > Materials and Methods Top


Subjects

From May 2002 to May 2014, 60 patients in The Second Affiliated Hospital of Kunming Medical University who suffered from advanced ampullary neoplasms and could not tolerate internal drainage operation or biliary stent placement were enrolled in this study. There were 22 males and 38 females. Their age was 53–84 years, with average age of 68.3 ± 4.5 years. All patients underwent routine physical and laboratory examinations including blood cell count, prothrombin time, liver and kidney function, electrocardiogram, and chest X-ray. Computer tomography and/or nuclear magnetic resonance imaging examinations were carried out to confirm the location of ampullary neoplasms and biliary obstruction. Upper gastrointestinal endoscopy examination was also performed to exclude pyloric obstruction, stomach tumor, or gastric ulcer. This study was approved by the Institutional Review Board of The Second Affiliated Hospital of Kunming Medical University. Written informed consent was obtained from all participants.

Percutaneous transhepatic cholangial drainage

PTCD was chosen as the primary therapy. Guided by B-mode real-time ultrasonography, after local anesthesia with 2% lidocaine, we inserted 20–21-gauge Chiba needle (Cook-Cope biliary tract puncture needle) into the biliary tract through the space on the right anterior axillary line junction with 7–8th intercostal space or below the xiphoid process. After the puncture had succeeded, a thin guidewire was inserted through the needle into the biliary tract, and then an 8.5F or 10.2F drainage tube (Cook-Cope biliary tract drainage tube) was imbedded for external drainage; meanwhile, the needle was removed.

Percutaneous endoscopic jejunostomy

After PTCD was implemented successfully, PEJ was implemented guided by ultrasound. The patients were at left recumbent position. Under local anesthesia, the percutaneous endoscopic gastrostomy (PEG) was performed, and then the PEJ operation was conducted. PEJ fistula (Flocare Bengmark Percutaneous Endoscopic Jejunostomy Catheters) was inserted into gastral cavity through PEG fistula opening above the abdominal wall; at the same time, the gastroscope was inserted again to find the head of fistula in the gastral cavity. Guided by gastroscope, the biopsy forceps were inserted to clamp the head end of PEJ fistula guidewire and then entered pylorus together guided by gastroscope. At this point, the gastroscope was inserted gradually. Meanwhile, the guide wire was gradually sent to the small intestine at the gastrostomize. It should be inserted with the gastroscope synchronously, and the speed should not be too fast. The guidewire should be prevented from tying a knot in the gastral cavity. After PEJ fistula was sent to jejunum, the end of guidewire was loosened by the biopsy forceps, and the gastroscope was retreated out of gastral cavity. PEJ fistula was gradually sent into stomach, and then the guidewire was drawn out. At last, the position of PEJ fistula remained unchanged and was fixed tightly to abdominal wall.

Enteral nutrition support

After 24–48 h from the operation, the vital signs of patients were stable, without discomfort. The borborygmus was normal. The enteral nutrient solution + bile were instilled through PEJ tube (the bile was kept in the drainage bag after it was drawn forth through PTCD tube, and then the bile was poured into a clean infusion bottle for enteral nutrition support). If it was well tolerated by patients, the energy of the enteral nutrient solution was gradually increased to be ≥25 kJ/kg.

Observation indexes

Before and 1, 2, 3, and 4 weeks after surgery, the body weight indexes (weight, body mass index [BMI]) were measured. The serum levels of bilirubin indexes (total bilirubin, direct bilirubin); liver function indexes (gamma-glutamyl transferase [GGT], alanine aminotransferase [ALT], and aspartate aminotransferase [AST]); and nutritional status indexes (albumin [ALB], transferrin [TRF], and prealbumin [PRE]) were determined by SUNMATIK-6020 automatic biochemical analyzer (Sunostik Medical Technology Co., Ltd., Changchun, China). The immunologic function indexes (CD3+, CD4+, and CD4+/CD8+) were determined by FACSCalibur flow cytometer (Becton Dickinson and Company, MD, USA).

Statistical analysis

All statistical analyses were carried out using SPSS17.0 software (SPSS Inc., Chicago, IL, USA). Data were presented as mean ± standard deviation. Comparisons between two groups were performed using t-test. P <0.05 was considered statistically significant.


 > Results Top


Overall surgery outcome

All sixty patients had good cooperation with the surgeons and had successfully completed PTCD + PEJ. During PTCD catheter insertion, the bile drainage tube was unobstructed, and there were no major bleeding, bile duct fistula, peritonitis, or other complication after PTCD catheter insertion; the abdominal distension, abdominal pain, diarrhea, and other discomforts were alleviated after PTCD. The average operation time of PEJ was 20.2 ± 2.3 min, and no circling or looping to nutrition tube occurred during operation. During PEJ, no choking cough, esophageal reflux, or other serious complications (digestive tract bleeding, perforation, etc.) occurred.

Comparison of body weight and body mass index before and after surgery

As shown in [Table 1], the body weights of the patients before surgery and 1, 2, 3, and 4 weeks after surgery were 56.35 ± 4.67 kg, 56.67 ± 5.52, 56.91 ± 6.88, 57.93 ± 3.12, and 58.25 ± 5.79, respectively, and that at 3 or 4 weeks after surgery was significantly higher than before surgery (P < 0.05). The BMI of patients before surgery and 1, 2, 3, and 4 weeks after surgery were 18.51 ± 1.76, 18.61 ± 2.33, 18.77 ± 3.06, 19.01 ± 2.92, and 19.37 ± 1.95 kg/m2, respectively, and that at 4 weeks after surgery was significantly higher than before surgery (P < 0.05).
Table 1: Comparison of body weight and body mass index before and after surgery

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Comparison of serum total bilirubin and direct bilirubin levels before and after surgery

The serum total bilirubin levels of patients before surgery and 1, 2, 3, and 4 weeks after surgery were 204.91 ± 16.10, 180.44 ± 12.81, 78.95 ± 6.66, 66.58 ± 6.12, and 68.42 ± 5.33 μmol/L, respectively; the direct bilirubin levels before surgery and 1, 2, 3, and 4 weeks after surgery were 145.79 ± 19.27, 120.53 ± 17.68, 58.51 ± 4.65, 37.09 ± 3.23, and 38.58 ± 2.62 μmol/L, respectively. From 2 weeks after surgery, both serum total bilirubin and direct bilirubin levels were significantly lower than before surgery (P < 0.05) [Table 2].
Table 2: Comparison of serum total bilirubin and direct bilirubin levels before and after surgery

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Comparison of liver function indexes before and after surgery

Before surgery and 1, 2, 3, and 4 weeks after surgery, the serum GGT levels of patients were 359.90 ± 33.67, 301.18 ± 40.39, 174.34 ± 20.56, 122.67 ± 21.93, and 119.15 ± 20.12; the ALT levels were 197.87 ± 22.01, 80.26 ± 7.17, 42.46 ± 4.32, 19.83 ± 3.15, and 18.24 ± 1.35; and the AST levels were 167.7 ± 18.72, 55.5 ± 8.86, 42.5 ± 3.44, 42 ± 4.45, and 41.5 ± 5.33, respectively. From 1 week after surgery, both ALT and AST levels were significantly lower than before surgery (P < 0.05); from 2 weeks after surgery, GGT level was significantly lower than before surgery (P < 0.05) [Table 3].
Table 3: Comparison of liver function indexes before and after surgery

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Comparison of nutritional status indexes before and after surgery

[Table 4] shows that before surgery and 1, 2, 3, and 4 weeks after surgery, the serum ALB levels of patients were 29.64 ± 3.15, 32.88 ± 4.34, 33.04 ± 3.68, 34.34 ± 2.13, and 35.93 ± 2.53 g/L; the TRF levels were 1.71 ± 0.09, 2.58 ± 0.28, 2.79 ± 0.39, 3.11 ± 0.48, and 3.15 ± 0.43 g/L; and the PRE levels were 0.22 ± 0.03, 0.31 ± 0.04, 0.38 ± 0.03, 0.38 ± 0.02, and 0.42 ± 0.53 g/L, respectively. From 1 week after surgery, the levels of all nutritional status indexes were significantly increased compared with before surgery (P < 0.05).
Table 4: Comparison of nutritional status indexes before and after surgery

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Comparison of immunologic function indexes before and after surgery

Before surgery and 1, 2, 3, and 4 weeks after surgery, the serum CD3+ cell contents were 56.64 ± 6.23%, 55.64 ± 4.87%, 68.56 ± 3.90%, 75.83 ± 8.11%, and 78.88 ± 9.22%; the serum CD4+ cell contents were 26.66 ± 1.99%, 27.67 ± 3.55%, 38.37 ± 5.01%, 49.03 ± 5.78%, and 49.15 ± 6.71%; and the CD4+/CD8+ ratios were 1.12 ± 0.21, 1.20 ± 0.19, 1.78 ± 0.21, 2.04 ± 0.25, and 2.22 ± 0.44, respectively. From 1 week after surgery, the immunologic function indexes of patients were significantly improved compared with before surgery (P < 0.05) [Table 5].
Table 5: Comparison of immunologic function indexes before and after surgery

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 > Discussion Top


Neoplasms of the ampulla of Vater belong to the group of periampullary tumors, which also include tumors originating from pancreas, common bile duct or duodenum.[10] The benign tumors of the ampulla are rare. Among these, the most common recognized is adenoma[11] whereas the other benign types (lipomas, neuromas, etc.) are very unusual.[12] Malignant tumors of the ampulla are also rare, and adenocarcinoma represents the most common pathological variety. Adenomatous tissue is found in 80% of adenocarcinomas,[13] suggesting that the malignant tumors arise from adenomas. There is little argument over the necessity of adenomas resection, while there is no doubt regarding the resection of malignant tumors, if it is possible.

Since Holm.[11] completed the first puncture case guided by ultrasonic guidance in 1991, PTCD technology has become increasingly perfect. It can eliminate obstruction and lighten jaundice effectively. As early as the end of the last century, some scholars considered PTCD as the preferred therapeutic method for the patients with malignant obstructive jaundice which lost the opportunity of surgical therapy.[12],[13] However, the hormonal loss after PTCD and enterohepatic circulation lacking bile may lead to disorder of multiple electrolyte metabolism. It is become one of the key links that adversely affects patients' survival period and living quality.

For the patients suffer from lesion of digestive system, the tube feeding is a common method.[14],[15] Patients have poor tolerance to traditional nasogastric feeding.[16] Gastrostomy needs anesthesia and laparotomy to place fistula, and thus increases patients' pain and adverse risk.[17] PEJ is characterized by simple operation, safety and few complication.[18] This treatment can be implemented for critical patients with poor corporeity and nutrition, and then it probably improves patients' poor station,[19] and the most important of all, it provides a path to carry out enteral nutrition that does not need to pass through upper gastrointestinal tract.

For patients who suffer from advanced malignant ampullary neoplasms, the classical surgical operation cannot remove the lesions and so had no absolute predominance. The most important work we can do is to eliminate obstruction of pancreaticobiliary duct and maintain patient state of nutrition so as to relieve patients' pain, prolong their survival period, and improve their quality of life.[20] In terms of eliminating biliary obstruction of the pancreaticobiliary duct, PTCD has become a primary therapy in minimally invasive surgery. Through PEJ, we find another way for enteral nutrition support + bile recycling.


 > Conclusion Top


PTCD combined with PEJ is a safe and effective method for maintaining nutrition state in patients with advanced ampullary neoplasms. This study has provided a reference for further clinical application of PEJ combined with PTCD. However, the sample size of this study is relatively small. Larger sample size will make the results more convincing. In our next studies, the sample size should be further increased for obtaining more satisfactory outcomes.

Acknowledgment

This work was supported by the National Natural Science Foundation of China (No. 81160114).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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Branum GD, Pappas TN, Meyers WC. The management of tumors of the ampulla of Vater by local resection. Ann Surg 1996;224:621-7.  Back to cited text no. 1
    
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Lee SY, Jang KT, Lee KT, Lee JK, Choi SH, Heo JS, et al. Can endoscopic resection be applied for early stage ampulla of Vater cancer? Gastrointest Endosc 2006;63:783-8.  Back to cited text no. 2
    
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Crist DW, Sitzmann JV, Cameron JL. Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg 1987;206:358-65.  Back to cited text no. 3
    
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Qian XJ, Zhai RY, Dai DK, Yu P, Gao L. Treatment of malignant biliary obstruction by combined percutaneous transhepatic biliary drainage with local tumor treatment. World J Gastroenterol 2006;12:331-5.  Back to cited text no. 5
    
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Wolfsen HC, Kozarek RA, Ball TJ, Patterson DJ, Botoman VA, Ryan JA. Long-term survival in patients undergoing percutaneous endoscopic gastrostomy and jejunostomy. Am J Gastroenterol 1990;85:1120-2.  Back to cited text no. 8
    
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Filippou DK, Pashalidis N, Skandalakis P, Rizos S. Malignant gastrointestinal stromal tumor of the ampulla of Vater presenting with obstructive jaundice. J Postgrad Med 2006;52:204-6.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Holm HH. Interventional ultrasound. Br J Radiol 1991;64:379-85.  Back to cited text no. 11
    
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Yamao K, Bhatia V, Mizuno N, Sawaki A, Ishikawa H, Tajika M, et al. EUS-guided choledochoduodenostomy for palliative biliary drainage in patients with malignant biliary obstruction: Results of long-term follow-up. Endoscopy 2008;40:340-2.  Back to cited text no. 12
    
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Stern N, Sturgess R. Endoscopic therapy in the management of malignant biliary obstruction. Eur J Surg Oncol 2008;34:313-7.  Back to cited text no. 13
    
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Abernathy GB, Heizer WD, Holcombe BJ, Raasch RH, Schlegel KE, Hak LJ. Efficacy of tube feeding in supplying energy requirements of hospitalized patients. JPEN J Parenter Enteral Nutr 1989;13:387-91.  Back to cited text no. 14
    
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Gessert CE, Mosier MC, Brown EF, Frey B. Tube feeding in nursing home residents with severe and irreversible cognitive impairment. J Am Geriatr Soc 2000;48:1593-600.  Back to cited text no. 15
    
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Hsu TC, Su CF, Huang PC, Lu SC, Tsai SL. Comparison of tolerance and change of intragastric pH between early nasogastric and nasojejunal feeding following resection of colorectal cancer. Clin Nutr 2006;25:681-6.  Back to cited text no. 16
    
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Faria GR, Taveira-Gomes A. Open gastrostomy by mini-laparotomy: A comparative study. Int J Surg 2011;9:263-6.  Back to cited text no. 17
    
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Zschau N, Nguyen N, Tam W, Schoeman M. Intestinal perforation: A rare complication of percutaneous endoscopic jejunostomy removal. Endoscopy 2008;40 Suppl 2:E178.  Back to cited text no. 18
    
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Shu JC, Yang QH, Lv X, Zhang WR, Li ME, Zhang XY, et al. Percutaneous endoscopic gastrostomy/jejunostomy combined with percutaneous transhepatic biliary drainage in treating malignant biliary obstruction. Med Princ Pract 2011;20:47-50.  Back to cited text no. 19
    
20.
Pancreatric Section, British Society of Gastroenterology; Pancreatic Society of Great Britain and Ireland; Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland; Royal College of Pathologists; Special Interest Group for Gastro-Intestinal Radiology. Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas. Gut 2005;54 Suppl 5:v1-16.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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