Clinical outcomes of hepaticojejunostomy and ERCP endoscopic bile duct stent implantation in the treatment of malignant obstructive jaundice: a retrospective analysis

Clinical outcomes of hepaticojejunostomy and ERCP endoscopic bile duct stent implantation in the treatment of malignant obstructive jaundice: a retrospective analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical outcomes of hepaticojejunostomy and ERCP endoscopic bile duct stent implantation in the treatment of malignant obstructive jaundice: a retrospective analysis Zhipeng Liu, Ziqiang Han, Zheyu Niu, Yijie Hao, Yuanzi Yu, Huaqiang Zhu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5400124/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Malignant obstructive jaundice (MOJ) refers to intrahepatic or extrahepatic bile ducts obstruction caused by the compression or infiltrative growth of malignant tumors, followed by cholestasis and jaundice. Hepaticojejunostomy (HJ) and Endoscopic Retrograde Cholangiopancreatography (ERCP) bile duct stent implantation are the common palliative treatment to reduce jaundice. The aim of current research was to investigate which treatment was better for patients with MOJ. Patients and methods: A retrospective analysis of 171 patients with distal bile duct obstruction due to malignancy admitted to the Department of Hepatobiliary Surgery and Gastroenterology in our hospital from February 2013 to August 2021. According to different treatment options, patients were divided into ERCP group (n = 64) and HJ group (n = 107). The primary end point was overall survival (OS); the secondary end points were postoperative bilirubin level, hospitalization time, recurrence time of obstructive jaundice, and the occurrence of recent postoperative complications. Results In this study, we found that There was no significant difference in the median OS between the ERCP group and the HJ group [mOS: 11.6 (95%CI9.4-13.8) months vs 13.3 (95%CI10.7-15.9) months, P = 0.978]. There was no statistical difference in the effect of reducing jaundice between the two groups (P > 0.05). The average hospitalization time in the ERCP group was 6.67 ± 4.02 days, which was significantly shorter than that in the HJ group (9.56 ± 5.38 days, P < 0.001). There was no significant difference in the total incidence of postoperative complications in the ERCP group compared with the HJ group (21.9% vs 21.5%, P = 0.953). However, pancreatitis often occurred in the ERCP group (P = 0.036). In terms of complications of biliary fistula, it mainly occurred in the HJ group (P = 0.029). Compared with the ERCP group, the recurrence time of obstructive jaundice was longer in the HJ group (P = 0.007). Conclusion This study showed that both treatments can effectively reduce bilirubin and improve liver function in patients with distal bile duct obstruction due to malignancy. Considering the long-term effect, HJ is superior to ERCP bile duct stenting. Malignant obstructive jaundice Hepaticojejunostomy ERCP Jaundice reduction Biliary fistula Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Malignant obstructive jaundice (MOJ) refers to intrahepatic or extrahepatic bile ducts obstruction caused by the compression or infiltrative growth of malignant tumors, followed by cholestasis and jaundice [ 1 ] . Malignant biliary obstruction is mainly caused by pancreatic head carcinoma, lower common bile duct carcinoma, carcinoma of Vaters ampulla, adenocarcinoma of duodenum and other metastatic carcinomas. Bilirubin is the main component of bile and liver with deposited bilirubin shows cholestatic changes. Bilirubin and bile acids enter into the blood circulation through the hepatic portal vein, deposit on the skin and mucous membranes to cause jaundice symptoms. Also, they stimulate the peripheral nerves of the skin to cause itching symptoms. Long-term cholestasis leads to liver dysfunction, just like elevated alanine transaminase (ALT), aspertate aminotransferase (AST) and alkaline phosphatase (ALP) [ 2 ] . Obstruction of bile ducts could also affect the function of other organs and systems, such as electrolyte imbalance, low immune function, depression of digestion and absorption function and malnutrition [ 3 – 5 ] . Because of its insidious onset, the diagnosis of MOJ was usually delayed and the treatment was difficult. Malignant tumors are susceptible in elderly persons, most patients cannot undergo radical surgical resection due to poor cardiopulmonary function. Also, early local infiltration or distant metastasis limit the radical surgical treatment of MOJ. Recent studies have shown that only 30% of MOJ are curatively resectable at present [ 6 – 9 ] . At the same time, MOJ-related tumors have a high degree of malignancy and poor prognosis. For example, the 5-year survival rate of pancreatic head cancer is less than 10% [ 10 ] and the 5-year survival rate of bile duct cancer is 10–20% [ 7 ] . Studies found that the natural course of MOJ was no more than 5 months without treatment [ 11 ] . Due to the low rate of radical treatment, most patients could only receive palliative treatment by reducing jaundice in order to improve liver function and living quality. The common treatments are HJ, ERCP bile duct stent implantation, Percutaneous Transhepatic cholangial Drainage (PTCD), Endoscopic Nasobiliary Drainage (ENBD) and trans-gastrointestinal endoscopic ultrasound-guided biliary drainage (EUS-BD). However, each option has both strengths and weaknesses. For example, HJ has a long distance for bile delivery and lower infection rate, but the operation is complicated and time-consuming. ERCP has advantages of less trauma, quick recovery and low cost, but is prone to postoperative reflux cholangitis and pancreatitis. PTCD and ENBD are simple in operation, but long-term external drainage can easily lead to electrolyte disturbances and reduce the quality of life. Among them, HJ and ERCP endoscopic bile duct stent implantation are internal drainage, which is more in consistent with the physiological structure. HJ and ERCP could also avoid the inconvenience caused by long-term cannulation and effectively improves the living quality of patients. However, it remains to be identified which treatment was better for patients with MOJ. In this study, we reviewed the survival prognosis, short-term and long-term postoperative complications of patients received respective HJ or ERCP. We found that both treatment could reduce bilirubin and improve liver function in low-level MOJ effectively. There was no difference in survival time as well as bilirubin decline and overall postoperative complication rates between the ERCP group and HJ group. Although ERCP had advantages of less surgical trauma and shorter hospitalization time, the incidence of postoperative re-obstructive jaundice in the HJ group was lower. Considering the long-term effect, HJ is superior to ERCP bile duct stenting. Material and methods Study design and patients A total of 171 patients with MOJ admitted to the Department of Hepatobiliary Surgery and Gastroenterology of the Provincial Hospital Affiliated to Shandong First Medical University from February 2013 to August 2021 were retrospectively collected. This study was approved by the Ethics Committee of the Provincial Hospital Affiliated to Shandong First Medical University (SWYX: NO.2022-292). All patients showed certain clinical symptoms, such as jaundice, weight loss, abdominal pain, skin pruritus, and gastrointestinal symptoms. Preoperative and postoperative serologic examination results were collected within 3 days before internal drainage and 2 weeks after the operation. All patients met the inclusion and exclusion criteria below. Inclusion criteria: 1. Obstructive jaundice caused by malignant tumor confirmed by histology, cytology or imaging (CT, MRI); 2. Eastern Cooperative Oncology Group performance status (ECOG-PS) ≤2; 3. Distal bile duct obstruction due to malignancy (pancreatic head cancer, lower common bile duct cancer, ampullary cancer, duodenal adenocarcinoma); 4. Inability to perform radical surgical resection or patients refuse radical resection; 5. Complete follow-up data. Exclusion criteria: 1. Previous or current presence of other malignant tumors; 2. Proximal bile duct obstruction due to malignancy (such as hilar cholangiocarcinoma, intrahepatic cholangiocarcinoma, gallbladder cancer, etc.); 3. Obstructive jaundice caused by benign diseases; 4. Minus jaundice with PTCD; 5. The follow-up data is missing or the patient data is incomplete. The patient's general condition, medial history, preoperative and postoperative blood routine examination, liver and kidney function, tumor markers, imaging and other report data were collected through the medical record system. According to the wishes of the patients and their families, the surgical methods were selected independently, and ERCP biliary stent implantation was performed in all patients with poor physical condition (cardiopulmonary insufficiency). Patients were divided into ERCP (n = 64) and HJ (n = 107) groups according to their treatment. HJ Duct jejunal Roux-en-Y anastomosis in condition of tracheal intubation anesthesia, routine laparotomy or laparoscopic operation. The gallbladder was routinely removed, free and transect the common bile duct to prepare for anastomosis. Create a Roux limb about 15cm away from the duodenojejunal junction and perform a jejunojejunostomy using the proximal end of the divided jejunum bring the Roux limb up through an opening in the mesentery of the colon. An incision of the same length as the diameter of the common bile duct was made 5cm at the end of the Roux, and the bile duct and jejunum were sutured consecutively with the barb line 4-0. Check for bleeding, place a drain and close the abdominal incision (Fig1A). ERCP bile duct stent implantation The duodenoscope passes through the esophagus and stomach cavity to check the duodenal papilla. The Olympus’ Mucosal incision knife was inserted through duodenal papilla and the guide wire was put into the common bile duct. The cholangiography showed that the common bile duct was obviously expanded. Incise the duodenal papilla and place the bile duct stent along the guide wire. Bile was seen flowing out, and withdrawn the scope (Fig1B). ERCP biliary stents the biliary stents used during the procedure contain plastic and metal. The stent type was chosen according to the patient's specific condition and economic status. Follow-up plan Follow-up-related data were obtained from patients' follow-up phone calls, regular review data and readmission records. Preoperative and postoperative general conditions, liver function, total bilirubin levels, and recent postoperative complications were recorded in detail in all patients. Overall survival (OS) was defined as the primary endpoint of the study from the date of onset to the date of death or to the date of termination of follow-up. Secondary endpoints: postoperative bilirubin level, length of hospital stay, recurrence time of obstructive jaundice, and recent postoperative complications. The end date of follow-up was April 2022, and the follow-up time was 0.9 to 79.6 months. Statistical analysis The collected data were systematically analyzed using SPPS version 26.0. Measurement data were expressed as mean ± standard deviation(`X ±s), and the comparison of measurement data was carried out using independent sample t test. The grade data were expressed as percentage, and the comparison of grade data was analyzed by χ2 test. Survival analysis was performed by the Kaplan-Meier method, median overall survival time (mOS) was calculated, and the curve was plotted. At the same time, Kaplan-Meier method was used to analyze the recurrence time of obstructive jaundice and draw a curve. P<0.05 means there is a difference, which is statistically significant. Results Comparison of general clinical features before surgery According to the inclusion and exclusion criteria, 171 patients who met the criteria were finally screened for inclusion in this retrospective study. Patients with distal bile duct obstruction due to malignancy were divided into ERCP group and HJ group according to the treatment of reducing jaundice. There were no significant differences in general clinical data such as gender, age, Eastern Cooperative Oncology Group performance status (ECOG-PS), tumor type, clinical manifestations (jaundice, cutaneous pruritus, abdominal pain, epigastric discomfort, weight loss, symptom of digestive tract), hypertension, and diabetes between the two groups before operation (P>0.05). The demographics and baseline characteristics were shown in Table 1. Postoperative liver function changes in the two groups of patients There were no significant differences in AST, ALT, ALP, gamma-glutamyltransferase (GGT), and total bilirubin (TB) between the two groups before and after operation (P>0.05). The postoperative liver function indexes were significantly improved compared with that before treatment (P<0.05) (Table 2). So, there was no difference between the two groups in reducing jaundice and improving liver function. Comparison of postoperative complication There were 37 complications in the two groups after operation. There were 14 cases in the ERCP group, with an incidence rate of 21.9%, 4 cases of pancreatitis, and 10 cases of biliary tract infection. Pancreatitis and biliary tract infection could be cured through postoperative symptomatic treatment such as anti-infection, acid-suppression and enzyme-suppression. There were 23 cases in the HJ group, with an incidence rate of 21.4%, 13 cases of biliary tract infection and 10 cases of biliary fistula. After anti-infection and adequate drainage, the patient's symptoms disappeared. No complication-related deaths in either group. There was no significant difference in the incidence of postoperative complications in the ERCP group compared with the HJ group (21.9% vs 21.5%, P=0.953). Among them, there was no significant difference in biliary tract infection between the ERCP group and the HJ group (15.6% vs 12.1%, P=0.519). However, in terms of complications of pancreatitis, it mainly occurred in the ERCP group (P=0.036) while biliary fistula mainly occurred in the HJ group (P=0.029). (Table 3). Analysis of hospitalization time and survival time The hospitalization time was from the first postoperative day to the discharge date. The average hospital stay in the ERCP group was 6.67±4.02 days, which was significantly shorter than that in the HJ group, which was 9.56±5.38 days (P<0.001), as shown in Fig. 2. The total median follow-up time between the two groups was 12.8 (95%CI 10.9-14.7) months, and there was no significant difference in mOS between the ERCP group and the HJ group [mOS: 11.6 (95%CI 9.4-13.8) months vs 13. 3 (95%CI 10.7-15.9) months, P=0.978], as shown in Fig. 3. Recurrence time of obstructive jaundice The recurrence time of obstructive jaundice was from the first operation to the second operation. There were 11 cases of obstructive jaundice in the two groups after operation, including 8 (12.5%) cases in the ERCP group and 3 (2.8%) cases in the HJ group. Compared with the ERCP group, the recurrence time of obstructive jaundice was longer in the HJ group (P=0.007)(Fig. 4). Discussion Distal bile duct obstruction due to malignancy has an insidious onset and no obvious clinical symptoms. When symptoms emerge, the patients are often already in an advanced disease stage or cannot undergo radical resection due to poor cardiopulmonary function. So, the main treatment measures for those patients are to relieve biliary obstruction and promote bile excretion. Long-term obstructive jaundice induces yellowing of the skin and sclera, skin itching, infection, liver insufficiency, renal insufficiency. Measures such as minus jaundice could reduce the functional impairment and clinical symptoms, improve the living quality of patients, and prolong the survival period of patients. At present, the measures to reduce jaundice are mainly divided into two aspects: internal drainage and external drainage. The palliative internal drainage is more in line with the physiological structure than the external drainage. Internal drainage relieves jaundice and corrects anhydrous electrolyte imbalance as well as digestive dysfunction, and maintains the enterohepatic circulation of bile better [ 12 ] . Long-term external drainage can easily lead to the loss of a large amount of bile and bile salts, causing electrolyte disturbances, intestinal dysfunction and other related problems. At the same time, the long-term external drainage tube may cause dislocate or prolapse of the drainage tube. And chronic inflammatory stimulation of the drainage tube orifice induces redness, swelling, heat and pain, etc., which affects the quality of life [ 13 , 14 ] . Relevant experimental studies have also shown that internal drainage is superior to external drainage in terms of intestinal immunity and bacterial translocation [ 12 ] . At present, the commonly internal drainage methods are HJ and ERCP. In this study, the effects of reducing jaundice and improving liver function in the HJ group and the ERCP group were positive. There were statistical differences between preoperative and postoperative bilirubin and liver transaminase (P 0.05). Compared with ERCP, longer time of postoperative recovery and hospital stay were found in HJ group. So, ERCP has the advantages of less surgical trauma and faster postoperative recovery. This study found that the mean hospital stay in the ERCP group was significantly shorter than that in the HJ group (E6.67 ± 4.02 days vs 9.56 ± 5.38 days, P < 0.001). Because HJ and ERCP have no therapeutic effect on the tumor itself, they simply relieve the obstruction of the biliary tract and improve the liver function and physical condition. So, there was no difference in the effect of the two treatment methods on the OS of patients (P = 0.978). Postoperative complications were compared in this study. With the expanding of surgical techniques, the incidence of postoperative complications such as bleeding and incision infection in patients has dropped considerably. In this study, the main complications after ERCP were biliary tract infection and pancreatitis, while the main complications after HJ were biliary tract infection and biliary fistula. There was no significant difference in the overall complication rate between the ERCP group and the HJ group (21.9% vs 21.5%, P = 0.953). Among them, there was no significant difference in biliary tract infection between the ERCP group and the HJ group (15.6% vs 12.1%, P = 0.519). However, the complications of pancreatitis were mainly concentrated in the ERCP group (P = 0.036). The occurrence of acute pancreatitis after ERCP. On the one hand, it is related to the difficulty of stent placement, causing damage to the nipple and Oddi sphincter, resulting in pancreatic juice drainage disorder [ 15 , 16 ] . On the other hand, it is related to the damage of hydrostatic pressure in pancreatic duct caused by over filling of contrast agent [ 17 ] . The incidence rate of acute pancreatitis in this study is 6.3%, which is consistent with the incidence of 4% − 8% in most research reports [ 18 ] . And the complications of biliary fistula were mainly concentrated in the HJ group (10 cases, P = 0.029). The occurrence of biliary fistula is mainly caused by anastomotic leakage. Generally, the biliary fistula rate after HJ varies from 2.3–5.6% [ 19 , 20 ] . In our study population, the incidence of biliary fistula was high (9.3%). The higher rate of biliary fistula may be related to the operation of the surgeon performing this step. In the HJ group, 72 patients underwent open surgery; 35 patients with laparoscopic surgery. There was no significant difference in the incidence of biliary fistula between the open HJ group and the laparoscopic HJ group (P = 0.115). Therefore, laparoscopic surgery does not increase the risk of biliary fistula [ 21 , 22 ] . This study investigated the recurrence time of obstructive jaundice. The results showed that the recurrence time of jaundice in the HJ group was longer than that in the ERCP group (2.8% vs 12.5%, P = 0.007). Because the HJ site is usually located in the upper segment of the tumor bile duct, the postoperative jaundice recurrence time is longer. The recurrence time of jaundice after ERCP is short, which may be related to the progressive growth of tumor. The tumor tissue invades from the side hole of the stent and causes the obstruction of the bile duct stent, which leads to the recurrence of jaundice. For patients with recurrent jaundice, repeat ERCP or PTCD external drainage can be performed after evaluation. As a minimally invasive palliative treatment method, ERCP endoscopic bile duct stent implantation to relieve biliary obstruction has been widely carried out in clinical practice. According to the different materials of bile duct stents, they are divided into plastic stents and metal stents. Plastic stents are cheap and can be used for short-term jaundice reduction (preoperative treatment of malignant biliary obstruction and benign biliary stricture). Because of the poor support, plastic stents are easy to be compressed and deformed by tumor growth when used in the treatment of malignant biliary obstruction and jaundice reduction. The diameter of metal stent is several times bigger than that of the plastic stent after expansion, but is more expensive [ 23 – 25 ] . Also, metal stents have less bacterial proliferation and fixation surfaces, it is not conducive to biofilm formation and cholestasis, which may contribute to lower recurrence rate of jaundice compared with plastic stent [ 24 , 26 , 27 ] . In a meta-analysis of different material biliary stents for the treatment of inoperable malignant distal biliary obstruction, the two types of stent had similar clinical success and complication rates in the treatment of malignant distal biliary obstruction. However, metal stents were associated with longer stent patency duration compared with plastic stents [ 28 ] . At the same time, a study on the failure time of plastic stents and metal stents showed that stent failure occurred in 10/16 patients (62.5%) in the plastic stent group, while 4/18 patients (22.2%) in the metal stent group (p = 0.034) and the median time to failure was 51 days for plastic stents and 80 days for metal stents (P = 0.002) [ 29 ] . According to two studies, metal bile duct stents are more suitable for malignant distal bile duct obstruction. With the development of materials science, newly stent designed to combined minus jaundice and anti-anti-tumor. Recent studies found that stent combined with 125 I particle strip implantation in the treatment of malignant obstructive jaundice can effectively alleviate jaundice, inhibit tumor growth and prolong survival time [ 30 , 31 ] . Endoscopic ultrasound guided biliary drainage (EUS-BD) is a high-end endoscopic technology. It is an effective method for patients with obstructive jaundice who have failed ERCP. Although ERCP is still the gold standard, a large number of studies have shown that EUS-BD can be used as an alternative even in patients who can successfully accept ERCP [ 32 – 34 ] . After ERCP failed to treat unresectable cancer, EUS-BD was more popular than PTCD (40.9% vs 21.7%) [ 35 ] . EUS-BD can be used as first-line treatment without ERCP. In 1986, Roux first advocated Y-type gastrojejunostomy with well clinical effect [ 36 ] . Later, it was applied to the biliary tract to perform Y-type anastomosis of the bile duct and jejunum. HJ is the most commonly used surgical procedure for malignant obstructive jaundice. Since the Roux-en-Y jejunal loop has a complete vascular supply, it has sufficient length for long-distance movement. And the intestinal segment anastomosed with the bile duct is antegrade peristalsis, which can prevent the reflux of intestinal contents. During HJ, the biliary jejunal anastomosis is guaranteed to be unobstructed which ensures the drainage effect. Also, the huge trauma and economic burden caused by the second or even multiple surgical treatments are avoided. However, HJ has the disadvantages of large surgical trauma, long postoperative recovery time, high hospitalization cost, damage to the normal physiological function of Oddi's sphincter, and reflux of intestinal bacteria to the bile duct. With the development of science and technology and the application of laparoscope, such minimally invasive surgery can reduce the surgical blow and is easy to be accepted by patients [ 21 , 37 ] . Weaknesses of this study: (1) The impact of postoperative systemic therapy was not analyzed, which may affect the assessment of patient survival time; (2) Small sample size, single-center study; (3) The imbalance between the two groups may affect the statistics of postoperative complications;(4) Stent types were not distinguished, and different types of stents affected the time of recurrence of obstructive jaundice. Therefore, this study needs multi-center and large-scale samples for further verification. The innovation of this study is that there are no reported differences between ERCP bile duct stent implantation and HJ. Conclusion In summary, the results of the study showed that there was no difference in survival time between the ERCP group and the HJ group. Two internal drainage measures achieved good clinical results in the treatment of MOJ, effectively reduced bilirubin and improved liver function. Nonetheless, we found no significant differences in the level of bilirubin decline or overall postoperative complication rates between the two groups. However, there are differences between the different complication rates, just like pancreatitis and biliary fistula. Although, ERCP has the advantages of less surgical trauma and shorter postoperative hospital stay, the HJ group has a longer recurrence time of obstructive jaundice, which avoids the trauma and economic pressure caused by readmission surgical treatment. Therefore, for the moment, considering all aspects, the long-term effect of HJ is better than ERCP. Declarations Disclosure The author reports no conflicts of interest in this work. Author Contribution L ZP wrote the article, H ZQ collected case data,N ZY and H YJ was responsible for designing the research plan, Y YZ and G HJ conducted statistical analysis, Z X and Z HQ assisted in patient coordination, L J and Y FJ provided guidance for the article writing. Acknowledgments This work is supported by National Natural Science Foundation of China (Grant No. 82200706). References Fargo MV, Grogan SP, Saguil A. Evaluation of Jaundice in Adults. American family physician 2017; 95 (3): 164-168 [PMID: 28145671] Shah R, John S. 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World journal of gastroenterology 2019; 25 (37): 5711-5731 [PMID: 31602170 DOI: 10.3748/wjg.v25.i37.5711] Tables Table 1 Preoperative baseline data of patients included in the study Characteristics ERCP HJ χ²value p value Number 64 107 Gender, n (%) 0.019 0.89 Male 40(62.5) 68(63.6) Female 24(37.5) 39(36.4) Age (years), n (%) 2.640 0.104 ≤60 13(20.3) 34(31.8) ＞60 51(79.7) 73(68.2) ECOG-PS, n (%) 0.889 0.346 1 16(25) 34(31.8) 2 48(75) 73(68.2) Tumour type, n (%) 3.135 0.536 Pancreatic head carcinomas 39(60.9) 77(72) Lower common bile duct carcinoma 20(31.3) 21(19.6) Carcinoma of Vaters ampulla 2(3.1) 4(3.7) Adenocarcinoma of duodenum 2(3.1) 4(3.7) Others 1(1.6) 1(0.9) Clinical feature，n (%) Jaundice 55(85.9) 96(89.7) 0.555 0.456 Cutaneous pruritus 18(28.1) 23(21.5) 0.966 0.326 Abdominal pain 27(42.2) 51(47.7) 0.484 0.487 Symptom of digestive tract 25(39.1) 36(33.6) 0.512 0.474 Epigastric discomfort 23(35.9) 43(40.2) 0.305 0.581 Weight loss 42(65.6) 64(59.8) 0.574 0.449 Hypertension, n (%) 29(45.3) 34(31.8) 3.154 0.076 Diabetes，n (%) 19(29.7) 29(27.1) 0.133 0.716 Smoke，n (%) 30(46.9) 40(37.4) 1.492 0.222 Drink，n (%) 27(42.2) 41(38.3) 0.250 0.617 Table 2 The liver function indicators in the two groups(`X±s) Groups ERCP HJ t value p value AST(U/L) Pre-treatment 156.3±102.4 164.9±127.2 0.458 0.648 Post-treatment 41.2±31.8 40.5±23.6 0.166 0.869 ALT(U/L) Pre-treatment 189.4±144.9 221.6±157.7 1.327 0.186 Post-treatment 59.2±43.1 65.2±51.5 0.79 0.431 ALP(U/L) Pre-treatment 545.2±452.9 540.8±376.2 0.069 0.945 Post-treatment 264.9±205.1 241.2±158.4 0.847 0.398 GGT(U/L) Pre-treatment 639±430.5 748.3±511.1 1.496 0.137 Post-treatment 228±212.7 237.1±202.8 0.279 0.781 TB(μmol/L) Pre-treatment 279.9±153.5 244±93.5 1.694 0.094 Post-treatment 80.7±68.8 63±44.1 1.844 0.068 Note: β represents the intra-group comparison between the two groups, P < 0.05. AST: aspartate aminotransferase; ALT: alanine aminotransferase; ALP: alkaline phosphatase；GGT: gamma-glutamyl transferase; TB: total bilirubin Table 3 The postoperative complications in the two groups (n, %) Groups ERCP HJ χ²value p value Acute pancreatitis 4(6.3) 0(0) 4.385 0.036 Biliary infection 10(15.6) 13(12.1) 0.416 0.519 biliary fistula 0(0) 10(9.3) 4.769 0.029 Incidence of complications 14(21.9) 23(21.4) 0.003 0.953 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5400124","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":376822709,"identity":"788bec67-3517-48f3-83f2-5c0a3fcd3872","order_by":0,"name":"Zhipeng Liu","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhipeng","middleName":"","lastName":"Liu","suffix":""},{"id":376822710,"identity":"a5751fd8-2f46-403b-a54c-648c82529178","order_by":1,"name":"Ziqiang Han","email":"","orcid":"","institution":"Dongying People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ziqiang","middleName":"","lastName":"Han","suffix":""},{"id":376822711,"identity":"d45d09b6-5e52-4d7d-bb86-350b34ba9745","order_by":2,"name":"Zheyu Niu","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zheyu","middleName":"","lastName":"Niu","suffix":""},{"id":376822712,"identity":"fd3bf6bc-829b-40a8-a854-2dc8a3a7ad91","order_by":3,"name":"Yijie Hao","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yijie","middleName":"","lastName":"Hao","suffix":""},{"id":376822713,"identity":"78898c4d-4046-4fe2-8a9a-bbc64ee7866e","order_by":4,"name":"Yuanzi Yu","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuanzi","middleName":"","lastName":"Yu","suffix":""},{"id":376822714,"identity":"8099eecf-9077-4525-b077-01c023238031","order_by":5,"name":"Huaqiang Zhu","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Huaqiang","middleName":"","lastName":"Zhu","suffix":""},{"id":376822715,"identity":"99c62816-dbd2-4a82-a391-f4ad73b1c9fd","order_by":6,"name":"Xu Zhou","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Zhou","suffix":""},{"id":376822716,"identity":"e48f4d15-6a40-4040-aa38-5b8938a733f7","order_by":7,"name":"Hengjun Gao","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hengjun","middleName":"","lastName":"Gao","suffix":""},{"id":376822717,"identity":"77ff53b1-80d9-405c-bd0e-64dceb8e0524","order_by":8,"name":"Jun Lu","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Lu","suffix":""},{"id":376822718,"identity":"a93b86f1-1ab8-4d11-bacf-47e5a0f7c799","order_by":9,"name":"Faji Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYBAC9gaGhAMgBj8zmJKQIaiF5wBUi2RbAlgLDzFaIMDgWAJEgLAW9gMPD/PU3LHbfIz5mNSNGgseBvbDRzfg1cKTkHCY59iz5G3H2JKNc44BHcaTlnYDnxZ7BpAWtsPJZvd7DB/nsAG1SPCY4dXCw/8AqOXf4WTjNh6Dwzn/iNEiAbSFt+2wnQEbj+Hj3DaitDxIODi373CCBMgvuX0SPGyE/MLDn5P84c23w/b8bczHpHO+1cnxsx8+hlcLUFMCEzAuEhtgfDb8ykGA/QDjD1DIjYJRMApGwSjABQD2I0jwaF0DAQAAAABJRU5ErkJggg==","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":true,"prefix":"","firstName":"Faji","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2024-11-06 06:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5400124/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5400124/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71481013,"identity":"4c8baeb4-85f6-429a-b650-e1670bed4fbf","added_by":"auto","created_at":"2024-12-16 06:00:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3909264,"visible":true,"origin":"","legend":"\u003cp\u003eA. Picture of HJ for distal bile duct obstruction due to malignancy. Laparoscopic images of the bile duct stump and biliary-enteric anastomosis; B. Image of stent implantation under ERCP for distal bile duct obstruction due to malignancy. Radiographic and endoscopic images taken under ERCP.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-5400124/v1/3d04a77e01e34bead8d25c97.png"},{"id":71481014,"identity":"387954b7-5eb4-4451-bc92-a8ae5283f99c","added_by":"auto","created_at":"2024-12-16 06:00:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":440314,"visible":true,"origin":"","legend":"\u003cp\u003eA. Histogram of the average length of stay in the two groups of patients *p\u0026lt;0.05, **p\u0026lt;0.01, ***p\u0026lt;0.001.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-5400124/v1/b9641345fec753057181d1c1.png"},{"id":71481011,"identity":"e1d78e7d-ba5f-4e89-9bca-1142a0504cd8","added_by":"auto","created_at":"2024-12-16 06:00:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":591084,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier survival curves show OS in patients with distal bile duct obstruction due to malignancyaccording to different treatment regimens. Comparison of OS between two groups of patients.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-5400124/v1/bf2878e8323c92cd19f8c63e.png"},{"id":71481015,"identity":"0f7de708-b446-44f0-8719-c75039a9c715","added_by":"auto","created_at":"2024-12-16 06:00:07","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":787717,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier analysis show the recurrence time of obstructive jaundice in patients with distal bile duct obstruction due to malignancy according to different treatment regimens. Comparison of the recurrence time of obstructive jaundice between two groups of patients.\u003c/p\u003e","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-5400124/v1/f91b36ca7aefd6adb5e0fec0.png"},{"id":77642314,"identity":"a760e4a4-3334-4b99-8dbb-28b6b0d3f29a","added_by":"auto","created_at":"2025-03-03 21:31:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6110846,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5400124/v1/cb9e8c75-1c1d-4ca4-ae4e-ab30e29ff8fe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical outcomes of hepaticojejunostomy and ERCP endoscopic bile duct stent implantation in the treatment of malignant obstructive jaundice: a retrospective analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMalignant obstructive jaundice (MOJ) refers to intrahepatic or extrahepatic bile ducts obstruction caused by the compression or infiltrative growth of malignant tumors, followed by cholestasis and jaundice\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Malignant biliary obstruction is mainly caused by pancreatic head carcinoma, lower common bile duct carcinoma, carcinoma of Vaters ampulla, adenocarcinoma of duodenum and other metastatic carcinomas. Bilirubin is the main component of bile and liver with deposited bilirubin shows cholestatic changes. Bilirubin and bile acids enter into the blood circulation through the hepatic portal vein, deposit on the skin and mucous membranes to cause jaundice symptoms. Also, they stimulate the peripheral nerves of the skin to cause itching symptoms. Long-term cholestasis leads to liver dysfunction, just like elevated alanine transaminase (ALT), aspertate aminotransferase (AST) and alkaline phosphatase (ALP)\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Obstruction of bile ducts could also affect the function of other organs and systems, such as electrolyte imbalance, low immune function, depression of digestion and absorption function and malnutrition\u003csup\u003e[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBecause of its insidious onset, the diagnosis of MOJ was usually delayed and the treatment was difficult. Malignant tumors are susceptible in elderly persons, most patients cannot undergo radical surgical resection due to poor cardiopulmonary function. Also, early local infiltration or distant metastasis limit the radical surgical treatment of MOJ. Recent studies have shown that only 30% of MOJ are curatively resectable at present\u003csup\u003e[\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. At the same time, MOJ-related tumors have a high degree of malignancy and poor prognosis. For example, the 5-year survival rate of pancreatic head cancer is less than 10%\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e and the 5-year survival rate of bile duct cancer is 10\u0026ndash;20%\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Studies found that the natural course of MOJ was no more than 5 months without treatment\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Due to the low rate of radical treatment, most patients could only receive palliative treatment by reducing jaundice in order to improve liver function and living quality. The common treatments are HJ, ERCP bile duct stent implantation, Percutaneous Transhepatic cholangial Drainage (PTCD), Endoscopic Nasobiliary Drainage (ENBD) and trans-gastrointestinal endoscopic ultrasound-guided biliary drainage (EUS-BD). However, each option has both strengths and weaknesses. For example, HJ has a long distance for bile delivery and lower infection rate, but the operation is complicated and time-consuming. ERCP has advantages of less trauma, quick recovery and low cost, but is prone to postoperative reflux cholangitis and pancreatitis. PTCD and ENBD are simple in operation, but long-term external drainage can easily lead to electrolyte disturbances and reduce the quality of life. Among them, HJ and ERCP endoscopic bile duct stent implantation are internal drainage, which is more in consistent with the physiological structure. HJ and ERCP could also avoid the inconvenience caused by long-term cannulation and effectively improves the living quality of patients. However, it remains to be identified which treatment was better for patients with MOJ.\u003c/p\u003e \u003cp\u003eIn this study, we reviewed the survival prognosis, short-term and long-term postoperative complications of patients received respective HJ or ERCP. We found that both treatment could reduce bilirubin and improve liver function in low-level MOJ effectively. There was no difference in survival time as well as bilirubin decline and overall postoperative complication rates between the ERCP group and HJ group. Although ERCP had advantages of less surgical trauma and shorter hospitalization time, the incidence of postoperative re-obstructive jaundice in the HJ group was lower. Considering the long-term effect, HJ is superior to ERCP bile duct stenting.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 171 patients with MOJ admitted to the Department of Hepatobiliary Surgery and Gastroenterology of the Provincial Hospital Affiliated to Shandong First Medical University from February 2013 to August 2021 were retrospectively collected. This study was approved by the Ethics Committee of the Provincial Hospital Affiliated to Shandong First Medical University (SWYX: NO.2022-292). All patients showed certain clinical symptoms, such as jaundice, weight loss, abdominal pain, skin pruritus, and gastrointestinal symptoms. Preoperative and postoperative serologic examination results were collected within 3 days before internal drainage and 2 weeks after the operation.\u0026nbsp;All patients met the inclusion and exclusion criteria below. Inclusion criteria: 1. Obstructive jaundice caused by malignant tumor confirmed by histology, cytology or imaging (CT, MRI); 2.\u0026nbsp;Eastern Cooperative Oncology Group performance status (ECOG-PS) \u0026le;2; 3.\u0026nbsp;Distal bile duct obstruction due to malignancy\u0026nbsp;(pancreatic head cancer, lower common bile duct cancer, ampullary cancer, duodenal adenocarcinoma); 4. Inability to perform radical surgical resection or patients refuse radical resection; 5. Complete follow-up data. Exclusion criteria: 1. Previous or current presence of other malignant tumors; 2.\u0026nbsp;Proximal bile duct obstruction due to malignancy\u0026nbsp;(such as hilar cholangiocarcinoma, intrahepatic cholangiocarcinoma, gallbladder cancer, etc.); 3. Obstructive jaundice caused by benign diseases; 4. Minus jaundice with PTCD; 5. The follow-up data is missing or the patient data is incomplete. The patient\u0026apos;s general condition, medial history, preoperative and postoperative blood routine examination, liver and kidney function, tumor markers, imaging and other report data were collected through the medical record system. According to the wishes of the patients and their families, the surgical methods were selected independently, and ERCP biliary stent implantation was performed in all patients with poor physical condition (cardiopulmonary insufficiency). Patients were divided into ERCP (n = 64) and HJ (n = 107) groups according to their treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHJ\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuct jejunal Roux-en-Y anastomosis in condition of tracheal intubation anesthesia, routine laparotomy or laparoscopic operation. The gallbladder was routinely removed, free and transect the common bile duct to prepare for anastomosis. Create a Roux limb about 15cm away from the duodenojejunal junction and perform a jejunojejunostomy using the proximal end of the divided jejunum bring the Roux limb up through an opening in the mesentery of the colon.\u0026nbsp;An incision of the same length as the diameter of the common bile duct was made 5cm at the end of the Roux, and the bile duct and jejunum were sutured consecutively with the barb line 4-0.\u0026nbsp;Check for bleeding, place a drain and close the abdominal incision (Fig1A).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eERCP bile duct stent implantation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;duodenoscope\u0026nbsp;passes through\u0026nbsp;the esophagus and stomach cavity to check the duodenal papilla. The\u0026nbsp;Olympus\u0026rsquo; Mucosal incision knife\u0026nbsp;was inserted through duodenal papilla and the guide wire was put into the common bile duct. The\u0026nbsp;cholangiography\u0026nbsp;showed that the common bile duct was obviously expanded. Incise the duodenal papilla and place the bile duct stent along the guide wire. Bile was seen flowing out, and withdrawn the scope (Fig1B).\u0026nbsp;ERCP biliary stents the biliary stents used during the procedure contain plastic and metal. The stent type was chosen according to the patient\u0026apos;s specific condition and economic status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up plan\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollow-up-related data were obtained from patients\u0026apos; follow-up phone calls, regular review data and readmission records. Preoperative and postoperative general conditions, liver function, total bilirubin levels, and recent postoperative complications were recorded in detail in all patients. Overall survival (OS) was defined as the primary endpoint of the study from the date of onset to the date of death or to the date of termination of follow-up. Secondary endpoints: postoperative bilirubin level, length of hospital stay,\u0026nbsp;recurrence time of obstructive jaundice, and recent postoperative complications. The end date of follow-up was April 2022, and the follow-up time was 0.9 to 79.6 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe collected data were systematically analyzed using SPPS version 26.0. Measurement data were expressed as mean \u0026plusmn; standard deviation(`X \u0026plusmn;s), and the comparison of measurement data was carried out using independent sample t test. The grade data were expressed as percentage, and the comparison of grade data was analyzed by \u0026chi;2 test. Survival analysis was performed by the Kaplan-Meier method, median overall survival time (mOS) was calculated, and the curve was plotted. At the same time, Kaplan-Meier method was used to analyze the recurrence time of obstructive jaundice and draw a curve. P\u0026lt;0.05 means there is a difference, which is statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eComparison of general clinical features before surgery\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the inclusion and exclusion criteria, 171 patients who met the criteria were finally screened for inclusion in this retrospective study. Patients with\u0026nbsp;distal bile duct obstruction due to malignancy\u0026nbsp;were divided into ERCP group and HJ group according to the treatment of reducing jaundice.\u0026nbsp;There were no significant differences in general clinical data such as gender, age, Eastern Cooperative Oncology Group performance status (ECOG-PS), tumor type, clinical manifestations (jaundice,\u0026nbsp;cutaneous pruritus, abdominal pain, epigastric discomfort, weight loss,\u0026nbsp;symptom of digestive tract), hypertension, and diabetes between the two groups before operation (P\u0026gt;0.05).\u0026nbsp;The demographics and baseline characteristics were shown in Table 1.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative liver function changes in the two groups of patients\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were no significant differences in AST, ALT, ALP,\u0026nbsp;gamma-glutamyltransferase (GGT), and total bilirubin (TB) between the two groups before and after operation (P\u0026gt;0.05). The postoperative liver function indexes were significantly improved compared with that before treatment (P\u0026lt;0.05) (Table 2). So, there was no difference between the two groups in reducing jaundice and improving liver function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of postoperative complication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were 37 complications in the two groups after operation. There were 14 cases in the ERCP group, with an incidence rate of 21.9%, 4 cases of pancreatitis, and 10 cases of biliary tract infection. Pancreatitis and biliary tract infection could be cured through postoperative symptomatic treatment such as anti-infection, acid-suppression and enzyme-suppression. There were 23 cases in the HJ group, with an incidence rate of 21.4%, 13 cases of biliary tract infection and 10 cases of biliary fistula. After anti-infection and adequate drainage, the patient\u0026apos;s symptoms disappeared. No complication-related deaths in either group.\u0026nbsp;There was no significant difference in the incidence of postoperative complications in the ERCP group compared with the HJ group (21.9% vs 21.5%, P=0.953). Among them, there was no significant difference in biliary tract infection between the ERCP group and the HJ group (15.6% vs 12.1%, P=0.519). However, in terms of complications of pancreatitis, it mainly occurred in the ERCP group (P=0.036) while biliary fistula mainly occurred in the HJ group (P=0.029). (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of hospitalization time and survival time\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe hospitalization time was from the first postoperative day to the discharge date. The average hospital stay in the ERCP group was 6.67\u0026plusmn;4.02 days, which was significantly shorter than that in the HJ group, which was 9.56\u0026plusmn;5.38 days (P\u0026lt;0.001),\u0026nbsp;as shown in Fig. 2. The total median follow-up time between the two groups was 12.8 (95%CI 10.9-14.7) months, and there was no significant difference in mOS between the ERCP group and the HJ group [mOS: 11.6 (95%CI 9.4-13.8) months \u003cem\u003evs\u003c/em\u003e 13.\u0026nbsp;3 (95%CI 10.7-15.9) months, P=0.978],\u0026nbsp;as shown in Fig. 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecurrence time of obstructive jaundice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe recurrence time of obstructive jaundice was from the first operation to the second operation. There were 11 cases of obstructive jaundice in the two groups after operation, including 8 (12.5%) cases in the ERCP group and 3 (2.8%) cases in the HJ group. Compared with the ERCP group, the recurrence time of obstructive jaundice was longer in the HJ group (P=0.007)(Fig. 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDistal bile duct obstruction due to malignancy has an insidious onset and no obvious clinical symptoms. When symptoms emerge, the patients are often already in an advanced disease stage or cannot undergo radical resection due to poor cardiopulmonary function. So, the main treatment measures for those patients are to relieve biliary obstruction and promote bile excretion. Long-term obstructive jaundice induces yellowing of the skin and sclera, skin itching, infection, liver insufficiency, renal insufficiency. Measures such as minus jaundice could reduce the functional impairment and clinical symptoms, improve the living quality of patients, and prolong the survival period of patients. At present, the measures to reduce jaundice are mainly divided into two aspects: internal drainage and external drainage. The palliative internal drainage is more in line with the physiological structure than the external drainage. Internal drainage relieves jaundice and corrects anhydrous electrolyte imbalance as well as digestive dysfunction, and maintains the enterohepatic circulation of bile better\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Long-term external drainage can easily lead to the loss of a large amount of bile and bile salts, causing electrolyte disturbances, intestinal dysfunction and other related problems. At the same time, the long-term external drainage tube may cause dislocate or prolapse of the drainage tube. And chronic inflammatory stimulation of the drainage tube orifice induces redness, swelling, heat and pain, etc., which affects the quality of life\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Relevant experimental studies have also shown that internal drainage is superior to external drainage in terms of intestinal immunity and bacterial translocation\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. At present, the commonly internal drainage methods are HJ and ERCP. In this study, the effects of reducing jaundice and improving liver function in the HJ group and the ERCP group were positive. There were statistical differences between preoperative and postoperative bilirubin and liver transaminase (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, there was no statistical difference between the HJ group and the ERCP group (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eCompared with ERCP, longer time of postoperative recovery and hospital stay were found in HJ group. So, ERCP has the advantages of less surgical trauma and faster postoperative recovery. This study found that the mean hospital stay in the ERCP group was significantly shorter than that in the HJ group (E6.67\u0026thinsp;\u0026plusmn;\u0026thinsp;4.02 days \u003cem\u003evs\u003c/em\u003e 9.56\u0026thinsp;\u0026plusmn;\u0026thinsp;5.38 days, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Because HJ and ERCP have no therapeutic effect on the tumor itself, they simply relieve the obstruction of the biliary tract and improve the liver function and physical condition. So, there was no difference in the effect of the two treatment methods on the OS of patients (P\u0026thinsp;=\u0026thinsp;0.978).\u003c/p\u003e \u003cp\u003ePostoperative complications were compared in this study. With the expanding of surgical techniques, the incidence of postoperative complications such as bleeding and incision infection in patients has dropped considerably. In this study, the main complications after ERCP were biliary tract infection and pancreatitis, while the main complications after HJ were biliary tract infection and biliary fistula. There was no significant difference in the overall complication rate between the ERCP group and the HJ group (21.9% \u003cem\u003evs\u003c/em\u003e 21.5%, P\u0026thinsp;=\u0026thinsp;0.953). Among them, there was no significant difference in biliary tract infection between the ERCP group and the HJ group (15.6% \u003cem\u003evs\u003c/em\u003e 12.1%, P\u0026thinsp;=\u0026thinsp;0.519). However, the complications of pancreatitis were mainly concentrated in the ERCP group (P\u0026thinsp;=\u0026thinsp;0.036). The occurrence of acute pancreatitis after ERCP. On the one hand, it is related to the difficulty of stent placement, causing damage to the nipple and Oddi sphincter, resulting in pancreatic juice drainage disorder\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. On the other hand, it is related to the damage of hydrostatic pressure in pancreatic duct caused by over filling of contrast agent\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. The incidence rate of acute pancreatitis in this study is 6.3%, which is consistent with the incidence of 4% \u0026minus;\u0026thinsp;8% in most research reports\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. And the complications of biliary fistula were mainly concentrated in the HJ group (10 cases, P\u0026thinsp;=\u0026thinsp;0.029). The occurrence of biliary fistula is mainly caused by anastomotic leakage. Generally, the biliary fistula rate after HJ varies from 2.3\u0026ndash;5.6%\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. In our study population, the incidence of biliary fistula was high (9.3%). The higher rate of biliary fistula may be related to the operation of the surgeon performing this step. In the HJ group, 72 patients underwent open surgery; 35 patients with laparoscopic surgery. There was no significant difference in the incidence of biliary fistula between the open HJ group and the laparoscopic HJ group (P\u0026thinsp;=\u0026thinsp;0.115). Therefore, laparoscopic surgery does not increase the risk of biliary fistula\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. This study investigated the recurrence time of obstructive jaundice. The results showed that the recurrence time of jaundice in the HJ group was longer than that in the ERCP group (2.8% \u003cem\u003evs\u003c/em\u003e 12.5%, P\u0026thinsp;=\u0026thinsp;0.007). Because the HJ site is usually located in the upper segment of the tumor bile duct, the postoperative jaundice recurrence time is longer. The recurrence time of jaundice after ERCP is short, which may be related to the progressive growth of tumor. The tumor tissue invades from the side hole of the stent and causes the obstruction of the bile duct stent, which leads to the recurrence of jaundice. For patients with recurrent jaundice, repeat ERCP or PTCD external drainage can be performed after evaluation.\u003c/p\u003e \u003cp\u003eAs a minimally invasive palliative treatment method, ERCP endoscopic bile duct stent implantation to relieve biliary obstruction has been widely carried out in clinical practice. According to the different materials of bile duct stents, they are divided into plastic stents and metal stents. Plastic stents are cheap and can be used for short-term jaundice reduction (preoperative treatment of malignant biliary obstruction and benign biliary stricture). Because of the poor support, plastic stents are easy to be compressed and deformed by tumor growth when used in the treatment of malignant biliary obstruction and jaundice reduction. The diameter of metal stent is several times bigger than that of the plastic stent after expansion, but is more expensive\u003csup\u003e[\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Also, metal stents have less bacterial proliferation and fixation surfaces, it is not conducive to biofilm formation and cholestasis, which may contribute to lower recurrence rate of jaundice compared with plastic stent\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. In a meta-analysis of different material biliary stents for the treatment of inoperable malignant distal biliary obstruction, the two types of stent had similar clinical success and complication rates in the treatment of malignant distal biliary obstruction. However, metal stents were associated with longer stent patency duration compared with plastic stents\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. At the same time, a study on the failure time of plastic stents and metal stents showed that stent failure occurred in 10/16 patients (62.5%) in the plastic stent group, while 4/18 patients (22.2%) in the metal stent group (p\u0026thinsp;=\u0026thinsp;0.034) and the median time to failure was 51 days for plastic stents and 80 days for metal stents (P\u0026thinsp;=\u0026thinsp;0.002)\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. According to two studies, metal bile duct stents are more suitable for malignant distal bile duct obstruction. With the development of materials science, newly stent designed to combined minus jaundice and anti-anti-tumor. Recent studies found that stent combined with \u003csup\u003e125\u003c/sup\u003eI particle strip implantation in the treatment of malignant obstructive jaundice can effectively alleviate jaundice, inhibit tumor growth and prolong survival time\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. Endoscopic ultrasound guided biliary drainage (EUS-BD) is a high-end endoscopic technology. It is an effective method for patients with obstructive jaundice who have failed ERCP. Although ERCP is still the gold standard, a large number of studies have shown that EUS-BD can be used as an alternative even in patients who can successfully accept ERCP\u003csup\u003e[\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e. After ERCP failed to treat unresectable cancer, EUS-BD was more popular than PTCD (40.9% vs 21.7%)\u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e. EUS-BD can be used as first-line treatment without ERCP.\u003c/p\u003e \u003cp\u003eIn 1986, Roux first advocated Y-type gastrojejunostomy with well clinical effect\u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e. Later, it was applied to the biliary tract to perform Y-type anastomosis of the bile duct and jejunum. HJ is the most commonly used surgical procedure for malignant obstructive jaundice. Since the Roux-en-Y jejunal loop has a complete vascular supply, it has sufficient length for long-distance movement. And the intestinal segment anastomosed with the bile duct is antegrade peristalsis, which can prevent the reflux of intestinal contents. During HJ, the biliary jejunal anastomosis is guaranteed to be unobstructed which ensures the drainage effect. Also, the huge trauma and economic burden caused by the second or even multiple surgical treatments are avoided. However, HJ has the disadvantages of large surgical trauma, long postoperative recovery time, high hospitalization cost, damage to the normal physiological function of Oddi's sphincter, and reflux of intestinal bacteria to the bile duct. With the development of science and technology and the application of laparoscope, such minimally invasive surgery can reduce the surgical blow and is easy to be accepted by patients\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWeaknesses of this study: (1) The impact of postoperative systemic therapy was not analyzed, which may affect the assessment of patient survival time; (2) Small sample size, single-center study; (3) The imbalance between the two groups may affect the statistics of postoperative complications;(4) Stent types were not distinguished, and different types of stents affected the time of recurrence of obstructive jaundice. Therefore, this study needs multi-center and large-scale samples for further verification. The innovation of this study is that there are no reported differences between ERCP bile duct stent implantation and HJ.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, the results of the study showed that there was no difference in survival time between the ERCP group and the HJ group. Two internal drainage measures achieved good clinical results in the treatment of MOJ, effectively reduced bilirubin and improved liver function. Nonetheless, we found no significant differences in the level of bilirubin decline or overall postoperative complication rates between the two groups. However, there are differences between the different complication rates, just like pancreatitis and biliary fistula. Although, ERCP has the advantages of less surgical trauma and shorter postoperative hospital stay, the HJ group has a longer recurrence time of obstructive jaundice, which avoids the trauma and economic pressure caused by readmission surgical treatment. Therefore, for the moment, considering all aspects, the long-term effect of HJ is better than ERCP.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDisclosure\u003c/h2\u003e \u003cp\u003eThe author reports no conflicts of interest in this work.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eL ZP wrote the article, H ZQ collected case data,N ZY and H YJ was responsible for designing the research plan, Y YZ and G HJ conducted statistical analysis, Z X and Z HQ assisted in patient coordination, L J and Y FJ provided guidance for the article writing.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eThis work is supported by National Natural Science Foundation of China (Grant No. 82200706).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFargo MV, Grogan SP, Saguil A. 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A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct.\u003cem\u003e Gastrointestinal endoscopy \u003c/em\u003e1998; \u003cstrong\u003e47\u003c/strong\u003e(1): 1-7 [PMID: 9468416 DOI: 10.1016/s0016-5107(98)70291-3]\u003c/li\u003e\n\u003cli\u003eMoss AC, Morris E, Mac Mathuna P. Palliative biliary stents for obstructing pancreatic carcinoma.\u003cem\u003e The Cochrane database of systematic reviews \u003c/em\u003e2006(1): Cd004200 [PMID: 16437477 DOI: 10.1002/14651858.CD004200.pub2]\u003c/li\u003e\n\u003cli\u003eScatimburgo M, Sagae VMT, Funari MP, Moura E, Bernardo W. Malignant distal biliary obstruction - palliative treatment-modality of endoscopic stent: metal stent \u0026times; plastic stent.\u003cem\u003e Revista da Associacao Medica Brasileira (1992) \u003c/em\u003e2022; \u003cstrong\u003e68\u003c/strong\u003e(4): 433-442 [PMID: 35649062 DOI: 10.1590/1806-9282.2022d684]\u003c/li\u003e\n\u003cli\u003eDavids PH, Groen AK, Rauws EA, Tytgat GN, Huibregtse K. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction.\u003cem\u003e Lancet (London, England) \u003c/em\u003e1992; \u003cstrong\u003e340\u003c/strong\u003e(8834-8835): 1488-1492 [PMID: 1281903 DOI: 10.1016/0140-6736(92)92752-2]\u003c/li\u003e\n\u003cli\u003eScatimburgo M, Ribeiro IB, de Moura DTH, Sagae VMT, Hirsch BS, Boghossian MB, McCarty TR, Dos Santos MEL, Franzini TAP, Bernardo WM, de Moura EGH. Biliary drainage in inoperable malignant biliary distal obstruction: A systematic review and meta-analysis.\u003cem\u003e World journal of gastrointestinal surgery \u003c/em\u003e2021; \u003cstrong\u003e13\u003c/strong\u003e(5): 493-506 [PMID: 34122738 PMCID: PMC8167848 DOI: 10.4240/wjgs.v13.i5.493]\u003c/li\u003e\n\u003cli\u003eSchmidt A, Riecken B, Rische S, Klinger C, Jakobs R, Bechtler M, K\u0026auml;hler G, Dormann A, Caca K. Wing-shaped plastic stents vs. self-expandable metal stents for palliative drainage of malignant distal biliary obstruction: a randomized multicenter study.\u003cem\u003e Endoscopy \u003c/em\u003e2015; \u003cstrong\u003e47\u003c/strong\u003e(5): 430-436 [PMID: 25590188 DOI: 10.1055/s-0034-1391232]\u003c/li\u003e\n\u003cli\u003eZhou WZ, Fu YM, Yang ZQ, Shi HB, Liu S, Xia JG, Zhou CG. 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Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review.\u003cem\u003e Gastrointestinal endoscopy \u003c/em\u003e2016; \u003cstrong\u003e83\u003c/strong\u003e(6): 1218-1227 [PMID: 26542374 DOI: 10.1016/j.gie.2015.10.033]\u003c/li\u003e\n\u003cli\u003eKhan M, Akbar A, Baron T, Khan S, Kocak M, Alastal Y, Hammad T, Lee W, Sofi A, Artifon E, Nawras A, Ismail M. Endoscopic Ultrasound-Guided Biliary Drainage: A Systematic Review and Meta-Analysis.\u003cem\u003e Digestive diseases and sciences \u003c/em\u003e2016; \u003cstrong\u003e61\u003c/strong\u003e(3): 684-703 [PMID: 26518417 DOI: 10.1007/s10620-015-3933-0]\u003c/li\u003e\n\u003cli\u003eKhashab M, Valeshabad A, Afghani E, Singh V, Kumbhari V, Messallam A, Saxena P, El Zein M, Lennon A, Canto M, Kalloo A. A comparative evaluation of EUS-guided biliary drainage and percutaneous drainage in patients with distal malignant biliary obstruction and failed ERCP.\u003cem\u003e Digestive diseases and sciences \u003c/em\u003e2015; \u003cstrong\u003e60\u003c/strong\u003e(2): 557-565 [PMID: 25081224 DOI: 10.1007/s10620-014-3300-6]\u003c/li\u003e\n\u003cli\u003ePalmieri V, Barkun A, Forbes N, Martel M, Lam E, Telford J, Sandha G, Paquin S, Sahai A, Chen Y. EUS-guided biliary drainage in malignant distal biliary obstruction: An international survey to identify barriers of technology implementation.\u003cem\u003e Endoscopic ultrasound \u003c/em\u003e2022 [PMID: 36204791 DOI: 10.4103/eus-d-21-00137]\u003c/li\u003e\n\u003cli\u003eHigashino M, Osugi H, Maekawa N, Tokuhara T, Tanimura S, Fukunaga Y, Kaseno S, Kinoshita H. [Usefulness of Roux-Y type bypass operation using pedicled jejunum in unresectable esophageal cancer].\u003cem\u003e Kyobu geka The Japanese journal of thoracic surgery \u003c/em\u003e1991; \u003cstrong\u003e44\u003c/strong\u003e(9): 753-758 [PMID: 1956136]\u003c/li\u003e\n\u003cli\u003eZhang H, Lan X, Peng B, Li B. Is total laparoscopic pancreaticoduodenectomy superior to open procedure? A meta-analysis.\u003cem\u003e World journal of gastroenterology \u003c/em\u003e2019; \u003cstrong\u003e25\u003c/strong\u003e(37): 5711-5731 [PMID: 31602170 DOI: 10.3748/wjg.v25.i37.5711]\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"704\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 704px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Preoperative baseline data of patients included in the study\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eERCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHJ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.019\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40(62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68(63.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24(37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39(36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.640\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026le;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13(20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34(31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e＞60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e51(79.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e73(68.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eECOG-PS, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.889\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.346\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34(31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48(75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e73(68.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTumour type, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.135\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.536\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePancreatic\u0026nbsp;head\u0026nbsp;carcinomas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39(60.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e77(72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLower common bile duct carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20(31.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21(19.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCarcinoma of Vaters ampulla\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2(3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4(3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAdenocarcinoma of duodenum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2(3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4(3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1(1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClinical feature，n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eJaundice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55(85.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e96(89.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.555\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.456\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCutaneous pruritus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18(28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23(21.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.966\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.326\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAbdominal\u0026nbsp;pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27(42.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e51(47.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.484\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.487\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSymptom of digestive tract\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25(39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36(33.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.512\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.474\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEpigastric discomfort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23(35.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e43(40.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.305\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.581\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWeight loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42(65.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e64(59.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.574\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.449\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHypertension, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29(45.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34(31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.154\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDiabetes，n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19(29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29(27.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.133\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.716\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSmoke，n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30(46.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40(37.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.492\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.222\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDrink，n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27(42.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41(38.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.250\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.617\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eThe liver function indicators in the two groups(`X\u0026plusmn;s)\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"520\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eGroups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eERCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHJ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eAST(U/L)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e156.3\u0026plusmn;102.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e164.9\u0026plusmn;127.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.458\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.648\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41.2\u0026plusmn;31.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.5\u0026plusmn;23.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.869\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eALT(U/L)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e189.4\u0026plusmn;144.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e221.6\u0026plusmn;157.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.327\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59.2\u0026plusmn;43.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65.2\u0026plusmn;51.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.431\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eALP(U/L)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e545.2\u0026plusmn;452.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e540.8\u0026plusmn;376.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.945\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e264.9\u0026plusmn;205.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e241.2\u0026plusmn;158.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.847\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.398\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eGGT(U/L)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e639\u0026plusmn;430.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e748.3\u0026plusmn;511.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.496\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.137\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e228\u0026plusmn;212.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e237.1\u0026plusmn;202.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.279\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.781\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eTB(\u0026mu;mol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e279.9\u0026plusmn;153.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e244\u0026plusmn;93.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.694\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.094\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80.7\u0026plusmn;68.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63\u0026plusmn;44.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.844\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.068\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 520px;\"\u003e\n \u003cp\u003eNote: \u0026beta; represents the intra-group comparison between the two groups, P \u0026lt; 0.05.\u003cbr\u003e\u0026nbsp;AST: aspartate aminotransferase; ALT: alanine aminotransferase; ALP: alkaline phosphatase；GGT: gamma-glutamyl transferase; TB: total bilirubin\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eThe postoperative complications in the two groups\u0026nbsp;(n, %)\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"578\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGroups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eERCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHJ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAcute pancreatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4(6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBiliary infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10(15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13(12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.416\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.519\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ebiliary\u0026nbsp;fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10(9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;Incidence of complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14(21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23(21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.953\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Malignant obstructive jaundice, Hepaticojejunostomy, ERCP, Jaundice reduction, Biliary fistula","lastPublishedDoi":"10.21203/rs.3.rs-5400124/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5400124/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eMalignant obstructive jaundice (MOJ) refers to intrahepatic or extrahepatic bile ducts obstruction caused by the compression or infiltrative growth of malignant tumors, followed by cholestasis and jaundice. Hepaticojejunostomy (HJ) and Endoscopic Retrograde Cholangiopancreatography (ERCP) bile duct stent implantation are the common palliative treatment to reduce jaundice. The aim of current research was to investigate which treatment was better for patients with MOJ.\u003c/p\u003e\u003ch2\u003ePatients and methods:\u003c/h2\u003e \u003cp\u003eA retrospective analysis of 171 patients with distal bile duct obstruction due to malignancy admitted to the Department of Hepatobiliary Surgery and Gastroenterology in our hospital from February 2013 to August 2021. According to different treatment options, patients were divided into ERCP group (n\u0026thinsp;=\u0026thinsp;64) and HJ group (n\u0026thinsp;=\u0026thinsp;107). The primary end point was overall survival (OS); the secondary end points were postoperative bilirubin level, hospitalization time, recurrence time of obstructive jaundice, and the occurrence of recent postoperative complications.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn this study, we found that There was no significant difference in the median OS between the ERCP group and the HJ group [mOS: 11.6 (95%CI9.4-13.8) months vs 13.3 (95%CI10.7-15.9) months, P\u0026thinsp;=\u0026thinsp;0.978]. There was no statistical difference in the effect of reducing jaundice between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The average hospitalization time in the ERCP group was 6.67\u0026thinsp;\u0026plusmn;\u0026thinsp;4.02 days, which was significantly shorter than that in the HJ group (9.56\u0026thinsp;\u0026plusmn;\u0026thinsp;5.38 days, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no significant difference in the total incidence of postoperative complications in the ERCP group compared with the HJ group (21.9% vs 21.5%, P\u0026thinsp;=\u0026thinsp;0.953). However, pancreatitis often occurred in the ERCP group (P\u0026thinsp;=\u0026thinsp;0.036). In terms of complications of biliary fistula, it mainly occurred in the HJ group (P\u0026thinsp;=\u0026thinsp;0.029). Compared with the ERCP group, the recurrence time of obstructive jaundice was longer in the HJ group (P\u0026thinsp;=\u0026thinsp;0.007).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study showed that both treatments can effectively reduce bilirubin and improve liver function in patients with distal bile duct obstruction due to malignancy. Considering the long-term effect, HJ is superior to ERCP bile duct stenting.\u003c/p\u003e","manuscriptTitle":"Clinical outcomes of hepaticojejunostomy and ERCP endoscopic bile duct stent implantation in the treatment of malignant obstructive jaundice: a retrospective analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-16 05:59:43","doi":"10.21203/rs.3.rs-5400124/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b2fd3f36-67f6-45f2-a174-58003322e77b","owner":[],"postedDate":"December 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-03T21:23:22+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-16 05:59:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5400124","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5400124","identity":"rs-5400124","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}