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Moon JH, Choi HJ, Koo HC, Han SH, Lee TH, Cho YD, Park SH, Kim SJ. Feasibility of placing a modified fully covered self-expandable metal stent above the papilla to minimize stent-induced bile duct injury in patients with refractory benign biliary strictures (with videos). Gastrointest Endosc 2012; 75:1080-5. [PMID: 22401821 DOI: 10.1016/j.gie.2012.01.016] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 01/09/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic placement of fully covered self-expandable metal stents (FCSEMS) has been attempted to manage benign biliary strictures, but currently available FCSEMSs may be associated with unintended complications, including de novo strictures, in patients with normal life expectancy. OBJECTIVE To evaluate the feasibility of an intraductally placed modified FCSEMS to minimize stent-induced bile duct injury in patients with benign biliary strictures. DESIGN Prospective observational clinical feasibility study. SETTING Tertiary-care academic center. PATIENTS This study involved 21 patients with symptomatic benign biliary strictures in whom conventional endoscopic management failed. INTERVENTION Strictured segments were 15 mm above the ampulla of Vater. The modified FCSEMS has convex margins, a lasso, and an anti-migrating waist on the central portion. Stents were placed entirely above the papilla and removed after 3 to 5 months. MAIN OUTCOME MEASUREMENTS Success, complications, removability, midterm outcome. RESULTS FCSEMSs were successfully placed inside the bile duct in all patients. No episodes of pancreatitis, cholangitis, or sepsis were noted during the stenting period. Stent migration occurred in 4 patients (19.0%), but 3 were asymptomatic during follow-up. All stents were removed successfully with rat-tooth forceps without complications. Post-stenting cholangiograms showed improvement of strictures in 20 of 21 patients, without de novo focal stricture. The clinical success rate was 95.2%, with one recurrent stricture. LIMITATIONS The small number and lack of comparison with other types of FCSEMSs. CONCLUSION Temporary intraductal placement of a newly modified FCSEMS effectively improved strictures and prevented potential stent-induced complications in patients with benign biliary strictures. Controlled large-scale trials are needed to confirm the long-term efficacy.
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Affiliation(s)
- Jong Ho Moon
- Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon/Seoul, Korea.
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152
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Yasuda I, Mukai T, Doi S, Tomita E, Moriwaki H. Temporary placement of covered self-expandable metallic stents in the management of benign biliary strictures. Dig Endosc 2012; 24 Suppl 1:28-33. [PMID: 22533748 DOI: 10.1111/j.1443-1661.2012.01273.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Currently, endoscopic intervention is widely attempted as the first-line treatment of benign biliary strictures because of its convenience and low morbidity. Plastic tube stents (PS) are usually used for such treatment; however, covered self-expandable metallic stents (C-SEMS) are becoming more commonly used at some institutions. The temporary placement of C-SEMS may lead to better outcomes because of their larger diameter and, therefore, better dilation of the stricture, especially in refractory cases. The aim of the present study was to evaluate the efficacy of the temporary placement of C-SEMS in the management of benign biliary strictures. METHODS We retrospectively reviewed our endoscopic retrograde cholangiopancreatography (ERCP) database (May 1996 to December 2010), and extracted the data of patients who underwent endoscopic treatment for benign biliary strictures. Then, the follow-up data from patient charts were reviewed to determine the long-term outcomes of those procedures. RESULTS All patients (n = 56) initially had a PS placed, with or without balloon dilation. However, C-SEMS placement was later attempted in 12 patients because the stricture was refractory to placement of the PS. During their follow-up periods, two patients died of unrelated diseases after 15 and 17 months, and another two still had the C-SEMS in place after 9 and 50 months. In the remaining eight patients, the C-SEMS was removed after a median placement period of 6 months (range, 2-15). Seven patients in this group have not experienced a recurrence at a median follow-up time of 48 months. However, in one patient, stenosis did recur 8 months after the C-SEMS was removed. CONCLUSIONS Temporary placement of C-SEMS can be a treatment option for benign biliary strictures, especially in refractory cases.
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Affiliation(s)
- Ichiro Yasuda
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
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153
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Klare P, Weber A, Dobritz M, Born P, Füllner R, Schmid RM, von Delius S. [Endoscopic and percutaneous intervention in the long-term treatment of benign biliary stenosis. A 71-year-old patient with cholestasis following radiotherapy]. Internist (Berl) 2012; 53:874-81. [PMID: 22527667 DOI: 10.1007/s00108-012-3053-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Benign biliary stenosis can have various causes and requires differentiation from disorders caused by malignant disease. Treatment of benign stenosis is often difficult and includes treatment modalities such as endoscopic, percutaneous or surgical interventions. Exact knowledge of the etiology and localization of the stenosis is essential when selecting the appropriate method of treatment. Here we present the case of a 71-year-old patient admitted to our hospital with cholangitis 13 years after undergoing radiotherapy of the renal bed due to hypernephroma of the right kidney. The patient was diagnosed with common bile duct stenosis due to the secondary effects of radiation, which is rarely reported in the literature. Our case covers a total treatment period of 15 years, enabling us to also discuss a viable sequence of treatment modalities in the treatment of benign bile duct stenosis.
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Affiliation(s)
- P Klare
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
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154
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García-Cano J. Use of fully covered self-expanding metal stents in benign biliary diseases. World J Gastrointest Endosc 2012; 4:142-7. [PMID: 22523615 PMCID: PMC3329614 DOI: 10.4253/wjge.v4.i4.142] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Revised: 02/24/2012] [Accepted: 03/30/2012] [Indexed: 02/05/2023] Open
Abstract
Biliary fully covered self-expanding metal stents (FCSEMS) are now being used to treat several benign biliary conditions. Advantages include small predeployment and large postexpansion diameters in addition to an easy insertion technique. Lack of imbedding of the metal into the bile duct wall enables removability. In benign biliary strictures that usually require multiple procedures, despite the substantially higher cost of FCSEMS compared with plastic stents, the use of FCSEMS is offset by the reduced number of endoscopic retrograde cholangiopancreatography interventions required to achieve stricture resolution. In the same way, FCSEMS have also been employed to treat complex bile leaks, perforation and bleeding after endoscopic biliary sphincterotomy and as an aid to maintain permanent drainage tracts obtained by means of Endoscopic Ultrasound-guided biliary drainage. Good success rates have been achieved in all these conditions with an acceptable number of complications. FCSEMS were successfully removed in all patients. Comparative studies of FCSEMS and plastic stents are needed to demonstrate efficacy and cost-effectiveness
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Affiliation(s)
- Jesús García-Cano
- Jesús García-Cano, Department of Digestive Diseases, Hospital Virgen de la Luz, 16002 Cuenca, Spain
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155
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Poley JW, Cahen DL, Metselaar HJ, van Buuren HR, Kazemier G, van Eijck CHJ, Haringsma J, Kuipers EJ, Bruno MJ. A prospective group sequential study evaluating a new type of fully covered self-expandable metal stent for the treatment of benign biliary strictures (with video). Gastrointest Endosc 2012; 75:783-9. [PMID: 22325806 DOI: 10.1016/j.gie.2011.10.022] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 10/15/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Fully-covered self expandable metal stents (fcSEMSs) are an alternative to progressive plastic stenting for the treatment of benign biliary strictures (BBS) with the prospect of a higher treatment efficacy and the need for fewer ERCPs, thereby reducing the burden for patients and possibly costs. Key to this novel treatment is safe stent removal. OBJECTIVE To investigate the feasibility and safety of stent removal of a fcSEMS with a proximal retrieval lasso: a long wire thread integrated in the proximal ends of the wire mesh that hangs freely in the stent lumen. Pulling it enables gradual removal of the stent inside-out. A secondary aim was success of stricture resolution. DESIGN Non-randomized, prospective follow-up study with 3 sequential cohorts of 8 patients with BBS. SETTING Academic tertiary referral center. PATIENTS Eligible patients had strictures either postsurgical (post-cholecystectomy (LCx) or liver transplantation (OLT)), due to chronic pancreatitis (CP), or papillary stenosis (PF). Strictures had to be located at least 2 cm below the liver hilum. All patients had one plastic stent in situ across the stricture and had not undergone previous treatment with either multiple plastic stents or fcSEMS. INTERVENTIONS The first cohort of patients underwent stent placement for 2 months, followed by 3 months if the stricture had not resolved. The second and third cohort started with 3 months and 4 months, respectively, both followed by another 4 months if indicated. Treatment success was defined by stricture resolution at cholangiography, the ability to pass an inflated extraction balloon and clinical follow-up (at least 6 months). MAIN OUTCOME MEASUREMENT safety of stent removal. Secondary outcomes were complications and successful stricture resolution. RESULTS A total of 23 patients (11 female; 20-67 yrs) were eligible for final analysis. One patient developed a malignant neuroendocrine tumor in the setting of CP. Strictures were caused by CP (13), OLT (6), LCx (3) and PF (1). In total 39 fcSEMS were placed and removed. Removals were easy and without complications. Transient pain after insertion was common (13 of 23/56%) but was easily managed by analgesics in all patients. Other complications were cholecystitis (1), cholangitis due to stent migration (1, stent replaced) or stent clogging (2, managed endoscopically) and worsening of CP (2). In these patients, the fcSEMS was removed and replaced after pancreatic sphincterotomy and PD stent placement. Median follow-up was 15 months (range 11-25). Overall treatment success was 61% (14/23); in the CP group 46%, in the remaining patients 80% (p = 0.11). Patients with stricture resolution after removal of the first stent (n = 7; success 6/7) showed a trent towards a more sustained treatment success than patients who needed a 2nd stent placement (n = 16; success 8/16); p = 0.12). LIMITATIONS Small number of patients with regard to secondary outcomes. CONCLUSION Removal of a new type of fcSEMS with a proximal retrieval lasso in patients with BBS proved easy and uncomplicated. Treatment success for CP strictures was higher compared to what is known from results of progressive plastic stenting protocols. For other indications treatment success was comparable to progressive plastic stenting, but with the prospect of fewer ERCP procedures.
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Affiliation(s)
- Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
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156
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Cheon YK, Oh HC, Cho YD, Lee TY, Shim CS. New 10F soft and pliable polyurethane stents decrease the migration rate compared with conventional 10F polyethylene stents in hilar biliary obstruction: results of a pilot study. Gastrointest Endosc 2012; 75:790-7. [PMID: 22301338 DOI: 10.1016/j.gie.2011.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Accepted: 11/09/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Migration of biliary stents is a well-documented problem that can result in a variety of complications. The newly designed polyurethane (PU) stent, which is made of a soft and pliable material, may prevent distal and proximal stent migration. OBJECTIVE To compare the migration rate of the PU stent with that of the conventional polyethylene stent (PE). DESIGN Prospective, comparative, randomized trial. SETTING Tertiary academic medical centers. PATIENTS Fifty patients with a hilar stricture who had not undergone a previous drainage procedure. INTERVENTION In patients with hilar stricture, random assignment of either a PU stent or PE stent. MAIN OUTCOME MEASUREMENT The rate of early proximal or distal migration before stent occlusion. RESULTS Overall and distal migration rates were significantly lower in the PU group than in the PE group (4.5% vs 29%, P = .032 and 4.5% vs 26.1%, P = .049, respectively). There was no significant difference between the migration rate in benign and malignant biliary strictures (5.9% vs 21.4%, P = .167). Sex, stent length, preprocedure bilirubin level, and Bismuth type were not associated with migration rate in either the PU or PE group. Median stent patency was 148 days (range 36-224 days) in the PU group and 151 days (range 40-241 days) in the PE group (P = .891). LIMITATIONS Small sample size. CONCLUSIONS Use of the new PU stent, which is soft and pliable, decreased distal migration. The PU stent patency rates appear similar, but this study is not powered to demonstrate equivalency of patency.
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Affiliation(s)
- Young Koog Cheon
- Digestive Disease Center, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea.
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157
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Abstract
Endoscopic therapy is essential in the management of malignant and benign biliary strictures. With new advancements in biliary stent technology and the many controversies surrounding biliary stenting, managing biliary strictures is not always straightforward. The purpose of this article is to review the major issues surrounding biliary stenting, summarize current treatment strategies, discuss advancements in stent technologies, and describe emerging indications of biliary stents.
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158
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Affiliation(s)
- Bret T Petersen
- Mayo Clinic and College of Medicine Rochester, Minnesota, USA
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159
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Haapamäki C, Udd M, Halttunen J, Lindström O, Mäkisalo H, Kylänpää L. Endoscopic treatment of anastomotic biliary complications after liver transplantation using removable, covered, self-expandable metallic stents. Scand J Gastroenterol 2012; 47:116-21. [PMID: 22150121 DOI: 10.3109/00365521.2011.639082] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Anastomotic bile duct complications after liver transplantation (LT) have been treated endoscopically by dilation and plastic tube stenting, with the stent therapy having moved toward using covered, self-expandable metallic stents (cSEMS) in recent years. The aim of this study was to analyze therapy outcome of post-LT anastomotic complications using cSEMS. MATERIAL AND METHODS Seventeen post-LT patients had 29 cSEMS (Allium stent, n = 23; Wallstent, n = 4; Micro-Tech, n = 2) placed during endoscopic retrograde cholangiopancreatography (ERCP). The fully covered stents (Allium, Micro-Tech) were placed entirely inside the common bile duct. Data were collected and analyzed in a retrospective manner. RESULTS These 17 patients had 19 stent treatment periods. Resolution was eventually established in all patients. There were four (14%) stent migrations. Pancreatitis was seen after one ERCP procedure, whereas five cases of cholangitis were seen. CONCLUSION Treatment of post-LT anastomotic complications with cSEMS seems to be both safe and efficient. Further assessment regarding indications, stent types and stenting time is needed.
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Affiliation(s)
- Carola Haapamäki
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
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160
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Gupta R, Reddy DN. Stent selection for both biliary and pancreatic strictures caused by chronic pancreatitis: multiple plastic stents or metallic stents? JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:636-9. [PMID: 21644060 DOI: 10.1007/s00534-011-0405-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Endoscopic stenting is an effective treatment option in the management of both benign biliary strictures and pancreatic ductal strictures. Plastic stents and self-expandable metal stents have been used with variable success for the management of both benign biliary strictures and pancreatic ductal strictures caused by chronic pancreatitis. Fully covered self-expandable metal stents of improved design represent a major technological advance which has added to the endoscopic armamentarium. Both multiple plastic stents and covered self-expandable metal stents have shown promising results. However, data to support the use of self-expandable metal stents over multiple plastic stents or vice versa are still lacking.
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Affiliation(s)
- Rajesh Gupta
- Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India
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161
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Endoscopic stenting for post-transplant biliary stricture: usefulness of a novel removable covered metal stent. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:640-5. [PMID: 21643818 DOI: 10.1007/s00534-011-0408-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic management of biliary anastomotic stricture (AS) following liver transplantation (LT) remains challenging. There are no dedicated self-expandable metal stents (SEMS) for this setting. METHODS A short fully covered SEMS (FCSEMS) with a retrieval suture was designed. Between July 2008 and June 2010, 13 patients with post-LT AS had this FCSEMS placed endoscopically, keeping the whole stent inside the bile duct across the AS with the retriever out of the papilla. The stents were removed by forceps under endoscopy according to a schedule. Technical success, complications, AS resolution and the outcome for the patients were observed. RESULTS Placement of the FCSEMS was successful on the first attempt in all patients. One patient with complicated infection did not respond to the stenting therapy and underwent stent retrieval ahead of schedule. Others kept well during stenting for a mean (SD) duration of 5.4 (1.7) months (range 2-8) without stent migration. All stents were removed successfully without great difficulty. AS resolution was obtained in all 12 patients, who were closely followed up for a mean (SD) time of 12.1 (8.0) months (range 1-26.5) after stent removal. Stricture recurrence occurred in one, who underwent a successful re-intervention with a second FCSEMS. Others remain free from symptoms and have normal liver function up to now. CONCLUSIONS Endoscopic treatment of post-LT AS using a removable FCSEMS is technically feasible, safe, and effective. This dedicated method may play an increasing role in the future management of benign biliary strictures.
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162
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Park JK, Moon JH, Choi HJ, Min SK, Lee TH, Cheon GJ, Cheon YK, Cho YD, Park SH, Kim SJ. Anchoring of a fully covered self-expandable metal stent with a 5F double-pigtail plastic stent to prevent migration in the management of benign biliary strictures. Am J Gastroenterol 2011; 106:1761-5. [PMID: 21788992 DOI: 10.1038/ajg.2011.212] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Fully covered self-expandable metal stents (FCSEMSs) can be effectively placed in patients with benign biliary stricture (BBS). However, stent migration is an inherent problem of FCSEMSs. We evaluated the efficacy of anchoring with a 5F double-pigtail plastic stent (anchoring stent) to prevent migration of an FCSEMS in patients with BBS. METHODS Between January 2007 and December 2009, 33 of 37 consecutive patients with BBS who had experienced treatment failure of at least one plastic stent placement were prospectively enrolled in this study. The patients with BBS were randomly assigned to undergo FCSEMS placement with or without an anchoring stent (anchoring group: 16 patients; non-anchoring group: 17 patients). The main outcome measures were the stent migration rate and success rates. RESULTS The technical success rate was 100% in both groups. Significantly less stent migration occurred in the anchoring group (6.3%, 1/16) than in the non-anchoring group (41.2%, 7/17; P=0.024). The median indwelling time was significantly longer in the anchoring group (154 days; range, 86-176 days) than in the non-anchoring group (114 days; range, 19-162 days; P=0.010). Improvement or resolution of the BBS was confirmed in 15 of 16 patients (93.8%) in the anchoring group, and in 12 of 17 patients (70.6%) in the non-anchoring group (P=0.101). CONCLUSIONS The placement of an anchoring stent appears to be a simple and effective method of preventing premature migration of FCSEMSs in patients with BBS. Appropriately powered studies are needed to confirm this finding.
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Affiliation(s)
- Jong Kyu Park
- Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon and Seoul, Korea
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163
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Poley JW, van Tilburg AJP, Kuipers EJ, Bruno MJ. Breaking the barrier: using extractable fully covered metal stents to treat benign biliary hilar strictures. Gastrointest Endosc 2011; 74:916-20. [PMID: 21821252 DOI: 10.1016/j.gie.2011.05.050] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 05/30/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Most benign biliary strictures nowadays are managed endoscopically with plastic stents or with a insertion of a fully covered self-expandable metal stent (fcSEMS). The paradigm for the treatment of benign hilar strictures precludes the use of an fcSEMS because it obstructs the intrahepatic bile ducts, in particular, the contralateral hepatic duct. It is unknown whether use of a plastic stent in the opposite hepatic duct after deployment of an fcSEMS across the liver hilum provides an adequate solution for this problem. OBJECTIVE To evaluate the use of an fcSEMS in combination with a contralateral plastic stent in the treatment of benign hilar strictures. DESIGN Case series. SETTING Tertiary referral hospital. PATIENTS Two consecutive patients with benign hilar strictures. INTERVENTIONS Placement of an intrahepatically deployed fcSEMS in conjunction with a contralateral 10F plastic stent for 4 to 5 months followed by stent removal and cholangiogram. MAIN OUTCOME MEASUREMENTS Clinical and laboratory follow-up of at least 9 months. RESULTS In both patients, the indwelling period of the stents was uneventful as was stent removal. Both strictures resolved, and there were no clinical or biochemical signs of a recurrent stricture. LIMITATIONS Small number of patients. CONCLUSIONS Treatment of benign hilar strictures with an fcSEMS deployed across the liver hilum in conjunction with a contralateral plastic stent placement is feasible without ensuing cholangitis caused by bile duct occlusion.
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Affiliation(s)
- Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
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164
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Vellody R, Willatt JM, Arabi M, Cwikiel WB. Temporary placement of stent grafts in postsurgical benign biliary strictures: a single center experience. Korean J Radiol 2011; 12:708-13. [PMID: 22043153 PMCID: PMC3194775 DOI: 10.3348/kjr.2011.12.6.708] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 06/09/2011] [Indexed: 01/19/2023] Open
Abstract
Objective To evaluate the effect of temporary stent graft placement in the treatment of benign anastomotic biliary strictures. Materials and Methods Nine patients, five women and four men, 22-64 years old (mean, 47.5 years), with chronic benign biliary anastomotic strictures, refractory to repeated balloon dilations, were treated by prolonged, temporary placement of stent-grafts. Four patients had strictures following a liver transplantation; three of them in bilio-enteric anastomoses and one in a choledocho-choledochostomy. Four of the other five patients had strictures at bilio-enteric anastomoses, which developed after complications following laparoscopic cholecystectomies and in one after a Whipple procedure for duodenal carcinoma. In eight patients, balloon-expandable stent-grafts were placed and one patient was treated by insertion of a self-expanding stent-graft. Results In the transplant group, treatment of patients with bilio-enteric anastomoses was unsuccessful (mean stent duration, 30 days). The patient treated for stenosis in the choledocho-choledochostomy responded well to consecutive self-expanding stent-graft placement (total placement duration, 112 days). All patients with bilio-enteric anastomoses in the non-transplant group were treated successfully with stent-grafts (mean placement duration, 37 days). Conclusion Treatment of benign biliary strictures with temporary placement of stent-grafts has a positive effect, but is less successful in patients with strictures developed following a liver transplant.
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Affiliation(s)
- Ranjith Vellody
- Department of Radiology, Division of Interventional Radiology, University of Michigan, MI 48109-5868, USA.
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165
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Abstract
Endoscopic treatment is the mainstay of therapy for benign billiary strictures, and surgery is reserved for selected patients in whom endoscopic treatment fails or is not feasible. The endoscopic approach depends mainly on stricture etiology and location, and generally involves the placement of one or multiple plastic stents, dilation of the stricture(s), or a combination of these approaches. Knowledge of biliary anatomy, endoscopy experience and a well-equipped endoscopy unit are necessary for the success of endoscopic treatment. This Review discusses the etiologies of benign biliary strictures and different endoscopic therapies and their respective outcomes. Data on newer therapies, such as the placement of self-expandable metal stents, and the treatment of biliary-enteric anastomotic strictures is also reviewed.
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Affiliation(s)
- Sergio Zepeda-Gómez
- Department of Gastrointestinal Endoscopy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Tlalpan, 14000 Mexico City, Mexico
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166
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Gupta K, Aparicio D, Freeman ML, Sakai C, Paione JB, Artifon ELA. Endoscopic biliary recanalization by using a needle catheter in patients with complete ligation or stricture of the bile duct: safety and feasibility of a novel technique (with videos). Gastrointest Endosc 2011; 74:423-8. [PMID: 21612775 DOI: 10.1016/j.gie.2011.03.1234] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 03/20/2011] [Indexed: 02/08/2023]
Affiliation(s)
- Kapil Gupta
- Department of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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167
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Hamada T, Nakai Y, Matsubara S, Isayama H, Narita A, Watanabe K, Koike Y, Matsukawa S, Kawase T, Koike K. Anchor-wire technique for multiple plastic biliary stents to prevent stent dislocation. World J Gastroenterol 2011; 17:3366-8. [PMID: 21876627 PMCID: PMC3160543 DOI: 10.3748/wjg.v17.i28.3366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 12/27/2010] [Accepted: 01/03/2011] [Indexed: 02/06/2023] Open
Abstract
In endoscopic placement of multiple plastic biliary stents (PBSs), we sometimes experience proximal dislocation of the first PBS at the time of subsequent PBS insertion. We describe the case of a 79-year-old male with obstructive jaundice caused by cholangiocarcinoma who needed to receive multiple PBS placements for management of cholangitis. Although proximal dislocation of the first PBS was observed, we prevented the dislocation via our technique of using guidewire inserted from the distal end of the first PBS to the side hole as the anchor-wire. We could complete this technique only by inserting guidewire through the side hole of the first PBS during the process of releasing the first PBS and pulling out the guidewire and the inner sheath. It did not matter whether the anchor-wire went towards the third portion of the duodenum or the duodenal bulb. Here we introduce this “anchor-wire technique”, which is useful for the prevention of PBS proximal dislocation in placing multiple PBSs.
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168
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Abstract
Biliary plastic stenting plays a key role in the endoscopic management of benign biliary diseases. Complications following surgery of the biliary tract and liver transplantation are amenable to endoscopic treatment by plastic stenting. Insertion of an increasing number of plastic stents is currently the method of choice to treat postoperative biliary strictures. Benign biliary strictures secondary to chronic pancreatitis or primary sclerosing cholangitis may benefit from plastic stenting in select cases. There is a role for plastic stent placement in nonoperative candidates with acute cholecystitis and in patients with irretrievable bile duct stones.
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169
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Abstract
Benign biliary diseases include benign biliary strictures (BBS), choledocholithiasis, and leaks. BBS encompass postoperative injury, anastomotic stricture, chronic pancreatitis, primary sclerosing cholangitis, and gallstone-related stricture. Therapeutic options for benign biliary diseases include surgical, percutaneous, and endoscopic interventions. Endoscopic options include placement of plastic stents as well as self-expanding metal stents (SEMS). SEMS can be uncovered, partially covered, and fully covered, and have been used with some success in resolution of strictures and leaks; however, complications limit their use. This article reviews the currently published experience on SEMS and attempts to define their current role in the treatment of benign biliary diseases.
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170
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Wang CM, Li X, Song S, Lv X, Luan J, Dong G. Newly designed Y-configured single-catheter stenting for the treatment of hilar-type nonanastomotic biliary strictures after orthotopic liver transplantation. Cardiovasc Intervent Radiol 2011; 35:184-9. [PMID: 21710309 DOI: 10.1007/s00270-011-0214-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 06/13/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE This study was designed to introduce our novel technique of percutaneous single catheter placement into the hilar bile ducts strictures while fulfilling the purpose of bilateral biliary drainage and stenting. We investigated the efficacy and safety of the technique for the treatment of hilar nonanastomotic biliary strictures. METHODS Ten patients who were post-orthotopic liver transplantation between July 2000 and July 2010 were enrolled in this study. Percutaneous Y-configured single-catheter stenting for bilateral bile ducts combined with balloon dilation was designed as the main treatment approach. Technical success rate, clinical indicators, complications, and recurrent rate were analyzed. RESULTS Technical success rate was 100%. Nine of the ten patients had biochemical normalization, cholangiographic improvement, and clinical symptoms relief. None of them experienced recurrence in a median follow-up of 26 months after completion of therapy and removal of all catheters. Complications were minor and limited to two patients. The one treatment failure underwent a second liver transplantation but died of multiple system organ failure. CONCLUSIONS Percutaneous transhepatic Y-configured single-catheter stenting into the hilar bile ducts is technically feasible. The preliminary trial of this technique combined with traditional PTCD or choledochoscopy for the treatment of hilar biliary strictures after orthotopic liver transplantation appeared to be effective and safe. Yet, further investigation is needed.
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Affiliation(s)
- Chang Ming Wang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Peking 100191, People's Republic of China
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171
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Abstract
Biliary strictures are one of the most common complications following liver transplantation, representing an important cause of morbidity and mortality in transplant recipients. The reported incidence of biliary stricture is 5% to 15% following deceased donor liver transplantations and 28% to 32% following living donor liver transplantations. Bile duct strictures following liver transplantation are easily and conveniently classified as anastomotic strictures (AS) or non-anastomotic strictures (NAS). NAS are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and the need for retransplantation. Current endoscopic strategies to correct biliary strictures following liver transplantation include repeated balloon dilatations and the placement of multiple side-by-side plastic stents. Endoscopic balloon dilatation with stent placement is successful in the majority of AS patients. In patients for whom gaining biliary access is technically difficult, a combined endoscopic and percutaneous/surgical approach proves quite useful. Future directions, including novel endoscopic retrograde cholangiopancreatography techniques, advanced endoscopy, and improved stents could allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. The aim of this review is to detail the present status of endoscopy in the diagnosis, treatment, outcome, and future directions of biliary strictures related to orthotopic liver transplantation from the viewpoint of a clinical gastroenterologists.
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Affiliation(s)
- Choong Heon Ryu
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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172
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Abstract
Biliary strictures are one of the most common complications following liver transplantation, representing an important cause of morbidity and mortality in transplant recipients. The reported incidence of biliary stricture is 5% to 15% following deceased donor liver transplantations and 28% to 32% following living donor liver transplantations. Bile duct strictures following liver transplantation are easily and conveniently classified as anastomotic strictures (AS) or non-anastomotic strictures (NAS). NAS are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and the need for retransplantation. Current endoscopic strategies to correct biliary strictures following liver transplantation include repeated balloon dilatations and the placement of multiple side-by-side plastic stents. Endoscopic balloon dilatation with stent placement is successful in the majority of AS patients. In patients for whom gaining biliary access is technically difficult, a combined endoscopic and percutaneous/surgical approach proves quite useful. Future directions, including novel endoscopic retrograde cholangiopancreatography techniques, advanced endoscopy, and improved stents could allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. The aim of this review is to detail the present status of endoscopy in the diagnosis, treatment, outcome, and future directions of biliary strictures related to orthotopic liver transplantation from the viewpoint of a clinical gastroenterologists.
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Affiliation(s)
- Choong Heon Ryu
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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173
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Ichiya T, Maguchi H, Takahashi K, Katanuma A, Osanai M, Kin T. Endoscopic management of laparoscopic cholecystectomy-associated bile duct injuries. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:81-6. [PMID: 20676698 DOI: 10.1007/s00534-010-0315-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE The efficacy of the endoscopic management of laparoscopic cholecystectomy (LC)-associated bile duct injuries is unclear because few studies on the issue report methods matched to injury type or long-term follow-up data. METHODS Records from our institution's 11-year experience with the endoscopic management of LC-associated bile duct injuries were reviewed. Leakage was managed with a 5- to 7F endoscopic nasobiliary drainage (ENBD) tube for 1 week without endoscopic sphincterotomy (EST). Stricture was managed with the placement of a single 7F plastic stent for 1-2 months without EST. RESULTS Fifteen cases were experienced. Of the 11 cases (77.8%) of leakage, 7 improved clinically and on imaging after ENBD, 2 did not resolve until after the placement of a single plastic 7F stent for several more days, and 2 others with leakage and high risk for accidental ENBD removal improved after the placement of a single 7F stent. All 4 cases of stricture resolved completely after the placement of a single 7F stent. There were no severe complications of the endoscopic procedure. At long-term follow-up, no patient had recurrence of symptoms or complications on imaging. CONCLUSIONS ENBD for leakage and biliary stenting for strictures are safe and effective treatments for these LC-associated injuries.
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Affiliation(s)
- Tamaki Ichiya
- Center for Gastroenterology, Teine-Keijinkai Hospital, 1-jo 12-chome, Maeda, Teine-ku, Sapporo 006-8555, Japan.
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174
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Baillie J. Clinical trial report: endoscopic treatment of postoperative bile duct strictures using multiple stents: long-term results. Curr Gastroenterol Rep 2011; 13:114-116. [PMID: 21222058 DOI: 10.1007/s11894-010-0173-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- John Baillie
- Section on Gastroenterology, Wake Forest University Baptist Medical Center, Nutrition Building, Floor E, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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175
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Anchoring flap versus flared end, fully covered self-expandable metal stents to prevent migration in patients with benign biliary strictures: a multicenter, prospective, comparative pilot study (with videos). Gastrointest Endosc 2011; 73:64-70. [PMID: 21184871 DOI: 10.1016/j.gie.2010.09.039] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 09/24/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recently, placement of fully covered self-expandable metal stents (FCSEMSs) has been proposed as an alternative treatment for the management of benign biliary strictures. However, the major limitations of FCSEMSs are frequent migration and removal complications. OBJECTIVE We conducted this study to compare the antimigration effects, complication rates, and short-term efficacy of 2 FCSEMSs with either an anchoring flap (AF) or a flared end (FE) at the proximal end of the stent. DESIGN A multicenter, prospective comparative pilot study. SETTING Two tertiary referral centers. PATIENTS A total of 43 patients with benign biliary stricture who were candidates for placement of FCSEMSs were assigned to the AF (n = 22) or the FE group (n = 21). INTERVENTIONS Predefined duration of placement and removal of FCSEMSs. RESULTS After a median period of placement of 6 months (interquartile range 4-6), no patients in the AF group and 33% of patients (7 of 21, 1 in proximal and 6 in distal) in the FE group had stent migration (P = .004). The removal rate of the FCSEMSs was 100% in both groups (per protocol, n = 22 in the AF group and n = 17 in the FE group). Immediate improvement of biliary stricture was 91% (20/22, per protocol) in the AF group and 88% (15/17, per protocol) in the FE group. All stents were removed without difficulty. LIMITATIONS Short-term follow-up after the removal of FCSEMSs. CONCLUSIONS With regard to the antimigration effect of FCSEMSs for benign biliary stricture, the AF design may be superior to the FE. For up to 6 months, both FCSEMSs can be endoscopically removed without complications. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00945516.).
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176
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Akamatsu N, Sugawara Y, Hashimoto D. Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: a systematic review of the incidence, risk factors and outcome. Transpl Int 2010; 24:379-92. [PMID: 21143651 DOI: 10.1111/j.1432-2277.2010.01202.x] [Citation(s) in RCA: 224] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biliary reconstruction remains common in postoperative complications after liver transplantation. A systematic search was conducted on the PubMed database and 61 studies of retrospective or prospective institutional data were eligible for this review. The study comprised a total of 14,359 liver transplantations. The overall incidence of biliary stricture was 13%; 12% among deceased donor liver transplantation (DDLT) patients and 19% among living donor liver transplantation (LDLT) recipients. The overall incidence of biliary leakage was 8.2%, 7.8% among DDLT patients and 9.5% among LDLT recipients. An endoscopic strategy is the first choice for biliary complications; 83% of patients with biliary stricture were treated by endoscopic modalities with a success rate of 57% and 38% of patients with leakage were indicated for endoscopic biliary drainage. T-tube placement was not performed in 82% of duct-to-duct reconstruction. The incidence of biliary stricture was 10% with a T-tube and 13% without a T-tube and the incidence of leakage was 5% with a T-tube and 6% without a T-tube. A preceding bile leak and LDLT procedure are accepted risk factors for anastomotic stricture. Biliary complications remain common, which requires further investigation and the refinement of reconstruction techniques and management strategies.
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Affiliation(s)
- Nobuhisa Akamatsu
- Department of Hepato-biliary-pancreatic Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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177
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Kim J, Ko GY, Sung KB, Gwon DI, Lee SG, Kim KM, Kim KA, Yoon HK. Percutaneously placed covered retrievable stents for the treatment of biliary anastomotic strictures following living donor liver transplantation. Liver Transpl 2010; 16:1410-20. [PMID: 21117251 DOI: 10.1002/lt.22173] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This study evaluated the feasibility and efficacy of covered retrievable stent placement compared with drainage catheter placement for treating biliary anastomotic strictures following living donor liver transplantation (LDLT). In 39 of 59 patients who underwent LDLT, balloon dilation of strictures and subsequent interposition of 14-French indwelling catheters were performed (group 1), whereas in 20 patients, 29 covered retrievable stents were percutaneously placed (group 2). The drainage catheters were positioned above the stricture after at least 12 weeks of internal drainage or following stent removal after at least 8 weeks of stent placement. The drainage catheters were removed when the follow-up cholangiogram revealed free passage of contrast media. In the presence of residual stricture, either of the following was performed: (1) balloon dilation of the stricture and replacement of the indwelling catheter or (2) placement of another covered retrievable stent for at least 12 weeks. Technical success was achieved in all recipients. Clinical success was higher in group 1 (95%) than in group 2 (70%) (P = 0.005), whereas the duration of treatment was significantly shorter in group 2 (197 ± 89 days) than in group 1 (278 ± 115 days) (P = 0.018). All stents were successfully removed at a median of 14 weeks after placement, except for 1 patient in whom early stent removal was inevitable and a second patient in whom the stent migrated completely. Stent migration rate was 24% (7 of 29 stents). In conclusion, treatment of biliary anastomotic strictures following LDLT is feasible using covered retrievable stents and has an acceptable clinical success rate with shorter treatment duration.
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Affiliation(s)
- Jinoo Kim
- University of Ulsan College of Medicine, Asan Medical Center, Radiology and Research Institute of Radiology, Seoul, Korea
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178
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Fatima J, Barton JG, Grotz TE, Geng Z, Harmsen WS, Huebner M, Baron TH, Kendrick ML, Donohue JH, Que FG, Nagorney DM, Farnell MB. Is there a role for endoscopic therapy as a definitive treatment for post-laparoscopic bile duct injuries? J Am Coll Surg 2010; 211:495-502. [PMID: 20801692 DOI: 10.1016/j.jamcollsurg.2010.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 06/11/2010] [Accepted: 06/11/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND Excellent results of surgical reconstruction of major bile duct injuries (BDIs) have been well-documented. Reports of successful definitive management of central bile duct leakage and stenoses have been reported infrequently. The aim of this study was to assess treatment and outcomes for operative and endoscopic treatment of BDI after laparoscopic cholecystectomy (LC) and define the role of endoscopy in management. STUDY DESIGN All patients undergoing treatment for post-laparoscopic BDI from 1998 to 2007 at Mayo Clinic, Rochester, Minnesota were reviewed. Outcomes of surgical and endoscopic intervention were analyzed. RESULTS BDI was identified in 159 patients (mean age 51 years). Injury was recognized intraoperatively in 39 (25%) patients. Primary intervention was surgical in 59 (37%) and endoscopic in 100 (63%) patients. Class A BDIs (n = 77) were successfully treated endoscopically in 76 (99%) patients. Seven had class D BDIs; 4 were managed surgically, and 3 endoscopically. Of 66 patients with E1 to E4 BDI, 44 (67%) were initially managed surgically and 22 (33%) endoscopically. Thirteen of the latter 22 underwent sustained endoscopic therapy (median stent time 7 months), which was successful in 10 (77%). Four patients with E5 were managed surgically. Median follow-up was 45 months. Sixty-three patients underwent Roux-en-Y hepaticojejunostomy reconstruction at Mayo; 3 (5%) failed and required stenting. None required operative revision. CONCLUSIONS Endoscopic management of class A BDI has excellent outcomes. Although surgical management remains the preferred therapy, short-term endoscopic treatment for class E1 to E4 can optimize the patient and operative field for reconstruction. Prolonged stenting in select patients with E1 to E4 characterized by stenosis is successful in the majority.
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179
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Ruiz Gómez F, Ramia Ángel JM, García-Parreño Jofré J, Figueras J. Lesiones iatrogénicas de la vía biliar. Cir Esp 2010; 88:211-21. [DOI: 10.1016/j.ciresp.2010.03.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 02/21/2010] [Accepted: 03/12/2010] [Indexed: 12/20/2022]
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Low symptomatic premature stent occlusion of multiple plastic stents for benign biliary strictures: comparing standard and prolonged stent change intervals. Gastrointest Endosc 2010; 72:558-63. [PMID: 20638060 DOI: 10.1016/j.gie.2010.05.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 05/24/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Benign biliary strictures are typically managed endoscopically whereby an increasing size or number of plastic stents is placed at ERCP. Stents are often changed every 3 to 4 months based on the known median patency of a single biliary stent, but patency data for multiple biliary stents are lacking. OBJECTIVE To assess the incidence of occlusion-free survival of multiple plastic biliary stents and the rate of premature occlusion if left in longer than 6 months. DESIGN Retrospective. SETTING Tertiary-care medical center (Charleston, SC). PATIENTS Consecutive patients who received multiple plastic stents for benign nonhilar biliary strictures from 1994 to 2008 were identified. INTERVENTIONS Exchange of multiple plastic biliary stents within 6 months (group 1) or 6 months or longer (group 2) after placement. MAIN OUTCOME MEASUREMENTS Symptomatic stent occlusion. RESULTS Seventy-nine patients with nonhilar extrahepatic benign biliary stricture underwent 125 ERCPs with multiple plastic biliary stents. Stents were scheduled for removal/exchange within 6 months in 52 patients (86 ERCPs) compared with after 6 months in 22 patients (26 ERCPs). The median interval between multiple stent placement and removal/exchange was 90 days for group 1 and 242 days for group 2. Premature stent occlusion occurred in 4 of 52 (7.7%) patients in group 1 versus 1 of 22 (4.5%) in group 2, with significantly longer occlusion-free survival in group 2 (log-rank P < .0001). LIMITATIONS Retrospective study at a single tertiary referral center. CONCLUSION Multiple plastic biliary stents for benign nonhilar strictures were associated with a low rate of premature symptomatic stent occlusion at more than 6 months and a longer occlusion-free survival.
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181
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Endotherapy of postoperative biliary strictures with multiple stents: results after more than 10 years of follow-up. Gastrointest Endosc 2010; 72:551-7. [PMID: 20630514 DOI: 10.1016/j.gie.2010.04.052] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Accepted: 04/29/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Endoscopic dilation of postoperative biliary strictures with increasing numbers of stents was first described by our group in 2001 with promising results after a long-term follow-up (mean 4 years). OBJECTIVE To verify results of endoscopic treatment of postoperative biliary strictures at a very-long-term follow-up. DESIGN Single center, follow-up study. SETTING Tertiary-care, academic referral center. PATIENTS A group of 42 patients from our 2001 study, who had undergone endoscopic dilation of postoperative biliary strictures with the multiple endoscopic stenting technique, underwent systematic follow-up. The last telephone follow-up was done in September 2009. INTERVENTION Clinical conditions and the occurrence of new biliary symptoms during the follow-up period were assessed, and results of the most recent liver function tests and abdominal US were recovered. MAIN OUTCOME MEASUREMENTS Occurrence of cholangitis and liver function test evaluation during the follow-up period. RESULTS Of the 40 patients who were alive at the end of the study published in 2001, 5 (12.5%) died of unrelated causes after a mean of 6.7 years (range 3-13.3 years) from the end of treatment, without further biliary symptoms. The overall mean follow-up time for the remaining 35 patients (87.5%) was 13.7 years (range 11.7-19.8 years). Seven patients (20%) experienced recurrent acute cholangitis after a mean of 6.8 years (range 3.1-11.7 years) from the end of treatment. All 7 of these patients underwent ERCP. Four of the 7 patients had postoperative biliary stricture recurrence (n = 4/35, 11.4%) that was retreated endoscopically with placement of stents, and the other 3 patients had common bile duct stones (n = 3/35, 8.6%) that were extracted. No stricture or bile duct stone recurrences after retreatment were recorded after a mean follow-up period of a further 7.1 years (range 2.5-12.1 years). Twenty-eight patients remained asymptomatic with normal liver function test results and abdominal US results after a mean follow-up period of 13.7 years (range 11.7-19.8 years). LIMITATIONS Telephone follow-up. CONCLUSION Results of multiple endoscopic stenting for postoperative biliary strictures remain excellent even after a very-long-term follow-up. The stricture recurrence rate is low, and recurrences can be retreated endoscopically.
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182
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Tee HP, James MW, Kaffes AJ. Placement of removable metal biliary stent in post-orthotopic liver transplantation anastomotic stricture. World J Gastroenterol 2010; 16:3597-600. [PMID: 20653071 PMCID: PMC2909562 DOI: 10.3748/wjg.v16.i28.3597] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Postoperative biliary strictures are the most common cause of benign biliary stricture in Western countries, secondary to either operative injury or bile duct anastomotic stricture following orthotopic liver transplantation (OLT). Surgery or endoscopic interventions are the mainstay of treatment for benign biliary strictures. We aim to report the outcome of 2 patients with refractory anastomotic biliary stricture post-OLT, who had successful temporary placement of a prototype removable covered self-expandable metal stent (RCSEMS). These 2 patients (both men, aged 44 and 53 years) were given temporary placement of a prototype RCSEMS (8.5 Fr gauge delivery system, 8 mm × 40 mm stent dimensions) in the common bile duct across the biliary stricture. There was no morbidity associated with stent placement and removal in these 2 cases. Clinical parameters improved after the RCSEMS placement. Long-term biliary patency was achieved in both the patients. No further biliary intervention was required within 14 and 18 mo follow-up after stent removal.
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183
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Kuroda Y, Tsuyuguchi T, Sakai Y, K C S, Ishihara T, Yamaguchi T, Saisho H, Yokosuka O. Long-term follow-up evaluation for more than 10 years after endoscopic treatment for postoperative bile duct strictures. Surg Endosc 2010; 24:834-40. [PMID: 19730951 DOI: 10.1007/s00464-009-0673-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Accepted: 07/27/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic stent therapy is routinely used to treat postoperative bile duct strictures. However, no studies have detailed long-term follow-up evaluation for more than 10 years. METHODS This study enrolled 22 consecutive patients with a diagnosis of postoperative bile duct strictures from 1987 to 2006. Cases involving digestive tract reconstruction were excluded. Dilation was performed after passage of a guidewire through the stricture followed by temporary stent placement. The final objective was to achieve stent free status after sufficient dilation. The stent was removed when the cholangiogram showed apparent resolution of the stricture. If stent removal was not possible within 12 months, the authors proposed a surgical treatment option. RESULTS Initial therapy was performed for 21 patients (21/ 22, 95%). The remaining patient had complete occlusion, which required surgical repair. For 3 of the 21 cases, guidewire passage through the narrow stricture under fluorographic guidance alone was impossible. However, visualization by peroral cholangioscope enabled passage of the guidewire in all three cases. In two cases, the stricture persisted longer than 12 months, rendering stent removal impossible. Therefore, stent removal within 12 months was achieved in 90% of the cases (19/21). Two patients requested prolonged stenting in lieu of the authors' proposal to repeat the surgery. This resulted in sufficient dilation after an additional 6 months. Consequently, a total of 21 patients were enrolled for long-term follow-up evaluation. The posttreatment follow-up period was 121 + or - 64 months (range, 31-254 months; median, 120 months). Three patients died of causes unrelated to hepatobiliary disease. The remaining patients were successfully followed up until this writing. The overall long-term success rate was 95% (20/21). No hepatobiliary malignancies developed within the follow-up period. CONCLUSIONS Endoscopic stent therapy is available for postoperative bile duct strictures. Long-term prognosis for more than 10 years is excellent. Repeat surgical interventions may be unavoidable in some cases, but endoscopic treatment should be proposed as the first-line treatment.
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Affiliation(s)
- Yasuhisa Kuroda
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-0856, Japan.
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184
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Binmoeller KF. Fully covered metal stents in the pancreatic duct: balancing trade-offs. Gastrointest Endosc 2010; 72:92-4. [PMID: 20620276 DOI: 10.1016/j.gie.2010.03.1064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 03/10/2010] [Indexed: 01/13/2023]
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185
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Bagul A, Pollard C, Dennison AR. A review of problems following insertion of biliary stents illustrated by an unusual complication. Ann R Coll Surg Engl 2010; 92:W27-31. [PMID: 20501006 DOI: 10.1308/147870810x12659688852239] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The management of obstructive jaundice resulting from both benign and malignant causes relies heavily on minimally invasive techniques and particularly with the insertion of biliary endoprostheses. Migration of these biliary stents is a well-documented problem and can result in a variety of complications including perforation, intra-abdominal sepsis, fistulae formation, obstruction and appendicitis. METHODS A literature search was performed using PubMed examining case reports, published abstracts and reviews to date (2009). In addition, we report a left groin abscess as a previously unreported complication following migration of a biliary endoprosthesis. FINDINGS Stent migration can lead to serious complications and produce significant morbidity and mortality. Symptomatic patients especially those with other co-morbid abdominal pathologies such as colonic diverticulae, parastomal hernia or abdominal hernias may be at an increased risk of perforation especially when straight plastic stents are used.
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Affiliation(s)
- Atul Bagul
- HPB Department, University Hospitals of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, UK.
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186
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Tabibian JH, Asham EH, Han S, Saab S, Tong MJ, Goldstein L, Busuttil RW, Durazo FA. Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video). Gastrointest Endosc 2010; 71:505-12. [PMID: 20189508 DOI: 10.1016/j.gie.2009.10.023] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Accepted: 10/14/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND The optimal endoscopic protocol for treating postorthotopic liver transplantation (OLT) anastomotic biliary strictures (ABSs) has not been established. OBJECTIVE To review the technique and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) with maximal stenting for post-OLT ABSs at our institution. DESIGN Retrospective study. SETTING Tertiary-care center. PATIENTS Eighty-three patients with a diagnosis of ABS. INTERVENTIONS ERCP with balloon dilation and maximal stenting. MAIN OUTCOME MEASUREMENTS Stricture resolution, stricture recurrence, and complication rates. RESULTS Of 83 patients, 69 completed treatment, of whom 65 (94%) achieved resolution and 4 (6%) required hepaticojejunostomy (HJ). The remaining 14 patients who did not achieve a study endpoint were excluded (9 deaths or redo OLT unrelated to biliary disease, and 5 without follow-up). Comparing the resolution group and the HJ group, there were, respectively, 8.0 and 3.5 total stents (P = .021), 2.5 and 1.3 stents per ERCP (P = .018) (maximum = 9), 4.2 and 2.8 ERCPs (P = .15), and 20 and 22 months from OLT to ABS diagnosis (P = .19). There were 2 cases of ERCP pancreatitis (0.7%) and 2 cases of periprocedural bacteremia of 286 total ERCPs and no episodes of cholangitis caused by stent occlusion. In a median follow-up of 11 months (range 0-39), 2 (3%) patients had ABS recurrence that was successfully re-treated with ERCP. A multivariate Cox model demonstrated that treatment success was directly related to the number of stents used in total and per ERCP. LIMITATIONS Retrospective study, single endoscopist. CONCLUSIONS Our maximal stenting protocol for ABSs is effective, safe, rarely associated with ABS recurrence, and conducive to less frequent stent exchange and therefore fewer ERCPs compared with conventional treatment.
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Affiliation(s)
- James H Tabibian
- Dumont-UCLA Liver Transplant Center, Los Angeles, California, USA.
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187
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Völgyi Z, Fischer T, Szenes M, Gasztonyi B. [Endoscopic management of postoperative biliary injuries]. Orv Hetil 2010; 150:2313-8. [PMID: 19995695 DOI: 10.1556/oh.2009.28767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The postoperative complications of the biliary tract, such as leakages and strictures, traditionally had been managed surgically, but from the 90s they are usually treated via endoscopic route. These complications occur most frequently after laparoscopic surgeries. Whenever biliary leakage is suspected, close collaboration between endoscopists and surgeons is needed. Immediate visualization of the biliary tract by ERCP is mandatory to confirm the diagnosis and to locate the exact site of the lesion. Various endoscopic techniques have been proved effective in treating post-cholecystectomy biliary leaks. The crucial point is to equalize the duodenal and the biliary pressures, allowing flow of the bile into the duodenum, advancing the healing of the lesion. This can be achieved with a simple endoscopic sphincterotomy or endoscopic sphincterotomy with subsequent insertion of a plastic stent. These methods seem to be equally suitable; however, for greater lesions stent placement is advisable. For strictures multiple stenting is the effective method, and the long standing effects also seem to be good.
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Affiliation(s)
- Zoltán Völgyi
- Zala Megyei Kórház, Belgyógyászati Osztály, Zalaegerszeg.
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188
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Abdel-Raouf A, Hamdy E, El-Hanafy E, El-Ebidy G. Endoscopic management of postoperative bile duct injuries: a single center experience. Saudi J Gastroenterol 2010; 16:19-24. [PMID: 20065569 PMCID: PMC3023096 DOI: 10.4103/1319-3767.58763] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND/AIM Biliary endoscopic procedures may be less invasive than surgery for management of postoperative bile duct injuries (POBDI). This retrospective work presents the experience of a single referral center during a period of 14 years in endoscopic management of POBDI. MATERIALS AND METHODS Between 1994 (March) and 2008 (May), ERCP had been performed on 277 patients suspected to have POBDI. Patients shown to have complete transaction of bile duct were prepared for definitive surgery. For patients with simple biliary leak, sphincterotomy was performed with stenting. Pneumatic dilatation and stenting were done on patients with biliary stricture and preserved ductal continuity. ERCP was repeated every 3 months till the site of narrowing disappeared. RESULTS The mean age was 45.3 years, 162 (58.5%) were females. The most common previous surgery was cholecystectomy (open, [N=119] 44%, and laparoscopic, [N=77] 28%). ERCP failed in 17 patients (6.1%). For successfully cannulated cases (N=260, 93.9%), the type of bile duct injury diagnosed at ERCP was completely ligated CBD (N=31/260 , 11.9%). Bile leakage was detected in (N=167/260, 64.2%) all patients with endoscopic sphincterotomy and stent insertion, the leak stopped in all of them. Biliary stricture was diagnosed in 33/260 patients (12.7%) and 17 of them had repeated balloon dilatation with stenting while the remaining had surgical correction. The success rate of endoscopic therapy for biliary strictures was 82%. Cholangiogram was normal in 29 patients (11.2%). CONCLUSIONS Endoscopic therapy is safe and effective in the management of postoperative bile duct leak. For postoperative bile ductal strictures, ERCP is a less favorable option.
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Affiliation(s)
- Ahmed Abdel-Raouf
- Gastroenterology Center, Mansoura University, Jehan St, 35516, Mansoura, Dakahlia, Egypt.
| | - Emad Hamdy
- Gastroenterology Center, Mansoura University, Jehan St, 35516, Mansoura, Dakahlia, Egypt
| | - Ehab El-Hanafy
- Gastroenterology Center, Mansoura University, Jehan St, 35516, Mansoura, Dakahlia, Egypt
| | - Gamal El-Ebidy
- Gastroenterology Center, Mansoura University, Jehan St, 35516, Mansoura, Dakahlia, Egypt
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189
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190
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Endoscopic management of biliary complications after adult living-donor versus deceased-donor liver transplantation. Transplantation 2009; 88:1280-5. [PMID: 19996927 DOI: 10.1097/tp.0b013e3181bb48c2] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although data about the incidence and management of biliary complications after deceased-donor liver transplantation (DDLT) are well defined, those pertaining to adult living-donor liver transplantation (LDLT) are conflicting. METHODS We retrospectively compared endoscopic retrograde cholangio-pancreatography (ERCP) findings in 30 LDLT vs. 357 DDLT consecutive adult recipients with duct-to-duct biliary reconstruction. LDLT and DDLT recipients were followed up for median durations of 30.5 and 36.0 months after the last ERCP, respectively. RESULTS Postoperative biliary complications were more frequently identified at ERCP after LDLT versus DDLT (10/30 [33.3%] vs. 34/357 [9.5%]; P<0.001). Complications mainly consisted of anastomotic biliary strictures (10/30 [33.3%] vs. 27/357 [7.6%]; LDLT vs. DDLT recipients, respectively; P<0.001) and biliary leaks (4/30 [13.3%] vs. 6/357 [1.7%]; LDLT vs. DDLT recipients, respectively; P=0.005; some patients had both complications). Stricture dilation was successful in 4/10 (40%) LDLT vs. 27/27 (100%) DDLT recipients (P<0.001), and bile ducts remained patent up to the end of follow-up without further intervention in 2/10 (20.0%) vs. 21/27 (77.8%) patients, respectively (P=0.002). Endoscopic treatment of bile leaks was successful in 3/4 (75.0%) vs. 5/6 (83.3%) LDLT versus DDLT recipients, respectively (NS). CONCLUSIONS Biliary complications were more frequent after LDLT compared with DDLT. Endoscopic treatment of anastomotic biliary strictures was successful in a minority of patients after LDLT, in contrast with DDLT. Most biliary leaks were successfully treated at endoscopy after LDLT or DDLT.
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191
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Abstract
Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Biliary strictures are classified as anastomotic or non-anastomotic strictures according to location and are defined by distinct clinical behaviors. Anastomotic strictures are localized and short. The outcome of endoscopic treatment for anastomotic strictures is excellent. Non-anastomotic strictures often result from ischemic and immunological events, occur earlier and are usually multiple and longer. They are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and need for retransplantation. Living donor OLT patients present a unique set of challenges arising from technical factors, and stricture risk for both recipients and donors. Endoscopic treatment of living donor OLT patients is less promising. Current endoscopic strategies for biliary strictures after OLT include repeated balloon dilations and placement of multiple side-by-side plastic stents. Lifelong surveillance is required in all types of strictures. Despite improvements in incidence and long term outcomes with endoscopic management, and a reduced need for surgical treatment, the impact of strictures on patients after OLT is significant. Future considerations include new endoscopic technologies and improved stents, which could potentially allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. This review focuses on the role of endoscopy in biliary strictures, one of the most common biliary complications after OLT.
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192
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Sakai Y, Tsuyuguchi T, Ishihara T, Yukisawa S, Sugiyama H, Miyakawa K, Kuroda Y, Yamaguchi T, Ozawa S, Yokosuka O. Long-term prognosis of patients with endoscopically treated postoperative bile duct stricture and bile duct stricture due to chronic pancreatitis. J Gastroenterol Hepatol 2009; 24:1191-7. [PMID: 19682193 DOI: 10.1111/j.1440-1746.2009.05878.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AIM To compare the outcome of endoscopic therapy for postoperative benign bile duct stricture and benign bile duct stricture due to chronic pancreatitis, including long-term prognosis. METHODS The subjects were 20 patients with postoperative benign bile duct stricture and 13 patients with bile duct stricture due to chronic pancreatitis who were 2 years or more after initial therapy. The patients underwent transpapillary drainage with tube exchange every 3 to 6 months until being free from the tube. Successful therapy was defined as a stent-free condition without hepatic disorder. RESULTS Endoscopic therapy was successful in 90% (18/20) of the patients with postoperative bile duct stricture. The stent was removed (stent free) in 100% (20/20) of the patients, but jaundice resolved in only 10% (2/20) of patients while biliary enzymes kept increasing. Restructure occurred in 5% (1/20) of the patients, but after repeat treatment the stent could be removed. In patients with bile duct stricture due to chronic pancreatitis the therapy was successful in only 7.7% (1/13) of the patients; the stent was retained in 92.3% (12/13) of the patients during a long period. Severe acute pancreatitis occurred in 3.0% (1/33) of the patients as an accidental symptom attributable to endoscopic retrograde cholangiopancreatography (ERCP); however, it remitted after conservative treatment. CONCLUSION Our results further confirm the usefulness of endoscopic therapy for postoperative benign bile duct strictures and good long-term prognosis of the patients.
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Affiliation(s)
- Yuji Sakai
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan.
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193
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Langer F, Györi G, Pokorny H, Burghuber C, Rasoul-Rockenschaub S, Berlakovich G, Mühlbacher F, Steininger R. Outcome of hepaticojejunostomy for biliary tract obstruction following liver transplantation. Clin Transplant 2009; 23:361-7. [DOI: 10.1111/j.1399-0012.2008.00923.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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194
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Tabibian JH, Asham EH, Goldstein L, Han SH, Saab S, Tong MJ, Busuttil RW, Durazo FA. Endoscopic treatment with multiple stents for post-liver-transplantation nonanastomotic biliary strictures. Gastrointest Endosc 2009; 69:1236-43. [PMID: 19249040 DOI: 10.1016/j.gie.2008.09.057] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Accepted: 09/24/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Over the past decade, ERCP has become the preferred method of treatment for biliary strictures in patients after orthotopic liver transplantation (OLT). Although data strongly support ERCP for treating anastomotic strictures, the little information available for the role of ERCP in the treatment of nonanastomotic strictures (NAS) has been unpromising. OBJECTIVE We investigated the efficacy and safety of using balloon dilation and multiple biliary stents to treat NAS. DESIGN A retrospective study. SETTING A tertiary-care medical center. PATIENTS Fifteen patients who were diagnosed with post-OLT NAS between January 2003 and June 2007. INTERVENTIONS ERCP with balloon dilation and multiple stenting. MAIN OUTCOME MEASUREMENTS Resolution, complication, and recurrence rates. RESULTS Eleven of the 15 patients completed endoscopic treatment, of whom 9 had cholangiographic improvement, biochemical normalization, and cholestatic symptom relief (treatment success), and 1 required retransplantation (treatment failure). None of the 9 successfully treated patients experienced NAS recurrence in a mean follow-up of 17 months. Of the remaining 4 patients, 1 died of nonbiliary causes and 3 were still undergoing treatment with stents in place, of whom 2 have near-normalized total serum bilirubin and were cholestatic symptom free. LIMITATIONS A retrospective study, small sample size, single endoscopist. CONCLUSIONS Endoscopic treatment of NAS with balloon dilation and multiple stents appears to be safe and effective, and it may reduce the need for retransplantation because of NAS. Larger studies are still required to confirm its utility as a mainstay for treating NAS and to determine what factors are associated with endoscopic treatment success.
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Affiliation(s)
- James H Tabibian
- Dumont-University of California Los Angeles Liver Transplant Center and UCLA Division of Digestive and Liver Diseases, Los Angeles, California, USA.
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195
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Kato H, Kawamoto H, Tsutsumi K, Harada R, Fujii M, Hirao K, Kurihara N, Mizuno O, Ishida E, Ogawa T, Fukatsu H, Yamamoto K, Yagi T. Long-term outcomes of endoscopic management for biliary strictures after living donor liver transplantation with duct-to-duct reconstruction. Transpl Int 2009; 22:914-21. [PMID: 19497069 DOI: 10.1111/j.1432-2277.2009.00895.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Biliary strictures after living donor liver transplantation (LDLT) with duct-to-duct (D-D) reconstruction are associated with postoperative morbidity and mortality. The aims of this study were to evaluate the long-term outcomes of endoscopic deployment of plastic stents, and to investigate factors associated with the stent deployment failure. Between April 2001 and May 2007, 96 patients received LDLT with D-D reconstruction at Okayama University Hospital. Among them, 41 patients (43%) had anastomotic biliary strictures, and all were referred first for endoscopic retrograde cholangiography (ERC). When deployment was unsuccessful, a percutaneous transhepatic procedure was employed. Successful stent deployment was achieved in 35 out of total 41 patients (85%) by both procedures. Among the 35 patients, 28 had their stents removed as a result of strictures resolution. Eight patients underwent ERC and repeated stent deployment as a result of recurrence of the strictures. Finally, 21 out of 41 (51%) patients with biliary stricture were completely treated by endoscopic therapy during the observation period (median 873 days: range 77-2060). By multivariate analysis, biliary leakage was associated with stent deployment failure. Endoscopic deployment of plastic stents is a first-line therapy for patients with biliary stricture after LDLT.
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Affiliation(s)
- Hironari Kato
- Department of Gastroenterology, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
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196
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Weber A, Feussner H, Winkelmann F, Siewert JR, Schmid RM, Prinz C. Long-term outcome of endoscopic therapy in patients with bile duct injury after cholecystectomy. J Gastroenterol Hepatol 2009; 24:762-9. [PMID: 19220666 DOI: 10.1111/j.1440-1746.2008.05713.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Bile duct lesions, including leaks and strictures, are immanent complications of open or laparoscopic cholecystectomy. Endoscopic procedures have gained increasing potential as the treatment of choice in the management of postoperative bile duct injuries. METHODS Between January 1996 and December 2006, 44 patients with biliary leakages and 12 patients with biliary strictures after cholecystectomy were identified by analyzing the endoscopic retrograde cholangiopancreatography database, clinical records, and cholangiograms. The long-term follow up of endoscopic treatment in biliary lesions after cholecystectomy was evaluated by this retrospective study. RESULTS In 34 of 35 patients (97%) with peripheral bile duct leakages, endoscopic therapy was successful. Transpapillary endoprothesis and/or nasobiliary drainage were removed after 31 (5-399) days. After stent removal, the median follow-up period was 81 (11-137) months. In patients with central bile duct leakages, the success rate after median 90 (4-145) days of endoscopic therapy was 66.7% (6/9 patients). The median follow up after stent removal in six successfully treated patients was 70 (48-92) months. Eleven of 12 patients (91.6%) with bile duct strictures had successfully completed stent therapy. The follow-up period of this patient group was 99 (53-140) months. CONCLUSIONS Endoscopic treatment of bile duct lesions after cholecystectomy is effective, particularly in patients with peripheral bile duct leakages and bile duct strictures. Therefore, it should be the first-line therapy used in these patients. Although endoscopic management is less successful in patients with central bile duct leakages, an attempt is warranted.
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Affiliation(s)
- Andreas Weber
- Department of Gastroenterology, Technical University of Munich, Munich, Germany.
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197
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Pawa S, Al-Kawas FH. ERCP in the management of biliary complications after cholecystectomy. Curr Gastroenterol Rep 2009; 11:160-166. [PMID: 19281705 DOI: 10.1007/s11894-009-0025-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Open cholecystectomy has been associated historically with 0.2% to 0.5% risk of postoperative biliary injury. Laparoscopic cholecystectomy, which has become the first-line surgical treatment of calculous gallbladder disease, has been associated with a 2.5-fold to fourfold increase in the incidence of postoperative bile duct injury. The biliary endoscopist can expect to see a varied spectrum of complications after cholecystectomy by either technique, including postoperative biliary strictures, bile leaks, and retained calculi in the biliary tree. Proper diagnosis and treatment are paramount in ensuring a satisfactory outcome after bile duct injury. Endoscopic retrograde cholangiopancreatography (ERCP) has become the primary modality for treatment and effectively manages most bile duct injuries.
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Affiliation(s)
- Swati Pawa
- Georgetown University Hospital, Washington, DC 20007, USA
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198
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Safdar K, Atiq M, Stewart C, Freeman ML. Biliary tract complications after liver transplantation. Expert Rev Gastroenterol Hepatol 2009; 3:183-95. [PMID: 19351288 DOI: 10.1586/egh.09.4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Biliary tract complications are an important source of morbidity after liver transplantation, and present a challenge to all involved in their care. With increasing options for transplantation, including living donor and split liver transplants, the complexity of these problems is increasing. However, diagnosis is greatly facilitated by modern noninvasive imaging techniques. A team approach, including transplant hepatology and surgery, interventional endoscopy and interventional radiology, results in effective solutions in most cases, such that operative reintervention or retransplantation is rarely required.
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Affiliation(s)
- Kamran Safdar
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
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199
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Abstract
Biliary disorders were once only accessible by orthodox surgery but are now diagnosed and treated by multiple methods and specialists. Therapeutic endoscopic retrograde cholangiopancreatography has flourished and continues to grow after its introduction with the first biliary spincterotomies in 1974 in Germany and Japan. The therapeutic biliary endoscopist contributes to the management of all biliary disorders and in many cases endoscopy is the preferable approach. However, endoscopic retrograde cholangiopancreatography remains a risky procedure and risk is best reduced by strictly limiting its use.
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200
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Stoeckler F, Hagmüller E, Rumpelt HJ, Weickert U. A rare cause of distal bile duct stenosis. J Gastrointest Cancer 2009; 38:157-9. [PMID: 19089672 DOI: 10.1007/s12029-008-9029-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION In a patient with a distal bile duct stenosis a definite diagnosis could not be made preoperatively. DISCUSSION The histologic evaluation of the surgical resection specimen revealed infiltration of the pancreatic head and the distal bile duct by breast tumor cells. CONCLUSION The metastasis was the only tumor manifestation after mastectomy 12 years ago.
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Affiliation(s)
- F Stoeckler
- Department of Medicine II, Klinikum Heilbronn, University of Heidelberg, Am Gesundbrunnen 20-26, 74078, Heilbronn, Germany
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