Percutaneous transhepatic treatment using retrievable covered stents in patients with benign biliary strictures: mid-term outcomes in 68 patients

Percutaneous placement of a retrievable fully covered metal stent with anchoring flaps for the treatment of biliary anastomotic stricture following LDLT

To investigate the outcomes following percutaneous placement of a retrievable fully covered self-expanding metal stent (fcSEMS) with anchoring flaps at proximal and distal ends for the treatment of biliary anastomotic strictures following living-donor liver transplantation (LDLT). We retrospectively reviewed the medical records of nine patients who underwent this procedure at our centre between April 2020 and March 2021. Percutaneous stent placement was technically successful in 100% patients, and all stents were successfully retrieved. No proximal or distal stent migration or occlusion was observed during the mean (±SD) stent indwelling period of 191(± 77) days. Clinical success was 89%. There was one major bleeding complication related to the biliary approach and one minor stent-related complication of calculus/sludge. During the mean (±SD) follow-up period of 595 ± 207 days after stent retrieval, only one patient developed recurrent clinical biliary stricture and symptoms. Percutaneous placement of a retrievable fcSEMS with anchoring flaps is safe and feasible for the treatment of biliary anastomotic strictures following LDLT.

Study protocol for a prospective, multicentre, phase II trial on endoscopic treatment using two fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy

INTRODUCTION

The current endoscopic treatment for postoperative benign hepaticojejunostomy anastomotic stricture (HJAS) has a high technical success rate and is highly effective in the short term. However, long-term results have shown a high rate of stenosis recurrence, which indicates an insufficient response to treatment. Three prospective studies on fully covered self-expandable metallic stent (FC-SEMS) treatment for benign HJAS used the stenosis resolution rate as the primary endpoint, and no study has yet used the long-term non-stenosis rate (at 12 months) as the primary endpoint.

METHODS AND ANALYSIS

We launched the 'saddle-cross study', which will be conducted as a multicentre, prospective intervention of endoscopic treatment using two modified FC-SEMSs (BONASTENT️ M-Intraductal) that have been improved for benign stenosis in patients with benign HJAS, with the long-term non-restenosis rate (at 12 months) as the primary endpoint. This study aims to evaluate the long-term non-restenosis rate (at 12 months) and safety of the saddle-cross technique for benign HJAS. We plan to enrol 50 participants.

ETHICS AND DISSEMINATION

This study has been approved by the Certified Review Board of the National Cancer Center, Japan (CRB3180009). The results will be reported at various conferences and published in international peer-reviewed journals.

The Use of Oblique-viewing Endoscopic Ultrasound for Accessing the Afferent Limb for Endoscopic Ultrasound-guided Biliary Drainage in Patients with Severe Stenotic Hepaticojejunal Anastomosis: One Case and Literature Review

BACKGROUND

The treatment of hepaticojejunal anastomotic strictures in patients with surgically altered anastomosis is challenging. Endoscopic ultrasound (EUS)-guided biliary drainage is being established as a feasible biliary drainage procedure. How can oblique-viewing endoscopic ultrasound (OV-EUS) safely reach the treatment area in the afferent limb for EUS-guided hepaticojejunostomy? This is a key, meaningful, and challenging question.

METHODS

A unique case of an OV-EUS-guided hepaticojejunostomy performed in a patient with severe stenotic hepaticojejunal anastomosis was reported, and the relevant literatures were reviewed.

RESULTS

There are only 3 previous case reports of EUS-guided transanastomotic drainage using OV-EUS. The above 3 cases reported did not elaborate on the key treatment details of the procedure. Especially how can the OV-EUS safely reach the treatment area in the afferent limb?

CONCLUSIONS

For patients with severe anastomotic stricture, when the retrograde or antegrade guide wire cannot pass through the stenosis to establish biliary drainage, OV-EUS can safely reach the treatment area in the afferent limb under the guidance of a fluoroscopic view and a guide wire. Thus, an OV-EUS-guided hepaticojejunostomy can be achieved.

A novel endoscopic technique using fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy: the saddle-cross technique (with video)

BACKGROUND

In recent years, the number of patients with hepaticojejunostomy anastomotic strictures has increased. Balloon dilation and placement of multiple plastic stents have proven effective for hepaticojejunostomy anastomotic strictures. However, for refractory strictures, there is often a need for repeated endoscopic procedures within a short period. This study aimed to assess the efficacy and safety of the new saddle-cross technique, which uses two fully covered self-expandable metallic stents.

METHODS

This was a retrospective analysis of 20 patients with benign hepaticojejunostomy anastomotic strictures who underwent placement of two fully covered self-expandable metallic stents at the National Cancer Center, Japan, from November 2017 to June 2021.

RESULTS

The technical and clinical success rates were 100% (20/20). The median time of the procedure was 61 (range 25-122) min. The scheduled stent removal rate was 70% (14/20). Spontaneous dislodgement of the stent was observed on computed tomography in five patients (25.0%). The non-restenosis rate 12 months after the saddle-cross technique was 88.2% (15/17). Procedure-related early adverse events included mild ascending cholangitis in three patients (15.0%) and sepsis in one patient (5.0%). Procedure-related late adverse events included mild ascending cholangitis in three patients (15.0%) and bile duct hyperplasia in one patient (5.0%).

CONCLUSIONS

The saddle-cross technique performed using two fully covered self-expandable metallic stents resulted in promising long-term stricture resolution with a high technical success rate. Based on these findings, the saddle-cross method can be considered an option for the standard procedure for benign hepaticojejunostomy anastomotic strictures.

Feasibility and safety of a novel 3D-printed biodegradable biliary stent in an in vivo porcine model: a preliminary study

To assess the feasibility and safety of a novel 3D-printed biodegradable biliary stent using polycaprolactone (PCL) in an in vivo porcine model. In this animal study using domestic pigs, biodegradable radiopaque biliary stents made of polycaprolactone (PCL) and barium sulfate were produced using 3D printing and surgically inserted into the common bile duct (CBD) of pigs (stent group, n = 12). Another five pigs were allocated to the control group that only underwent resection and anastomosis of the CBD without stent insertion. To check the position and status of the stents and stent-related complications, follow-up computed tomography (CT) was performed every month. The pigs were sacrificed 1 or 3 months after surgery, and their excised CBD specimens were examined at both the macroscopic and microscopic levels. Three pigs (one in the stent group and two in the control group) died within one day after surgery and were excluded from further analysis; the remaining 11 in the stent group and 3 in the control group survived the scheduled follow-up period (1 month, 5 and 1; and 3 months, 6 and 2 in stent and control groups, respectively). In all pigs, no clinical symptoms or radiologic evidence of biliary complications was observed. In the stent group (n = 11), stent migration (n = 1 at 3 months; n = 2 at 1 month) and stent fracture (n = 3 at 2 months) were detected on CT scans. Macroscopic evaluation of the stent indicated no significant change at 1 month (n = 3) or fragmentation with discoloration at 3 months (n = 5). On microscopic examination of CBD specimens, the tissue inflammation score was significantly higher in the stent group than in the control group (mean ± standard deviation (SD), 5.63 ± 2.07 vs. 2.00 ± 1.73; P = 0.039) and thickness of fibrosis of the CBD wall was significantly higher than that of the control group (0.46 ± 0.12 mm vs. 0.21 ± 0.05 mm; P = 0.012). Despite mild bile duct inflammation and fibrosis, 3D-printed biodegradable biliary stents showed good feasibility and safety in porcine bile ducts, suggesting their potential for use in the prevention of postoperative biliary strictures.

Percutaneous Transhepatic Treatment of Benign Bile Duct Strictures Using Retrievable Covered Stents: Long-Term Outcomes in 148 Patients

OBJECTIVE

To investigate the long-term outcomes of percutaneous treatment of benign biliary strictures using temporary placement of a retrievable expanded polytetrafluoroethylene (PTFE) covered stent.

MATERIALS AND METHODS

We retrospectively analyzed the outcomes of 148 patients (84 male and 64 female; age range, 11-92 years) who underwent percutaneous transhepatic placement and removal of a retrievable PTFE-covered stent for the treatment of benign biliary strictures between March 2007 and August 2019 through long-term follow-up. Ninety-two patients had treatment-naïve strictures and 56 had recurrent/refractory strictures.

RESULTS

Stent placement was technically successful in all 148 patients. The mean indwelling period of the stent was 2.4 months (median period, 2.3 months; range, 0.2-7.7 months). Stent migration, either early or late, occurred in 28 (18.9%) patients. Clinical success, defined as resolution of stricture after completing stent placement and removal, was achieved in 94.2% (131 of 139 patients). The overall complication rate was 15.5% (23 of 148 patients). During the mean follow-up of 60.2 months (median period, 52.7 months; range, 1.6-146.1 months), 37 patients had a recurrence of clinically significant strictures at 0.5-124.5 months after removal of biliary stent and catheter (median, 16.1 months). The primary patency rates at 1, 3, 5, 7, and 10 years after removal of biliary stent and catheter were 88.2%, 70.0%, 66.2%, 60.5%, and 54.5%, respectively. In the multivariable Cox proportional hazard regression analysis, sex, age, underlying disease, relation to surgery, stricture type, biliary stones, history of previous treatment, and stricture site were not significantly associated with the primary patency.

CONCLUSION

Long-term outcomes suggest that percutaneous treatment of benign biliary strictures using temporary placement of retrievable PTFE-covered stents may be a clinically effective method.

Endoskopisches Management von Gallengangskomplikationen nach Leberchirurgie

Biliäre Komplikationen stellen häufige Komplikationen nach Leberchirurgie dar und tragen wesentlich zur postoperativen Morbidität und Mortalität bei. Den größten Anteil dieser machen Gallengangsleckagen und -strikturen aus, wobei die Leckagen nach Cholezystektomie und Leberresektion dominieren und die Strikturen ein wesentliches Problem nach Lebertransplantationen darstellen. Patienten nach orthotoper Lebertransplantation stellen besonders vulnerable Patienten dar, deren biliäre Komplikationen von denen nach Cholezystektomie und Leberresektion differieren und niederschwellig sowie mit größter Vorsicht behandelt werden müssen. Mit der endoskopischen retrograden Cholangiografie steht ein exzellentes Verfahren zur Behandlung dieser Komplikationen zur Verfügung. Die therapeutischen Möglichkeiten beinhalten die endoskopische Sphinkterotomie, die Anlage von Prothesen und Dilatationen. Mittels dieser Verfahren können Erfolgsraten in bis zu 90% der Fälle erreicht werden. Bei Hepatikojejunostomien bestehen alternative Interventionsmöglichkeiten wie die ballon- oder motorunterstützte antegrade Enteroskopie, die perkutan-transhepatische Cholangiodrainage oder mit zunehmendem Einsatz die endosonografisch gestützten Verfahren.

Biliary stones or ulcers at the choledochojejunal anastomotic site involving the jejunal mucosa at stent removal may be recurrent factors in patients with benign choledochojejunal anastomotic stenosis undergoing endoscopic biliary stenting using fully-covered self-expandable metal stents

BACKGROUND

Temporary fully-covered self-expandable metal stent (FCSEMS) placement is performed for benign choledochojejunal anastomotic stenosis (bCJS). However, recurrence may develop after stricture resolution. We investigated endoscopic biliary stenting using FCSEMS for bCJS.

METHODS

Sixteen bCJS patients with FCSEMS placement were retrospectively analyzed. FCSEMS was removed endoscopically after 2 months. Technical success, stricture resolution, recurrence, and adverse events were evaluated.

RESULTS

The technical success rate for FCSEMS placement was 94% (15/16). Biliary stones were detected and extracted in 4 patients. FCSEMS removal was successfully performed on 14 patients, excluding 1 with stent migration. At FCSEMS removal, stricture resolution was noted in 14 patients; however, 4 had anastomotic ulcers. The median follow-up was 319 days. Three patients with a history of repeated plastic stent placement had no recurrence. Four out of 15 patients (27%) had recurrence, and three had no recurrence after additional interventions. Biliary stones before first FCSEMS placement (p=0.003) or anastomotic ulcers at FCSEMS removal (p=0.018) were associated with recurrence.

CONCLUSIONS

Although FCSEMS placement was useful for stricture resolution, recurrence was detected in patients with biliary stones before first FCSEMS placement or anastomotic ulcers at FCSEMS removal. Anastomotic ulcers are a risk factor for recurrence and only detected by endoscopy.

Long-term results of oversized balloon dilation for benign anastomotic biliary strictures: initial two-center experience

OBJECTIVE

To describe, assess the feasibility of, and quantify the long-term patency achieved with percutaneous transhepatic biliary dilation using the anastomotic biliary stricture (ABS) oversized balloon dilation technique as a single-step procedure for the treatment of benign anastomotic biliary strictures following hepatobiliary surgery.

MATERIALS AND METHODS

This was a retrospective, two-center study including 16 consecutive cases of symptomatic benign biliary-enteric strictures. After assessment of the diameter of the bile duct by computed tomography or magnetic resonance imaging, the strictures were dilated with oversized balloons (40-50% larger than the bile duct diameter) and an external biliary-enteric drain was placed. After drain removal, clinical symptoms and laboratory test results were evaluated every three months, whereas follow-up magnetic resonance imaging was performed at 30 days out and follow-up computed tomography was performed at 6 and 12 months out.

RESULTS

The mean follow-up time was 31.8 ± 8.15 months. Kaplan-Meier-estimated 1-, 2-, and 3-year patency rates were 88.2%, 82.4%, and 82.4%, respectively. There was one major complication-a small dehiscence of the anastomosis-which extended the catheter dwell time. Minor complications occurred in two cases-one small perihepatic hematoma and one segmental thrombosis of the left portal branch-neither of which required further intervention.

CONCLUSION

The single-step ABS oversized balloon dilation technique is a feasible treatment for benign anastomotic biliary-enteric strictures. The technique appears to be associated with high rates of long-term clinical success and patency.

A Complex In Vitro Degradation Study on Polydioxanone Biliary Stents during a Clinically Relevant Period with the Focus on Raman Spectroscopy Validation

Biodegradable biliary stents are promising treatments for biliary benign stenoses. One of the materials considered for their production is polydioxanone (PPDX), which could exhibit a suitable degradation time for use in biodegradable stents. Proper material degradation characteristics, such as sufficient stiffness and disintegration resistance maintained for a clinically relevant period, are necessary to ensure stent safety and efficacy. The hydrolytic degradation of commercially available polydioxanone biliary stents (ELLA-CS, Hradec Králové, Czech Republic) in phosphate-buffered saline (PBS) was studied. During 9 weeks of degradation, structural, physical, and surface changes were monitored using Raman spectroscopy, differential scanning calorimetry, scanning electron microscopy, and tensile and torsion tests. It was found that the changes in mechanical properties are related to the increase in the ratio of amorphous to crystalline phase, the so-called amorphicity. Monitoring the amorphicity using Raman spectroscopy has proven to be an appropriate method to assess polydioxanone biliary stent degradation. At the 1732 cm⁻¹ Raman peak, the normalized shoulder area is less than 9 cm⁻¹ which indicates stent disintegration. The stent disintegration started after 9 weeks of degradation in PBS, which agrees with previous in vitro studies on polydioxanone materials as well as with in vivo studies on polydioxanone biliary stents.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Percutaneous Image-Guided Biliary Procedures

Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.

Technical Notes on Fluoroscopy-Guided Removal of Metallic Ureteral Stents

This manuscript describes various techniques for fluoroscopy-guided removal of metallic ureteral stents. Fifteen patients underwent 17 fluoroscopy-guided removal procedures of 22 metallic ureteral stents. The simple or modified snare or retrieval hook technique was primarily used for antegrade access, whereas the loop snare technique was primarily used for retrograde access. Overall 64.7% of the stents were removed using the initial retrieval technique, and 82.4% were removed using an adjunct technique. Procedure-related complications included hematuria in 41.2% of cases and resolved spontaneously in all patients. Fluoroscopy-guided removal of metallic ureteral stents is safe and effective.

Percutaneous Management of Benign Biliary Strictures

Benign biliary strictures are often due to a variety of etiologies, most of which are iatrogenic. Clinical presentation can vary from asymptomatic disease with elevated liver enzymes to obstructive jaundice and recurrent cholangitis. Diagnostic imaging methods, such as ultrasound, multidetector computed tomography, and magnetic resonance imaging (cholangiopancreatography), are used to identify stricture location, extent, and possible source of biliary obstruction. The management of benign biliary strictures requires a multidisciplinary team approach and include endoscopic, percutaneous, and surgical interventions. Percutaneous biliary interventions provide an alternative diagnostic and therapeutic approach, especially in patients who are not amenable to endoscopic evaluation. This review provides an overview of benign biliary strictures and percutaneous management by interventional radiologists. Diagnostic evaluation with percutaneous transhepatic cholangiography and treatment options, including biliary drainage, balloon dilation, retrievable/biodegradable stents, and other innovative minimally invasive options, are discussed.

Extraluminal Recanalization for Biliary Duct-to-Duct Anastomotic Obstruction After Living Donor Liver Transplantation: Experience in Eight Patients

PURPOSE

To investigate clinical outcomes and safety of extraluminal recanalization for duct-to-duct anastomotic obstruction after living donor liver transplantation (LDLT).

MATERIALS AND METHODS

Extraluminal recanalization was performed as a salvage procedure after failure of intraluminal cannulation in eight patients who underwent percutaneous transhepatic treatment of duct-to-duct anastomotic obstruction 11.0 ± 5.27 months after LDLT between October 2012 and April 2019. Technical details, safety, and outcomes of extraluminal recanalization were investigated.

RESULTS

Total ten sessions of extraluminal recanalization were performed in the eight patients with the stiff backend of a 0.035 inch hydrophilic guide wire, 22-gauge Chiba needle, or Colapinto needle. Percutaneous common bile duct access was performed in three sessions to obtain a straight course for the puncture. There was one instance of subcapsular and intraparenchymal hematoma requiring placement of an additional drainage catheter and conservative treatment. During a follow-up period ranging from 18.4 to 100.7 months, the drainage catheter was removed in seven of the eight patients, including three patients who had recurrent stricture requiring repeat percutaneous treatment and one who underwent a routine change of an endoscopic retrograde biliary drainage catheter.

CONCLUSIONS

Extraluminal recanalization can be an effective and safe salvage procedure after failed intraluminal cannulation of duct-to-duct anastomotic obstruction in LDLT.

Percutaneous Treatment of Benign Biliary Anastomotic Strictures: Retrievable Covered Self-Expandable Metal Stent with Fixation String Versus Large-Bore Catheters

PURPOSE

To retrospectively compare the safety and efficacy of a covered self-expandable metal stent (CSEMS) with a transhepatic fixation string and a large-bore catheter for benign biliary anastomotic stricture after hepatobiliary surgery.

MATERIALS AND METHODS

From March 2012 to June 2017, 49 patients with benign biliary anastomotic strictures, untreatable with endoscopy, were included. Twenty-three patients (catheter group) were treated with a large-bore catheter (with progressive catheter upsizing to 16-18 Fr), whereas 26 patients (stent group) were treated by CSEMS (10-mm stent) placement. Technical success, clinical success, primary patency, recurrent strictures, complication rate, and catheter or stent indwelling time were compared between the groups.

RESULTS

Technical success and clinical success were achieved in all patients. In the stent group, stent retrieval was successful in all patients. The overall complication rate was 24.5% (catheter group vs. stent group, 30.4% vs. 19.2%; P = .363). Stent migration occurred in 1 patient during follow-up (1/26, 3.8%). The mean indwelling time was 10.3 ± 3.0 months (range, 8-16 months; median, 10 months) in the catheter group and 4.0 ± 1.2 months (range, 3-7 months; median, 4 months) in the stent group (P < .001). Recurrent strictures occurred in 10 (43.5%) patients in the catheter group and 4 (15.4%) patients in the stent group (P = .030). The 1- and 3-year primary patency rates were 82.6% and 69.3% in the catheter group and 92.3% and 84.4% in the stent group (P = .042).

CONCLUSIONS

Percutaneous placement of a retrievable CSEMS showed superior intermediate-term outcomes over a large-bore catheter in patients with benign biliary anastomotic strictures.

Absorbable stents for treatment of benign biliary strictures: long-term follow-up in the prospective Spanish registry

OBJECTIVES

Benign strictures of the bile duct may be difficult to treat endoscopically due to altered bowel anatomy. Furthermore, recurrence of stenosis and symptoms remains high. The aim of the Spanish Prospective Registry BiELLA study was to investigate the safety and efficacy of absorbable stents in the treatment of benign biliary strictures and their outcomes on the medium and long-term follow-up.

METHODS

A prospective, multicenter, observational, non-randomized study (the BiELLA study) was conducted from January 2014 to September 2018. One hundred fifty-nine patients with benign biliary strictures, mostly postsurgical, were enrolled for implantation of absorbable biliary stents in the 11 participating Spanish tertiary hospitals. The average patient follow-up was 45.4 ± 15.9 months (range, 12-60 months). The follow-up data included symptoms, biochemical parameters, and ultrasound images at 1, 6, and 12 months and then yearly for up to 60 months.

RESULTS

The immediate technical and clinical success rates were 100%. In all patients, stent placement resulted in improvement of clinical symptoms and biochemical parameters. The primary mean patency for stent was 86.7, 79.6, and 78.9% at 12, 36, and 60 months, respectively (95% CI). Biliary restenosis and occlusion occurred in 40 (26.6%) patients. Of the 40 patients, 18 (12%) patients were treated with a second stent and 22 (14.6%) patients had operative repair of the recurrent strictures. There were no major complications associated with stent implantation.

CONCLUSIONS

Implantation of an absorbable polydioxanone biliary stent is safe and effective for treatment of benign biliary strictures refractory to balloon dilatation or other biliary intervention.

KEY POINTS

• Percutaneous implantation of biodegradable prostheses for the treatment of benign postsurgical biliary strictures is a safe and effective procedure. • More than 75% of the patients presented patency of the stented biliary tree at 5 years follow-up. • Absorbable stents improved clinical symptoms and signs (jaundice, itching, fever), and laboratory parameters in a few days after stent placement.

EUS-guided biliary drainage for the management of benign biliary strictures in patients with altered anatomy: A single-center experience

Background and Objectives:

The management of benign biliary stricture in patients with altered anatomy secondary to surgery is challenging. Percutaneous transhepatic biliary drainage (BD) represents the standard therapy for benign biliary stricture, but it is associated with nontrivial morbidity rates. Despite the increasing application of guided BD (EUS-BD) for the management of malignant obstruction, its role in patients with benign biliary stricture is limited. This retrospective study aimed to evaluate the feasibility, safety, and clinical effectiveness of EUS-BD with multiple transanastomotic plastic stent treatment in patients with benign biliary stricture.

Materials and Methods:

This study included consecutive patients who underwent EUS-BD for benign biliary stenosis at our center. EUS-BD with fully covered self-expandable metal stent placement was performed first. When feasible, the stricture was treated by balloon dilation with the placement of a transanastomotic double-pigtail plastic stent. Scheduled procedures were repeated to remove the metal stent and replace the plastic stent to treat the stenosis. Technical success and adverse events (AEs) were assessed.

Results:

Twelve patients underwent EUS-BD for benign biliary strictures. Procedural and clinical successes were achieved in all patients (100%). Multistenting treatment was performed in 10/12 patients (77%). The median number of stents inserted, maximum number of stents placed, and median time of retreatment were 2.4 (range: 1–4), 4, and 3.4 (range: 1–7), respectively. In total, 4/12 patients (33.3%) developed AEs that required endoscopic interventions (Clavien-Dindo Grade III).

Conclusions:

EUS-BD with the placement of multiple trans-stenosis plastic stents is a safe, feasible, and well-tolerated alternative for the management of benign biliary stricture in patients with surgery-altered anatomy. Long-term follow-up is necessary to support our results.

Novel Application of Internal-External Drainage Catheter as Biliary Stent for Percutaneous Transhepatic Treatment of Biliary Strictures in Living Donor Liver Transplantation Recipient Patients

OBJECTIVES

Although endoscopic management is considered as the first-line treatment for biliary strictures, it may be challenging in living donor liver transplant recipients due to the complex nature of duct-to-duct reconstruction. In this study we present the use of a pigtail drainage catheter as a biliary stent to treat biliary strictures after a living donor liver transplant.

METHODS

Twenty-seven patients with biliary strictures were treated with our novel technique. In this technique, a pigtail catheter was trimmed into 3 parts (proximal, middle, and distal portions). A suture string was passed through the distal hole of the middle portion, which was then reversed and used as a stent while the proximal portion was used as a pusher. Following balloon dilation of the stenotic segment, the distal, reversed middle, and proximal portions were loaded over the guidewire. After proper placement of the stent, the retractor suture string, pusher, and guidewire were removed. The stent was removed during the third or fourth month of placement through endoscopic retrograde cholangiopancreatography (ERCP) in all patients.

RESULTS

No significant complications developed during the procedure or follow-up period. Ten patients required re-stenting by ERCP during the same session. The mean follow-up period was 2 years. Cholestase enzymes and bilirubin levels were within normal limits in all patients during follow-up.

CONCLUSION

Stents derived from drainage catheter facilitate treatment of biliary strictures in patients not eligible for the retrograde approach. This stent is cheap, easy to implement, can be easily removed by ERCP, and re-stenting can be applicable in retrograde if needed.

Benign biliary strictures: prevalence, impact, and management strategies

Benign biliary strictures (BBSs) may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bile-duct injury, or at biliary anastomoses following liver transplantation. Treatment aims to relieve symptoms of biliary obstruction, maintain long-term drainage, and preserve liver function. Endoscopic therapy, including stricture dilatation and stenting, is effective in most cases and the first-line treatment of BBS. Radiological and surgical therapies are reserved for patients whose strictures are refractory to endoscopic interventions. Response to treatment is dependent upon the technique and accessories used, as well as stricture etiology. In this review, we discuss the various BBS etiologies and their management strategies.

Endobiliary Radiofrequency Ablation in the Percutaneous Management of Refractory Benign Bilioenteric Anastomosis Strictures

OBJECTIVE

The purpose of this study is to evaluate the safety and efficacy of endobiliary radiofrequency ablation (RFA) in the percutaneous management of benign bilioenteric anastomosis strictures that are refractory to balloon dilatation and long-term drainage.

MATERIALS AND METHODS

Twenty-one patients (11 men) with a mean age of 47.9 years (range, 26-73 years) underwent percutaneous balloon dilatation and long-term drainage for benign bilioenteric anastomosis strictures. Endobiliary RFA was performed in six patients (four men; mean age, 53.1 years; range, 43-63 years) whose strictures did not respond to balloon dilatation and long-term drainage.

RESULTS

Presenting symptoms were jaundice (n = 21), pain (n = 19), pruritus (n = 17), and cholangitis (n = 15). The symptoms appeared 1384 days (range, 4-7592 days) after surgery. The technical success rate was 100%. The overall clinical success rate was 95.2% (20/21) with a mean follow-up of 67.3 months (range, 9-148 months) after catheter removal. In 15 patients, associated biliary stones were removed. Two patients with recurrent strictures were successfully retreated. Endobiliary RFA was successful and catheter removal could be achieved in all six patients (100%) whose disease did not respond to multiple balloon dilatation sessions and long-term drainage. The mean symptom-free period after endobiliary RFA and catheter removal was 430 days (range, 270-575 days). One patient with refractory disease (4.7%), for whom endobiliary RFA was not performed, underwent surgery. There were no major complications.

CONCLUSION

Endobiliary ablation may be used safely and effectively in the percutaneous management of benign bilioenteric anastomosis strictures that are refractory to balloon dilatation and long-term drainage, with promising results.

Management of Biliary Strictures: State-of-the-Art Review

Biliary strictures can be broadly classified as benign or malignant. Benign biliary strictures are most commonly iatrogenic in nature and are a consequence of hepatobiliary surgery. Cholangiocarcinoma and adenocarcinoma of the pancreas are the most common causes of malignant biliary obstruction. This article reviews state-of-the-art minimally invasive techniques used to manage these strictures. In addition, the roles of (a) recently introduced biodegradable biliary stents in the management of benign biliary strictures and (b) intraprocedural imaging and navigation tools, such as cone-beam CT, in percutaneous reconstruction of the biliary-enteric anastomosis are discussed.

Percutaneous treatment of benign bilioenteric anastomotic strictures: temporary covered stent placement versus balloon dilatation

OBJECTIVES

To compare percutaneous temporary covered stent placement with balloon dilatation in the treatment of benign stricture of bilioenteric anastomosis.

METHODS

From November 2004 to August 2017, 56 patients with benign bilioenteric anastomotic strictures underwent percutaneous transhepatic treatment. A temporary covered stent designed for spontaneous migration was placed in 23 patients (stent group). Balloon dilatation was performed in 33 patients (balloon group). The technical success, percutaneous transhepatic biliary drainage (PTBD) indwelling times, stent indwelling times and patency rates were retrospectively compared between the two groups.

RESULTS

Technical success was achieved in all patients in the stent group and in 96.8% (32/33) of patients in the balloon group. All stents spontaneously migrated into the jejunum, and stent indwelling times were 3-9 months (median, 6 months). The PTBD indwelling time was shorter for the stent group than for the balloon group (median, 7 vs. 71 days, p = 0.001). Recurrent strictures occurred more frequently in the balloon group than in the stent group (54.5% vs. 13.0%, p = 0.002; hazard ratio 3.7). The 1- and 3-year primary patency rates were 90.2% and 84.9% for the stent group and 75.1% and 52.8% for the balloon group, respectively (p = 0.04).

CONCLUSIONS

Percutaneous temporary covered stenting is an effective treatment in patients with benign bilioenteric anastomotic strictures. It provides longer patency and shorter PTBD indwelling time compared with balloon dilatation.

KEY POINTS

• A temporary covered stent designed for spontaneous migration is a feasible and effective treatment for patients with benign bilioenteric anastomotic strictures. • Percutaneous temporary covered stents provide longer patency and shorter drainage catheter indwelling time compared with conventional balloon dilatation. • A covered stent with flared ends spontaneously migrated after 3-9 months.

The endoscopist and malignant and non-malignant biliary obstruction

Patients with biliary strictures often represent a diagnostic and therapeutic challenge, due to the site and complexity of biliary obstruction and wide differential diagnosis. Multidisciplinary decision making is required to reach an accurate and timely diagnosis and to plan optimal care. Developments in endoscopic ultrasound and peroral cholangioscopy have advanced the diagnostic yield of biliary endoscopy, and novel optical imaging techniques are emerging. Endoscopic approaches to biliary drainage are preferred in most scenarios, and recent advances in therapeutic endoscopic ultrasound allow drainage where the previous alternatives were only percutaneous or surgical. Here we review recent advances in endoscopic practice for the diagnosis and management of biliary strictures. This article is part of a Special Issue entitled: Cholangiocytes in Health and Diseaseedited by Jesus Banales, Marco Marzioni and Peter Jansen.

Benign Biliary Strictures

Differentiating benign and malignant biliary strictures is a challenging and important clinical scenario. The typical presentation is indolent and involves elevation of liver enzymes, constitutional symptoms, and obstructive jaundice with or without superimposed or recurrent cholangitis. While overall the most common causes of biliary strictures are malignant, including cholangiocarcinoma and pancreatic adenocarcinoma, benign strictures encompass a wide spectrum of etiologies including iatrogenic, autoimmune, infectious, inflammatory, and congenital. Imaging plays a crucial role in evaluating strictures, characterizing their extent, and providing clues to the ultimate source of biliary obstruction. While ultrasound is a good screening tool for biliary ductal dilatation, it is limited by a poor negative predictive value. Magnetic resonance cholangiopancreatography is more than 95% sensitive and specific for detecting biliary strictures with the benefit of precise anatomic localization. Other commonly employed imaging modalities include endoscopic retrograde cholangiopancreatography with endoscopic ultrasound, contrast-enhanced CT, and cholangiography. First-line treatment of benign biliary strictures is endoscopic dilation and stenting. In patients with anatomy that precludes endoscopic cannulation, percutaneous biliary drain insertion and balloon dilation is preferred.

Benign Biliary Strictures: Diagnostic Evaluation and Approaches to Percutaneous Treatment

Interventional radiologists are often consulted to help identify and treat biliary strictures that can result from a variety of benign etiologies. Mainstays of noninvasive imaging for benign biliary strictures include ultrasound, contrast-enhanced computed tomography and magnetic resonance imaging, magnetic resonance cholangiopancreatography, and computed tomography cholangiography. Endoscopic retrograde cholangiography is the invasive diagnostic procedure of choice, allowing both localization of a stricture and treatment. Percutaneous biliary interventions are reserved for patients who are not candidates for endoscopic retrograde cholangiography (eg, history of distal gastrectomy and biliary-enteric anastomosis to a jejunal roux limb). This review discusses the roles of percutaneous transhepatic cholangiography and biliary drainage in the diagnosis of benign biliary strictures. The methodology for crossing benign biliary strictures, approaches to balloon dilation, management of recalcitrant strictures (ie, large-bore biliary catheters and retrievable covered stents), and the expected outcomes and complications of percutaneous treatment of benign biliary strictures are also addressed.

Self-expandable biodegradable biliary stents in porcine model

BACKGROUND

Treatment or prevention of a benign biliary tree stricture is an unresolved problem. A novel self-expandable biodegradable polydioxanon biliary stent in a porcine model was studied.

MATERIALS AND METHODS

This new stent was used in 23 pigs. Feasibility and safety of surgical stenting, time of biodegradation, and histologic reaction in 2, 8, 13, and 20 wk of a follow-up were studied. All stents were inserted into a common bile duct through a duodenal papilla following small dilatation. After surgical evaluation of abdominal cavities, the pigs were sacrificed to remove common bile ducts with the stents. All bile ducts were assessed by macroscopic and histopathologic examination.

RESULTS

Self-expansion was correct in all cases. Neither bile duct obstruction nor postsurgical complications were observed. Macroscopic evaluation indicated lightening of the stent color in 2 wk, a partial disintegration in 8 wk, and a complete absorption in 13 and 20 wk. Histologic evaluation in general substantiated a mild-to-moderate inflammatory reaction in the lamina propria during the whole follow up and had no clinical consequences. No cholangitis, necrosis, abscess, or excessive fibroplasia was found in a hepatoduodenal ligament.

CONCLUSIONS

Our results suggest that polydioxanon biodegradable self-expanding stents seem to be useful for biliary system implantation, offer a good biocompatibility, and completely degrade within 13 wk.

Percutaneous balloon dilatation and long-term drainage as treatment of anastomotic and nonanastomotic benign biliary strictures

PURPOSE

This study was designed to determine the effectiveness of percutaneous balloon dilation and long-term drainage of postoperative benign biliary strictures.

METHODS

Medical records of patients with postoperative benign biliary strictures, in whom percutaneous transhepatic biliary drainage (PTBD) and balloon dilation was performed between January 1999 and December 2011, were retrospectively reviewed. PTBD and balloon dilation (4-10 mm) were followed by placement of internal-external biliary drainage catheters (8.5-12 F). Patients were scheduled for elective tube changes, if necessary combined with repeated balloon dilation of the stenosis, at 3-week intervals up to a minimum of 3 months.

RESULTS

Ninety-eight patients received a total of 134 treatments. The treatment was considered technically successful in 98.5%. Drainage catheters were left in with a median duration of 14 weeks. Complications occurred in 11 patients. In 13 patients, percutaneous treatment was converted to surgical intervention. Of 85 patients in whom percutaneous treatment was completed, 11.8% developed clinically relevant restenosis. Median follow-up was 35 months. Probability of patency at 1, 2, 5, and 10 years was 0.95, 0.92, 0.88, and 0.72, respectively. Overall, 76.5% had successful management with PTBD. Restenosis and treatment failure occurred more often in patients who underwent multiple treatments. Treatments failed more often in patients with multiple strictures. All blood markers of liver function significantly decreased to normal values.

CONCLUSIONS

Percutaneous balloon dilation and long-term drainage demonstrate good short- and long-term effectiveness as treatment for postoperative benign biliary strictures with an acceptably low complication rate and therefore are indicated as treatment of choice.