Role of Biliary Stress Manometry after Biliary Stricture Dilation in Living Donor Liver Transplant Recipients

The Utility of Biliary Manometry in Assessing Early Catheter Removal After Percutaneous Balloon Dilatation of Hepaticojejunostomy Strictures

Background and objective

Percutaneous balloon dilatation followed by long-term internal-external biliary catheter (IEBC) placement is the standard radiological management for postoperative hepaticojejunostomy (HJ) strictures. The treatment is considered successful when cholangiography shows a free flow of contrast across the anastomosis and the patient passes a "clinical test". However, these tests may not be suitable predictors of long-term successful treatment outcomes. The purpose of this study was to assess the utility of biliary manometry in the evaluation of successful treatment outcomes after HJ stricture dilatation and IEBC placement and its efficacy as a tool for early catheter removal.

Patients and methods

A total of 14 patients underwent percutaneous balloon dilatation of HJ strictures with IEBC placement. A two-to-three-month interval was maintained between sessions of exchanging or upsizing IEBCs. Biliary manometry was performed after a mean duration of 6.3 months. Intra-biliary pressure of <15 mmHg was considered as the success threshold.

Results

Among the 14 patients, 11 patients passed initial manometry and had their IEBCs removed and were followed up for a mean duration of 47.8 months. Of these, one patient developed biliary obstruction after six months and underwent repeat HJ stricture dilatation and long-term IEBC placement. Three patients failed manometry and underwent re-dilatation of HJ strictures with IEBC placement. Using Kaplan-Meier survival analysis, the probability of patients remaining stricture-free after HJ stricture dilatation was found to be 100% at three months and 91% at six, 12, 18, 24, 36, and 47.8 months.

Conclusion

Biliary manometry prevents subjective variations in determining treatment endpoints and helps to assess early catheter removal after percutaneous balloon dilatation of HJ strictures.

Novel Non-Surgical Interventions for Benign Inflammatory Biliary Strictures in Infants: A Report of Two Cases and Review of Current Pediatric Literature

Benign biliary strictures are uncommon in children. Classically, these cases are managed surgically, however less invasive approaches with interventional radiology and or endoscopy may have similar results and improved safety profiles While benign biliary strictures have been described in literature on several occasions in young children, (most older than 1 year and once in an infant 3 months of age), all reported cases were managed surgically. We present two cases of benign biliary strictures in infants less than 6 months of age that were managed successfully with novel non-invasive procedures and a review of all current pediatric cases reported in the literature. Furthermore, we describe the use of a Rendezvous procedure, which has not been reported as a treatment approach for benign biliary strictures.

Percutaneous management of resistant biliary-enteric anastomotic strictures with the use of a combined cutting and conventional balloon cholangioplasty protocol: a single-center experience

PURPOSE

To evaluate the safety and technical efficacy of percutaneous transhepatic dilation of resistant biliary-enteric anastomotic strictures using a combination of cutting and conventional balloons and evaluate midterm results.

MATERIALS AND METHODS

A retrospective review of patients with biliary-enteric anastomotic strictures treated with percutaneous transhepatic cutting balloon dilation was performed. Cutting balloon dilation was followed by dilation with the use of a conventional balloon with a diameter larger than that of the cutting balloon. Technical success was defined by the composite criteria of fluent passage of manually injected contrast medium through the anastomoses into the small bowel and absence of bile duct dilatation compared with the cholangiogram obtained before the procedure. Clinical and laboratory parameters, including serum bilirubin, alkaline phosphatase, and total leukocyte counts, were monitored in all patients at regular intervals after a technically successful procedure.

RESULTS

Between January 2012 and September 2013, eight patients (three men and five women) with a mean age of 50 years (range, 32-75 y) underwent 11 sessions of combined cutting and conventional balloon cholangioplasty. The procedure was technically successful in all patients. There were no major complications during the procedure. During the follow-up period (mean, 14 mo; range, 8-24 mo), all patients remained free of any biliary obstructive symptoms and had normal laboratory parameters with the absence of biliary dilatation on ultrasound examinations.

CONCLUSIONS

Cutting balloon dilation is a safe adjunctive option for the treatment of biliary-enteric anastomotic strictures resistant to conventional balloon dilation with acceptable midterm patency rates.

Biliary strictures after orthotopic liver transplantation: long-term results of percutaneous treatment in patients with nonfeasible endoscopic therapy

PURPOSE

The aim of this study was to evaluate our experience with percutaneous treatment of biliary strictures after orthotopic liver transplantation in adult patients without the endoscopic access possibility and to evaluate the technical outcomes and long-term clinical results of this treatment.

MATERIALS AND METHODS

Thirty percutaneous procedures were performed in adult liver transplant recipients (13 men, 17 women, mean age 46.4 years) in our institution between 1996 and 2010. Patients were treated with balloon dilatation and biliary duct drainage due to anastomotic stenosis (n = 20), nonanastomotic stenosis (n = 7), or due to stenosis caused by lymphoproliferation (n = 3). The percutaneous procedure was the first line of treatment due to hepaticojejunoanastomosis (n = 18) or after unsuccessful endoscopic therapy (n = 12).

RESULTS

Technical success was achieved in 27 patients (90%). The remaining three patients only achieved external drainage with subsequent surgery. There were two complications (6.3%). Long-term clinical success, defined as the absence of clinical, laboratory, or sonographic signs of stricture recurrence was achieved in 22 patients (73.3%) for a mean follow-up of 5.8 years.

CONCLUSION

Percutaneous treatment--balloon dilatation and biliary duct drainage--is a first-line option to manage biliary duct strictures in liver recipient, when endoscopic treatment is not possible or unsuccessful. It has a high technical success rate and low complication rate with favorable long-term results.

Is the biliary manometric perfusion test effective in the evaluation of balloon dilatation treatment success of benign biliary strictures?

BACKGROUND

The success of balloon dilatation treatment of benign biliary strictures (BBS) is usually evaluated by 'clinical test'. For objective evaluation of treatment success, measurement of the pressure inside the biliary tree after treatment has been proposed.

AIM

The aim of this article is to assess the role of biliary manometric perfusion test (BMPT) in the evaluation of treatment success of BBS and to assess the long term biliary patency after evaluation by BMPT.

MATERIALS AND METHODS

From February 2003 to January 2008, 12 patients (median age 53.5 years) after balloon dilatation treatment were evaluated by BMPT. BMPT was done after a mean of 3 dilatations over a mean period of 6.85 months. An intrabiliary pressure less than 20 cm of water during the test was considered as success threshold.

RESULTS

The pressures during BMPT were less than 20 cm of water in 11 out of 12 patients. Subsequently the drain was removed and patients were followed up clinically. Two patients on follow-up required re-intervention 13 days and 11 months later. The remaining 9 patients had no evidence of biliary obstruction at a mean following of 15.3 months. Using the statistical Kaplan-Meier analysis, the probability of biliary patency up to 9 months was 90.9% and at 1, 2 and 3 years was 77%.

CONCLUSION

BMPT is effective in the evaluation of treatment success of BBS. It is simple, cost effective, gives immediate results and helps us to determine the treatment end point.