Long-term results of percutaneous biliary balloon dilation treatment for benign hepaticojejunostomy strictures: are repeated balloon dilations necessary?

Late cholangitis after pancreatoduodenectomy: A common complication with or without anatomical biliary obstruction

BACKGROUND

Postoperative cholangitis is a common complication after pancreatoduodenectomy that can occur with or without anatomical biliary obstruction. This study aimed to investigate the incidence, diagnosis, treatment, and risk factors of cholangitis after pancreatoduodenectomy.

METHODS

We performed a retrospective cohort study of consecutive patients who underwent pancreatoduodenectomy in 2 Dutch tertiary pancreatic centers (2010-2019). Primary outcome was postoperative cholangitis, defined as systemic inflammation with abnormal liver tests without another focus of infection, at least 1 month after resection. Diagnostic and therapeutic strategies were evaluated. Two types of postoperative cholangitis were distinguished; obstructive cholangitis (benign stenosis of the hepaticojejunostomy) and nonobstructive cholangitis. Potential risk factors were identified using logistic regression analysis.

RESULTS

Postoperative cholangitis occurred in 93 of 900 patients (10.3%). Median time to first episode of cholangitis was 8 months (interquartile range 4-16) after pancreatoduodenectomy. Multiple episodes of cholangitis occurred in 44 patients (47.3%) and readmission was necessary in 83 patients (89.2%). No cholangitis-related mortality was observed. Obstructive cholangitis was seen in 37 patients (39.8%) and nonobstructive cholangitis in 56 patients (60.2%). Surgery was performed for cholangitis in 7 patients (7.5%) and consisted of revision of the hepaticojejunostomy or elongation of the biliary limb. Postoperative biliary leakage (odds ratio 2.56; 95% confidence interval 1.42-4.62; P = .0018) was independently associated with postoperative cholangitis.

CONCLUSION

Postoperative cholangitis unrelated to cancer recurrence was seen in 10% of patients after pancreatoduodenectomy. Nonobstructive cholangitis was more common than obstructive cholangitis. Postoperative biliary leakage was an independent risk factor.

The contribution of EUS to the management of endoscopic and surgical complications

Endoscopic Ultrasound (EUS) stands as a remarkable innovation in the realm of gastroenterology and its allied disciplines. EUS has evolved to such an extent that it now assumes a pivotal role in both diagnosis and therapeutics. In addition, it has developed as a tool which is also capable of addressing complications arising from endoscopic and surgical procedures. This minimally invasive technique combines endoscopy with high-frequency ultrasound, facilitating, high-resolution images of the gastrointestinal tract and adjacent structures. Complications within the gastrointestinal tract, whether stemming from endoscopic or surgical procedures, frequently arise due to disruption in the integrity of the gastrointestinal tract wall. While these complications are usually promptly detected, there are instances where their onset is delayed. EUS plays a dual role in the management of these complications. Firstly, in its ability to assess and increasingly to definitively manage complications through drainage procedures. It is increasingly employed to manage post-surgical collections, abscesses biliary strictures and bleeding. Its high-resolution imaging capability allows precise real-time visualisation of these complications.

EUS-BD for calibration of benign stenosis of the bile duct in patients with altered anatomy or inaccessible papilla

Background and study aims In cases of inaccessible papilla, EUS-guided biliary drainage (EUS-BD) has been described as an alternative to calibrate benign biliary stenosis. However, few studies are available. Patients and methods This tw-center, retrospective study was designed to evaluate technical success and clinical success at 1 year. All patients who underswent EUS-BD without the rendezvous technique used for calibration of benign biliary stenosis were included from 2016 to 2022. Patients underwent EUS-hepaticogastrostomy (EUS-HGS) during the first session. Then, HGS was used to access the bile duct, allowing calibration of the stenosis: Dilation of the biliary stenosis and placement of double pigtail stents through the stenosis for 1 year. Results Thirty-six patients were included. Technical success was 89% (32/36), with four failures to cross the stenosis but EUS-HGS was performed in 100% of the cases. Nine patients were excluded during calibration because of oncological relapse in six and complex stenosis in three. Three patients had not yet reached 1 year of follow-up. Twenty patients had a calibration for at least 1 year. Clinical success after stent placement was considered in all cases after 1 year of follow-up. Thirteen patients underwent stent removal and no relapse occurred after 435 days of follow-up (SD=568). Global morbidity was 41.7% (15/36) with only one serious complication (needing intensive care), including seven cases of cholangitis due to intrabiliary duct obstruction and five stent migrations. No deaths were reported. Conclusions EUS-BD for calibration in case of benign biliary stenosis is an option. Dedicated materials are needed to decrease morbidity.

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.

Robotic Revision of Hepaticojejunostomy for Benign Biliary Stricture

Surgical revision of biliary enteric anastomoses (BEA) can be a challenging undertaking and a robotic platform may provide advantages that address many of the technical obstacles. We present our technical approach and outcomes for patients undergoing robotic revision of BEA for benign strictures. A retrospective review was performed for robot-assisted benign BEA revision at our institution. Operative details, perioperative metrics, and outcomes are reported. Four patients underwent anastomotic revision following previously failed non-operative management. There were no intraoperative complications, mean length of stay was 4-days, and all patients experienced resolution of presenting clinical signs and symptoms. No patients required reoperation and there was no mortality. Postoperative outcomes were consistent with findings reported for other interventional modalities. Based on our experience we conclude robotic intervention in this context is safe and improves the technical feasibility of this complex procedure.

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.

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.

CIRSE Standards of Practice on Percutaneous Transhepatic Cholangiography, Biliary Drainage and Stenting

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing percutaneous transhepatic cholangiography, biliary drainage and stenting. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

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.

Endoscopic Balloon Dilation for Benign Bilioenteric Stricture: Outcomes and Factors Affecting Recurrence

BACKGROUND

Balloon dilation (BD) is a simple, effective procedure for postoperative benign bilioenteric strictures (BBESs). Factors associated with BBES recurrence after endoscopic BD have not been studied adequately. This study examined the outcomes and 1-year recurrence factors in patients with BBES who underwent endoscopic BD.

METHODS

Patients who underwent endoscopic BD as an initial treatment between April 2008 and March 2017 were retrospectively assessed. The median time to recurrence of BBES (RBBES) and recurrence factors were evaluated.

RESULTS

The study group comprised 55 patients (median age 72 years). The rate of RBBES was 52.7% (29/55), and the median time to RBBES was 2.78 years (95% confidence interval [CI] 1.17-4.40). RBBES was observed in 32.7% (18/55) within 1 year after endoscopic BD. The significant factors associated with recurrence within 1 year, revealed by multivariate analysis, were: postoperative bile leak (p = 0.001; hazard ratio [HR] 10.94; 95% CI 2.47-48.39); BBES onset within 6 months, postoperatively (p = 0.013; HR 6.18; 95% CI 1.46-26.21); no intrahepatic stones (p = 0.049; HR 3.05; 95% CI 1.01-9.22); and remaining balloon waist (p = 0.005; HR 5.71; 95% CI 1.69-19.31). The median time to RBBES was significantly shorter in patients with these recurrence factors (0.88 years vs. not reached, p = 0.004). Patients exhibiting at least two recurrence factors were significantly more likely to experience recurrence (p < 0.001).

CONCLUSION

Endoscopic BD is effective for BBES, especially for patients with no recurrence factors. Consideration of endoscopic BD and additional treatment may be necessary for patients with recurrence factors.

Percutaneous endobiliary radiofrequency ablation for refractory benign hepaticojejunostomy and biliary strictures

PURPOSE

The objective of this study was to determine the safety and efficacy of percutaneous endobiliary radiofrequency ablation (ERFA) and balloon dilation for the treatment of hepaticojejunostomy (HJ) strictures resistant to surgery and/or other interventions.

MATERIALS AND METHODS

Eighteen patients who underwent percutaneous ERFA for HJ stricture were included. There were 10 men and 8 women with a mean age of 48.3±10.8 (SD) years (range: 33-69 years). The 18 patients had a total of 29 benign HJ strictures secondary to cholecystectomy (14 patients; 78.0%), Whipple procedure (3 patients; 16.6%) or blunt abdominal trauma (1 patient; 5.4%). The different end-points were technical success, clinical success, recurrence, procedure-related mortality, and morbidity.

RESULTS

Technical and clinical success rates were 100% and 83.3%, respectively. No mortality and major procedure-related complications were observed. One patient experienced minor complication (self-limited pleural effusion). Two patients did not show favorable response to ERFA whereas 10 patients had no stricture recurrence during a mean follow-up period of 7.3 months±1.0 (SD) (range: 4-10 months).

CONCLUSION

ERFA is a safe and effective treatment for benign HJ and biliary strictures. However, more studies involving more patients with a long-term follow-up period should be made to fully determine the long-term results of ERFA.

Incidence and Risk Factors of Cholangitis after Hepaticojejunostomy

BACKGROUND

After hepatobiliary-pancreatic surgery, hepaticojejunostomy cholangitis is a rare condition; the true incidence rate of postoperative cholangitis is unknown. Therefore, our study aimed to determine the incidence rate and timing of postoperative cholangitis after biliary-enteric anastomosis, and to evaluate risk factors and management strategies.

METHODS

Our single-center retrospective study included 583 patients who had undergone biliary-enteric anastomosis for hepatobiliary-pancreatic diseases. Demographic and treatment data were extracted from the medical records, and the association between potential risk factors and the development of postoperative cholangitis evaluated using a prospectively collected database.

RESULTS

Postoperative cholangitis developed in 45/583 patients (incidence rate, 7.7%), on average 18.3 ± 27.4 months (median = 6.9 months) after surgery. On multivariate analysis, the following factors were independently associated with postoperative cholangitis after biliary-enteric anastomosis: male sex, benign condition, and postoperative complication with a Clavien-Dindo classification grade > III. Among patients with postoperative cholangitis, a biliary stricture developed in 57.8% (26/45) of cases. Percutaneous balloon dilatation (73.1%) and endoscopic stenting (11.5%) were used as initial treatment of the stricture, with surgical revision being required in only 15.4% of cases of hepaticojejunostomy stricture.

CONCLUSION

Biliary-enteric anastomotic cholangitis after hepaticojejunostomy is a distinct disease process. Although non-operative management of postoperative cholangitis is successful in many cases, further research is required to better understand patient- and physician-related factors that predispose patients to postoperative cholangitis.

The Utility of a Benign Biliary Stricture Protocol in Preventing Symptomatic Recurrence and Surgical Revision

PURPOSE

To determine whether treating benign biliary strictures via a stricture protocol reduced the probability of developing symptomatic recurrence and requiring surgical revision compared to nonprotocol treatment.

MATERIALS AND METHODS

A stricture protocol was designed to include serial upsizing of internal/external biliary drainage catheters to a target maximum dilation of 18-French, optional cholangioplasty at each upsizing, and maintenance of the largest catheter for at least 6 months. Patients were included in this retrospective analysis if they underwent biliary ductal dilation at a single institution from 2005 to 2016. Forty-two patients were included, 25 women and 17 men, with an average age of 51.9 years (standard deviation ± 14.6). Logistic regression models were used to determine the probability of symptomatic recurrence and surgical revision by stricture treatment type.

RESULTS

Twenty-two patients received nonprotocol treatment, while 20 received treatment on a stricture protocol. After treatment, 7 (32%) patients in the nonprotocol group experienced clinical or laboratory recurrence of a benign stricture, whereas only 1 patient in the stricture protocol group experienced symptom recurrence. Patients in the protocol group were 8.9 times (95% confidence interval [CI] = 1.4-175.3) more likely to remain symptom free than patients in the nonprotocol group. Moreover, patients in the protocol group had an estimated 89% reduction in the probability of undergoing surgical revision compared to patients receiving nonprotocol treatment (odds ratio = .11, 95% CI = .01-.73).

CONCLUSIONS

Establishing a stricture protocol may decrease the risk of stricture recurrence and the need for surgical revision when compared to a nonprotocol treatment approach.

Imaging and radiological interventions in extra-hepatic portal vein obstruction

Extrahepatic portal vein obstruction (EHPVO) is a primary vascular condition characterized by chronic long standing blockage and cavernous transformation of portal vein with or without additional involvement of intrahepatic branches, splenic or superior mesenteric vein. Patients generally present in childhood with multiple episodes of variceal bleed and EHPVO is the predominant cause of paediatric portal hypertension (PHT) in developing countries. It is a pre-hepatic type of PHT in which liver functions and morphology are preserved till late. Characteristic imaging findings include multiple parabiliary venous collaterals which form to bypass the obstructed portal vein with resultant changes in biliary tree termed portal biliopathy or portal cavernoma cholangiopathy. Ultrasound with Doppler, computed tomography, magnetic resonance cholangiography and magnetic resonance portovenography are non-invasive techniques which can provide a comprehensive analysis of degree and extent of EHPVO, collaterals and bile duct abnormalities. These can also be used to assess in surgical planning as well screening for shunt patency in post-operative patients. The multitude of changes and complications seen in EHPVO can be addressed by various radiological interventional procedures. The myriad of symptoms arising secondary to vascular, biliary, visceral and neurocognitive changes in EHPVO can be managed by various radiological interventions like transjugular intra-hepatic portosystemic shunt, percutaneous transhepatic biliary drainage, partial splenic embolization, balloon occluded retrograde obliteration of portosystemic shunt (PSS) and revision of PSS.

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.

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.