Percutaneous transhepatic cholangioscopic treatment of patients with benign bilio-enteric anastomotic strictures

Percutaneous transhepatic cholangioscopy-assisted biliary polypectomy for local palliative treatment of intraductal papillary neoplasm of the bile duct

BACKGROUND

Intraductal papillary neoplasm of the bile duct (IPNB) is a premalignant biliary-type epithelial neoplasm with intraductal papillary or villous growth. Currently reported local palliative therapeutic modalities, including endoscopic nasobiliary drainage, stenting and biliary curettage, endoscopic biliary polypectomy, percutaneous biliary drainage, laser ablation, argon plasma coagulation, photodynamic therapy, and radiofrequency ablation to relieve mechanical obstruction are limited with weaknesses and disadvantages. We have applied percutaneous transhepatic cholangioscopy (PTCS)-assisted biliary polypectomy (PTCS-BP) technique for the management of IPNB including mucin-hypersecreting cast-like and polypoid type tumors since 2010.

AIM

To assess the technical feasibility, efficacy, and safety of PTCS-BP for local palliative treatment of IPNB.

METHODS

Patients with mucin-hypersecreting cast-like or polypoid type IPNB and receiving PTCS-BP between September 2010 and December 2019 were included. PTCS-BP was performed by using a half-moon type snare with a soft stainless-steel wire, and the tumor was snared and resected with electrocautery. The primary outcome was its feasibility, indicated by technical success. The secondary outcomes were efficacy, including therapeutic success, curative resection, and clinical success, and safety.

RESULTS

Five patients (four with mucin-hypersecreting cast-like type and one with polypoid type IPNB) were included. Low- and high-grade intraepithelial neoplasia (HGIN) and recurrent IPNB with invasive carcinoma were observed in one, two, and two patients, respectively. Repeated cholangitis and/or obstructive jaundice were presented in all four patients with mucin-hypersecreting cast-like type IPNB. All five patients achieved technical success of PTCS-BP. Four patients (three with mucin-hypersecreting cast-like type and one with polypoid type IPNB) obtained therapeutic success; one with mucin-hypersecreting cast-like type tumors in the intrahepatic small bile duct and HGIN had residual tumors. All four patients with mucin-hypersecreting IPNB achieved clinical success. The patient with polypoid type IPNB achieved curative resection. There were no PTCS-BP-related serious adverse events.

CONCLUSION

PTCS-BP appears to be feasible, efficacious, and safe for local palliative treatment of both mucin-hypersecreting cast-like and polypoid type IPNB.

A case of hepaticojejunal anastomotic obstruction after a living-donor liver transplantation and recanalization using a high-frequency knife under the rendezvous technique

A 65-year-old woman underwent living-donor liver transplantation (left-lobe graft: GWRW ratio, 0.54) for cirrhosis caused by autoimmune hepatitis. At 68 years, she was diagnosed with obstructive cholangitis due to stricture during a hepaticojejunostomy following impaired liver function. Endoscopic balloon dilation of anastomosis and placement of a plastic stent resulted in improved liver function. However, at 72 years, the patient experienced a flare-up of liver damage. The plastic stent had fallen out, and although endoscopic stenotic dilation was attempted, the anastomotic site was obstructed completely. Therefore, recanalization of the hepaticojejunostomy was attempted using a rendezvous technique. A percutaneous transhepatic biliary drainage tube was inserted through the B3 bile duct, and the complete obstructed anastomosis was confirmed by percutaneous transhepatic and transjejunal approaches. The anastomosis was reopened by excising the scarred tissues from the jejunal side using a 1.5-mm high-frequency knife. A 14-Fr. catheter for the internal fistula tube was percutaneously placed at the opened anastomosis to achieve anastomotic site recanalization. The patient's liver damage improved after the re-internalization, and no symptom recurrence such as obstructive cholangitis developed for 1 year. There are few reports of recanalization of the hepaticojejunostomy with a high-frequency knife. Herein, we report the case with a literature review.

Percutaneous Transhepatic Cholangioscopy Interventions-Updates

Percutaneous transhepatic cholangioscopy (PTCS) was initially described around the same time that peroral cholangioscopy (POSC) was developed. The cited utility attributed to PTCS is the ability to be utilized in the subset of patients with surgical proximal bowel anatomy, often precluding the use of traditional POSC. However, since first described, PTCS use has been limited due to a lack of physician awareness and a lack of procedure-specific equipment and supplies. With recent developments of PTSC-specific equipment, there has been an expansion in the possible interventions able to be performed during PTCS, resulting in a rapid increase in clinical use. This short review will serve as a comprehensive update of the previous and more recent novel interventions now able to be performed during PTCS.

[Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]

Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.

Novel technique for recanalization of severe hepaticojejunal obstruction using a transseptal needle in a pediatric liver transplant recipient

BACKGROUND

Endoscopic and PTB interventions are common nonsurgical interventions for biliary anastomotic strictures that occur after liver transplantation. When these nonsurgical interventions fail, surgical re-anastomosis is considered; however, this is quite invasive and can cause additional injury that may lead to graft loss. We report a case in which conventional nonsurgical interventions failed, but a new method that involve the use of a transseptal needle-a device to create a transseptal left-heart access during cardiac catheter interventions-was successfully used in recanalization of the hepaticojejunal anastomotic obstruction.

CASE

A 21-year-old man, who had received living-donor liver transplantation for biliary atresia at the age of 23 months presented with recurrent cholangitis and liver dysfunction due to a biliary anastomotic stricture of the hepaticojejunostomy. Therapeutic interventions for biliary stricture, including the PTB approach, double-balloon enteroscopic approach, and rendezvous approach failed. We then performed needle puncture of the anastomotic obstruction using a transseptal needle and succeeded in recanalizing the complete anastomotic obstruction. To perform the procedures safely, we evaluated the organ and needle positions using biplane fluoroscopy and placed a balloon in the afferent jejunal limb as a target for puncture. The 12 Fr catheter via the biliary route was removed 7 months after the procedure, without using a catheter, there was no recurrent stricture or cholangitis for 26 months.

CONCLUSION

Using a transseptal needle to manage hepaticojejunal anastomotic obstruction can reduce the number of patients who need surgical re-anastomosis.

Endoscopic neo-anastomosis by Rendez-vous technique for the treatment of complete occlusion of bilioenteric anastomoses and distal bile ducts (case series)

BACKGROUND AND AIMS

The complete occlusion of bilioenteric anastomoses is a rare and challenging clinical condition. Repeated surgery is burdened with technical difficulties and significant morbidity. We report the first series of completely occluded bilioenteric anastomoses resp. distal bile duct successfully treated by simultaneous percutaneous and retrograde endoscopic interventions.

PATIENTS AND METHODS

This case series includes 4 patients with obstructive jaundice and/or recurring cholangitis and pain due to complete fibrotic occlusion of a hepaticojejunostomy (3 patients) and the distal bile duct (1 patient). After performing PTCD and stepwise dilation of the biliocutaneous tract, we tried to approach the occluded anastomosis from 2 sides by simultaneous percutaneous cholangioscopy and peroral device-assisted enteroscopy/duodenoscopy. By cutting through the separating tissue layer with a needle knife under endoscopic and fluoroscopic control using diaphanoscopy, a new anastomosis should be established followed by dilation of the neoanastomosis with subsequent percutaneous transhepatic drainage for a minimum of 1 year to prevent re-occlusion.

RESULTS

The Rendez-vous maneuver was successful in 3/4 cases. In one case, the retrograde access to the anastomosis failed, so the neoanastomosis was cut under cholangioscopic and fluoroscopic guidance only. The neoanastomosis could be established successfully in all 4 cases. Jaundice, cholangitis, and pain disappeared. Minor periinterventional adverse events were cholangitis (n = 1) and pneumonia (n = 1) due to aspiration, which could be managed conservatively. No serious adverse events were observed, and no re-occlusion of any neoanastomosis occurred during the follow-up before and after removal of the percutaneous drainage.

CONCLUSION

Simultaneous percutaneous cholangioscopy and device-assisted enteroscopy/duodenoscopy with endoscopic creation of a neoanastomosis is a possible concept for the treatment of completely occluded bilioenteric anastomoses and distal bile ducts. This case series confirms the feasibility, safety, and long-term effectiveness of this treatment.

Repeated balloon dilatation with long-term biliary drainage for treatment of benign biliary-enteric anastomosis strictures: A STROBE-compliant article

Percutaneous balloon dilatation for benign biliary-enteric anastomosis stricture has been the most widely used alternative to endoscopic treatment. However, patency results from the precedent literature are inconsistent.The objective of this study was to evaluate the safety and feasibility of repeated balloon dilatation with long-term biliary drainage for the treatment of benign biliary-enteric anastomosis strictures.Data from patients with benign biliary-enteric anastomosis strictures who underwent percutaneous transhepatic cholangiography (PTC), repeated balloon dilatation with long-term biliary drainage (repeated-dilatation group; n = 23), or PTC and single balloon dilatation with long-term biliary drainage (single-dilatation group; n = 26) were reviewed. Postoperative complications, jaundice remission, and sustained anastomosis patency were compared between the groups.All procedures were successful. No severe intraoperative complications, such as biliary bleeding and perforation, were observed. The jaundice remission rate in the first week was similar in the 2 groups. During the 26-month follow-up period, 3 patients in the repeated-dilatation group had recurrences (mean time to recurrence: 22.84 ± 0.67 months, range: 18-26 months). In the single-dilatation group, 15 patients had recurrences (mean time to recurrence = 15.28 ± 1.63 months, range: 3-18 months). The duration of patency after dilatation was significantly better in the repeated-dilatation group (P = .01). All patients with recurrence underwent repeat PTC followed by balloon dilatation and biliary drainage.Repeated balloon dilatation and biliary drainage is an effective, minimally invasive, and safe procedure for treating benign biliary-enteric anastomosis strictures, and provides significantly higher patency rates than single dilatation.

Comparison Between Endoscopic Biliary Stenting Combined with Balloon Dilation and Balloon Dilation Alone for the Treatment of Benign Hepaticojejunostomy Anastomotic Stricture

BACKGROUND

Hepaticojejunostomy anastomotic stricture (HJAS) is an important complication of biliary reconstructive surgery but has no standard treatment. We aimed to evaluate the outcomes of endoscopic treatment for benign HJAS and identify the risk factors for its recurrence.

METHODS

This study retrospectively analyzed 176 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for HJAS between April 2008 and March 2016. The outcome of endoscopic biliary stenting combined with balloon dilation (EBS group) and balloon dilation alone (balloon group) was evaluated.

RESULTS

The scope was successfully inserted into the HJ site in 93.8% patients (165/176), and 139 patients underwent endoscopic treatment after HJAS was confirmed. Successful biliary drainage was achieved in 137 patients by using ERCP and rendezvous procedures. Among these, 103 patients were included in balloon group and 34 patients were in EBS group. HJAS was resolved in 132 patients; five died from recurrence of primary disease. The 1 (3)-year bile duct patency rates in the balloon and EBS groups were 62.5% (46.6%) and 89.4% (84.7%), respectively (p = 0.015). Univariate analysis showed that balloon dilation (p = 0.009) and early HJAS formation (time from surgery to ERCP < 1 year) (p = 0.02) were risk factors for HJAS recurrence. In the multivariate analysis, balloon dilatation was identified as independent risk factors for HJAS recurrence.

CONCLUSIONS

Balloon dilation without stent deployment and early HJAS formation are risk factors for HJAS recurrence after endoscopic treatment. Stent deployment might be recommended for definite resolution of HJAS.

Endoscopic management of biliary strictures post-liver transplantation

Biliary complications play a significant role in morbidity of liver transplant recipients. Biliary strictures occur between 10%-25% of patients with a higher incidence in living donor recipients compared to deceased donors. Strictures can be classified as either anastomotic or non-anastomotic and may be related to ischemic events. Endoscopic management of biliary strictures in the post-transplant setting has become the preferred initial approach due to adequate rates of resolution of anastomotic and non-anastomotic strictures (NAS). However, several factors may increase complexity of the endoscopic approach including surgical anatomy, location, number, and severity of bile duct strictures. Many endoscopic tools are available, however, the approach to management of anastomotic and NAS has not been standardized. Multi-disciplinary techniques may be necessary to achieve optimal outcomes in select patients. We will review the risk factors associated with the development of bile duct strictures in the post-transplant setting along with the efficacy and complications of current endoscopic approaches available for the management of bile duct strictures.

Percutaneous transhepatic cholangioscopy and lithotripsy in treating difficult biliary ductal stones: Two case reports

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is preferred for managing biliary obstruction in patients with bilio-enteric anastomotic strictures (BEAS) and calculi. In patients whose duodenal anatomy is altered following upper gastrointestinal (UGI) tract surgery, ERCP is technically challenging because the biliary tree becomes difficult to access by per-oral endoscopy. Advanced endoscopic therapies like balloon-enteroscopy or rendevous-ERCP may be considered but are not always feasible. Biliary sepsis and comorbidities may also make these patients poor candidates for surgical management of their biliary obstruction.

CASE SUMMARY

We present two 70-year-old caucasian patients admitted as emergencies with obstructive cholangitis. Both patients had BEAS associated with calculi that were predominantly extrahepatic in Patient 1 and intrahepatic in Patient 2. Both patients were unsuitable for conventional ERCP due to surgically-altered UGl anatomy. Emergency biliary drainage was by percutaneous transhepatic cholangiography (PTC) in both cases and after 6-weeks’ maturation, PTC tracts were dilated to perform percutaneous transhepatic cholangioscopy and lithotripsy (PTCSL) for duct clearance. BEAS were firstly dilated fluoroscopically, and then biliary stones were flushed into the small bowel or basket-retrieved under visualization provided by the percutaneously-inserted video cholangioscope. Lithotripsy was used to fragment impacted calculi, also under visualization by video cholangioscopy. Satisfactory duct clearance was achieved in Patient 1 after one PTCSL procedure, but Patient 2 required a further procedure to clear persisting intrahepatic calculi. Ultimately both patients had successful stone clearance confirmed by check cholangiograms.

CONCLUSION

PTCSL offers a pragmatic, feasible and safe method for biliary tract clearance when neither ERCP nor surgical exploration is suitable.

A Review on the Management of Biliary Complications after Orthotopic Liver Transplantation

Orthotopic liver transplantation is the definitive treatment for end-stage liver disease and hepatocellular carcinomas. Biliary complications are the most common complications seen after transplantation, with an incidence of 10-25%. These complications are seen both in deceased donor liver transplant and living donor liver transplant. Endoscopic treatment of biliary complications with endoscopic retrograde cholangiopancreatography (commonly known as ERCP) has become a mainstay in the management post-transplantation. The success rate has reached 80% in an experienced endoscopist's hands. If unsuccessful with ERCP, percutaneous transhepatic cholangiography can be an alternative therapy. Early recognition and treatment has been shown to improve morbidity and mortality in post-liver transplant patients. The focus of this review will be a learned discussion on the types, diagnosis, and treatment of biliary complications post-orthotopic liver transplantation.

[Management of Intrahepatic Duct Stone]

Intrahepatic duct (IHD) stone is the presence of calculi within the intrahepatic bile duct specifically located proximal to the confluence of the left and right hepatic ducts. This stone is characterized by its intractable nature and frequent recurrence, requiring multiple therapeutic interventions. Without proper treatment, biliary strictures and retained stones can lead to repeated episodes of cholangitis, liver abscesses, secondary biliary cirrhosis, portal hypertension, and death from sepsis or hepatic failure. The ultimate treatment goals for IHD stones are complete removal of the stone, the correction of the associated strictures, and the prevention of recurrent cholangitis. A surgical resection can satisfy the goal of treatment for hepatolithiasis, i.e., complete removal of the IHD stones, stricture, and the risk of cholangiocarcinogenesis. On the other hand, in some cases, such as bilateral IHD stones, surgery alone cannot achieve these goals. Therefore, the optimal treatments require a multidisciplinary approach, including endoscopic and radiologic interventional procedures before and/or after surgery. Percutaneous transhepatic cholangioscopic lithotomy (PTCS-L) is particularly suited for patients at poor surgical risk or who refuse surgery and those with previous biliary surgery or stones distributed in multiple segments. PTCS-L is relatively safe and effective for the treatment of IHD stones, and complete stone clearance is mandatory to reduce the sequelae of IHD stones. An IHD stricture is the main factor contributing to incomplete clearance and stone recurrence. Long-term follow-up is required because of the overall high recurrence rate of IHD stones and the association with cholangiocarcinoma.

Endoscopic balloon dilatation for benign hepaticojejunostomy anastomotic stricture using short double-balloon enteroscopy in patients with a prior Whipple's procedure: a retrospective study

Background

Endoscopic retrograde cholangiography using a short double-balloon endoscope (DB-ERC) is a promising minimally-invasive method for accessing hepaticojejunostomy (HJ) anastomosis in patients with surgically altered anatomy. We aimed to evaluate the immediate and long-term outcomes of balloon dilatation for benign HJ anastomotic stricture (HJAS) in patients who had previously undergone Whipple’s procedure using a DB-ERC.

Methods

We conducted a retrospective analysis of 46 patients who underwent balloon dilatation alone with a DB-ERC for benign HJAS between November 2008 and November 2014. The median follow-up duration was 3.5 (interquartile range [IQR], 1.9–5.1) years.

Results

The technical and clinical success rates were 100%, and adverse events occurred in 7% (3/46, cholangitis). The median hospitalization period was seven (IQR, 5–10) days. Of 42 patients (91%) followed-up for > 1 year, 24 (51%) had recurrent HJAS at a median of 1.2 (IQR, 0.6–2.9) years after balloon dilatation. The cumulative anastomotic patency rates at 1, 2, and 3 years were 73, 55, and 49%, respectively. In univariate analysis, early stricture formation (< 1 year) was a risk factor for recurrent stenosis, although no statistically significant risk factors were observed in multivariate analysis.

Conclusions

Endoscopic balloon dilatation with DB-ERC for benign HJAS is effective and safe, having good immediate technical success and few adverse events. Further improvements to this procedure are needed to prevent recurrent HJAS.

An Update on Endoscopic Management of Post-Liver Transplant Biliary Complications

Biliary complications are the most common post-liver transplant (LT) complications with an incidence of 15%-45%. Furthermore, such complications are reported more frequently in patients who undergo a living-donor LT compared to a deceased-donor LT. Most post-LT biliary complications involve biliary strictures, bile leakage, and biliary stones, although many rarer events, such as hemobilia and foreign bodies, contribute to a long list of related conditions. Endoscopic treatment of post-LT biliary complications has evolved rapidly, with new and effective tools improving both outcomes and success rates; in fact, the latter now consistently reach up to 80%. In this regard, conventional endoscopic retrograde cholangiopancreatography remains the preferred initial treatment. However, percutaneous transhepatic cholangioscopy is now central to the management of endoscopy-resistant cases involving complex hilar or multiple strictures with associated stones. Many additional endoscopic tools and techniques-such as the rendezvous method, magnetic compression anastomosis , and peroral cholangioscopy-combined with modified biliary stents have significantly improved the success rate of endoscopic management. Here, we review the current status of endoscopic treatment of post-LT biliary complications and discuss conventional as well as the aforementioned new tools and techniques.

A comparative evaluation of treatment methods for bile duct stones after hepaticojejunostomy between percutaneous transhepatic cholangioscopy and peroral, short double-balloon enteroscopy

BACKGROUND

Bile duct stones after hepaticojejunostomy are considered a troublesome adverse event. Although percutaneous transhepatic procedures using a cholangioscopy is performed to treat these bile duct stones, a peroral endoscopic procedure using a short, double-balloon enteroscope (sDBE) is an alternative. This study aimed to compare the immediate and long-term outcomes of both treatments for bile duct stones in patients who underwent prior hepaticojejunostomy.

METHODS

Between October 2001 and May 2013, 40 consecutive patients were treated for bile duct stones after hepaticojejunostomy at a tertiary care hospital. Initial success with biliary access, biliary intervention-related technical success, clinical success, adverse events, hospitalization duration, and stone-free survival were retrospectively evaluated.

RESULTS

The initial success rates for biliary access were 100% (8/8) with percutaneous transhepatic cholangioscopy (PTCS) and 91% (29/32) with sDBE. In three patients in whom biliary access during initial sDBE failed, successful access with subsequent PTCS was achieved, and biliary intervention-related technical success and clinical success were eventually achieved in all 40 patients. The rate of adverse events was significantly lower with sDBE than with PTCS (10% versus 45%; p = 0.025). The median hospitalization duration for complete stone clearance was significantly shorter with sDBE than with PTCS (10 versus 35 days; p < 0.001). During the median 7.2 year or 3.1 year follow up, the probabilities of being stone-free at 1, 2, and 3 years were 100%, 73%, and 64% for PTCS and 85%, 65%, and 59% for sDBE, respectively (p = 0.919).

CONCLUSIONS

sDBE was useful, with few adverse events and short hospitalization; therefore, experienced endoscopists can consider it as first-line treatment for bile duct stones in patients with prior hepaticojejunostomy.

Percutaneous Transhepatic Cholangioscopy in Bilioenteric Anastomosis Stricture

Bilioenteric anastomosis strictures are a serious complication of biliary surgery, and often result in recurrent cholangitis, choledocholithiasis, biliary cirrhosis, and hepatic failure. Bilioenteric reconstructive surgery is the standard treatment of choice for such complications. However, percutaneous transhepatic cholangioscopy (PTCS), also known as per-oral endoscopic-guided intervention, is a less invasive procedure that is becoming an increasingly popular alternative. This review describes the PTCS procedure (including the preparation process), as well as the diagnostic and therapeutic role of PTCS in bilioenteric anastomosis strictures.

Percutaneous transhepatic cholangioscopy for biliary complications after liver transplantation: a single center experience

BACKGROUND

Some biliary complications after liver transplantation (LT) are difficult to manage by endoscopic or radiologic intervention alone. In these cases, percutaneous transhepatic cholangioscopy (PTCS) can be used as an adjuvant option.

METHODS

Patients who underwent PTCS for post-LT biliary complications between August 1992 and January 2016 were retrospectively reviewed.

RESULTS

Fifteen patients underwent PTCS for post-LT biliary complications. The median age at LT was 47 years and 11 patients were male. Indications for LT were as follows: decompensated liver cirrhosis (n = 9), hepatocellular carcinoma (n = 5), and acute fulminant liver failure (n = 1). Single living donor was common (n = 11) and duct-to-duct anastomosis was performed in 11 patients. The median age at PTCS was 52 years and indications for PTCS were as follows: intrahepatic duct stone (n = 10), common bile duct stone (n = 1), biliary cast (n = 1), and biliary stricture (n = 3). There were no significant PTCS-related morbidity and mortality. However, four patients (26.7%) needed additional radiologic intervention (n = 2) or surgery (n = 2) after PTCS.

CONCLUSIONS

Percutaneous transhepatic cholangioscopy in conjunction with endoscopic and radiologic interventions can aid in managing post-LT biliary complications and avoiding reoperation.

Percutaneous endoscopic management of intrahepatic stones in patients with altered biliary anatomy: A case series

Incidence of primary intrahepatic stones (IHS) in India is very less as compared to the Far East. However patients with altered biliary anatomy are prone for IHS formation secondary to anastomotic stricture formation. Indian data on percutaneous endoscopic management of IHS is scare. Five patients with IHS were managed percutaneously. All patients had undergone Roux-en-Y hepaticojejunostomy and were not suitable for direct endoscopic intervention. All patients underwent percutaneous biliary drainage followed by cholangioscopy-guided laser lithotripsy. Crushed stones were pushed across the anastomotic site using basket/balloon and ductal clearance was achieved. Good stone pulverization could be achieved in five patients (100 %). Complete ductal clearance could be achieved in all patients (100 %). Cholangioscopy-guided treatment of IHS can be valuable alternative to surgery in select group of patients especially those having dilated biliary tree with absence of intrahepatic strictures. However long-term follow up studies are required to see for recurrence of stone formation.

Percutaneous Transhepatic Cholangioscopy

The role of the interventional radiologist continues to expand in the treatment of biliary disease. Percutaneous transhepatic cholangioscopy (PTCS) provides direct visualization of the biliary system for diagnostic and therapeutic interventions, especially in cases where anatomical considerations prohibit a peroral approach. Visual inspection and endoscopically guided biopsy allow differentiation between benign and malignant lesions, as well as accurate assessment of the tumor extent for surgical planning. Studies have demonstrated greater than 95% accuracy with PTCS in diagnosing biliary malignancies. Cholangioscopy is also used to treat obstructive stones in the biliary system, which may require laser lithotripsy. PTCS-guided removal of biliary stones is highly successful, with complete stone removal from the bile ducts occurring in approximately 90% of cases. Overall, PTCS is a safe and effective procedure, with severe complications occurring in less than 8% of patients. The purpose of this review is to familiarize its reader with common indications for PTCS, techniques for procedural success, expected outcomes, and management of potential complications.

Results of endoscopic treatment for the management of stenotic end-to-side hepaticoduodenostomy

PURPOSE

The outcome of endoscopic treatment for the management of surgical end-to-side hepaticoduodenostomy (HD) has not been extensively studied. The aim of this study was to evaluate the results of endoscopic management of HD.

METHODS

The medical records of 17 patients with HD stenosis who were referred to the ERCP unit between August 2003 and June 2012 for endoscopic intervention were retrospectively analyzed.

RESULTS

Fourteen patients presented with cholangitis, of whom, jaundice was the presenting complaint in 3 patients. Eight patients (47.1%) who had stents placed for a median of 2 (min, 1; max, 3) ERCP periods remained asymptomatic for a median stent-free period of 19.5 months (min, 7; max, 96 mo). Five patients (29.4%) who had stents placed for a median of 2 (min, 1; max, 5) ERCP periods presented with an episode of stone-related cholangitis for a mean of 41.8±28.9 months after stent removal. These 5 patients remained asymptomatic for a median of 9.5 months (min, 5; max, 40 mo) after endoscopic stone extraction. Three patients with HD (17.6%) were followed up with stents for 4 to 19 ERC periods. One HD patient (5.9%) who had cholangitis associated with secondary biliary cirrhosis died of cholangitis-related complications, despite the treatment with stents for 4 ERC periods.

CONCLUSION

Endoscopic management is also a realistic treatment option for stenotic HD anastomosis, although success rates may vary.

Percutaneous transhepatic biliary drainage in patients with postsurgical bile leakage and nondilated intrahepatic bile ducts

OBJECTIVE AND BACKGROUND

Bile leakage is a serious postoperative complication and percutaneous transhepatic biliary drainage (PTBD) may be an option when endoscopic treatment is not feasible. In this retrospective study, we established technical and clinical success rates as well as the complication rates of PTBD in a large group of patients with postoperative bile leakage.

METHODS

Data on all patients with nondilated intrahepatic bile ducts who underwent a PTBD procedure for the treatment of bile leakage between January 2000 and August 2012 were retrospectively assessed. Data included type of surgery, site of bile leak, previous attempts of bile leak repair, interval between surgery and PTBD placement. Outcome measures were the technical and clinical success rates, the procedure-related complications, and mortality rate.

RESULTS

A total of 63 patients were identified; PTBD placement was technically successful in 90.5% (57/63) after one to three attempts. The clinical success rate was 69.8% (44/63). Four major complications were documented (4/63; 6.3%): liver laceration, pneumothorax, pleural empyema, and prolonged hemobilia. One minor complication involved pain.

CONCLUSIONS

PTBD is an effective treatment with low complication rates for the management of postsurgical bile leaks in patients with nondilated bile ducts.

Percutaneous transhepatic cholangioscopy: does its role still exist?

Percutaneous transhepatic cholangioscopy (PTCS) is the most widely used modality for diagnosis and treatment of biliary disease. Although many other novel technologies have been developed based on recent advances in endoscopy, PTCS has its own role. In diagnostics, PTCS is used for evaluation of indeterminate biliary strictures, bile duct tumors, and postoperative biliary strictures that cannot be reached by a peroral approach. In therapeutics, the removal of bile duct stones, dilatation of bile duct strictures including postoperative anastomosis site strictures, and local tumor therapy are indications of PTCS. Especially in a therapeutic role, PTCS has the advantage of maneuverability due to a shorter endoscopic length compared to other cholangioscopic modalities. Hence, PTCS has its own indispensable diagnostic and therapeutic roles.

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

PURPOSE

To determine the safety, efficacy, and long-term results of percutaneous biliary balloon dilation (PBBD) of benign hepaticojejunostomy strictures and evaluate the necessity of repeated PBBD in this setting.

MATERIALS AND METHODS

PBBD was performed after traversing hepaticojejunostomy strictures in 89 patients (40 male, 49 female; age range, 19-84 y; mean age ± SD, 54.5 y ± 14.0), who were divided into three groups: group I (one satisfactory initial PBBD; n = 41), group II (two or more PBBDs with satisfactory initial PBBD; n = 33), and group III (two or more PBBDs without satisfactory PBBD; n = 15). Groups I and II were randomized. The primary outcome measure was the absence of clinical biliary obstruction symptoms at 24 months. Secondary outcome measures included technical and clinical success, primary and secondary patency, major complications, and mortality. Categoric variables were compared between groups I and II.

RESULTS

Procedure-related mortality and major morbidity rates were 0% and 5.6%, respectively. Mean primary and secondary patency durations were 45.3 months ± 2.2 and 71.3 months ± 15.4, respectively. The follow-up period was 36.4 months ± 15.1. The primary outcome measure was achieved in 73% of patients. Technical and clinical success rates (secondary outcome measures) were 97.8% and 84.3%, respectively. Repeated PBBD procedures were not satisfactory in 16.9% of patients. No significant differences in categoric variables were observed between groups I and II.

CONCLUSIONS

PBBD of benign hepaticojejunostomy strictures is a safe and effective procedure. Repeated PBBD is not required when the first procedure is successful.

Temporary placement of stent grafts in postsurgical benign biliary strictures: a single center experience

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.

Using percutaneous transhepatic cholangioscopic lithotripsy for intrahepatic calculus in hostile abdomen

BACKGROUND

Hepatolithiasis is a challenging condition to treat especially in patients with previous hepatobiliary surgery. Percutaneous Transhepatic Cholangioscopic Lithotripsy (PTCSL) is an attractive salvage option for the treatment of recurrent hepatolithiasis. We reviewed our experience using PTCSL in treating 4 patients with previous complex abdominal surgery.

METHODS

We studied the 4 patients who underwent PTCSL from October 2007 to July 2009. We reviewed the operative procedures, workflow of performing PTCSL in our institution and the outcome of the procedure. PTCSL was performed in our institution using 3 mm cholangioscope (Dornier MedTech(®)) and Holmium laser with setting at 0.8 J, 20 Hz and 16 W. This was performed through a Percutaneous Transhepatic Cholangio-catheter inserted by interventional radiologists.

RESULTS

There were 4 patients with a median age of 50 (43-69) years. The median duration of the condition prior to PTCSL was 102 (60-156) months. Three patients had recurrent pyogenic cholangitis (RPC) with recurrent intrahepatic stone. They all had prior complex hepatobiliary operations. The median duration of surgery was 130 (125-180) min. There was minimal intra-operative blood loss. The first procedure was performed under local anaesthesia and sedation, however, with experience the subsequent 3 patients had the procedure performed under general anaesthesia. The median size of bile duct was 18 (15-20) mm prior to the procedure. The number of stones ranged from one to three with the largest size of stone comparable to the size of bile duct. The median follow up was 18 (10-24) months. All patients were symptom free with neither stone recurrence or cholangitis at the last follow up.

CONCLUSION

PTCSL is a feasible and an effective treatment method for patients with recurrent biliary stone following complex abdominal surgery as the success rates from open surgery and endoscopic procedures are limited. Excellent results can be expected with this minimally invasive technique.

Percutaneous transhepatic biliary drainage (PTBD) with or without stenting-complications, re-stent rate and a new risk stratification score

OBJECTIVES

To review the success rate and number of complications in patients with obstructive jaundice treated with percutaneous transhepatic biliary drainage (PTBD), and to stratify the procedural risk of both PTBD and biliary stenting.

SUBJECTS AND METHODS

948 procedures performed in 704 consecutive patients with obstructive jaundice over a 7 year period were reviewed: 345 male; 359 females, mean age 70.1 years (range 48-96 years). Statistical analysis included X ( 2 ) test and multivariate logistic regression analysis.

RESULTS

The technical success rate was 99%. The mortality related to the procedure was 2% and the 30-day mortality 13%. 91 (13%) stents inserted occluded during the study period. Predictors for stent failure and re-stenting were a diagnosis of cholangiocarcinoma, a lesion in the distal CBD, a high bilirubin, high urea and high white cell count and post procedure cholangitis. Factors significantly related to complications and 30-day mortality were retrospectively reviewed to devise a risk stratification score.

CONCLUSIONS

PTBD and stenting offer a safe and effective method in providing palliative treatment for patients with biliary obstruction. Patients likely to have high levels of morbidity and mortality can be predicted before PTBD, using a risk stratification score, highlighting the need for closer clinical observation and delayed stent placement.

Ectopic opening of the common bile duct and duodenal stenosis: an overlooked association

Background

Ectopic opening of the common bile duct into the duodenal bulb (EO-CBD-DB) is a rare disease that may be complicated by duodenal ulcer, deformity, stenosis and biliary stones. The aim of this study is to report clinical presentations, endoscopic diagnosis and treatment of this entity as well as to investigate its association with duodenal stenosis.

Methods

Gastroduodenoscopic findings and radiological imaging were evaluated for ectopic papilla and duodenal stenosis. Diagnostic methods, endoscopic procedures and long-term outcomes of the endoscopic treatment were presented.

Results

EO-CBD-DB was found in 74 (77.1%) of the 96 patients with duodenal deformity/stenosis (79 male, 17 female, mean age: 58.5, range: 30-87 years). The papilla with normal appearance was retracted to the bulb in 11 while it was at its usual location in the remaining 11. The history of biliodigestive surgery was more common in patients with EO-CBD-DB who were frequently presented with the common bile duct stone-related symptoms than the other patients. Thirteen (17.6%) of the patients with EO-CBD-DB were referred to surgery. Endoscopic treatment was completed in 60 (81.1%) patients after an average of 1.7 (range: 1-6) procedures. These patients were on follow-up for 24.8 (range: 2-46) months. Endoscopic intervention was required in 12 (20%) of them because of recurrent biliary problems. Treatment of the patient who had stricture due to biliary injury during laparoscopic cholecystectomy is still continued.

Conclusions

The presence of EO-CBD-DB should be considered particularly in middle-aged male patients who have duodenal deformity/stenosis. Endoscopic treatment is feasible in these patients. The long-term outcomes of endoscopic therapy need to be compared with surgical treatment.

Long-term outcome of endoscopic and/or percutaneous transhepatic therapy in patients with biliary stricture after orthotopic liver transplantation

BACKGROUND

Biliary strictures are a serious complication after liver transplantation. Endoscopic and percutaneous transhepatic procedures have gained an increasing potential for the management of this problem.

OBJECTIVE

Long-term follow-up of endoscopic and/or percutaneous transhepatic therapy of biliary strictures after liver transplantation was evaluated.

PATIENTS AND METHODS

Between January 1996 and December 2007, 47 patients with biliary stricture after liver transplantation were identified by analysing the endoscopic database, hospital charts and cholangiograms. Long-term follow-up was evaluated using cholangiograms, transabdominal ultrasound, laboratory parameters and physical examination.

RESULTS

The type of biliary stricture after liver transplantation was subdivided into anastomotic stricture (n = 29), non-anastomotic stricture (n = 14) and bilioenterostomy stricture (n = 4). Of the patients, 38/47 were treated by endoscopic procedures (ERCP), and 9/47 patients were treated by percutaneous transhepatic procedures (PTBD). In 2 of 47 patients combined approaches (rendezvous technique) were performed. Overall, 23/29 patients in the anastomotic group, 12/14 patients in the non-anastomotic group, and 3/4 patients in the bilioenterostomy group had successfully completed endoscopic and/or percutaneous transhepatic therapy. Biliary drainage could be respectively terminated after median 9 (1-83), 11 (1-89) and 10 (4-14) months.

CONCLUSIONS

Endoscopic as well as percutaneous transhepatic approaches in combination or as monotherapy are effective in the management of anastomotic and non-anastomotic strictures after liver transplantation.

Percutaneous transhepatic cholangioscopic intervention in the management of complete membranous occlusion of bilioenteric anastomosis: report of two cases

Postoperative biliary stricture is a relatively rare but serious complication of biliary surgery. Although Rouxen-Y hepaticojejunostomy or choledochojejunostomy are well-established and fundamental therapeutic approaches, their postoperative morbidity and mortality rates have been reported to be up to 33% and 13%, respectively. Recent studies suggest that percutaneous transhepatic intervention is an effective and less invasive therapeutic modality compared with traditional surgical treatment. Compared with fluoroscopic intervention, percutaneous with cholangioscopy may be more useful in biliary strictures, as it can provide visual information regarding the stricture site. We recently experienced two cases complete membranous occlusion of the bilioenteric anastomosis and successfully treated both patients using percutaneous transhepatic cholangioscopy.

Updates in the treatment of gallstones

For the treatment of symptomatic gallbladder stones, laparoscopic cholecystectomy is the procedure of choice. However, open cholecystectomy is advisable in some situations, and a new technique - natural-orifice transluminal endoscopic surgery - has been described recently. In addition, nonsurgical approaches have also been used in patients with gallbladder stones. For the treatment of common bile duct stones, endoscopic approaches comprise the most important and commonly used modality but, under certain conditions, surgical removal should be considered if the stones cannot be managed nonsurgically. Patients with concomitant gallbladder and common bile duct stones may have various options, depending on the patient's condition and the availability of local expertise. Intrahepatic stones usually have a lower rate of successful treatment compared with gallbladder or extrahepatic bile duct stones. Localized intrahepatic bile duct stones may be cured by surgical resection, or they may be safely and effectively managed using peroral or percutaneous cholangioscopy. Overall, a multidisciplinary approach is important for the optimal management of difficult gallstone diseases.

Complications of percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts

Percutaneous transhepatic biliary drainage (PTBD) have been described as an effective technique to obtain biliary access. Between January 1996 and December 2006, a total of 419 consecutive patients with endoscopically inaccessible bile ducts underwent PTBD. The current retrospective study evaluated success and complication rates of this invasive technique. PTBD was successful in 410/419 patients (97%). The success rate was equal in patients with dilated and nondilated bile ducts (p=0.820). In 39/419 patients (9%) procedure related complications could be observed. Major complications occurred in 17/419 patients (4%). Patients with nondilated intrahepatic bile ducts had significantly higher complication rates compared to patients with dilated intrahepatic bile ducts (14.5% vs. 6.9%, respectively [p=0.022]). Procedure related deaths were observed in 3 patients (0.7%). In conclusion, percutaneous transhepatic biliary drainage is an effective procedure in patients with dilated and nondilated intrahepatic bile ducts. However, patients with nondilated intrahepatic bile ducts showed a higher risk for procedure related complications.

Long-term outcome of percutaneous transhepatic therapy for benign bilioenteric anastomotic strictures

PURPOSE

To evaluate the long-term outcomes of a percutaneous transhepatic approach in benign bilioenteric anastomoses with calibration of the stenosis to 15 F and extended internal/external drainage.

MATERIALS AND METHODS

Between February 2000 and May 2007, the efficacy of this percutaneous transhepatic procedure was retrospectively studied in 39 patients with benign postoperative bilioenteric anastomotic strictures. The main purpose of the protocol was to repair the anastomosis by calibration of the stenosis to 15 F with a silicone drain and perform internal/external drainage for at least 1 year. The follow-up period ranged from 12 to 65 months (mean, 34.4 months), and outcomes were classified according to the patient's clinical symptoms and laboratory parameters and the need for further interventions.

RESULTS

The procedure was successful in 38 of 39 patients. Four patients were lost to follow-up during or after drainage. The duration of drainage (41 internal catheters in 34 patients) ranged from 126 days to 488 days (mean, 346 d). Twenty-seven patients had positive outcomes during the mean follow-up of 34 months, and six patients had negative outcomes. The bile duct patency probability according to the Kaplan-Meier method was and 70.6% at 34 months after drain removal.

CONCLUSIONS

Percutaneous treatment of benign biliary strictures with calibrated stent implantation and extended drainage has good long-term results and may be an effective alternative to surgery. Advantages over surgery are its minimal invasiveness and reduced risk of complications.

Reducing residual and recurrent stones by hepatectomy for hepatolithiasis

The long-term outcomes of 97 consecutive patients with hepatolithiasis, who underwent treatment from January 1971 to June 2006, were analyzed. The short-term outcomes included the rate of residual stones and complications after treatment, whereas the long-term results included the stone recurrence rate. In 22 of the 97 (22.7%) patients, residual stones were found after treatment for hepatolithiasis. The incidence of residual stones was 0% in hepatectomy patients, 48.6% in cholangioenterostomy patients (p < 0.001, compared with hepatectomy), 25.0% in T-tube drainage patients (p = 0.015, compared with hepatectomy), and 10.0% in percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) patients. In 15 of the 66 (22.7%) patients who were treated for hepatolithiasis, recurrent stones were found after intervals of 5 to 24 years. The incidence of recurrent stones was 13.9% in hepatectomy patients, 28.5% in cholangioenterostomy patients, 25.0% in T-tube drainage patients, and 50.0% in PTCSL patients (p = 0.021, compared with hepatectomy). Hepatectomy appears to be the most effective treatment for selected patients with isolated left hepatolithiasis (L). In PTCSL procedures, favorable results have been obtained when the stones were completely cleared; however, the incidence of recurrent stones is high in patients after PTCSL.