Postradiotherapy benign biliary stricture: successful treatment by self-expandable metallic stent

Radiation-induced cholangitis with hepatocellular carcinoma

There are no reports of hepatocellular carcinoma complicating postradiotherapy cholangitis. We report the case of a 45-year-old patient who had undergone upper abdominal radiotherapy for Hodgkin's disease, 21 years before, which was complicated years later by cholangitis with stricture of the common bile duct. Biliodigestive anastomosic surgery was scheduled due to recurrent angiocholitis, and hepatocellular carcinoma was discovered. The patient died from carcinoma some months later.

Biliary complications associated with selective internal radiation (SIR) therapy for unresectable liver malignancies

Selective internal radiation (SIR) therapy using 90yttrium microspheres is effective for treating selected cases of unresectable liver malignancies with little morbidity. We herein report two cases illustrating a very rare complication of SIR. A 68-year-old patient with inoperable recurrent hepatocellular carcinoma received one treatment of SIR with 90yttrium microspheres and 4 months later presented with obstructive jaundice. Percutaneous transhepatic cholangiography revealed diffusely dilated intrahepatic ducts with multiple biliary strictures. Hepatic angiography showed normal hepatic arterial branches with no evidence of vascular insufficiency. Liver biopsy finally revealed cholestasis, cholangitis, and fibrosis, consistent with radiation-induced damage. Another 56-year-old patient with unresectable colorectal liver metastases presented with cholangitis 4 weeks after SIR. Ultrasonography showed no biliary dilatation, and endoscopic retrograde cholangiopancreatography demonstrated a normal biliary tree. Liver biopsy subsequently confirmed radiation-induced cholangitis.

Systematic appraisal of the role of metallic endobiliary stents in the treatment of benign bile duct stricture

OBJECTIVE

To carry out a systematic appraisal of the current status of the use of metallic endobiliary stents in the treatment of benign biliary strictures.

METHODS

A computerized search of the MEDLINE and EMBASE databases identified 37 studies providing detailed clinical course data on outcome of metallic endobiliary stent placement in 400 patients. Pooled data were examined for etiology of stricture, indications for stent placement, procedure-related complications, and outcome with reference to stent patency.

RESULTS

The median (range) number of patients per report was 8 (2-54) with a median recruitment period of 44 (9-126) months. The most frequent indications were postoperative biliary strictures in 123 (31%), stenosed biliary-enteric anastomoses in 79 (20%), and biliary strictures following liver transplantation in 88 (22%). During a median follow up of 31 (1-111) months, 139 (35%) stents occluded, and there are little patency data beyond 2 years after deployment, with 99 (25%) known to be patent at 3 years from stent placement.

CONCLUSIONS

These pooled data on 400 patients constitute the largest collective report to date on the use of metallic endobiliary stents for benign biliary strictures. The results show a critical lack of data on long-term patency such that at the present time, metallic endobiliary stents should not be used for benign stricture in those patients with a predicted life expectancy greater than 2 years.

Systematic appraisal of the role of metallic endobiliary stents in the treatment of benign bile duct stricture

OBJECTIVE

To carry out a systematic appraisal of the current status of the use of metallic endobiliary stents in the treatment of benign biliary strictures.

METHODS

A computerized search of the MEDLINE and EMBASE databases identified 37 studies providing detailed clinical course data on outcome of metallic endobiliary stent placement in 400 patients. Pooled data were examined for etiology of stricture, indications for stent placement, procedure-related complications, and outcome with reference to stent patency.

RESULTS

The median (range) number of patients per report was 8 (2-54) with a median recruitment period of 44 (9-126) months. The most frequent indications were postoperative biliary strictures in 123 (31%), stenosed biliary-enteric anastomoses in 79 (20%), and biliary strictures following liver transplantation in 88 (22%). During a median follow up of 31 (1-111) months, 139 (35%) stents occluded, and there are little patency data beyond 2 years after deployment, with 99 (25%) known to be patent at 3 years from stent placement.

CONCLUSIONS

These pooled data on 400 patients constitute the largest collective report to date on the use of metallic endobiliary stents for benign biliary strictures. The results show a critical lack of data on long-term patency such that at the present time, metallic endobiliary stents should not be used for benign stricture in those patients with a predicted life expectancy greater than 2 years.

Endoluminal reconstruction of the canine common biliary duct

PURPOSE

Extrahepatic biliary duct injuries such as transections, stenoses, and biliary leaks are well-known complications of upper abdominal surgeries. The popularization of laparoscopic cholecystectomies in the early 1990's resulted in an increase in the numbers of these reported injuries. The surgical repair of these injuries may be challenging. In this feasibility study, we were presented with the opportunity to evaluate a novel polytetrafluoroethylene (PTFE) covered stent graft that could be useful in common bile duct reconstructions. The long-term goal of this research is to offer the surgeon a new technique for reconstructing the biliary duct or repairing biliary strictures.John G. Zografakis MD, was the first place winner in the Basic Sciences Resident Competition at the Ohio American College of Surgeons meeting.

METHODS

Seven dogs were originally enrolled in the study. After general endotracheal anesthesia and open cholecystectomy, the common bile duct was identified in each dog. A guide wire was then passed through the neck of the cystic duct, anterograde into the common bile duct, through the Ampulla of Vater and into the duodenum. A stent graft delivery system was placed over the wire, and the covered stent graft was deployed within the lumen of the common bile duct. Study outcomes included graft patency and assessment of the bio-incorporation of the graft and the effectiveness of the graft to drain the biliary system as determined by liver enzyme tests.

RESULTS

Three implants were harvested at 1 month, and 2 grafts were harvested each at 3 months and 6 months postoperatively. All of the stent grafts were patent. Liver enzyme tests revealed that all dogs had increased serum levels of alkaline phosphatase, alanine aminotransferase (ALT) serum glutamate pyruvate transaminase (SGPT) and aspartate aminotransferase (AST) serum glutamic oxaloacetic transaminase (SGOT). Four dogs had increased total bilirubin. These increases were all measured in the immediate postoperative period. Peak levels for each measure were reached between 4 and 10 days and then gradually trended toward baselines by 1 month postoperatively. We did not observe meaningful changes in serum albumin or total protein. One dog suffered a tear in the common bile duct due to balloon overinflation. This tear was suture repaired when the graft was implanted. However, bile leakage was found when the graft was harvested at 1 month postoperatively. There appeared to be minimal bio-incorporation of the stent-grafts into the biliary duct wall, and there was no pronounced inflammatory response found in the duct wall or surrounding tissues.

CONCLUSIONS

We are encouraged by these early results. Additional studies are planned to evaluate a self-expanding PTFE covered stent graft and a percutaneous delivery system.

Use of self-expandable metallic stents in benign GI diseases

BACKGROUND

The self-expandable metallic stent is of proven benefit in patients with malignant disease; however, its use in patients with benign disease is not well established. There are few data available regarding long-term complications and outcomes with use of self-expandable metallic stents in benign disease and virtually none regarding attempted removal once the acute problem is resolved.

METHODS

Thirteen patients who had a self-expandable metallic stent placed for benign GI disorders were included in a retrospective analysis. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes.

RESULTS

Thirteen patients (7 women, 6 men; mean age 67 years, range 34-84 years) had one or more self-expandable metallic stents placed for benign disease and were followed for a mean of 3.4 years (3 weeks to 10 years). Of the 13 patients, 8 had esophageal stents, 4 biliary stents, and 1 had dual stents placed in the pancreaticobiliary tree. Complications developed in 8 (62%) patients; 4 (31%) ultimately died, either from the primary disease process (3) or from stent-related complications (1).

CONCLUSIONS

Self-expandable metallic stent placement is effective treatment for benign esophageal leaks, providing the stent can be removed. It also may be used in either the esophagus or biliary tree in patients who are poor candidates for surgery and short expected survival. However, a self-expandable metallic stent should not be placed in a patient with a benign GI disorder who has a significant life expectancy and is a good candidate for surgery.

Successful removal of a stone and an expandable metallic stent from the biliary tract of a patient with acute occlusive pyogenic cholangitis

We removed a biliary stone and the metallic stent placed two years previously in a patient with benign biliary strictures. An 80-year-old woman who had been inplanted with an expandable metallic stent (EMS) to prevent obstruction by a large common bile duct stone about two years before as an emergency measure in another hospital, was afficted with acute occlusive pyogenic cholangitis (AOPC) and hospitalized in our hospital. After treating the AOPC, we successfully removed the EMS with a cholangioscope and normal biopsy forceps through the percutaneous transhepatic channel under fluoroscopy. The type of the EMS was Accufulex stent. To remove it was easier than expected. Once it started to unravel, it was removed from the common bile duct within a few minutes.

Percutaneous transhepatic placement of metallic stents in the treatment of complicated intrahepatic biliary stricture with hepatolithiasis: a preliminary report

OBJECTIVE

We aimed to study the effect of the metallic modified Gianturco-Rosch Z-stent in the management of refractory intrahepatic long-segment biliary strictures with hepatolithiasis.

METHODS

Six symptomatic patients with hepatolithiasis and coexisting intrahepatic long-segment biliary strictures, who failed to respond to the silastic external-internal biliary stenting, were selected. The metallic modified Gianturco-Rosch Z-stent was placed via percutaneous transhepatic cholangiography at the strictured site. Patients were followed regularly to evaluate for recurrence of cholangitis, stones, or strictures.

RESULTS

No complications were observed during the procedures. No recurrent strictures or formed calculi were found in these six patients during follow-up periods of 29 to 64 months. However, cholangitis and intrahepatic biliary muddy sludge occurred at 7 and 30 months in two patients after the placement of the metallic Z-stent. Percutaneous transhepatic cholangioscopy was used to clear sludge completely.

CONCLUSIONS

Our experience suggests that the metallic stent is a well-tolerated and promising alternative in the management of refractory intrahepatic long-segment biliary strictures with hepatolithiasis. Though biliary sludge may develop, it can be detected and cleared early. Repeated surgery can thus be avoided.

Plastic and metal stents for postoperative benign bile duct strictures: the best and the worst

BACKGROUND

Endoscopic treatment of postoperative benign bile duct strictures (BBDS) is technically challenging, and the long-term outcome after stricture dilation remains poorly defined.

METHODS

Forty-eight cases of postoperative BBDS with attempted endoscopic treatment (either transient plastic stenting or definitive metal stent insertion) were reviewed.

RESULTS

Endoscopic stricture dilation succeeded in 47 of 48 cases (98%). No procedure-related mortality was observed; 16 (33%) procedure-related or stent-associated complications were observed during treatment. Endoscopic treatment was interrupted in five patients. Stricture relapse occurred in 6 of 6 (100%) and 7 of 36 (19%) patients after metal stent insertion and plastic stent removal, respectively (p < 0.001) (mean follow-up periods 50+/-12 and 44+/-34 months, respectively). After plastic stent removal, stricture relapses were more frequent among patients with strictures related to liver transplantation as opposed to other surgical procedures (p < 0.05); these recurrent strictures were successfully treated by repeated insertion of plastic stents on a temporary basis. At the end of follow-up, all but one patient treated with plastic stents had normal serum alkaline phosphatase values.

CONCLUSION

Metal stents proved to be inadequate for treating postoperative BBDS. Temporary insertion of a plastic stent (possibly repeated) provided long-term results equal or superior to those reported for surgical biliary drainage. Repeated insertion of plastic stents was more frequently indicated for strictures related to liver transplantation compared with other surgical procedures.