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Schepis T, Boškoski I, Tringali A, Costamagna G. Role of ERCP in Benign Biliary Strictures. Gastrointest Endosc Clin N Am 2022; 32:455-475. [PMID: 35691691 DOI: 10.1016/j.giec.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Benign biliary strictures (BBS) can be associated with several causes, with postoperative and inflammatory strictures representing the most common ones. Endoscopy represents nowadays the first-line treatment in the management of BBS. Endoscopic balloon dilatation, plastic stents placement, fully covered metal stent placement, and magnetic compression anastomosis are the endoscopic techniques available for the treatment of BBS. The aim of this study is to perform a review of the literature to assess the role of endoscopy in the management of BBS and to evaluate the application of the different procedures in the different clinical settings.
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Affiliation(s)
- Tommaso Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy.
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy
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2
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Cantù P, Mauro A, Cassinotti E, Boni L, Vecchi M, Penagini R. Post-operative biliary strictures. Dig Liver Dis 2020; 52:1421-1427. [PMID: 32868211 DOI: 10.1016/j.dld.2020.07.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 07/14/2020] [Accepted: 07/23/2020] [Indexed: 12/11/2022]
Abstract
Post-operative biliary stricture is a cumbersome condition, secondary to biliary or vascular damage. Its risk factors include biliary or vascular anatomical variants, local inflammation, and poor surgical expertise. Intra-operative diagnosis is difficult, and in most cases, patients present with obstructive symptoms within a few weeks. Magnetic resonance cholangiography is a pivotal test to confirm the clinical picture, to study the level of the damage, and to guide treatment. Nowadays, endoscopic stenting is the first-line treatment in most centers. Multi-stenting treatment achieves long-term clinical success for more than 90% of patients, however multiple procedures are needed. In order to optimize healthcare provider costs, shorter duration endotherapies with covered metal stents are under evaluation. Radiological and surgical approaches are considered in the event of endoscopy failure.
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Affiliation(s)
- Paolo Cantù
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy.
| | - Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy; Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Elisa Cassinotti
- Department of Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
| | - Luigi Boni
- Department of Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
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Bak J, Hwang J, Park S, Kang HW. Integration of optical applicator with balloon catheter for photothermal treatment of biliary stricture. Lasers Surg Med 2017; 49:781-786. [DOI: 10.1002/lsm.22688] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Jinoh Bak
- Interdisciplinary Program of Marine-Bio, Electrical & Mechanical Engineering; Pukyong National University; Busan Korea
| | - Jieun Hwang
- Interdisciplinary Program of Marine-Bio, Electrical & Mechanical Engineering; Pukyong National University; Busan Korea
| | - Suhyun Park
- School of Electrical and Electronics Engineering; Chung-Ang University; Seoul South Korea
| | - Hyun Wook Kang
- Interdisciplinary Program of Marine-Bio, Electrical & Mechanical Engineering; Pukyong National University; Busan Korea
- Department of Biomedical Engineering; Pukyong National University; Busan Korea
- Center for Marine-Integrated Biomedical Technology (BK21 Plus); Pukyong National University; Busan Korea
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4
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Abstract
Differentiating benign and malignant biliary strictures is a challenging and important clinical scenario. The typical presentation is indolent and involves elevation of liver enzymes, constitutional symptoms, and obstructive jaundice with or without superimposed or recurrent cholangitis. While overall the most common causes of biliary strictures are malignant, including cholangiocarcinoma and pancreatic adenocarcinoma, benign strictures encompass a wide spectrum of etiologies including iatrogenic, autoimmune, infectious, inflammatory, and congenital. Imaging plays a crucial role in evaluating strictures, characterizing their extent, and providing clues to the ultimate source of biliary obstruction. While ultrasound is a good screening tool for biliary ductal dilatation, it is limited by a poor negative predictive value. Magnetic resonance cholangiopancreatography is more than 95% sensitive and specific for detecting biliary strictures with the benefit of precise anatomic localization. Other commonly employed imaging modalities include endoscopic retrograde cholangiopancreatography with endoscopic ultrasound, contrast-enhanced CT, and cholangiography. First-line treatment of benign biliary strictures is endoscopic dilation and stenting. In patients with anatomy that precludes endoscopic cannulation, percutaneous biliary drain insertion and balloon dilation is preferred.
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Affiliation(s)
- Ashley Altman
- Department of Radiology, The University of Chicago, Chicago, Illinois
| | - Steven M Zangan
- Department of Radiology, The University of Chicago, Chicago, Illinois
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Ferreira R, Loureiro R, Nunes N, Santos AA, Maio R, Cravo M, Duarte MA. Role of endoscopic retrograde cholangiopancreatography in the management of benign biliary strictures: What’s new? World J Gastrointest Endosc 2016; 8:220-231. [PMID: 26962404 PMCID: PMC4766255 DOI: 10.4253/wjge.v8.i4.220] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/18/2015] [Accepted: 12/15/2015] [Indexed: 02/05/2023] Open
Abstract
Benign biliary strictures comprise a heterogeneous group of diseases. The most common strictures amenable to endoscopic treatment are post-cholecystectomy, post-liver transplantation, related to primary sclerosing cholangitis and to chronic pancreatitis. Endoscopic treatment of benign biliary strictures is widely used as first line therapy, since it is effective, safe, noninvasive and repeatable. Endoscopic techniques currently used are dilation, multiple plastic stents insertion and fully covered self-expandable metal stents. The main indication for dilation alone is primary sclerosing cholangitis related strictures. In the vast majority of the remaining cases, temporary placement of multiple plastic stents with/without dilation is considered the treatment of choice. Although this approach is effective, it requires multiple endoscopic sessions due to the short duration of stent patency. Fully covered self-expandable metal stents appear as a good alternative to plastic stents, since they have an increased radial diameter, longer stent patency, easier insertion technique and similar efficacy. Recent advances in endoscopic technique and various devices have allowed successful treatment in most cases. The development of novel endoscopic techniques and devices is still ongoing.
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Abstract
OBJECTIVE The objectives of this analysis were to compare the outcomes of bile duct injuries by specialist over time and the role of management timing and biliary stents. BACKGROUND Postoperative bile duct injuries require multidisciplinary management. In recent years, advancements have occurred in patient evaluation and in timing and type of therapy. METHODS A multidisciplinary team managed 528 patients over 18 years. Mean age was 52 years; 69% were women and 95% had a cholecystectomy and/or bile duct exploration. Patients were classified by the Strasberg system as having bile leaks (type A, n = 239, 45%) or bile duct injuries (types B-E, n = 289, 55%). Injury outcomes from 1993 to 2003 (n = 132) were compared with those from 2004 to 2010 (n = 157). A successful outcome was defined as no need for further intervention after the initial 12 months of therapy. Standard statistical methods were employed. RESULTS Patients with bile leaks were managed almost exclusively by endoscopists (96%) with a 96% success rate. Patients with bile duct injuries were managed most often by endoscopists (N = 115, 40%) followed by surgeons (N = 104, 36%) and interventional radiologists (N = 70, 24%). Overall success rates were best for surgery (88%, P < 0.05) followed by endoscopy (76%) and interventional radiology (50%) and improved over time (78% vs 69%). Outcomes were best for surgery in recent years (95% vs 80%, P < 0.05) and for patients stented for more than 6 months (P < 0.01). CONCLUSIONS Almost all bile leaks and many bile duct injuries can be managed successfully by endoscopists. Selected proximal injuries can be treated by interventional radiologists with modest success. Outcomes of bile duct injuries are best with surgical management and in patients who are stented for more than 6 months.
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Ryu CH, Kim MH, Lee SS, Park DH, Seo DW, Lee SK. Temporary Placement of Fully Covered Self-expandable Metal Stents in Benign Biliary Strictures. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2013; 62:49-54. [DOI: 10.4166/kjg.2013.62.1.49] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Choong Heon Ryu
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Myung-Hwan Kim
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wan Seo
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management in most situations when a benign biliary stricture is suspected. Although management principles are similar in all subgroups, the anticipated response rates, need for ancillary medical and endoscopic approaches, and use of less proven strategies vary between differing causes. Exclusion of malignancy should always be a focus of management. Newer endoscopic techniques such as endoscopic ultrasound, cholangioscopy, confocal endomicroscopy, and metal biliary stenting are increasingly complementing traditional ERCP techniques in achieving long-term sustained stricture resolution. Surgery remains a definitive management alternative when a prolonged trial of endoscopic therapy does not achieve treatment goals.
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Abstract
Strictures at the hilum are caused by varied conditions and don't usually become symptomatic until obstructing the bile ducts, thus posing diagnostic and therapeutic challenges to physicians. ERCP is the method of choice for tissue diagnosis and decompression. MRCP or MRI with dedicated liver protocol provides a unique ability to visualize anatomy and promote procedure planning. In patients with unresectable tumor, endoscopic biliary stenting is a palliative approach. Percutaneous or EUS-guided approach is reserved for endoscopic failure. Various new modalities such as radiotherapy, chemotherapy and Photodynamic therapy have emerged but their superiority needs to be confirmed with Randomized Control studies.
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Affiliation(s)
- Indu Srinivasan
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA, USA
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Klare P, Weber A, Dobritz M, Born P, Füllner R, Schmid RM, von Delius S. [Endoscopic and percutaneous intervention in the long-term treatment of benign biliary stenosis. A 71-year-old patient with cholestasis following radiotherapy]. Internist (Berl) 2012; 53:874-81. [PMID: 22527667 DOI: 10.1007/s00108-012-3053-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Benign biliary stenosis can have various causes and requires differentiation from disorders caused by malignant disease. Treatment of benign stenosis is often difficult and includes treatment modalities such as endoscopic, percutaneous or surgical interventions. Exact knowledge of the etiology and localization of the stenosis is essential when selecting the appropriate method of treatment. Here we present the case of a 71-year-old patient admitted to our hospital with cholangitis 13 years after undergoing radiotherapy of the renal bed due to hypernephroma of the right kidney. The patient was diagnosed with common bile duct stenosis due to the secondary effects of radiation, which is rarely reported in the literature. Our case covers a total treatment period of 15 years, enabling us to also discuss a viable sequence of treatment modalities in the treatment of benign bile duct stenosis.
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Affiliation(s)
- P Klare
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
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Abstract
Biliary stents have now been in use for over two decades. Although a plethora of literature has been published on them, this review article is unique in its attempt to summarize important landmark trials and their implications on the management of various pancreatico-biliary disorders. This article will cover the various types of stents currently being used, established and upcoming indications, techniques of placement, and complications associated with stent use.
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12
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Abstract
Benign biliary diseases include benign biliary strictures (BBS), choledocholithiasis, and leaks. BBS encompass postoperative injury, anastomotic stricture, chronic pancreatitis, primary sclerosing cholangitis, and gallstone-related stricture. Therapeutic options for benign biliary diseases include surgical, percutaneous, and endoscopic interventions. Endoscopic options include placement of plastic stents as well as self-expanding metal stents (SEMS). SEMS can be uncovered, partially covered, and fully covered, and have been used with some success in resolution of strictures and leaks; however, complications limit their use. This article reviews the currently published experience on SEMS and attempts to define their current role in the treatment of benign biliary diseases.
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13
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Redwan AA. Multidisciplinary approaches for management of postcholecystectomy problems (surgery, endoscopy, and percutaneous approaches). Surg Laparosc Endosc Percutan Tech 2011; 19:459-69. [PMID: 20027088 DOI: 10.1097/sle.0b013e3181bc4567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE A prospective study to evaluate the postcholecystectomy problem management. PATIENTS AND METHODS From March 2005 to April 2007, 210 patients were managed using surgery, endoscopy, and percutaneous approaches. RESULTS Endoscopy was therapeutic in 183 cases [stones (81), stricture (55), leakage (35)], and only diagnostic in 24 cases. Percutaneous approaches were carried out in 34 cases as diagnostic in 19 cases, stenting in 2 cases, and combined with endoscopy in 13 cases. Surgery was carried out in 40 cases either urgent in 10 cases (4.8%), or planned in 30 cases (14.3%), for peritoneal lavage in 7 cases, choledocholithotomy in 8 cases, undo ligation and T-tube drainage in 5 cases, common bile duct repair splinted by T tube in 3 cases, choledochoduodenostomy in 1 case, and Roux-en-Y choledochojejunostomy in 18 cases. CONCLUSIONS Endoscopy is effective and safe not only for diagnostic but also for therapeutic approaches, especially when combined with percutaneous approaches that help in failure cases, but surgery remains as the gold standard treatment not only for the cases, which failed to be treated by less invasive approaches, but also in cases that are mandatory to be explored as peritonitis.
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Affiliation(s)
- Alaa Ahmad Redwan
- General Surgery Department, Assuit University Hospitals, Assuit University, Assuit, Egypt.
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Kuroda Y, Tsuyuguchi T, Sakai Y, K C S, Ishihara T, Yamaguchi T, Saisho H, Yokosuka O. Long-term follow-up evaluation for more than 10 years after endoscopic treatment for postoperative bile duct strictures. Surg Endosc 2010; 24:834-40. [PMID: 19730951 DOI: 10.1007/s00464-009-0673-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Accepted: 07/27/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic stent therapy is routinely used to treat postoperative bile duct strictures. However, no studies have detailed long-term follow-up evaluation for more than 10 years. METHODS This study enrolled 22 consecutive patients with a diagnosis of postoperative bile duct strictures from 1987 to 2006. Cases involving digestive tract reconstruction were excluded. Dilation was performed after passage of a guidewire through the stricture followed by temporary stent placement. The final objective was to achieve stent free status after sufficient dilation. The stent was removed when the cholangiogram showed apparent resolution of the stricture. If stent removal was not possible within 12 months, the authors proposed a surgical treatment option. RESULTS Initial therapy was performed for 21 patients (21/ 22, 95%). The remaining patient had complete occlusion, which required surgical repair. For 3 of the 21 cases, guidewire passage through the narrow stricture under fluorographic guidance alone was impossible. However, visualization by peroral cholangioscope enabled passage of the guidewire in all three cases. In two cases, the stricture persisted longer than 12 months, rendering stent removal impossible. Therefore, stent removal within 12 months was achieved in 90% of the cases (19/21). Two patients requested prolonged stenting in lieu of the authors' proposal to repeat the surgery. This resulted in sufficient dilation after an additional 6 months. Consequently, a total of 21 patients were enrolled for long-term follow-up evaluation. The posttreatment follow-up period was 121 + or - 64 months (range, 31-254 months; median, 120 months). Three patients died of causes unrelated to hepatobiliary disease. The remaining patients were successfully followed up until this writing. The overall long-term success rate was 95% (20/21). No hepatobiliary malignancies developed within the follow-up period. CONCLUSIONS Endoscopic stent therapy is available for postoperative bile duct strictures. Long-term prognosis for more than 10 years is excellent. Repeat surgical interventions may be unavoidable in some cases, but endoscopic treatment should be proposed as the first-line treatment.
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Affiliation(s)
- Yasuhisa Kuroda
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-0856, Japan.
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Abdel-Raouf A, Hamdy E, El-Hanafy E, El-Ebidy G. Endoscopic management of postoperative bile duct injuries: a single center experience. Saudi J Gastroenterol 2010; 16:19-24. [PMID: 20065569 PMCID: PMC3023096 DOI: 10.4103/1319-3767.58763] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND/AIM Biliary endoscopic procedures may be less invasive than surgery for management of postoperative bile duct injuries (POBDI). This retrospective work presents the experience of a single referral center during a period of 14 years in endoscopic management of POBDI. MATERIALS AND METHODS Between 1994 (March) and 2008 (May), ERCP had been performed on 277 patients suspected to have POBDI. Patients shown to have complete transaction of bile duct were prepared for definitive surgery. For patients with simple biliary leak, sphincterotomy was performed with stenting. Pneumatic dilatation and stenting were done on patients with biliary stricture and preserved ductal continuity. ERCP was repeated every 3 months till the site of narrowing disappeared. RESULTS The mean age was 45.3 years, 162 (58.5%) were females. The most common previous surgery was cholecystectomy (open, [N=119] 44%, and laparoscopic, [N=77] 28%). ERCP failed in 17 patients (6.1%). For successfully cannulated cases (N=260, 93.9%), the type of bile duct injury diagnosed at ERCP was completely ligated CBD (N=31/260 , 11.9%). Bile leakage was detected in (N=167/260, 64.2%) all patients with endoscopic sphincterotomy and stent insertion, the leak stopped in all of them. Biliary stricture was diagnosed in 33/260 patients (12.7%) and 17 of them had repeated balloon dilatation with stenting while the remaining had surgical correction. The success rate of endoscopic therapy for biliary strictures was 82%. Cholangiogram was normal in 29 patients (11.2%). CONCLUSIONS Endoscopic therapy is safe and effective in the management of postoperative bile duct leak. For postoperative bile ductal strictures, ERCP is a less favorable option.
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Affiliation(s)
- Ahmed Abdel-Raouf
- Gastroenterology Center, Mansoura University, Jehan St, 35516, Mansoura, Dakahlia, Egypt.
| | - Emad Hamdy
- Gastroenterology Center, Mansoura University, Jehan St, 35516, Mansoura, Dakahlia, Egypt
| | - Ehab El-Hanafy
- Gastroenterology Center, Mansoura University, Jehan St, 35516, Mansoura, Dakahlia, Egypt
| | - Gamal El-Ebidy
- Gastroenterology Center, Mansoura University, Jehan St, 35516, Mansoura, Dakahlia, Egypt
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van Boeckel PGA, Vleggaar FP, Siersema PD. Plastic or metal stents for benign extrahepatic biliary strictures: a systematic review. BMC Gastroenterol 2009; 9:96. [PMID: 20017920 PMCID: PMC2805674 DOI: 10.1186/1471-230x-9-96] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Accepted: 12/17/2009] [Indexed: 12/17/2022] Open
Abstract
Background Benign biliary strictures may be a consequence of surgical procedures, chronic pancreatitis or iatrogenic injuries to the ampulla. Stents are increasingly being used for this indication, however it is not completely clear which stent type should be preferred. Methods A systematic review on stent placement for benign extrahepatic biliary strictures was performed after searching PubMed and EMBASE databases. Data were pooled and evaluated for technical success, clinical success and complications. Results In total, 47 studies (1116 patients) on outcome of stent placement were identified. No randomized controlled trials (RCTs), one non-randomized comparative studies and 46 case series were found. Technical success was 98,9% for uncovered self-expandable metal stents (uSEMS), 94,8% for single plastic stents and 94,0% for multiple plastic stents. Overall clinical success rate was highest for placement of multiple plastic stents (94,3%) followed by uSEMS (79,5%) and single plastic stents (59.6%). Complications occurred more frequently with uSEMS (39.5%) compared with single plastic stents (36.0%) and multiple plastic stents (20,3%). Conclusion Based on clinical success and risk of complications, placement of multiple plastic stents is currently the best choice. The evolving role of cSEMS placement as a more patient friendly and cost effective treatment for benign biliary strictures needs further elucidation. There is a need for RCTs comparing different stent types for this indication.
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Affiliation(s)
- Petra G A van Boeckel
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Mahajan A, Ho H, Sauer B, Phillips MS, Shami VM, Ellen K, Rehan M, Schmitt TM, Kahaleh M. Temporary placement of fully covered self-expandable metal stents in benign biliary strictures: midterm evaluation (with video). Gastrointest Endosc 2009; 70:303-9. [PMID: 19523620 DOI: 10.1016/j.gie.2008.11.029] [Citation(s) in RCA: 168] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Accepted: 11/12/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Benign biliary strictures (BBS) have been endoscopically managed with placement of multiple plastic stents. Uncovered metal stents have been associated with mucosal hyperplasia and partially covered self-expandable metal stents with migration. Recently, fully covered self-expandable metal stents (CSEMSs) with anchoring fins have become available. OBJECTIVE Our purpose was to analyze the efficacy and complication rates of CSEMSs in the treatment of BBS. DESIGN CSEMSs (10-mm diameter) were placed in 44 patients with BBS. CSEMSs were left in place until adequate biliary drainage was achieved, confirmed by resolution of symptoms, normalization of liver function tests, and imaging. SETTING Tertiary care center with long-standing experience with metal stents. PATIENTS A total of 44 patients with BBS (28 men, median age 53.5 years) were included. The preprocedure diagnoses included chronic pancreatitis (n = 19), gallstone-related strictures (n = 14), post liver transplant (n = 9), autoimmune pancreatitis (n = 1), and primary sclerosing cholangitis (n = 1). INTERVENTION ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or rat tooth. MAIN OUTCOME MEASUREMENTS Stricture resolution and morbidity. RESULTS The median time of CSEMS placement was 3.3 months (interquartile range 3.0-4.8). Resolution of the BBS was confirmed in 34 of 41 patients (83%) after a median postremoval follow-up time of 3.8 months (interquartile range 1.2-7.7). Complications were observed in 6 (14%) patients after CSEMS placement and in 4 (9%) after CSEMS removal. LIMITATION Pilot study from a single center. CONCLUSION Temporary placement of CSEMSs for BBS may offer an alternative to plastic stenting. Further investigation is required to further assess safety and long-term efficacy.
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Affiliation(s)
- Anshu Mahajan
- Digestive Health Center, University of Virginia Health System, Charlottesville, Virginia 22908-0708, USA
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Pawa S, Al-Kawas FH. ERCP in the management of biliary complications after cholecystectomy. Curr Gastroenterol Rep 2009; 11:160-166. [PMID: 19281705 DOI: 10.1007/s11894-009-0025-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Open cholecystectomy has been associated historically with 0.2% to 0.5% risk of postoperative biliary injury. Laparoscopic cholecystectomy, which has become the first-line surgical treatment of calculous gallbladder disease, has been associated with a 2.5-fold to fourfold increase in the incidence of postoperative bile duct injury. The biliary endoscopist can expect to see a varied spectrum of complications after cholecystectomy by either technique, including postoperative biliary strictures, bile leaks, and retained calculi in the biliary tree. Proper diagnosis and treatment are paramount in ensuring a satisfactory outcome after bile duct injury. Endoscopic retrograde cholangiopancreatography (ERCP) has become the primary modality for treatment and effectively manages most bile duct injuries.
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Affiliation(s)
- Swati Pawa
- Georgetown University Hospital, Washington, DC 20007, USA
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Glas L, Courbière M, Ficarelli S, Milot L, Mennesson N, Pilleul F. Long-term outcome of percutaneous transhepatic therapy for benign bilioenteric anastomotic strictures. J Vasc Interv Radiol 2008; 19:1336-43. [PMID: 18725096 DOI: 10.1016/j.jvir.2008.05.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Revised: 05/16/2008] [Accepted: 05/22/2008] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- Ludivine Glas
- Department of Gastrointestinal Imaging, Hôpital Edouard Herriot, Hospices Civils de Lyon, Pavillon G, H, Place d'Arsonval, 69008 Lyon, France
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Kang DO, Kim TH, You SS, Min HJ, Kim HJ, Jung WT, Lee OJ. Successful endoscopic treatment of biliary stricture following mesenteric tear caused by blunt abdominal trauma. World J Gastroenterol 2008; 14:2277-9. [PMID: 18407610 PMCID: PMC2703861 DOI: 10.3748/wjg.14.2277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Biliary duct injuries are frequently iatrogenic, being associated with surgery for gallbladder stones. However, blunt abdominal trauma such as a motor vehicle crash is a rare cause of extrahepatic biliary stricture. A few reports have been published on biliary strictures treated with endoscopic therapy. In the present study, we describe a suprapancreatic biliary stricture associated with mesenteric tear following road traffic accident. We performed endoscopic stent placement, which was successful in relieving the biliary stricture.
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Farah M, McLoughlin M, Byrne MF. Endoscopic retrograde cholangiopancreatography in the management of benign biliary strictures. Curr Gastroenterol Rep 2008; 10:150-156. [PMID: 18462601 DOI: 10.1007/s11894-008-0036-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Several conditions may cause benign biliary stricture formation. Intraoperative bile duct injury, most often sustained during laparoscopic cholecystectomy, is the leading cause. Although surgical bypass procedure was the traditional treatment of choice for benign extrahepatic biliary strictures, therapeutic endoscopic retrograde cholangiopancreatography has recently come into favor; however, success rates have been variable and largely dependent on the underlying etiology. Because endoscopic therapy may be unsuccessful, a multidisciplinary approach to management, with surgical or radiological intervention if necessary, should be considered.
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Affiliation(s)
- Myriam Farah
- Division of Gastroenterology, Vancouver General Hospital, University of British Columbia, 2329 West Mall, Vancouver, British Columbia, Canada
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22
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Kassab C, Prat F, Liguory C, Meduri B, Ducot B, Fritsch J, Choury AD, Pelletier G. Endoscopic management of post-laparoscopic cholecystectomy biliary strictures. Long-term outcome in a multicenter study. ACTA ACUST UNITED AC 2006; 30:124-9. [PMID: 16514393 DOI: 10.1016/s0399-8320(06)73127-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this retrospective study was to assess the long term results of long-lasting endoscopic stenting for benign biliary strictures related to laparoscopic cholecystectomy. Additional biological and morphological data were collected from these patients during follow-up. METHODS Patients undergoing ERCP for post-laparoscopic cholecystectomy biliary stricture in one of the three participating centers between 1990 and December 2001 were identified. Only patients with successful endoscopic stenting were subsequently included and analyzed. Follow-up data were obtained from referring centers, general practitioners and patients or relatives. Hepatic blood tests and abdominal ultrasound were proposed to all the patients who had not undergone further treatments after stent removal. RESULTS Eight-eight patients had undergone ERCP for benign biliary stricture related to laparoscopic cholecystectomy. Stenting failed in 19 patients. Balloon dilatation alone was used in four patients. Strictures were successfully stented in 65 patients. The mean number of stents inserted at the same time was 1.6. The mean duration of stenting was 14 months (range 1-120 months). Eighteen patients (28%) developed biliary or pancreatic symptoms during stenting. ERCP was considered satisfactory at the end of stenting (i.e. no remaining stricture or minor remaining change on ERCP) in 45 patients (69%). Twenty-two patients were lost to follow-up. Twenty-nine out of forty-three patients (67%) remained symptom-free with normal updated blood tests and abdominal ultrasound during a mean follow-up of 28 months (range 12-117 months) after stent removal. None of the patients with a normal ERCP at the end of stenting developed stricture recurrence during follow-up. Eleven patients were operated (8 with persistence of stricture, 2 for stricture recurrence up to 63 months after stent removal, 1 for pancreatitis). CONCLUSION Based on clinical, morphological and biological criteria, a long-term success was obtained in 70% of patients with post-laparoscopic cholecystectomy benign biliary strictures, after several months of endoscopic stenting.
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Tesdal IK, Roeren T, Weiss C, Jaschke W, Dueber C. Metallic Stents for Treatment of Benign Biliary Obstruction: A Long-term Study Comparing Different Stents. J Vasc Interv Radiol 2005; 16:1479-87. [PMID: 16319154 DOI: 10.1097/01.rvi0000173014.99278.08] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To investigate the role of metallic stents in the treatment of benign biliary strictures and analyze the differences in primary patency associated with the various types of stents deployed. MATERIALS AND METHODS Between 1990 and 1997, 21 patients with benign obstructive jaundice were treated with transhepatic placement of metallic stents (11 Wallstents in 10 patients, nine Palmaz stents in seven patients, and four tantalum Strecker stents in four patients). Nineteen patients presented with strictures not responding to balloon angioplasty (postsurgical, n = 13; cholangitis, n = 5; unknown, n = 1). Estimates for cumulative patency, patency rate in the different stent groups, and survival were calculated with use of life-table analysis; the log-rank test was used to compare the different stent groups. The prognostic relevance of the selected variables-stent type, stent length, etiology, and location-were modeled with respect to patency according to Weibull distribution. RESULTS The median follow-up time was 80.5 months (range, 2-116 months). The median survival time was 91 months. One patient was lost to follow-up after 3 months. Repeat intervention for recurrent obstructive jaundice was necessary in 11 patients (55%), and the median patency rate was 26 months (range, 2-96 months). The Palmaz stent was the most effective in achieving long-term patency, with a median patency duration of 36 months (range, 22-96 months), versus 9 months (range, 3-67 months) for the Wallstent and 6 months (range, 2-15 months) for the tantalum Strecker stent. The cumulative patency rate with the Palmaz stent was significantly higher than for the tantalum Strecker stent (log-rank test, P = .017) and nonsignificantly higher compared with the Wallstent (log-rank test, P = .07). Multivariate analysis showed that the type of stent (Wald test, P = .003) and stent length (Wald test, P < .0001) influenced the patency rate. CONCLUSIONS These results suggest that the type of stent and the stent length have a significant influence on the patency rate. In this series, the Palmaz stent was most effective in achieving long-term patency in benign biliary strictures.
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Affiliation(s)
- I Kaare Tesdal
- Department of Clinical Radiology, Universitätsklinikum, Mannheim, Germany.
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Cahen DL, van Berkel AMM, Oskam D, Rauws EAJ, Weverling GJ, Huibregtse K, Bruno MJ. Long-term results of endoscopic drainage of common bile duct strictures in chronic pancreatitis. Eur J Gastroenterol Hepatol 2005; 17:103-8. [PMID: 15647649 DOI: 10.1097/00042737-200501000-00019] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Endoscopic stent therapy is an established treatment modality for postoperative biliary strictures. At present, biliary stenting is also widely applied in chronic pancreatitis (CP), but results regarding long-term outcome are scarce. METHODS All CP patients who underwent endoscopic biliary drainage of a benign stricture in our hospital between 1987 and 2000 were included in this retrospective study. RESULTS Fifty-eight CP patients underwent biliary stenting (median age, 54 years; 44 male). The procedure-related mortality rate was 2% and the complication rate 4%. Median follow-up was 45 months (range, 0-182 months). Endoscopic treatment was successful in 22 patients (38%). Concomitant acute pancreatitis was the only factor identified as predictive of a successful outcome by multivariate analyses. Subanalysis of these 12 patients revealed a success rate of 92%, as opposed to 24% in cases without acute inflammation. In this latter group, continued stenting beyond a 1-year period almost never resulted in additional stricture resolvement. If stricture resolution was accomplished, however, no recurrences were observed. CONCLUSIONS For biliary strictures due to CP, without evidence of concomitant acute pancreatitis, the long-term success rate of endoscopic therapy is poor and only one out of four strictures is treated successfully. When a biliary stricture has not resolved after 1 year of endoscopic stenting, surgery should be considered.
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Affiliation(s)
- Djuna L Cahen
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands.
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Enya M, Yasuda I, Mukai T, Shinoda T, Otsuji K, Iwasa J, Nakai M, Tomita E, Moriwaki H. Endoscopic treatment for benign biliary strictures: Can placement of a covered metallic stent be an option in refractory cases? Dig Endosc 2004. [DOI: 10.1111/j.1443-1661.2004.00312.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Costamagna G, Shah SK, Tringali A. Current management of postoperative complications and benign biliary strictures. Gastrointest Endosc Clin N Am 2003; 13:635-48, ix. [PMID: 14986791 DOI: 10.1016/s1052-5157(03)00103-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Postoperative complications after surgery of the biliary tract are usually amenable to endoscopic treatment. Such complications are most frequent after laparoscopic cholecystectomy. Bile leaks and bile duct strictures are the two main biliary injuries. Bile leaks are usually detected during the early postoperative period and can be treated by endoscopic drainage of the biliary tree (endoscopic sphincterotomy with or without nasobiliary drain). Postoperative biliary strictures are usually identified months or years after surgery. Endoscopic placement of an increasing number of plastic stents can achieve morphologic disappearance of the stricture and persistent dilation on long-term follow-up in most cases.
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Familiari L, Scaffidi M, Familiari P, Consolo P, Ficano L, Micelic D, Martorana G, Tarantello M. An endoscopic approach to the management of surgical bile duct injuries: nine years' experience. Dig Liver Dis 2003; 35:493-7. [PMID: 12870736 DOI: 10.1016/s1590-8658(03)00223-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The evaluation of the endoscopic treatment of surgical bile duct injuries, especially in the management of post-operative strictures, remains controversial. AIM The aim of this study was to evaluate the feasibility of using endoscopic management from a study of the clinical reports of two of the main endoscopy units in Sicily. PATIENTS AND METHODS A total of 137 consecutive patients were selected. There were 85 simple biliary fistulas: 64 from the cystic duct stump; 19 from the gall bladder bed; and two from intra-hepatic bile ducts. There were 52 biliary lesions: 15 complete transections; 12 incomplete lesions of the common bile duct with six associated strictures; five complete or incomplete sections of the right antero-medial duct; and 20 incomplete strictures (without leak). RESULTS The success rate was 96.3% for simple biliary fistulas. Endoscopic therapy was feasible only in 40.6% of lesions of the common bile duct or the right antero-medial duct (13/32), but with 100% success. In the case of strictures (with or without associated leak), there was a good outcome in 88.2% of patients who completed the therapeutic procedure. CONCLUSIONS Endoscopic management of simple biliary fistulas and incomplete lesions of the common bile duct is the preferred approach. If continued for 12-24 months, with the placement of three or more 10F stents, the management of stenoses is guaranteed to yield good results.
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Affiliation(s)
- L Familiari
- Digestive Endoscopy Unit, Department of Medicine and Pharmacology, University of Messina, Messina, Italy.
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Rumalla A, Petersen BT, Baron TH, Burgart LJ, Herman LJ, Wiersema MJ, Gostout CJ. Development of a swine model for benign stenosis of the bile duct by endoscopic application of intraluminal thermal injury. Gastrointest Endosc 2003; 57:73-7. [PMID: 12518135 DOI: 10.1067/mge.2003.27] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND A simple animal model is desirable for the study of endoscopic therapies used in the management of biliary strictures. The aim of this study was to identify a method for inducing benign biliary stenoses in a porcine model by using endoscopic techniques. METHODS Endoscopic retrograde cholangiography was performed in 9 swine. Intraluminal injury was applied to the common hepatic duct with graded applications of either a heat probe or a multipolar probe. Cholangiography was repeated at 7-day intervals. If a stricture was not identified by 28 days, injury was created at another site in the common hepatic duct by using a higher energy dose. After a stricture was identified, the animal was killed and bile duct samples were obtained for histopathologic evaluation. RESULTS Thirteen thermal injuries were created in the 9 animals. Six of 7 heat probe treatments and 1 of 6 multipolar probe treatments resulted in a stricture (p = 0.025, Fisher exact test). Applications of the heat probe at 10 or 15 J produced a stricture in 6 of 6 cases. All strictures were indistinguishable histopathologically from benign strictures in humans. CONCLUSIONS The application of intraluminal thermal injury with a heat probe results in a reproducible animal model of benign biliary stenosis.
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Affiliation(s)
- Ashwin Rumalla
- Developmental Endoscopy Unit, Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
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Draganov P, Hoffman B, Marsh W, Cotton P, Cunningham J. Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple stents. Gastrointest Endosc 2002; 55:680-6. [PMID: 11979250 DOI: 10.1067/mge.2002.122955] [Citation(s) in RCA: 227] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The long-term efficacy of sequential insertion of multiple plastic stents for benign biliary strictures is poorly defined. The aims of this study were to evaluate the long-term outcome (bile duct patency, complications) of this therapy and to identify predictors of a good outcome. METHODS Retrospective review of 29 cases of benign biliary strictures treated with sequential plastic stent insertion in progressively increasing numbers and/or of increasing diameter. RESULTS Stricture etiology was as follows: postoperative 19 (66%), chronic pancreatitis 9 (31%), and idiopathic 1 (3%). Therapy succeeded in 18 patients (62%) (mean follow-up 48.0 [11.56] months after stent removal). Therapy failed in 11 patients (38%) (mean interval to failure 11.59 [9.79] months after stent removal). The 2 groups of patients in which therapy failed had either a hilar stricture (n = 4, 25% success) or distal common bile duct stricture caused by chronic pancreatitis (n = 9, 44% success). In the remaining cases, therapy succeeded in 13 of 16 (81% success). The observed differences in success rate among subgroups were not statistically significant. There were no ERCP-related deaths. One episode of mild pancreatitis and 2 episodes of cholangitis developed during 126 ERCPs over a period of stent insertion of 36 patient years. CONCLUSIONS In selected patients with benign biliary strictures, sequential endoscopic insertion of multiple biliary stents may lead to long-term success that could be equal to or superior to surgery with minimal morbidity. Hilar strictures and those caused by chronic pancreatitis appear to respond poorly to this therapy.
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Affiliation(s)
- Peter Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida 32610, USA
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Eickhoff A, Jakobs R, Leonhardt A, Eickhoff JC, Riemann JF. Endoscopic stenting for common bile duct stenoses in chronic pancreatitis: results and impact on long-term outcome. Eur J Gastroenterol Hepatol 2001; 13:1161-7. [PMID: 11711771 DOI: 10.1097/00042737-200110000-00007] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The overall incidence of common bile duct strictures due to chronic pancreatitis is reported to be approximately 10-30%. It remains a challenging problem for gastroenterologists and surgeons. The exact role of endoscopic stenting has not yet been clearly defined. DESIGN AND METHODS Thirty-nine patients with chronic pancreatitis and symptomatic common bile duct stenoses underwent endoscopic stenting and were studied retrospectively. We were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the stents in the long term. RESULTS Indications for endoscopic stenting were symptomatic cholestasis, jaundice or cholangitis. The initial serum bilirubin was 8.3 mg/dl and the diameter of the common bile duct was 14.2 mm before stenting. Within 3-7 days of stenting, all patients presented improvement of jaundice and cholestasis. After a median stenting time of 9 months (range 1-144 months), 46% of the patients demonstrated regression of the stricture and clinical improvement, 26% required further stenting, and 28% were referred to surgery. Five patients received a self-expandable metal Wallstent. Thirty-one per cent demonstrated complete clinical recovery of the stricture as well as 10.2% a complete, radiologically verified stricture regression in a median follow-up of 58 months. CONCLUSIONS There seems to be a therapeutic benefit for short-term endoscopic treatment but medium-term and long-term outcome remains questionable. Endoscopic stenting should be applied as an initial therapy before surgery, but it can be the definitive approach for older and morbid patients or cases with complete stricture regression after stent removal. Overall, it should not be considered as a routine procedure for symptomatic cases.
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Affiliation(s)
- A Eickhoff
- Medical Department C, Klinikum Ludwigshafen gGmbH, Germany.
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31
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Costamagna G, Pandolfi M, Mutignani M, Spada C, Perri V. Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc 2001; 54:162-8. [PMID: 11474384 DOI: 10.1067/mge.2001.116876] [Citation(s) in RCA: 318] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic dilation with stents has been proposed as an alternative to hepaticojejunostomy for management of postoperative biliary strictures. Good long-term results with double 10F plastic stent insertion for 1 year have been reported in 74% to 90% of cases. This is a review of our experience with a more aggressive approach. METHODS The technique, short-term results, and long-term results of placement of increasing numbers of stents until complete disappearance of the biliary stricture are reported. At each exchange, the maximum possible number of stents in relation to the tightness of the stricture and diameter of the bile duct were inserted. All stents were removed at the end of treatment. RESULTS The records of 45 of 55 patients with postoperative biliary strictures treated in this manner and observed consecutively were reviewed retrospectively. By intention-to-treat analysis the success rate was 89% (40/45). Early complications developed in 4 (9%) patients (3 cholangitis, 1 pancreatitis) and stent occlusion that required early exchange occurred in 8 (18%) patients. There was 1 death caused by a stroke 2 months after a stent exchange. Forty-two patients completed the protocol (mean number of stents 3.2 +/- 1.3; range 1-6). Mean duration of treatment was 12.1 +/- 5.3 months (range 2-24 months). Two patients died of unrelated causes during follow-up. Among the remaining 40 patients there was no recurrence of symptoms caused by relapsing biliary stricture at a mean follow-up of 48.8 months (range 2-11.3 years). One patient sustained 2 episodes of cholangitis but without stricture recurrence. CONCLUSIONS This more aggressive approach to endoscopic treatment with stents may improve long-term results for patients with postoperative biliary strictures.
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Affiliation(s)
- G Costamagna
- Digestive Endoscopy Unit, Department of Surgery, Catholic University, Rome, Italy
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Farnbacher MJ, Rabenstein T, Ell C, Hahn EG, Schneider HT. Is endoscopic drainage of common bile duct stenoses in chronic pancreatitis up-to-date? Am J Gastroenterol 2000; 95:1466-71. [PMID: 10894580 DOI: 10.1111/j.1572-0241.2000.02078.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Common bile duct (CBD) stenoses often complicate chronic pancreatitis (CP). Although endoscopic drainage is employed as a standard procedure in malignant CBD stenoses, it is not yet the approved standard therapy of CBD stenosis in CP. METHODS The records of 31 patients with CBD stenosis in CP who had undergone endoscopic placement of plastic endoprostheses into the bile duct between January 1991 and February 1997 were analyzed retrospectively. In all, 18 patients suffered from jaundice and 13 patients exclusively showed serological cholestasis. Upstream dilation of the CBD (19 +/- 6.6 mm, 12-35 mm) was detected by ERCP in all patients. In total, 101 endoprostheses were implanted endoscopically, exchanged after 3 +/- 2 months, and removed after 10 +/- 8 months. RESULTS All jaundiced patients showed immediate improvement of cholestasis after drainage. At the time of last exchange or after stent removal, prestenotic CBD dilation was reduced in 55% of all patients. Complete regression of stenosis and prestenotic dilation was accomplished only in 13%; dilation remained unchanged in 10%, and even showed progression in 22%. A total of 29 patients were followed-up over 24 months. Cholestatic parameters remained normal in all patients with complete normalization of the CBD, and were only moderately increased in another 10 patients, 7 and 28 months after stent removal, respectively. CONCLUSIONS Technical and immediate clinical success of CBD stenting in patients with CBD stenoses due to CP is high; however, long-term complete normalization of the bile duct is rare. Endoscopic drainage of CBD-stenosis in patients with CP can be recommended to alleviate acute cholestasis, but not yet as a definite treatment.
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Affiliation(s)
- M J Farnbacher
- Medizinische Klinik I mit Poliklinik, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Lascarides CE, Bini EJ, Newman E, Gordon RB, Sidhu GS, Cohen J. Intrinsic common bile duct stricture: an unusual presentation of retroperitoneal fibrosis. Gastrointest Endosc 1999; 50:102-5. [PMID: 10385734 DOI: 10.1016/s0016-5107(99)70356-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- C E Lascarides
- Department of Medicine, Division of Gastroenterology, New York VA Medical Center, New York, NY 10010, USA
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Imrie CW, Brombacher GD. Sclerosing cholangitis: a rare etiology for acute pancreatitis. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1998; 23:71-5. [PMID: 9520093 DOI: 10.1007/bf02787505] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Primary sclerosing cholangitis as the cause of acute pancreatitis is a rare phenomenon with only one previous case having been found by ourselves in the English literature. Over a period of 2 yr, two patients with acute pancreatitis secondary to primary sclerosing cholangitis were seen in this unit. The first patient is currently being treated with ursodeoxycholic acid and repeat endoscopic sphincterotomies, whereas the second required liver transplantation.
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Abstract
Benign biliary strictures can now be effectively treated with endoscopic therapy in a variety of clinical situations. Despite recent developments in imaging techniques (endoscopic ultrasound and magnetic resonance imaging), it is often difficult to differentiate benign from malignant biliary strictures. The sensitivity of tissue diagnosis (cytology and needle biopsy) at endoscopic retrograde cholangiopancreatography (ERCP) remains poor (40-50%), and further diagnostic methods are required. Endoscopic therapy offers a definitive treatment in 70-90% of patients following post-operative biliary stricture, including anastomotic strictures following liver transplant. Endoscopic therapy successfully achieves symptomatic, biochemical, and cholangiographic response, and may improve survival in patients with primary sclerosing cholangitis. Strictures secondary to chronic pancreatitis are resistant to standard endoscopic therapy and metallic endoprotheses have been trialed with varying success. Endoscopic therapy is technically difficult and should be performed in specialized centres using a multidisciplinary approach.
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Affiliation(s)
- J C Gibbons
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
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37
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Röthlin MA, Löpfe M, Schlumpf R, Largiadèr F. Long-term results of hepaticojejunostomy for benign lesions of the bile ducts. Am J Surg 1998; 175:22-6. [PMID: 9445233 DOI: 10.1016/s0002-9610(97)00229-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hepaticojejunostomy has been the method of choice for the treatment of benign lesions of the extrahepatic bile ducts for years. In the era of minimally invasive and interventional techniques, a review of its long-term results is necessary to set the standard with which these new techniques have to be compared. METHODS A retrospective analysis was carried out for 51 patients (16 females, 35 males) aged 24 to 83 years (average 48 +/- 13) who had undergone hepaticojejunostomy for benign lesions at our institution between 1980 and 1989. Twelve patients had had up to 4 prior operations of their bile ducts. The main indications for operation were chronic pancreatitis (n = 33) and iatrogenic bile duct lesions (n = 15). If possible, a low end-to-side hepaticojejunostomy was performed. The Hepp-Couinaud approach was saved for high strictures and recurrences. All patients were reassessed by questionnaire at an average of 7.6 years (range 2 to 13) after the operation. RESULTS Four Hepp-Couinaud and 47 low hepaticojejunostomies were performed. Postoperative complications were seen in 17 patients (33%), 4 of whom had a reoperation. One patient died, for a mortality rate of 2%. The hospital stay averaged 24 +/- 17 days (range 8 to 90). Late complications developed in 13 patients (25%) 2 months to 6 years after the operation. Stenosis and cholangitis necessitated reoperation in 3 cases, cholangitis without stenosis was treated in 4, and other complications were seen in 5 cases. One patient died with a liver abscess, and 12 died of causes unrelated to the operation. When questioned, 31 of 35 patients were in good or very good condition. CONCLUSIONS Hepaticojejunostomy is a safe and reliable method for the treatment of benign lesions of the bile ducts even in young patients in need of a long-term biliary bypass.
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Affiliation(s)
- M A Röthlin
- Department of Surgery, Zürich University Hospital, Switzerland
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Jacob H, Fenster J, Zinberg J, Kadish S. Biliary balloon dilation using a triple-lumen balloon catheter. Gastrointest Endosc 1996; 44:465-8. [PMID: 8905370 DOI: 10.1016/s0016-5107(96)70101-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- H Jacob
- St. John's Episcopal Hospital South Shore Division, Cedarhurst, New York
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