Benign Biliary Strictures: A Systematic Review on Endoscopic Treatment Options

Off-label use of Lumen-apposing metal stents for treatment of short benign biliary strictures

BACKGROUND

Endoscopic stenting is the mainstay of treatment for benign biliary strictures. There is a not-negligible rate of recurrence and stent migration. Lumen-apposing metal stents (LAMS) have a unique design with short length, large diameter and wide flanges which make them less prone to migration.

AIMS

To describe the intraluminal use of LAMS to treat short benign biliary strictures.

METHODS

All consecutive patients who underwent bi-flanged LAMS placement for benign biliary strictures, in approximately 6 years, were retrospectively included. Primary outcomes were technical and clinical success; secondary outcomes were number of endoscopic procedures, adverse events evaluation and stricture recurrence during follow-up.

RESULTS

Seventy patients (35 male, mean age 67) were enrolled; bilio-enteric anastomotic stricture was the most common etiology. Technical and clinical success were 100 % and 85.7 %, respectively. Patients with post-surgical stricture had a higher success rate than patients with non-surgical stricture or with bilio-enteric anastomotic stricture (90.4 %, 86.3 % and 81.4 %, respectively). Adverse events were 12/70 (17.1 %): stent migration was the most frequent (8/70, 11.4 %). Stricture recurrence was found in 10/54 patients (18.5 %).

CONCLUSION

LAMS placement could be safe and effective treatment for short benign biliary strictures in patients in which a significant caliber disproportion between stricture and the duct above was revealed.

A Short Fully Covered Self-Expandable Metal Stent for Management of Benign Biliary Stricture Not Caused by Living-Donor Liver Transplantation

Background: This study evaluated the effectiveness of short fully covered self-expanding metal stents (FCSEMS) with an anti-migration design in treating benign biliary strictures (BBS) not related to living donor liver transplantation (LDLT). Methods: A retrospective analysis was conducted on 75 patients who underwent FCSEMS insertion for BBS management. Stents were initially kept for 3 months and exchanged every 3 months until stricture resolution. Adverse events and stricture recurrence after FCSEMS removal were assessed during follow-up. Results: The study outcomes were technical success, stenosis resolution, and treatment failure. Technical success was 100%, with stricture resolution in 99% of patients. The mean onset time of BBS post-surgery was 4.4 years, with an average stent indwelling period of 5.5 months. Stricture recurrence occurred in 20% of patients, mostly approximately 18.8 months after stent removal. Early cholangitis and stent migration were noted in 3% and 4% of patients, respectively. Conclusions: This study concludes that short FCSEMS demonstrate high efficacy in the treatment of non-LDLT-related BBS, with a low incidence of interventions and complications. Although this is a single-center, retrospective study with a limited sample size, the findings provide preliminary evidence supporting the use of short FCSEMS as a primary treatment modality for BBS. To substantiate these findings, further research involving multicenter studies is recommended to provide additional validation and a broader perspective.

Refractory benign biliary stricture due to chronic pancreatitis in two patients treated using endoscopic ultrasound-guided choledochoduodenostomy fistula creation: case reports

Benign biliary stricture (BBS) is a complication of chronic pancreatitis (CP). Despite endoscopic biliary stenting, some patients do not respond to treatment, and they experience recurrent cholangitis. We report two cases of CP with refractory BBS treated using endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) fistula creation. A 50-year-old woman and a 60-year-old man both presented with obstructive jaundice secondary to BBS due to alcoholic CP. They underwent repeated placement of a fully covered self-expandable metal stent for biliary strictures. However, the strictures persisted, causing repeated episodes of cholangitis. Therefore, an EUS-CDS was performed. The stents were eventually removed and the patients became stent-free. These fistulas have remained patent without cholangitis for more than 2.5 years. Fistula creation using EUS-CDS is an effective treatment option for BBS.

Post-trans-arterial chemoembolization hepatic necrosis and biliary stenosis: Clinical charateristics and endoscopic approach

Liver cancer is the fifth most common tumor and the second highest death-related cancer in the world. Hepatocarcinoma (HCC) represents 90% of liver cancers. According to the Barcelona Clinic Liver Cancer group, different treatment options could be offered to patients in consideration of tumor burden, liver function, patient performance status and biochemical marker serum concentration such as alpha-fetoprotein. Trans-arterial chemoembolization (TACE) is the treatment of choice in patients with diagnosis of unresectable HCC not eligible for liver transplantation, and preserved arterial supply. TACE is known to be safe and its complications are generally mild such as post-TACE syndrome, a self-resolving adverse event that occurs in about 90% of patients after the procedure. However, albeit rarely, more severe adverse events such as biloma, sepsis, hepatic failure, chemoagents induced toxicities, and post-TACE liver necrosis can occur. A prompt diagnosis of these clinical conditions is fundamental to prevent further complications. As a result, biliary stenosis could be a rare post-TACE necrosis complication and can be difficult to manage. Complications from untreated biliary strictures include recurring infections, jaundice, chronic cholestasis, and secondary biliary cirrhosis.

Endoscopic electroincision of challenging benign biliopancreatic strictures

Background and study aims  Endoscopic drainage of benign biliary and pancreatic strictures can be challenging, especially when tightness of the stenosis does not allow passage of mechanical and pneumatic dilation catheters. Electroincision of benign biliopancreatic can be considered in selected cases. Patients and methods  Three male patients (mean age 33 years, range 9-60) underwent endoscopic retrograde cholangiopancreatography to drain anastomotic biliary stricture (ABS) following orthotopic liver transplantation (n = 2) and pancreatic duct stenosis due to abdominal trauma (n = 1). The biliopancreatic strictures could be passed only with a thin 0.020-inch hydrophilic guidewire. Conventional mechanical and pneumatic dilators failed to pass the strictures due to weakness of the guidewire. Therefore, electrosurgical incision by over-the-wire 6Fr cystotome or needle-knife was attempted using pure cut current. Results  The two cases of ABS were approached also by cholangioscopy and the 6Fr cystotome easily passed the strictures, allowing subsequent pneumatic dilatation and insertion of multiple plastic stents. The patient with a pancreatic duct stricture underwent electrosurgical incision using a thin needle knife over-the-wire, resulting in insertion of a 7Fr pancreatic stent. No adverse events occurred; all the patients were discharged within 24 to 48 hours. Conclusions  Electrosurgical incision of benign biliopancreatic strictures could be considered in selected patients whom conventional dilation techniques fail.

Bio-Degradable Stents: Primary Experience in a Tertiary Hepatopancreaticobiliary Center in the United Kingdom

BACKGROUND

Management of benign biliary strictures (BBS) post bilioenteric anastomoses requires a multidisciplinary approach including surgical, radiological, and/or endoscopic input. Patients often need multiple hospital visits for treatment with the long-term possibility of restenosis. Conventionally BBS have been treated with serial percutaneous transhepatic biliary dilatations necessitating repeat procedures for drain exchange or removal. Surgery may become necessary in refractory strictures. In the last decade, there have been increasing reports of the use of biodegradable stents (BDS) in treating biliary strictures mainly to address the need for repeated procedures for drain exchange.

AIM

 This study aimed to report the early outcomes in patients with BBS treated with BDS.

METHODS

Retrospective analysis of prospectively collected data was performed in patients who had a bilioenteric anastomosis presenting with an anastomotic stricture and were intended to be treated with BDS. The primary endpoints reported were technical success (defined as a successful resolution of stricture on repeat cholangiogram) and clinical success (defined as the absence of repeated cholangitis). Clavien-Dindo (CD) grade of complication was reported.

RESULTS

Twelve patients presented with BBS and nine patients had BDS. Three patients were not considered suitable for BDS due to a non-traversable stricture and had surgery. The male-female ratio was 1:2. There was 100% technical and clinical success with one patient having stent migration not needing intervention. The procedure took an average of 45 min. In seven (77.7%) patients, it was safely performed under local anesthesia with sedation. Two patients preferred general anesthesia. There was no restenosis noted at a median follow-up of 11 months.

CONCLUSION

The use of BDS in the treatment of BBS is a safe and effective procedure. Longer-term follow-up with multi-institutional reporting on a national database is needed to assess its long-term benefits.