The current diagnosis and treatment of benign biliary stricture

Purpose

As laparoscopic cholecystectomy and liver transplantation (LT) have become more common, so has biliary stricture. Fortunately, endoscopic treatment has almost simultaneously been developed. This article reviews the recent reports concerning the management of benign biliary strictures (BBS).

Methods

The literature regarding the diagnosis and treatment of BBS is reviewed after an electronic search of PubMed from 1982 to 2009 was performed.

Results

Despite the existence of diagnostic tools including tumor markers, brush cytology, intraductal ultrasonography and other imaging modalities, differentiating BBS from malignant stricture remains challenging, as does differentiating IgG4-related sclerosing cholangitis from other benign strictures. Endoscopic treatment with balloon dilation of the stricture and serial insertions of stents is the preferred initial treatment for BBS. However, the outcomes of endoscopic treatments for primary sclerosing cholangitis or chronic pancreatitis are poorer than those for post-surgical biliary stricture. When endoscopic treatments fail to repair complicated biliary strictures such as Bismuth types III, IV, and V, surgical repair is recommended. Among the non-anastomotic BBS, intrahepatic bilateral type strictures after LT may require repeat transplantation.

Conclusion

Early referral to tertiary centers with an alliance among hepatobiliary surgeons, interventional radiologists, and endoscopists is necessary to assure optimal results.     

Evaluation of cold knife urethrotomy for the treatment of anastomotic stricture after radical retropubic prostatectomy

PURPOSE: We evaluated the efficacy of cold knife urethrotomy for anastomotic stricture after radical retropubic prostatectomy. MATERIALS AND METHODS: We contacted all patients who underwent cold knife urethrotomy for a symptomatic anastomotic stricture from May 1, 1992 through January 1, 2000 at our institution. A control group of patients who underwent radical retropubic prostatectomy but did not complain of a decreased urine stream was similarly evaluated. Maximum urinary flow rate, post-void residual urine volume, American Urological Association (AUA) symptom index for benign prostatic hyperplasia, and continence status with a questionnaire adapted from the RAND-University of California-Los Angeles Prostate Cancer Index were determined in each study participant. RESULTS: We identified and contacted 61 patients. Complete data were collected on 36 of the 52 patients (59%) who agreed to participate. Mean time after urethrotomy was 31 months (range 1 to 77). In the control group the mean time after prostatectomy was 18.6 months (range 3 to 95). There was no statistically significant difference in the measured urinary parameters of maximum flow rate, post-void residual urine volume, AUA symptom index or continence status in the study and control groups. CONCLUSIONS: Cold knife urethrotomy provides a safe and effective response for the initial treatment of patients with anastomotic stricture after radical retropubic prostatectomy. Maximum urinary flow, post-void residual volume, AUA symptom score and perceptions of continence are similar to those in patients who underwent radical retropubic prostatectomy and had no complaints of a weak urine stream.     

输尿管狭窄的治疗进展

随着泌尿外科微创手术的普及,各类医源性的输尿管损伤后狭窄增多,临床治疗较为棘手。本文就各类输尿管狭窄,尤其是长段输尿管狭窄的各种治疗方法及疗效进行总结。     

Interventional treatment of biliary stricture

Biliary stenting is a well-established intervention in pancreatic-biliary disease. Although interventional therapy is an excellent less-invasive method that can improve the quality of life of patients with stricture of the bile duct, inappropriate application can be harmful. The procedure includes the endoscopic as well as percutaneous transhepatic approach. The indications for each procedure depend upon the characteristics of the lesion, and technical feasibility must also be considered. Two types of prosthesis, the plastic tube stent (TS) and expandable metallic stent(EMS), are available. Since the former costs less and has the advantage of removability compared with the latter, it can be used in the treatment of benign strictures and for temporary stenting of resectable malignant strictures. However, the TS has a short patency period because it is likely to become occluded by clogging. In contrast, the EMS has a long patency period due to its large diameter, and multiple stents can be placed in hepatic hilar strictures. Tumor ingrowth is a major late complication of EMS. To maintain patency, other procedures such as radiation, microwave coagulation therapy, and hyperthermia can be considered in combination with EMS, which may contribute to further improvement in survival and quality of life in patients with unresectable malignant biliary strictures. Those procedures should not be performed in patients with benign biliary strictures since the EMS cannot be removed, and the long-term outcome after placement remains to be clarified.     

Surgical treatment of reflux stricture of the esophagus

Ten children, aged 7 months to 15 years, with peptic esophageal stricture, were treated surgically. In four of the children, the stricture had occurred after esophageal anastomosis. Peptic stricture was diagnosed by esophagography, pH monitoring, manometry, and esophagoscopy. Barrett's esophagus was found in two children. Nine children underwent transabdominal Nissen fundoplication initially. In the first child of this series, a tight anastomotic stricture had been excised 2 weeks before fundoplication. Seven children became complaint-free within 2 or 3 months after fundoplication without any dilatation, and two children with anastomotic stricture improved after 1 or 2 postoperative dilatations. The condition of one boy, with a 6-year history of tight stricture, did not improve with repeat Nissen and subsequent dilatations. Histological examination showed proliferation of smooth muscle cells in the submucosa. A conservative surgical approach is effective for the management of peptic esophageal stricture in children, and direct surgical intervention for stricture should be attempted only in cases of stricture resistant to antireflux surgery with a long history of reflux.     

Topical mitomycin-C for the treatment of anal stricture

Background

Anal stricture is a well-known and feared consequence of anorectal surgery. Daily dilatations are often prescribed in the immediate postoperative period to avoid stricture of the anus. Nonetheless, stricture may still occur and, particularly in older children, may require multiple dilatations under anesthesia. Topical mitomycin-C has been found to be effective in the treatment of strictures at various anatomical locations. In this article, we review our experience with topical mitomycin-C as an adjunct to anal dilatation for children with anal stricture.

Materials and methods

Cases of children with anal stricture who were treated with a single application of topical mitomycin-C as an adjunct to anal dilatation between 2000 and 2008 were analyzed retrospectively. Anal diameter was measured with Hegar dilators. Cottonoid swabs soaked in mitomycin-C were placed on the anal mucosa for 5 minutes after dilatation. Treatment success was defined by sustained improvement in anal size, decrease in symptoms, parental satisfaction, and need for additional intervention.

Results

Ten children with anal stricture who underwent anal dilatation with application of topical mitomycin-C were identified. All children presented with severe constipation. Average increase in anal size after dilatation under sedation was 5.7 mm (±3.2 mm). Average improvement in anal diameter on first clinic visit after mitomycin-C application was 3.7 mm. On follow-up, only 1 child required repeated intervention for stricture after treatment with mitomycin-C. No complications were associated with the use of mitomycin-C.

Conclusions

All children treated with mitomycin-C showed early improvement in their anal size after dilatation under sedation. A single application of topical mitomycin-C allowed them to retain an increased anal diameter over time and avoid additional dilatations. Furthermore, the application of mitomycin-C in our population was straightforward and safe. Therefore, we advocate its use as an adjunct to anal dilatation under sedation in the treatment of severe anal stricture.     

食管良性狭窄的治疗

目的 探讨食管良性狭窄外科治疗的效果与经验。方法 1982年2月至2001年2月，治疗食管良性狭窄45例。手术治疗42例中局限性狭窄段食管纵切横缝1例。食管部分切除食管胃吻合术5例，结肠代食管术36例，单纯扩张治疗1例，保守治疗2例，全组中胃或空肠造瘘21例，经食管镜或胃造瘘顺行或逆行扩张11例次。结果 43例痊愈，2例保守治疗者均死亡。结论 食管良性狭窄可运用机械扩张缓解，食管腐蚀性狭窄持续扩张1年以上者，应积极手术治疗，在食管重建术中以结肠代食管术为好。     

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目的 分析胆肠吻合术治疗肝内胆管结石并胆道狭窄的选择和疗效。方法 对１９９１年９月至１９９８年１２月６９例行胆肠吻合术的肝内胆管结石并胆道狭窄病例进行总结,包括临床表现、结石部位、狭窄情况、手术方式和治疗效果等。结果 胆管狭窄主要位于１￣２级胆管内。５１例（７３．９％）行肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术,１８例（２６．１％）采用胆总管十二指肠吻合术,随访结果表明,肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合     

颅外颈动脉狭窄的支架成形术治疗

颈动脉狭窄是引起中风从而致残甚至死亡的主要原因。颈动脉内膜切除术(CEA)是公认的标准术式，但近年国内、外学者越来越多地将颈动脉支架成形术(carotid angioplasty and stenting，CAS)应用于颅外颈动脉狭窄的治疗。1980年，Kerber等首先报道应用腔内球囊扩张术治疗颈动脉狭窄。以后     

Long-term results of the treatment of male urethral stricture

The authors present 56 patients treated for urethral stricture between 1976 and 1983. Patients without recurrence of the stricture were followed for more than 5 years, the mean follow-up was 8 years +/- 2.1 (standard-deviation) (5 to 12 years). Thirty-eight patients (67.9%) had a recurrent stricture. Patient age ranged from 29 to 86 years (mean age 61 +/- 12.8 years). The best results were obtained with a one-stage anastomotic procedure and urethroplasty with foreskin graft. Patient age and topography of the stricture are not prognostic factors. Traumatic and infectious strictures have a better prognosis than other forms (the difference is statistically significant: chi-square = 3.9; P inferior to 0.05).     

Evaluation of the results of the treatment of male urethral stricture with a follow-up of more than 5 years

149 cases of urethral stricture were treated in the Urology Department from 1971 to 1984. All of these patients have therefore been treated with a minimal follow-up of 5 years. There were 87 cases of post-traumatic stricture, 53 of whom were lost to follow-up during the survey, 8 died and 26 patients were able to be reviewed. The remaining 62 cases consisted of post-infectious strictures, with 37 patients lost to follow-up during the survey, 1 patient who died and 24 patients who were reviewed. The patients reviewed were assessed according to the criteria of the SFU (French Urology Society) survey. Direct vision internal urethrotomy was performed in 33 cases with 18 very good or good results (54%), segmental resection was performed in 10 cases with 7 very good or good results, urethroplasty was performed in 4 cases with 2 good results and 2 urethral dilatations were performed with 2 good results. The failures were essentially treated by more complex surgery (urethroplasty).