Long-term follow-up after biliary stent placement for postoperative bile duct stenosis

BACKGROUND: The outcome of temporary biliary stent placement for postoperative bile duct stenosis was retrospectively evaluated with the main aim of assessing long-term complications after stent removal. METHODS: ERCP was performed between 1981 and 1991 in 74 patients with postoperative bile duct stenoses. Two 10F stents were inserted for a maximum of 12 months with stent exchange every 3 months to avoid cholangitis caused by clogging. RESULTS: Stent insertion failed in 11 patients with complete and 4 patients with incomplete biliary obstruction. Early complications occurred in 14 patients (19%) including 2 deaths. Therefore 57 patients were included in the stent phase of the study. In 10 patients the referring physician did not adhere to the treatment protocol, and nonelective stent exchange for jaundice and/or cholangitis was necessary in 7 (70%). Of the 47 patients treated according to protocol, complications developed in 40% during the period with stents in situ. Stents were eventually removed in 44 patients who were subsequently followed for a median of 9.1 years. Late complications developed in 15 patients (34%) including recurrent stenosis in 9 (20%). All cases of recurrent stenosis occurred within 2 years of stent removal. CONCLUSIONS: Endoscopic treatment is feasible in 80% of patients who undergo an ERCP for postoperative bile duct stenosis. After stent insertion and during the time with stents in situ, complications occur at a significant rate but are usually mild or reflect the patient's underlying condition. After stent removal, recurrent stenosis develops in 20% of patients within 2 years of stent removal. Endoscopic treatment should be the initial management of choice for postoperative bile duct stenosis.     

Long-term follow-up after endoscopic biliary stent placement for bile duct strictures from laparoscopic cholecystectomy

BACKGROUND/AIMS: The outcome of endoscopic biliary stent insertion for postoperative bile duct stenosis was retrospectively evaluated. METHODOLOGY: Fifty-seven patients with biliary stenosis from laparoscopic cholecystectomy were included from February 1992 to January 2000. One to three stents were inserted for an average of 12.4 months, with stent exchange every 3 months to avoid cholangitis caused by clogging. RESULTS: Successful stent insertion was achieved in 43/57 (75.4%) patients. Stent insertion failed in 10 patients with complete and in 4 patients with incomplete biliary obstruction. Early complications occurred in 4 patients. Late complications occurred in 5/43 patients. Five patients experienced recurrence of stenosis. CONCLUSIONS: Endoscopic treatment should be the initial management of choice for postoperative bile duct stenosis.     

Hepatic artery infusion of 5-FUDR after prior systemic 5-fluorouracil.

Twenty-one patients with disseminated colon carcinoma and clinically significant liver metastases were treated with 5-FUDR via hepatic artery infusion (HAI). All patients had previously received systemic chemotherapy consisting of either 5-fluorouracil aone or in combination with other agents. At the time of the initiation of the HAI, clinical disease in all patients was progressing. A PR of hepatic metastases was noted in eight patients (35%) with a median and mean duration of response of 4.5 and 5.0 months respectively. The median and mean survival from the start of HAI for responders was 8.0 and 9.0 months and for nonresponders was 1.0 and 1.6 months respectively. It appears that a significant response rate can be achieved with HAI of 5-FUDR in spite of previous exposure to fluorinated pyrimidines.     

Endoscopic management with inside stent for proximal benign biliary stricture after laparoscopic cholecystectomy

Endoscopic placement of a plastic stent is the standard drainage for a symptomatic benign biliary stricture. Although a removable fully covered self-expandable metal stent has been applied for distal benign biliary stricture, placement of a plastic stent remains the standard treatment for proximal benign biliary stricture. Placement of a plastic stent above the papilla (inside stent) is an alternative to the conventional method because of its preventive effect against the dysfunction of the stent in patients with proximal benign biliary stricture.     

Endoscopic biliary stenting for treatment of bile leakage after hepatic resection

BACKGROUND/AIMS: Persistent bile leakage after hepatic resection may cause intraperitoneal sepsis and hepatic failure. Surgical treatment for bile leakage carries a high risk. Endoscopic treatment has only infrequently been documented. METHODOLOGY: Ten patients underwent endoscopic biliary stenting without sphincterotomy for persistent (9-138 days; median, 19 days) bile leakage after hepatic resection. Bile leakage was complicated by intraperitoneal sepsis in seven patients. RESULTS: ERCP showed bile leakage from the bile duct stump in nine patients. Stent placement was successful without complications in all 10 patients. Bile leakage disappeared within 1-17 days (mean, 5 days) in all patients. After 55-91 days, the stent was removed and ERCP confirmed disappearance of the leak. No patients have developed recurrent bile leakage for a mean of 4.1 years of follow-up after stent removal. CONCLUSIONS: Endoscopic biliary stenting is a safe and effective treatment for persistent bile leakage after hepatic resection. Endoscopic treatment may eliminate the need for difficult operations in high risk postoperative cases.     

Cholangiojejunal fistula caused by bile duct stricture after intraoperative injury to the common hepatic artery

A 68‐year‐old man, admitted for the treatment of recurrent cholangitis after a pancreatoduodenectomy (PD) performed 3 years previously was diagnosed as having multiple hepaticolithiasis. On laparotomy, the hepatic artery was not recognized. The anastomosed common hepatic duct was obstructed, and a fistula had been formed between the right hepatic duct and the Roux limb of the jejunum. Lithotripsy was performed from this fistula and it was reanastomosed. Angiography was performed postoperatively and it revealed common hepatic artery injury, most likely to have occurred during the previous PD. The patient's postoperative course was uneventful and he has been asymptomatic for 8 months after the operation, indicating that reanastomosis of the fistula can be an effective method. The stricture of the anastomosis was suspected to be mainly due to cholangial ischemia, because no episode of anastomotic leak or retrograde biliary infection had occurred during the PD perioperative period. There are several reports of late stricture of anastomosis 5 or more years after cholangiojejunostomy. This patient, therefore, requires further long‐term follow up.     

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.     

Endoscopic ultrasound-guided biliary stent placement using Soehendra stent retriever.

Symptomatic bilary obstruction with duodenal nar-rowing requires either surgical or percutaneous biliary drainage procedure. We report a 54-year-old woman suffering from carcinoma of the head of pancreas, who had combined duodenal and bilary obstruction and underwent successful endoscopic ultrasound-guided transduodenal biliary stent placement.     

Role of interventional therapy in hepatic artery stenosis and non-anastomosis bile duct stricture after orthotopic liver transplantation

AIM: To analyze the clinical manifestations and the effectiveness of therapy in patients with orthotopic liver transplantation (OLT)-associated hepatic artery stenosis (HAS) and non-anastomosis bile duct stricture. METHODS: Nine cases were diagnosed as HAS and non-anastomosis bile duct stricture. Percutaneous transluminal angioplasty (PTA) was performed in four HAS cases, and expectant treatment in other fi ve HAS cases; percutaneous transhepatic bile drainage, balloon dilation, stent placement were performed in all nine cases. RESULTS: Diffuse intra-and extra-bile duct stricture was observed in nine cases, which was associated with bile mud siltation and biliary infection. Obstruction of the bile duct was improved obviously or removed. Life span/ follow-up period was 13-30 mo after PTA of four HAS cases, 6-23 mo without PTA of other fi ve cases. CONCLUSION: Progressive, non-anastomosis, and diffuse bile duct stricture are the characteristic manifestations of HAS and non-anastomosis bile duct stricture after OLT. These are often associated with bile mud siltation, biliary infection, and ultimate liver failure. Interventional therapy is signifi cantly benefi cial.     

Proximal bile duct stricture caused by a pancreatic pseudocyst: intra-operative placement of a metallic stent.

A 61 year-old man presented with a proximal bile duct stricture caused by a pancreatic pseudocyst, which is of rare occurrence. Although it could not be determined pre-operatively whether the lesion was caused by cholangiocarcinoma or inflammatory disease, a laparotomy revealed that the proximal extrahepatic bile duct was surrounded and constricted by a pancreatic pseudocyst extending into the hepatoduodenal ligament. Since the stricture was not relieved only by removing the contents of the pseudocyst and surgical biliary diversion was considered too difficult, a self-expandable metallic stent was placed intra-operatively, at the strictured site, under ultrasonic guidance, via the transhepatic approach. The post-operative course of the patient was uneventful, and he remains well 22 months after the operation. The intra-operative placement of a metallic stent into the biliary tract can be an alternative option in the relief of biliary obstruction.     

Pancreatic-duct stent placement facilitates difficult common bile duct cannulation

BACKGROUND: Cannulation of the common bile duct can be difficult in certain instances. Difficult cannulation has been demonstrated to be a risk factor for post-ERCP pancreatitis. We report a technique to facilitate difficult cannulation that uses a pancreatic-duct stent to guide biliary cannulation. METHODS: A retrospective review of all ERCPs performed at our institution from October 1, 2000 to June 30, 2004 (1638) was performed to identify all cases in which a pancreatic-duct stent was placed to guide common bile duct cannulation. Charts on these patients then were reviewed to assess cannulation success and complications. In addition, indications for the ERCP and previously failed cannulation attempts by outside physicians were documented. OBSERVATIONS: Thirty-nine patients had pancreatic-duct stents placed as an aid to guide common bile duct cannulation. Successful cannulation of the bile duct was achieved in 38 of the 39 patients (97.4%) Procedure-related pancreatitis occurred in two patients and was mild in both. There were no procedure-related deaths. CONCLUSIONS: In cases of difficult common bile duct cannulation, placement of a pancreatic-duct stent as a guide to aid common bile duct cannulation appears to be an effective and safe technique.     

Endoscopic biliary prostheses as treatment for benign postoperative bile duct strictures

We evaluated the efficacy of endoscopically placed biliary stents as treatment for 32 benign postoperative biliary strictures in 29 patients. Five patients also had bile fistulas. Stents were inserted for a mean of 162 days and then removed. ERCPs were obtained before stent insertion and again after removal. Responses were followed and categorized as excellent, good, or poor. Stent insertion was successful in 25 patients (86%), 23 of which have a mean follow-up of 19 months (range, 2 to 42 months) after stent removal. Seventy-four percent had an excellent (48%) or good (26%) response. Early postoperative strictures and fistulas responded favorably. We conclude that benign postoperative biliary strictures can be treated successfully by endoscopic prostheses.