Postoperative bile duct strictures

Opinion statement  

Endoscopic therapy for benign bile duct strictures

Endoscopic therapy was attempted in 25 patients with benign strictures of the bile duct. In 23 patients, treatment involved endoscopic balloon dilation of the stricture zone or balloon dilation plus endoprosthesis placement. In 22 of 25 patients (88%), there was benefit from the endoscopic treatment. In 20 of 23 patients, there was significant radiographic improvement (p less than 0.001) in the diameter of their stricture following endoscopic therapy. All patients with elevated liver enzymes demonstrated rapid improvement following treatment. There was no significant morbidity or mortality associated with endoscopic treatment of benign biliary tract strictures. Follow-up study (mean, 4 +/- 0.3 years) discloses no recurrence of symptoms or elevated enzymes indicative of recurrent strictures. The treatment of benign bile duct strictures by a combination therapy of balloon dilation and stent placement provides a safe and effective treatment modality and an alternative to operative intervention.     

Endoscopic management of benign bile duct strictures

Endoscopic treatment for benign biliary strictures has largely replaced surgical and percutaneous approaches because of lower morbidity and mortality. However, endoscopic therapy often requires multiple procedures and serial stenting for 1 year or longer. Although the optimal algorithm for endoscopic therapy is unknown, most experts agree that maximal dilation and stenting for a period of at least 3 months will result in the best short- and long-term outcomes. Dominant strictures related to sclerosing cholangitis are more challenging to manage and typically respond best to dilation alone or with shorter-term stent therapy. When considering endoscopic treatment, the location and etiology of the stricture have important prognostic implications that may prompt earlier referral to a different subspecialist or alter the endoscopic strategy. Newer stent technologies, such as fully covered self-expandable metallic stents, may alter the treatment paradigm, although future studies are needed before this strategy can be endorsed. This article reviews the current evidence supporting endoscopic therapy for benign biliary strictures, reviews the clinical predictors of long-term success, underscores the technical aspects of dilation and stent placement, and considers future directions for endoscopic treatment.     

Pancreatic stent placement for duct disruption

BACKGROUND: The aim of this study was to identify predictors of outcome after pancreatic duct stent placement for duct disruption. METHODS: Patients were identified from endoscopy databases. Disruption was defined by extravasation of contrast from the pancreatic duct during endoscopic retrograde pancreatography. Data collected included demographic information, imaging studies, management before and outcome after stent placement. Success was defined as resolution of the disruption clinically, on radiologic imaging, and/or at endoscopic retrograde pancreatography. RESULTS: Forty-three patients (23 women, 20 men; mean age 57 years, [SD] 15.2 years) were studied. The etiology of pancreatic duct disruption was acute pancreatitis in 24, chronic pancreatitis in 9, operative injury in 7, and trauma in 3 patients. In 25 patients there was resolution of the disruption, whereas stent therapy was unsuccessful in 16 and the outcome was indeterminate in 2 patients. On univariate analysis, stent positioned to bridge the disruption (p = 0.04) and longer duration of stent therapy (p = 0.002) were associated with a successful outcome. Female gender (p = 0.05) and acute pancreatitis (p = 0.05) were associated with a lack of success. On multivariate analysis, only the bridging stent position remained correlated to outcome. Complications occurred in 4 patients. CONCLUSIONS: A bridging stent is associated with a successful outcome after pancreatic duct stent placement for duct disruption.     

Bile duct strictures associated with hepatic arterial infusion chemotherapy

We report 6 cases of bile duct strictures in patients receiving intraarterial floxuridine chemotherapy for metastatic colon carcinoma. The computed tomographic and cholangiographic features of these cases mimic those seen with primary sclerosing cholangitis. The postulated mechanism for development of biliary strictures is direct toxicity and/or occlusion of the peribiliary vascular plexus with resultant biliary fibrosis.     

Current management of benign and malignant bile duct strictures

Benign and malignant bile duct strictures require multidisciplinary management. The radiologist, endoscopist and surgeon must assess the general conditions of the patient, as well as the etiology of the stenosis and the therapeutic options (palliative, temporal, or definitive). Stenotic injuries that maintain bilioenteric continuity are susceptible to radiologic and/or endoscopic treatment, specially benign lesions, usually appearing in the postsurgical period. Injuries with loss of continuity require surgical management in almost every case. Iatrogenic bile duct injuries with preserved continuity (Strasberg A and D) may be treated by endoscopy. Types B and C, in which a liver segment loses communication with the remaining bile tree, need surgical repair and/or resection. Complete sections of the bile ducts require surgical intervention, with hepatojejunostomy being the best choice. The use of metallic endoluminal stents is almost prohibited in these types of injuries. Benign, non-iatrogenic injuries (sclerosing cholangitis, autoimmune cholangiopathy) require surgical intervention in rare occasions. Malignant injuries are extremely aggressive and only a small percentage (less than 15%) is candidate for curative resection, which unfortunately does not preclude recurrence.     

Interventional endoscopy for benign and malignant bile duct strictures

During the past years several endoscopic and interventional techniques have been developed for the treatment of bile duct strictures and have had a strong impact on therapeutic regimens. Benign stenoses of the bile duct are mainly caused by cholecystectomy or liver resection or by inflammatory diseases. Insertion of an endoprosthesis insertion or balloon dilation is clinically successful in 60 to 90 % of these patients and will result in adequate opening of the stricture. To date, only bile duct stenosis in chronic pancreatitis are not improved satisfactorily by endoscopy. The insertion of an endoprosthesis is a cornerstone in the treatment of malignant obstructive jaundice in patients with cancer. Several comparative studies have demonstrated the advantages of self-expanding metal stents (SEMS) over plastic prostheses in terms of patency. A selective use of SEMS is mandatory, as the costs for SEMS are high and many patients with malignant jaundice will die with their first plastic prosthesis in situ without stent occlusion. In patients with hilar cholangiocarcinoma, the combination of photodynamic therapy and endoprosthesis insertion might result in a survival advantage. The use of bioabsorbable stent materials or coating of the stent with antiproliferative drugs will improve the treatment results in the future.     

Evaluation of indeterminate bile duct strictures by intraductal US

BACKGROUND: Cholangiography and tissue sampling (brush cytology, biopsy) are the standard nonsurgical techniques for determining whether a bile duct stricture is benign or malignant. The aim of this study was to determine whether intraductal US is of assistance in distinguishing benign from malignant biliary strictures. METHODS: A retrospective review was undertaken of 30 patients with indeterminate bile duct strictures who underwent ERCP and tissue sampling from September 1999 to November 2000. A 20 MHz over-the-guidewire intraductal US catheter probe was used during ERCP for further examination of the strictures. Final diagnoses of malignant strictures (18 patients) were confirmed histopathologically; confirmation of benign stricture (12 patients) was based on negative tissue sampling plus extended clinical follow-up. RESULTS: Based on retrospective blinded review, the diagnosis by ERCP was correct in 67% of patients, by tissue sampling in 68%, by combined ERCP/tissue sampling in 67%, and by intraductal US in 90% (p = 0.04 vs. ERCP/tissue sampling) of cases. No complication of intraductal US or ERCP was recorded. CONCLUSIONS: Intraductal US is safe and can improve on the ability at ERCP to distinguish benign from malignant biliary strictures.     

Pancreatic duct drainage in chronic pancreatitis.

Pancreatic duct drainage is an effective method of dealing with many of the surgical complications of chronic pancreatitis without sacrificing pancreatic endocrine or exocrine function. Between 65 and 90% of patients with intractable pain of chronic pancreatitis and a dilated pancreatic duct will have substantial pain relief with complete ductal drainage by a lateral pancreaticojejunostomy. The mortality of this procedure ranges from 0 to 5%. In spite of operation, late mortality of this disease remains high with 1/3 to 1/2 of patients dying within 10 years. Fixed biliary tract obstruction and upper gastrointestinal obstruction can also complicate chronic pancreatitis. We have combined drainage of the common bile duct and stomach with pancreaticojejunostomy to deal with these problems and have found no increase in morbidity or mortality. Pseudocysts occur more frequently in patients with chronic pancreatitis. We have also combined pseudocyst drainage with lateral pancreaticojejunostomy in 26 patients having both pseudocysts and chronic pancreatitis. These patients achieve the same degree of pain relief noted in patients undergoing lateral pancreaticojejunostomy alone without any increase in morbidity or mortality. Drainage procedures are safe and effective and are our preferred method of dealing with obstructive complications of chronic pancreatitis.     

Intraductal optical coherence tomography for investigating main pancreatic duct strictures

BACKGROUND AND STUDY AIMS: Optical coherence tomography (OCT) permits high-resolution imaging of tissue microstructures using a probe that can be inserted into the main pancreatic duct (MPD) through a standard endoscopic retrograde cholangiopancreatography (ERCP) catheter. This prospective study was designed to assess the diagnostic capacity of OCT to differentiate between nonneoplastic and neoplastic lesions in patients with MPD segmental strictures. PATIENTS AND METHODS: Twelve consecutive patients with documented MPD segmental stricture were investigated by endoscopic ultrasonography (EUS), with fine-needle aspiration cytology if necessary, and ERCP, followed by brush cytology and OCT scanning. RESULTS: OCT recognized a differentiated three-layer architecture in all cases with normal MPD or chronic pancreatitis, while in all the neoplastic lesions the layer architecture appeared totally subverted, with heterogeneous backscattering of the signal. The accuracy of OCT for detection of neoplastic tissue was 100% compared with 66.7% for brush cytology. In one case, neither OCT scanning nor brush cytology was possible because of the severity of the stricture. CONCLUSIONS: This pilot study showed that OCT is feasible during ERCP, in cases of MPD segmental stricture, and was superior to brush cytology in distinguishing nonneoplastic from neoplastic lesions.     

Endoscopic ultrasound and fine-needle aspiration of unexplained bile duct strictures

OBJECTIVES: The aim of this study was to assess the utility of endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) in patients with unexplained common bile duct strictures after endoscopic retrograde cholangiopancreatography (ERCP) and intraductal tissue sampling. METHODS: Records were reviewed for all subjects undergoing EUS for evaluation of unexplained bile duct strictures at our institution. 40 subjects had either a final histologic diagnosis (24) or no evidence of malignancy after at least 1 yr of follow-up (16). RESULTS: The finding of a pancreatic head mass and/or an irregular bile duct wall had sensitivity for malignancy of 88%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 84%. Bile duct wall thickness >/=3 mm had a sensitivity for malignancy of 79%, specificity of 79%, positive predictive value of 73%, and negative predictive value of 80%. Sensitivity of EUS FNA for malignancy was 47% with specificity 100%, positive predictive value 100%, and negative predictive value 50%. CONCLUSIONS: Sonographic features may be more sensitive than EUS FNA for diagnosis of unexplained bile duct strictures and include presence of a pancreatic mass, an irregular bile duct wall, or bile duct wall thickness > 3 mm. EUS FNA cytology is specific but insensitive for diagnosis. EUS improves the diagnosis of otherwise unexplained bile duct strictures.     

内镜治疗术后胆漏和继发胆管狭窄

目的 探讨内镜治疗手术后并发胆漏和继发胆管狭窄的方法及效果。方法 胆漏患 者均先行内镜下十二指肠乳头切开,行鼻胆管引流术,继续保留原有胆道、腹腔引流。待胆道、腹腔引 流停止1-2周证实胆漏愈合后拔管,伴有胆道狭窄的患者在拔除鼻胆引流管后置入塑料内支架,持 续扩张2-3个月。结果 22例胆漏患者鼻胆引流3-4周后胆漏处均闭合,13例胆管狭窄置入内支 架者,10例支架取出后狭窄解除,2例合并肝总管狭窄者经重新置入双支架3个月后效果良好,1例 左肝管狭窄伴结石者,再置入单支架,术后仍有胆道感染症状反复出现。结论 内镜治疗可列为手术 后胆漏或继发胆管狭窄治疗的首选方法。     

Benign pancreatic duct strictures: medical and endoscopic therapy.

Pancreatic duct strictures usually reflect underlying pancreatic disease and are likely caused by one or more of the following: acute or chronic pancreatitis, benign or malignant pancreatic neoplasm, pseudocyst and trauma. The characteristics of pancreatic strictures are identified, and medical and endoscopic therapy options are reviewed.     

Value of exfoliative cytology for investigating bile duct strictures.

The cause of a biliary tract stricture may be difficult to determine radiologically. Exfoliative biliary cytology was evaluated in 62 patients (median age 65 years, range 30-94) with biliary tract strictures presenting to the Hepatobiliary Unit between January 1984 and December 1989. Bile samples were taken during endoscopic retrograde cholangiopancreatography (ERCP) in 42 patients, percutaneous cholangiography in 14, and both in six. The site of stricturing was upper third of the bile duct in 43% (n = 27), middle third in 10% (n = six), and lower third in 47% (n = 29). Of the 47 patients with radiological appearances of a malignant stricture, 22 (47%) had histological confirmation by biopsy either under computed tomography guidance, at endoscopy, at operation, or at necropsy. Fourteen of the 47 patients had positive cytology (30%). In seven patients cytology alone established the presence of malignancy (15%) and in the other seven positive cytology was confirmed by histology. The addition of cytology to tissue biopsy therefore allowed malignancy to be confirmed in 29 of the 47 patients (62%). None of the 15 patients subsequently shown to have benign disease had positive cytology. Sensitivity of the technique was 30% and specificity 100%. Samples for exfoliative cytology are simple to obtain, the results are highly specific and should be a routine part of the investigation of biliary strictures.