Percutaneous fibercholangioscopies

This is a report on our experience in 309 percutaneous fiberendoscopies of the biliary tract done in 106 patients of the 115 scheduled for the procedure. We describe the relevant approaches, techniques, complications and results. In particular, percutaneous transhepatic cholangioscopies (PTCS) were accomplished on transhepatic percutaneous drainages located radiologically in 35 patients: in 13 for differential diagnosis to distinguish between malignant and benign stenoses (diagnostic accuracy in 92% of the biopsies), in 22 cases with therapeutic intent, including 14 lithotomies for extrahepatic biliary tract calculosis, combined in 4 cases with a simple dilatation of the papilla and a percutaneous "descending" papillotomy; in 7 patients a dilatation of the biliary tract (BT) or of the stenosis of a biliodigestive anastomosis was accomplished (malignant in 4 patients, benign in 3 patients). In 38 patients postoperative percutaneous transhepatic cholangioscopies were performed along surgically located transparietohepatic drains, both to assess the biliodigestive anastomosis healing process carried out by two different techniques (30 patients), and to complete the biliary tract drainage as part of the primary and secondary endoscopic surgical treatment of massive intrahepatic lithiasis. In two further patients affected by such pathology, PTCS was done in combination with fibercholangioscopy performed via a transjejunal approach using a V?lker drain on a Y-shaped loop. Nine of these patients were treated successfully and one patient later underwent a left hepatectomy, since attempts to drain that area had remained unsuccessful. The transjejunal approach was carried out in 3 patients as a diagnostic measure: in two cases to check the lithotomy, and in one case to check a cholangiojejunal anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

An endoscopic approach to biliary complications following orthotopic liver transplantation

Abstract: Biliary complications following orthotopic liver transplantation (OLT) may be associated with significant morbidity and mortality. In this report, we reviewed our endoscopic experience of managing post OLT biliary complications in 79 patients over a 12‐year period. Methods: OLT (n = 423) recipients between 10/86 and 12/98 were obtained from the transplant registry at the Johns Hopkins Hospital. OLT recipient who underwent at least one endoscopic retrograde cholangiography (ERC) were identified through a radiology database. Indications, findings and interventions performed were noted for each ERC report. Outpatient and inpatients medical records were reviewed for outcome and complications. Results: Seventy‐nine (79/423, 18.7%) patients had at least one ERC for suspected biliary complication. Sixty‐four (15.1%) patients had at least one or more biliary complications. The mean follow‐up for patients with abnormal ERC was 33.9 months. Nineteen patients had bile leaks; 10 of these patients had leak at the exit site of the T‐tube and five patients had at the anastomosis. Biliary stenting with or without endoscopic sphincterotomy led to resolution of bile leak in 16 patients. Three patients failed endoscopic therapy: one underwent surgery and two had percutaneous drainage. Twenty‐five patients presented with biliary strictures. Nineteen strictures were at the anastomotic or just proximal to the anastomosis, one at the hilum (ischemic in nature) and three were at the distal, recipient common bile duct; one had strictures at the anastomosis as well as the distal recipient bile duct and another had diffuse intrahepatic strictures. Seventeen patients in the stricture group improved with endoscopic intervention. One patient was re‐transplanted (diffuse intrahepatic strictures), but no patient underwent percutaneous drainage. Conclusions: ERC is safe and effective in the diagnosis and management of biliary complications following liver transplantation with choledochocholedochal anastomosis and obviates the need for surgical or percutaneous transhepatic approaches in majority of cases.     

Biliary guidewire facilitates bile duct biopsy and endoscopic drainage

BACKGROUND: The introduction of a guidewire through bile duct strictures may facilitate transpapillary bile duct biopsy and subsequent biliary drainage. METHODS: Endoscopic bile duct biopsy was attempted in 61 patients with bile duct strictures. After the introduction of a guidewire into the bile duct, biopsy forceps were inserted via the papilla. Both devices were inserted through the working channel (3.2 mm in diameter) of a conventional duodenoscope. After the procedure, an endoscopic naso-biliary drainage catheter was advanced along the guidewire. The success rate of inserting the biopsy forceps, the sensitivity of the biopsy, and the success rate of endoscopic biliary drainage after the biopsy were analyzed prospectively. RESULTS: The final diagnosis was malignant strictures in 50 patients and benign strictures in 11. The success rate of inserting biopsy forceps without performing endoscopic papillary balloon dilation was 85%. The sensitivity of the biopsy for primary bile duct cancer (83%) was significantly higher (P < 0.05) than that of pancreatic cancer (47%). All patients had successful endoscopic biliary drainage after the procedure. CONCLUSION: A previously placed guidewire facilitates insertion of biopsy forceps and endoscopic biliary drainage. The histological diagnosis of cancer is more likely with bile duct cancer than with pancreatic cancer.     

Percutaneous treatment of intrahepatic lithiasis]

AIM: To present our experience with percutaneous intracorporeal electrohydrolic lithotripsy in the treatment of intrahepatic lithiasis.SUBJECTS AND METHODS: From January 1989 to November 1998, 53 patients with intrahepatic lithiasis were treated with percutaneous intracorporeal electrohydrolic lithotripsy. Twenty-six patients had primary intrahepatic lithiasis. Intrahepatic stones were associated with intrahepatic duct abnormalities in 11 patients, 9 had strictures and 2 had cystic dilatations. Twenty-seven patients had secondary intrahepatic lithiasis formed a biliodigestive bypass in 20 patients. Intracorporeal electrohydrolic lithotripsy was performed under cholangioscopic guidance in all patients. The endoscope was introduced into the biliary ducts through a cutaneobiliary tract in 51 patients, through a cutaneocholecystic tract in one and through a cutaneojejunal tract in one. These tracts were created and gradually dilated in two sessions three days apart. In twenty-two patients stenosis or sharp angulation prevented adequate positioning of the scope which was only successful after balloon dilation or insertion of a stiff wire.RESULTS: Complete clearance of stones was achieved in 49 patients (92%). Biliary or hepaticojejunostomy strictures were successfully dilated with an angioplasty balloon in all patients. Ten patients (19%) had early complications: four had bilomas treated by percutaneous drainage, three had resolutive onset of cholangitis, two had transient arterial hemobilia, and one had a pneumothorax. The mean duration of follow-up was five years. During this period, 5 patients (9%) had recurrent symptoms of biliary obstruction. Among these patients, three (5.7%) had recurrent symptomatic intrahepatic lithiasis, one had a recurrent biliary stricture and one had secondary sclerosing cholangitis. Treatment of recurrent stones was repeated intracorporeal electrohydrolic lithotripsy in two and left hepatectomy in one; recurrent biliary stricture was treated by hepaticojejunostomy and secondary sclerosing cholangitis by antibiotics.CONCLUSION: Intracorporeal electrohydrolic lithotripsy is effective and safe and should be proposed as the first line treatment of primary or secondary intrahepatic lithiasis.     

Tumor vessel: a valuable cholangioscopic clue of malignant biliary stricture

BACKGROUND: An irregularly dilated and tortuous vessel, the so-called tumor vessel, is considered to be one of the cholangioscopic features that suggest biliary malignancy. This is a prospective analysis of the presence of a tumor vessel as a finding that discriminates between benign and malignant biliary strictures. METHODS: From August 1997 to August 1998, a total of 63 patients with biliary strictures diagnosed with endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography obtained during percutaneous transhepatic biliary drainage tube placement were included in this study. Strictures were characterized as benign or malignant based on the observation of tumor vessels. The results were compared with those of percutaneous transhepatic cholangiography-guided biopsy and final diagnosis. RESULTS: Forty-one patients were confirmed to have malignant strictures and 22 had benign biliary strictures. Cancer was confirmed by histopathologic evaluation of biopsies in 33 of 41 patients with malignancy (80.4%). Tumor vessel was seen in 25 of 41 patients with malignancy (61%). No patients with benign stricture had tumor vessels. Of the 8 patients with negative percutaneous transhepatic cholangioscopy-guided biopsies but with a final diagnosis of malignancy, 6 had tumor vessels. Combining the observation of tumor vessel and percutaneous transhepatic cholangiography-guided biopsy resulted in a diagnosis of malignancy in 39 of 41 patients (96%) and significantly increased the rate of preoperative diagnosis when compared with percutaneous transhepatic cholangiography-guided biopsy or presence of tumor vessel alone (p<0.05). CONCLUSION: The presence of tumor vessel may be a valuable cholangioscopic finding that indicates the presence of a malignant biliary stricture. The combination of tumor vessel observation and percutaneous transhepatic cholangiography-guided biopsy may improve the preoperative diagnosis of malignancy.     

A case of biliary cast syndrome after cadaveric liver transplantation]

We experienced one fatal case of biliary cast syndrome after cadaveric liver transplantation involving both intrahepatic ducts. A 58-year-old man underwent cadaveric liver transplantation because of hepatitis B virus related liver cirrhosis and concomitant hepatocellular carcinoma. Five weeks after the liver transplantation, postoperative course was complicated by development of acute cholangitis. Subsequent endoscopic retrograde cholangiography revealed diffuse intrahepatic bile duct strictures without filling defects. Percutaneous liver biopsy, which was done to exclude rejection, revealed biliary cast. Successful endoscopic removal was precluded due to its diffuse involvement. Because of the deterioration of patient's condition by refractory biliary obstruction and cholangitis, retransplantation from cadaveric donor was performed. Debridement of the biliary tree after graft removal yielded a near-complete cast of the intrahepatic ductal system. Biliary cast syndrome should be suspected when jaundice or cholangitis is associated with dilated ducts on abdominal imaging studies in cadaveric liver transplantation recipients. Initial therapeutic options include removal of biliary cast after endoscopic or percutaneous cholangiography. Although endoscopic retrieval of biliary cast by endoscopic retrograde cholangiopancreatography could be employed as a first-line management, other modalities such as endoscopic nasobiliary drainage, percutaneous transhepatic drainage, or retransplantation should be considered when complete removal is not feasible and the condition of the recipient deteriorates.     

Stenosis of the left hepatic duct with intrahepatic lithiasis: treatment by the percutaneous transhepatic approach

The authors report the case of a 78-year-old woman suffering from cholangitis secondary to intrahepatic biliary stricture and intrahepatic lithiasis. Successful management consisted of successive percutaneous transhepatic internal-external biliary drainage, balloon dilatation of the stricture and gallstone mobilisation and removal through the stricture. No complications were noted.     

Expandable Metallic Stents: in the Benign Strictures of Intrahepatic Ducts in Patients with Primary Intrahepatic Stones

Abstract: In Korea there is a prevalence for primary intrahepatic stones. Patients with primary intrahepatic stones and oriental cholangiohepatitis ofen have accompanying intrahepatic strictures. Despite complete removal of the intrahepatic stones, sustained intrahepatic strictures will evoke bile stasis and impairment of liver function. So the correction of intrahepatic strictures in addition to the removal of the stones is important in the management of primary intrahepatic stones. We inserted self-expandable metallic stents in 16 patients with primary intrahepatic stones for the correction of intrahepatic strictures after complete removal of their intrahepatic stones. All of the patients had a previous history of abdominal surgery for the removal of intrahepatic stones. The criteria for insertion of expandable metallic stents was recurrent stenosis after successful balloon dilatation. The metallic stents inserted were Gianturco-Rosch stents (24F) and the stents were inserted via a T-tube or percutaneous transhepatic biliary drainage (PTBD) track. In the follow-up period of an average of 12 months (9–15 months), 14 (88%) out of 16 patients experienced relief of pruritus and improved liver function. But two patients (12%) with secondary biliary cirrhosis showed no improvement of their clinical symptoms and signs. In conclusion, these findings suggest that expandable metallic stents will be useful in the management of intrahepatic strictures, which recurred after successful balloon dilatation, in patients with primary intrahepatic stones.     

Endoscopic biliary drainage in patients with amebic liver abscess and biliary communication.

BACKGROUND: Percutaneous drainage or surgery is required when amebic liver abscess (ALA) fails to respond to medical management. In some of these patients, non-response may be due to communication of ALA with the biliary tree. This report describes our experience with the use of endoscopic biliary draining in such patients. METHODS: Medical records of patients with ALA undergoing either needle aspiration or percutaneous pigtail drainage were retrieved; the indications for drainage were: abscess volume exceeding 250 mL, a thin rim of tissue (< 1 cm thick) around the abscess, systemic toxic features and failure to improve on medical treatment. Patients with abscess drain output >25 mL/day persisting for 2 weeks or presence of bile in the drain fluid underwent endoscopic biliary drainage. RESULTS: A total of 115 patients with ALA underwent percutaneous treatment. None of the 25 patients with needle aspiration needed any further treatment. Of the 90 who underwent catheter drainage, the catheter could be removed within one week in 77 patients; the remaining 13 patients (median age 42 years, range 24-65; all men) had an abscess-biliary communication. In them, the median catheter output was 88 mL/day (range 45-347) and 54 mL/day (28-177) at 2 days and 2 weeks after catheter placement. The drain fluid contained bile in all 13 patients and in addition contained pus in 10 patients. Eleven patients had a solitary abscess and two had multiple abscesses. Cholangiogram showed biliary communication in all 13 patients. All patients were treated with placement of 10F biliary endoprosthesis or 10F nasobiliary drain. Pigtail catheter was removed within 1 week in 11 of 13 patients. CONCLUSION: In patients with amebic liver abscess communicating with the biliary tree, biliary stenting may hasten clinical recovery and allow early removal of liver abscess catheter drain.     

Percutaneous endoscopic management of intrahepatic stones in patients with altered biliary anatomy: A case series

Incidence of primary intrahepatic stones (IHS) in India is very less as compared to the Far East. However patients with altered biliary anatomy are prone for IHS formation secondary to anastomotic stricture formation. Indian data on percutaneous endoscopic management of IHS is scare. Five patients with IHS were managed percutaneously. All patients had undergone Roux-en-Y hepaticojejunostomy and were not suitable for direct endoscopic intervention. All patients underwent percutaneous biliary drainage followed by cholangioscopy-guided laser lithotripsy. Crushed stones were pushed across the anastomotic site using basket/balloon and ductal clearance was achieved. Good stone pulverization could be achieved in five patients (100 %). Complete ductal clearance could be achieved in all patients (100 %). Cholangioscopy-guided treatment of IHS can be valuable alternative to surgery in select group of patients especially those having dilated biliary tree with absence of intrahepatic strictures. However long-term follow up studies are required to see for recurrence of stone formation.     

ERCP and pyogenic liver abscess.

BACKGROUND: Liver abscess is commonly biliary in origin. We assessed the role of endoscopic retrograde cholangiopancreatography (ERCP) in patients with pyogenic liver abscesses. METHODS: Between January 1986 and December 1997, 63 patients with pyogenic liver abscesses were referred for ERCP. Twenty-one patients had a history of previous biliary procedures including cholecystectomy (21), biliary-enteric bypass (9), surgical sphincteroplasty (5), and endoscopic sphincterotomy (2). Demographic data, clinical features, biochemical parameters, treatment, clinical progress, and follow-up were recorded and analyzed. RESULTS: Two patients required laparotomy and 61 patients underwent guided aspiration and/or drainage at a median interval of 3 days after presentation. ERCP was performed at a median of 8 days (range 1 to 69 days) after initial treatment and succeeded in 90% of cases with no associated complication or death. Abnormalities were shown in 29 (46%) patients: biliary obstruction due to stones or strictures (15), ductal dilatation alone (7), spontaneous choledochoduodenal fistula (3), communication between abscesses and biliary tree (3), and splaying of biliary ducts by space-occupying effect (2). No abnormality was found in 34 patients. Eight patients underwent endoscopic therapy including sphincterotomy (5), stone extraction (6), and nasobiliary drainage (2). Overall mortality rate from liver abscesses was 6%. CONCLUSIONS: ERCP is useful in the treatment of patients with pyogenic liver abscesses.     

Endoscopic drainage of pyogenic liver abscesses with suspected biliary origin

OBJECTIVES: Pyogenic liver abscesses remain an important and life-threatening clinical problem but their causes and management have changed over the last two decades. The aim of this study was to assess the feasibility and the impact of an endoscopic approach in the management of liver abscesses with suspected biliary origin. METHODS: We reviewed the records of 16 patients suffering from pyogenic liver abscess, who underwent endoscopic retrograde cholangiopancreatography (ERCP) in the setting of biliary diseases between January 1995 and December 2004. Nine patients had an underlying neoplastic disease; 13 had a history of biliary endoscopic maneuvers. When the collections were communicating with the biliary tree, an endoscopic drainage of the abscess was performed either by sphincterotomy, dilation, insertion of a nasobiliary catheter, or stenting. In noncommunicating liver abscesses associated with bile duct abnormalities, biliary decompression was obtained by insertion or replacement of biliary stents. RESULTS: Fourteen patients had liver abscesses communicating with the biliary system and underwent an endoscopic drainage of the cavity. Ten of these patients had an exclusive endoscopic drainage of the abscess, while four cases required additional percutaneous drainage. The two noncommunicating abscesses were associated with previous insertion of biliary stents; these were cured percutaneously after endoscopic stent replacement. Among the 16 patients, 13 had a rapid resolution of symptoms (81%). CONCLUSION: This initial clinical experience suggests that ERCP can demonstrate communications between the biliary tract and liver abscesses, and that an internal drainage of the cavity is feasible and safe.     

Biochemical and radiological predictors of malignant biliary strictures

AIM: Differentiation of benign biliary strictures (BBS) from malignant biliary strictures (MBS) remains difficult despite improvement in imaging and endoscopic techniques. The aim of this study was to identify the clinical, biochemical and or radiological predictors of malignant biliary strictures.METHODS: We retrospectively reviewed all charts of patients who had biliary strictures (BS) on endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous cholangiography (PTC) in case of unsuccessful ERCP from March 1998 to August 2002. Patient characteristics, clinical features, biochemical, radiological and biopsy results were all recorded. Stricture etiology was determined based on cytology,biopsy or clinical follow-up. A receiver operator characteristic (ROC) curve was constructed to determine the optimal laboratory diagnostic criterion threshold in predicting MBS.RESULTS: One hundred twenty six patients with biliary strictures were enrolled, of which 72 were malignant. The mean age for BBS was 53 years compared to 62.4 years for MBS (P=0.0006). Distal bile duct stricture was mainly due to a malignant process 48.6% vs 9% (P=0.001). Alkaline phosphates and AST levels were more significantly elevated in MBS (P=0.0002). ROC curve showed that a bilirubin level of 84 μmol/L or more was the most predictive of MBS with a sensitivity of 98.6%, specificity of 59.3% and a positive likelihood ratio of 2.42 (95% CI=0.649-0.810). Proximal biliary dilatation was more frequently encountered in MBS compared to BBS, 73.8% vs39.5% (P=0.0001). Majority of BBS (87%) and MBS (78%) were managed endoscopically.CONCLUSION: A serum bilirubin level of 84 μmol/L or greater is the best predictor of MBS. Older age, proximal biliary dilatation, higher levels of bilirubin, alkaline phosphatase, ALT and AST are all associated with MBS. ERCP is necessary to diagnose and treat benign and malignant biliary strictures.     

Late postoperative complications in patients with pancreaticobiliary maljunction

BACKGROUND/AIMS: Reports on the late postoperative complications in patients with pancreaticobiliary maljunction (PBM) are limited. METHODOLOGY: Eighteen PBM patients with biliary dilatation and 12 without biliary dilatation were surgically treated at our institute. These 30 PBM patients were retrospectively reviewed, with particular attention to late postoperative complications. RESULTS: Nineteen patients without biliary malignancies underwent resection of the extrahepatic bile duct (BD) and hepaticojejunostomy. Two patients without biliary dilatation or malignancy underwent cholecystectomy alone. Nine patients with malignancies underwent hepatectomy with extrahepatic BD resection in 7 patients, pancreatoduodenectomy (PD) in 1, and PD + hepatectomy in 1. The median follow-up duration was 110 months. All patients without malignancies are presently alive in good healthy condition and have not developed any malignancy postoperatively. Late postoperative complications were seen in 6 (20%). Four patients with biliary dilatation were surgically or endoscopically treated for intrahepatic lithiasis 3, 12, 42 and 54 months after initial operation. One of them had a pancreatic protein plug 216 months after surgery, and was treated with papilloplasty after open laparotomy. In one patient without biliary dilatation, pancreatic protein plug and intrahepatic lithiasis were found 60 and 72 months after surgery, respectively, and both were treated endoscopically. CONCLUSIONS: Intrahepatic lithiasis and pancreatic protein plug are frequent late postoperative complications. The intrapancreatic residual choledochus or dilated pancreatic duct seems to be related to pancreatic protein plug. However, intrahepatic lithiasis may occur regardless of the pattern of the biliary tract dilatation. Careful, long-term follow-up is important in patients with PBM.     

Role of multi-detector computed tomography for biliary complications after liver transplantation

AIM: To investigate the diagnostic performance of multi-detector computed tomography (MDCT) in detecting biliary complications after orthotopic liver transplantation (OLT).METHODS: Eighty-three consecutive OLT recipients, who presented with clinical or biochemical signs of biliary complications, underwent MDCT examination. Two experienced radiologists assessed MDCT images in consensus to determine biliary complications. Final confirmation was based on percutaneous transhepatic cholangiography or endoscopic retrograde cholangiography in 58 patients, surgery in four patients, liver biopsy in 10, and clinical and sonography follow-up in 11 patients.RESULTS: Biliary complications were eventually confirmed in 62 of 83 patients (74.7%), including anastomotic biliary strictures in 32, nonanastomotic biliary strictures in 21, biliary stones in nine (5 with biliary strictures), anastomotic bile leak in five, and biloma in six (all with nonanastomotic strictures, and 2 with biligenic hepatic abscess). Twenty-one patients had no detection of biliary complications. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of MDCT for detecting biliary strictures were 90.6%, 86.7%, 89.2%, 92.3% and 83.9%, respectively. For detecting biliary stones, anastomotic bile leak and biloma, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of MDCT were all 100%.CONCLUSION: MDCT is a useful screening tool for detecting biliary complications after OLT.     

Endoscopic biliary stenting in a district general hospital.

During a 48 month period to December 1990, 367 patients, median age 75 years, with obstructive jaundice caused by common bile duct stones (201), malignant biliary obstruction (148), and benign biliary strictures (18), underwent therapeutic endoscopic retrograde cholangiopancreatography. Endoscopic biliary stenting and drainage was achieved in 343 of 367 patients attempted (93%), seven patients requiring a combined percutaneous endoscopic approach. Endoscopic stenting failed in 24 patients because of malignant duodenal infiltration (10), Billroth 2 gastrectomy (6), tight and extensive biliary strictures (6), peripapillary diverticulum (1), and technical failure (1). Prolonged follow up was available in 91% (311 of 343). The 30 day mortality was 5% (17 of 343), which included two procedure related deaths (0.6%) from fulminant pancreatitis and major sphincterotomy site bleeding. Early complications occurred in 14% (48 of 343) and late complications occurred in 11.9% (35 of 294) patients, as of the original 343, 17 had died within 30 days and another 32 were lost to follow up. Eighty patients with incomplete bile duct clearance and eight patients with benign biliary strictures had biliary stents inserted for 12-48 months (median 30). Endoscopic biliary stenting services are necessary in a district general hospital with technical success, death and morbidity rates comparable to other studies.     

Use of a modified angioplasty balloon catheter in the dilatation of tight biliary strictures.

Nineteen biliary strictures were dilated using a modified angioplasty balloon catheter to allow insertion of a 10F prosthesis. In each instance biliary strictures were successfully dilated which had previously been too tight to widen with standard endoscopic biliary dilating catheters. Eleven patients had malignant hilar strictures, four malignant distal common bile duct strictures, and four benign strictures. There were no complications as a result of the procedure and satisfactory biliary drainage was established in all patients. We conclude that tight biliary strictures can be successfully dilated using a modified angioplasty balloon catheter.     

The combination of stricture dilation, endoscopic needle aspiration, and biliary brushings significantly improves diagnostic yield from malignant bile duct strictures.

BACKGROUND: Brush cytology, routinely performed at ERCP to assess malignant-appearing biliary strictures, is limited by relatively low sensitivity and negative predictive value. This study assessed whether the combination of stricture dilation, endoscopic needle aspiration, and biliary brushing improves diagnostic yield. METHODS: In a prospective nonrandomized study, 46 consecutive patients were evaluated with malignant-appearing biliary strictures at ERCP. Twenty-four patients (Group A) underwent standard brush cytology alone and 22 patients (Group B) underwent stricture dilatation to 10F, endoscopic needle aspiration, and subsequent biliary brushing by using the Howell biliary system. The diagnostic yields for both techniques were compared. RESULTS: Of the 46 patients, 34 had proven malignant strictures (14 Group A, 20 Group B). Compared with brushing alone, the combination of stricture dilatation, endoscopic needle aspiration, and subsequent biliary brushing significantly increased both the sensitivity (57% vs. 85%, p < 0.02) and specificity (80% vs. 100%, p < 0.02) of cytology with positive brushings in all patients with pancreatic or gallbladder carcinoma. CONCLUSIONS: The combination of stricture dilation, endoscopic needle aspiration, and biliary brushing significantly improves diagnostic yield for malignant bile duct strictures and may particularly be of benefit for extrinsic strictures caused by pancreatic or gallbladder carcinoma.     

胆道支架移位在胆道良性疾病中的影响因素

目的:探讨胆道良性狭窄中胆道塑料支架移位的影响因素.方法:回顾性分析2005-01/2009-12 244例因胆道良性狭窄在天津市南开医院进行内镜逆行胆管内支架引流术(endoscopic retrogradebiliary drainage,ERBD)的病例资料、记录狭窄的原因、部位,支架的长度和数量,支架移位的方向...     

Biliary Tract Obstruction Secondary to Malignant Lymphoma: Experience at a Referral Center

Lymphoma is a rare cause of biliary obstruction and, on cholangiography, may mimic other causes of obstructive jaundice. The optimum treatment for these patients is unclear. The aim of this study is to evaluate the incidence, clinical and imaging findings, management, and outcome of biliary obstruction caused by lymphoma. Our database was searched retrospectively for patients with biliary obstruction due to lymphoma between 1999 and 2005. Biliary obstruction secondary to lymphoma was found in 7 (0.6%) of 1123 patients with malignant biliary obstruction. One patient had benign biliary obstruction related to lymphoma. Of the eight patients (five male, three female; mean age, 34.50 ± 17.93 years), four had Hodgkin’s disease and four had non-Hodgkin’s lymphoma. Biliary obstruction occurred as part of the initial or early presentation of lymphoma in two patients. The most common cause of obstruction was compression of the biliary tract by enlarged lymph nodes (six patients). Cholangiographic appearances were diverse: narrowing of the common bile duct (six patients), splayed and narrowed common bile duct (one patient), and multiple strictures and dilatations of the intrahepatic bile ducts (one patient). Biliary drainage was performed in all patients including endoscopic stent placement in six patients, nasobiliary drainage in one, and choledochoduodenostomy in one. Hyperbilirubinemia resolved in all but one of the patients with a stent; however, none could be maintained in a stent-free condition. Five patients died within 1 year after onset of jaundice. One of the surviving patients developed a late benign stricture at the site of the earlier lymphoma. We conclude that lymphoma should be considered in the differential diagnosis of obstructive jaundice, particularly in younger patients. We suggest that biliary drainage by the endoscopic or percutaneous route is necessary for the treatment of these patients. Late benign strictures may develop. Biliary obstruction is a sign of poor prognosis in lymphoma.