Efficacy of multiple biliary stenting for refractory benign biliary strictures due to chronic calcifying pancreatitis

AIM To investigate endoscopic therapy efficacy for refractory benign biliary strictures(BBS) with multiple biliary stenting and clarify predictors.METHODS Ten consecutive patients with stones in the pancreatic head and BBS due to chronic pancreatitis who underwent endoscopic therapy were evaluated. Endoscopic insertion of a single stent failed in all patients. We used plastic stents(7F, 8.5F, and 10F) and increased stents at intervals of 2 or 3 mo. Stents were removed approximately 1 year after initial stenting. BBS and common bile duct(CBD) diameter were evaluated using cholangiography. Patients were followed for ≥ 6 mo after therapy, interviewed for cholestasis symptoms, and underwent liver function testing every visit. Patients with complete and incomplete stricture dilations were compared.RESULTS Endoscopic therapy was completed in 8(80%) patients, whereas 2(20%) patients could not continue therapy because of severe acute cholangitis and abdominal abscess, respectively. The mean number of stents was 4.1 ± 1.2. In two(20%) patients, BBS did not improve; thus, a biliary stent was inserted. BBS improved in six(60%) patients. CBD diameter improved more significantly in the complete group than in the incomplete group(6.1 ± 1.8 mm vs 13.7 ± 2.2 mm, respectively, P = 0.010). Stricture length was significantly associated with complete stricture dilation(complete group; 20.5 ± 3.0 mm, incomplete group; 29.0 ± 5.1 mm, P = 0.011). Acute cholangitis did not recur during the mean follow-up period of 20.6 ± 7.3 mo.CONCLUSION Sequential endoscopic insertion of multiple stents is effective for refractory BBS caused by chronic calcifying pancreatitis. BBS length calculation can improve patient selection procedure for therapy.     

Spontaneous regression of a pancreatic head mass and biliary obstruction due to autoimmune pancreatitis.

BACKGROUND: Autoimmune pancreatitis is an evolving entity. METHODS: A patient who had spontaneous regression of a pancreatic head mass and biliary obstruction due to autoimmune pancreatitis is presented. RESULTS: A 58-year-old diabetic woman with jaundice was referred for pancreatic head carcinoma diagnosed by magnetic resonance imaging (MRI). At laparotomy, a pancreatic head mass (4 x 3 cm) that involved the transverse mesocolon and two other hard masses (1 cm) in the pancreatic body and tail were found. The gallbladder was palpated as a hard tumor mass. Frozen section examination of the gallbladder and pancreatic biopsies revealed cholecystitis and pancreatitis with lymphoplasmacytic infiltration. The common bile duct was brittle and unsuitable for anastomosis. Starting 1 month after the operation, drainage from the biliary catheter decreased gradually and stopped. There was no parenchymal lesion on MRI examination in the 2nd postoperative month. Cholangiography from the percutaneous catheter showed flow of contrast agent into the duodenum. Serum immunoglobulin G, G4 and E levels were increased. CONCLUSION: To the best of our knowledge, this is the first report of spontaneous regression of a pancreatic head mass and biliary obstruction due to autoimmune pancreatitis.     

New canine model of chronic pancreatitis due to chronic ischemia with incomplete pancreatic duct obstruction

A new experimental model of chronic pancreatitis was produced by a combination of chronic ischemia and incomplete obstruction of the pancreatic duct. Ischemia was induced by ligation and separation of branches flowing into the left pancreatic lobe from the splenic artery. Incomplete ductal obstruction was achieved by ligation and separation of the minor pancreatic duct and placement of a polyethylene tube in the major pancreatic duct. Macroscopic examination at 6 months after model preparation showed that the pancreas was hard, with severe inflammatory change. In the secretin test, the flow rate of pancreatic juice, amylase output and bicarbonate concentration were significantly reduced as compared with the controls. Pancreatography revealed dilatation and meandering of the major pancreatic duct and poor visualization of its secondary and tertiary bifurcations. The histopathological findings consisted of a decrease in the pancreatic parenchyma, replacement of fat, severe inflammatory cell infiltration, extensive fibrosis and tubular complexes. This model most closely resembles human chronic pancreatitis, and is a very useful instrument.     

Pyogenic liver abscess after choledochoduodenostomy for biliary obstruction caused by autoimmune pancreatitis

INTRODUCTION The differentiation of autoimmune pancreatitis (AIP) from pancreatic cancer is sometimes difficult because these diseases share many clinical features[1]. When pancreatic cancer cannot be ruled out, laparotomy or pancreatic resection may be p…     

Malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer

Malignant biliary obstruction generally results from primary malignancies of the pancreatic head, bile duct, gallbladder, liver, and ampulla of Vater. Metastatic lesions from other primaries to these organs or nearby lymph nodes are rarer causes of biliary obstruction. The most common primaries include renal cancer, lung cancer, gastric cancer, colorectal cancer, breast cancer, lymphoma, and melanoma. They may be difficult to differentiate from primary hepato-pancreato-biliary cancer based on imaging studies, or even on biopsy. There is also no consensus on the optimal method of treatment, including the feasibility and effectiveness of endoscopic intervention or surgery. A thorough review of the literature on pancreato-biliary metastases and malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer is presented. The diagnostic modality and clinical characteristics may differ significantly depending on the type of primary cancer. Different primaries also cause malignant biliary obstruction in different ways, including direct invasion, pancreatic or biliary metastasis, hilar lymph node metastasis, liver metastasis, and peritoneal carcinomatosis. Metastasectomy may hold promise for some types of pancreato-biliary metastases. This review aims to elucidate the current knowledge in this area, which has received sparse attention in the past. The aging population, advances in diagnostic imaging, and improved treatment options may lead to an increase in these rare occurrences going forward.     

Long term treatment of biliary stricture due to chronic pancreatitis with a metallic stent

The exact role of endoprostheses in the management of chronic pancreatitis-associated biliary strictures has not yet been clearly established. We report an unusual case of a patient with this condition who was treated for an unexpectedly long term with a self-expanding metallic endoprosthesis. There has only been one previous report of the use of metallic stents in this situation. It appears that metallic endoprostheses may have a role to play in the management of selected patients who have chronic pancreatitis-associated bile duct stricture.     

Role of prophylactic endoscopic sphincterotomy in patients with acute biliary pancreatitis due to transient common bile duct obstruction

BACKGROUND AND AIM: The role of prophylactic endoscopic sphincterotomy in patients with transient common bile duct obstruction is controversial. The aim of this study was to assess the value of performing prophylactic endoscopic sphincterotomy in patients suffering from acute biliary pancreatitis and absent common bile duct stones on endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Hospital notes of patients admitted to our unit with a diagnosis of acute pancreatitis from January 2000 to January 2005 were reviewed. Endoscopic sphincterotomy was performed when patients were deemed unfit for cholecystectomy, suffering from a severe attack of acute pancreatitis and/or showing evidence of transient common bile duct obstruction. The outcomes of patients with and without endoscopic sphincterotomy were compared. RESULTS: A total of 427 patients were admitted with a diagnosis of acute pancreatitis during the study period. Eighty-eight patients with absent common bile duct stones on ERCP were identified. Endoscopic sphincterotomy was performed in 71 patients and not performed in 17 patients. There was no significant difference in recurrent pancreatitis rates (1.4% vs 5.8%, P = 0.35), recurrent biliary complication rates (5.6% vs 5.9%, P = 1) or mortality rates (5.8% vs 1.5%, P = 0.35). The time to recurrent complications (38.4 days vs 41.0 days, P = 0.38) was not significantly different between the two groups. There was no ERCP-related morbidity or mortality. CONCLUSION: Prophylactic endoscopic sphincterotomy is not recommended in patients with transient common bile duct obstruction or as an option to cholecystectomy in elderly patients. Early cholecystectomy should be performed.     

Endoscopic biliary drainage in chronic pancreatitis

Between April 1982 and March 1988, 25 patients with chronic pancreatitis presented with biliary stenosis and significant cholestasis. They were treated by endoprosthesis placement. Nineteen patients had jaundice, and, initially, seven had cholangitis (including three with hepatic abscesses). ERCP was successful in all 25 patients. Cholangitis, cholestasis, and jaundice resolved in all cases after stent placement. Two patients died in the 2 months after treatment. Complete follow-up (mean duration, 14 months, range 7 to 42 months) was available for 19 of the 23 remaining patients. Migration of the stent occurred in 10 patients and stent blockage in 8 patients, with relapsing cholestasis (N = 12), cholangitis (N = 4), or without symptoms (N = 2). Only three of these patients are now asymptomatic without a stent in place after 12 to 72 months. In all of the other cases, stents have been replaced or patients have been treated by surgery. We conclude that endoscopic biliary drainage is an effective treatment for resolving cholangitis or jaundice in patients with chronic pancreatitis and biliary stenosis, but that the results of definitive endoscopic drainage for these patients are less satisfactory because resolution of the stricture after removal of the stent is rarely obtained.     

Biliary tract obstruction in chronic pancreatitis

Bile duct strictures are a common complication in patients with advanced chronic pancreatitis and have a variable clinical presentation ranging from an incidental finding to overt jaundice and cholangitis. The diagnosis is mostly made during investigations for abdominal pain but jaundice may be the initial clinical presentation. The jaundice is typically transient but may be recurrent with a small risk of secondary biliary cirrhosis in longstanding cases. The management of a bile duct stricture is conservative in patients in whom it is an incidental finding as the risk of secondary biliary cirrhosis is negligible. Initial conservative treatment is advised in patients who present with jaundice as most will resolve once the acute on chronic attack has subsided. A surgical biliary drainage is indicated when there is persistent jaundice for more than one month or if complicated by secondary gallstones or cholangitis. The biliary drainage procedure of choice is a choledocho-jejunostomy which may be combined with a pancreaticojejunostomy in patients who have associated pain. Since many patients with chronic pancreatitis have an inflammatory mass in the head of the pancreas, a Frey procedure is indicated but a resection should be performed when there is concern about a malignancy. Temporary endoscopic stenting is reserved for cholangitis while an expandable metal stent may be indicated in patients with severe co-morbid disease.     

Conservative management of biliary obstruction due to Fasciola hepatica.

We report a case of temporary biliary obstruction due to fascioliasis. This case report shows that in Central Europe, fascioliasis is one of the differential diagnoses of abdominal pain, especially if it is associated with eosinophilia. Successful medical treatment is possible even with obstruction of the bile duct.     

Endoscopic treatment for biliary stricture secondary to chronic pancreatitis

The causes of benign biliary stricture include chronic pancreatitis, primary/immunoglobulin G4-related sclerosing cholangitis and complications of surgical procedures. Biliary stricture due to fibrosis as a result of inflammation is sometimes encountered in patients with chronic pancreatitis. Frey's procedure, which can provide pancreatic duct drainage with decompression of biliary stricture, can be an initial treatment for chronic pancreatitis with pancreatic and bile duct strictures with upstream dilation. When patients are high-risk surgical candidates or hesitate to undergo surgery, endoscopic treatment appears to be a potential second-line therapy. Placement of multiple plastic stents is currently considered to be the best choice as endoscopic treatment for biliary stricture due to chronic pancreatitis. Temporary placement with a fully covered metal stent has become an attractive option due to the lesser number of endoscopic retrograde cholangiopancreatography (ERCP) sessions and its large diameter. Further clinical trials comparing multiple placement of plastic stents with placement of a covered metal stent for biliary stricture secondary to chronic pancreatitis are awaited.     

Histomorphological liver changes due to extrahepatic biliary stresia

Among 137 non-selected liver tissue specimens of 101 infants between 1968 and 1978 six cases of extrahepatic biliary atresia were found. For the pathologist examining the liver cylinder the differential diagnosis between biliary atresia and neonatal hepatitis may be extemely difficult. Findings typical of extrahepatic biliary atresia, such as obstruction of portal tracts, cannot be observed before the 4th or 6th week. Formerly, biliary atresia was considered as a congenital deformity. However, under morphologic aspects a positive syntrophy or a causative relationship between neonatal hepatitis and biliary atresia can at present not be excluded.     

Successful intervention with a longitudinal pancreaticojejunostomy for chronic pancreatitis due to obstruction of the pancreatogastrostomy after pancreatoduodenectomy

A 50-year-old man with a cancer of the papilla of Vater underwent pylorus-preserving pancreatoduodenectomy reconstructed with pancreatogastrostomy in 2002. He began to complain of upper abdominal and back pain in April 2008. Abdominal CT scan revealed pancreatolithiasis with dilatation of the remnant main pancreatic duct. An upper intestinal endoscopy could not discern the orifice of the pancreatic duct. He was treated by transgastric EUS-guided drainage of the pancreatic duct several times, and ESWL for pancreatolithiasis. However, he had repeated pancreatitis. Surgical intervention was carried out to treat the obstructive pancreatitis in April 2009. Longitudinal pancreaticojejunostomy was performed without resection of the obstructive pancreatogastrostomy. The postoperative recovery was uneventful, and the patient remains asymptomatic after the second operation. We concluded that the longitudinal pancreaticojejunostomy is a safe and effective alternative for chronic pancreatitis after stenotic pancreatico-digestive tract anastomosis following pancreatoduodenectomy, especially for cases in which endoscopic stenting is ineffective.     

Differential leptin responses to acute and chronic biliary obstruction in rats

BACKGROUND/AIMS: Recently leptin, a protein released from adipocytes, has been identified as a potent circulating satiety factor. We therefore undertook this series of experiments to examine leptin's role in the anorexia associated with biliary obstruction. METHODS: Rats underwent either surgical bile duct resection (BDR) or sham resection (sham). Body weight, and food and water intake were measured during a baseline period and for 8 days after surgery. At 4, 8 and 16 h as well as on days 2, 4, 6, and 8 postsurgery, sham and BDR rats were sacrificed and sera collected for subsequent measurement of leptin hormone concentration by RIA. White adipose tissue was collected on days 2, 4, 6 and 8 for leptin mRNA determination by Northern blot. RESULTS: Obstructive cholestasis in BDR rats caused significant anorexia for up to 7 days post-surgery, whereas in sham rats, a significant decrease in food intake was only observed in the first 24-h period following surgery. In both sham and BDR rats, water intake was significantly decreased during the first 24-h period after surgery, but had recovered to baseline levels by day 2 in both groups. Fat pad mass corrected to body weight was not significantly different between the two experimental groups. Serum leptin levels were significantly increased 4 and 8 h after surgery, had normalized by 16 h post-surgery, and were then decreased in BDR rats on days 2, 4, 6 and 8 compared with controls. Leptin mRNA levels in epididymal fat pads were decreased by approximately 2-fold in BDR rats compared with sham rats on days 2, 4, 6 and 8. Furthermore, day 5 BDR and sham rats demonstrated similar anorectic responses to centrally administered leptin. CONCLUSIONS: Leptin production is significantly increased early after biliary obstruction but is reduced after prolonged biliary obstruction. Increased circulating leptin levels may contribute to the profound anorexia observed early after biliary obstruction but appear not to mediate the anorexia observed during more chronic biliary obstruction.