Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents.

Twenty patients with chronic pancreatitis and signs of biliary obstruction were treated by endoscopic placement of self expandable metal mesh stents, and followed up prospectively. Eleven had been treated previously with plastic endoprostheses. All had persistent cholestasis, seven patients had jaundice, and three overt cholangitis. Endoscopic stent placement was successful in all cases. No early clinical complication was seen and cholestasis, jaundice or cholangitis rapidly resolved in all patients. Mean follow up was 33 months (range 24 to 42) and consisted of clinical evaluation, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP). In 18 patients, successive ERCPs and cholangioscopies have shown that the metal mesh initially embeds in the bile duct wall and is rapidly covered by a continuous tissue by three months. The stent lumen remained patent and functional throughout the follow up period except in two patients who developed epithelial hyperplasia within the stent resulting in recurrent biliary obstruction, three and six months after placement. They were treated endoscopically with standard plastic stents with one of these patients ultimately requiring surgical drainage. No patient free of clinical or radiological signs of epithelial hyperplasia after six months developed obstruction later. This new treatment could become an effective alternative to surgical biliary diversion if further controlled follow up studies confirm the initial impression that self expandable metal mesh stents offer a low morbidity alternative for longterm biliary drainage in chronic pancreatitis without the inconvenience associated with plastic stents.     

Endoscopic ultrasound-guided biliary drainage performed for refractory bile duct stenosis due to chronic pancreatitis: a case report

We report a case of the patient who underwent endoscopic ultrasound-guided biliary drainage (EUS-BD) for refractory bile duct stenosis due to chronic pancreatitis. The patient had repeatedly undergone endoscopic biliary stenting for bile duct stenosis due to chronic pancreatitis. Because of repeated relapses of cholangitis and jaundice, transpapillary treatment was judged to have reached its limits. Surgical bypass was attempted but had to be abandoned due to adhesions. Thus, EUS-BD was performed. The procedure was successful, and placement of a covered expandable metallic stent (C-EMS) relieved cholangitis. Two months after placement, the C-EMS was removed, and the patient became stent-free but closure of the fistula subsequently occurred.     

Treatment of symptomatic distal common bile duct stenosis secondary to chronic pancreatitis: comparison of single vs. multiple simultaneous stents

BACKGROUND: Common bile duct stenosis occurs in up to 30% of patients with chronic pancreatitis. Most such stenoses are found incidentally during ERCP, but others manifest as obstructive jaundice, recurrent cholangitis, secondary biliary cirrhosis, or choledocholithiasis. Operative drainage has been the main treatment despite the potentially high morbidity in patients with chronic pancreatitis. Endoscopic biliary drainage with a single stent has been successful in the short term. The aim of this study was to determine the long-term benefit of a single stent vs. multiple simultaneous stents for treatment of patients with chronic pancreatitis and symptoms because of distal common bile duct stenosis. METHODS: Twelve consecutive patients with chronic pancreatitis and common bile duct stenosis underwent endoscopic placement of multiple simultaneous stents and were followed prospectively (Group II). Results were compared with a group of 34 patients in whom a single stent was placed before the start of the present study (Group I). All 46 patients (35 men, 11 women; age range 30-71 years) had chronic pancreatitis and common bile duct stenosis, and presented with symptoms indicative of obstruction (abdominal pain, jaundice, elevated biochemical tests of liver function, acute pancreatitis, cholangitis). The 34 patients in Group I had single stent (10F, 7-9 cm) placement, with exchange at 3 to 6 month intervals (1-4 exchanges) over a mean of 21 months. The 12 patients in Group II underwent placement of multiple simultaneous stents at 3-month intervals (single 10F stents added sequentially) over a mean of 14 months. Mean follow-up was 4.2 years in Group I and 3.9 years for Group II. Factors assessed included symptoms, biochemical tests of liver function, diameter of common bile duct stenosis, and complications. RESULTS: In Group I, (34 patients), a total of 162 single stent placement/exchanges were performed (mean 5/patient). In Group II (12 consecutive patients), 8 patients had 4 (10F) stents placed simultaneously, and 4 patients had 5 (10F) stents. At the end of the treatment period, near normalization of biochemical tests of liver function was observed for all patients in Group II, whereas only marginal benefit was noted for patients in Group I. Four patients in Group I had recurrent cholangitis (6 episodes), whereas no patient in Group II had post-procedure cholangitis. In the 12 patients with multiple stents, distal common bile duct stenosis diameter increased from a mean of 1.0 mm to 3.0 mm after treatment; no change in diameter was noted in patients treated with a single stent. CONCLUSIONS: Distal common bile duct stenosis secondary to chronic pancreatitis can be treated long term by stent placement. Multiple, simultaneous stents appear to be superior to single stent placement and may provide good long-term benefit. The former resulted in near normalization of biochemical tests of liver function and an increase in distal common bile duct diameter. Multiple stent placement may obviate the need for surgical diversion procedures.     

Endoscopic treatment of chronic pancreatitis

OBJECTIVES: Endoscopy offers an alternative to surgery for the treatment of ductal complications in patients with chronic pancreatitis. The aim of this study was to evaluate the efficacy of endoscopic treatment on pain, cholestasis and pseudocysts in these patients. PATIENTS AND METHODS: Thirty-nine patients (37 M, 2 F, mean age 44), were included in the study. All patients had at least one of the following criteria demonstrated by imaging tests: dilatation of the main pancreatic duct (MPD) with or without stricture (N = 13), bile duct stricture (N = 12), or pancreatic pseudocyst (N = 14) with pancreatic duct stricture (N = 11) or biliary stricture (N = 3). Pancreatic or biliary sphincterotomy, insertion of pancreatic or biliary stent, pseudocyst drainage with stent placement were performed according to ductal abnormalities. Patients were evaluated early and followed up during the stenting period, and after stent removal. RESULTS: Patients underwent a median of 3.5 endoscopic procedures with an interval of 2.2 months between 2 stenting sessions. A pancreatic or biliary stent was inserted in 25 patients with ductal abnormalities and in 11 patients with pseudocysts. Endoscopic pseudocyst drainage was performed in 6 cases. The mean stenting time was 6 months (range: 3-21). Mean follow-up after stent removal was 9.7 (2-48) months. Complications of endoscopic treatment were encountered in 7% of patients with no deaths. Pain relief was achieved after the first endoscopic procedure and during the overall stenting period in all patients. Recurrence of pain was observed after stent removal in 5/11 patients, requiring surgery in 4. Cholestasis decreased and biochemical values normalized within one month after biliary stenting. Recurrence of cholestasis was observed early after stent removal in 4/9 patients who required complementary surgical treatment. No recurrence of pancreatic pseudocyst was observed after endoscopic drainage and stent removal during the follow-up period. CONCLUSIONS: Endoscopic treatment of pain from pancreatic pseudocysts or ductal strictures is effective in the short-term and in the period of ductal stenting. However, the optimal duration of the latter remains to be determined.     

Is endoscopic drainage of common bile duct stenoses in chronic pancreatitis up-to-date?

OBJECTIVE: Common bile duct (CBD) stenoses often complicate chronic pancreatitis (CP). Although endoscopic drainage is employed as a standard procedure in malignant CBD stenoses, it is not yet the approved standard therapy of CBD stenosis in CP. METHODS: The records of 31 patients with CBD stenosis in CP who had undergone endoscopic placement of plastic endoprostheses into the bile duct between January 1991 and February 1997 were analyzed retrospectively. In all, 18 patients suffered from jaundice and 13 patients exclusively showed serological cholestasis. Upstream dilation of the CBD (19 +/- 6.6 mm, 12-35 mm) was detected by ERCP in all patients. In total, 101 endoprostheses were implanted endoscopically, exchanged after 3 +/- 2 months, and removed after 10 +/- 8 months. RESULTS: All jaundiced patients showed immediate improvement of cholestasis after drainage. At the time of last exchange or after stent removal, prestenotic CBD dilation was reduced in 55% of all patients. Complete regression of stenosis and prestenotic dilation was accomplished only in 13%; dilation remained unchanged in 10%, and even showed progression in 22%. A total of 29 patients were followed-up over 24 months. Cholestatic parameters remained normal in all patients with complete normalization of the CBD, and were only moderately increased in another 10 patients, 7 and 28 months after stent removal, respectively. CONCLUSIONS: Technical and immediate clinical success of CBD stenting in patients with CBD stenoses due to CP is high; however, long-term complete normalization of the bile duct is rare. Endoscopic drainage of CBD-stenosis in patients with CP can be recommended to alleviate acute cholestasis, but not yet as a definite treatment.     

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.     

Endoscopic management of acute calculous cholangitis

Acute cholangitis is associated with significant morbidity and mortality. Endoscopic drainage procedures have been shown to be a safe and effective mode of treatment in acute cholangitis. As there is paucity of large series on endoscopic management of acute cholangitis, a study was performed to evaluate safety and efficiency of endoscopic biliary decompression in acute cholangitis. The study included 89 consecutive patients (mean age 55 ± 15 years; range 35–70 years; 50 males) with acute cholangitis requiring biliary drainage. Main presenting features were upper abdominal pain (84%), fever with chills (90%) and jaundice (74%). Altered sensorium, hypotension, features of peritonitis and acute renal failure were present in 15, 11, 18 and 5%, respectively. Endoscopic procedures performed were endoscopic sphincterotomy (ES) with stone extraction (n= 40); ES with endoscopic nasobiliary drainage (ENBD; n= 30); ENBD without ES (n= 8); and ES with stent placement (n= 11). Of the 89 patients, 85 (95%) responded within 48–72 h. Endoscopic common duct clearance could be achieved in 58 of 78 (74%) patients, whereas in 11 patients undergoing stent placement, stone extraction was not attempted. Complications included post-sphincterotomy bleed (n= 2), retroduodenal perforation (n= 1) and acute pancreatitis (n= 1) with an overall complication rate of 4.4%. All the complications were seen in patients undergoing ES with stone extraction. Mortality was 3.3%. In conclusion, endoscopic biliary drainage is a safe and effective mode of treatment for acute cholangitis. Endoscopic nasobiliary drainage or stent placement is safer than ES in acute cholangitis as an initial step.     

Endoscopic retrograde cholangiopancreatography in infants and children.

BACKGROUND: Although many reports describe the use of diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in children, few mention therapeutic application of this technique in pediatric patients with pancreatic or biliary disease. METHODS: We report our 4-year experience of 80 ERCPs performed in 59 children for obstructive jaundice or cholestasis with dilatation of the biliary tree (32 children), biliary atresia (11), recurrent pancreatitis (8), and blunt trauma to the abdomen (8). RESULTS: The patients' ages ranged from 5 weeks to 18 years. The appropriate duct was cannulated in 94% of cases. Common bile duct sphincterotomy was performed in 35 patients and pancreatic duct sphincterotomy in one. Multiple procedures were done in 16 patients where biliary stents were inserted; in one patient with chronic pancreatitis and pancreaticolithiasis, pancreatic stent was inserted. Four patients developed mild pancreatitis, one had moderate pancreatitis and one had leak of contrast, which was treated by administration of clear fluids orally for one day. One patient with benign stenosis of the hepatic duct developed cholangitis after migration of the stent into the bowel lumen. CONCLUSION: Diagnostic and therapeutic ERCP can be done as safely and effectively in pediatric patients as in adults.     

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.     

Treatment of benign biliary strictures in chronic pancreatitis by self-expandable metal stents

AIM: To determine the efficacy the value of self-expandable metal stents in patients with benign biliary strictures caused by chronic pancreatitis. METHOD: 61 patients with symptomatic common bile duct strictures caused by alcoholic chronic pancreatitis were treated by interventional endoscopy. RESULTS: Initial endoscopic drainage was successful in all cases, with complete resolution of obstructive jaundice. Of 45 patients who needed definitive therapy after a 12-months interval of interventional endoscopy, 12 patients were treated with repeated plastic stent insertion (19.7%) or by surgery (n = 30; 49.2%). In 3 patients a self-expandable metal stent was inserted into the common bile duct (4.9%). In patients treated with metal stents, no symptoms of biliary obstruction occurred during a mean follow-up period of 37 (range 18-53) months. The long-term success rate of treatment with metal stents was 100%. CONCLUSIONS: Endoscopic drainage of biliary obstruction by self-expandable metal stents provides excellent long-term results. To identify patients who benefit most from self-expandable metal stent insertion, further, prospective randomized studies are necessary.     

放置金属支架姑息性解除恶性胆道梗阻57例

目的内镜法放置胆道支架,姑息性治疗胆管恶性梗阻的最大缺陷是支架的阻塞,造成阻塞的重要原因之一是通常的塑料支架口径较小,而放置可膨式金属支架使得内引流中口径达到1cm.方法我们从1994年4月-1996年5月放置膨胀式金属道支架治疗57例无法根治的恶性梗阻性黄疸患者,其中采用内镜法置管54例,经皮肝穿刺法3例.结果导丝定位后支架放置的成功率为95%,2例发生胆管炎,经保守治疗得以控制.术后两周内黄疸完全消退21例,明显减退23例,然而9例患者在平均147d 后由于引流失效出现晚期胆管炎.全组有23例术前采用鼻胆管和3例采用内置管临时性引流,临时性引流具有可预先了解引流效果和控制炎症的优点.结论对于无法切除的恶性胆道梗阻患者,放置金属胆道支架可有效解除黄疸,改善生活质量,但欲获得最佳疗效,需严格掌握置管指证.为获得持久的引流效果.肿瘤两端支架的长度不宜短于2cm;对肝门部胆管癌,Bismuth 分型对挑选合适的引流部位有较大的参考价值.     

Result of endoscopic biliary drainage in hilar cholangiocarcinoma

Patients with hilar obstruction usually require bilateral biliary drainage. The prognosis of patients who fail bilateral biliary drainage after contrast injection into both intrahepatic ducts is poor due to a high infection rate in the undrained segments. The incidence of post-endoscopic retrograde cholangiopancreatography cholangitis in those with successful bilateral biliary drainage was less, but still significant. Incomplete subsegmental intrahepatic duct drainage is suggested to be responsible for post-biliary drainage cholangitis in cases of advanced hilar tumors. This study was undertaken to determine the incidence of post-endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and stent clogging in different types of malignant biliary obstruction after biliary drainage. From our endoscopic retrograde cholangiopancreatography database, there were 63 patients who underwent endoscopic biliary drainage between September 2000 and November 2001, for malignant biliary obstruction. Sixty-one endoscopic retrograde cholangiopancreatographies had biliary drainage performed (2 patients who failed biliary drainage were excluded). We divided our patients into 3 groups: Group 1 = Bismuth I, Group 2 = Bismuth II, and Group 3 = Bismuth III and IV. All but 2 Group 1 patients had successful biliary endoprosthesis (plastic [n = 13], metallic [n = 12], failed [n = 2]) placement into an extrahepatic duct. All patients from Group 2 (n = 10) and 20 patients from Group 3 (n = 26) had successful bilateral biliary drainage. Unilateral biliary drainage was performed in 6 patients from Group 3, each with a plastic endoprosthesis. The incidence of post-biliary drainage cholangitis (new onset of fever >38.5 degrees C with leukocytosis), jaundice resolution (normal bilirubin level), and the duration of endoprosthesis patency were compared among the 3 groups. The incidences of post-endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and the duration of endoprosthesis patency were: Group 1 (4%, 96%, and 87.2 days, respectively), Group 2 (10%, 100%, and 69.1 days, respectively) and Group 3 (57.7%, 73.1%, and 41.3 days, respectively). Of those patients who did not undergo surgery, patients from Group 3 required endoprosthesis exchange sooner than others. The outcome of biliary drainage in patients with advanced hilar tumors (Bismuth III or IV) was poorer than hilar tumor at earlier stages (Bismuth I or II).     

经内镜鼻胆管引流术与经内镜胆道支架置入术在低位恶性梗阻性黄疸术前胆道引流效果比较的Meta分析

目的比较经内镜鼻胆管引流术(ENBD)和经内镜胆道支架置入术(EBS)在低位恶性梗阻性黄疸术前胆道引流中的有效性及安全性。方法在中英文数据库中检索从建库至2020年8月发表的有关ENBD与EBS在低位恶性梗阻性黄疸术前胆道引流疗效对照研究的所有中英文文献,对纳入的研究进行质量评价和数据提取后,采用RevMan 5.3软件进行Meta分析,比较ENBD与EBS术前胆管炎发生率、术前胰腺炎发生率、支架障碍率、术前术后总并发症发生率、术后胰漏率的差异。结果最终纳入6项研究,包括1182例患者。Meta分析结果显示,在术前胰腺炎发生率、支架障碍率、术前术后总并发症发生率方面,ENBD组与EBS组比较差异均无统计学意义(OR分别为0.66、1.14、0.69,95%CI分别为0.44~0.99、0.56~2.31、0.41~1.15,P值分别为0.05、0.72、0.15)。但是,ENBD组相较于EBS降低了术前胆管炎发生率和术后胰漏率,差异均有统计学意义(OR分别为0.34、0.53,95%CI分别为0.23~0.50、0.32~0.88,P值分别为<0.00001、0.01)。结论对于诊断明确的低位恶性胆道梗阻患者,术前胆道引流使用ENBD优于使用EBS。未来需要更多的多中心大样本随机对照试验来验证这一结论。     

WHICH TYPES OF DRAINAGE TUBE SHOULD WE SELECT FOR ENDOSCOPIC BILIARY DRAINAGE? CURRENT STATUS

Biliary drainage is a standard procedure for cholangitis or obstructive jaundice due to biliary obstruction. However, criterion for the selection of types of drainage tube is not established. The authors analyzed the types of drainage tube used in the University of Tokyo, Tokyo, Japan, during the month of June 2005, and they treated 63 cases. For drainage for cholangitis (31), the authors used endoscopic naso‐biliary drainage (ENBD) tube in 74.1% and plastic stent in 25.9%. In contrast, for the cholestesis cases (16), the authors used ENBD tube in 37.5% and plastic stent in 63.5%. For the unresectable biliary malignancy cases (8) with improved jaundice, the authors used covered metallic stent in seven distally stricture cases and uncovered metallic stent in one proximally stricture case. The remaining eight cases received plastic stent placement. There were six cases of residual common bile duct stones and two cases of prevention of cholangitis after papillectomy. For the patients with unresectable biliary malignancies at distal portion, the authors consider that covered metallic stent is a standard endoprosthesis. For drainage for cholangitis, the authors used ENBD tube because bile juice flow is able to be checked any time. However, the authors used plastic stent rather than ENBD tube for the drainage of cholestesis. A larger study for selection of drainage tube for these aspects is needed in the future.     

Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis

Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.     

Endoscopic biliary drainage by 7 Fr or 10 Fr stent placement in patients with acute cholangitis

Background and Study Aims Endoscopic biliary drainage is an established mode of treatment for acute cholangitis. We compared the safety and efficacy of 7 Fr and 10 Fr stent placement for biliary drainage in patients with acute cholangitis. Patients and Methods We recruited 40 patients with severe cholangitis who required endoscopic biliary drainage. Patients were randomized to have either a 7 Fr or a 10 Fr straight flap stent placement during endoscopy. Outcome measures included complications related to endoscopic retrograde cholangiopancreatography (ERCP) and clinical outcome. Results Of 40 patients, 20 were randomized to the 7 Fr stent group and 20 to the 10 Fr stent group. All patients had biliary obstruction due to stones in the common bile duct. Indications for biliary drainage were: fever >100.4°F (n = 27), hypotension (n = 6), peritonism (n = 10), impaired consciousness (n = 8), and failure to improve with conservative management (n = 13). Biliary drainage was achieved in all patients. Abdominal pain, fever, jaundice, hypotension, peritonism, and altered sensorium improved after a median period of 3 days in both groups. Leukocyte counts became normal after a median time of 4 days in the 7 Fr stent group and 6 days in the 10 Fr stent group. There were no ERCP-related complications. There were no instances of occlusion or migration of stent. The success rates of biliary drainage in cholangitis were not affected by the size of stent used. Conclusions Biliary drainage by 7 Fr stent or 10 Fr stent is equally safe and effective treatment for patients with severe cholangitis.     

Stent versus surgery

Following the introduction of percutaneous and endoscopic biliary drainage there has been an ongoing debate about the indications and outcomes of endoscopic versus surgical drainage in a variety of bilio-pancreatic disorders. The evidence-based literature concerning four different areas of pancreatobiliary diseases have been reviewed. Preoperative endoscopic biliary drainage in patients with obstructive jaundice should not be used routinely but only in selected patients. For patients with biliary leakage and bile duct strictures after a laparoscopic cholecystectomy, endoscopic stent therapy might be first choice and surgery should be used for failures of endoscopic treatment. Surgery is the treatment of choice after transection of the bile duct (the major bile duct injuries). The majority of patients with obstructive jaundice due to advanced pancreatic cancer will undergo endoscopic drainage but for relatively fit patients with a prognosis of more than 6 months, surgical drainage or even palliative resection might be considered. For patients with persistent pain due to chronic pancreatitis surgical drainage combined with limited pancreatic head resection might be first choice for pain relief. Most importantly, the management of patients with these pancreatobiliary diseases should be performed by a multidisciplinary HPB approach and teamwork consisting of gastroenterologists, radiologists and surgeons.     

Benign biliary strictures related to chronic pancreatitis: Balloons,stents, or surgery

Opinion statement Benign biliary strictures are seen in a subset of patients with chronic pancreatitis. Most patients are asymptomatic and require no intervention. In some patients, benign strictures can become symptomatic. In these patients, the aim of biliary drainage is to prevent long-term complications such as recurrent cholangitis and secondary biliary cirrhosis. The possibility of a malignant stricture should always be excluded. Successful endoscopic drainage of biliary obstruction has no influence on pain pattern in patients with chronic pancreatitis. At the first diagnosis of a symptomatic biliary stricture due to chronic pancreatitis, a polyethylene stent can be inserted endoscopically. If the stricture is still present despite stent exchange with serial insertion of multiple stents every 3 months for 1 year, surgery is indicated as definitive treatment. The role of self-expandable metal stents in the management of benign biliary strictures due to chronic pancreatitis is unclear, but they may be useful for nonoperative candidates and a select group of patients in whom surgery is planned. The aim of surgical therapy is to definitively treat the benign biliary stricture, especially in younger patients, who presumably have a longer lifespan.     

Use of a partially covered self-expandable metallic stent to treat a biliary stricture secondary to chronic pancreatitis complicated by recurrent cholangitis: a case report

The patient was a 69 year old man who had been diagnosed with alcoholic chronic pancreatitis and lower common bile duct (CBD) stricture. He subsequently developed cholangitis 2-3 times a year, and we replaced the endoscopic biliary stent (EBS) each time. In April 2010, he was admitted because of complication by a liver abscess and acute cholangitis. We performed percutaneous transhepatic liver abscess drainage. The inflammatory findings then rapidly improved, but the patient developed acute cholangitis due to the sludge and the stones. Then, we placed a partially covered self-expandable metallic stent (C-SEMS) in the lower CBD and performed endoscopic lithotripsy through the C-SEMS, and the cholangitis subsequently improved. Two weeks after, we removed the C-SEMS endoscopically and replaced it with a 10 Fr plastic stent; since then there have been no recurrences of cholangitis. Our experience in this case suggested that when a plastic stent is placed long-term to treat a biliary stricture associated with chronic pancreatitis, it might be useful to also control biliary sludge and stones using a C-SEMS.     

Urgent endoscopic ultrasound-guided choledochoduodenostomy for acute obstructive suppurative cholangitis-induced sepsis

Acute obstructive suppurative cholangitis (AOSC) due to biliary lithiasis is a life-threatening condition that requires urgent biliary decompression. Although endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the current gold standard for biliary decompression, it can sometimes be difficult because of failed biliary cannulation. In this retrospective case series, we describe three cases of successful biliary drainage with recovery from septic shock after urgent endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) was performed for AOSC due to biliary lithiasis. In all three cases, technical success in inserting the stents was achieved and the patients completely recovered from AOSC with sepsis in a few days after EUS-CDS. There were no procedure-related complications. When initial ERCP fails, EUS-CDS can be an effective life-saving endoscopic biliary decompression procedure that shortens the procedure time and prevents post-ERCP pancreatitis, particularly in patients with AOSC-induced sepsis.