Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple stents

BACKGROUND: The long-term efficacy of sequential insertion of multiple plastic stents for benign biliary strictures is poorly defined. The aims of this study were to evaluate the long-term outcome (bile duct patency, complications) of this therapy and to identify predictors of a good outcome. METHODS: Retrospective review of 29 cases of benign biliary strictures treated with sequential plastic stent insertion in progressively increasing numbers and/or of increasing diameter. RESULTS: Stricture etiology was as follows: postoperative 19 (66%), chronic pancreatitis 9 (31%), and idiopathic 1 (3%). Therapy succeeded in 18 patients (62%) (mean follow-up 48.0 [11.56] months after stent removal). Therapy failed in 11 patients (38%) (mean interval to failure 11.59 [9.79] months after stent removal). The 2 groups of patients in which therapy failed had either a hilar stricture (n = 4, 25% success) or distal common bile duct stricture caused by chronic pancreatitis (n = 9, 44% success). In the remaining cases, therapy succeeded in 13 of 16 (81% success). The observed differences in success rate among subgroups were not statistically significant. There were no ERCP-related deaths. One episode of mild pancreatitis and 2 episodes of cholangitis developed during 126 ERCPs over a period of stent insertion of 36 patient years. CONCLUSIONS: In selected patients with benign biliary strictures, sequential endoscopic insertion of multiple biliary stents may lead to long-term success that could be equal to or superior to surgery with minimal morbidity. Hilar strictures and those caused by chronic pancreatitis appear to respond poorly to this therapy.     

Endoscopic treatment of sphincterotomy-associated distal common bile duct strictures by using sequential insertion of multiple plastic stents

BACKGROUND: A rare, late complication of endoscopic biliary sphincterotomy is the occurrence of short strictures extending from the papillary orifice to the distal parts of the extraduodenal common bile duct. METHODS: We evaluated the efficacy of the sequential insertion of multiple stents in the treatment of endoscopic biliary sphincterotomy associated common bile duct strictures. The design of the study is a prospective, single-arm observational study at a university-affiliated teaching hospital of 20 patients with distal common bile duct strictures because of choledocholithiasis-related endoscopic biliary sphincterotomy. Endoscopic treatment consisted of the sequential insertion of an increasing number of plastic stents with ever-larger diameters in 3-month follow-up intervals until stricture resolution. The primary outcome of the study was the rate of resolution of the stricture. The parameters measured were the duration of placement of stents, the maximum diameter, the total number of stents, and the total number of endoscopic sessions required for dilation of the strictures. RESULTS: After a median of 9.0 months of stent placement (range 3-22 months) and a median of 20F maximum stent diameter (range 10F-30F), 18 patients (90%) remained stent-free for a median of 14.5 months (range 6-38 months). Two patients (10%) had stricture recurrences at 10 and 24 months. Multivariate regression analysis demonstrated that the time elapsed after endoscopic biliary sphincterotomy was significantly associated with the stent-placement time (however, significance was removed by correction for multiple testing) and the number of ERCPs required for dilation. The initial common bile duct size was significantly associated with the total stent number and diameter needed for stricture resolution (however, significance was removed by correction for multiple testing). Limitations are the low case number and the single-arm, noncontrolled study design. CONCLUSIONS: Sequential insertion of an increasing number of biliary stents affords effective treatment of the distal biliary strictures that develop as a late complication of endoscopic biliary sphincterotomy.     

Medium-term results of endoscopic treatment of common bile duct strictures in chronic calcifying pancreatitis with increasing numbers of stents

OBJECTIVES: The goal of this study was to evaluate our medium-term results on common bile duct stenting with increasing numbers of stents on strictures due to chronic calcifying pancreatitis. BACKGROUND: Common bile duct strictures frequently complicate the course of chronic calcifying pancreatitis. The effectiveness of endoscopic stenting to resolve definitely these strictures is still debated. STUDY: Twenty-nine patients with common bile duct stricture due to chronic calcifying pancreatitis were stented and followed up. Biliary sphincterotomy, dilation of the stricture, and insertion of plastic biliary stents (7.5-10 F) were performed. Patients were scheduled for elective stent changing/restenting at 3-month intervals or any time when it was urgently indicated. Our basic intention was to insert the maximum possible number of stents to reach as large diameter as the stricture allowed. All stents were removed after the disappearance of common bile duct dilatation or left in place in cases of persisting strictures. RESULTS: Eighteen patients (60%) had complete radiologic and serologic recovery after a mean of 21.1 months overall stenting time and had a stent free follow-up period for a mean of 12.1 months without recurrence of stricture. Five patients (16%) still have stents in place after 26 months. Three patients (13%) required surgery. There were 3 deaths (10%): 1 for unrelated cause and 2 with septic shock of biliary origin. CONCLUSIONS: Most chronic calcifying pancreatitis patients with common bile duct strictures respond to the increasing numbers of endoscopic stents, and remain stent free for medium term periods. Less patients (30%) does not benefit of biliary stenting, who are candidates for surgery.     

Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents

BACKGROUND: Endoscopic dilation with stents has been proposed as an alternative to hepaticojejunostomy for management of postoperative biliary strictures. Good long-term results with double 10F plastic stent insertion for 1 year have been reported in 74% to 90% of cases. This is a review of our experience with a more aggressive approach. METHODS: The technique, short-term results, and long-term results of placement of increasing numbers of stents until complete disappearance of the biliary stricture are reported. At each exchange, the maximum possible number of stents in relation to the tightness of the stricture and diameter of the bile duct were inserted. All stents were removed at the end of treatment. RESULTS: The records of 45 of 55 patients with postoperative biliary strictures treated in this manner and observed consecutively were reviewed retrospectively. By intention-to-treat analysis the success rate was 89% (40/45). Early complications developed in 4 (9%) patients (3 cholangitis, 1 pancreatitis) and stent occlusion that required early exchange occurred in 8 (18%) patients. There was 1 death caused by a stroke 2 months after a stent exchange. Forty-two patients completed the protocol (mean number of stents 3.2 +/- 1.3; range 1-6). Mean duration of treatment was 12.1 +/- 5.3 months (range 2-24 months). Two patients died of unrelated causes during follow-up. Among the remaining 40 patients there was no recurrence of symptoms caused by relapsing biliary stricture at a mean follow-up of 48.8 months (range 2-11.3 years). One patient sustained 2 episodes of cholangitis but without stricture recurrence. CONCLUSIONS: This more aggressive approach to endoscopic treatment with stents may improve long-term results for patients with postoperative biliary strictures.     

Self-expanding metallic stent for benign biliary strictures: seven-year follow-up

We report two cases of benign biliary strictures managed by metallic stent placement because the patients refused surgical repair. One patient is a 67-year-old man who had a stricture of the right hepatic duct and a bile leak following a cholecystectomy. The second patient is a 50-year-old man who had a stricture of the left hepatic duct following a right hepatic lobectomy for hepatolithiasis. For treatment of these bile duct strictures, a Gianturco-Rosch Z stent was placed in the former case and a Wallstent in the latter. Luminal patency of the stent was maintained for 7 years in the former case but in the latter, luminal stenosis of the stent was induced soon after placement. However, in the former, bile stasis in the left hepatic duct system, which emptied into the side of the stent, gradually developed without signs or symptoms of cholangitis or biliary obstruction. Therefore, the use of metallic stents for benign biliary stricture remains controversial. However, if metallic stent placement is the only therapeutic option, it is necessary to maintain bile flow not only through the stent but also in the bile ducts which flow into the side of the stent.     

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.     

Side-by-side placement of bilateral endoscopic metal stents for the treatment of postoperative biliary stricture

Postoperative biliary strictures are usually complications of cholecystectomy. Endoscopic plastic stent prosthesis is generally undertaken for treating benign biliary strictures. Recently, fully covered metal stents have been shown to be effective for treating benign distal biliary strictures. We present the case of a 53-year-old woman with liver injury in which imaging studies showed a common hepatic duct stricture. Endoscopic retrograde cholangiopancreatography also confirmed the presence of a common hepatic duct stricture. Temporally fully covered metal stents with dilated diameters of 6 mm were placed in a side-by-side fashion in the left and right hepatic ducts, respectively. We removed the stents 2 months after their placement. Subsequent cholangiography revealed an improvement in the biliary strictures. Although we were apprehensive about the fully covered metal stents obstructing the biliary side branches, we noted that careful placement of the bilateral metal stents did not cause any complications. Side-by-side deployment of bilateral endoscopic fully covered metal stents can be one of the safe and effective therapies for postoperative biliary stricture.     

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.     

Covered metallic stent for ischemic hilar biliary stricture

Compared with surgery, endoscopic treatment is safe and highly effective for a postoperative hilar benign bile duct stricture (BDS). However, the long-term outcome of conventional placement of a single biliary stent for hilar benign BDS is generally poor. Although the placement of multiple biliary stents is preferred, multiple stenting in a BDS is difficult. Alternatively, single or multiple stent placement above the papilla ('inside stent') or fully-covered self-expandable metallic stents (SEMS) are feasible approaches for benign BDS. Nevertheless, controversy remains regarding whether and how to perform endoscopic biliary drainage for a hilar benign BDS. In patients with hilar benign BDS, endoscopic biliary drainage can be performed by placing conventional plastic stents across the papilla, plastic stents above the papilla or fully-covered SEMS. Individualized treatment should be considered. We report the placement of a fully-covered SEMS for a hilar benign biliary stricture after extended left hepatectomy.     

Endoscopic management of post-laparoscopic cholecystectomy biliary strictures. Long-term outcome in a multicenter study

OBJECTIVES: The aim of this retrospective study was to assess the long term results of long-lasting endoscopic stenting for benign biliary strictures related to laparoscopic cholecystectomy. Additional biological and morphological data were collected from these patients during follow-up. METHODS: Patients undergoing ERCP for post-laparoscopic cholecystectomy biliary stricture in one of the three participating centers between 1990 and December 2001 were identified. Only patients with successful endoscopic stenting were subsequently included and analyzed. Follow-up data were obtained from referring centers, general practitioners and patients or relatives. Hepatic blood tests and abdominal ultrasound were proposed to all the patients who had not undergone further treatments after stent removal. RESULTS: Eight-eight patients had undergone ERCP for benign biliary stricture related to laparoscopic cholecystectomy. Stenting failed in 19 patients. Balloon dilatation alone was used in four patients. Strictures were successfully stented in 65 patients. The mean number of stents inserted at the same time was 1.6. The mean duration of stenting was 14 months (range 1-120 months). Eighteen patients (28%) developed biliary or pancreatic symptoms during stenting. ERCP was considered satisfactory at the end of stenting (i.e. no remaining stricture or minor remaining change on ERCP) in 45 patients (69%). Twenty-two patients were lost to follow-up. Twenty-nine out of forty-three patients (67%) remained symptom-free with normal updated blood tests and abdominal ultrasound during a mean follow-up of 28 months (range 12-117 months) after stent removal. None of the patients with a normal ERCP at the end of stenting developed stricture recurrence during follow-up. Eleven patients were operated (8 with persistence of stricture, 2 for stricture recurrence up to 63 months after stent removal, 1 for pancreatitis). CONCLUSION: Based on clinical, morphological and biological criteria, a long-term success was obtained in 70% of patients with post-laparoscopic cholecystectomy benign biliary strictures, after several months of endoscopic stenting.     

Use of fully covered self-expanding metal stents in benign biliary diseases

Biliary fully covered self-expanding metal stents (FCSEMS) are now being used to treat several benign biliary conditions. Advantages include small predeployment and large postexpansion diameters in addition to an easy insertion technique. Lack of imbedding of the metal into the bile duct wall enables removability. In benign biliary strictures that usually require multiple procedures, despite the substantially higher cost of FCSEMS compared with plastic stents, the use of FCSEMS is offset by the reduced number of endoscopic retrograde cholangiopancreatography interventions required to achieve stricture resolution. In the same way, FCSEMS have also been employed to treat complex bile leaks, perforation and bleeding after endoscopic biliary sphincterotomy and as an aid to maintain permanent drainage tracts obtained by means of Endoscopic Ultrasound-guided biliary drainage. Good success rates have been achieved in all these conditions with an acceptable number of complications. FCSEMS were successfully removed in all patients. Comparative studies of FCSEMS and plastic stents are needed to demonstrate effi cacy and cost-effectiveness     

Long-term outcome of endoscopic therapy in patients with bile duct injury after cholecystectomy

Background and Aim:  Bile duct lesions, including leaks and strictures, are immanent complications of open or laparoscopic cholecystectomy. Endoscopic procedures have gained increasing potential as the treatment of choice in the management of postoperative bile duct injuries.
Methods:  Between January 1996 and December 2006, 44 patients with biliary leakages and 12 patients with biliary strictures after cholecystectomy were identified by analyzing the endoscopic retrograde cholangiopancreatography database, clinical records, and cholangiograms. The long-term follow up of endoscopic treatment in biliary lesions after cholecystectomy was evaluated by this retrospective study.
Results:  In 34 of 35 patients (97%) with peripheral bile duct leakages, endoscopic therapy was successful. Transpapillary endoprothesis and/or nasobiliary drainage were removed after 31 (5–399) days. After stent removal, the median follow-up period was 81 (11–137) months. In patients with central bile duct leakages, the success rate after median 90 (4–145) days of endoscopic therapy was 66.7% (6/9 patients). The median follow up after stent removal in six successfully treated patients was 70 (48–92) months. Eleven of 12 patients (91.6%) with bile duct strictures had successfully completed stent therapy. The follow-up period of this patient group was 99 (53–140) months.
Conclusions:  Endoscopic treatment of bile duct lesions after cholecystectomy is effective, particularly in patients with peripheral bile duct leakages and bile duct strictures. Therefore, it should be the first-line therapy used in these patients. Although endoscopic management is less successful in patients with central bile duct leakages, an attempt is warranted.     

Endoscopic stenting for postoperative biliary strictures due to hepatic hydatid disease: effectiveness and long-term outcome

BACKGROUND: Postoperative strictures due to hepatic hydatid disease caused by Echinococcus surgery is considered to be a rare cause of benign bile duct strictures, especially in the Western world. GOALS: The aim of this retrospective study is to demonstrate possible characteristics of the strictures as well as the effectiveness of long-term endoscopic stenting. STUDY: Between 1994 and 2001, we treated 10 of these cases in our clinic. All patients had surgery for hepatic Echinococcus disease one or more times. These types of benign biliary strictures, secondary to surgery of hepatic hydatid disease, were multiple and located in the proximal common bile duct. Endoscopic stent therapy was carried out in all cases containing transpapillary approach with plastic prostheses (7.5-11 French) or transhepatic approach with Yamakawa prostheses (16 French). Nine patients were available for follow-up. RESULTS: In 6 patients (66%), the stents were removed after a median period of 22.5 months with radiologic and clinical signs of improvement. Three patients required prolonged dilatation therapy because of stricture-recurrence. There was low overall morbidity and we recognized no therapy-associated mortality. CONCLUSIONS: Endoscopic stent therapy is a safe nonoperative method for the treatment of postoperative benign biliary strictures due to hepatic hydatid disease.     

Placement of a fully covered self-expandable metal stent in a young patient with chronic pancreatitis

Plastic stent insertion is a treatment option for pancreatic duct stricture with chronic pancreatitis. However, recurrent stricture is a limitation after removing the plastic stent. Self-expandable metal stents have long diameters and patency. A metal stent has become an established management option for pancreatic duct stricture caused by malignancy but its use in benign stricture is still controversial. We introduce a young patient who had chronic pancreatitis and underwent several plastic stent insertions due to recurrent pancreatic duct stricture. His symptoms improved after using a fully covered self-expandable metal covered stent and there was no recurrence found at follow-up at the outpatient department.     

Removal of an embedded "covered" biliary stent by the "stent-in-stent" technique

A 46-year-old man was admitted with obstructive jaundice and cross-sectional imaging with computed tomography suggested distal biliary obstruction.A distal common bile duct stricture was found at endoscopic retrograde cholangiopancreatography(ERCP)and cytology was benign.A 6 cm fully covered self-expanding metal stent(SEMS)was inserted across the stricture to optimize biliary drainage.However,the SEMS could not be removed at repeat ERCP a few months later.A further fully covered SEMS was inserted within the existing stent to enable extraction and both stents were retrieved successfully a few weeks later.Fully covered biliary(SEMS)are used to treat benign biliary strictures.This is the first reported case of inability to remove a fully-covered biliary SEMS.Possible reasons for this include tissue hyperplasia and consequent overgrowth into the stent proximally,or chemical or mechanical damage to the polymer covering of the stent.Application of the stent-in-stent technique allowed successful retrieval of the initial stent.     

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.     

A three year follow up of self expanding metal stents in the endoscopic palliation of longterm survivors with malignant biliary obstruction.

Effective palliation of malignant biliary obstruction with conventional 10 or 12 French gauge straight polyethylene endoprostheses is limited by stent occlusion, which typically occurs four to five months after insertion. Short term follow up studies of self expanding metal stents (Wallstent, Schneider, UK) in the treatment of patients with malignant biliary obstruction have shown that their use is associated with fewer episodes of stent occlusion compared with plastic stents. There are few data, however, on the longterm patency and durability of metal stents in malignant disease. Between May 1989 and May 1992, metal stents were inserted in 28 patients with malignant bile duct strictures secondary to ampullary tumour (n = 10), pancreatic carcinoma (n = 10), cholangiocarcinoma (n = 7), and porta hepatis nodes from colorectal carcinoma (n = 1). The follow up of these patients until May 1993 is reported with a median follow up of 14.6 months. Twenty two of 28 (78.6%) patients remained free of jaundice or cholangitis. The median period of stent patency was 8.2 months (range 1.0-32.5). Thirteen patients represented with jaundice or cholangitis and endoscopic retrograde cholangiopancreatography showed evidence of stent occlusion due to tumour ingrowth. Successful clearance of metal stents was achieved by balloon trawling, or insertion of a polyethylene stent. In conclusion, metal stents provide improved longterm palliation for patients with malignant biliary strictures with fewer episodes of occlusion compared with conventional stents.     

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.     

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

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

Liver resection for the treatment of post-cholecystectomy biliary stricture with vascular injury

AIM:To report experience with liver resection in a select group of patients with postoperative biliary stricture associated with vascular injury.METHODS:From a prospective database of patients treated for benign biliary strictures at our hospital,cases that underwent liver resections were reviewed.All cases were referred after one or more attempts to repair bile duct injuries following cholecystectomy(open or laparoscopic).Liver resection was indicated in patients with Strasberg E3/E4(hilar stricture)bile duct lesions associated with vascular damage(arterial and/or portal),ipsilateral liver atrophy/abscess,recurrent attacks of cholangitis,and failure of previous hepaticojejunostomy.RESULTS:Of 148 patients treated for benign biliary strictures,nine(6.1%)underwent liver resection;eight women and one man with a mean age of 38.6 years.Six patients had previously been submitted to open cholecystectomy and three to laparoscopic surgery.The mean number of surgical procedures before definitive treatment was 2.4.All patients had Strasberg E3/E4injuries,and vascular injury was present in all cases.Eight patients underwent right hepatectomy and one underwent left lateral sectionectomy without mortality.Mean time of follow up was 69.1 mo and after longterm follow up,eight patients are asymptomatic.CONCLUSION:Liver resection is a good therapeutic option for patients with complex postoperative biliary stricture and vascular injury presenting with liver atrophy/abscess in which previous hepaticojejunostomy has failed.