Biliary changes in extrahepatic portal venous obstruction: compression by collaterals or ischemic?

BACKGROUND: The postulated mechanisms of biliary abnormalities in extrahepatic portal venous obstruction (EHPVO) are either extrinsic compression by collaterals or ischemic injury due to venous thrombosis. If the former hypothesis is correct, then biliary changes should revert to normal after portasystemic shunt surgery. METHODS: Five patients with EHPVO who underwent portasystemic shunt surgery were studied. One of these patients had obstructive jaundice due to portal cavernoma. Endoscopic retrograde cholangiography (ERC) was performed before as well as after the shunt surgery. Doppler ultrasound and splenoportovenography were obtained to confirm the diagnosis of EHPVO as well as shunt patency. RESULTS: All patients had biliary abnormalities on pre-shunt ERC. The post-shunt ERC showed partial reversal of biliary abnormalities in 3 patients, complete reversal in 1 patient, and no reversal in 1 patient. Smooth strictures opened after shunt surgery and proximal dilatation disappeared in most patients. The indentations and caliber irregularities disappeared after shunt surgery, whereas angulations and ectasias of biliary ducts persisted. CONCLUSION: Shunt surgery results in regression of some of the biliary abnormalities and relieves biliary obstruction, suggesting that mechanical compression by collaterals is the mechanism behind biliary abnormalities in EHPVO. However, some biliary changes persist after shunt surgery signifying fixed obstruction due to ischemia or fibrous scarring. Thus, the two theories are not mutually exclusive.     

Portal biliopathy: a study of 39 surgically treated patients

Background

Portal biliopathy (PBP) denotes intra- and extrahepatic biliary duct abnormalities that occur as a result of portal hypertension and is commonly seen in extrahepatic portal vein obstruction (EHPVO). The management of symptomatic PBP is still controversial.

Methods

Prospectively collected data for surgically managed PBP patients from 1996 to 2007 were retrospectively analysed for presentation, clinical features, imaging and the results of surgery. All patients were assessed with a view to performing decompressive shunt surgery as a first-stage procedure and biliary drainage as a second stage-procedure if required, based on evaluation at 6 weeks after shunt surgery.

Results

A total of 39 patients (27 males, mean age 29.56 years) with symptomatic PBP were managed surgically. Jaundice was the most common symptom. Two patients in whom shunt surgery was unsuitable underwent a biliary drainage procedure. A total of 37 patients required a proximal splenorenal shunt as first-stage surgery. Of these, only 13 patients required second-stage surgery. Biliary drainage procedures (hepaticojejunostomy [n = 11], choledochoduodenostomy [n = 1]) were performed in 12 patients with dominant strictures and choledocholithiasis. One patient had successful endoscopic clearance of common bile duct (CBD) stones after first-stage surgery and required only cholecystectomy as a second-stage procedure. The average perioperative blood product transfusion requirement in second-stage surgery was 0.9 units and postoperative complications were minimal with no mortality. Over a mean follow-up of 32.2 months, all patients were asymptomatic. Decompressive shunt surgery alone relieved biliary obstruction in 24 of 37 patients (64.9%) and facilitated a safe second-stage biliary decompressive procedure in the remaining 13 patients (35.1%).

Conclusions

Decompressive shunt surgery alone relieves biliary obstruction in the majority of patients with symptomatic PBP and facilitates endoscopic or surgical management in patients who require second-stage management of biliary obstruction.     

Portal biliopathy in patients with non-cirrhotic portal hypertension: does the type of surgery affect outcome?

Objectives

After portosystemic anastomoses for biliopathy, some patients continue to suffer biliary obstruction. The effects of splenectomy and devascularization of the abdominal oesophagus and upper stomach are unclear. The aim of the current study was to determine the features of portal biliopathy (PB) in patients with non-cirrhotic portal hypertension, and to investigate outcomes in these patients after surgical procedures.

Methods

A retrospective study of 56 patients who underwent surgery for PB during 1996–2010 was conducted. Data on presenting features, treatment received and outcomes were analysed.

Results

In total, 41 of these patients had extrahepatic portal venous obstruction and 15 had non-cirrhotic portal fibrosis. Forty patients underwent shunt surgery and 16 underwent splenectomy and devascularization. Median bilirubin levels fell from 1.8 mg/dl (range: 0.4–5.9 mg/dl) to 1.0 mg/dl (range: 0.3–5.4 mg/dl) after shunt surgery and from 1.9 mg/dl (range: 0.6–4.0 mg/dl) to 1.2 mg/dl (range: 0.6–5.2 mg/dl) after splenectomy–devascularization. On follow-up, five of 33 patients had persistent jaundice after successful shunt surgery. These patients had a history of multiple endoscopic stentings and three patients had demonstrated a dominant common bile duct stricture preoperatively.

Conclusions

Portal biliopathy was reversed in 38 of 43 patients by either portosystemic shunting or splenectomy–devascularization. In five patients, direct biliary decompressive procedures were required because of shunt blockage or a non-reversible biliary stricture.     

Biliary strictures complicating pancreaticoduodenectomy.

BACKGROUND: Biliary-enteric anastomotic strictures may complicate pancreaticoduodenectomy. Anastomotic ischaemia and reflux of gastric and enteric contents with secondary bacterobilia and cholangitis may contribute. METHODS: Four patients (3 females, 1 male) with a mean age of 50 yr (range 26-73 yr) presented 1-12 yr following pancreaticoduodenectomy with features suggestive of biliary-enteric anastomotic stricture formation. These included recurrent cholangitis, obstructive jaundice, and liver abscess. Diagnosis was confirmed by percutaneous or endoscopic cholangiography. Endoscopic and radiological management were unsuccessful, and revision surgery in the form of a Roux-en-Y hepaticojejunostomy was required. RESULTS: Three patients remain asymptomatic 10-30 mo postoperatively. Jaundice recurred at 15 mo in one patient owing to re-stricture formation and the development of secondary biliary cirrhosis; a liver transplantation is being considered. CONCLUSION: Early diagnosis and prompt management of biliary-enteric stricture is essential if secondary biliary cirrhosis is to be avoided. Definitive therapy is best accomplished with a Roux-en-Y hepaticojejunostomy that places the gastric and biliary anastomoses onto separate jejunal limbs.     

Therapeutic approaches for portal biliopathy: A systematic review

Portal biliopathy(PB) is defined as the presence of biliary abnormalities in patients with non-cirrhotic/nonneoplastic extrahepatic portal vein obstruction(EHPVO) and portal cavernoma(PC). The pathogenesis of PB is due to ab extrinseco compression of bile ducts by PC and/or to ischemic damage secondary to an altered biliary vascularization in EHPVO and PC. Although asymptomatic biliary abnormalities can be frequently seen by magnetic resonance cholangiopancreatography in patients with PC(77%-100%), only a part of these(5%-38%) are symptomatic. Clinical presentation includes jaundice, cholangitis, cholecystitis, abdominal pain, and cholelithiasis. In this subset of patients is required a specific treatment. Different therapeutic approaches aimed to diminish portal hypertension and treat biliary strictures are available. In order to decompress PC, surgical porto-systemic shunt or transjugular intrahepatic porto-systemic shunt can be performed, and treatment on the biliary stenosis includes endoscopic(Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy, balloon dilation, stone extraction, stent placement) and surgical(bilioenteric anastomosis, cholecystectomy) approaches. Definitive treatment of PB often requires multiple and combined interventions both on vascular and biliary system. Liver transplantation can be considered in patients with secondary biliary cirrhosis, recurrent cholangitis or unsuccessful control of portal hypertension.     

Treatment of complications of hepatic hydatid disease by ERCP

BACKGROUND: The aim of this study was to evaluate the effectiveness of endoscopic sphincterotomy for preoperative and postoperative complications of hepatic hydatid disease. METHODS: Nineteen patients underwent endoscopic treatment for complications of hepatic hydatid disease. Indications for ERCP in 5 patients treated before surgery (Group A) were obstructive jaundice in 1 and acute cholangitis in 4. In 14 patients treated after surgery (Group B), the indication was acute cholangitis in 6, obstructive jaundice 2, and persistent external drainage in 6 patients. OBSERVATIONS: In group A, ERCP detected hydatid vesicles within the bile duct. All patients underwent endoscopic sphincterotomy and clearance of the duct with no complications. The 6 patients in Group B with persistent external drainage had biliary fistulas that resolved after endoscopic treatment within 10 to 20 days. Among the 8 patients with postoperative obstructive jaundice or acute cholangitis, 7 had cyst remnants obstructing the bile duct and 1 had findings of sclerosing cholangitis. All underwent endoscopic sphincterotomy and clearance of the bile duct without complications. After treatment, all patients, with the exception of the one with sclerosing cholangitis, remained asymptomatic. CONCLUSION: Endoscopic sphincterotomy is a safe and effective treatment for biliary complications of hepatic hydatid disease.     

Biliary strictures complicating pancreaticoduodenectomy

Summary Background. Biliary-enteric anastomotic strictures may complicate pancreaticoduodenectomy. Anastomotic ischaemia and reflux of gastric and enteric contents with secondary bacterobilia and cholangitis may contribute. Methods. Four patients (3 females, 1 male) with a mean age of 50 yr (range 26–73 yr) presented 1–12 yr following pancreaticoduodenectomy with features suggestive of biliary-enteric anastomotic stricture formation. These included recurrent cholangitis, obstructive jaundice, and liver abscess. Diagnosis was confirmed by percutaneous or endoscopic cholangiography. Endoscopic and radiological management were unsuccessful, and revision surgery in the form of a Roux-en-Y hepaticojejunostomy was required. Results. Three patients remain asymptomatic 10–30 mo postoperatively. Jaundice recurred at 15 mo in one patient owing to re-stricture formation and the development of secondary biliary cirrhosis; a liver transplantation is being considered. Conclusion. Early diagnosis and prompt management of biliary-enteric stricture is essential if secondary biliary cirrhosis is to be avoided. Definitive therapy is best accomplished with a Roux-en-Y hepaticojejunostomy that places the gastric and biliary anastomoses onto separate jejunal limbs.     

Portal biliopathy

Biliary ductal changes are a common radiological finding in patients with portal hypertension, however only a small percentage of patients (5%-30%) develop symptomatic bile duct obstruction. The exact pathogenesis is not clear, but an involvement of factors such as bile duct compression by venous collaterals, ischemia, and infection is accepted by most authors. Although endoscopic retrograde cholangiopancreatography was used to define and diagnose this condition, magnetic resonance cholangiopancreatography is currently the investigation of choice for diagnosing this condition. Treatment is indicated only for symptomatic cases. Portosystemic shunts are the treatment of choice for symptomatic portal biliopathy. In the majority of patients, the changes caused by biliopathy resolve after shunt surgery, however, 15%-20% patients require a subsequent bilio-enteric bypass or endoscopic management for persistent biliopathy. There is a role for endoscopic therapy in patients with bile duct stones, cholangitis or when portosystemic shunt surgery is not feasible.     

Management of endoscopic biliary stenting for choledocholithiasis: Evaluation of stent-exchange intervals

AIM To evaluate the best management of plastic stents in patients with choledocholithiasis who were unfit for endoscopic stone removal or surgery. METHODS Between April 2007 and September 2017, 87 patients(median age 83.7 years) with symptomatic choledocholithiasis were treated with insertion of 7-Fr plastic stents because complete endoscopic stone retrieval was difficult, and their general condition was not suitable for surgery. Seventy of these patients agreed to regular stent management and stent exchange was carried out at every 6 mo(Group A, n = 35) or every 12 mo(Group B, n = 35). The remaining 17 patients did not accept regular stent exchange, and stents were replaced when clinical symptoms appeared(Group C). We evaluated the frequency of biliary complication and stent patency rate during follow-up periods. RESULTS The patency rate of biliary plastic stents was 91.4% at 6 mo(Group A) and 88.6% at 12 mo(Group B), respectively. Acute cholangitis occurred in 2.9% of Group A patients and in 8.6% of Group B patients. In Group C, median stent patency was 16.3 mo, and stent exchange was carried out in 70.6% of cases because of acute cholangitis or obstructive jaundice. Although a high incidence of acute cholangitis occurred, there was no biliary-related mortality. CONCLUSION Plastic stent exchange at 12-mo intervals is considered a safe procedure for patients with choledocholithiasis. Long-term biliary stenting increases biliary complications, but it can be an acceptable option for select patients who are medically unfit for further invasive procedures.     

Portal biliopathy

In patients with portal hypertension, particularly with extrahepatic portal vein obstruction, portal biliopathy producing biliary ductal and gallbladder wall abnormalities are common. Portal cavernoma formation, choledochal varices and ischemic injury of the bile duct have been implicated as causes of these morphological alterations. While a majority of the patients are asymptomatic, some present with a raised alkaline phosphatase level, abdominal pain, fever and cholangitis. Choledocholithiasis may develop as a complication and manifest as obstructive jaundice with or without cholangitis. Endoscopic sphincterotomy and stone extraction can effectively treat cholangitis when jaundice is associated with common bile duct stone(s). Definitive decompressive shunt surgery is sometimes required when biliary obstruction is recurrent and progressive.     

Effect of shunt surgery on spleen size, portal pressure and oesophageal varices in patients with non-cirrhotic portal hypertension

Shunt surgery is considered to be the treatment of choice in patients with non-cirrhotic portal hypertension. There is little data on the effect of side-to-side lieno-renal (SSLR) shunt on oesophageal variceal size, splenic size and splenic pulp pressure (SPP) in patients with non-cirrhotic portal hypertension. We evaluated pre- and postoperatively endoscopic grading of varices, splenic size and SPP for predicting shunt patency in 86 patients with non-cirrhotic portal hypertension: 56 with extrahepatic portal venous obstruction (EHPVO) and 30 with non-cirrhotic portal fibrosis (NCPF). The EHPVO patients with patent shunts (n= 47) showed significant reduction in SPP (pre-operative 43.56±7.9 vs postoperative 29.96±7.7 cm of saline), splenic size (6.5±2.8 vs 4.00±2.6 cm below costal margin) and varices grades (2.96±0.5 vs 0.92±0.8). Patients with blocked shunt (n= 9) did not show significant reduction in SPP and varices grades. However, there was reduction in spleen size (8.6±3.0 vs 6.3±4.3). In the NCPF group, 28 had patent shunts and showed significant reduction in SPP (46.3±13.5 vs 33.8±7.6 cm of saline), splenic size (9.1±3.3 vs 6.8±4.6 cm below costal margin) and varices grades (2.8±0.7 vs 1.05±0.96). As only two patients with NCPF had blocked shunts, no statistical comparison between patients with patent and patients with blocked shunts could be done. In conclusion, following SSLR, there is a significant reduction in SPP and varices grades in patients with patent shunts. Endoscopic grading of varices can be used to predict shunt patency. However, spleen size is not a good criteria for predicting shunt patency.     

ENDOSCOPIC NASOBILIARY DRAINAGE: CURRENT INDICATIONS AND EVALUATION OF THE PRODUCTS

Endoscopic nasobiliary drainage (ENBD) is a well established mode of biliary decompression. Although ENBD is certainly an uncomfortable procedure with the potential risk of spontaneous dislocation or removal of the drainage catheter by disoriented patients, it has several advantages over endoscopic biliary drainage (EBD) using an indwelling stent. The current indications for ENBD are: (i) temporary drainage to treat obstructive jaundice and cholangitis caused by malignant or benign biliary stricture; (ii) urgent drainage to treat suppurative cholangitis primarily caused by common bile duct stones; (iii) temporary drainage after stone removal in patients with suspected incomplete clearance and/or with cholangitis; and (iv) biliary leaks that occur primarily after surgery, as well as other indications. Different types of nasobiliary catheters are currently available that have been designed with various diameters, shapes, and materials. However, the current catheters are not considered by most endoscopists to be sufficient. Further improvements are needed to achieve better drainage and better maneuverability.     

"Cloggology" revisited: endoscopic or surgical decompression of malignant biliary obstruction

In this study, 50 consecutive patients over age 60 with obstructive jaundice secondary to malignant stricture of the distal common bile duct were identified by endoscopic cholangiography. The patients were then randomized to palliative therapy with either endoscopic endoprosthesis or bypass surgery. Prospective indices of survival time, complication rates, hospitalization requirements, and quality of life were followed. All 25 patients randomized to endoprosthesis were treated by this procedure, whereas only 19 of 25 patients randomized to bypass surgery underwent operative biliary-digestive anastomosis. No difference in the above indices were found between the two groups. The authors concluded that palliation of obstructive jaundice due to a malignant bile duct stricture with endoscopically placed biliary stent is as effective as operative bypass.     

Endoscopic management of Mirizzi''s syndrome.

BACKGROUND: The accepted management of Mirizzi's syndrome is surgical, but endoscopic and percutaneous management have been described. AIM: To review our experience of endoscopic intervention for Mirizzi's syndrome. PATIENTS AND METHODS: ERCP reports of patients presenting for endoscopic management of choledocholithiasis between March 1989 and June 1995 were reviewed. Those with cholangiographic evidence of Mirizzi's syndrome were selected for study. Patient records and cholangiograms were reviewed and follow up was recorded from the notes or by telephone contact with patients, their relatives, or doctors. RESULTS: Twenty five patients had Mirizzi's syndrome. Sixteen were female and their median age was 67 years (range 28-91). Ten presented with painless jaundice, nine with painful jaundice, four with cholangitis, and two had pain as their only symptom. Twelve were referred for surgery and 11 of these had preliminary endoscopic therapy. Thirteen have been treated solely with endoscopic therapy. Treatment in this group was aimed at relieving jaundice and removing stones. Stones were completely removed in three patients. Nine patients have been treated with long term stents, and one awaits extracorporeal shockwave lithotripsy of the gall bladder. Complications of treatment occurred in four of 25 after ERCP. CONCLUSIONS: Endoscopic treatment of Mirizzi's syndrome is effective as a temporising measure before surgery and can be definitive treatment for unsuitable surgical candidates.     

Early EUS of the bile duct before endoscopic sphincterotomy for acute biliary pancreatitis.

BACKGROUND: Endoscopic sphincterotomy can benefit patients with suspected biliary pancreatitis, although there are procedure-related complications. EUS can be used to select patients for endoscopic sphincterotomy. The results of this strategy were assessed. METHODS: Information on patients referred for EUS were recorded in a database. One hundred twenty-three patients with suspected biliary pancreatitis (57 men, 66 women; median age 55 years) were included and followed. All underwent EUS followed by endoscopic sphincterotomy during the same procedure if choledocholithiasis was identified. Outcomes were studied in relation to the initial severity of biliary pancreatitis (Ranson and Balthazar scores), presence of stones, and time span between onset of biliary pancreatitis and EUS plus endoscopic sphincterotomy. RESULTS: Thirty-five patients (28%) had a Ranson score greater than 3 on admission and 38 (31%) were Balthazar D-E. The median time from admission to EUS was 3 days. EUS imaging of the bile duct was complete in all but 3 patients. Thirty-three patients (27%) had choledocholithiasis on EUS and underwent endoscopic sphincterotomy. Stones were more frequent in patients with jaundice (p < 0.005) and when EUS was performed less than 3 days after admission (p < 0.05). One hundred patients (81%) recovered without complication. Two patients (1.6%) died, 1 had recurrent BP develop, 6 (5%) had further biliary symptoms, and 16 (13%) had complications of pancreatitis develop (9 pseudocysts). There were 3 mild endoscopic sphincterotomy-related complications (complication rate 6.5%). CONCLUSIONS: In this series in which endoscopic sphincterotomy was performed selectively depending on the endosonographic presence or absence of ductal stones early in the course of the pancreatitis, and not according to its predicted severity, mortality and complications of endoscopic sphincterotomy were low and unrelated to the predicted severity of biliary pancreatitis or the presence of choledocholithiasis. Controlled trials are needed to confirm the superiority of this strategy compared with ERCP alone for the management of biliary pancreatitis.     

Endoscopic treatment for suprapancreatic biliary stricture following blunt abdominal trauma

OBJECTIVES: Suprapancreatic biliary stricture associated with blunt abdominal trauma is extremely rare. Therefore, no definitive treatment modality for this stricture has been fully established. This study was designed to evaluate the efficacy and long-term follow-up of endoscopic treatment for suprapancreatic biliary stricture following blunt abdominal trauma. METHODS: Data from the institution's prospectively collected endoscopic retrograde cholangiopancreatography (ERCP) database, medical records, radiological findings, and trauma registry with operative records were used to identify patients with suprapancreatic biliary stricture associated with blunt abdominal trauma. RESULTS: Eight patients (six men and two women) with a median age of 36 yr (interquartile range [IQR] 29-53 yr) were included in this study. The median interval between the initial trauma and the onset of symptoms was 23 days (IQR 16-51 days). The median length of biliary stricture was 1 cm (IQR 0.6-1 cm). Endoscopic plastic stent placement was successfully performed in all patients included in the study. The median duration of stent placement was 2 months (IQR 2-2.8 months). Follow-up ERCP showed improved or resolved biliary stricture in all patients. There was no recurrence of symptoms after the removal of the stents; therefore, surgery was unnecessary in these patients. Long-term follow-up (median 33 months) was also excellent. CONCLUSIONS: Endoscopic plastic stent placement may be a good candidate for first-line management for suprapancreatic biliary strictures following blunt abdominal trauma. Furthermore, the long-term results for this type of biliary stricture with endoscopic stent placement may be excellent.     

The benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis

Objective: Endoscopic nasobiliary drainage for acute cholangitis is performed with or without endoscopic sphincterotomy. However, sphincterotomy carries a small but important risk of complications. We evaluated the benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis.
Methods: A total of 166 patients underwent endoscopic nasobiliary drainage with sphincterotomy (73 patients, sphincterotomy group) or without (93 patients, nonsphincterotomy group). The indications were acute cholangitis due to choledocholithiasis (120 patients) or benign (10 patients) or malignant (36 patients) biliary stricture. Patient backgrounds were similar in the two groups. The outcomes of nasobiliary drainage were compared between the groups.
Results: Nasobiliary drainage was successful in 69 patients (95%) in the sphincterotomy group and in 89 (96%) in the nonsphincterotomy group. Efficient drainage was achieved in 67 patients (92%) in the sphincterotomy group and in 87 (94%) in the nonsphincterotomy group. Procedure-related complications developed in eight sphincterotomy-group patients (hemorrhage in three, acute cholecystitis in three, acute pancreatitis in one, catheter withdrawal in one) and in two nonsphincterotomy patients (pancreatitis in one, catheter withdrawal in one) (11% vs 2%;   p < 0.05  ). There were no deaths.
Conclusions: Endoscopic nasobiliary drainage without endoscopic sphincterotomy is a simple, safe, and effective treatment for acute cholangitis. This procedure is especially useful for critically ill patients and those with coagulopathy.     

Endoscopic sphincterotomy vs. endoscopic papillary balloon dilation for choledocholithiasis in patients with liver cirrhosis and coagulopathy

BACKGROUND: To determine whether endoscopic papillary balloon dilation decreases the risk of hemorrhage without increasing the risk of acute pancreatitis, the results of endoscopic papillary balloon dilation were compared with those of endoscopic biliary sphincterotomy in patients with cirrhosis and coagulopathy. METHODS: Twenty-one patients with liver cirrhosis with coagulopathy had endoscopic papillary balloon dilation for choledocholithiasis from January 2001 to September 2003. Twenty patients with cirrhosis and coagulopathy who underwent endoscopic biliary sphincterotomy from January 1998 to December 2000, served as a historical control group. RESULTS: The rate of endoscopic biliary sphincterotomy related hemorrhage was 30% (6/20), whereas the rate for endoscopic papillary balloon dilation related hemorrhage was 0% (p=0.009). With regard to rates of hemorrhage in relation to Child-Pugh class, most (n=5) of the bleeding complications occurred in patients with Child-Pugh class C cirrhosis; bleeding occurred in only one patient with Child-Pugh B cirrhosis. There was no significant difference between the endoscopic biliary sphincterotomy and the endoscopic papillary balloon dilation groups for procedure-related pancreatitis (10% vs. 4.7%, respectively; p>0.05). CONCLUSIONS: Endoscopic papillary balloon dilation may significantly reduce the risk of bleeding compared with endoscopic biliary sphincterotomy in patients with advanced cirrhosis and coagulopathy. In these patients, the substitution of endoscopic papillary balloon dilation for endoscopic biliary sphincterotomy is recommended for treatment of choledocholithiasis.     

Long-term results of endoscopic drainage of common bile duct strictures in chronic pancreatitis

OBJECTIVES: Endoscopic stent therapy is an established treatment modality for postoperative biliary strictures. At present, biliary stenting is also widely applied in chronic pancreatitis (CP), but results regarding long-term outcome are scarce. METHODS: All CP patients who underwent endoscopic biliary drainage of a benign stricture in our hospital between 1987 and 2000 were included in this retrospective study. RESULTS: Fifty-eight CP patients underwent biliary stenting (median age, 54 years; 44 male). The procedure-related mortality rate was 2% and the complication rate 4%. Median follow-up was 45 months (range, 0-182 months). Endoscopic treatment was successful in 22 patients (38%). Concomitant acute pancreatitis was the only factor identified as predictive of a successful outcome by multivariate analyses. Subanalysis of these 12 patients revealed a success rate of 92%, as opposed to 24% in cases without acute inflammation. In this latter group, continued stenting beyond a 1-year period almost never resulted in additional stricture resolvement. If stricture resolution was accomplished, however, no recurrences were observed. CONCLUSIONS: For biliary strictures due to CP, without evidence of concomitant acute pancreatitis, the long-term success rate of endoscopic therapy is poor and only one out of four strictures is treated successfully. When a biliary stricture has not resolved after 1 year of endoscopic stenting, surgery should be considered.     

IDIOPATHIC BENIGN STRICTURES OF THE EXTRAHEPATIC BILE DUCT: RESULTS OF ENDOSCOPIC THERAPY

Background: Idiopathic, benign, non‐traumatic, non‐inflammatory strictures of bile ducts are rare. We report cases with benign non‐traumatic, non‐inflammatory strictures of bile ducts diagnosed on histopathology of endoscopic tissue specimens and managed with endoscopic therapy. Methods: Eight patients with benign non‐traumatic, non‐inflammatory strictures of bile ducts were studied. Diagnosis of benign stricture was based on imaging studies (ultrasound and CT scanning), normal CA 19–9 levels, negative brush cytology and histopathology, endoscopic retrograde cholangiopancreatography (ERCP) and no evidence of malignancy on follow up. Endoscopic balloon dilatation of stricture was performed and biliary stent was placed. Results: Median age was 42 years and five patients were males. Clinical presentation included jaundice (5), abdominal pain (7), fever (2) and pruritus (6). Liver function tests and imaging studies revealed features of obstructive jaundice. ERCP revealed smooth concentric and tapering stricture in all patients. Brush cytology and histopathological specimen revealed cubocolumnar epithelium surrounded by fibrous tissue without inflammation and negative for malignant cells. All patients got relief of fever, jaundice, pain and pruritus after balloon dilatation and stenting. Symptoms completely resolved in a median of 24 days. Liver function tests normalized in a median of 36 days. Follow up ERCP after 6 months did not show evidence of stricture and stent could be removed successfully in all patients. Thereafter, for a median follow up of 19 months, patients remained asymptomatic and their liver function tests and ultrasound were normal. Conclusions: Benign strictures of extrahepatic bile ducts can be non‐traumatic and non‐inflammatory without any cause and can be managed successfully with endoscopic balloon dilatation and biliary stenting.