Endoscopic management of benign bile duct strictures

Endoscopic treatment for benign biliary strictures has largely replaced surgical and percutaneous approaches because of lower morbidity and mortality. However, endoscopic therapy often requires multiple procedures and serial stenting for 1 year or longer. Although the optimal algorithm for endoscopic therapy is unknown, most experts agree that maximal dilation and stenting for a period of at least 3 months will result in the best short- and long-term outcomes. Dominant strictures related to sclerosing cholangitis are more challenging to manage and typically respond best to dilation alone or with shorter-term stent therapy. When considering endoscopic treatment, the location and etiology of the stricture have important prognostic implications that may prompt earlier referral to a different subspecialist or alter the endoscopic strategy. Newer stent technologies, such as fully covered self-expandable metallic stents, may alter the treatment paradigm, although future studies are needed before this strategy can be endorsed. This article reviews the current evidence supporting endoscopic therapy for benign biliary strictures, reviews the clinical predictors of long-term success, underscores the technical aspects of dilation and stent placement, and considers future directions for endoscopic treatment.     

Endoscopic therapy for benign bile duct strictures

Endoscopic therapy was attempted in 25 patients with benign strictures of the bile duct. In 23 patients, treatment involved endoscopic balloon dilation of the stricture zone or balloon dilation plus endoprosthesis placement. In 22 of 25 patients (88%), there was benefit from the endoscopic treatment. In 20 of 23 patients, there was significant radiographic improvement (p less than 0.001) in the diameter of their stricture following endoscopic therapy. All patients with elevated liver enzymes demonstrated rapid improvement following treatment. There was no significant morbidity or mortality associated with endoscopic treatment of benign biliary tract strictures. Follow-up study (mean, 4 +/- 0.3 years) discloses no recurrence of symptoms or elevated enzymes indicative of recurrent strictures. The treatment of benign bile duct strictures by a combination therapy of balloon dilation and stent placement provides a safe and effective treatment modality and an alternative to operative intervention.     

Endoscopic ultrasound guided fine-needle aspiration and biopsy of pancreatic cysts

Pancreatic cystic lesions (PCLs) are often incidentally found on cross-sectional imaging. Long strides have been made in the past decade with improved quality and optics of cross-sectional imaging and endoscopic ultrasound (EUS), but a singular reliable test to appropriately characterize and risk-stratify PCLs has still eluded us. EUS allows high-resolution imaging of the pancreatic parenchyma and the ductal system, for assessment of PCL characteristics, with features concerning for malignancy and additionally provides an opportunity to sample the cyst to obtain fluid or cells for further diagnostic testing. This presents new sets of challenges, which include devising suitable equipment or needles and techniques for reliable and safe tissue acquisition, as well as provision of an adequate cytology or tissue sample to the pathologist, in order to arrive at an accurate diagnosis. This article will review the current role of EUS in the diagnosis and characterization of PCLs, with a focus on available strategies and pitfalls of cytology, cyst-fluid biomarkers, and biopsy acquisition techniques; and future directions to increase the yield and accuracy.     

Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation

BACKGROUND: Optimal therapy for anastomotic biliary strictures occurring after orthotopic liver transplantation (OLT) remains to be defined. We reviewed our experience with endoscopic therapy for such strictures and contrasted it with reported data. METHODS: Endoscopic therapy was performed with balloon dilation alone; no patients received an endoprosthesis. Responses were characterized as good if the patient improved clinically and no subsequent procedures were required after one or more dilations within a 3-month period; partial if clinically significant obstruction resolved but cholestasis persisted or there was a need for further endoscopic management beyond the initial 3 months; poor if subsequent surgery or percutaneous procedures were required; and failed if endoscopic access or dilation could not be accomplished. RESULTS: Fifteen patients underwent 23 endoscopic retrograde cholangiopancreatographies for post-OLT anastomotic strictures. Postprocedure follow-up averaged 25.2 months. Cholangiography was successful in all 23 procedures; free duct access was achieved in 22 of 23 procedures. The strictures were successfully accessed for dilation in 11 of 15 patients and in 19 of 23 procedures. Outcome was deemed good in 4 (27%), partial in 3 (20%), and poor in 5 (33%) patients. Endoscopic therapy failed in 3 (20%). Poor outcomes were due to the early recognition of severe lesions (2 treated surgically) or to short-term responses to dilation alone (3). The procedural complication rate of 17.4% included 3 episodes of transient cholangitis (i.e., elevation of liver enzymes associated with fever that lasted less than 3 days) and 1 self-limited episode of postsphincterotomy bleeding, which required the transfusion of 2 units packed red blood cells. In published series the combined success rate of balloon dilation alone for treatment of anastomotic strictures is 41%, whereas for dilation plus stent placement it is 75%. CONCLUSION: Endoscopic balloon dilation alone is not a reliable method of therapy for anastomotic strictures occurring after OLT. Dilation followed by short- to intermediate-term stent placement appears to provide a more durable result.     

Endoscopic biliary prostheses as treatment for benign postoperative bile duct strictures

We evaluated the efficacy of endoscopically placed biliary stents as treatment for 32 benign postoperative biliary strictures in 29 patients. Five patients also had bile fistulas. Stents were inserted for a mean of 162 days and then removed. ERCPs were obtained before stent insertion and again after removal. Responses were followed and categorized as excellent, good, or poor. Stent insertion was successful in 25 patients (86%), 23 of which have a mean follow-up of 19 months (range, 2 to 42 months) after stent removal. Seventy-four percent had an excellent (48%) or good (26%) response. Early postoperative strictures and fistulas responded favorably. We conclude that benign postoperative biliary strictures can be treated successfully by endoscopic prostheses.     

Postoperative bile duct strictures

Opinion statement  

Intraductal ultrasound substantiates diagnostics of bile duct strictures of uncertain etiology

AIM:To report the largest patient cohort study investigating the diagnostic yield of intraductal ultrasound (IDUS) in indeterminate strictures of the common bile duct.METHODS:A patient cohort with bile duct strictures of unknown etiology was examined by IDUS.Sensitivity,specificity and accuracy rates of IDUS were calculated relating to the definite diagnoses proved by histopathology or long-term follow-up in those patients who did not undergo surgery.Analysis of the endosonographic report allowed drawing conclusions with respect to the T and N staging in 147 patients.IDUS staging was compared to the postoperative histopathological staging data allowing calculation of sensitivity,specificity and accuracy rates for T and N stages.The endoscopic retrograde cholangio-pancreatography and IDUS procedures were performed under fluoroscopic guidance using a side-viewing duodenoscope (Olympus TJF 160,Olympus,Ltd.,Tokyo,Japan).All procedures were performed under conscious sedation (propofol combined with pethidine) according to the German guidelines.For IDUS,a 6 F or 8 F ultrasound miniprobe was employed with a radial scanner of 15-20 MHz at the tip of the probe (Aloka Co.,Tokyo,Japan).RESULTS:A total of 397 patients (210 males,187 females,mean age 61.43 ± 13 years) with indeterminate bile duct strictures were included.Two hundred and sixty-four patients were referred to the department of surgery for operative exploration,thus surgical histopathological correlation was available for those patients.Out of 264 patients,174 had malignant disease proven by surgery,in 90 patients benign disease was found.In these patients decision for surgical exploration was made due to suspicion for malignant disease in multimodal diagnostics (computed tomography scan,endoscopic ultrasound or magnetic resonance imaging).Twenty benign bile duct strictures were misclassified by IDUS as malignant while 14 patients with malignant strictures were initially misdiagnosed by IDUS as benign resulting in sensitivity,specificity and accuracy ratesof 93     

Endoscopic ultrasound-guided fine-needle aspiration in pulmonary medicine

Endoscopic ultrasound-guided fine-needle aspiration has significantly increased the capacity of pulmonary diagnostic procedures. Since this method was introduced, 1212 examinations have been performed at two centres of pulmonary medicine. Data on indications, procedures, findings, diagnostic yield and complications have been recorded. This paper describes the experiences thus gained regarding the possibilities and limitations of the method and assesses the current significance of the technique in pulmonary medicine according to previous studies. In primary diagnosis of mediastinal tissue alterations and in staging of malignant diseases the method offers a low-complication diagnostic measure which has a seminal impact on therapy in many cases, even though in daily practise the diagnostic accuracy of published studies is not always attained.     

Endoscopic and endobronchial ultrasound real-time fine-needle aspiration for staging of the mediastinum in lung cancer

Mediastinal lymph node metastases in patients with non-small cell lung cancer are a critical determinant of operability. Mediastinoscopy is invasive, requires general anesthesia, and carries appreciable morbidity. The development of minimally invasive techniques for the pathologic staging of lung cancer is important. We report a one-stop minimally invasive method for the pathologic diagnosis and staging of the majority of the mediastinum under conscious sedation using a novel prototype endobronchial ultrasound probe with a real-time fine-needle aspiration (FNA) facility in combination with conventional endoscopic ultrasound FNA.     

Endoscopic ultrasound fine-needle aspiration characteristics of primary adenocarcinoma versus other malignant neoplasms of the pancreas

BACKGROUND:

Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) is often used to assist in the evaluation of pancreatic lesions and may help to diagnose benign versus malignant neoplasms. However, there is a paucity of literature regarding comparative EUS characteristics of various malignant pancreatic neoplasms (primary and metastatic).

OBJECTIVE:

To compare and characterize primary pancreatic adenocarcinoma versus other malignant neoplasms, hereafter referred to as nonprimary pancreatic adenocarcinoma (NPPA), diagnosed by EUS-guided FNA.

METHODS:

The present study was a retrospective analysis of a prospectively maintained database. The setting was a tertiary care, academic medical centre. Patients referred for suspected pancreatic neoplasms were evaluated. Based on EUS-FNA characteristics, primary pancreatic adenocarcinoma was differentiated from other malignant neoplasms. The subset of other neoplasms was defined as malignant lesions that were ‘NPPAs’ (ie, predominantly solid or solid/cystic based on EUS appearance and primary malignant lesions or metastatic lesions to the pancreas). Pancreatic masses that were benign cystic lesions (pseudocyst, simple cyst, serous cystadenoma) and focal inflammatory lesions (acute, chronic and autoimmune pancreatitis) were excluded.

RESULTS:

A total of 230 patients were evaluated using EUS-FNA for suspected pancreatic mass lesions. Thirty-eight patients were excluded because they were diagnosed with inflammatory lesions or had purely benign cysts. One hundred ninety-two patients had confirmed malignant pancreatic neoplasms (ie, pancreatic adenocarcinoma [n=144], NPPA [n=48]). When comparing adenocarcinoma with NPPA lesions, there was no significant difference in mean age (P=0.0675), sex (P=0.3595) or average lesion size (P=0.3801). On average, four FNA passes were necessary to establish a cytological diagnosis in both lesion subtypes (P=0.396). Adenocarcinomas were more likely to be located in the pancreatic head (P=0.0198), whereas masses in the tail were more likely to be NPPAs (P=0.0006). Adenocarcinomas were also more likely to exhibit vascular invasion (OR 4.37; P=0.0011), malignant lymphadenopathy (P=0.0006), pancreatic duct dilation (OR 2.4; P=0.022) and common bile duct dilation (OR 2.87; P=0.039).

CONCLUSIONS:

Adenocarcinoma was more likely to be present in the head of the pancreas, have lymph node and vascular involvement, as well as evidence of pancreatic duct and common bile duct obstruction. Of all malignant pancreatic lesions analyzed by EUS-FNA, 25% were NPPA, suggesting that FNA is crucial in establishing a diagnosis and may be helpful in preoperative planning.     

Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (FNA) of liver lesions.

BACKGROUND: Endoscopic ultrasonography (EUS) is not traditionally thought to be clinically applicable in liver imaging. EUS-guided fine-needle aspiration of the liver has not been well described. METHODS: A prospective study was conducted in which 574 consecutive patients with a history or suspicion of gastrointestinal or pulmonary malignant tumor undergoing upper EUS examinations underwent EUS evaluation of the liver. Fourteen (2.4%) patients were found to have focal liver lesions and underwent EUS-guided fine-needle aspiration. RESULTS: The median largest diameter of the liver lesions was 1.1 cm (range 0.8 to 5.2 cm). The mean number of passes was 2.0 (range 1 to 5 passes). All fine-needle passes yielded an adequate specimen. One of the 14 patients underwent EUS-guided fine-needle aspiration of 2 liver lesions. Fourteen of the 15 liver lesions sampled by means of EUS-guided fine-needle aspiration were malignant and one was benign. Before EUS, computed tomography (CT) depicted liver lesions in only 3 of 14 (21%) patients. Seven of 14 patients had a known cancer diagnosis. For the other 7, the initial diagnosis of cancer was made by means of EUS-guided fine-needle aspiration of the liver. There were no immediate or late complications. CONCLUSIONS: EUS can detect small focal liver lesions that are not detected at CT. Findings of EUS-guided fine-needle aspiration can confirm a cytologic diagnosis of liver metastasis and establish a definitive M stage that may change clinical management.     

Current management of benign and malignant bile duct strictures

Benign and malignant bile duct strictures require multidisciplinary management. The radiologist, endoscopist and surgeon must assess the general conditions of the patient, as well as the etiology of the stenosis and the therapeutic options (palliative, temporal, or definitive). Stenotic injuries that maintain bilioenteric continuity are susceptible to radiologic and/or endoscopic treatment, specially benign lesions, usually appearing in the postsurgical period. Injuries with loss of continuity require surgical management in almost every case. Iatrogenic bile duct injuries with preserved continuity (Strasberg A and D) may be treated by endoscopy. Types B and C, in which a liver segment loses communication with the remaining bile tree, need surgical repair and/or resection. Complete sections of the bile ducts require surgical intervention, with hepatojejunostomy being the best choice. The use of metallic endoluminal stents is almost prohibited in these types of injuries. Benign, non-iatrogenic injuries (sclerosing cholangitis, autoimmune cholangiopathy) require surgical intervention in rare occasions. Malignant injuries are extremely aggressive and only a small percentage (less than 15%) is candidate for curative resection, which unfortunately does not preclude recurrence.