Endoscopic management of hilar biliary strictures

Hilar biliary strictures are caused by various benign and malignant conditions. It is difficult to differentiate benign and malignant strictures. Postcholecystectomy benign biliary strictures are frequently encountered. Endoscopic management of these strictures is challenging. An endoscopic method has been advocated that involves placement of increasing number of stents at regular intervals to resolve the stricture. Malignant hilar strictures are mostly unresectable at the time of diagnosis and only palliation is possible.Endoscopic palliation is preferred over surgery or radiological intervention. Magnetic resonance cholangiopancreaticography is quite important in the management of these strictures. Metal stents are superior to plastic stents. The opinion is divided over the issue of unilateral or bilateral stenting.Minimal contrast or no contrast technique has been advocated during endoscopic retrograde cholangiopancreatography of these patients. The role of intraluminal brachytherapy, intraductal ablation devices, photodynamic therapy, and endoscopic ultrasound still remains to be defined.     

PROPHYLACTIC PANCREAS STENTING FOLLOWED BY NEEDLE‐KNIFE FISTULOTOMY IN PATIENTS WITH SPHINCTER OF ODDI DYSFUNCTION AND DIFFICULT CANNULATION: NEW METHOD TO PREVENT POST‐ERCP PANCREATITIS

Introduction: The aim of the present study was to reduce post‐endoscopic retrograde cholangiopancreatography (ERCP) complications with a combination of early needle‐knife access fistulotomy and prophylactic pancreatic stenting in selected high‐risk sphincter of Oddi dysfunction (SOD) patients with difficult cannulation. Methods: Prophylactic pancreatic stent insertion was attempted in 22 consecutive patients with definite SOD and difficult cannulation. After 10 min of failed selective common bile duct cannulation, but repeated (>5×) pancreatic duct contrast filling, a prophylactic small calibre (3–5 Fr) pancreatic stent was inserted, followed by fistulotomy with a standard needle‐knife, then a standard complete biliary sphincterotomy followed. The success and complication rates were compared retrospectively with a cohort of 35 patients, in which we persisted with the application of standard methods of cannulation without pre‐cutting methods. Results: Prophylactic pancreatic stenting followed by needle‐knife fistulotomy was successfully carried out in all 22 consecutive patients, and selective biliary cannulation and complete endoscopic sphincterotomy were achieved in all but two cases. In this group, not a single case of post‐ERCP pancreatitis was observed, in contrast with a control group of three mild, 10 moderate and two severe post‐ERCP pancreatitis cases. The frequency of post‐ERCP pancreatitis was significantly different: 0% versus 43%, as were the post‐procedure (24 h mean) amylase levels: 206 U/L versus 1959 U/L, respectively. Conclusions: In selected, high‐risk, SOD patients, early, prophylactic pancreas stent insertion followed by needle‐knife fistulotomy seems a safe and effective procedure with no or only minimal risk of post‐ERCP pancreatitis. However, prospective, randomized studies are awaited to lend to support to our approach.     

内镜下逆行胰胆管造影术在完全性内脏反位中的临床应用价值

目的评价在完全性内脏反位(SIT)患者中进行经内镜逆行胰胆管造影术(ERCP)的有效性和安全性。方法回顾性分析2008年12月至2018年12月在杭州市第一人民医院消化内镜中心行ERCP治疗的SIT患者的资料,评估插镜成功率、插管成功率、治疗成功率和并发症发生情况。结果共有10例SIT患者进行了11例次ERCP,其中胆总管结石7例,胆总管结石合并胆总管下端狭窄1例,胆总管下端恶性狭窄1例,胆总管下端良性狭窄1例。所有患者采用常规左侧卧位,插镜成功率为100%,胆道插管的成功率为100%,总体治疗成功率为100%,有2例放置金属支架的患者术后出现腹痛,给予保守治疗后好转。结论在SIT患者中施行ERCP安全有效。     

Management issues in post living donor liver transplant biliary strictures

Biliary complications are common after living donor liver transplant(LDLT) although with advancements in surgical understanding and techniques, the incidence is decreasing. Biliary strictures are more common than leaks. Endoscopic retrograde cholangiopancreatography(ERCP) is the first line modality of treatment of post LDLT biliary strictures with a technical success rate of 75%-80%. Most of ERCP failures are successfully treated by percutaneous transhepatic biliary drainage(PTBD) and rendezvous technique. A minority of patients may require surgical correction. ERCP for these strictures is technically more challenging than routine as well post deceased donor strictures. Biliary strictures may increase the morbidity of a liver transplant recipient, but the mortality is similar to those with or without strictures. Post transplant strictures are short segment and soft, requiring only a few session of ERCP before complete dilatation. Long-term outcome of patients with biliary stricture is similar to those without stricture. With the introduction of new generation cholangioscopes, ERCP success rate may increase, obviating the need for PTBD and surgery in these patients.     

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.     

胆道支架移位在胆道良性疾病中的影响因素

目的:探讨胆道良性狭窄中胆道塑料支架移位的影响因素.方法:回顾性分析2005-01/2009-12 244例因胆道良性狭窄在天津市南开医院进行内镜逆行胆管内支架引流术(endoscopic retrogradebiliary drainage,ERBD)的病例资料、记录狭窄的原因、部位,支架的长度和数量,支架移位的方向...     

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     

Needle-knife fistulotomy in patients with periampullary diverticula and difficult bile duct cannulation

Background and Aim: Needle‐knife fistulotomy has commonly been used for overcoming difficult bile duct cannulation. Periampullary diverticula (PAD) can be an impediment to endoscopic retrograde cholangiopancreatography (ERCP) procedures. There are little data on needle‐knife fistulotomy in patients with PAD. We evaluated the efficacy and safety of needle‐knife fistulotomy between patients with and without PAD. Methods: Data from December 2005 to October 2010 were reviewed. Patients who underwent needle‐knife fistulotomy were divided into the group with PAD and the group without PAD (control group). The technical success and complications were compared. Results: A total of 3012 ERCP cases were analyzed. Needle‐knife fistulotomy was performed in 154 out of 3012 cases (5.1%) with 138 of these patients (89.6%) experiencing successful bile duct cannulation. The overall cannulation success rate was not significantly different between PAD group (n = 33) and control group (n = 121) (93.9% vs 88.4%; P = 0.523). There was no significant difference in pancreatitis, bleeding and perforation between the two groups. Conclusions: Needle‐knife fistulotomy can be performed effectively and safely in patients with periampullary diverticula and difficult bile duct cannulation.     

Progress in the endoscopic management of benign biliary strictures

Benign biliary strictures can now be effectively treated with endoscopic therapy in a variety of clinical situations. Despite recent developments in imaging techniques (endoscopic ultrasound and magnetic resonance imaging), it is often difficult to differentiate benign from malignant biliary strictures. The sensitivity of tissue diagnosis (cytology and needle biopsy) at endoscopic retrograde cholangiopancreatography (ERCP) remains poor (40-50%), and further diagnostic methods are required. Endoscopic therapy offers a definitive treatment in 70-90% of patients following post-operative biliary stricture, including anastomotic strictures following liver transplant. Endoscopic therapy successfully achieves symptomatic, biochemical, and cholangiographic response, and may improve survival in patients with primary sclerosing cholangitis. Strictures secondary to chronic pancreatitis are resistant to standard endoscopic therapy and metallic endoprotheses have been trialed with varying success. Endoscopic therapy is technically difficult and should be performed in specialized centres using a multidisciplinary approach.     

Biliary strictures in the liver transplant patient

Biliary complications are the most common adverse events following liver transplantation (LT). Living donor LT have a higher rate of biliary complications compared with deceased donor LT. Multiple risk factors have been implicated in the development of biliary strictures, which could be categorized into recipient, graft, operative factors, and postoperative factors. Bile duct strictures following LT are classified as biliary anastomotic strictures or nonanastomotic strictures. Nonanastomotic strictures have a less favorable response to endoscopic management. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT. For treating anastomotic strictures, endoscopic retrograde cholangiopancreatography directed balloon dilatation complemented with the placement of multiple plastic stents has become the standard of care and results in stricture resolution in over 90% of cases. Temporary placement of fully covered self-expanding metal stents (FCSEMSs) has not been demonstrated to be superior mostly because of the high migration rate of current FCSEMSs models. FCSEMS with special antimigratory design may be superior and cost-effective compared with multiple plastic stents, but need evaluation in prospective and randomized trials.     

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.     

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.     

Treatment of post liver transplantation bile duct stricture with self-expandable metallic stent

Objective. The aim of this study is to report our experience using self-expandable covered metallic stents (Wallstent) to treat different types of biliary strictures after orthotopic liver transplantation (OLT). Patients and methods. Between January 1999 and July 2004, 222 OLTs were performed with choledocho-choledochostomy (CC) bile duct reconstruction. An anastomotic biliary stricture was diagnosed and treated by endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous procedures in 100 patients (45%). The group of 21 patients (mean age 57.0±5.6 years) that were eventually treated with a biliary Wallstent was studied retrospectively. Results. Significant persistent proximal or anastomotic strictures were diagnosed in 4 and 17 patients, respectively. A Wallstent was inserted by ERCP or through a percutaneous route in 18 and 3 patients, respectively. The mean interval between diagnosis and Wallstent insertion was 179.7±292.8 (0–1113) days. The mean total number of procedures required per patient was 7.4±5.5. The mean stent primary patency duration was 10.8±7.8 (0.9–25.1) months with a 24-month primary patency rate of 26% at a mean follow-up time of 37.8±17.2 months. A hepatico-jejunostomy was performed in five patients (24%). Two patients (10%) underwent retransplantation for diffuse ischemic cholangitis or chronic rejection. The overall complication rate was 4%. Conclusion. Treatment of post-transplant biliary stenosis using a Wallstent is a valuable option for delaying or avoiding surgery in up to 70% of patients. Proximal stenosis can be treated in the same manner in selected patients with major comorbidities.     

Endoscopic biodegradable biliary stents in the treatment of benign biliary strictures: First report of clinical use in patients

The first clinical experience of endoscopically inserted polydioxanone biodegradable biliary stents (BDBS) in the treatment of benign biliary strictures is reported. Two patients with a benign common bile duct stricture were endoscopically treated with 8‐mm‐bore BDBS during endoscopic retrograde cholangiography. Both BDBS insertions were technically successful and without adverse events. At 6 months, the stricture resolution was excellent and BDBS degradation was predicted in repeated magnetic resonance imaging. The first experience with endoscopic BDBS seems promising in the treatment of benign biliary strictures. During 6 months of follow up, BDBS seemed sufficient for remodeling and resolution of strictures. Further studies are needed to confirm the effectiveness of biodegradable biliary stents in endoscopic management of benign biliary strictures.     

New role of the dual knife for precut papillotomy in difficult bile duct cannulation

The dual knife is usually used for endoscopic submucosal dissection (ESD). To date, however, there have been no clinical trials of the safety and effectiveness of precut papillotomy using the dual knife for biliary access in patients failing conventional endoscopic retrograde cholangiopancreatography (ERCP) cannulation. We herein report 18 patients who underwent precut papillotomy with the dual knife. All had intact papilla, and had failed deep cannulation of the bile ducts. After successful biliary cannulation and standard endoscopic sphincterotomy, if necessary, stone removal or plastic or metal stent insertion was attempted. Selective bile‐duct cannulation was achieved in all 18 patients (100%), at an average time of 4.2 min (range, 3–6 min). Of these 18 patients, six had malignant bile duct obstruction and 12 had common bile duct stones. One patient developed post‐ERCP pancreatitis, which resolved after conservative management. There were no deaths related to the procedure.     

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.     

Biliary strictures after liver transplantation

Biliary strictures are one of the most common complications following liver transplantation, representing an important cause of morbidity and mortality in transplant recipients. The reported incidence of biliary stricture is 5% to 15% following deceased donor liver transplantations and 28% to 32% following living donor liver transplantations. Bile duct strictures following liver transplantation are easily and conveniently classified as anastomotic strictures (AS) or non-anastomotic strictures (NAS). NAS are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and the need for retransplantation. Current endoscopic strategies to correct biliary strictures following liver transplantation include repeated balloon dilatations and the placement of multiple side-by-side plastic stents. Endoscopic balloon dilatation with stent placement is successful in the majority of AS patients. In patients for whom gaining biliary access is technically difficult, a combined endoscopic and percutaneous/surgical approach proves quite useful. Future directions, including novel endoscopic retrograde cholangiopancreatography techniques, advanced endoscopy, and improved stents could allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. The aim of this review is to detail the present status of endoscopy in the diagnosis, treatment, outcome, and future directions of biliary strictures related to orthotopic liver transplantation from the viewpoint of a clinical gastroenterologists.     

Difficult Biliary Access for ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is a technically-demanding procedure. The ability to selectively cannulate the bile duct and pancreatic duct (PD) quickly and atraumatically is the key to successful therapeutic ERCP, and to minimizing post-ERCP complications, especially pancreatitis (PEP). Prophylactic stenting of the PD has significantly reduced the risk of severe PEP. Difficult ERCP access refers to the length of time and number of attempts it takes to achieve deep cannulation of the desired duct. If biliary access cannot be achieved quickly, PD stenting over a guide wire is recommended, which facilitates further attempts to enter the bile duct. Familiarity with guide wires and needle knife papillotomy technique are necessary to achieve close to 100?% biliary cannulation. Anatomic abnormalities, from gastric outlet strictures, periampullary diverticula, and ampullary masses to surgical rearrangement of the upper GI tract, contribute to the difficulty of performing ERCP. Adjunctive techniques to overcome these problems include percutaneous transhepatic biliary access and endoscopic ultrasound (EUS)-guided puncture of the bile duct through the stomach or duodenal wall. Therapeutic EUS is emerging as a major tool in the management of pancreatic and biliary disease, and will likely replace many therapeutic ERCP techniques in the next decade.     

Endoscopic retrograde cholangiopancreatography is safe and effective in patients 90 years of age and older

GOALS: To review our experience of endoscopic retrograde cholangiopancreatography (ERCP) in patients 90 years and older. BACKGROUND: ERCP is effective in the investigation and treatment of biliary disease; however, in the very elderly, a perception of high procedural risk and lack of efficacy may limit its use. STUDY: Retrospective analysis of ERCPs performed on patients 90 years of age and older from one institution. RESULTS: Between 1987-2000, 23 ERCPs were performed on patients 90 years of age and more (16 women; age range, 90-96 years). The primary indications were obstructive jaundice (16 patients), pancreatitis (2), cholangitis (1), unexplained abdominal pain (1), and planned follow-up (3). The main endoscopic findings were common bile duct (CBD) stone (15 patients), pancreatic carcinoma (2), cholangiocarcinoma (2), and dilated duct (only 1). Sixteen sphincterotomies were performed, with successful common duct clearance in 10 patients. Seven biliary stents were inserted for benign disease and three, for malignancy. In two patients, CBD cannulation was unsuccessful. Three minor hemorrhages were controlled endoscopically. Three patients died of nonprocedural causes. CONCLUSIONS: ERCP is safe and effective in the very elderly. The decision to undergo ERCP should be determined by clinical need.     

A prospective evaluation of cytology from biliary strictures.

BACKGROUND: Bile duct strictures may be benign or malignant. A definite diagnosis is desirable to advise patients of their prognosis and to identify any amenable to curative surgery. AIMS: To compare different methods of cytology sampling from biliary strictures and evaluate the use of cytology in this context. PATIENTS AND METHODS: In a prospective study 54 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) had cytology samples obtained as follows: (1) biliary stricture brushings, (2) from the screw thread of a "Soehendra stent retriever" inserted through the stricture, (3) from the proximal end of a blocked biliary stent, and (4) cellular material spun down from a 20 ml specimen of bile. Examination of slides and rinsings was performed by an expert cytologist who graded them for the adequacy of the sample and for evidence of malignancy. RESULTS: Prolonged follow up disclosed malignancy in 52 of the 54 cases, the other two being chronic pancreatitis. Bile samples provided adequate cytology samples in 44%, the Soehendra stent retriever in 70%, retrieved stents in 84%, and cytology brush sampling in 96%. Overall, 28 malignancies were detected by cytology, including 14 of 28 pancreatic carcinomas and 12 of 16 cholangiocarcinomas. Twenty two of the malignancies were detected by brush sampling and the other methods added a total of another six cases. CONCLUSIONS: Cytology sampling is best done by brushing the biliary stricture. Cytology sampling can confirm the diagnosis in 75% of cholangiocarcinomas and 50% of pancreatic carcinomas. The techniques involved are simple to perform and should be routine clinical practice whenever potentially malignant biliary strictures are encountered at ERCP.