Balloon Dilatation Of Biliary Strictures Research Articles

Single Balloon Enteroscopy (SBE) Assisted Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) in Patients with Roux-en-Y Anastomosis

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis is a complex challenge. Long length of afferent limb after an acute angle at the jejunojejunostomy and altered location of the biliary orifice make biliary cannulation difficult. Single balloon enteroscopy assisted ERCP (SBE-ERCP) is a promising alternative to conventional approaches. The purpose of this study was to assess the efficacy and safety of SBE-ERCP in patients with Roux-en-Y reconstruction at a high volume tertiary referral center. This is a retrospective cohort study. All procedures were performed by a single, experienced pancreatobiliary endoscopist. Patient demographics and related clinical data were obtained. The rate of procedure successes and complications were determined. Fourteen patients (nine women) with a median age of 63years (range 35-83years) underwent 22 SBE-ERCP procedures from March 2009 to May 2011. Surgically altered anatomy consisted of Whipple procedure (n=4), hepaticojejunostomy (n=9) and partial gastrectomy (n=1). Indications for SBE-ERCP were obstructive jaundice (n=10), cholangitis (n=7), post-PTC internalization (n=3) and biliary stent extraction/exchange (n=2). The hepaticojejunostomy site (HJS) was reached in 15 (68%) procedures. Successful interventions were performed in 11 (73%) of 15 cases, including balloon dilation of biliary strictures (n=3), insertion of biliary stents (n=7), retrieval of biliopancreatic stents (n=4) and biliary stone extraction (n=4). The mean procedural time for successful interventions was 97.6min (range 73-147min). No procedural complications occurred during the median follow-up of 501days (range 22-1,242days). SBE-ERCP is safe and carries an acceptable success rate in experienced hands.

Percutaneous transhepatic treatment of hepaticojejunal anastomotic biliary strictures after living donor liver transplantation

Endoscopic treatment has largely replaced surgery as the initial treatment for biliary strictures following living donor liver transplantation; however, this treatment is nearly impossible in patients who have previously undergone hepaticojejunostomy (HJ). We therefore retrospectively evaluated the efficacy of percutaneous transhepatic treatment in patients who developed HJ strictures following living donor liver transplantation. Percutaneous transhepatic biliary drainage and subsequent balloon dilation of biliary strictures were performed on 83 patients. Serial exchanges of drainage tubes with larger diameters up to 14 Fr were performed at 4-week intervals. Drainage tubes were removed if follow-up cholangiography revealed fluent passage of the contrast medium without recurrence of symptoms or changes in the biochemical findings. The clinical outcome, tube independence rate, and patency rate following drainage tube removal were retrospectively evaluated. Except for 2 patients who had failed negotiation of biliary strictures, clinical success was achieved in all 81 patients following percutaneous transhepatic treatment, and the drainage tubes were removed from 76 (93.8%) of these 81 patients. Tubes were removed 11.2 +/- 7.4 months after initial percutaneous transhepatic biliary drainage. The recurrence rate at a mean of 36.0 +/- 26.2 months following drainage tube removal was 15.8%. One- and three-year primary patency rates were 95.3% +/- 2.7% and 80.9% +/- 5.2%, respectively. In conclusion, percutaneous transhepatic treatment is an effective alternative treatment for HJ strictures following living donor liver transplantation. However, further research will be required in order to minimize the duration of treatment and the stricture recurrence rate following tube removal.

Biliary Strictures in Hepatic Transplantation: Treatment with Self-Expanding Z Stents

To determine the long-term results of Gianturco-Rösch Z (GRZ) stent placement for the treatment of recurrent, benign biliary strictures in liver transplant recipients. During a 5-year period, eight orthotopic liver transplant recipients underwent transhepatic placement of GRZ stents to treat 12 recurrent biliary strictures (six anastomotic, six intrahepatic). Prior treatment of 11 strictures with balloon dilation therapy had failed. Patients were followed up for 1-65 months. Stent placement was successful in all patients. Stent position remained stable in all but one patient. Three patients died (1, 25, and 28 months after stent placement), all with patent stents. Four patients required no further biliary intervention. Two of the other four patients needed intermittent biliary balloon dilation with removal of bile duct debris. The third patient had a stable, nonobstructing stenosis in the stent. The fourth passed his stents and needed no further intervention. GRZ stents are useful in patients who are refractory to repetitive balloon dilation of biliary strictures or who are poor surgical candidates.

A New Therapeutic Approach Towards Balloon Dilatation of Biliary Strictures Using a Peroral Cholangioscope

Abstract:Balloon dilatation of biliary strictures using a peroral cholangioscope was used on 10 patients who had biliary strictures accompanied by proximally located stones. A dilation sufficient for the passage of a cholangioscope was obtained in 8 of 10 patients including all of the 6 patients with extrahepatic strictures and 2 of the 4 patients with intrahepatic ones. After successful dilatation of the strictures, peroral cholangioscopic lithotripsy was performed in 4 of the 8 patients whose gallstones were too large to be removed with a conventional stone basket: electrohydraulic lithotripsy in 3 patients and Nd: YAG Laser lithotripsy in one patient. Complete stone clearance was achieved in 5 patients with extrahepatic strictures. Three patients, 1 with the extrahepatic strictures and 2 with the intrahepatic strictures had partial stone clearance. A follow‐up study (27 months on average) disclosed no recurrence of symptoms or elevated laboratory tests indicative of restrictures. Balloon dilatation with a peroral cholangioscope might be a safe and effective treatment as a new approach for biliary strictures especially for extrahepatic lesions, as an alternative to surgical intervention.

Transhepatic Balloon Dilation of Biliary Strictures in Liver Transplant Patients: A 10-year Experience

The authors report their initial and long-term results using transhepatic balloon dilation to treat biliary strictures in liver transplant patients. Over a 10-year period, 72 liver transplant patients with biliary strictures underwent 81 balloon dilation treatments. Anastomotic strictures were present in 56 patients; nonanastomotic strictures were present in 16. Initial technical success was achieved in 64 of 72 patients (89%). Balloon dilation failed in eight patients (11%), and they were treated surgically. Complications occurred in nine (12%) patients, and all were successfully treated. Within the first 6 months, five patients (6.9%) required surgical revision. Three patients (4.2%) underwent repeated liver transplantation; and five patients (6.9%) died. Fifty-one patients in whom balloon dilation was initially successful were available for at least a 6-month follow-up. Life-table analysis showed an overall 81% +/- 4.8 success rate at 6 months; it dropped to 70% +/- 6.2 at 6 years. For anastomotic strictures, it was 77% +/- 5.8 at 6 months and 66% +/- 7.3 at 6 years. For nonanastomotic strictures, it was 94% +/- 6.2 at 6 months, which dropped to 84% +/- 10 at 5 years. Transhepatic balloon dilation represents an effective and relatively safe treatment for biliary stricture in liver transplant recipients.

Primary Sclerosing Cholangitis

Primary sclerosing cholangitis is a rare disease of unknown etiology. Sclerosis of the bile ducts may actually be the final result of multiple factors such as autoimmune, bacterial, congenital, drug, or viral injury. The most commonly associated diseases are ulcerative colitis and chronic pancreatitis. Except in the earliest stages of the disease, liver histologic findings are not specific. Most patients present with jaundice, pain, and pruritus, although an increasing number of asymptomatic patients with inflammatory bowel disease and abnormal liver function are being identified. Cholangiography is key to the diagnosis and is usually pathognomonic except in the unusual case where primary sclerosing cholangitis is confused with cholangiocarcinoma. Many forms of medical therapy have been tried, including antibiotics, azathioprine, cholestyramine, colchicine, cyclosporine, D-penicillamine, steroids, and ursodeoxycholic acid. To date, none of these medications has been proved to alter the course of this disease. Recent reports of ursodeoxycholic acid trials have been encouraging, but long-term results of ongoing randomized trials have yet to be published. In recent years, balloon dilatation of biliary strictures has been accomplished via endoscopic and percutaneous transhepatic approaches. However, in patients with primary sclerosing cholangitis, these nonoperative manipulations must be done repeatedly, may entail multiple general anesthetics, and are difficult to perform. We believe that a direct surgical approach to the biliary tree with long-term transhepatic stenting is indicated in selected patients with severe hilar or extrahepatic stricturing, persistent jaundice or recurrent cholangitis, and no evidence of cirrhosis. Hepatic transplantation should be reserved for patients with primary sclerosing cholangitis who have well-established cirrhosis and have not responded to other therapeutic measures.