Benign Common Bile Duct Stricture Research Articles

HPB P33 Management of Gallstone Disease with Deranged Liver Function Tests – Single Centre Experience

Abstract Background Laparoscopic cholecystectomy (LC) has emerged as the gold standard for the treatment of symptomatic cholelithiasis, however, things are not quite so clear when it comes to managing cholelithiasis with suspected common bile duct (CBD) stones and debate continues among surgeons about the optimal pathway of management. The current recommendation is that patients with symptomatic cholelithiasis should be investigated for CBD stones. There is controversy because investigating for suspected choledocholithiasis by means of Magnetic resonance cholangiopancreatography (MRCP)/ pre-operative or post-operative Endoscopic retrograde cholangiopancreatography (ERCP)/ laparoscopic cholecystectomy with on-table cholangiography (OTC) may lead to subsequent over or under treatment with significant morbidity, readmissions, decline in Health Related Quality of Life (HRQoL) and costs to the health service. We conducted a retrospective clinical audit to compare our care provision for symptomatic gall stone disease with suspected choledocholithiasis against the guidelines laid down by Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) in 2016, NICE (2014) and European Society of Gastrointestinal Endoscopy (ESGE). This also highlights the importance of a single stage approach (LC with OTC) for management of gall stones with suspected CBD stones. Methods A retrospective audit was conducted for 18 months at a referral centre for hepato-pancreato-biliary (HPB) diseases, with available expertise for management of CBD stones, endoscopically and surgically. All patients admitted to general surgery facility with a diagnosis of gallstone disease with deranged liver function tests (LFTs), and suspicious of having or diagnosed to have common bile duct stones were included in the study. Patients aged 18 years and above with symptomatic gall stones suspected to have or diagnosed with choledocholithiasis were included, while patients with cholelithiasis but no evidence of stones in CBD on initial investigations were excluded. A total of 95 patients who met the inclusion and exclusion criteria were included in the study. We used the guidelines put forth by AUGIS (2016), NICE guidelines (2014), British Society of Gastroenterology (BSG) in 2017 and European Society of Gastrointestinal Endoscopy (ESGE) 2019 to compare management of symptomatic gallstone disease. Data with regards to length of hospital stay, comorbidities, investigations done, diagnosis, management, readmissions before undergoing further investigations or having a surgery (laparoscopic cholecystectomy) with or without on-table cholangiogram (OTC) were analysed. Data analysis for this set of data was done using numbers, percentages and descriptive statistics, using SPSS 25.0. Results Out of 95 patients, 90 had deranged LFTs at presentation (3 presented with cholangitis) and 5 had suspicious findings on initial imaging. The diagnosis included Mirizzi syndrome, pancreatitis, Choledocholithiasis, Biliary colic, Acute cholecystitis and benign CBD stricture. Out of 95 patients, 76 of them had Ultrasound abdomen as their initial investigation, mostly on the day of admission. 41 patients had MRCP, 73% of them during their index admission. Amongst the 95, 59% underwent ERCP, 76.8% of them during the index admission. The median time from admission to MRCP and ERCP was 5 and 8 days, respectively. Out of 56 patients who underwent ERCP, 9 of them had it done within 72 hours of admission. Overall, 22 patients underwent LC with OTC. Out of 95 patients, 51 patients underwent LC. Out of 79 patients who were fit for surgery, 28 of them were still awaiting surgery. Amongst 18 patients who had Pancreatitis at presentation, 14 of them underwent ERCP. Out of which 3 of them had LC during index admission. The maximum length of stay observed amongst 95 patients was 36. Amongst the 95 patients, the study also records that 13 patients had readmissions before they underwent ERCP or LC. Conclusions We found 16% compliance with the guidelines in regards to the timing of biliary decompression with ERCP. Our results show 66.66% compliance with guidelines, with regards to timing of biliary decompression in Cholangitis. The study reflects a significant non-adherence to the guidelines as 68.40% of patients could not have definitive management within the recommended time frame. Looking into the finer details, we found that 35.40% of the patients did not have their surgery at the time of the audit. 22% of patients had LC performed in accordance with the recommendations, while the timing of surgery in 78% of patients showed no compliance with the guidelines. Guidelines for management of patients with gallstone disease associated with CBD stones was not met for majority of patients. A significant number of patients were readmitted to the hospital because of delay in receiving further investigations or definitive surgery. There may be a role for multidisciplinary team meetings to identify patients requiring expedited ERCP, which in turn may translate into early definitive surgical management. Laparoscopic cholecystectomy with OTC, with or without laparoscopic CBD exploration or post-operative ERCP can be incorporated as an alternative to pre-operative ERCP to reduce patient morbidity and length of hospital stay.

Role of multidetector computed tomography in differentiating benign and malignant common bile duct strictures

Objective: To evaluate the diagnostic features in differentiating malignant from benign common bile duct (CBD) strictures using contrast-enhanced multidetector computed tomography (MDCT). Patients and Methods: An ambispective study from January 1, 2008 to December 31, 2010, on fifty patients with liver function tests suggestive of obstructive jaundice and an ultrasound showing biliary obstruction were included. A nonenhanced computed tomography (CT) was done before the administration of the contrast medium and then scans were routinely obtained in four phases: early arterial , late arterial, portal venous, and delayed phases. The CT scans acquired were reviewed on a picture archiving and communication system workstation. CT findings were interpreted with regard to wall thickness, the location, length involved, enhancement pattern, presence of invasion, and margins of the stricture. These were compared with the attenuation of the normal CBD wall, the maximum CBD diameter proximal, and pancreatic duct dilatation. Results: The mean age ± standard deviation of patients was 62.84 ± 11.61 years (range: 38–82 years). Among the fifty patients included in the study, 31 (62%) had malignant CBD stricture. The involved segments of malignant CBD strictures were significantly longer with significantly larger maximum proximal CBD diameter, considerably thicker and irregular stricture wall and showing more enhancement during delayed phase. No significant differences were found between malignant and benign CBD strictures with respect to stricture location. Conclusions: Presence of irregular margins, invasion into neighboring tissues, long-segment involvement, more proximal CBD dilatation, and hyperenhancement in delayed and portal venous phases in contrast-enhanced MDCT helps in the differentiation of malignant from benign CBD strictures.

Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a specialized endoscopic procedure to view the biliary and pancreatic ducts fluoroscopically. First introduced in the 1970s as a diagnostic tool, ERCP has since evolved primarily into a therapeutic modality and is today regarded as the premier tool for performing therapeutic interventions involving the biliary and pancreatic ductal systems. Relatively complex, ERCP requires advanced training. Although generally considered safe, it does carry a risk of significant complications, including pancreatitis; thus, the most important factor to mitigate complications is to ensure the presence of an appropriate indication for the procedure. This review addresses the indications (e.g., disorders of the major duodenal papilla, biliary diseases, and pancreatic diseases), contraindications, protocol, and complications of ERCP, as well as an overview of the tools available for ERCP procedures. Figures show ampullary adenomas, choledocholithiasis, Mirizzi syndrome, benign common bile duct stricture, primary sclerosing cholangitis, malignant biliary stricture, bile leak, type I and III choledochal cysts, chronic pancreatitis, pancreatic ductal disruption, classic fish-mouth appearance of the papilla in a patient with main duct intraductal papillary mucinous neoplasm, pancreas divisum, side-viewing duodenoscope used for ERCP, and selected tools of ERCP. Tables list the Rome III criteria, risk-stratifying patients for choledocholithiasis, diagnostic criteria for acute cholangitis, choledochal cyst classification, and the Cambridge classification system for chronic pancreatitis. This review contains 15 highly rendered figures, 5 tables, and 77 references.

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.

Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a specialized endoscopic procedure to view the biliary and pancreatic ducts fluoroscopically. First introduced in the 1970s as a diagnostic tool, ERCP has since evolved primarily into a therapeutic modality and is today regarded as the premier tool for performing therapeutic interventions involving the biliary and pancreatic ductal systems. Relatively complex, ERCP requires advanced training. Although generally considered safe, it does carry a risk of significant complications, including pancreatitis; thus, the most important factor to mitigate complications is to ensure the presence of an appropriate indication for the procedure. This review addresses the indications (e.g., disorders of the major duodenal papilla, biliary diseases, and pancreatic diseases), contraindications, protocol, and complications of ERCP, as well as an overview of the tools available for ERCP procedures. Figures show ampullary adenomas, choledocholithiasis, Mirizzi syndrome, benign common bile duct stricture, primary sclerosing cholangitis, malignant biliary stricture, bile leak, type I and III choledochal cysts, chronic pancreatitis, pancreatic ductal disruption, classic fish-mouth appearance of the papilla in a patient with main duct intraductal papillary mucinous neoplasm, pancreas divisum, side-viewing duodenoscope used for ERCP, and selected tools of ERCP. Tables list the Rome III criteria, risk-stratifying patients for choledocholithiasis, diagnostic criteria for acute cholangitis, choledochal cyst classification, and the Cambridge classification system for chronic pancreatitis. This review contains 15 highly rendered figures, 5 tables, and 77 references.

Endoscopic ultrasonography for differentiation of malignant and benign common bile duct strictures

Endoscopic ultrasonography for differentiation of malignant and benign common bile duct strictures

ERCP with double-channel endoscope for patients with Billroth-II gastroenterostomy

Objective To evaluate the therapeutic effect and safety of forward-viewing, double- channel endoscope in the process of ERCP in patients with bile duct diseases after Billroth- Ⅱ gastroenteros- tomy. Methods ERCP was applied to 46 patients with bile duct diseases using forward-viewing, double- channel endoscope. All patients had the history of BiUroth- Ⅱ gastroenterostomy. The success rate of selec- tive cannulation, complication rate and the outcome of all the patients were recorded. Results The proce- dure succeeded in 38 patients with a success rate of 82. 6%, and failed in 8. Of all the failing cases, the af- ferent loop couldn＇t be accessed in 6, failure in biliary cannulation in 2. Of 38 successful cases, bile duct stones were successfully removed in 31, metal stents placed for malignant bile duct obstruction in 4, and en- doscopic balloon dilation for benign common bile duct stricture in 3. All patients recovered without complica- tions of perforation, delayed bleeding or pancreatitis. Conclusion For patients with history of Billroth- Ⅱ gastroenterostomy, ERCP with forward-viewing, double-channel endoscope yields to a higher success rate and lower complication rate. Key words: Cholangiopancreatography, endoscopic retrograde; BiUroth- Ⅱ gastroenterostomy; Double-channel endoscope

Differentiation of infiltrative cholangiocarcinoma from benign common bile duct stricture using three-dimensional dynamic contrast-enhanced MRI with MRCP

To retrospectively evaluate the criteria for discriminating infiltrative cholangiocarcinoma from benign common bile duct (CBD) stricture using three-dimensional dynamic contrast-enhanced (3D-DCE) magnetic resonance imaging (MRI) combined with magnetic resonance cholangiopancreatography (MRCP) imaging and to determine the predictors for cholangiocarcinoma versus benign CBD stricture. 3D-DCE MRI and MRCP images in 28 patients with infiltrative cholangiocarcinoma and 23 patients with benign causes of CBD stricture were reviewed retrospectively. The final diagnosis was based on surgical or biopsy records. Two radiologists analysed the MRI images for asymmetry, including the wall thickness, length, and enhancement pattern of the narrowed CBD segment, and upstream CBD dilatation. MRI findings that could be used as predictors were identified by univariate analysis and multivariable stepwise logistic regression analysis. Malignant strictures were significantly thicker (4.4 ± 1.2 mm) and longer (16.7 ± 7.7 mm) than the benign strictures (p < 0.05), and upstream CBD dilatation was larger in the infiltrative cholangiocarcinoma cases (20.7 ± 5.7 mm) than in the benign cases (16.5 ± 5.2 mm; p = 0.018). During both the portal venous and equilibrium phases, hyperenhancement was more frequently observed in malignant cases than in benign cases (p < 0.001). The results of the multivariable stepwise logistic regression analysis showed that both hyperenhancement of the involved CBD during the equilibrium phase and the ductal thickness were significant predictors for malignant strictures. When two diagnostic predictive values were used in combination, almost all patients with malignant strictures (n = 26, 92.9%) and benign strictures (n = 21, 91.3%) were correctly identified; the overall accuracy was 92.2% with correct classifications in 47 of the 51 patients. Infiltrative cholangiocarcinoma and benign CBD strictures could be effectively differentiated using DCE-MRI and MRCP based on hyperenhancement during the equilibrium phase and bile wall thickness of the involved segment.

Choledochoduodenostomy as the Biliary–Enteric Bypass of Choice for Benign and Malignant Distal Common Bile Duct Strictures

Choledochoduodenostomy (including hepaticoduodenostomy) for common bile duct (CBD) strictures has been underused because of concerns regarding postoperative duodenal fistula and cholangitis attending the so-called "sump syndrome." An institutional retrospective review of 55 consecutive choledochoduodenostomy procedures for CBD strictures from 1995 to 2011 was performed to examine its suitability as the biliary-enteric bypass procedure of choice. There were 30 male (55%) and 25 female (45%) patients with a mean age of 49 years (range, 13 to 73 years). Thirty-seven (67%) patients had benign CBD strictures and 18 (33%) had unresectable periampullary adenocarcinomas. Forty-nine (89%) underwent choledochoduodenostomy and six (11%) underwent hepaticoduodenostomy. There were no 30-day postoperative deaths, anastomotic leaks, or intra-abdominal abscesses. Five patients (9%) sustained Clavien Grade III or IV complications. Over a mean long-term follow-up of 29 months (range, 1 to 162 months), there was one anastomotic stricture successfully managed by endoscopic dilation and temporary stenting. Liver function tests in all other patients returned to and remained within normal limits. We conclude that choledochoduodenostomy is the preferred biliary-enteric bypass for both benign and malignant distal CBD strictures because of its ease, safety, and durability. Persistent fears of duodenal fistula and the "sump syndrome" are not warranted by the empiric data and should be abandoned.

Retrograde biliary stenting in patients with pancreatobiliary diseases

Aim. To evaluate the results of retrograde biliary stenting in patients with pancreatobiliary diseases. Methods. In 2008-2012, 85 retrograde biliary stenting procedures were performed in 65 patients (28 men and 37 women) with pancreatobiliary diseases aged 33 to 86 years. Obstructive jaundice was diagnosed in 44 of 65 patients (in 67% of cases), ascending cholangitis - in 14 (21%) patients. Endoscopic biliary stenting was performed in 47 patients with benign pancreatobiliary diseases (chronic and post-surgical pancreatitis, benign common bile duct stricture, Mirizzi syndrome, intradiverticular papilla, common bile duct bile stones) and in 18 patients with malignancies (cancers of pancreas head, bile ducts and papillary cancer). Plastic biliary stents with a (diameter 2.5 to 3.3 mm) were used for stenting. Results. Endoscopic biliary stenting allows to resolve the clinical manifestations of оbstructive jaundice and cholangitis, to eliminate pain, to prevent the development of pancreatitis, to prepare patients for surgery. Serious complications of biliary stenting (stent migration in common bile duct, acute cholangitis) were observed in 5 of 85 procedures (5.9% of cases), and all were resolved after repeated endoscopic intervention. Conclusion. Endoscopic retrograde biliary stenting is a safe and effective treatment option for patients with both benign and malignant pancreatobiliary diseases, it is characterized by low rate of specific complications (5.8%) and had reduced the risk of acute pancreatitis in patients with papillostenosis and stricture of the common bile duct terminal part down to 3%.

Removable fully covered self-expandable metal stents in the treatment of common bile duct strictures due to chronic pancreatitis: A case series

The aim of this study was to test the removability of fully covered self-expandable metal stents (FCSEMS) in patients with a benign common bile duct (CBD) stricture. A FCSEMS was inserted in six patients with a CBD stricture due to chronic pancreatitis who were considered to be unfit for surgery, and stent removal was attempted after predefined intervals of 4 and 6 months. FCSEMS were successfully placed in all patients (100 % placement success) and stent extraction was accomplished in four patients (66 % removal rate), all of whom achieved stricture resolution (66 % resolution rate). In one patient a recurrent stenosis developed after 6 months (recurrence rate 25 %). Proximal stent migration occurred in two patients. In conclusion, FCSEMS removal was possible in the majority of patients and results regarding stricture dilation were promising. Nevertheless, before FCSEMS can become an acceptable treatment option for benign CBD strictures, innovative stent design modifications are necessary and removability must be ascertained.

Percutaneous Transhepatic Use of a Cutting Balloon in the Treatment of a Benign Common Bile Duct Stricture

Percutaneous Transhepatic Use of a Cutting Balloon in the Treatment of a Benign Common Bile Duct Stricture

Percutaneous Transhepatic Use of a Cutting Balloon in the Treatment of a Benign Common Bile Duct Stricture

Benign biliary strictures (BBS) are difficult to treat. The majority of them are treated either endoscopically or using percutaneous techniques either with stents or conventional angioplasty balloons. To our knowledge we present the first case of use of a cutting balloon in the treatment of BBS through a percutaneous approach.

Differentiating Malignant from Benign Common Bile Duct Stricture with Multiphasic Helical CT

To evaluate retrospectively the use of multiphasic helical computed tomography (CT) to differentiate malignant and benign common bile duct (CBD) strictures in patients with only a focal CBD stricture and to determine predictors for this differentiation. Institutional review board approval and informed patient consent were not required. Fifty patients (35 men, 15 women; age range, 35-87 years; mean age, 61.6 years) with only a focal CBD stricture comprised the sample for this study (32 malignant and 18 benign strictures). The diagnosis of all malignant and five benign CBD strictures was confirmed by reviewing patients' surgical and pathology records; in 13 benign CBD strictures, the diagnosis was confirmed by means of clinical features. Multiphasic CT findings were analyzed with regard to the wall thickness, location, length, and enhancement pattern of the involved CBD, the upstream CBD diameter, and other findings. CT features to identify benign and malignant CBD strictures were compared by means of univariate analysis and multivariable stepwise logistic regression analysis. Malignant strictures were longer (17.9 mm +/- 6.6 [+/- standard deviation]) than benign strictures (8.9 mm +/- 6.8) (P < .0001), and upstream CBD diameters were larger in malignant cases (22.0 mm +/- 5.4) than in benign cases (17.8 mm +/- 4.6) (P = .033). The involved wall thickness was more than 1.5 mm in 26 malignant cases and three benign cases (P < .0001). During both hepatic arterial and portal venous phases, greater enhancement than that in the normal CBD were more frequently observed in malignant cases (in 27 and 30 patients for hepatic arterial and portal venous phase scans, respectively) than in benign cases (in two and three patients, respectively) (P < .0001). Results of multivariable stepwise logistic regression analysis showed that hyperenhancement of the involved CBD during the portal venous phase was the only variable that could be used to independently differentiate malignant from benign strictures. Hyperenhancement of the involved CBD during the portal venous phase is the main factor distinguishing malignant from benign CBD strictures.

Use of Removable Covered Expandable Metal Stents (RCEMS) in the Treatment of Benign Distal Common Bile Duct (CBD) Strictures: A Feasibility Study

The endoscopic treatment of benign CBD strictures comprises of sequential plastic stent insertion in progressively increasing numbers and resolves 65-85% of post surgical strictures and 20-40% of strictures due to chronic pancreatitis (CP). We aimed to assess the feasibility of using RCEMS, especially its removability, in the treatment of benign CBD strictures. Methods: First, proof of principle was tested in 3 patients with irresectable pancreatic cancer (CA). Subsequently, 4 patients with CP with a benign distal CBD stricture were included.

The Role of Anesthesiology During the Performance of Endoscopic Retrograde Cholangiopancreatography: Indications and Outcomes at a Tertiary Care Center

Background: Adequate sedation and amnesia are important in the performance of ERCP's. In the ill or uncooperative patient the decision to involve anesthesiology for administrating monitored anesthesia care (MAC) or general anesthesia (GA) is often important for patient safety and procedural success. We evaluated characteristics, indications, and complications in patients undergoing ERCP with anesthesiology assistance at our tertiary referral center. Results: From 7/1/02 to 6/30/04 2077 ERCP's were performed. A total of 192 procedures were performed in 111 patients with anesthesiology assistance. One hundred eighty-nine patients received GA and 3 received MAC. Sixty patients were female. The average procedural age was 43.9 years. Indications for GA or MAC included age of 18 or less (34%), ASA class IV (10.4 %), inability to sedate during an earlier procedure (11.4 %), chronic narcotic use (14.1 %), age 85 or greater (6 %), and sepsis (4.6 %). Thirty-four percent were ASA II and 40.6 % were ASA class III. Eight had PSC, 11 had choledochoceles, and 2 were pregnant. Ninety-one percent of procedures were therapeutic. Findings: 6 normal exams, pancreatic duct dilation in 75, common bile duct (CBD) dilation in 57, CDB stone in 30, benign CBD stricture in 35, benign pancreatic duct stricture 39, malignant biliary stricture in 11, pseudocyst 16, anastomotic stricture after liver transplantation in 9, pancreatic divisum in 5, and pancreatic mass in 5 patients. Procedural success was 98%. Anesthesia complications occurred in 2 patients (1%) (prolonged paralysis and uncomplicated ventricular tachycardia). Thirty- four patients were discharged the same day. Seventy-two were discharged within 24 hours of the procedure. Thirty-six of the 72 had sphincterotomies necessitating a 24 hour observational stay at our institution. Fifteen patients were discharged within 48 hours. Eight patients were admitted for an average of 6.9 days. The remaining 57 procedures were performed on hospitalized patients. Conclusion: Anesthesia support is employed in a variety of conditions and not limited to those with multiple comorbidities. The involvement of anesthesiology increases the procedural success and can be accomplished with low morbidity.

Laparoscopic balloon dilatation and brush biopsy of benign common bile duct stricture

Laparoscopic balloon dilatation and brush biopsy of benign common bile duct stricture

Laparoscopic transgastric endoscopic retrograde cholangiopancreatography for benign common bile duct stricture after Roux-en-Y gastric bypass

Access to the gastric remnant and duodenum is lost after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Traditionally, a percutaneous transhepatic access to the common bile duct has been used to manage choledocholithiasis and duct strictures. We present a novel method of laparoscopic transgastric endoscopic retrograde cholangiopancreatography for managing a benign biliary stricture after a Roux-en-Y gastric bypass.