Biliary Endoprosthesis Research Articles

Liver abscesses--complications after prosthesis and stent occlusions

Patients with malignant, unresectable biliary strictures and endoprosthesis or stents for drainage often develop liver abscess. The aim of the investigation was to assess the relationship and the factors causing the development of these abscesses. 9 patients with a median age of 65.6 years, liver abscess and endoprosthesis or stents were studied retrospectively. The occlusions were made visible sonographically and by ERC or PTC. With sonography the abscess was diagnosed and punctured. 5 patients (56%) had a bile duct carcinoma, two patients had a distal tumor stenosis, one a tumor of the gallbladder and one an obstructive jaundice due to liver metastases. 8 patients required a percutaneous drainage (PTCD). 6 cases of occlusions were found. 1 patient had a biliary obstruction because of a broken endoprosthesis. On an average it took 11.6 months from the first endoprosthesis or stent placement to the formation of an abscess. Plastic endoprostheses tend to occlude more rapidly (5 months versus 17.6 with stents). After the sonographically guided puncture of the liver abscess, i.v. antibiotics were given for 5 to 14 days. The antibiotics were continued orally. Two cases required a sonographically placed percutaneous drainage. 78% of the abscesses could be cured. One patient died because of sepsis. Liver abscesses were connected with intrahepatic carcinomas (56%). In such cases drainage is difficult and requires many interventions. Furthermore, we find this especially after percutaneous transhepatic drainage and with plastic endoprostheses.

Value of ultrasound in follow-up of biliary metal stents--initial results

Self-expandable metallic biliary endoprostheses (= "stents") are an accepted therapeutic alternative in the palliative treatment of malignant biliary obstruction. The physiological direction of bile flow is re-established for a varying period of time. Sonography is an acutely available modality for the evaluation of symptomatic patients who are carriers of such endoprostheses. The cause of recurrent obstructive jaundice can be diagnosed quickly and a new intervention can be planned carefully.

Accidental placement of a biliary endoprosthesis in the portal vein

A 58-year old man presented with jaundice. Imaging studies showed a pancreatic mass suggesting cancer. A 7-Fr biliary endoprosthesis was introduced. Seven days later the man was readmitted with increasing jaundice, and exchange of the endoprosthesis was requested. The procedure was performed in an endoscopy room without radiography facilities. The endoprosthesis was removed; access to the biliary system seemed straightforward. Contrast injection with fluoroscopy showed duct dilatation and a 9-cm, 10-Fr endoprosthesis was introduced. Immediately, bleeding originating from the endoprosthesis was observed that stopped after 4 minutes. CT was performed ([Fig. 1]). The hemoglobin level remained stable. That same day pancreaticoduodenectomy was performed. No bleeding problems were encountered upon removal of the endoprosthesis. Several thrombi were removed from the portal vein. At histopathology pancreatic adenocarcinoma was found. Seven years later there is no evidence to suggest residual or recurrent disease.

Endoscopic retrieval of a proximally migrated biliary stent within the gallbladder lumen

Endoscopic techniques for retrieval of migrated biliary endoprostheses include stent cannulation and subsequent balloon retrieval, balloon placement parallel to the stent with traction retrieval, and the use of a wire basket, snare, Soehendra stent retriever, or rat-tooth forceps [1] [2] [3]. The technique chosen depends on the extent of proximal stent migration, the presence of ductal dilatation or biliary stricture, and the endoscopist’s experience. This report describes the retrieval of a proximally migrated biliary stent located within the gallbladder lumen.

経皮経肝胆道内瘻術が奏効した外傷性総胆管狭窄の１例

経皮経肝胆道内瘻術が奏効した外傷性総胆管狭窄の１例

Cholangiocarcinoma: A compact review of the literature

Cholangiocarcinoma (CC) is a devastating cancer arising from biliary epithelia. Unfortunately, the incidence of this disease is increasing in Western countries. These tumors progress insidiously, and liver failure, biliary sepsis, malnutrition and cancer cachexia are general modes of death associated with this disease. To date, no established therapy for advanced disease has been established or validated. However, our knowledge in tumor biology is increasing dramatically and new drugs are under investigation for treatment of this notorious tumor. In clinical practice, there are better diagnostic tools in use to facilitate an earlier diagnosis of CC, at least in those patients with known risk factors. CC is resectable for cure in only a small percentage of patients. Preoperative staging for vascular and biliary extension of CC is very important in this tumor. Laparoscopy and recently endosonography seem to protect against unnecessary laparotomies in these patients. During the last 15 years, aggressive surgical approaches, including combined liver resections and vascular reconstructive surgical expertise, have improved survival in patients with CC. Surgery is contraindicated in CC cases having primary sclerosing cholangitis (PSC). Although CC was previously considered a contraindication to liver transplantation, new cautious protocols, including neo-adjuvant chemoradiation therapies and staging procedures before the transplantation, have made it possible to achieve long-term survival after liver transplantation in this disease. New ablative therapies with photodynamic therapy, intraductal high-intensity ultrasonography and chemotherapy-impregnated plastic biliary endoprosthesis are important steps in the palliative management of extra-hepatic CCs. Radiofrequency and chemo-embolization methods are also applicable for intra-hepatic CCs as palliative modes of treatment. We need more prospective randomized controlled trials to evaluate the role of the new emerging therapies for CC patients.

Traitement des complications biliaires après cholécystectomie par cœlioscopie : étude rétrospective de 27 patients

Biliary injuries after laparoscopic cholecystectomy are rare but serious. Their mortality rate can reach 9%. Aim of the study Describe the management of biliary injuries after laparoscopic cholecystectomy in our center. Patients Between January 1995 and June 2005, 27 patients (13 women, 14 men) were treated. The mean age was 53 years old (range, 18–92 years). The biliary injuries were common bile duct sections (n=16, 60%), common bile duct stenoses (n=5, 18.5%), biliary fistulas from the cystic duct (n=4, 15%), and biliary fistulas from an aberrant biliary duct (n=2, 7.5%). Results Acute cholecystis was present in 40% of cases (n=11). An intraoperative cholangiography was done in 12 patients (44%). The mortality rate was 0%. Of the common bile duct sections, 43% were diagnosed during the cholecystectomy (n=7) or after the cholecystectomy within a mean of 11.2 days (n=9). Common bile duct injuries were treated in 16 cases with hepatojejunostomy and in five cases with an external biliary drain. Fistulas from the cystic duct were diagnosed within a mean 14.8 days. A fistula from an aberrant biliary duct was diagnosed during the cholecystectomy (n=1) or in the second postoperative day (n=1). Fistulas were treated with a clip on the cystic duct (n=2), an external biliary drain (n=1), a biliary endoprosthesis (n=1), and the biliary aberrant duct suture (n=2). Conclusion Common bile duct injuries are a serious complication because their treatment is a hepaticojejunostomy in 75% of cases.

Late Migration of Two Covered Biliary Stents Through a Spontaneous Bilioenteric Fistula in a Patient with Malignant Biliary Obstruction

We report a case of simultaneous late migration of two ePTFE-FEP covered biliary endoprostheses (Viabil, W.L. Gore, Flagstaff, AZ, USA) that were percutaneously implanted for the treatment of malignant obstructive jaundice. The first Viabil covered stent was placed successfully without any evidence of dislocation or other complication during follow-up. Occlusion of the stent occurred 4 months later and was treated with the placement of a second stent of the same type. Thirteen months later the patient became symptomatic. Percutaneous transhepatic cholangiography (PTC) revealed the presence of a choledocho-duodenal fistula and the disappearance of the two endoprostheses previously implanted. A third metallic stent was then percutaneously positioned through the bilioenteric fistula. The computed tomography scan that followed for the detection of the metallic bodies did not reveal the dislocated metallic stents. Stent migration is a well-known complication of uncovered metallic stents, though Viabil stent migration is assumed to be most unlikely to happen due to the stent's anchoring barbs. Furthermore, the stent had already been tightly fixed by tumor over- and ingrowth, as recognized in previous imaging. This is a very unusual case, describing the disappearance of two metallic foreign bodies encapsulated by tumor.

Intraductal Stent (“Inside Stent”) Placement for Post Liver Transplant Duct-to-Duct Anastomotic Biliary Strictures: A Feasibility Study

Introduction: Placement of a biliary stent entirely within the bile duct above the intact biliary sphincter (“inside stent”) has been shown to decrease the incidence of stent occlusion in animal studies. Biliary sphincter preservation may reduce biliary bacterial colonization and resultant stent occlusion, and also decrease sphincterotomy related complications. Aim: To assess the feasibility of inside stent placement for anastomotic biliary strictures after liver transplantation with duct-to-duct anastomosis. Methods: Patients found to have an anastomotic biliary stricture during ERCP underwent inside stent placement. Biliary endoprostheses (8.5 Fr-10 Fr 5 cm) with one internal flap and with the distal flap removed to allow passage of the stent above the papilla were placed endoscopically during ERCP. The entire stent was intraductal, straddling the stricture, with its distal end above the biliary sphincter. A 7 cm long 2.0 prolene suture was affixed to the distal side-hole of the stent to facilitate removal of the stent. After stent deployment the suture traversed the papilla with its distal end in the duodenum. Results: An inside stent was placed in 10 patients with anastomotic biliary strictures and abnormal liver tests after liver transplantation. Median duration of stenting was 69.5 days (4-113 days) before patients underwent a scheduled follow-up ERCP for stent removal. At subsequent ERCP, normalization of, or >50% improvement in AST, ALT, alkaline phosphatase and total bilirubin was seen in 6/10 (60%), 6/10 (60%), 8/10 (80%) and 9/10 (90%) patients respectively. Stent occlusion based on the 10 cm water cup test was seen in one asymptomatic patient after 83 days. There was no incidence of cholangitis, pancreatitis, bleeding or perforation after inside stent placement or removal. Stents were removed by grasping the suture with a rat-tooth forceps to remove the stent from the duct and then subsequently snared. The suture was pulled off the stent in 1 case and the stent was then removed from the duct with a rat-tooth forceps. At follow-up ERCP, 9 of 10 stents were noted to be in good position (1 stent migrated upstream above the stricture). Of the 9 patients with improvement in bilirubin after inside stenting, 3 patients required further endoscopic therapy (2 with sphincterotomy and transpapillary stenting and 1 with biliary sphincterotomy alone). Conclusions: Biliary inside stent placement is a safe, feasible, sphincter-preserving option for therapy of anastomotic biliary strictures after liver transplantation. Further studies comparing inside stents with standard transpapillary stents in the post-transplant setting are required.

Treatment of biliary obstruction in selected patients by endoscopic ultrasonography (EUS)-guided transluminal biliary drainage

Endoscopic retrograde cholangiopancreatography (ERCP)-guided implantation of a biliary endoprosthesis or stent is the gold standard treatment for biliary obstructions. When the papilla cannot be traversed because there is pyloric or duodenal stenosis, or the catheter cannot be introduced, or because of previous gastrointestinal surgery (Billroth II gastric resection, Whipple procedure, gastrectomy with Roux-en-Y reconstruction), the alternative treatment is considered to be percutaneous transhepatic cholangiography and drainage (PTCD). The aim of the study was to investigate the further alternative of endoscopic ultrasound (EUS)-guided transgastric or transjejunal biliary drainage where PTCD failed or was declined, and particularly, the feasibility and outcome of this option. Over 3 years all appropriate consecutive patients (as defined above) were enrolled in this prospective, observational, single-center, case series study, and patient and intervention data were recorded. Feasibility was characterized by success rate (regression of cholestasis), and outcomes by complication rate, mortality, and follow-up findings. Between November 2002 and December 2005, eight patients (in 10 interventions) underwent this new biliary drainage procedure. The routes were transesophageal (n = 1), transgastric (n = 4), and transjejunal (n = 3, including a rendezvous technique with ERCP [n = 1]). The indications were cholestasis, arising from recurrent tumor growth (n = 5, 62.5%), that included gastric carcinoma after previous gastrectomy (n = 4) and a periampullary carcinoma after previous Whipple procedure (n = 1); arising from Klatskin tumor (n = 2, 25%); and from benign stenosis of a hepaticojejunostomy (n = 1, 12.5%). Five patients (62.5%) received a metal stent, and three (37.5%) had a plastic prosthesis (8.5-Fr double-pigtail). The technical success rate was 90% (9/10) and the clinical success rate was 88.9% (8/9). There was only one case of cholangitis (12.5%) and slight postinterventional pain, but no severe complications such as bleeding or perforation, and no mortality. During follow-up (range 4 weeks to 3 years) re-interventions were needed in two patients (20%) because of increasing cholestasis; these resulted in technical success and clinical improvement. EUS-guided transgastric or transjejunal biliary drainage is a reasonable, feasible and encouraging treatment option in selected patients as indicated, with a low peri-interventional risk. It broadens the therapeutic spectrum but still needs further evaluation and follow-up investigation.

An innovative percutaneous technique for the removal and replacement of dysfunctioning plastic biliary endoprostheses (PBE) in the management of malignant billiary occlusions

The purpose of this study was to assess the feasibility and clinical impact of the percutaneous removal and replacement of dysfunctioning plastic biliary endoprostheses (PBE). Over a period of 24 months, we observed eight patients (age 54-82 years; mean 65) with dysfunctioning PBE. After transhepatic cholangiography and bile duct catheterisation, the endoprostheses were grasped with a gooseneck snare and pushed into the duodenum using a long introducer sheath. Subsequently, we implanted six metallic stents in middle and distal occlusions and four plastic endoprostheses in two patients with proximal occlusion. Clinical and ultrasound followup was performed 1, 3 and 6 months after the procedure and then yearly. The procedure was technically successful in all patients. No major complication occurred. All patients were discharged without biliary drainage catheters. During the follow-up period (mean: 7.1 months), four patients died and two occlusions of metallic stents were treated by implanting a further metallic stent. Percutaneous removal of a dysfunctioning PBE is feasible and allows better quality of life owing to the absence of biliary drainage. Patency of metallic stents is higher than that of PBE. Larger studies are clearly required to validate this approach.

Plastic Biliary Stent Occlusion: Factors Involved and Possible Preventive Approaches

Endoscopic biliary stenting is today the most common palliative treatment for patients suffering from obstructive jaundice associated with malignant hepatobiliary tumors or benign strictures. However, recurrent jaundice, with or without cholangitis, is a major complication of a biliary endoprosthesis insertion. Thus, stent removal and replacement with a new one frequently occurs as a consequence of device blockage caused by microbial biofilm growth and biliary sludge accumulation in the lumen. Factors and mechanisms involved in plastic stent clogging arising from epidemiological, clinical and experimental data, as well as the possible strategies to prevent biliary stent failure, will be reviewed and discussed.

Complications and treatment of migrated biliary endoprostheses: A review of the literature

Endoscopic biliary stent insertion is a well-established procedure. It is especially successful in treating postoperative biliary leaks, and may prevent surgical intervention. A routine change of endoprostheses after 3 mo is a common practice but this can be prolonged to 6 mo. We reported a colonic perforation due to biliary stent dislocation and migration to the rectosigmoid colon, and reviewed the literature.

Endoscopic Retrieval of a Proximally Migrated, Deeply Embedded Pancreatic Duct Stent Using a Rat Tooth Forceps

Case Report: A 33-year-old female who had undergone multiple ERCPs for recurrent abdominal pain was admitted to our hospital with persistent pain and pancreatitis 9 days post-ERCP. Prior pancreatic duct (PD) stent placement was complicated by proximal migration into the PD. Multiple failed attempts at stent retrieval with a basket, stent retriever, balloon, and autotome all failed to successfully engage the stent, and only pushed the stent more proximally. Endoscopic retrieval of the migrated stent was then attempted at our institution. The PD was cannulated with a 3.9F sphincterotome (Boston Scientific) preloaded with a.021 inch diameter guidewire (Wilson-Cook). Pancreatogram showed the stent deeply embedded in the tail. An initial retrieval attempt using a 4 mm x 2 cm Hurricane Rx Dilation Balloon (Boston Scientific) partially inflated alongside the stent to facilitate traction removal was unsuccessful. We then advanced a rat tooth alligator jaw grasping forceps (Olympus) to the tail, successfully grabbed the stent, and removed the stent by carefully withdrawing the forceps (Figure 1). Repeat pancreatogram revealed no evidence of contrast extravasation from the PD. A 5F 10 cm Zimmon pancreatic stent (Wilson-Cook) was placed. The patient's pancreatitis improved over the next several days.Figure 1Discussion: The majority of proximally migrated PD stents can be retrieved using the same techniques and devices that are utilized for the retrieval of migrated biliary endoprostheses. In difficult cases, surgical intervention or the use of novel techniques utilizing interventional radiologic accessories have been reported. In the present case, we demonstrated the removal of a deeply embedded, proximally migrated PD stent with the use of standard grasping forceps. We report the novel technique of using a rat tooth forceps for the retrieval of a deeply embedded PD stent. This modality is safe and demonstrates that standard endoscopic accessories can be utilized in favor of less readily available interventional equipment from fields outside of gastroenterology. [figure 1]

Nonmalignant portal vein thrombosis in adults

Portal vein thrombosis (PVT) consists of two different entities: acute PVT and chronic PVT. Acute PVT usually presents as abdominal pain. When the thrombus extends to the mesenteric venous arches, intestinal infarction can occur. Chronic PVT is usually recognized after a fortuitous diagnosis of hypersplenism or portal hypertension, or when there are biliary symptoms related to portal cholangiopathy. Local risk factors for PVT, such as an abdominal inflammatory focus, can be identified in 30% of patients with acute PVT; 70% of patients with acute and chronic PVT have a general risk factor for PVT, most commonly myeloproliferative disease. Early initiation of anticoagulation therapy for acute PVT is associated with complete and partial success in 50% and 40% of patients, respectively. A minimum of 6 months' anticoagulation therapy is recommended for the treatment of acute PVT. For patients with either form of PVT, permanent anticoagulation therapy should be considered if they have a permanent risk factor. In patients with large varices, beta-adrenergic blockade or endoscopic therapy seems to prevent bleeding as a result of portal hypertension, even in patients on anticoagulation therapy. In patients with jaundice or recurrent biliary symptoms caused by cholangiopathy, insertion of a biliary endoprosthesis is the first treatment option. Overall, the long-term outcome for patients with PVT is good, but is jeopardized by cholangiopathy and transformation of underlying myeloproliferative disease into myelofibrosis or acute leukemia.

Deliberate Puncture of the Bile Duct and Duodenal Wall for Placement of a Biliary Endoprosthesis in a Rendezvous Procedure

Deliberate Puncture of the Bile Duct and Duodenal Wall for Placement of a Biliary Endoprosthesis in a Rendezvous Procedure

Differential Treatment of Biliary Obstructions with the Alternative EUS-Guided Transgastric Or Transjejunal Cholangiodrainage

ERCP-guided implantation of a biliary endoprosthesis or of a stent has been established as gold standard for the treatment of biliary obstructions. In cases with not reachable papilla because of pyloric/duodenal stenosis, not introducible catheter into the papilla or after previous gastrointestinal surgery (BII/Whipple procedure, gastrectomy with Roux-en-Y reconstruction), PTCD is considered the alternative therapeutic option. The aim of the study was to investigate, as further alternative, the EUS-guided transgastric or transjejunal cholangiodrainage in patients who decline PTCD or in case of its failure, in particular, its feasibility and outcome. Patients & Methods: All consecutive patients (as defined in the “Aim”) were enrolled in this prospective observational unicenter study (case series) through a 3-year time period and patient- and intervention-related specifics were documented. Feasibility was characterized by success rate (regressive cholestasis), outcome by complication rate, mortality and follow-up. Data represent an interims analysis. Results: From XI/2002-X/2005, 8 patients (No. of interventions, n = 10) underwent this new route of cholangiodrainage: i) Transesophageally, n = 1; ii) transgastrically, n = 4; iii) transjejunally, n = 3 (among them rendezvous technique with ERCP, n = 1). The main indication was cholestasis in i) recurrent tumor growth (n = 5, 62.5%) of a gastric carcinoma after previous gastrectomy (n = 4) or of a periampullary carcinoma after previous Whipple procedure (n = 1), ii) Klatskin tumor (n = 2; 25%) and iii) a benign stenosis of a hepaticojejunostomy (n = 1; 12.5%). Five patients (62.5%) received a metal stent, whereas in 3 subjects (37.5%), a plastic prosthesis was used (8.5-French double pigtail). While the technical success rate was 90% (n = 9/10), there was a clinical success rate of 88.9% (n = 8/9). Two re-interventions (20%) became necessary because of increasing cholestasis parameters resulting in technical success and clinical improvement. There were no severe complications such as bleeding or perforation (mortality, 0%). Conclusion: EUS-guided transgastric or transjejunal cholangiodrainage is a reasonable, feasible and encouraging treatment option in selected patients as indicated with a low periinterventional risk which broadens the therapeutic spectrum but still needs further evaluation and follow-up investigation.

Endoscopic Management of Persistent Biliary Leakage Resulting from Complete Transection of the Bile Duct at Cholecystectomy

Injuries to the bile duct are not uncommon during cholecystectomy. While minor injuries are amenable to endoscopic therapy, major ones, such as complete transection of the duct, require surgical intervention. We report on the endoscopic management of such injuries. We included in the study ten patients who had persistent postoperative bile drainage (either through a surgically placed catheter or through a biliocutaneous fistula) after their cholecystectomy procedure had been complicated by complete transection of the bile duct. Plastic biliary endoprostheses were placed in the bilioma through the papilla of Vater. In one patient, both the right and the left hepatic ducts were opacified by injecting contrast material through the drainage catheter and it was possible to place stents in both the ducts. All the patients improved clinically after the procedure. In one patient the stent became dislodged and an elective Roux-en-Y hepaticojejunostomy was performed, but it was possible to remove the stents from all the other patients. Two patients were referred for surgery but in both cases the bile flow through the bile duct was shown to be so good on nuclear imaging that they were not operated on. All the non-operated patients are well after a mean +/- SD follow-up of 22.3 +/- 5.5 months. Placement of biliary stents in the bilioma is a useful adjunct to percutaneous drainage in patients with complete transection of the bile duct. After placement of a biliary stent in the bilioma the percutaneous drainage catheter may be removed. In one of our study patients it was also possible to place stents in the intrahepatic ducts and the bile duct was reconstructed. Long-term follow-up of these patients and further studies are required to assess the role of endoscopic management as an alternative to surgery in patients with this condition.

Gallbladder sepsis after stent insertion for bile duct obstruction: Management by percutaneous cholecystostomy

Of 364 patients undergoing insertion of a biliary endoprosthesis in 1989, six (1.6 per cent) developed gallbladder sepsis. Three patients had cholangiocarcinoma, two had carcinoma of the pancreas and one had a benign biliary stricture. Two of the five patients with malignancy had gallbladder stones, and the patient with a benign stricture developed stones after 3 years of stenting. Three patients developed gallbladder sepsis early after endoprosthesis insertion (less than 6 days), while in the other three it occurred late (greater than 6 months). All six patients failed to respond to antibiotics and were successfully managed by percutaneous cholecystostomy; the patient with a benign biliary stricture also had cholecystolithotomy. The gallbladder drainage tubes were removed or became dislodged at intervals varying from 2 weeks to 6 months without complications. Percutaneous cholecystostomy is the treatment of choice for gallbladder sepsis unresponsive to antibiotics in patients with a biliary endoprosthesis in situ.

Palliation of irresectable hilar cholangiocarcinoma with biliary drainage and radiotherapy.

Twelve patients with irresectable or recurrent hilar cholangiocarcinoma were treated with internal biliary drainage followed by intraluminal (iridium-192) and external-beam radiotherapy. Biliary drainage was accomplished by means of a combined surgical and interventional radiological approach. Initial biliary decompression was performed surgically by tumour resection, intrahepatic biliary enteric bypass or distal biliary-enteric anastomosis with a temporary stent. Maintenance of internal biliary drainage and application of intraluminal radiotherapy were accomplished radiologically with the use of percutaneous dilatation and metallic expandable biliary endoprostheses. Median survival was 14.5 months; all 12 patients survived for at least 6 months. Early complications during radiotherapy were minor and included two patients with cholangitis and one with transient haemobilia. Jaundice was relieved in ten of 12 patients, while episodes of cholangitis were seen during long-term follow-up in 11 (median 1.5 episodes per patient). Internal biliary drainage, in conjunction with radiotherapy, appears to be safe and effective palliation of irresectable or recurrent hilar cholangiocarcinoma. Patients can maintain a reasonable quality of life with an acceptable incidence of cholangitis, without the hindrance of external drainage devices.