Biliary-enteric Anastomotic Strictures Research Articles

A novel technique of percutaneous transhepatic treatment of biliary-enteric anastomotic occlusive strictures with compliant balloon-occluded distal cholangiography and large-bore catheter: a retrospective case series.

Endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary balloon dilatation (PTBD) is a challenge in resolving biliary-enteric anastomotic occlusive strictures (BEAOS) and/or coexisting stones. The biliary-enteric anastomosis (BEA) often cannot be seen because of the surgically altered gastrointestinal anatomy. Here, a technique that combined percutaneous compliant-occluded distal cholangiography and the maintenance of a large-bore catheter is described to resolve this issue. A retrospective review of 10 patients who presented with BEAOS with/without coexisting stones who were treated with percutaneous compliant balloon-occluded distal cholangiography, bile duct stone removal, and the maintenance of a large-bore catheter between February 2017 and January 2021 was performed. Treatment response, laboratory examinations, including hepatic function tests, routine blood tests, and blood electrolytes, complications, and imaging data were evaluated. Paired t-tests were used to investigate the difference of laboratory examinations before and after the procedure. All 10 cases were technically successful. A total of 9 stones in 6 patients were successfully removed by the compliant balloon. All catheters were removed after the patency of the stricture was confirmed by percutaneous transhepatic cholangiography (PTHC) 6 months later. No severe adverse events occurred during the perioperative period. There were 2 patients who experienced episodes of cholangitis during the follow-up period (mean, 17 months; range, 4-24 months), and neither BEAOS nor bile duct stones recurred within 2 years after the procedure. White blood cells (WBC), total bilirubin (TB), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) were (6.0±1.4)×109/L and (6.0±1.6)×109/L (P=0.91), 31.4±15.7 and 29.6±10.3 µmol/L (P=0.74), 50.8±20.0 and 85.8±67.0 U/L (P=0.16), and 42.6±15.2 and 71.8±44.9 U/L (P=0.09) pre and postintervention, respectively. Percutaneous transhepatic compliant balloon-occluded distal cholangiography and the maintenance of a large-bore catheter probably provide an effective and safe alternative method for resolving BEAOS and/or coexisting stones.

Nursing of a child with biliary-enteric anastomotic strictures complicated by intestinal obstruction after liver transplantation

Nursing of a child with biliary-enteric anastomotic strictures complicated by intestinal obstruction after liver transplantation

The strategy of laparoscopic surgery for asymptomatic antenatally diagnosed choledochal cyst

BackgroundThe aim was to investigate the characteristics, surgical management, and outcomes of asymptomatic patients with antenatally diagnosed choledochal cysts (ADCCs) and to justify the strategy of laparoscopic surgery (LS) for them in our hospital.MethodsWe developed our LS strategy for asymptomatic ADCCs. Patients with asymptomatic ADCCs who underwent LS or open surgery (OS) during January 2010 and January 2020 were included. Patients with recorded symptomatic ADCCs were exclude. All data of group LS and group OS were statistically compared and analyzed.ResultsTwenty-five patients received LS and 18 patients received OS were included. There was no significant difference in baseline characteristics between the groups. A total of 65.1% of biliary sludge formation was detected preoperatively by ultrasonography (US) (72.0% in group LS, 55.6% in group OS, P = 0.26). Compared to the OS group, the LS group had a longer operative time (313.4 ± 27.2 vs. 154.0 ± 11.9 min, P = 0.02), shorter postoperative fasting period (3.1 ± 1.2 vs. 6.2 ± 2.3 days, P = 0.03), and shorter postoperative hospital stay (5.1 ± 1.9 vs. 9.2 ± 1.1 days, P = 0.03). The incidence of late complications, such as reflux cholangitis, adhesive intestinal obstruction, and biliary enteric anastomotic stricture with stone formation, was not significantly different between the two groups. The liver function and liver stiffness of all patients in the two groups were normal.ConclusionsBased on the strategy for asymptomatic ADCCs in our hospital, the perioperative safety and midterm follow-up results after LS were satisfactory and comparable to those after OS.

Outcome of percutaneous transhepatic biliary interventions in the management of biliary enteric anastomotic strictures with hepatolithiasis

To evaluate percutaneous transhepatic biliary interventions (PTBI) using the ADDFREE (Access-Drain-Dilate-Flush-REpeat periodically-Evaluate and remove) technique and its outcomes in patients with biliary enteric anastomotic strictures (BEAS) and hepatolithiasis. A retrospective review was undertaken of patients having hepatolithiasis with BEAS who underwent PTBI with a therapeutic intent (from January 2010 to January 2021) was performed. The technical and clinical successes of PTBI were analysed. Technical success was divided into duct access, crossing of BEAS, stricture resolution, and calculi clearance. Improvement of liver function tests, resolution of leucocytosis and presenting complaints were considered as clinical success. The patients were followed-up for a minimum duration of 6-months. Eighteen patients received PTBI in form of the ADDFREE technique. Hepatolithiasis was bilobar (44.4%), unilobar in multiple ducts (unilobar-m; 27.8%) and unilobar in a single duct (unilobar-s; 27.8%) along with anastomotic stricture. The average number of sessions of stone clearance for bilobar, unilobar-m, and unilobar-s was 4.4 (±1.6), 3.6 (±2.4), and 1.5 (±0.5), respectively. Clinical success was observed in 14 (77.8%), while one patient had recurrence of calculi and received repeat treatment. Bile culture was positive for bacterial organisms in 17 (94.4%) patients. No major complication were seen while minor complication were seen in five patients consisting of self-limiting haemobilia (n=1), per-catheter bile leak (n=2) and aggravation of cholangitis (n=2). PTBI, consisting of bile duct access, cholangioplasty, and calculi clearance, is a safe and effective technique for the treatment of patients having hepatolithiasis secondary to BEAS.

Novel Surgical Technique for the Management of Biliary-Enteric Anastomotic Strictures

Novel Surgical Technique for the Management of Biliary-Enteric Anastomotic Strictures

P-L08 Novel surgical technique for the management of biliary-enteric anastomotic strictures

Abstract Background This study presents an invented surgical technique for dealing with biliary-enteric anastomotic strictures with the potential to replace currently used methods in certain cases. Methods In this retrospective study, a novel surgical technique was introduced in the management of eight patients with bilioenteric strictures between January 2016 and May 2018. Results Our new technique was associated with a 100% success rate where patency of anastomosis was achieved in all patients along the 28 month follow-up period. Only two of the patients developed a complication including wound-site infection, and cholangitis at the 17th month follow-up. None of the patients developed intrahepatic biliary dilation or stricture recurrence. Conclusions This novel surgical approach may reduce recurrent medical and radiological interventions and the need for anastomosis revision. It may also lessen the rate of complications. However, larger scale studies are needed to confirm such findings.

Novel surgical technique for the management of biliary-enteric anastomotic strictures

Aims: This study presents an invented surgical technique for dealing with biliary-enteric anastomotic strictures with the potential to replace currently used methods in certain cases. Methods: In this retrospective study, a novel surgical technique was introduced in the management of eight patients with bilioenteric strictures between January 2016 and May 2018. Results: Our new technique was associated with a 100% success rate where patency of anastomosis was achieved in all patients along the 28 month follow-up period. Only two of the patients developed a complication including wound-site infection, and cholangitis at the 17th month follow-up. None of the patients developed intrahepatic biliary dilation or stricture recurrence. Conclusion: This novel surgical approach may reduce recurrent medical and radiological interventions and the need for anastomosis revision. It may also lessen the rate of complications. However, larger scale studies are needed to confirm such findings.

Abstract No. 562 Paclitaxel drug-coated balloon cholangioplasty in the treatment of biliary-enteric anastomotic stricture

Treatment of biliary-enteric (B-E) anastomotic stricture is difficult, often requiring protracted management via several procedures. Stricture restenosis is a common issue; paclitaxel drug coated balloons (DCB) have been shown to reduce restenosis via an antiproliferative mechanism in peripheral arterial disease applications; use of these devices may reduce lesion restenosis in anastomotic strictures. In this study, we seek to evaluate the efficacy of DCB treatment of B-E anastomotic strictures. Patients who underwent treatment of B-E anastomotic strictures with DCB from 9/2016 to present were reviewed. Patients received initial percutaneous drain placement; approximately 1 week later standard/cutting balloon angioplasty and 7 mm DCB application for 3 minutes at nominal inflation was performed. Symptom improvement was qualitatively assessed. Alkaline phosphatase (AP) and total bilirubin (TBili) values were collected prior to initial biliary intervention and following DCB cholangioplasty. Paired t-test was performed; significance was determined at p <0.05. Six patients (5M:1F, mean age 70) with B-E anastomotic strictures treated with DCB were identified; technical success was achieved in 5; these patients experienced symptomatic improvement. One patient had B-E stricture at a transplant hepaticojejunostomy. Four patients were found to have benign strictures, one patient had a malignant stricture and represents the only treatment failure. Prior to internal/external drain placement and DCB cholangioplasty, the average TBili was 3.8 ± 1.9 (mean ± SEM), which trended downward to 1.4 ± 0.6 (mean ± SEM) following DCB therapy (p = 0.08). Prior to internal/external drain placement and DCB cholangioplasty, the average AP was 439 ± 136 which decreased to 262 ± 77 (p = 0.03). No complications were encountered in this series. DCB cholangioplasty demonstrates early promise in the treatment of benign biliary-enteric anastomotic stricture. Further study needs to be performed to validate these findings and precisely define patients that could benefit from this intervention.

Percutaneous Management of Biliary Enteric Anastomotic Strictures: An Institutional Review.

PurposeStricture formation at the biliary enteric anastomotic site is a common complication due to fibrotic healing. Few therapeutic options are available for biliary-enteric anastomotic site stricture (BES) including new surgical reconstruction or percutaneous transhepatic biliary drainage followed by balloon dilation of BES or stent placement. The purpose of this study is to assess the technical success, complications and reintervention rate of percutaneous transhepatic balloon dilatation (PTBD) of BES after iatrogenic bile duct injuries (BDI).MethodsA retrospective review of patients who underwent PTBD for benign resistant BES, previously treated for iatrogenic BDI, from December 2004 to January 2016 was performed. Diagnostic transhepatic cholangiogram was performed to assess the level of obstruction. BES was dilated using 8-12 mm diameter balloons followed by placement of eight to ten Fr internal-external drainage catheters, which were removed after three to six weeks post-PTBD cholangiogram. Follow-up by clinical assessment, liver function tests, and ultrasound was done. Fischer exact test was used to determine if there was a significant association between PTBD sessions and recurrent strictures.ResultsIn total, 37 patients underwent 66 sessions of PTBD, including 10 (27%) males and 27 (73%) females. The mean age was 41.3 years (range 23–70 years). Out of these, 29 (78%) were treated with choledochojejunostomy and eight (22%) with hepaticojejunostomy. 100% technical success was achieved in all the PTBD sessions. Nineteen (51.3%) patients were treated with a single PTBD session. Mean follow-up time was 36 months (range 1–75 months). Eighteen (48.7%) patients needed reintervention, out of these, 11 (29.7%) were symptom-free after second session on three-year follow-up, three (8%) were symptom-free after the third session of PTBD. No significant difference was observed in risk of recurrent strictures after first and second PTBD sessions [18 (48%) vs. 7 (39%); p-value 0.495]. In four (11%) patients, the symptoms persisted and BES recurred even after third session and those were treated by placing metallic stent. In total, three (8.1%) patients got complicated with the stone formation; in two (5%) patients stone was successfully removed percutaneously and in one (3%) patient percutaneous attempt failed so it was followed by surgical removal.ConclusionPTBD is a safe and useful treatment option for benign BES for long-term symptom-free time-period. However, there is no significant difference in developing recurrent BES after PTBD sessions. Few patients with resistant strictures might require stent placement.

Better long-term outcomes with hilar ductoplasty and a side-to-side Roux-en-Y hepaticojejunostomy

BackgroundWhether a wide hilar hepaticojejunostomy after bile duct cyst (BDC) excision can prevent the development of postoperative complications remains an unanswered question. We compared our outcomes after a minimum of 2-y follow-up in patients with Todani type Ia choledochal cyst treated with hilar ductoplasty followed by a side-to-side Roux-en-Y hepaticojejunostomy (ductoplasty group) or radical cyst resection with an end-to-side Roux-en-Y hepaticojejunostomy (conventional group). MethodsWe retrospectively reviewed the records of patients with Todani type Ia choledochal cyst who received radical cyst excision from January 1997 to December 2012, and we compared the groups' postoperative complications and surgical outcomes. ResultsThe groups' baseline demographics were similar, except for age. The gender distribution and preoperative presenting symptoms were comparable in the ductoplasty (n = 72) and conventional (n = 53) groups (all P > 0.05). Average age was 37.0 y for the ductoplasty group and 41.8 y for the conventional group (P = 0.024). The short-term complication rate of the groups was not significantly different (conventional group, 13.2% [7/53]; ductoplasty group, 8.3% [6/72]; all P > 0.05). A significant between-group difference was found in the long-term complication rate of biliary-enteric anastomotic strictures (9.4% in the conventional group and 0% in the ductoplasty group, P = 0.012). The rates of satisfactory surgical outcomes were 91.1% and 77.1% in the ductoplasty and conventional groups, respectively (P = 0.036). ConclusionsThe application of hilar ductoplasty with a side-to-side Roux-en-Y hepaticojejunostomy as the primary surgery for bile duct cyst excision significantly reduced the postoperative complication of biliary-enteric anastomotic stricture and greatly improved our patients' prognosis with regard to biliary function.

Incidence of hepaticojejunostomy stricture after hepaticojejunostomy

Operations requiring biliary-enteric anastomosis are uncommon, and the true incidence of postoperative stricture is unknown. Our goal was to determine the timing, incidence, and management of stricture after biliary-enteric anastomosis. We used 5% Medicare claims data (1996-2011) to identify patients ≥66years who underwent an operation requiring a biliary-enteric anastomosis. A cumulative incidence curve was used to describe timing of stricture diagnosis. The use of imaging and intervention was evaluated. A Cox proportional hazards model was constructed to identify factors associated with stricture. A total of 3,374 patients underwent an operation requiring either a hepaticojejunostomy (54.33%; N=1,833) or choledochojejunostomy (45.67%; N=1,541); 2-year survival was 57.0%. Overall, 403 (11.9%) patients developed a stricture. The cumulative incidence of stricture was 12.5% at 2years. Mean time to stricture diagnosis was 16.8±21.6months (median=8.5months); 23% of patients with a stricture required hospitalization for cholangitis (N=94). Only 18 (4.5%) patients with a stricture required reoperation. Younger age (hazard ratio 0.98; 95% confidence interval 0.98-0.99) was associated with a decreased likelihood of stricture formation; presence of an endostent (hazard ratio 1.66; 95% confidence interval 1.35-2.04) predicted stricture formation. Biliary-enteric anastomotic strictures occur with significant frequency after a biliary-enteric anastomosis. Although many patients are managed nonoperatively, stricture diagnosis remains burdensome.

Tu1572 Overtube-Assisted Enteroscopy ERCP Compared With Percutaneous Transhepatic Biliary Drains for Treatment of Biliary-Enteric Anastomotic Strictures in Patients With Long Limb Surgical Biliary Bypass

Tu1572 Overtube-Assisted Enteroscopy ERCP Compared With Percutaneous Transhepatic Biliary Drains for Treatment of Biliary-Enteric Anastomotic Strictures in Patients With Long Limb Surgical Biliary Bypass

Percutaneous Management of Resistant Biliary-Enteric Anastomotic Strictures with the Use of a Combined Cutting and Conventional Balloon Cholangioplasty Protocol: A Single-Center Experience

PurposeTo evaluate the safety and technical efficacy of percutaneous transhepatic dilation of resistant biliary-enteric anastomotic strictures using a combination of cutting and conventional balloons and evaluate midterm results. Materials and MethodsA retrospective review of patients with biliary-enteric anastomotic strictures treated with percutaneous transhepatic cutting balloon dilation was performed. Cutting balloon dilation was followed by dilation with the use of a conventional balloon with a diameter larger than that of the cutting balloon. Technical success was defined by the composite criteria of fluent passage of manually injected contrast medium through the anastomoses into the small bowel and absence of bile duct dilatation compared with the cholangiogram obtained before the procedure. Clinical and laboratory parameters, including serum bilirubin, alkaline phosphatase, and total leukocyte counts, were monitored in all patients at regular intervals after a technically successful procedure. ResultsBetween January 2012 and September 2013, eight patients (three men and five women) with a mean age of 50 years (range, 32–75 y) underwent 11 sessions of combined cutting and conventional balloon cholangioplasty. The procedure was technically successful in all patients. There were no major complications during the procedure. During the follow-up period (mean, 14 mo; range, 8–24 mo), all patients remained free of any biliary obstructive symptoms and had normal laboratory parameters with the absence of biliary dilatation on ultrasound examinations. ConclusionsCutting balloon dilation is a safe adjunctive option for the treatment of biliary-enteric anastomotic strictures resistant to conventional balloon dilation with acceptable midterm patency rates.

Percutaneous Transhepatic Balloon Dilation of Biliary-Enteric Anastomotic Strictures after Surgical Repair of Iatrogenic Bile Duct Injuries

PurposeTo evaluate the efficacy of percutaneous balloon dilation of biliary-enteric anastomotic strictures resulting from surgical repair of laparoscopic cholecystectomy-related bile duct injuries.Material and MethodsA total of 61 patients were referred to our institution from 1995 to 2010 for treatment of obstruction at the biliary-enteric anastomosis following surgical repair of laparoscopic cholecystectomy-related bile duct injuries. Of these 61 patients, 27 underwent surgical revision upon stricture diagnosis, and 34 patients were managed using balloon dilation. Of these 34 patients, 2 were lost to follow up, leaving 32 patients for analysis. The primary study objective was to determine the clinical success rate of balloon dilation of biliary-enteric anastomotic strictures. Secondary study objectives included determining anastomosis patency, rates of stricture recurrence following treatment, and morbidity.ResultsBalloon dilation of biliary-enteric anastomotic strictures was clinically successful in 21 of 32 patients (66%). Anastomotic stricture recurred in one of 21 patients (5%) after an average of 13.1 years of follow-up. Patients who were unsuccessfully managed with balloon dilation required significantly more invasive procedures (6.8 v. 3.4; p = 0.02) and were left with an indwelling biliary catheter for a significantly longer period of time (8.8 v. 2.0 months; p = 0.02) than patients whose strictures could be resolved by balloon dilation. No significant differences in the number of balloon dilations performed (p = 0.17) or in the maximum balloon diameter used (p = 0.99) were demonstrated for patients with successful or unsuccessful balloon dilation outcomes.ConclusionPercutaneous balloon dilation of anastomotic biliary strictures following surgical repair of laparoscopic cholecystectomy-related injuries may result in lasting patency of the biliary-enteric anastomosis.

Introducing Paclitaxel-Eluting Balloons as a New Treatment Option of Biliary-Enteric Anastomotic Stricture After Liver Transplantation

Introducing Paclitaxel-Eluting Balloons as a New Treatment Option of Biliary-Enteric Anastomotic Stricture After Liver Transplantation

Mo1320 Overtube-Assisted Enteroscopy ERCP vs. Percutaneous Transhepatic Biliary Drains for Treatment of Biliary-Enteric Anastomotic Strictures in Patients With Long Limb Surgical Biliary Bypass

Patients with long limb surgical biliary bypass (LLSBB) may develop biliary-enteric anastomotic strictures (AS). Percutaneous transhepatic biliary drains (PTBD) and surgical revision may be required. Preliminary experience with overtube assisted ERCP (OA-ERCP)stricturoplasty to treat AS is promising. AIM: Compare and evaluate technical success, complications, and duration of treatment for OA-ERCP vs. PTBD to achieve resolution of AS in patients with LLSBB.

Benign biliary strictures: current endoscopic management

Endoscopic treatment is the mainstay of therapy for benign billiary strictures, and surgery is reserved for selected patients in whom endoscopic treatment fails or is not feasible. The endoscopic approach depends mainly on stricture etiology and location, and generally involves the placement of one or multiple plastic stents, dilation of the stricture(s), or a combination of these approaches. Knowledge of biliary anatomy, endoscopy experience and a well-equipped endoscopy unit are necessary for the success of endoscopic treatment. This Review discusses the etiologies of benign biliary strictures and different endoscopic therapies and their respective outcomes. Data on newer therapies, such as the placement of self-expandable metal stents, and the treatment of biliary-enteric anastomotic strictures is also reviewed.

MR evaluation of biliary-enteric anastomotic stricture: Does contrast-enhanced T1W MRC provide additional information?

To compare T2W-MRCP and T1W contrast-enhanced MRC (CE-MRC) using Gd-BOPTA for evaluation of biliary-enteric anastomotic (BEA) stricture. Twenty-one patients who were suspected to have BEA stricture underwent T2W-MRCP and CE-MRC on a 1.5T scanner. Images were evaluated for evidence of anastomotic stricture. Composite gold standard was used including the findings on percutaneous transhepatic cholangiogram or percutaneous transhepatic biliary dilatation, surgery, alkaline phosphatase level and clinical follow-up. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of T2W-MRCP for the diagnosis of anastomotic stricture were 94.4%, 80%, 94.4% and 80% respectively. On CE-MRC, biliary excretion was seen in only 60.87% anastomoses and only these were taken for analysis. The sensitivity, specificity, PPV and NPV of CE-MRC for the diagnosis of anastomotic stricture were 40%, 75%, 80% and 33.3%. The combined evaluation of T2W-MRCP and CE-MRC showed sensitivity, specificity, PPV and NPV of 83.3%, 80%, 93.8% and 57.1%. At present, T2W-MRCP is still the diagnostic modality of choice in the evaluation of patients with BEA stricture and the usage of Gd-BOPTA enhanced MRC is inappropriate in this setting.

Mo1461 Biliary-Enteric Anastomotic Stricturoplasty Using Overtube-Assisted Enteroscopy ERCP in Patients With Long Limb Surgical Biliary Bypass

Limited data exists on ERCP in long limb surgical biliary bypass (LLSBB) patients. A subset of Roux-Y liver transplant and other LLSBB develop benign biliary-enteric anastomotic strictures (AS). Conventionally, patients undergo PTC and multiple drain exchanges. Surgical revision may be required. Only case reports exist on ERCP techniques to treat AS in patients with LLSBB.

Abstract No. 92: Management of Biliary-Enteric Anastomotic Strictures After Surgical Repair of Bile Duct Injuries: Is Percutaneous Transhepatic Balloon Dilation Durable?

Abstract No. 92: Management of Biliary-Enteric Anastomotic Strictures After Surgical Repair of Bile Duct Injuries: Is Percutaneous Transhepatic Balloon Dilation Durable?