Bilioenteric Anastomotic Stricture Research Articles

Efficacy and long-term outcomes of single-balloon enteroscopy-assisted treatment for biliary obstruction after choledochojejunostomy.

To evaluate the long-term efficacy of single-balloon enteroscopy endoscopic retrograde cholangiography (SBE-ERC) for the treatment of biliary obstruction and to analyze the factors affecting the recurrence of benign bilioenteric anastomotic stricture after SBE-ERC treatment. The clinical data of patients with biliary diseases treated with SBE-ERC after choledochojejunostomy in our hospital from January 2015 to December 2021 were analyzed retrospectively for the success rates of diagnosis and treatment and the incidence of complications. Patients who were diagnosed with benign bilioenteric anastomotic stricture were followed up. The independent factors affecting recurrence were obtained by univariate and multivariate analyses using the Kaplan‒Meier method and Cox proportional hazard regression model. A total of 289 SBE-ERCs were performed in 165 patients. The overall success rate was 83.0% (240/289). The incidence of postoperative complications was 5.2% (15/289). The 108 successfully treated patients diagnosed with benign bilioenteric anastomotic stricture were followed up. Twenty-six percent (29/108) of patients had recurrent stricture after SBE-ERC. The biliary patency rates at 1year, 2years and 5years after SBE-ERC were 90.1%, 69.3%, and 53.9%, respectively. Single-factor analysis revealed the absence of intrahepatic biliary gas imaging during endoscopy ( =5.366, P = 0.021), a diameter of balloon dilatation during the last endoscopic treatment less than 0.8cm ( =4.552, P = 0.033), and the presence of a thread in the anastomosis ( =8.921, P = 0.003) as risk factors for recurrence. A non-indwelling biliary plastic stent ( =14.868, P < 0.001) and undergoing only one ERCP treatment ( =13.313, P = 0.001) were risk factors for the recurrence of benign stricture after SBE-ERC resection. Multivariate analysis revealed that the absence of a stent (HR = 0.15, 95% CI 0.06-0.40, P = 0.001), absence of intrahepatic biliary gas imaging during endoscopy (HR = 0.39, 95% CI 0.17-0.91, P = 0.03) and the presence of a thread in the anastomosis (HR = 3.69, 95% CI 1.59-8.57, P = 0.002) were independent risk factors for stricture recurrence. Treating biliary disease after choledochojejunostomy with SBE-ERC is safe and effective, with a good immediate technical success rate and an acceptable incidence of complications. SBE-ERC has long-term efficacy in the treatment of benign bilioenteric anastomotic stricture. The absence of intrahepatic biliary gas imaging during endoscopy, non-indwelling biliary stents and the existence of anastomotic threads are independent risk factors for the recurrence of benign bilioenteric anastomotic stricture.

Off-label use of Lumen-apposing metal stents for treatment of short benign biliary strictures

BackgroundEndoscopic stenting is the mainstay of treatment for benign biliary strictures. There is a not-negligible rate of recurrence and stent migration. Lumen-apposing metal stents (LAMS) have a unique design with short length, large diameter and wide flanges which make them less prone to migration. AimsTo describe the intraluminal use of LAMS to treat short benign biliary strictures. MethodsAll consecutive patients who underwent bi-flanged LAMS placement for benign biliary strictures, in approximately 6 years, were retrospectively included. Primary outcomes were technical and clinical success; secondary outcomes were number of endoscopic procedures, adverse events evaluation and stricture recurrence during follow-up. ResultsSeventy patients (35 male, mean age 67) were enrolled; bilio-enteric anastomotic stricture was the most common etiology. Technical and clinical success were 100 % and 85.7 %, respectively. Patients with post-surgical stricture had a higher success rate than patients with non-surgical stricture or with bilio-enteric anastomotic stricture (90.4 %, 86.3 % and 81.4 %, respectively). Adverse events were 12/70 (17.1 %): stent migration was the most frequent (8/70, 11.4 %). Stricture recurrence was found in 10/54 patients (18.5 %). ConclusionLAMS placement could be safe and effective treatment for short benign biliary strictures in patients in which a significant caliber disproportion between stricture and the duct above was revealed.

Use of a Cutting Balloon Dilation as a Rescue Therapy in Patients with Benign Bilioenteric Anastomotic Strictures Refractory to Conventional Balloon Dilation

Use of a Cutting Balloon Dilation as a Rescue Therapy in Patients with Benign Bilioenteric Anastomotic Strictures Refractory to Conventional Balloon Dilation

Use of a Cutting Balloon Dilation as a Rescue Therapy in Patients with Benign Bilioenteric Anastomotic Strictures Refractory to Conventional Balloon Dilation

Percutaneous balloon dilation with or without placement of an external biliary drain is a nonoperative alternative method for treating benign bilioenteric anastomotic strictures. Although this procedure has a high technical success rate, outcomes are less optimal when attempting to dilate refractory tight strictures. For the stricture, cutting balloon can be an option. We present four patients with benign bilioenteric anastomotic strictures refractory to conventional balloon dilation. To the patients, a peripheral cutting balloon over-the-wire system was inflated, following subsequent conventional non-compliant balloon dilation. After the balloon dilation treatment, an external drainage catheter was placed through the stricture site and maintained for up to 30 days. Technical and end-treatment success was achieved in all four patients. In conclusion, the use of cutting balloon dilation may appear to be a safe and effective alternative method of treatment in patients with benign bilioenteric anastomotic strictures refractory to conventional balloon dilation.

Multiple Biliary Stones: a Rare Long-term Complication after Whipple Procedure

A hypertensive, diabetic woman underwent a successful Whipple procedure at the age of 84 due to carcinoma of the ampulla of Vater. She presented an extremely rare complication 24 months after the surgery, consisting of acute cholangitis due to multiple biliary lithiases associated with a bilioenteric anastomotic stricture. The diagnosis was confirmed with computed tomography, magnetic resonance cholangiopancreatography, and cholangiography.The patient was successfully treated with multiple percutaneous transhepatic cholangioplasties.

Redo hepaticojejunostomy in the management of bilioenteric anastomotic strictures

Background: The Roux-en-Y hepaticojejunostomy (RYHJ) is the commonly done drainage procedure for strictures which occasionally follow operations on the gallbladder and bile ducts. However, 8%–40% of these anastomoses become narrowed again and the redo operation is technically challenging. There are only a few reports which have examined the results of these revision procedures and we therefore decided to analyse our experience of this unusual operation. Aim: To study the role of redo-hepaticojejunostomy in the management of bilio-enteric anastomotic strictures. Materials and Methods: Between January 2010 and January 2016, we performed 23 redo-hepaticojejunostomies for the strictures following an initial hepaticojejunostomy which was done for benign indications in our department and followed them for a minimum of 2 years with clinical, biochemical and radiological tests. Results: There were 7 males and 16 were females who had a median age of 37 years (range 15–63 years). The median interval between the index operation and the stricture recurrence was 10 months. Thirteen (57%) patients underwent initial surgical revision and 10 had the procedure following unsuccessful percutaneous intervention. The median length of hospital stay was 10 days and 21 (91%) only had minor complications. There was no operative mortality. On follow-up of all 23 patients after 2–8 years, six (26%) patients developed stricture recurrence, of whom three were managed with percutaneous dilatation and three required a second revisional surgery. Seventeen patients are symptom-free. Conclusion: Redo RYHJ is a feasible option for strictures following an initial biliary enteric anastomosis with no surgical mortality and three-quarters of the patients being rendered symptom-free.

Pay attention to the diagnosis and treatment of long-term complications after pancreatectomy

Recently,with growing numbers of pancreatectomy and continuous improvement of comprehensive treatment,more patients have survived surgery of benign or malignant pancreatic tumors. As a result, pancreatic surgeons meet more long-term complications after pancreatic surgery. For many years,there is no uniform definition, diagnosis or therapeutic standard for long-term complications after pancreatic surgery. Such unsatisfactory situation has an indirectly negative impact on the life quality of patients as well as development of clinical research. By reviewing literature,the definition,diagnostic criteria and treatment strategies of some common long-term complications after pancreatic surgery were analyzed, including bilioenteric anastomotic stricture, pancreatic exocrine or endocrine insufficiency,and pancreatico-digestive tract anastomotic stricture,in order to improve the treatment effect of long-term complications and life quality of these patients.

Metallic stent placement versus catheter drainage for malignant bilioenteric anastomotic stricture.

The purpose of the study was to compare self-expandable metallic stent placement with catheter drainage for malignant bilioenteric anastomotic stricture in terms of efficacy and safety. This study included 54 patients with malignant bilioenteric anastomotic stricture treated from March 2016 to February 2021. Twenty-seven patients underwent insertion of self-expandable metallic stent (Stent group); the remaining twenty-seven patients underwent internal-external catheter drainage (Catheter group). Technical success was defined as successful placement of stent or drainage catheter in the appropriate position; clinical success was defined as a 20% reduction in serum bilirubin within 1week after the procedure, compared with baseline. Complications, duration to stent/catheter malfunction, and overall survival were evaluated. Technical success was achieved in all patients in both groups. In the Stent group, 21 patients received one stent and the other 6 patients required two stents. Clinical success rates were similar between the groups [Stent group, 92.6% (25/27); Catheter group, 88.9% (24/27)]. There were no major complications. The median duration to stent/catheter malfunction was significantly longer in the Stent group (130days) than in the Catheter group (82days; P = 0.010). The median overall survival was also significantly longer in the Stent group (187days) than in the Catheter group (118days; P = 0.038). Self-expandable metallic stent placement might be better than internal-external catheter drainage for malignant bilioenteric anastomotic stricture in terms of the duration before stent/catheter malfunction and patient survival.

Clinical application of laparoscopy combined with choledochoscopy in patients with bilioenteric anastomotic stricture with access via the jejunal loops.

ObjectiveBilioenteric anastomotic stricture is a serious complication following choledochojejunostomy. Some patients develop intrahepatic lithiasis and biliary tract infection without dilation of the intrahepatic bile duct. The present study was performed to investigate the safety and efficacy of laparoscopy combined with choledochoscopy in patients with bilioenteric anastomotic stricture with access via the jejunal loops.MethodsThe data of 10 patients (7 men and 3 women; mean age, 60.8 ± 9.7 years; age range, 51–76 years) with potential bilioenteric anastomotic stricture without dilation of the intrahepatic bile duct from January 2015 to December 2019 were retrospectively reviewed.ResultsAll 10 patients underwent surgery, and their clinical parameters were recorded. The mean surgery time was 181.5 ± 35.4 minutes, and the mean estimated blood loss was 32.0 ± 15.5 mL. No patients developed serious complications during the perioperative period. The short-term outcome analysis at 12 months indicated that the stenosis had been effectively dilated and that the liver function had improved.ConclusionsThe results of the present study demonstrated that laparoscopy combined with choledochoscopy with access via the jejunal loops is feasible in the treatment of bilioenteric anastomotic stricture and intrahepatic lithiasis.

The application of percutaneous transhepatic cholangioscopy in the treatment of benign bilioenteric anastomotic stricture:a report of 9 cases

Objective: To investigate the feasibility and effectiveness of percutaneous transhepatic cholangioscopy(PTCS) in the treatment of bilioenteric anastomotic stricture after choledochojejunostomy. Methods: From April 2016 to April 2020, the clinical data of 9 patients (7 males and 2 females, aged 40-76 years) who underwent percutaneous transhepatic cholangioscopy(PTCS) for stricture expansion and lithotomy at Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine were retrospectively analyzed. The operation was divided into two stages. In the first stage, ultrasound-guided percutaneous intrahepatic bile duct puncture was performed, and the sheath tube was inserted and fixed. In the second stage, percutaneous choledochoscopy was used for anastomotic stricture after sinus formation.The clinical outcome was evaluated by related biochemical indexes. Results: The operation time was (53.3±31.0)minutes(range:15-120 minutes).The postoperative hospital stay was (4.4±2.3)days(range:2-9 days).After systematic treatment, the preoperative symptoms, such as abdominal pain, jaundice, fever and shivering, disappeared in 8 patients. The range of alkaline phosphatase was 122-1 334 U/L before operation and 85-702 U/L after operation. The range of gamma glutamyl transpeptidase was 44-1 219 U/L before operation and 46-529 U/L after operation. Conclusion: PTCS is a safe and effective option for minimally invasive treatment of bilioenteric anastomotic stricture.

Percutaneous treatment of benign bilioenteric anastomotic strictures: temporary covered stent placement versus balloon dilatation.

To compare percutaneous temporary covered stent placement with balloon dilatation in the treatment of benign stricture of bilioenteric anastomosis. From November 2004 to August 2017, 56 patients with benign bilioenteric anastomotic strictures underwent percutaneous transhepatic treatment. A temporary covered stent designed for spontaneous migration was placed in 23 patients (stent group). Balloon dilatation was performed in 33 patients (balloon group). The technical success, percutaneous transhepatic biliary drainage (PTBD) indwelling times, stent indwelling times and patency rates were retrospectively compared between the two groups. Technical success was achieved in all patients in the stent group and in 96.8% (32/33) of patients in the balloon group. All stents spontaneously migrated into the jejunum, and stent indwelling times were 3-9months (median, 6months). The PTBD indwelling time was shorter for the stent group than for the balloon group (median, 7 vs. 71days, p = 0.001). Recurrent strictures occurred more frequently in the balloon group than in the stent group (54.5% vs. 13.0%, p =0.002; hazard ratio 3.7). The 1- and 3-year primary patency rates were 90.2% and 84.9% for the stent group and 75.1% and 52.8% for the balloon group, respectively (p = 0.04). Percutaneous temporary covered stenting is an effective treatment in patients with benign bilioenteric anastomotic strictures. It provides longer patency and shorter PTBD indwelling time compared with balloon dilatation. • A temporary covered stent designed for spontaneous migration is a feasible and effective treatment for patients with benign bilioenteric anastomotic strictures. • Percutaneous temporary covered stents provide longer patency and shorter drainage catheter indwelling time compared with conventional balloon dilatation. • A covered stent with flared ends spontaneously migrated after 3-9months.

Severe Biliary Stricture Dilation Using the Soehendra Stent Retriever with a Short-Type Balloon Enteroscope in Patients with Surgically Altered Anatomies

BackgroundBalloon enteroscopy (BE) can be used for endoscopic retrograde cholangiography (ERC) to treat biliary strictures in patients with surgically altered anatomies. However, biliary strictures, including bilioenteric anastomotic strictures, are often very severe and dilation catheters cannot pass through them. The Soehendra stent retriever (SSR) is like a screw drill and can be useful for dilating severe strictures, but the utility of SSR during BE-assisted ERC (BE-ERC) is unclear. This study aimed to examine the efficacy and safety of a dilation technique using the SSR during BE-ERC. MethodsBetween 2014 and 2018, 28 patients with surgically altered gastrointestinal anatomies and severe biliary strictures underwent BE-ERC, and the SSR was used for the dilation procedures. We evaluated the technical success, therapeutic success, and adverse event rates associated with SSR dilation. ResultsThe technical success rate was 93% (26/28). The procedures undertaken on two patients with non-anastomotic strictures failed technically because the SSR was not long enough to reach the strictures. The therapeutic success rate was 96% (25/26) for the patients whose procedures were technically successful. The adverse event rate was 7% (2/28), and the adverse events were mild and improved with conservative management. No bleeding or duct perforations occurred. ConclusionsAlthough the indications for using the SSR in patients with non-anastomotic strictures should be considered based on the distance between the tip of the scope and the stricture’s location, SSR dilation may be a useful option during BE-ERC if a biliary stricture is very severe.

Bilioenteric anastomotic stricture in patients with benign and malignant tumors: prevalence, risk factors and treatment

Stricture formation at the bilioenteric anastomosis is a rare but important postoperative complication. However, information on this complication is lacking in the literature. In the present study, we aimed to assess its prevalence and predictive factors, and report our experience in managing bilioenteric anastomotic strictures over a ten-year period. A total of 420 patients who had undergone bilioenteric anastomosis due to benign or malignant tumors between February 2001 and December 2011 were retrospectively reviewed. Univariate and multivariate modalities were used to identify predictive factors for anastomotic stricture occurrence. Furthermore, the treatment of anastomotic stricture was analyzed. Twenty-one patients (5.0%) were diagnosed with bilioenteric anastomotic stricture. There were 12 males and 9 females with a mean age of 61.6 years. The median time after operation to anastomotic stricture was 13.6 months (range, 1 month to 5 years). Multivariate analysis identified that surgeon volume (≤30 cases) (odds ratio: -1.860; P=0.044) was associated with the anastomotic stricture while bile duct size (>6 mm) (odds ratio: 2.871; P=0.0002) had a negative association. Balloon dilation was performed in 18 patients, biliary stenting in 6 patients, and reoperation in 4 patients. Five patients died of tumor recurrence, and one of heart disease. Bilioenteric anastomotic stricture is an uncommon complication that can be treated primarily by interventional procedures. Bilioenteric anastomosis may be performed by a surgeon in his earlier training period under the guidance of an experienced surgeon. Bile duct size >6 mm may play a protective role.

Utility of temporary deployment of fully covered self-expandable metal stents for post-operative benign bilioenteric anastomotic stricture

Utility of temporary deployment of fully covered self-expandable metal stents for post-operative benign bilioenteric anastomotic stricture

EUS hepaticogastrostomy for bilioenteric anastomotic strictures: a permanent access for repeated ambulatory dilations? Results from a pilot study.

Background and study aims: Postsurgical benign bilioenteric anastomotic strictures are a major adverse event of biliary surgery and endoscopic treatment, including endoscopic retrograde cholangiopancreatography (ERCP), is challenging in this setting. We present an innovative approach to treating this complication. Patients and methods: Patients underwent endoscopic ultrasound (EUS)-hepaticogastrostomy (HG) to treat nonmalignant biliary obstructions. A first endoscopy was performed to create the hepaticogastrostomy and to drain the biliary tree. The second step had a therapeutic purpose: antegrade dilation of the anastomosis. Results: Four men and three women with benign bilioenteric anastomotic strictures were included. Patients presented with jaundice or recurrent cholangitis. A fully covered HG stent was successfully deployed during the first endoscopy. During the second step, repeat antegrade dilation was performed through the HG in four cases (1 – 4 dilations) followed by double pigtail stenting in three cases. In three other patients, the stenosis was not crossable and a double pigtail stent was placed to maintain biliary drainage. All patients had symptom relief at the end of follow-up (45 weeks, range 33 – 64). Conclusions: Dilation of anastomotic stenosis through a hepaticogastrostomy is feasible and may provide permanent biliary drainage or recurrent access to the biliary tree in patients with altered anatomy. Double pigtail stents might prevent migration.

Selection of living donor liver grafts for patients weighing 6kg or less.

In the field of pediatric living donor liver transplantation (LDLT), physicians sometimes must reduce the volume of left lateral segment (LLS) grafts to prevent large-for-size syndrome. There are 2 established methods for decreasing the size of an LLS graft: the use of a segment 2 (S2) monosegment graft and the use of a reduced LLS graft. However, no procedure for selecting the proper graft type has been established. In this study, we conducted a retrospective investigation of LDLT and examined the strategy of graft selection for patients weighing ≤6 kg. LDLT was conducted 225 times between May 2001 and December 2012, and 15 of the procedures were performed in patients weighing ≤6 kg. We selected S2 monosegment grafts and reduced LLS grafts if the preoperative computed tomography (CT)-volumetry value of the LLS graft was >5% and 4% to 5% of the graft/recipient weight ratio, respectively. We used LLS grafts in 7 recipients, S2 monosegment grafts in 4 recipients, reduced S2 monosegment grafts in 3 recipients, and a reduced LLS graft in 1 recipient. The reduction rate of S2 monosegment grafts for use as LLS grafts was 48.3%. The overall recipient and graft survival rates were both 93.3%, and 1 patient died of a brain hemorrhage. Major surgical complications included hepatic artery thrombosis in 2 recipients, bilioenteric anastomotic strictures in 2 recipients, and portal vein thrombosis in 1 recipient. In conclusion, our graft selection strategy based on preoperative CT-volumetry is highly useful in patients weighing ≤6 kg. S2 monosegment grafts are effective and safe in very small infants particularly neonates.

Peripheral portal vein-oriented non-dilated bile duct puncture for percutaneous transhepatic biliary drainage.

To evaluate the efficacy of peripheral portal vein (PV)-oriented non-dilated bile duct (BD) puncture for percutaneous transhepatic biliary drainage (PTBD). Thirty-five patients with non-dilated BDs underwent PTBD for the management of various biliary disorders, including benign bilioenteric anastomotic stricture (n = 24), BD stricture (n = 5) associated with iatrogenic BD injury, and postoperative biliary leakage (n = 6). Under ultrasonographic guidance, percutaneous transhepatic puncture using a 21-G needle was performed along the running course of the peripheral targeted non-dilated BD (preferably B6 for right-sided approach, and B3 for left-sided approach) or along the accompanying PV when the BD was not well visualized. This technique could provide an appropriate insertion angle of less than 30° between the puncture needle and BD running course. The puncture needle was then advanced slightly beyond the accompanying PV. The needle tip was moved slightly backward while injecting a small amount of contrast agent to obtain the BD image, followed by insertion of a 0.018-inch guide wire (GW). A drainage catheter was then placed using a two-step GW method. PTBD was successful in 33 (94.3%) of the 35 patients with non-dilated intrahepatic BDs. A right-sided approach was performed in 25 cases, while a left-sided approach was performed in 10 cases. In 31 patients, the first PTBD attempt proved successful. Four cases required a second attempt a few days later to place a drainage catheter. PTBD was successful in two cases, but the second attempt also failed in the other two cases, probably due to poor breath-holding ability. Although most patients (n = 26) had been experiencing cholangitis with fever (including septic condition in 8 cases) before PTBD, only 5 (14.3%) patients encountered PTBD procedure-related complications, such as transient hemobilia and cholangitis. No major complications such as bilioarterial fistula or portal thrombosis were observed. There was no mortality in our series. Peripheral PV-oriented BD puncture for PTBD in patients with non-dilated BDs is a safe and effective procedure for BD stricture and postoperative bile leakage.

Endoscopic ostium incision at non-malignant post-surgical bilioenteric anastomotic stricture after complex abdominal surgery

Endoscopic ostium incision at non-malignant post-surgical bilioenteric anastomotic stricture after complex abdominal surgery

Sp706 Expanding Indication: EUS-Guided Hepaticoduodenostomy in Isolated Right Intrahepatic Duct Obstruction

Expanding Indication: EUS-Guided Hepaticoduodenostomy in Isolated Right Intrahepatic Duct Obstruction Se Jeong Park*, Do Hyun Park, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee, Myung-Hwan Kim After failed ERCP, other alternative biliary accesses such as PTBD, repeated ERCP, or surgical bypass could be considered. PTBD has a complication rate of 10% to 30% such as bile leak, bleeding, and peritonitis. Repeat ERCP could be as an alternative if immediate biliary drainage is not required. Surgical bypass is effective, but is associated with considerable mortality and morbidity. EUSguided transgastric imaging of dilated left intrahepatic duct is a useful technique to drain the left biliary system and an effective alternative for percutaneous transhepatic biliary drainage after failed ERCP. To date, EUS-guided biliary drainage in isolated right hepatic duct obstruction has not been attempted. In our center, 4 consecutive patients were candidates for EUS-guided right hepatic duct approach within recent year with last case in October 2012. We performed three kinds of approaches to the right hepatic duct using EUS; (1) using a cholangiogram obtained by EUS-guided transduodenal puncture of the right hepatic duct as a “roadmap” to assist retrograde cannulation, (2) EUS-guided transduodenal puncture of the right hepatic duct and an antegrade balloon dilatation and stenting for bilioenteric anastomotic strictures in a patient with hepaticojejunostomy, and (3) transluminal stenting as an antegrade bypass stenting between the right hepatic duct and the duodenal wall under EUSguidance. EUS-guided hepaticoduodenostomry (EUS-HD) of right hepatic duct by expert hands may be a relatively safe and feasible alternatives after failed ERCP. Moreover, an availability in the same session without dicontinuation of sedation after failed ERCP is another great advantage. In contrast, the other alternative accesses such as PTBD, repeated ERCP, and surgery almost need another session for further procedure on a different day. Further, large multicentered study may help enhance our results.

Su1426 Endoscopic Balloon Dilation Using a Short Double-Balloon Enteroscopy Is Useful and Safe for Treatment of Benign Bilioenteric Anastomotic Stricture After Pancreatoduodenectomy

The aim of this study was to evaluate the usefulness and safety of endoscopic balloon dilation for benign bilioenteric anastomotic stricture after pancreatoduodenectomy (PD) using a short double-balloon enteroscopy (DBE).