Dominant Strictures Research Articles

The role of orthotopic liver transplantation in the management of sclerosing cholangitis

Our recommendations are to manage asymptomatic patients with biannual clinical and biochemical follow-up examinations. Symptomatic non-cirrhotic patients who have diffuse SC should be enrolled in trials addressing the efficacy of medical therapy such as UDCA. Patients with diffuse disease and cirrhosis of the liver should be considered for liver transplantation. Symptomatic patients with a dominant stricture should first undergo rigorous investigation to rule out CCA. Disease in those noncirrhotic patients who are deemed to have benign strictures should initially be managed by means of dilation or surgical excision, although careful monitoring and review will be needed because most will continue with progressive disease, eventually showing signs of portal hypertension and cirrhosis. Patients with dominant strictures and cirrhosis should be considered for orthotopic liver transplantation. Liver transplantation in experienced units now offers more than 80% of patients a full and effective rehabilitation, with more than 75% alive at 5 yr. A progressive, advancing decompensating cholestatic disorder with an increasing risk of underlying malignancy can be stopped, giving the patient a high quality of life. More than half of patients report an improvement in the symptoms of their inflammatory bowel disease.

The role of orthotopic liver transplantation in the management of sclerosing cholangitis

Our recommendations are to manage asymptomatic patients with biannual clinical and biochemical follow-up examinations. Symptomatic non-cirrhotic patients who have diffuse SC should be enrolled in trials addressing the efficacy of medical therapy such as UDCA. Patients with diffuse disease and cirrhosis of the liver should be considered for liver transplantation. Symptomatic patients with a dominant stricture should first undergo rigorous investigation to rule out CCA. Disease in those noncirrhotic patients who are deemed to have benign strictures should initially be managed by means of dilation or surgical excision, although careful monitoring and review will be needed because most will continue with progressive disease, eventually showing signs of portal hypertension and cirrhosis. Patients with dominant strictures and cirrhosis should be considered for orthotopic liver transplantation. Liver transplantation in experienced units now offers more than 80% of patients a full and effective rehabilitation, with more than 75% alive at 5 yr. A progressive, advancing decompensating cholestatic disorder with an increasing risk of underlying malignancy can be stopped, giving the patient a high quality of life. More than half of patients report an improvement in the symptoms of their inflammatory bowel disease.

Pancreatic stents: Why? When?

S SHERMAN, GA LEHMAN. Pancreatic stents: Why? When? Can J Gastro, enterol 1993;7(6):485,492. Placement of endoprosthesis in the biliary tree is a well-established therapeutic modality. Application of similar techniques to the pancreas are emerging. Pancreatic duct stents have been place<l to seal duct disruptions, bridge dominant strictures, drain pseudocysts, treat symptomatic minor and/or major sphincter stenos is, bypass obstructing pancreatic duct stones, prevent procedure,induced pancreatitis and serve as a guide for sphincterotomy. In this review, the authors will analyze the current indications and complications a.,.,ociated with pancreatic duct Stent therapy. Selection of appropriate candi, dates appears important for optimal results of therapy. However, definite recommendations are difficult to make because there are few controlled studies, follow,up in most series is brief and there are no comparison studies of endoscopic versus surgical therapy. At present, conservatism is the appropriate general rule in these therapeutic endeavours.

Improving biliary-enteric drainage in primary sclerosing cholangitis: experience with endoscopic methods.

Six jaundiced patients with primary sclerosing cholangitis and a dominant biliary stricture were managed by endoscopic placement of endoprostheses. Five showed considerable improvement within weeks of stenting: their serum bilirubin concentration fell from mean (range) 266 mumol/l (63-681) to 65 mumol/l (10-280) after one month. One patient required a liver transplant at five months because of continued deterioration in hepatic function. Follow up of 12-49 months in the remaining five patients shows sustained biochemical improvement, with repeat cholangiograms indicating doubling of the minimum calibre of the extrahepatic bile duct in four patients and considerable shortening of stricture length in three. Three patients developed sepsis at the time of the initial endoprosthesis insertion: surgical drainage was necessary in one. Endoscopic methods of improving biliary-enteric drainage in jaundiced patients with primary sclerosing cholangitis may be preferable to surgical and percutaneous methods, which may complicate subsequent liver transplantation.

Critical Appraisal of Therapeutic Endoscopy in Biliary Tract Diseases

Endoscopic treatment (by sphincterotomy) is now the preferred method for patients with retained or recurrent bile duct stones after surgery. It is also applicable to many acutely ill or high-risk patients who have not undergone cholecystectomy. Endoscopic stenting is preferable to the percutaneous transhepatic method for palliation of malignant biliary obstruction in patients unfit or unsuitable for surgery. Balloon dilatation and stenting can be used for management of postoperative bile duct trauma and biliary fistulae, and in patients with dominant strictures in sclerosing cholangitis. Papillary stenosis and sphincter of Oddi dysfunction can be treated by sphincterotomy after careful patient selection. Endoscopy is a new and simpler form of surgery. A team approach including endoscopists, surgeons, and radiologists is essential for appropriate patient care and for objective evaluation of new methods.

Nonoperative dilatation of dominant strictures in primary sclerosing cholangitis.

While most cases of primary sclerosing cholangitis are characterized by multifocal bile duct strictures, a few have a localized high-grade stricture (dominant stricture) superimposed on diffuse disease. This dominant stricture may cause jaundice or bacterial cholangitis in some patients. Dominant strictures were percutaneously dilated in 14 patients with primary sclerosing cholangitis and jaundice or bacterial cholangitis. Stricture dilatation produced a significant decrease in the frequency of cholangitis and a significant decrease in serum bilirubin in those with recent onset of jaundice. The only complication was bacteremia or cholangitis in five patients. Three of nine patients with successful dilatations developed recurrent strictures at 6-18 months. Balloon dilatation should be considered the treatment of choice for dominant strictures in symptomatic patients with primary sclerosing cholangitis who have recent onset of jaundice (less than 6 months' duration) or recurrent episodes of bacterial cholangitis.