Management Of Biliary Strictures Research Articles

Endoscopic Therapy of Posttransplant Biliary Stenoses After Right-Sided Adult Living Donor Liver Transplantation

Endoscopic treatment of biliary strictures after liver transplantation is a therapeutic challenge. In particular, outcomes of endoscopic therapy of biliary complications in the case of duct-to-duct anastomosis after living related liver transplantation are limited. The aim of this study was to evaluate the feasibility and success of an endoscopic treatment approach to posttransplant biliary strictures (PTBS) after right-sided living donor liver transplantation (RLDLT) with duct-to-duct anastomosis. Ninety patients who received adult-to-adult RLDLT in our center were screened retrospectively with respect to endoscopic treatment of PTBS. Therapy was judged as successful when cholestasis parameters returned to normal and bile duct narrowing was reduced significantly after the completion of therapy. Forty of 90 RLDLT patients received duct-to-duct anastomosis, 12 (30%) showed PTBS. Seven of 12 patients were treated successfully by endoscopy; the remaining 5 patients were treated primarily by surgery. Most patients were treated by balloon dilatation followed by insertion of endoprostheses. A median of 2.5 dilatation sessions were necessary and the median treatment duration was 8 months. One patient developed endoscopy-treatable recurrent stenosis, no surgical intervention was necessary. Mild pancreatitis occurred in 7.9% and cholangitis in 5.3% of the procedures. One minor bleeding episode occurred during sphincterotomy. Bleeding was managed endoscopically. Endoscopic therapy of adult-to-adult right living related liver transplantation with duct-to-duct anastomosis is feasible and frequently is successful. The duct-to-duct anastomosis offers the possibility of endoscopic treatment. Endoscopic treatment of posttransplant biliary strictures is safe, with a low specific complication rate.

Current management of biliary strictures.

The definitive management of benign biliary strictures depends upon numerous factors, including the complexity and location of the stricture, the degree of inflammation and fibrosis, the presence of ongoing infection or sepsis, and the capability and experience of the surgeon and interventional radiologist at the institution.For some,such as high-risk or compromised patients or those with anastomotic strictures, percutaneous or endoscopic techniques may be most appropriate not only for diagnosis and delineation of the anatomy, but also as initial forms of management. However, successful outcomes regarding the management of most benign biliary strictures requires careful planning by a multidisciplinary team with regard to preoperative preparation, thorough diagnostic studies, and appropriate operative approach.Whatever most appropriate treatment option is selected, the need for careful long-term follow-up must be strongly emphasized, as no therapy is totally free of stricture recurrence.

Long Term Outcome of Endoscopic Management of Biliary Strictures Following Liver Transplantation

Background: Biliary strictures are a common complication following orthotopic liver transplantation (OLT). ERCP with biliary stenting has been used successfully to treat these strictures but the long-term outcome is unknown. Methods: Twenty-two of 251 patients who underwent OLT from 1/90 and 11/95 developed biliary strictures. Medical records through 12/02 of these 22 patients were reviewed to determine the long-term success of endoscopic therapy. We compared the total number of episodes of jaundice or cholangitis, ERCPs, percutaneous cholangiography, graft and patient survival, and number of patients who remained stent-free at 5 years post OLT in those with only anastomotic strictures to those with donor hepatic duct (DHD) strictures. Results: Twelve of 22 patients had DHD strictures and 10 patients had anastomotic strictures. Patients with DHD strictures required significantly more ERCPs until stricture resolution. The average time to endoscopically documented resolution of strictures was significantly longer in the DHD stricture group than in the anastomotic stricture group (23.7 months versus 3.2 months, p = 0.01). There was no difference in the number of episodes of cholangitis, jaundice, and need for percutaneous cholangiography between the two groups. Five years following liver transplantation, 9 of 12 patients with DHD strictures were stent-free and 9 of 10 patients with anastomotic strictures were stent-free. Overall patient and graft survival did not differ between the two groups. None of the patients died from endoscopic procedure related mortality, or biliary sepsis. Conclusion: Endoscopic management of anastomotic and donor hepatic duct strictures following OLT is safe, effective, and durable. Endoscopic management of DHD strictures is not associated with reduced patient or graft survival when compared to anastomotic strictures but more intensive management is required.

Long-term follow-up of percutaneous transhepatic balloon cholangioplasty in the management of biliary strictures after liver transplantation.

This study evaluated the efficacy of a protocol of initial balloon dilation for biliary strictures after liver transplantation. Complete records from 96 patients with biliary strictures were retrospectively reviewed. Seventy-six patients received percutaneous transhepatic balloon cholangioplasty (PTBC) after initial placement of biliary drainage (percutaneous transluminal cholangiography [PTC]) tube. In most cases, three dilations were performed with a 4 to 8 week interval between procedures. Follow-up ranged from 6 months to 10 years. PTBC successfully treated strictures in 39 of 76 (51.3%) cases. Factors favoring successful PTBC included older age at transplant, shorter cold ischemic time, and single strictures. There were nine recurrent strictures after PTBC, all of which were successfully treated by nonoperative measures. The number of dilations performed affected both the likelihood of success and the long-term risk of stricture recurrence. Of the 37 PTBC failures, 14 underwent subsequent surgical revision. When both angiographic and surgical modalities were considered, treatment success was associated with first transplants, shorter cold ischemic time and operative time, and less intraoperative transfusion requirements. Factors associated with treatment failure included multiple, central hepatic duct, and intrahepatic strictures. PTC-tube independence was achieved in 51 of 76 (67%) patients using the combined approach of PTBC and surgery for PTBC failures. PTBC is an effective initial modality for treating posttransplant biliary strictures. Prolonged cold ischemic and operative times and multiple or peripheral strictures predispose to treatment failure. Solitary extrahepatic strictures that fail PTBC are salvageable with surgical revision with excellent results.

Endoscopic Management of Biliary Obstruction Caused by Cavernous Transformation of the Portal Vein

Background Symptomatic biliary obstruction caused by cavernous transformation of the portal vein isan extremely rare disorder for which there is no consensus as to optimal treatment. The results of endoscopic treatments in a small group of patients is reviewed. Methods A total of 10 patients (5 men, 5 women; mean age 36.1 years, range 17–48 years) with severe biliary strictures were treated between 1995 and 2001. Biliary sphincterotomy was performed in all patients. Four patients also underwent balloon dilation, nasobiliary drainage, and stone or sludge extraction by using a balloon. All patients had stent insertion. Observations The mean duration of therapy was 3.3 years (range 1–7 years). There was no complication directly related to the endoscopic procedures except for hemobilia that occurred in one patient during stent removal. Cholangitis developed in 5 patients during the therapy period and was treated endoscopically. In 4 patients, significant improvement in the biliary stricture was observed and stents were removed in 3. These patients were followed without stent insertion for one year. Conclusions Endoscopic management of biliary stricture caused by cavernous transformation of the portal vein appears to be effective and safe.

Endoscopic management of biliary strictures after duct-to-duct biliary reconstruction in right-lobe living-donor liver transplantation

The aims of this study were to characterize the features of the biliary strictures that occur after duct-to-duct biliary reconstruction during right-lobe living-donor liver transplantation (LDLT) and to evaluate the feasibility of correcting such stricture endoscopically by inserting an "inside stent," that is, a short internal stent, above the sphincter of Oddi. Biliary stricture occurred in 26 (35.6%) of 73 consecutive patients who underwent right-lobe LDLT with duct-to-duct biliary reconstruction from July 1999 through October 2001 and survived for more than 3 months. Of the 26 patients who had biliary stricture, 22 were referred for endoscopic retrograde cholangiography (ERC) and 4 for percutaneous cholangiography. ERC disclosed biliary stricture in 19 (86.4%) of the 22 patients who underwent the procedure. One patient had an unbranched stricture, 16 had a fork-shaped stricture, 1 had a trident-shaped stricture, and 1 had a stricture with more than three branches. Fourteen (73.7%) of the patients with strictures were treated endoscopically by inserting inside stents ranging from 7 F to 12 F in size, three underwent a Roux-en-Y hepaticojejunostomy to repair their stricture, and two were closely observed as outpatients. Of the 14 patients who were treated with the inside-stent, only 1 had acute cholangitis immediately after the procedure and underwent a Roux-en-Y hepaticojejunostomy. The other 13 patients who were treated with the inside stent have not required surgical repair for as long as an average of 586 days. Endoscopic placement of an inside stent is useful for treating biliary strictures in patients who have undergone right-lobe LDLT with duct-to-duct reconstruction.

Development of a swine model for benign stenosis of the bile duct by endoscopic application of intraluminal thermal injury

Background: A simple animal model is desirable for the study of endoscopic therapies used in the management of biliary strictures. The aim of this study was to identify a method for inducing benign biliary stenoses in a porcine model by using endoscopic techniques. Methods: Endoscopic retrograde cholangiography was performed in 9 swine. Intraluminal injury was applied to the common hepatic duct with graded applications of either a heat probe or a multipolar probe. Cholangiography was repeated at 7-day intervals. If a stricture was not identified by 28 days, injury was created at another site in the common hepatic duct by using a higher energy dose. After a stricture was identified, the animal was killed and bile duct samples were obtained for histopathologic evaluation. Results: Thirteen thermal injuries were created in the 9 animals. Six of 7 heat probe treatments and 1 of 6 multipolar probe treatments resulted in a stricture ( p = 0.025, Fisher exact test). Applications of the heat probe at 10 or 15 J produced a stricture in 6 of 6 cases. All strictures were indistinguishable histopathologically from benign strictures in humans. Conclusions: The application of intraluminal thermal injury with a heat probe results in a reproducible animal model of benign biliary stenosis. (Gastrointest Endosc 2003;57:73-7.)

Biliary strictures after liver transplantation

Biliary complications are common after orthotopic liver transplantation, and biliary strictures occur in 1% to 23% of all liver transplants performed. Biliary strictures are typically divided into anastomotic or nonanastomotic strictures, with different risk factors for each type. Endoscopic retrograde cholangiography is the procedure of choice for the diagnosis and management of most biliary strictures after liver transplantation. In this article, we review the incidence, pathogenesis, and risk factors for biliary strictures occurring after liver transplantation. We discuss the relationship between the type of biliary anastomosis and the subsequent development of biliary strictures. Finally, we discuss the indications for endoscopic intervention and focus on the endoscopic management of biliary strictures after liver transplantation.

Novel use of stone extraction balloon catheter in the management of biliary strictures

Novel use of stone extraction balloon catheter in the management of biliary strictures

Novel use of stone extraction balloon catheter in the management of biliary strictures

Novel use of stone extraction balloon catheter in the management of biliary strictures

4673 Results of endoscopic management of biliary stricture after orthotopic liver transplantation.

BS is a common biliary complication after OLT. We report our results of endoscopic biliary treatment(ERx)in these pts. Patients and Methods: From 5/88 to 8/99, 121 OLT pts with a choledocho- choledochostomy anastomosis (CDC) were referred for ERCP for cholestasis evaluation. Fifty-five pts (28 men, 27 women; mean age 36.5 yrs, range 9-68) were found to have BS. BS were classified by their location into anastomotic (AS) and nonanastomotic (NAS). NAS were thought to be ischemic in origin. Pts with BS underwent dilation with balloon (4-10 mm) or Soehendra dilators (6-11.5 F) followed by stenting (5-11.5 F). One or more stents were placed with or without endoscopic sphincterotomy. Stent(s) were removed, replaced or upsized at 1-3 month intervals until the stricture diameter achieved approximately 65% of the narrower adjacent duct. The cholangiograms from 25 pts were available to review (pre and post Rx) for the change in parameters. (Table, * p

Endoscopic management of biliary strictures in liver transplant recipients: effect on patient and graft survival

Background: Biliary strictures in liver transplant recipients cause significant morbidity and can lead to reduced patient and graft survival. Methods: Of 251 liver transplant recipients, 22 patients with biliary strictures were categorized into two groups: donor hepatic duct (n = 12) or anastomotic (n = 10). Strictures were dilated and stented. Endoscopic therapy was considered successful if a patient did not require repeat stenting or dilation for 1 year. Results: Patient and graft survival did not differ significantly in the 22 patients compared with patients without strictures (relative risk of death and graft survival 1.8 and 1.3). Donor hepatic duct strictures required significantly longer therapy than anastomotic strictures (median days 185 versus 67, p = 0.02). Twenty-two months after the first endoscopic treatment, 73% of the donor hepatic duct stricture group were stent free compared with 90% of the anastomotic group ( p = 0.02). The former group had significantly more ( p < 0.05) hepatic artery thrombosis (58.3% versus 10%), cholangitis (58.3% versus 30%), choledocholithiasis (91% versus 10%), and endoscopic interventions. No patient undergoing endoscopic treatment required retransplantation or biliary reconstruction during a median follow-up of 35.7 months. Conclusion: Endoscopic therapy of biliary strictures after liver transplantation is effective and is not accompanied by reduced patient or graft survival. (Gastrointest Endosc 1998;47:128-35)

Management of Biliary Strictures Due to Laparoscopic Cholecystectomy

Injury to the extrahepatic bile ducts during laparoscopic cholecystectomy (LC) is a cause of serious long-term patient morbidity. In order to identify management strategies and outcome, we undertook a retrospective review and analysis of patients referred to the Department of Surgery and the Division of Gastroenterology for management of bile duct strictures due to injury at LC. Eighteen patients (15 women, 3 men) with a mean age of 41 years were identified over a 4-year period. Six patients had injuries identified at LC. Ten patients had previously undergone an attempt at operative repair (8 end-to-end anastomoses, 1 choledochoduodenostomy, 1 cystic duct jejunostomy). There were 5 Bismuth Grade I strictures, 6 Grade II, 2 Grade III and 5 Grade IV. Ten patients were managed nonoperatively with stents placed by radiologic or endoscopic techniques. Four patients were managed with operation alone (2 choledochojejunostomy, 1 hepaticojejunostomy, and 1 external T-tube drainage) and 4 patients with a combined endoscopic and operative approach (all 4 with hepaticojejunostomy after initial endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography management). Bile duct strictures due to LC are frequently located in the proximal bile ducts (Bismuth II-IV) and are technically difficult to repair. In the majority of cases, injuries are unrecognized at LC. Both immediate and delayed repair attempts prior to referral were frequently unsuccessful. Many bile duct strictures can be managed successfully in the early postoperative period with endoscopic and radiologic stenting techniques. Strictures which cannot be managed nonoperatively are repaired with Roux-en-Y hepaticojejunostomy. The high number of failures with previous end-to-end anastomosis suggests that LC bile duct transection injuries recognized at operation should be managed initially with Roux-en-Y hepaticojejunostomy.

Failure of metallic stents in long-term management of biliary strictures after liver transplantation

Failure of metallic stents in long-term management of biliary strictures after liver transplantation

Nonoperative therapy of a complicated biliary stricture

Three recent reports have described external placement of biliary drains for common bile duct (CBD) strictures in children. We report combining endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), and transductal stenting for the precise diagnosis and management of a complicated CBD stricture. A $$5{\raise0.5ex\hbox{$\scriptstyle 1$}\kern-0.1em/\kern-0.15em\lower0.25ex\hbox{$\scriptstyle 2$}}$$ -year-old boy diagnosed with hepatic rhabdomyosarcoma was treated with induction chemotherapy and extended left hepatic resection. Postoperative neutrophil dysfunction contributed to multiple septic complications requiring three operative procedures for drainage. During these septic episodes cholangitis occurred with a peak serum bilirubin level of 30 mg/dl that finally stabilized at 20 mg/dl. The patient could not be cleared of biliary sepsis. PTC was performed with simultaneous ERCP. A well-defined, discrete CBD stricture was delineated and an external biliary drain was placed. Three weeks later, after the sepsis had cleared and the bilirubin level had markedly decreased, a transhepatic intraductal stent was placed exiting in the duodenum. This was later internalized and remained in place. The patient died 6 months later from a massive pelvic recurrence of his tumor. He suffered no further biliary complications and maintained normal bilirubin levels until his death. We conclude that modalities well-documented in adults for non-operative management of biliary strictures (PTC, ERCP, stents) can be used successfully in the pediatric population in selected cases.

Percutaneous cholangiography in the management of biliary stricture.

Percutaneous cholangiography in the management of biliary stricture.