Placement Of Multiple Plastic Stents Research Articles

The utility of self-expanding metal stents in benign biliary strictures- a retrospective case series

BackgroundBenign biliary strictures can have a significant negative impact on patient quality of life. There are several modalities which can be utilized with the goal of stricture resolution. These techniques include balloon dilatation, placement of multiple plastic stents and more recently, the use of metal stents. The aim of this study was to evaluate the local success of self-expanding metal stents in successfully resolving benign biliary strictures.MethodsThis was a single institution, retrospective case series. Patients included in our study were patients who underwent endoscopic retrograde cholangiopancreatography with placement of self expanding metal stents for benign biliary strictures at our institution between 2016–2022. Patients were excluded for the following: malignant stricture, and inability to successfully place metal stent. Data was evaluated using two-sided t-test with 95% confidence interval.ResultsA total of 31 patients underwent placement of 43 self-expanding metal stents and met inclusion criteria. Mean age of patients was 59 ± 10 years, and were largely male (74.2% vs. 25.8%). Most strictures were anastomotic stricture post liver transplant (87.1%), while the remainder were secondary to chronic pancreatitis (12.9%). Complications of stent placement included cholangitis (18.6%), pancreatitis (2.3%), stent migration (20.9%), and inability to retrieve stent (4.7%). There was successful stricture resolution in 73.5% of patients with anastomotic stricture and 33.3% of patients with stricture secondary to pancreatitis. Resolution was more likely if stent duration was > / = 180 days (73.3% vs. 44.4%, p < 0.05). There was no demonstrated added benefit when stent duration was > / = 365 days (75% vs. 60.9%, p = 0.64).ConclusionsThis study demonstrates that self expanding metal stents are a safe and effective treatment for benign biliary strictures, with outcomes comparable to plastic stents with fewer interventions. This study indicates that the optimal duration to allow for stricture resolution is 180–365 days.

Management of distal benign biliary stricture

Endoscopic treatment consists of passing the stricture and placement of at least one large bore plastic stent, followed by further sessions of stenting with multiple plastic stents. Temporary placement of multiple plastic stents is the recommended approach in patients with benign biliary strictures. Self-expandable metal stents have a larger diameter compared to plastic stents and can be covered and uncovered. Placement of uncovered metal stents in patients with benign biliary strictures is strongly discouraged. However, covered self-expandable metal stents can be safely placed in selected patients.

Late results in the endoscopic treatment of cicatricial bile duct strictures

Aim. To evaluate the late results of staged endoscopic treatment of patients with corrosive bile duct strictures.Materials and methods. The study included 41 patients with corrosive bile duct strictures varying in etiology and localization. The patients were observed over a seven-year period, most of whom had already undergone endoscopic treatment.Results. The technical success rate amounted to 100%. The procedure of staged stenting was completed in 34 out of 37 patients under observation. The clinical success rate, defined as the release of a stricture, reached 94%. In the postoperative period, the incidence of complications amounted to 8.8%. Only 2 out of 34 patients who had undergone stenting exhibited stricture recurrence.Conclusion. The staged placement of multiple plastic stents is characterized by high technical and clinical success rates while involving few complications, as well as a consistently low rate of stricture recurrence in the long-term period.

Fully Covered Self-expanding Stents are Cost-effective at Remediating Biliary Strictures in Patients With Chronic Pancreatitis

Benign biliary strictures (BBS) develop in up to 10% to 30% of patients with chronic pancreatitis (CP).1 Endoscopic endoprosthetics via endoscopic retrograde cholangiopancreatography (ERCP) has become the standard of care for remediating these strictures. Seventy percent to eighty percent of these strictures resolve with sequential or concurrent placement of multiple plastic stents (MPS).1,2 More recently, placement of fully covered self-expanding metal stents (FCSEMS) have been shown to have similar outcomes as MPS.3-6 FCSEMS provide a larger radial diameter and require fewer procedures, but may have drawbacks, including a higher risk of migration, cholecystitis, delamination, and tissue ingrowth. A recent study demonstrated that FCSEMS with a 12-month indwell had similar outcomes to MPS with fewer ERCP needed.7 However, the cost-effectiveness of either strategy for managing BBS has not been assessed previously nor has the impact of additional reimbursement to cover the cost of FCSEMS on the cost-effectiveness of FCSEMS utilization.

Metal versus plastic stents in the management of benign biliary strictures: systematic review and meta-analysis of randomized controlled trials.

Benign biliary strictures (BBS) are usually treated with endoscopic retrograde cholangiopancreatography (ERCP) with the placement of multiple plastic stents (MPS) or a covered self-expandable metal stent (CSEMS). In this meta-analysis, we compared the efficacy and safety of MPS and CSEMS in the management of BBS. We reviewed several databases from inception to 28 April 2021 to identify RCTs that compared MPS with CSEMS in the management of BBS. Our outcomes of interest were stricture resolution, stricture recurrence, adverse events, stent migration and mean number of ERCPs to achieve stricture resolution. Data were analyzed using a random-effects model. We included eight RCTs with 524 patients. We found no significant difference in the rate of stricture resolution (risk ratio, 1.02; 95% CI, 0.96-1.10), stricture recurrence (risk ratio, 1.68; 95% CI, 0.72-3.88) or adverse events (risk ratio, 1.17; 95% CI, 0.73-1.87) between groups. Mean number of ERCPs was significantly lower in the CSEMS group (SMD, -1.99; 95% CI, -3.35 to -0.64). The rate of stent migration was significantly higher in the CSEMS group. CSEMS are comparable in efficacy and safety to MPS in the management of BBS but require fewer ERCPs to achieve stricture resolution.

Comparison of clinical outcomes of multiple plastic stents and covered metal stent in refractory pancreatic ductal strictures in chronic pancreatitis- a systematic review and meta-analysis

BackgroundSymptomatic pancreatic duct (PD) strictures in chronic pancreatitis refractory to single plastic stenting are usually managed by placement of multiple plastic stents (MPS). Fully covered self-expanding metallic stents (FCSEMS) have also been used in the management of these patients. However, the overall efficacy and safety of different types of stents is unclear from the currently available studies. We performed this meta-analysis to assess the efficacy and complications from MPS and FCSEMS in patients with PD strictures refractory to treatment with single plastic stents. MethodsSeveral electronic databases were searched for all the studies evaluating the outcome of placement of multiple plastic stents and fully covered metal stents in patients with PD strictures refractory to single plastic stenting. We calculated the Weighted Pooled Ratio (WPR) with Confidence Interval (CI) between the MPS and FCSEMS. ResultsA total of 13 studies (including 2 abstracts) were included in the analysis. MPS were placed in 106 patients and FCSEMS in 192 patients. Improvement in pain after stenting (P = 0.794), risk of recurrence of pain after removal of stent (P = 0.48) and stricture recurrence after stent removal (P = 0.52) were comparable between MPS and FCSEMS. Risk of endoscopic re-intervention was also comparable between metal stents and MPS. However, FCSEMS was associated with overall higher risk of adverse events (P < 0.0001). ConclusionFCSEMS are comparable to multiple plastic stents in the treatment of symptomatic refractory PD strictures. However, use of FCSEMS is associated with increased risk of adverse events.

Bilateral balloon expandable biodegradable stent (Y-stent) for postcholecystectomy perihilar biliary stricture.

Bilateral balloon expandable biodegradable stent (Y-stent) for postcholecystectomy perihilar biliary stricture.

The placement of multiple plastic stents still has important roles in candidates for chemotherapy for unresectable perihilar cholangiocarcinoma.

Placement of uncovered self-expandable metallic stents (U-SEMSs) of patients with unresectable perihilar cholangiocarcinoma (UPHC) is recommended as the treatment of first choice to address bile stasis. The aim of this study was to determine which of the following two endoscopic stents might be the stent of first choice for the treatment of biliary stasis in patients with UPHC: plastic stents (PSs) or U-SEMSs. U-SEMSs, deployed as a stent-in-stent, were selected as the stents of first choice from 2013 and 2014, while PSs began to be selected as the stents of first choice from 2015 onward. The median time to recurrent biliary obstruction were 66days in the PS group (N=38) and 105days in the U-SEMS group (N=37; P=.04). Emergency endoscopy was necessitated in 76.3% (29/38) of patients of the PS group and 54.1% (20/37) of patients of the U-SEMS group (P=.0434). The success rate of the first reintervention was 96.5% (27/29) in the PS group and 55% (11/20) in the U-SEMS group (P=.0002). Sustainable chemotherapy could be carried out in 55.2% of patients in the PS group and 32.4% of patients in the U-SEMS group (P=.0472). Multivariate analysis identified selection of U-SEMS as the stent of first choice as the only independent factor predictive of successful reintervention (P=.0016, odds ratio=0.058). However, the stent selection was not an independent factor for feasible chemotherapy. Plastic stent placement could enhance the success rate of reintervention in patients with UPHC and might be facilitated by sustainable chemotherapy. However, stent selection might not have an influence on the prognosis.

Fully covered self-expanding metal stents for benign biliary stricture after orthotopic liver transplant: 5-year outcomes

Minimally invasive treatments of anastomotic benign biliary stricture (BBS) after orthotopic liver transplantation (OLT) include endoscopic placement of multiple plastic stents or fully covered self-expandable metal stents (FCSEMSs). No multiyear efficacy data are available on FCSEMS treatment after OLT. We prospectively studied long-term efficacy and safety of FCSEMS treatment in adults aged≥18 years with past OLT, cholangiographically confirmed BBS, and an indication for ERCP with stent placement. Stent removal was planned after 4 to 6 months, with subsequent follow-up until 5 years or stricture recurrence. Long-term outcomes were freedom from stricture recurrence, freedom from recurrent stent placement, and stent-related serious adverse events (SAEs). In 41 patients, long-term follow-up began after FCSEMS removal (n= 33) or observation of complete distal migration (CDM) (n= 8). On an intention-to-treat basis, the 5-year probability of remaining stent-free after FCSEMS removal or observation of CDM was 48.9% (95% confidence interval [CI], 33.2%-64.7%) among all patients and 60.9% (95% CI, 43.6%-78.2%) among 31 patients with over 4 months of FCSEMS indwell time. In 28 patients with stricture resolution at FCSEMS removal or observed CDM (median, 5.0 months indwell time), the 5-year probability of no stricture recurrence was 72.6% (95% CI, 55.3%-90%). Sixteen patients (39%) had at least 1 related SAE, most commonly cholangitis (n= 10). By 5 years after temporary FCSEMS treatment of post-OLT BBS, approximately half of all patients remained stent-free on an intention-to-treat basis. Stent-related SAEs (especially cholangitis) were common. FCSEMS placement is a viable long-term treatment option for patients with post-OLT BBS. (Clinical trial registration number: NCT01014390.).

Biodegradable versus multiple plastic stent implantation in benign biliary strictures: A systematic review and meta-analysis

PurposeBenign biliary strictures arise mostly from iatrogenic injuries during surgical procedures and various inflammatory causes. Endoscopic placement of multiple plastic stents (MPS) is often regarded as the first-line therapy, albeit not without limitations. Biodegradable biliary stents (BDBS) present an alternative therapeutic option aimed at overcoming these shortcomings.The long-term stricture resolution rates between BDBS and MPS implantation in patients with benign biliary strictures (BBS) was therefore analyzed and compared, regardless of etiology. MethodUsing predefined data fields, all articles published up to July 2018 were retrospectively selected and independently extracted by two authors and then excluded according to predefined criteria. Additional studies were identified by manually searching through article references. Any disagreements between authors on study selection were resolved by consensus. Results3 studies for BDBS (n = 133) and 6 for MPS technique (n = 441) met the inclusion criteria. The overall success rate (defined as no stricture recurrence during follow-up) for BDBS implantation was 83 % (95 % [CI], 0.76–0.89), compared to 84 % (95 % [CI], 0.78–0.89) in the MPS group. Overall stent-related complication rates were reported to be slightly inferior in the BDBS group when compared to MPS, except for cholangitis (24.1 % vs. 6.1 %, respectively) and haemobilia (3% vs <1%, respectively). On average, BDBS required less interventions than MPS use (1 vs. 3, respectively). ConclusionsThe insertion of BDBS in the treatment of benign biliary strictures does not seem to be inferior to multiple plastic stents in resolving and maintaining long-term biliary duct patency, albeit exhibiting higher rates of post-procedural cholangitis.

Metallic vs plastic stents to treat biliary stricture after liver transplantation: a systematic review and meta-analysis based on randomized trials.

Background and study aims The first-line approach to anastomotic biliary stricture after orthotopic liver transplantation (OLTX) involves endoscopic retrograde cholangiopancreatography (ERCP). The most widely used technique is placement of multiple plastic stents, but discussions are ongoing on the benefits of fully-covered self-expandable metallic stents (FCEMS) in this situation. This study aimed to compare results from use of plastic and metal stents to treat biliary stricture after transplantation. Patients and methods Searches were performed in the Medline, EMBASE, SciELO/LILACS, and Cochrane databases, and only randomized studies comparing the two techniques were included in the meta-analysis. Results Our study included four randomized clinical trials totaling 205 patients. No difference was observed between the stricture resolution rate (RD: 0.01; 95 %CI [−0.08 – 0.10]), stricture recurrence (RD: 0.13; 95 %CI [−0.03 – 0.28]), and adverse events (RD: −0.10; 95 %CI [−0.65 – 0.44]) between the plastic and metallic stent groups. The metallic stent group demonstrated benefits in relation to the number of ERCPs performed (MD: −1.86; 95 %CI [−3.12 to −0.6]), duration of treatment (MD: −105.07; 95 %CI [−202.38 to −7.76 days]), number of stents used (MD: −10.633; 95 %CI [−20.82 to −0.44]), and cost (average $ 8,288.50 versus $ 18,580.00, P < 0.001). Conclusions Rates of resolution and recurrence of stricture are similar, whereas the number of ERCPs performed, number of stents used, duration of treatment, and costs were lower in patients treated with FCEMS, which shows that this device is a valid option for initial treatment of post-OLTX biliary stricture.

Single brand, fully-covered, self-expandable metal stent for the treatment of benign biliary disease: when should stents be removed?

The two most relevant endoscopic treatable benign biliary diseases (BBD) are benign biliary strictures (BBSs) and biliary leaks (BLs), often associated with high morbidity. The most common endoscopic treatment for biliary strictures involves placement of multiple plastic stents (PSs), with or without balloon dilation, followed by planned exchange of the stents. Thus, there continues to be high interest in pursuing alternative endoscopic approaches that may achieve better results with fewer interventions. In this setting, the use of a fully-covered, self-expandable metal stent (FCSEMS) is an attractive alternative to single or multiple PSs for the treatment of BBDs. A single metal stent can remain in place for a longer period of time before removal; however, the maximum time the stent can be remain in place is still not well defined. The aim of this review is to determine the removal time of the TaeWoong® FCSEMS, placed for BBD. According to our data analysis, considering the absence of loss of the covering of the FCSEMS and of any adverse events during and after stent removal, leaving the TaeWoong medical FCSEMS in situ for an 8 months' period seems to be acceptable for benign biliary diseases. Further studies need to evaluate their removability at 1 year.

Endoscopic management of biliary strictures after living donor liver transplantation.

Living donor liver transplantation (LDLT) is an effective alternative to deceased liver transplantation (DDLT) for end-stage liver disease. Although advances in surgical techniques, immunosuppressive management, and post-transplant care have improved the overall outcomes of LDLT, biliary strictures remain the major unsolved problem. Endoscopic retrograde cholangiopancreatography (ERCP) is currently considered the first-line therapy for biliary strictures following LDLT with duct-to-duct reconstruction, with percutaneous and surgical interventions reserved for patients with unsuccessful management via ERCP. Endoscopic management of biliary strictures is technically more challenging in LDLT than in DDLT because of the complexity of the biliary anastomosis, in addition to the tortuous and angulated biliary system. Placement of one or more plastic stents after balloon dilation has been the standard strategy for post-LDLT stricture, but this requires multiple stent exchange to prevent stent occlusion until stricture resolution. Inside stents might prevent duodenobiliary reflux and thus have longer stent patency, obviating the need for multiple ERCPs. Newly developed covered self-expandable metallic stents with anti-migration systems are alternatives to the placement of multiple plastic stents. With the advent of deep enteroscopy, biliary strictures in LDLT patients with Roux-en-Y hepaticojejunostomy are now treatable endoscopically. In this review, we discuss the short- and long-term outcomes of endoscopic management of post-LDLT strictures as well as recent advances in this field.

Covered Metal Stents vs. Multiple Plastic Stents for Management of Benign Biliary Strictures: A Systematic Review and Meta-analysis 2016 ACG Presidential Poster Award

Introduction: Endoscopic treatment of benign biliary strictures (BBS) can be achieved by placement of multiple plastic stents (MPS) or covered self-expandable metal stents (cSEMS). We conducted a systematic review and meta-analysis to evaluate the cumulative efficacy (stricture resolution & recurrence) and safety (adverse events) of cSEMS for treatment of BBS. We also compared the efficacy and safety of MPS that of cSEMS in the management of BBS.Figure 1Methods: We searched Medline and Embase from inception to 05/28/16 to identify both observational studies evaluating the stricture resolution rate and safety of cSEMS in BBS and randomized controlled trials (RCTs) comparing cSEMS with plastic stents for management of BBS. Weighted pooled rates (WPR) were calculated for stricture resolution/recurrence with the use of cSEMS. Risk ratios (RR) were calculated for stricture resolution, recurrence and adverse events (AEs) while comparing cSEMS with plastic stents. Difference in means was calculated for number of ERCPs required in each group. These were analyzed using random effects model. Meta-regression was done to explore heterogeneity. Quality assessment was done with Cochrane tool and Newcastle Ottawa Scale (NOS) for RCTs and observational studies, respectively. Results: Twenty three studies with 1175 patients were included in the meta-analysis to evaluate the cumulative efficacy and safety of cSEMS & 4 RCTs with 213 patients were included in the comparative analysis of cSEMS and plastic stents. All RCTs had high risk of performance bias. On NOS evaluation, 4, 12 and 3 studies were of high, moderate and low quality. WPR for cumulative stricture resolution with cSEMS was 84% (79%, 88%), with considerable heterogeneity (I2=73%). WPR for stricture recurrence was 14% (9%,19%), with moderate heterogeneity (I2=58%). Rates of AEs requiring intervention were: stent migration with cholangitis (1%), stent occlusion with cholangitis (4%), cholangitis after stent removal (1%), cholecystitis (1%) and pancreatitis (4.5%). Rate of asymptomatic stent migration before scheduled removal was 8.7%. The pooled RR comparing cSEMS with MPS for stricture resolution was 1.07 (0.97, 1.18) with no heterogeneity (I2=0%). RR for stricture recurrence was 0.88 (0.48,1.63) with no heterogeneity (I2=0%) and for AEs was 1.11 (0.49,2.51) with low heterogeneity (I2=30%). Difference in means for number of ERCPs required was -1.66 (-2.38,-0.91) with low heterogeneity (I2=52%) in favor of cSEMS.Figure 2Figure 3Conclusion: cSEMS have a cumulative stricture resolution and recurrence rates of 84% and 14%, respectively. No difference was found in stricture resolution, stricture recurrence and AEs between cSEMS and plastic stents. However, cSEMS treatment was associated with significantly fewer ERCP sessions.

Effect of Covered Metallic Stents Compared With Plastic Stents on Benign Biliary Stricture Resolution: A Randomized Clinical Trial.

Endoscopic placement of multiple plastic stents in parallel is the first-line treatment for most benign biliary strictures; it is possible that fully covered, self-expandable metallic stents (cSEMS) may require fewer endoscopic retrograde cholangiopancreatography procedures (ERCPs) to achieve resolution. To assess whether use of cSEMS is noninferior to plastic stents with respect to stricture resolution. Multicenter (8 endoscopic referral centers), open-label, parallel, randomized clinical trial involving patients with treatment-naive, benign biliary strictures (N = 112) due to orthotopic liver transplant (n = 73), chronic pancreatitis (n = 35), or postoperative injury (n = 4), who were enrolled between April 2011 and September 2014 (with follow-up ending October 2015). Patients with a bile duct diameter less than 6 mm and those with an intact gallbladder in whom the cystic duct would be overlapped by a cSEMS were excluded. Patients (N = 112) were randomized to receive multiple plastic stents or a single cSEMS, stratified by stricture etiology and with endoscopic reassessment for resolution every 3 months (plastic stents) or every 6 months (cSEMS). Patients were followed up for 12 months after stricture resolution to assess for recurrence. Primary outcome was stricture resolution after no more than 12 months of endoscopic therapy. The sample size was estimated based on the noninferiority of cSEMS to plastic stents, with a noninferiority margin of -15%. There were 55 patients in the plastic stent group (mean [SD] age, 57 [11] years; 17 women [31%]) and 57 patients in the cSEMS group (mean [SD] age, 55 [10] years; 19 women [33%]). Compared with plastic stents (41/48, 85.4%), the cSEMS resolution rate was 50 of 54 patients (92.6%), with a rate difference of 7.2% (1-sided 95% CI, -3.0% to ∞; P < .001). Given the prespecified noninferiority margin of -15%, the null hypothesis that cSEMS is less effective than plastic stents was rejected. The mean number of ERCPs to achieve resolution was lower for cSEMS (2.14) vs plastic (3.24; mean difference, 1.10; 95% CI, 0.74 to 1.46; P < .001). Among patients with benign biliary strictures and a bile duct diameter 6 mm or more in whom the covered metallic stent would not overlap the cystic duct, cSEMS were not inferior to multiple plastic stents after 12 months in achieving stricture resolution. Metallic stents should be considered an appropriate option in patients such as these. clinicaltrials.gov Identifier: NCT01221311.

Endoscopic management with multiple plastic stents of anastomotic biliary stricture following liver transplantation: long-term results.

Anastomotic biliary stricture (ABS) is the most common biliary complication after orthotopic liver transplantation (OLT) and can be successfully managed endoscopically. The long-term results of a protocol using placement of multiple plastic stents to treat ABS following OLT were analyzed. All patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for OLT-related biliary complications at our Endoscopy Unit between July 1994 and March 2012 were retrospectively identified from the ERCP database. Patients with an ABS treated with an increasing number of plastic stents were included in the study. Follow-up after stent removal was obtained by telephone contact with the patient and/or referring physician and by liver function tests (LFTs) evaluation. 56 patients, treated with an increasing number of plastic stents until resolution of the stricture, were included. Five patients were then excluded (unrelated death during treatment, n = 3; incomplete treatment because of poor compliance, n = 2), and 51/56 patients reached study end points and were included in the analysis. Resolution of ABS was obtained in 50/51 patients; 1 patient required hepaticojejunostomy because of failure to pass the stricture with the guidewire (per protocol resolution, 98 %). Mean duration of endoscopic treatment was 11.5 months, with a median 4 ERCPs per patient. Immediate ERCP-related adverse events occurred in 3/56 patients (5.4 %). After a median follow-up of 5.8 years from stent removal, 3/50 patients (6 %) had recurrence of ABS. These 3 patients were successfully treated again endoscopically and are asymptomatic after a further median follow-up of 5.6 years. At long-term follow-up, endoscopic treatment with multiple plastic stents of ABS following OLT appeared to be effective in most patients. Stricture recurrence is rare and can be successfully treated again endoscopically.

Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation.

Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation (LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.

Role of endoscopic retrograde cholangiopancreatography in the management of benign biliary strictures: What's new?

Benign biliary strictures comprise a heterogeneous group of diseases. The most common strictures amenable to endoscopic treatment are post-cholecystectomy, post-liver transplantation, related to primary sclerosing cholangitis and to chronic pancreatitis. Endoscopic treatment of benign biliary strictures is widely used as first line therapy, since it is effective, safe, noninvasive and repeatable. Endoscopic techniques currently used are dilation, multiple plastic stents insertion and fully covered self-expandable metal stents. The main indication for dilation alone is primary sclerosing cholangitis related strictures. In the vast majority of the remaining cases, temporary placement of multiple plastic stents with/without dilation is considered the treatment of choice. Although this approach is effective, it requires multiple endoscopic sessions due to the short duration of stent patency. Fully covered self-expandable metal stents appear as a good alternative to plastic stents, since they have an increased radial diameter, longer stent patency, easier insertion technique and similar efficacy. Recent advances in endoscopic technique and various devices have allowed successful treatment in most cases. The development of novel endoscopic techniques and devices is still ongoing.

A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos)

Endoscopic management of postcholecystectomy biliary leaks is widely accepted as the treatment of choice. However, refractory biliary leaks after a combination of biliary sphincterotomy and the placement of alarge-bore (10F) plastic stent can occur, and the optimal rescue endotherapy for this situation is unclear. To compare the clinical effectiveness of the use of a fully covered self-expandable metal stent(FCSEMS) with the placement of multiple plastic stents (MPS) for the treatment of postcholecystectomy refractory biliary leaks. Prospective study. Two tertiary-care referral academic centers and one general district hospital. Forty consecutive patients with refractory biliary leaks who underwent endoscopic management. Temporary placement of MPS (n= 20) or FCSEMSs (n= 20). Clinical outcomes of endotherapy as well as the technical success, adverse events, need for reinterventions, and prognostic factors for clinical success. Endotherapy was possible in all patients. After endotherapy, closure of the leak was accomplished in 13patients (65%) who received MPS and in 20 patients (100%) who received FCSEMSs (P= .004). TheKaplan-Meier (log-rank) leak-free survival analysis showed a statistically significant difference between the 2 patient populations (χ(2) [1]= 8.30; P< .01) in favor of the FCSEMS group. Use of<3 plastic stents (P= .024), a plastic stent diameter<20F (P= .006), and a high-grade biliary leak (P= .015) were shown to be significant predictors oftreatment failure with MPS. The 7 patients in whom placement of MPS failed were retreated with FCSEMSs, resulting in closure of the leaks in all cases. Non-randomized design. In our series, the results of the temporary placement of FCSEMSs for postcholecystectomy refractory biliary leaks were superior to those from the use of MPS. A randomized study is needed to confirm our results before further recommendations.

Tuberculosis biliary stricture simulating as cholangiocarcinoma.

Tuberculosis (TB) is a rare cause of biliary stricture that is difficult to diagnose preoperatively. Patient present with obstructive jaundice, which may be confused with hepatobiliary malignancies. Suspicion of the disease with knowledge and awareness and establishing tissue diagnosis along with advent of image guided FNAC, endoscopic brush cytology and PCR testing of bile, diagnosis of hepatobiliary TB can be made without the need of laparotomy. Biliary TB is a potentially curable condition when diagnosed preoperatively requiring antituberculosis therapy & avoiding surgery [1]. Surgery is most often required for relief of biliary obstruction [2]. Failure to obtain preoperative tissue diagnosis may lead to histological diagnosis of biliary TB only after major surgery. TB of lower end of common bile duct (CBD) and periampullary region often forms pseudotumour and strictures mimicking cholangio carcinoma [3]. Hepatobiliary TB may be caused by three ways: (1) Spread of caseous material from the portal tracts into the bile ducts (most often), (2) Secondary inflammation-related tuberculous periportal lymphadenitis, (3) Spread of caseous material through the ampulla of Vater and ascending along the CBD [4]. Benign biliary strictures fall into two etiological groups: Traumatic (Post operative, Blunt, or Penetrating injury) and Nontraumatic (Sclerosing cholangitis, Recurrent pyogenic cholangitis, Chronic pancreatitis, Mirizzi syndrome) [5]. Various other benign conditions are Eosinophilic granuloma, Duodenal papillitis, Infestations due to Ascaris lumbricoides and Clonorchis sinensis. Tuberculous biliary stricture is due to the secondary endo luminal inflammatory process and scarring. Tuberculous biliary stricture involves all parts of the biliary tree, but commonly involving CBD [6]. We came across five cases of Tubercular biliary stricture in last six years. All the patients had no specific clinical findings & there was lack of constitutional symptoms of TB such as fever and night sweat, absence of past history of TB, negative tuberculin skin test, lack of radiological evidence of old or active TB. CBD was involved with either stricture or pseudo tumour [Table/Fig-1]. [Table/Fig-1]: Findings of five cases in present study The factors like (1) a past history of TB, (2) other systemic manifestations like pulmonary or generalized lymph node involvement, (3) associated involvement of other abdominal organs, (4) mild jaundice, (5) abdominal pain more than an abdominal mass, (6) image guided FNAC or biopsy in suspected cases, and (7) the geographic area where the patient resides might help in differentiating biliary TB from biliary tract malignancy [7]. Preoperative diagnosis of TB as the cause of obstructive jaundice is extremely difficult often compelling major resectional surgery such as whipples pancreatoduodenectomy. In most of the cases, final diagnosis is reached in the postoperative period by the histological finding of caseation necrosis and epitheloid granuloma formation and Langhans giant cells [1]. All the patients in our study were put on ATT. Patients without surgery showed improvement and are on regular follow up. My research review on various documented articles reflects the need to diagnose this disguising condition with various available investigations keeping TB in mind [Table/Fig-2]. [Table/Fig-2]: Comparison of various published literature with the present study There are several proposed investigations for preoperative diagnosis, for example, detection of acid fast bacilli (AFB) after staining or culture in the biliary fluid aspirate during ERCP, FNAC, and frozen section [18]. PCR technique for Mycobacterium TB from biliary fluid is helpful because of its sentivity [6]. The tubercular biliary stricture can be cured with antitubercular medications with excellent prognosis. In few reported cases, the biliary stricture does not resolve with medical therapy alone and requires surgical intervention and biliary metallic stent placement [1]. Whipples pancreastoduodenectomy is done for distal CBD stricture and choledochoduodenostomy is required in multiple strictures. Sequential placement of multiple plastic stents has been shown to be effective, as the stents both enable biliary drainage and act as dilators [17] . Although favourable results can be achieved by medical therapy and with repeated stenting of the bile ducts, long-term follow-up is required due to the risk of post-treatment cicatricial stenosis [5] . If preoperative diagnosis is established, major surgery can be avoided, which increases morbidity and mortality. Patients presenting with a short history with relatively good health from tuberculosis endemic country like India, tubercular biliary stricture should be kept in mind as a differential diagnosis. These benign lesions should be differentiated from malignant masquerade, equally keeping in mind not to mistake malignant lesions for benign lesions.