Bile Duct Stricture Research Articles

Revised Clinical Practice Guideline of Korean Pancreatobiliary Association for Common Bile Duct Stones: Endoscopic Management of Difficult Common Bile Duct Stones

Difficult common bile duct (CBD) stones are difficult to remove using conventional stone clearance methods such as endoscopic papillary sphincterotomy. In this guideline, we present several recommendations and relevant information on the endoscopic treatment of difficult CBD stones. For the primary treatment of large CBD stones in patients without distal bile duct stricture, we recommend limited endoscopic sphincterotomy followed by endoscopic papillary large balloon dilation. For large CBD stones that are difficult to remove with conventional endoscopic treatment methods, we recommend electrohydraulic or laser lithotripsy under cholangioscopy. Short-term biliary stenting is recommended in patients with CBD stones that are difficult to remove by these methods. Finally, endoscopic treatment via small bowel enteroscopy or percutaneous transhepatic cholangioscopy may be an option in patients with surgically altered anatomy.

Effectiveness of endoscopic papillectomy with stent placement in pancreatic and bile ducts for treating duodenal papillary adenoma: a retrospective study

BackgroundDuodenal papillary adenoma, a potentially malignant benign tumor is primarily treated with endoscopic papillectomy. Despite its efficacy, endoscopic papillectomy has a high complication rate. This study investigates whether pancreatic duct and common bile duct stent placement can mitigate these complications.MethodsIn a retrospective observational analysis, 79 patients with duodenal papillary adenoma, treated with endoscopic papillectomy at our center, were studied. The cohort included patients who underwent endoscopic papillectomy with no stents placement, common bile duct stent placement alone, pancreatic duct stent placement alone, or stents placement in both ducts. We assessed the outcomes of endoscopic papillectomy, including complete resection rate and recurrence rate as the primary and secondary outcomes respectively. In the meantime, the incidence of complications were also analysed as the safety outcomes.ResultsComplete resection rates did not significantly differ between patients with or without stent placement (85.7% P group vs. 89.2% N-P group, P = 0.64). Early complication rates were similar across groups. However, significant reduction in common bile duct stenosis was observed in the stenting group (0% B group vs. 10.5% N-B group, P = 0.03). Furthermore, stent placement correlated with lower adenoma recurrence rates during follow-up (2.4% P group vs. 16.2% N-P group, P = 0.03; 2.4% B group vs. 15.8% N-B group, P = 0.04).ConclusionsPancreatic duct and common bile duct stent placement in endoscopic papillectomy may decrease late complications, particularly common bile duct stenosis, and reduce the recurrence of duodenal papillary adenoma.Trial registrationThis study received approval from the Institutional Review Board and Ethics Committee of Beijing Friendship Hospital (Approval No. BFHHZS20230203), and retrospectively registered in www.ClinicalTrials.gov (NCT06301048, Initial Release date: 02/18/2024, Last Public Release date: 03/03/2024).

STATE OF CELLULAR IMMUNITY IN PURULENT CHOLANGITIS

Abstract. Objective: To study the state of the cellular link of immunity in acute and chronic cholangitis. Materials and methods. Cholangitis always worsens the condition of the biliary system. Depending on the magnitude of the pathological changes in the bile ducts, we distinguished three groups of patients. Group I – cholangitis caused by obstruction of the main extrahepatic bile ducts due to choledocholithiasis, group II – cholangitis in conditions of cicatricial strictures of the main bile ducts, and group III – cholangitis in conditions of already performed reconstruction of the duct system. The indicators of the cellular link of immunity were studied separately in each group. The results. The conducted studies indicate an imbalance of the immune system in patients with different courses of cholangitis. The presence of inflammation of a mild degree of severity causes stimulation of almost all links of the immune system, while the cellular branch reacts first. Conclusions. Long-term cholangitis was accompanied by suppression of the main markers of T-lymphocyte differentiation — CD2+, CD3+, CD4+ and CD8+, which take part in antigen presentation, signal transmission to other cells and affect their adhesive properties.

Clinically oriented look into diagnostics and therapy of primary sclerosing cholangitis. Review of literature

Introduction: Primary sclerosing cholangitis (PSC) is a complex liver disorder marked by multifocal bile duct strictures and dilatations, leading to cholestasis and liver fibrosis. Although the exact cause is unknown, autoimmune mechanisms are strongly suspected. Aim of the Study: This paper reviews current knowledge on PSC, covering its etiology, prevalence, treatment options, and practical management strategies. Current State of Knowledge: PSC management focuses on symptom relief and liver transplantation, with limited success in pharmacological treatments. New therapies, including immune modulators and anti-fibrotic agents, show promise but require further research. Liver transplantation remains the most effective treatment, though recurrence risks necessitate ongoing monitoring. Materials and Methods: This article reviews the current understanding of PSC, including its pathophysiology, diagnostic approaches, clinical features, and management strategies. A comprehensive literature search was conducted using PubMed and Google Scholar, with articles selected based on relevant keywords and evaluated for inclusion in this review. Conclusions: Effective management of PSC necessitates a multidisciplinary approach involving hepatologists, gastroenterologists, radiologists, and transplant surgeons. Ongoing efforts to better understand PSC’s pathogenesis, refine diagnostic methods, and develop more effective therapies are crucial for improving patient outcomes.

Association of Crohn’s Disease and Hepatic Cirrhosis Post-Primary Sclerosing Cholangitis: A Case Report

Primary sclerosing cholangitis (PSC) is a distinct entity associated with inflammatory bowel disease (IBD). We report the case of a 49-year-old patient with ileocecal Crohn’s disease of the stenosing phenotype, presenting with perianal lesions in the form of fistulas, who was diagnosed with PSC complicated by hepatic cirrhosis following the development of clinical and biological cholestasis, as well as his first ascitic decompensation. After initiating treatment with azathioprine for Crohn's, he experienced significant abdominal pain, ascites, and jaundice, leading to further investigations. MRI revealed bile duct stenosis, and endoscopic procedures confirmed portal hypertension. After excluding secondary causes, a diagnosis of PSC was made. Treatment with methotrexate and ursodeoxycholic acid resulted in clinical improvement. The discussion emphasizes the rare but notable association between Crohn's disease and PSC, outlining diagnostic challenges and management strategies. It highlights the poor prognosis linked to PSC, including risks of cirrhosis and colorectal cancer, with recommendations for regular monitoring and surveillance for dysplasia in patients with both conditions. Overall, the study underscores the need for careful management and ongoing research into effective treatments for this challenging dual diagnosis.

S2496 A Rare Presentation: Cholangitis Secondary to Distal Common Bile Duct (CBD) Stricture From Extramedullary Plasmacytoma

S2496 A Rare Presentation: Cholangitis Secondary to Distal Common Bile Duct (CBD) Stricture From Extramedullary Plasmacytoma

Reconstructive interventions on bile ducts in patients with benign obstructive jaundice

Aim. To evaluate immediate and long-term results of surgical reconstruction of the biliary system in various types of benign obstructive jaundice.Materials and methods. The study enrolled 110 patients with choledocholithiasis, iatrogenic biliary strictures, common bile duct strictures, as well as strictures of biliodigestive and biliobiliary anastomoses. Patients were divided into 3 groups. Group 1 included 43 patients with multiple choledocholithiasis and bile duct dilatation >15 mm. Group 2 enrolled 35 patients with multiple choledocholithiasis and hepaticolithiasis who were intraoperatively diagnosed with stricture, injury, or pressure ulcers of the common bile duct wall. Group 3 included 32 patients with cicatricial and iatrogenic biliary strictures. The immediate and long-term results of surgical treatment were compared.Results. In group 1, the survival rate comprised 89.4%, the average duration of surgery amounted to 137 minutes, complications involved wound infection, bile leakage, bile peritonitis. In group 2, the survival rate accounted for 91.4%, the average duration of surgery comprised 192 minutes; strictures of biliodigestive anastomosis were detected in the remote period, and reconstructive surgeries were performed. Group 3 revealed the survival rate of 100%, the average duration of surgery of 215 minutes, and no complications in the long term.Conclusion. The diameter of the common bile duct, its wall changes, size of gallstones, signs of cholangitis, patency of the bile papilla, and localization of biliary stricture determine the surgical tactics, when performing biliary reconstruction in patients with non-cancerous obstructive jaundice. In case minimally invasive surgery is found impossible under conditions of multiple choledocholithiasis, common bile duct diameter >15 mm, and preservation of its wall, choledocholithotomy with Kerr drainage is considered to be optimal. In case of damage to the CBD wall and patency of the bile papilla, preference shall be given to hepaticoenterostomy. Bile duct reconstruction with stent drainage is indicated for treatment of cicatricial and iatrogenic biliary strictures.

Feasibility of Endoscopic Ultrasound-Guided Hepaticogastrostomy for Malignant Hilar Biliary Obstruction.

Almost all previous reports on endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) involve malignant distal bile duct strictures. However, the feasibility of EUS-HGS for malignant hilar biliary obstruction (MHBO) remains unclear. This study aimed to evaluate the efficacy and safety of EUS-HGS for MHBO and identify the risk factors associated with technical failure. In this multicenter retrospective study, we reviewed consecutive patients who underwent EUS-HGS between April 2017 and March 2023 at five institutions. We assessed the overall feasibility and efficacy of EUS-HGS for MHBO, including the factors associated with technical failure, using multivariable logistic regression analysis. A total of 85 patients were enrolled (mean age, 72years; 36.4% female). Thirty-six patients (42.3%) had surgically altered anatomy, and 43 (50.6%) underwent biliary stenting by transpapillary or percutaneous biliary drainage before EUS-HGS. The rates of technical success, clinical success, and adverse events were 87.0% (74/85), 76.4% (65/85), and 11.8% (10/85), respectively. Multivariable analysis demonstrated that a bile duct diameter ≤ 4mm was the only independent risk factor for technical failure (odds ratio, 6.12; 95% confidence interval, 1.02-36.6; P = 0.047). The most common reason for technical failure was cholangiography failure (45.4%), followed by inappropriate guidewire position (36.4%). EUS-HGS is a challenging but promising treatment option for MHBO. Patients with a bile duct diameter ≤ 4mm or inappropriate guidewire position should be careful as these factors can lead to the technical failure of EUS-HGS for MHBO.

Safety and efficacy of HK-660S in patients with primary sclerosing cholangitis: A randomized double-blind phase 2a trial.

A clinical unmet need persists for medications capable of modulating the progression of primary sclerosing cholangitis (PSC). This study aimed to assess the clinical feasibility of HK-660S (beta-lapachone) in PSC. In this multicenter, randomized, double-blind, placebo-controlled, parallel-group phase 2 trial, participants were assigned in a 2:1 ratio to receive either 100 mg of HK-660S or a placebo twice daily for 12 weeks. The primary outcomes were the reduction in serum alkaline phosphatase (ALP) levels and the percentage of participants showing improvements in PSC severity, as determined by magnetic resonance cholangiopancreatography (MRCP) with the Anali score. Secondary endpoints included changes in liver stiffness and adverse events. The analysis included 21 patients, 15 receiving HK-660S, and six receiving a placebo. Improvements in the Anali score were observed in 13.3% of the HK-660S group, with no improvements in the placebo group. HK-660S treatment resulted in a 15.2% reduction in mean ALP levels, compared to a 6.6% reduction in the placebo group. A stratified ad-hoc analysis based on baseline ALP levels showed a statistically significant response in the HK-660S group among those with ALP levels greater than twice the upper limit of normal, with a 50% responder rate (p = 0.05). Additionally, 26.7% of the HK-660S group showed improvements in the enhanced liver fibrosis score, with no improvements in the placebo group. HK-660S was generally well-tolerated. HK-660S is well-tolerated among patients with PSC and may improve bile duct strictures, decrease serum ALP levels, and reduce liver fibrosis. (cris.nih.go.kr, Number KCT0006590).

A Case of Hepatocellular Carcinoma with Pseudoaneurysm Rupture after Biliary Stent Placement for Bile Duct Stricture due to Heavy Ion Radiotherapy

A Case of Hepatocellular Carcinoma with Pseudoaneurysm Rupture after Biliary Stent Placement for Bile Duct Stricture due to Heavy Ion Radiotherapy

Implementing Massive Parallel Sequencing into Biliary Samples Obtained through Endoscopic Retrograde Cholangiopancreatography for Diagnosing Malignant Bile Duct Strictures.

Despite advancements in radiologic, laboratory, and pathological evaluations, differentiating between benign and malignant bile duct strictures remains a diagnostic challenge. Recent developments in massive parallel sequencing (MPS) have introduced new opportunities for early cancer detection and management, but these techniques have not yet been rigorously applied to biliary samples. We prospectively evaluated the Oncomine Comprehensive Assay (OCA) and the Oncomine Pan-Cancer Cell-Free Assay (OPCCFA) using biliary brush cytology and bile fluid obtained via endoscopic retrograde cholangiopancreatography from patients with bile duct strictures. The diagnostic performance of MPS testing was assessed and compared to the pathological findings of biliary brush cytology and primary tissue. Mutations in TP53, BRAF, CTNNB1, SMAD4, and K-/N-RAS identified in biliary brush cytology samples were also detected in the corresponding bile fluid samples from patients with extrahepatic cholangiocarcinoma. These mutations were also identified in the bile fluid samples, but with variant allele frequencies lower than those in the corresponding biliary brush cytology samples. In control patients diagnosed with gallstones, neither the biliary brush cytology samples nor the bile fluid samples showed any pathogenic mutations classified as tier 1 or 2. Our study represents a prospective investigation into the role of MPS-based molecular testing in evaluating bile duct strictures. MPS-based molecular testing shows promise in identifying actionable genomic alterations, potentially enabling the stratification of patients for targeted chemotherapeutic treatments. Future research should focus on integrating OCA and OPCCFA testing, as well as similar MPS-based assays, into existing surveillance and management protocols for patients with bile duct strictures.

IgG4 Sclerosing Cholangitis: Entity Rarely Described in Children

IgG4-related sclerosing cholangitis (IgG4-SC) is known in the adult patients as a steroid-responsive biliary disease, frequently associated with autoimmune pancreatitis; The diagnosis of IgG4-SC may be difficult to differentiate from primary sclerosing cholangitis (PSC) or cholangiocarcinoma; This entity is been described in the absence of pancreatic implication. It is defined by high level of serum IgG4 in contrast to primary sclerosing cholangitis. It’is morphologically characterized by dense lymphoplasmacellular infiltration, particularly IgG4+ plasma cells and CD4+ T cells and extensive fibrosis in bile duct. In patients with IgG4-related sclerosing cholangitis, response to steroid therapy is high; in patients with PSC corticosteroid therapy is unsuccessful. An Early recognition of IgG4-SC can save patients from potential harmful and unnecessary surgical interventions. In the literature, cholangiocarcinoma in patients with IgG4- related sclerosing cholangitis was not described, whereas cholangiocarcinoma develops in up to 10-30% of patients with PSC. We present the case of a 3 years old child with features of sclerosing IgG4 cholangitis with asymptomatic elevation in liver enzymes, bile duct strictures on imaging, characteristic pathology findings, elevated serum IgG4, without signs of pancreatic involvement, and excellent response to corticosteroids. Pediatric gastroenterologists and hepatologists, as well as pediatric hepatopathologists, need to be aware of IgG4-SC as a disease entity.

Splenic subcapsular hematoma following endoscopic retrograde cholangiopancreatography: A case report and review of literature

BACKGROUND Splenic injury following endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication. The literature contains around 30 articles reporting various degrees of splenic injuries resulting from ERCP since the first report of splenic rupture after ERCP in 1989. CASE SUMMARY This report describes a case of splenic hematoma and stent displacement in a 69-year-old male patient who developed these conditions 7 days after undergoing ERCP and stenting. The patient had bile duct stenosis caused by a malignant tumor that was obstructing the bile duct. The diagnosis was confirmed by epigastric computed tomography and magnetic resonance cholangiopancreatography. The patient was successfully treated with percutaneous transhepatic cholangial drainage, endoscopic pyloric stent placement, and conservative management. The causes of splenic injury following ERCP are discussed. CONCLUSION ERCP has the potential to cause splenic injury. If a patient experiences symptoms such as abdominal pain, decreased blood pressure, and altered hematology after the procedure, it's important to be thoroughly investigated for postoperative bleeding and splenic injury.

Portal vein stenting blocked the inflow tract and completely resolved bile duct varices, formed by cavernous transformation of the portal vein.

There is no established treatment for bleeding bile duct varices (BDVs). We report the first case of portal vein (PV) stenting completely eradicating bleeding BDVs. A 70-year-old male with malignant lymphoma developed BDVs due to PV obstruction, which had caused compression and stricture of the distal bile duct. Endoscopic retrograde cholangiography was performed to evaluate the stricture and bleeding from the ruptured BDV was observed. Endoscopic hemostasis was difficult, requiring reopening of the extra-hepatic PV and reducing the blood flow to the BDVs for hemostasis. Therefore, PV stenting was performed. During the procedure, portal angiography confirmed an inflow tract to the BDVs. Therefore, covered stents were placed in the PV and adjusted to block the inflow tract to the BDVs at the distal end. After stenting, the BDVs were successfully blocked and all PV blood flowed through the stent placed in the extra-hepatic PV. Two weeks after stenting, the BDVs had disappeared completely and the bleeding has not recurred for months. We experienced a case in which PV stenting not only reopened an obstructed PV but also successfully occluded the inflow tract. This case demonstrates the potential of PV stenting for the treatment of hemorrhagic BDVs.

Effect of surgical complications on outcomes of children with hepatoblastoma: a retrospective cohort study.

This study aimed to investigate the incidence of severe surgical complications among children with hepatoblastoma, identify their risk factors, and evaluate the influence of surgical complications on long-term outcomes. Children with hepatoblastoma who underwent liver resection at our hospital between September 1992 and January 2023 were included in this study. Clinical data were retrospectively reviewed, and patients were categorized into complication and non-complication groups based on the need for radiological or surgical interventions or massive intraoperative blood loss (> 80mL/kg). Out of the 40 patients, 9 experienced severe complications (massive blood loss, n = 7; bile leakage, n = 3; and common bile duct stricture, n = 1). The participation of experienced liver surgeons was significantly greater in the non-complication group than in the complication group. The median duration from surgery to the start of postoperative chemotherapy was significantly shorter in the non-complication group than in the complication group. The overall 5-year survival rate was significantly higher in the non-complication group than in the complication group. Severe surgical complications were associated with a worse prognosis. An experienced liver surgeon should participate in technically demanding liver resections.

Only repeatedly elevated IgG4 levels in primary sclerosing cholangitis may distinguish a particular patient phenotype

BackgroundPrimary sclerosing cholangitis (PSC) is a chronic liver disease leading to inflammation with scaring and strictures of bile ducts, which can lead to liver cirrhosis. A subtype of PSC characterized by high serum IgG4 (sIgG4) levels has been reported to be associated with poor outcomes, but the exact role and the longitudinal development of sIgG4 levels in PSC progression remains to be clarified. The aim of this study was to investigate if subsequent analysis of sIgG4 levels allows the identification of the PSC phenotype with high sIgG4.MethodssIgG4 values were repeatedly analysed in a well-characterized European PSC cohort of 110 individuals. Biochemical parameters, clinical endpoints, death and liver transplantation were compared between PSC subgroups.Results12.7% (n = 14) of PSC patients showed increased sIgG4 levels (PSC-IgG4). The values normalized in 57.1% (n = 8; PSC-IgG4norm) during follow-up measurements, whereas the values remained permanently elevated in 42.9% (n = 6; PSC-IgG4const). Serum values of AP and γGT were significantly higher in PSC-IgG4const compared to PSC-IgG4norm at final blood sampling. Furthermore, mean age at PSC diagnosis was markedly lower in PSC-IgG4const compared to PSC-IgG4norm.ConclusionsThis is the first study analyzing longitudinal development of sIgG4 in PSC. Our data indicate that only sequential determination of sIgG4 levels allow to accurately distinguish between the PSC phenotype with high sIgG4 and PSC with low sIgG4.Graphical abstract

Management of a Portobiliary Fistula and Obstructive Biliopathy in a Split Liver Graft Transplant Recipient Posthepaticojejunostomy with Portal Stent Graft

AbstractBiliary complications following liver transplantations, in the form of bile leak and bile duct strictures, are well recognized. Portobiliary fistulas in the transplant setting are rare, but may cause potentially life-threatening complications. The presented case shows the successful treatment of a hilar portobiliary fistula in a transplanted liver posthepaticojejunostomy with portal vein stent graft followed by biliary drainage with percutaneous hepaticojejunostomy stricture dilatation.

Anastomotic metabolic and bariatric surgeries with same-day discharge: 30-day outcomes of a cohort from a high-volume center in Canada

BackgroundOn the basis of our extensive experience in same-day discharge (SDD) sleeve gastrectomy, we extended this management strategy to anastomotic metabolic and bariatric surgeries (MBS). ObjectivesTo retrospectively analyze early outcomes (≤30 d) after anastomotic MBS with planned SDD (≤12 hr). SettingUniversity Hospital, Canada; Public Practice. MethodsSDD anastomotic MBS were proposed with strict preoperative criteria and included single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S), Roux-en-Y gastric bypass (RYGB), one-anastomosis gastric bypass (OAGB), and single-anastomosis sleeve ileal bypass (SASI). Enhanced recovery after bariatric surgery protocols and post-anesthesia care unit criteria were followed. Unplanned overnight stay, emergency department (ED) visit, readmission, morbidity-mortality, and reintervention rates were analyzed. ResultsSince 2021, 208 patients (191 female and 17 male) have undergone SDD anastomotic MBS, with 76% conversion procedures: 92 SADI-S, 72 RYGB, 35 OAGB, and 9 SASI (mean age = 41.4 yr and mean preoperative body mass index = 41.9 kg/m2). Unplanned overnight stays and ED visits were 4.8% and 4.3%, respectively. Readmission rate was 5.8% (5 SADI-S, 5 RYGB, 1 OAGB, and 1 SASI). Overall morbidity rate was 14.9%, including 3.9% major complications. Within 30 days postoperatively, there were 2 duodenal leaks, 1 intrabdominal collection, 1 common bile duct stenosis, and 1 acute appendicitis in the SADI-S group. There were 2 occlusions on the jejunojejunal anastomosis and 1 bleeding on the gastrojejunal anastomosis in the RYGB group. Five (2.4%) required reintervention with no mortality. ConclusionsWe report low and acceptable rates of unplanned overnight stay, readmission, and reintervention. Early outcomes suggest that SDD anastomotic MBS seems safe and feasible with an experienced team, selective criteria, and appropriate postoperative follow-up.

Long-Term Outcome of Revision Hepaticojejunostomy in Postcholecystectomy Bile Duct Stricture: A Tertiary Center Experience

Long-Term Outcome of Revision Hepaticojejunostomy in Postcholecystectomy Bile Duct Stricture: A Tertiary Center Experience

Three-dimensional visualization technology for guiding one-step percutaneous transhepatic cholangioscopic lithotripsy for the treatment of complex hepatolithiasis.

Biliary stone disease is a highly prevalent condition and a leading cause of hospitalization worldwide. Hepatolithiasis with associated strictures has high residual and recurrence rates after traditional multisession percutaneous transhepatic cholangioscopic lithotripsy (PTCSL). To study one-step PTCSL using the percutaneous transhepatic one-step biliary fistulation (PTOBF) technique guided by three-dimensional (3D) visualization. This was a retrospective, single-center study analyzing, 140 patients who, between October 2016 and October 2023, underwent one-step PTCSL for hepatolithiasis. The patients were divided into two groups: The 3D-PTOBF group and the PTOBF group. Stone clearance on choledochoscopy, complications, and long-term clearance and recurrence rates were assessed. Age, total bilirubin, direct bilirubin, Child-Pugh class, and stone location were similar between the 2 groups, but there was a significant difference in bile duct strictures, with biliary strictures more common in the 3D-PTOBF group (P = 0.001). The median follow-up time was 55.0 (55.0, 512.0) days. The immediate stone clearance ratio (88.6% vs 27.1%, P = 0.000) and stricture resolution ratio (97.1% vs 78.6%, P = 0.001) in the 3D-PTOBF group were significantly greater than those in the PTOBF group. Postoperative complication (8.6% vs 41.4%, P = 0.000) and stone recurrence rates (7.1% vs 38.6%, P = 0.000) were significantly lower in the 3D-PTOBF group. Three-dimensional visualization helps make one-step PTCSL a safe, effective, and promising treatment for patients with complicated primary hepatolithiasis. The perioperative and long-term outcomes are satisfactory for patients with complicated primary hepatolithiasis. This minimally invasive method has the potential to be used as a substitute for hepatobiliary surgery.