Treatment Of Benign Biliary Strictures Research Articles

Covered self-expandable metal stents for benign biliary tract diseases

Benign biliary diseases are often managed endoscopically using plastic stents. Benign biliary strictures (BBS) respond to placement of multiple large-bore plastic stents, though requiring multiple procedures to place stents, and to exchange stents to prevent and/or treat stent occlusion. Bile leaks close using plastic stents, which divert bile away from the leak into the duodenum. Covered self-expandable metal stents (CSEMS), intended for palliation of malignant biliary obstruction, have been used to treat benign biliary diseases. Advantages include small predeployment and large postexpansion diameters. Lack of imbedding of the metal into the bile duct wall enables removability. For strictures, one CSEMS is inserted without need for dilation and remains in place for up to 6 months. Successful removal has been reported in all cases. Long-term stricture resolution is achieved in up to 92%. Adverse events include migration and new stricture formation. For treatment of complex bile leaks, the covering and large diameter allow successful closure in nearly all cases. Other uses of CSEMS include treatment of postsphincterotomy bleeding and closure of perforations. CSEMS show promise for treatment of BBS and complex biliary leaks. Successful resolution can be achieved in the majority of patients with the advantage of fewer procedures, which offsets their higher cost.

Temporary Placement of Retrievable Fully Covered Metallic Stents versus Percutaneous Balloon Dilation in the Treatment of Benign Biliary Strictures

Purpose To compare retrospectively percutaneous transhepatic primary placement of a retrievable self-expanding metallic stent with percutaneous balloon dilation for the treatment of benign biliary strictures. Materials and Methods From 2005–2009, 66 patients with benign biliary strictures in whom an endoscopic approach failed or in whom such an approach was inaccessible were evaluated. Of 66 patients, 31 underwent balloon dilation, and 35 underwent temporary metallic stent placement. The etiologies of the benign strictures were anastomotic stricture after surgery (n = 54), stricture secondary to intraoperative injury (n = 9), inflammatory stricture (n = 2), and stricture secondary to trauma (n = 1). Results The primary patency rates were significantly better in the stent group (87% at 3 years) than in the balloon group (44% at 3 years; P = .022). The indwelling period of percutaneous transhepatic biliary drainage (PTBD) catheters after the initial procedure was able to be significantly reduced in the stent group (median 2.5 months) compared with the balloon group (median 4.5 months; P = .001). Significant bleeding (associated with PTBD) occurred in one patient in the balloon group. In the stent group, stent migration occurred in two patients, and one patient underwent surgery for stent removal after failure of removal under fluoroscopic guidance. Conclusions Percutaneous primary placement of a retrievable self-expanding metallic stent showed superior intermediate-term results compared with percutaneous balloon dilation for the treatment of benign biliary strictures. In addition, the indwelling period of PTBD catheters can be significantly reduced using temporary stent placement.

Mo1498 A Long Term Results (Up to 5 Years) of a Prospective Randomized Analysis of Plastic Versus Covered Self-Expandable Metal Stent in Patients With Post-Surgical Stricture

Mo1498 A Long Term Results (Up to 5 Years) of a Prospective Randomized Analysis of Plastic Versus Covered Self-Expandable Metal Stent in Patients With Post-Surgical Stricture

Mo1450 Feasibility and Safety of Temporary Placement of a Fully Covered Self Expandable Metal Stent for Treatment of Benign Biliary Strictures Due to Chronic Pancreatitis: A Multi-Center Experience

Mo1450 Feasibility and Safety of Temporary Placement of a Fully Covered Self Expandable Metal Stent for Treatment of Benign Biliary Strictures Due to Chronic Pancreatitis: A Multi-Center Experience

Mo1497 The First Prospective, Group Sequential Study Evaluating a New Type of Fully Covered Self Expandable Metal Stent for the Treatment of Benign Biliary Strictures

Fully-covered self expandable metal stents (fcSEMS) are an alternative for progressive plastic stenting to treat benign biliary strictures (BBS)and might reduce patient burden and costs. Key to this novel treatment is a safe stent removal.

Abstract No. 64: The endpoint of percutaneous treatment of benign biliary strictures: Manometric perfusion test

Abstract No. 64: The endpoint of percutaneous treatment of benign biliary strictures: Manometric perfusion test

Temporary Placement of Stent Grafts in Postsurgical Benign Biliary Strictures: a Single Center Experience

ObjectiveTo evaluate the effect of temporary stent graft placement in the treatment of benign anastomotic biliary strictures.Materials and MethodsNine patients, five women and four men, 22-64 years old (mean, 47.5 years), with chronic benign biliary anastomotic strictures, refractory to repeated balloon dilations, were treated by prolonged, temporary placement of stent-grafts. Four patients had strictures following a liver transplantation; three of them in bilio-enteric anastomoses and one in a choledocho-choledochostomy. Four of the other five patients had strictures at bilio-enteric anastomoses, which developed after complications following laparoscopic cholecystectomies and in one after a Whipple procedure for duodenal carcinoma. In eight patients, balloon-expandable stent-grafts were placed and one patient was treated by insertion of a self-expanding stent-graft.ResultsIn the transplant group, treatment of patients with bilio-enteric anastomoses was unsuccessful (mean stent duration, 30 days). The patient treated for stenosis in the choledocho-choledochostomy responded well to consecutive self-expanding stent-graft placement (total placement duration, 112 days). All patients with bilio-enteric anastomoses in the non-transplant group were treated successfully with stent-grafts (mean placement duration, 37 days).ConclusionTreatment of benign biliary strictures with temporary placement of stent-grafts has a positive effect, but is less successful in patients with strictures developed following a liver transplant.

347e: Temporary Placement of Covered Self-Expandable Metal Stents (CSEMS) in Benign Biliary Strictures (BBS): Eight Years of Experience

Benign biliary strictures (BBS) have been endoscopically managed with placement of multiple plastic stents. Uncovered metal stents have been associated with mucosal hyperplasia and long term data on covered self-expandable metal stents (CSEMS) are still lacking in BBS. We report the efficacy and complication rates of CSEMS in the treatment of BBS.

S1467: Self-Expandable, Removable, Fully Covered Metal Stents to Dilate Common Bile Duct Strictures Secondary to Chronic Pancreratitis: Preliminary Results

Hepaticojejunostomy(H-J) is the standard treatment of benign biliary strictures(BBS) due to chronic pancreatitis(CP). Self-expandable metal stents(SEMS) may represent a medium-term solution in pts with CP-related BBS who refuse surgery or are poor surgical candidates.

T1565: A Prospective, Group Sequential Study Evaluating a New Type of Fully Covered Self Expandable Metal Stent With a Proximal Retrieval Lasso for the Treatment of Benign Biliary Strictures

T1565: A Prospective, Group Sequential Study Evaluating a New Type of Fully Covered Self Expandable Metal Stent With a Proximal Retrieval Lasso for the Treatment of Benign Biliary Strictures

S1442: Fully Covered Self-Expandable Metal Stents (CSEMS) With Fins for Anastomotic Strictures Following Liver Transplantation: Long Term Analysis

Biliary complications following liver transplantation (LT) are a major source of morbidity, occurring in up to 15% of recipients. In current practice, plastic stents are typically used to manage post LT complications. However, metal stents have shown promise for treatment of benign biliary strictures. We report the long term efficacy and safety of using fully covered self expanding metal stent (CSEMS) with fins for the treatment of anastomotic strictures following LT.

T1529: Treatment of Benign Distal Biliary Strictures With Fully Covered Self-Expanding Metallic Stents

ERCP insertion of multiple plastic stents has been the standard of treatment for benign biliary strictures (BBS). Reports on the use of biliary self-expanding metallic stents (SEMS), either partially covered or fully covered (FCSEMS) are increasing. We present our initial experience with the new fully covered Wallflex® biliary SEMS (Boston Scientific, Natick, Mass) to treat several distal BBS.

Placement of removable metal biliary stent in post-orthotopic liver transplantation anastomotic stricture

Postoperative biliary strictures are the most common cause of benign biliary stricture in Western countries, secondary to either operative injury or bile duct anastomotic stricture following orthotopic liver transplantation (OLT). Surgery or endoscopic interventions are the mainstay of treatment for benign biliary strictures. We aim to report the outcome of 2 patients with refractory anastomotic biliary stricture post-OLT, who had successful temporary placement of a prototype removable covered self-expandable metal stent (RCSEMS). These 2 patients (both men, aged 44 and 53 years) were given temporary placement of a prototype RCSEMS (8.5 Fr gauge delivery system, 8 mm x 40 mm stent dimensions) in the common bile duct across the biliary stricture. There was no morbidity associated with stent placement and removal in these 2 cases. Clinical parameters improved after the RCSEMS placement. Long-term biliary patency was achieved in both the patients. No further biliary intervention was required within 14 and 18 mo follow-up after stent removal.

Plastic or metal stents for benign extrahepatic biliary strictures: a systematic review

BackgroundBenign biliary strictures may be a consequence of surgical procedures, chronic pancreatitis or iatrogenic injuries to the ampulla. Stents are increasingly being used for this indication, however it is not completely clear which stent type should be preferred.MethodsA systematic review on stent placement for benign extrahepatic biliary strictures was performed after searching PubMed and EMBASE databases. Data were pooled and evaluated for technical success, clinical success and complications.ResultsIn total, 47 studies (1116 patients) on outcome of stent placement were identified. No randomized controlled trials (RCTs), one non-randomized comparative studies and 46 case series were found. Technical success was 98,9% for uncovered self-expandable metal stents (uSEMS), 94,8% for single plastic stents and 94,0% for multiple plastic stents. Overall clinical success rate was highest for placement of multiple plastic stents (94,3%) followed by uSEMS (79,5%) and single plastic stents (59.6%). Complications occurred more frequently with uSEMS (39.5%) compared with single plastic stents (36.0%) and multiple plastic stents (20,3%).ConclusionBased on clinical success and risk of complications, placement of multiple plastic stents is currently the best choice. The evolving role of cSEMS placement as a more patient friendly and cost effective treatment for benign biliary strictures needs further elucidation. There is a need for RCTs comparing different stent types for this indication.

IS THE BILIARY MANOMETRIC PERFUSION TEST EFFECTIVE IN THE EVALUATION OF BALLOON DILATATION TREATMENT SUCCESS OF BENIGN BILIARY STRICTURES?

The success of balloon dilatation treatment of benign biliary strictures (BBS) is usually evaluated by 'clinical test'. For objective evaluation of treatment success, measurement of the pressure inside the biliary tree after treatment has been proposed. The aim of this article is to assess the role of biliary manometric perfusion test (BMPT) in the evaluation of treatment success of BBS and to assess the long term biliary patency after evaluation by BMPT. From February 2003 to January 2008, 12 patients (median age 53.5 years) after balloon dilatation treatment were evaluated by BMPT. BMPT was done after a mean of 3 dilatations over a mean period of 6.85 months. An intrabiliary pressure less than 20 cm of water during the test was considered as success threshold. The pressures during BMPT were less than 20 cm of water in 11 out of 12 patients. Subsequently the drain was removed and patients were followed up clinically. Two patients on follow-up required re-intervention 13 days and 11 months later. The remaining 9 patients had no evidence of biliary obstruction at a mean following of 15.3 months. Using the statistical Kaplan-Meier analysis, the probability of biliary patency up to 9 months was 90.9% and at 1, 2 and 3 years was 77%. BMPT is effective in the evaluation of treatment success of BBS. It is simple, cost effective, gives immediate results and helps us to determine the treatment end point.

BILIARY MANOMETRIC PERFUSION TEST IN THE EVALUATION OF BENIGN BILIARY STRICTURE TREATMENT - A CASE REPORT

Benign biliary strictures treated radiologically by percutaneous dilatation treatment are usually evaluated by 'clinical test'. For objective evaluation of treatment success, measurement of the pressure inside the biliary tree has been proposed. The aim of this article is to report our experience with the measurement of the pressure in the biliary tree after treatment, to present the biliary manometric perfusion test (BMPT) as an alternative method of treatment evaluation and to demonstrate why the perfusion test is a better method of evaluation. A 65 year old lady with post operative biliary stricture and symptoms of jaundice was treated in our Department with percutaneous dilatation treatment and long-term drainage. The perfusion test (BMPT) was adopted for evaluating treatment success after the treatment for 9 months. An intrabiliary pressure less than 20 cms of water during perfusion test was considered success threshold. The test was carried out without any complications and the pressure inside the biliary tree was less than 20 cms of water during the test. Eventually the drain was removed. On follow-up at 6 months the patient developed no recurrence of jaundice and the quality of life improved clinically. Periodic liver function tests during follow-up were normal. The perfusion test (BMPT) is promising efficacious alternative method for the evaluation of radiological treatment of benign biliary strictures. It helps us to decide the end points in treatment and also helps in identifying patients who might later develop strictures.

Retrievable Biliary Stent-Graft in the Treatment of Benign Biliary Strictures

To investigate the technical and clinical efficacy of a retrievable stent-graft in the treatment of benign biliary strictures. From February 2004 to December 2006, 29 patients with 32 benign biliary strictures (17 patients with 18 chronic cholangitis strictures and 12 with 14 postoperative strictures) were enrolled in this study. Twenty-four patients had 26 recurrent strictures despite prolonged catheter interposition after balloon dilation procedures. Five patients with six strictures had not previously undergone interventional treatment. A total of 36 stent-grafts were placed, and all stent-grafts were removed by means of a percutaneous route or via a T-tube 6.7 weeks (range, 2-10 weeks) after stent-graft placement. The retrievable stent-grafts were successfully placed and removed in all cases. Migration occurred in four of the 36 (11%) stent-grafts (11%). Immediately after stent-graft removal, all strictures were widened significantly. From 2 days to 8 weeks after removal, 29 of 32 lesions (91%) remained patent with or without recurrence of minimal strictures. During the mean follow-up of 27.9 months (range, 9-34 months), none of the 29 lesions had recurrence of clinically significant strictures. The primary patency rate was 90.6%. Three additional stent-graft placements for recurrent stricture were required in three lesions (9.4%). During a mean follow-up of 13.3 months (range, 9-16 months), two patients had no evidence of biliary obstruction. The secondary patency rate and clinical success rate was 97% (31 of 32 lesions). The placement and removal of a retrievable stent-graft in the treatment of benign biliary strictures is technically feasible and appears to be a clinically effective method.

Long-term Outcome of Percutaneous Transhepatic Therapy for Benign Bilioenteric Anastomotic Strictures

To evaluate the long-term outcomes of a percutaneous transhepatic approach in benign bilioenteric anastomoses with calibration of the stenosis to 15 F and extended internal/external drainage. Between February 2000 and May 2007, the efficacy of this percutaneous transhepatic procedure was retrospectively studied in 39 patients with benign postoperative bilioenteric anastomotic strictures. The main purpose of the protocol was to repair the anastomosis by calibration of the stenosis to 15 F with a silicone drain and perform internal/external drainage for at least 1 year. The follow-up period ranged from 12 to 65 months (mean, 34.4 months), and outcomes were classified according to the patient's clinical symptoms and laboratory parameters and the need for further interventions. The procedure was successful in 38 of 39 patients. Four patients were lost to follow-up during or after drainage. The duration of drainage (41 internal catheters in 34 patients) ranged from 126 days to 488 days (mean, 346 d). Twenty-seven patients had positive outcomes during the mean follow-up of 34 months, and six patients had negative outcomes. The bile duct patency probability according to the Kaplan-Meier method was and 70.6% at 34 months after drain removal. Percutaneous treatment of benign biliary strictures with calibrated stent implantation and extended drainage has good long-term results and may be an effective alternative to surgery. Advantages over surgery are its minimal invasiveness and reduced risk of complications.

PERCUTANEOUS TREATMENT OF BENIGN BILIARY STRICTURES AND BILIARY MANOMETRIC PERFUSION TEST

Benign biliary strictures are usually treated surgically or endoscopically. When these strictures are not accessible by endoscope or when open repair is not possible, percutaneous dilatation treatment is indicated. The efficacy of treatment is usually evaluated by clinical trial which includes leaving a small non-functional catheter in situ and following liver function tests. The evaluation may be effectively done by the biliary manometric perfusion test. The aim of this paper is to emphasize the importance of percutaneous dilatation treatment of benign biliary strictures with focus on the role of the biliary manometric perfusion test and its future prospects. Based on the literature and our own experience, this article gives a short overview of percutaneous treatment of benign biliary strictures, indications, techniques, complications and results. The treatment of these strictures has an overall success rate between 60 to 90%. This article also explains the biliary manometric test, the technique and its importance in evaluation of treatment success. Benign biliary strictures of the hepatic duct junction or bilio-enteric anastomosis are difficult to treat surgically and are endoscopically inaccessible. Percutaneous treatment by balloon dilatation and long term external-internal drainage is feasible in the majority of these patients. It is minimally invasive, safe and effective. The evaluation of the treatment success may be more effectively done by the manometric perfusion test. It is easy, reliable, less time-consuming giving immediate results, and relatively safe.

Percutaneous Transhepatic Use of a Cutting Balloon in the Treatment of a Benign Common Bile Duct Stricture

Benign biliary strictures (BBS) are difficult to treat. The majority of them are treated either endoscopically or using percutaneous techniques either with stents or conventional angioplasty balloons. To our knowledge we present the first case of use of a cutting balloon in the treatment of BBS through a percutaneous approach.