Treatment Of Biliary Strictures Research Articles

Harnessing magnetic forces: Discovery and development of biliary strictures treatment with compression anastomosis

Magnetic compression anastomosis (MCA) is emerging as a promising alternative that uses magnetic force to create an anastomosis bypassing the stenosis in biliary strictures (BSs) where techniques such as percutaneous transhepatic biliary drainage and endoscopic retrograde cholangiopancreatography with stent placement are inadequate in the presence of complete obstruction or severe stenosis. MCA offers potential benefits such as less operative trauma, shorter hospital stay and lower complication rates. By placing magnets proximal and distal to the stenosis, necrosis of fibrotic tissue occurs, creating a new anastomosis. Investigating the role of MCA in the treatment of BS is crucial because of its potential to revolutionize care, improve outcomes and reduce healthcare costs. It offers an alternative for patients who are not suitable for conventional surgery. A comprehensive review of the principles, techniques, outcomes and applications of MCA is essential to inform clinicians, researchers and policy makers and to guide future research and clinical practice to optimize patient care for BSs.

Research progress on biliary stents

Bile duct stenosis is a common condition in gastroenterology and hepatobiliary surgery and can be divided into benign stenosis and malignant stenosis according to different etiologies. The implantation of a gall stent into the site of the stenosis or obstruction is currently an important means of treating the bile duct stenosis. Biliary stents encompass two main types: plastic stents and metal stents. In recent years, biodegradable biliary stents and drug-eluting stents have also emerged. The material and structure of biliary stents have an important influence on their performance. In this paper, the research progress on biliary stent implantation technology in the treatment of biliary stenosis is reviewed. Besides, the advantages and disadvantages of biliary stents made from different materials and structures, along with their respective indications are summarized, and the development trend of degradable biliary stents is prospected.

Peroral Cholangioscopy in the Diagnosis and Treatment of Biliary Strictures

Objective: To determine the role of and indications for peroral cholangioscopy using the SpyGlass system in the differential diagnosis of biliary tract lesions and in case of biliary strictures, based on the literature data analysis and our own experience.Materials and methods: Peroral cholangioscopy is mainly used for the differential diagnosis of biliary tract lesions. During peroral cholangioscopy, we carefully consider gross signs of damage to the bile duct mucosa: abnormal capillary vascular pattern, granulation tissue and other types of proliferation, palpatory characteristics of the wall. Morphology should also be verified during image-guided intraductal forceps biopsy.Results: Peroral endoscopy of the biliary tract significantly increases the effectiveness of differential diagnosis between various types of biliary strictures.Direct examination of the bile duct mucosa with optical forceps biopsy and morphological verification increases the sensitivity and specificity of stricture type determination up to 83.3%–96% and 90.9%–99%, respectively. The diagnostic value of peroral cholangioscopy in the diagnosis of malignant and benign biliary tract lesions exceeds the effectiveness of endoscopic retrograde cholangiopancreatography, even with fluoroscopy-guided verification of ducts.Conclusions: Peroral cholangioscopy with its enormous potential plays an important role in management of patients with various diseases of the bilio-pancreatoduodenal area, including biliary strictures. We formulated key indications for peroral cholangioscopy based on the literature data analysis and our own experience with this technique in patients with bile duct pathology, including nondifferentiated biliary strictures.

Biliary stricture after major hepatectomy with bile duct resection: incidence and risk factors

Background: An understanding of the incidence and treatment of biliary stricture after major hepatectomy (MH) with bile duct resection (BDR) is limited by small-volume series and/or lack of long-term follow-up. The aim of this study was to evaluate the incidence, risk factors, and treatment strategy of biliary stricture after MH with BDR. We hypothesized that biliary stricture after MH with BDR is more common than previously appreciated and is successfully managed with percutaneous interventions.

Feasibility and Safety of ERCP in the Treatment of Biliary Strictures after Liver Transplantation: With a Report of 37 Cases.

Background Liver transplantation (LT) is an effective treatment option for patients with end-stage liver disease; biliary complications are important cause of death in posttransplant patients. Endoscopic retrograde cholangiopancreatography (ERCP) has an irreplaceable role in the diagnosis and treatment of patients with biliary tract disease. Methods The clinical data of patients with biliary strictures (BS) after LT treated with ERCP admitted to the Third Xiangya Hospital of Central South University from September 2016 to October 2021 were reviewed; the changes in temperature, bilirubin, and albumin before and after treatment and postoperative complications were analyzed. Results A total of 41 patients were included in the study, and biliary stents were successfully placed in 37 cases (90.2%), while 4 cases (9.8%) were unsuccessful due to complete BS. Patients with ERCP guided biliary stenting had a significant improvement in bilirubin index compared to the preoperative period (P < 0.05). 27 patients (73.0%) had complete relief of symptoms after 1 ERCP-guided treatment, and 10 patients (27.0%) developed BS again at different times after the first ERCP treatment, among which 8 patients developed BS again within 1 year after the first treatment and 2 patients developed BS again after 1 year after the first treatment. The incidence of endoscopy-related adverse events was 35.14%, with no serious adverse events. Conclusion ERCP-guided biliary stenting was an effective and safety treatment for BS after LT.

Digital single-operator cholangioscopy for biliary stricture after cadaveric liver transplantation.

BACKGROUNDBiliary strictures after liver transplantation (LT) remain clinically arduous and challenging situations, and endoscopic retrograde cholangiopancreatography (ERCP) has been considered as the gold standard for the management of biliary strictures after LT. Nevertheless, in the treatment of biliary strictures after LT with ERCP, many studies show that there is a large variation in diagnostic accuracy and therapeutic success rate. Digital single-operator peroral cholangioscopy (DSOC) is considered a valuable diagnostic modality for indeterminate biliary strictures.AIMTo evaluate DSOC in addition to ERCP for management of biliary strictures after LT.METHODSNineteen patients with duct-to-duct biliary reconstruction who underwent ERCP for suspected biliary complications between March 2019 and March 2020 at Beijing Chaoyang Hospital, Capital Medical University, were consecutively enrolled in this observational study. After evaluating bile ducts using fluoroscopy, cholangioscopy using a modern digital single-operator cholangioscopy system (SpyGlass DS™) was performed during the same procedure with patients under conscious sedation. All patients received peri-interventional antibiotic prophylaxis. Biliary strictures after LT were classified according to the manifestations of choledochoscopic strictures and the manifestations of transplanted hepatobiliary ducts.RESULTSTwenty-one biliary strictures were found in a total of 19 patients, among which anastomotic strictures were evident in 18 (94.7%) patients, while non-anastomotic strictures in 2 (10.5%), and space-occupying lesions in 1 (5.3%). Stones were found in 11 (57.9%) and loose sutures in 8 (42.1%). A benefit of cholangioscopy was seen in 15 (78.9%) patients. Cholangioscopy was crucial for selective guidewire placement prior to planned intervention in 4 patients. It was instrumental in identifying biliary stone and/or loose sutures in 9 patients in whom ERCP failed. It also provided a direct vision for laser lithotripsy. A space-occupying lesion in the bile duct was diagnosed by cholangioscopy in one patient. Patients with biliary stricture after LT displayed four types: (A) mild inflammatory change (n = 9); (B) acute inflammatory change edema, ulceration, and sloughing (n = 3); (C) chronic inflammatory change; and (D) acute suppurative change. Complications were seen in three patients with post-interventional cholangitis and another three with hyperamylasemia.CONCLUSIONDSOC can provide important diagnostic information, helping plan and perform interventional procedures in LT-related biliary strictures.

Treatment of biliary stenosis using percutaneous transhepatic cholangiobiopsy with biopsy forceps of varying diameter.

The present study aimed to compare the clinical results and pathological diagnostic quality of percutaneous transhepatic cholangiobiopsy for biliary obstruction using biopsy forceps (BFs) of varying diameter. A total of 57 patients with obstructive jaundice who underwent percutaneous transhepatic cholangiobiopsy and drainage with 1 of 2 BFs diameters (6.0-mm BFs, n=30; 4.5-mm BFs, n=27) between February 2018 and May 2019 were retrospectively assessed. BFs were compared in terms of their sample quality, diagnostic accuracy, sensitivity, specificity, number of passes, and complication rate. All 57 patients underwent the procedure successfully and the technical success rate was 100%. The 6.0- and 4.5-mm BFs demonstrated a diagnostic accuracy of 80% (24/30) and 85% (23/27), respectively (P=0.733), and a sensitivity of 78% (22/28) and 86% (22/26), respectively (P=0.729). The specificity of both the 6.0- and 4.5-mm BFs was 100%. The complication rate was 10% (3/30) with the 6.0-mm BFs and 19% (5/27) with the 4.5-mm BFs (P=0.456). The mean number of biopsies was 2.9±0.6 with the 6.0-mm BFs compared with 3.6±1.0 with the 4.5-mm BFs (P<0.001). The 6.0-mm BFs provided a larger biopsy size and a less crushed specimen compared with the 4.5-mm BFs. The overall tissue scores were 5.2±0.8 with 6.0-mm BFs and 4.5±1.0 with 4.5-mm BFs (P=0.012). There was no statistically significant difference in the clinical results between the 2 BFs in the context of percutaneous transhepatic cholangiobiopsy. Superior samples were obtained using the 6.0-mm BFs, with a fewer number of passes. The complication rate did not increase compared with the 4.5-mm BFs.

New anti-reflux plastic stent to reduce the risk of stent-related cholangitis in the treatment of biliary strictures.

BACKGROUNDThere is little data available on the role of new anti-reflux plastic stents (ARPSs). AIMTo compare the use of ARPSs with that of traditional plastic stents (TPSs) for patients with biliary strictures.METHODSConsecutive patients with biliary strictures who underwent first endoscopic biliary stenting between February 2016 and May 2019 were included. The onset of stent-related cholangitis, stent patency, clinical success, and other adverse events were evaluated.RESULTSSixty-seven patients in the ARPS group and 66 patients in the TPS group were included in the final analyses. Fewer patients experienced stent-related cholangitis in the ARPS group than that in the TPS group (8 patients vs 18 patients; P = 0.030). The median time till the onset of first stent-related cholangitis was later in the ARPS group than that in the TPS group (128.5 d vs 76 d; P = 0.039). The cumulative median stent patency in the ARPS group was 185 d, which was significantly longer than that in the TPS group (133 d; P = 0.001). The clinical success rates and other adverse events did not significantly differ between both groups.CONCLUSIONPlacement of new ARPS might be a safe and effective optional therapeutic strategy to reduce the risk of stent-related cholangitis and prolong stent patency.

Feasibility of balloon-based endobiliary radiofrequency ablation under cholangioscopy guidance in a swine model

Although endobiliary radiofrequency ablation (RFA) has demonstrated considerable potential for the treatment of biliary strictures, conventional catheter RFA has several limitations. This study aimed to evaluate the feasibility of a novel cholangioscopy (CS)-guided balloon-based RFA procedure in vivo using a swine model. CS-guided balloon-RFA was performed under endoscopic retrograde cholangiography guidance at target temperatures of 60 ℃ or 70 ℃, which were maintained for 60 s. We evaluated the technical feasibility, adverse events, and histological effects associated with the procedure. Twelve sites were ablated in seven miniature pigs. The CS-guided balloon-RFA procedure was technically successful in all cases without any hindrance. Mucosal changes could be detected during RFA, and the ablation area was identified on CS. Necropsy was performed in four pigs on the same day as the procedure: the tissue samples showed coagulative necrosis, and the entire internal circumference of the bile duct was uniformly ablated. The mean lengths of the ablation area in the samples ablated at 60 °C and 70 °C were 20.64 and 22.18 mm, respectively, while the mean depths were 3.46 and 5.07 mm, respectively. The other three pigs were reared and euthanized and autopsied 35 days after the procedure. The site to be ablated had replaced the granulation tissue and fibrotic changes. No adverse events were observed in any case. CS-guided balloon-RFA appears to be a promising option for treating biliary strictures. This preliminary study could pave the way for the evaluation of this procedure in future human clinical trials.

Research Progress of Antibacterial Biliary Stent

Biliary stent has been widely used in the treatment of biliary stricture and obstruction, it can relieve the pain of patients effectively, but bacterial infection and stent obstruction are still troublesome after surgery. We introduce the mechanism of infection and stent blockage caused by bacterial invasion after biliary stent implantation, and expound the formation mechanism of bacterial biofilm and bile sludge in this review. Antibacterial biliary stent is an effective way to inhibit biliary tract infection, the literatures on antibacterial modification of biliary stent with different antibacterial methods in domestic and abroad are reviewed, and the research prospect of antibacterial biliary stent is summarized and prospected.

PTBD in the Treatment of Biliary Stricture after Liver Transplantation

PTBD in the Treatment of Biliary Stricture after Liver Transplantation

Benign Bile Duct Strictures

Bile duct strictures can prove to be an extremely difficult diagnostic problem. The majority of Benign bile duct strictures (80%) are unfortunately iatrogenic, the injury occurring after a routine laparoscopic (incidence 0.4-0.6%) or open (incidence 0.2-0.3%) cholecystectomy. The existence of a number of anatomical variations add to the incidence of biliary injury either in isolation or with associated vascular injury. There are also a number of other causes of both iatrogenic and non-iatrogenic causes of benign bile duct strictures. Improved imaging modalities have aided the recognition of the anatomical extent of the stricture and in planning the treatment. Classification of bile duct injury was described by Bismuth in 1982, further modifications were described by Strasberg in 1995. Associated vascular injuries were classified both by Stewart-Way and Bektas et al in the Hannover Classification in 2007. Treatment of biliary stricture depends on the time of diagnosis and type of final injury. While surgery provides the mainstay of treatment, certain select conditions may lend themselves to endoscopic therapy and interventional therapy.

PTBD in the Treatment of Biliary Stricture after Liver Transplantation

The purpose is to evaluate effectivity and influence on hepatic function indexes of percutaneous transhepatic biliary drainage (PTBD) in the treatment of biliary stricture after liver transplantation. Twenty-six patients with biliary stricture after liver transplantation were selected as the subjects. Hepatic function indexes such as albumin, direct bilirubin, glutamate transaminase, andγ-glutamyl transpeptidase(y-GT) were compared before and after the PTBD. There was significant difference between pre-procedure and post-procedure albumin value (P < 0.05). Most of patients (21/26) showed improvement of direct bilirubin, glutamate transaminase, and y-GT, and relief of obstructive jaundice symptoms. PTBD shows good effectivity of relieving obstructive jaundice symptoms and reducing hepatic function indexes in patients with biliary stricture after liver transplantation. However, the decrease of albumin should also be concerned.

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.

Predicting Efficacy of Plastic Stents for Posttransplantation Biliary Strictures.

Biliary strictures (BS) are a common complication of liver transplantation. The standard treatment is sequential insertion of increasing numbers of plastic stents by endoscopic retrograde cholangiopancreatography (ERCP). Despite high success rates, some strictures fail to resolve and require surgery as definitive treatment. To identify predictors of response or failure of standard endoscopic treatment, allowing earlier referral to alternative modalities when needed and avoiding unnecessary procedures. Database of Gastroenterology Department at Tel Aviv Medical Center was retrospectively reviewed, and data regarding patients who underwent liver transplantation and developed BS were analyzed. Thirty-one patients met the study criteria. Twenty-four (77.4%) resolved with plastic stenting and 7 ultimately required surgery. There were no significant differences between stent responders and nonresponders regarding demographics, transplant and postoperative hospitalization data, time from transplantation to presentation with stricture, total number of ERCP sessions, or maximal number of stents.A trend toward difference was noted in the time elapsed between the first and the second ERCP, whereby ERCP nonresponders required a second procedure sooner than responders. Patients presenting to their second procedure as scheduled ultimately had a 95% endoscopic success rate, whereas those presenting urgently with acute cholangitis had a 55% failure rate (P=0.02). Urgent repeat ERCP is a harbinger of ultimate failure of plastic stent treatment for BS after liver transplant. This finding may assist earlier triage of these patients toward alternative treatment such as metal stents or surgery, thus sparing needless procedures and complications.

Treatment of Biliary Stricture After Live Donor Liver Transplantation With Combined Metal and Plastic Stent Insertion: A Feasibility and Safety Study.

Fully covered self-expandable metal stents (Fc-SEMSs) have a challenging use in the treatment of anastomosis strictures after live donor liver transplantation (LDLT) because they can occlude secondary branch biliary ducts when placed above the biliary bifurcation. In this study, we evaluated the technical feasibility and safety of combining Fc-SEMSs with plastic stent(s) inserted to the secondary branch biliary ducts for the treatment of anastomosis stricture after LDLT. The study group included 22 patients (12 men, aged 51±11 years) with anastomotic biliary stricture after LDLT. A Fc-SEMS, 8 to 10 mm in diameter, was inserted to the straight, dilated main duct and plastic stent(s) were inserted to the secondary branches to avoid their occlusion. Stents were left in place for 2 months and removed with a stent retrieving forceps. Technical feasibilities, including technical success, successful removal, and adverse events of this novel strategy, were evaluated. Fc-SEMSs were successfuly deployed and removed in all of the cases. Three (13.6%) patients had pain requiring intravenous analgesia and Fc-SEMS had to be removed because of unbearable pain in one of them. Three (13.6%) patients developed cholangitis due to occlusion of unrecognized secondary branch biliary ducts. Primary stricture resolution rate was achieved in 17 (89.5%) of 19 patients. Recurrence was observed in 3 (17.6%) patients after a mean follow-up duration of 154.3±52.6 (range, 104-304) days. Combination of Fc-SEMS and plastic stent(s) is technically feasible and safe for the treatment of anastomotic biliary strictures after LDLT.

Biliary-duodenal anastomosis using magnetic compression following massive resection of small intestine due to strangulated ileus after living donor liver transplantation: a case report

BackgroundDespite the improvements of surgical techniques and postoperative management of patients with liver transplantation, biliary complications are one of the most common and important adverse events. We present a first case of choledochoduodenostomy using magnetic compression following a massive resection of the small intestine due to strangulated ileus after living donor liver transplantation.Case presentationThe 54-year-old female patient had end-stage liver disease, secondary to liver cirrhosis, due to primary sclerosing cholangitis with ulcerative colitis. Five years earlier, she had received living donor liver transplantation using a left lobe graft, with resection of the extrahepatic bile duct and Roux-en-Y anastomosis. The patient experienced sudden onset of intense abdominal pain. An emergency surgery was performed, and the diagnosis was confirmed as strangulated ileus due to twisting of the mesentery. Resection of the massive small intestine, including choledochojejunostomy, was performed. Only 70 cm of the small intestine remained. She was transferred to our hospital with an external drainage tube from the biliary cavity and jejunostomy. We initiated total parenteral nutrition, and percutaneous transhepatic biliary drainage was established to treat the cholangitis. Computed tomography revealed that the biliary duct was close to the duodenum; hence, we planned magnetic compression anastomosis of the biliary duct and the duodenum. The daughter magnet was placed in the biliary drainage tube, and the parent magnet was positioned in the bulbus duodeni using a fiberscope. Anastomosis between the left hepatic duct and the duodenum was accomplished after 25 days, and the biliary drainage stent was placed over the anastomosis to prevent re-stenosis. Contributions to the successful withdrawal of parenteral nutrition were closure of the ileostomy in the adaptive period, preservation of the ileocecal valve, internal drainage of bile, and side-to-side anastomosis.ConclusionsCholedochoduodenostomy with magnet compression could be a less invasive and safer method for treatment of biliary stricture that cannot be accessed by conventional surgery.

Intrahepatic cholangiojejunostomy for complex biliary stenosis after pediatric living‐donor liver transplantation

The treatment of biliary stenosis after pediatric LDLT is challenging. We describe an innovative technique of peripheral IHCJ for the treatment of patients with complex biliary stenosis after pediatric LDLT in whom percutaneous treatment failed. During surgery, the percutaneous biliary drainage is removed and a flexible metal stylet is introduced trough the tract. Subsequently, the most superficial aspect of the biliary tree is recognized by palpation of the stylet's round tip in the liver surface. The liver parenchyma is then transected until the bile duct is reached. A side-to-side anastomosis to the previous Roux-en-Y limb is performed over a silicone stent. Among 328 pediatric liver transplants performed between 1988 and 2015, 26 patients developed biliary stenosis. From nine patients requiring surgery, three patients who had received left lateral grafts from living-related donors due to biliary atresia were successfully treated with IHCJ. After a mean of 45.6months, all patients are alive with normal liver morphological and function tests. The presented technique was a feasible and safe surgical option to treat selected pediatric recipients with complex biliary stenosis in whom percutaneous procedures or rehepaticojejunostomy were not possible, allowing complete resolution of cholestasis and thus avoiding liver retransplantation.

Diagnostic Approach in Biliary Strictures After Pediatric Liver Transplantation.

BACKGROUND The diagnosis of post-liver transplant biliary strictures (BS) requires a high degree of clinical suspicion because of the diversity of symptoms and usually mild clinical presentation. If quickly treated, successful outcome is achieved most cases. The aim of our study was to analyze the value of diagnostic methods in BS after pediatric LTx. MATERIAL AND METHODS We retrospectively reviewed clinical data of children with BS after liver transplantation, with the main focus on diagnostic methods, including imaging studies and histology. All patients underwent endoscopic, transhepatic, or surgical treatment of the stricture. RESULTS Sixty-seven patients after LTx performed at the median age of 9.1 years (0.4-18) developed BS, mostly within the first 12 months (40%). Laboratory findings at diagnosis were: bilirubin 4.65 (5.8±SD), GGTP 434 (382.9±SD), and ALT 126.5 (116.8±SD); 16 patients presented with bilirubin level <1 mg% and 4 with GGTP below 100 IU. Ultrasound scan (USS) visualized dilatation of the bile ducts in 53 (79%) patients. Overall sensitivity of hepatobiliary scintigraphy (HBS) was 93%, with dilatation of bile ducts in 69% and impaired excretion in 68% of patients. MRCP showed 100% accuracy in detecting biliary dilatation and a stricture was visualized in 39%. Liver histology was consistent with biliary obstruction in 66%. Treatment of BS was successful in the majority of cases, with 89% graft survival. CONCLUSIONS Non-invasive investigations are highly sensitive in post-transplant BS and should play the key role in diagnostic algorithms.

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See also: Treatment of biliary strictures with fully covered self-expandable metal stents after pancreaticoduodenectomyEndoscopy eFirstDOI: 10.1055/s-0042-119033