Pdf proximal biliary strictures mimicking hilar cholangiocarcinoma. Biliary stricture, also known as bile duct stricture, occurs when the bile duct gets smaller or narrower. Successful management of benign biliary strictures with. Oct 23, 2018 biliary strictures can be broadly classified as benign or malignant. Current diagnosis and treatment of benign biliary strictures after. Endoscopic management of benign biliary strictures after.
The pathogenesis of benign biliary stricture is still unclear. Y hepaticojejunostomy, pancreaticoduodenectomy or choledochojejunostomy are increasingly seen. Typical balloon sizes utilized are 810 mm, though this can vary. Despite advances in surgical techniques, benign biliary strictures after living donor liver. Benign biliary strictures bbss are often the consequence of iatrogenic injury during laparoscopic. In many instances, benign strictures can be effectively treated by cholangioplasty. Benign strictures of the biliary tree have different etiologies, each with different natural histories and responses to therapeutic endoscopic retrograde. Benign biliary strictures bbs can be caused by postoperative injury, anastomotic injury following orthotopic liver transplantation olt, chronic pancreatitis, primary role of fully covered selfexpandable metal stent for treatment of benign biliary strictures and bile leaks nonthalee pausawasadi. The bile duct is the tube that takes bile from the liver to the small bowel. Treatment of postcholecystectomy biliary strictures with. Biliary strictures frequently present a challenge in terms of diagnosis, which requires a multidisciplinary approach. Detecting malignancies at an earlier stage is of paramount importance for effective management. Endoscopic treatment of benign biliary strictures and cystic. Postcholecystectomy bile duct stricture can develop even after several years of index surgery.
The choice of the type of stent is dependent mainly on the etiology of biliary stricture. Negotiation of postoperative biliary strictures may sometimes be much more difficult than malignant. Isolated igg4related sclerosing cholangitis is less common. Longterm results of metallic stents for benign biliary strictures. Most common benign biliary strictures amandable to endoscopic. Biliary strictures present a diagnostic challenge, especially when no etiology can be. Several conditions may cause benign biliary stricture formation. Other benign diseases of the biliary tract ercp is indicated for the evaluation and treatment of benign biliary strictures, congenital bile duct abnormalities, and postoperative adverse events such as anastomotic strictures and biliary leaks. Management of bile duct injury benign biliary stricture should be done at a biliary center which has. The intrapancreatic portion of the cbd is most commonly involved due to fibrosis of the periductal pancreatic parenchyma 24. Lap chole multiple factors contribute to stricture formation following laparoscopic cholecystectomy misinterpretation of the cystic duct as the common bile duct mcc. Kortan,11 claudio navarrete,12 joyce peetermans, daniel blero,1.
Biliary endoscopy for benign and malignant biliary strictures. Intraoperative bile duct injury, most often sustained during laparoscopic cholecystectomy, is the leading cause. Treatment aims to relieve symptoms of biliary obstruction, maintain longterm drainage, and preserve liver function. In a nonrandomized study at centers in 11 countries, 187 patients with benign biliary strictures received fcsems.
Bile is a substance that helps in digestion of fatty food and excreting getting rid of harmful substances. Recently, fullycovered selfexpanding metal stents fcsemss have been used to treat bbs because they can be removed readily and are characterized by long patency duration and fewer endoscopic treatments. The management landscape is constantly evolving, with the development of modifiable selfexpandable metal stents and biodegradable stents. Isolated igg4related sclerosing cholangitis misdiagnosed. Dr m k chouhan professor and hod of surgery dr snmc,jodhpur candidatedr sumer 2. Benign biliary stricture authorstream presentation. During 6 months of follow up, bdbs seemed sufficient for remodeling and resolution of strictures. Endoscopic stent therapy is considered as firstline therapy for benign biliary strictures bbs. The main manifestations of benign biliary stricture are scar contracture and stenosis of bile duct, especially at the hepatic hilum or above8. Benign biliary strictures bbs usually occur as a complication of biliary surgery or secondary to underlying diseases chronic pancreatitis, choledocholithiasis, sclerosing cholangitis. Pdf benign biliary strictures bbss may form from chronic.
Role of mrcp in differentiation of benign and malignant. Sep 18, 2019 biliary strictures due to chronic pancreatitis are among the most difficult to treat. Iatrogenic causes, such as cholecystectomy and orthotopic liver transplantation, are the most. Removal was scheduled at 1012 months for patients with chronic pancreatitis or cholecystectomy and at 46 months for patients who received liver transplants. Role of fully covered selfexpandable metal stent for. May 25, 2014 pathological effects of biliary obstruction fibrosis and scarring biliary fistula biliary stasis liver atrophy repeated cholangitis biliary cirrhosis and phtn 7. The role of ercp in benign diseases of the biliary tract. Temporary placement of a single fullycovered selfexpanding metal stent fcsems may offer safe and effective treatment with fewer reinterventions. The most common cause of perihilar obstruction is cholangiocarcinoma, especially in thailand. Management of benign biliary strictures springerlink. Benign biliary strictures pose difficult management problems. Benign biliary strictures, current treatment options in. Benign biliary strictures bbs and postcholecystectomy bile leaks have traditionally been treated endoscopically with plastic stents. Treatment aims to relieve symptoms of biliary obstruction.
The most pertinent and critical differentiation is between benign and. Benign biliary strictures are most commonly a consequence of injury at laparoscopic cholecystectomy or fibrosis after biliary enteric anastomosis. Progress in the endoscopic management of benign biliary. Benign biliary strictures bbs usually occur as a complication of biliary surgery or secondary to underlying diseases chronic pancreatitis, choledocholithiasis. Improvements in existing technologies as well as the implementation of novel technologies and techniques have the potential to.
Chronic pancreatitis accounts for about 10% of all benign biliary strictures, and the prevalence of strictures in patients with chronic pancreatitis varies from 3% to 46% 24. A biliary stricture is a narrowing of the common bile duct. Benign perihilar stricture represents less than 20% of cases. Benign hilar bile duct strictures resected as perihilar. Biliary strictures due to chronic pancreatitis are among the most difficult to treat. External metallic circle in hepaticojejunostomy bmc. Fully covered selfexpanding metal stents fcsems are gaining acceptance for the treatment of benign biliary strictures. The management of benign biliary strictures often entails cholangioplasty, internalexternal multihole biliary drain placement, andor subsequent stenting in cases of recalcitrant stenosis.
Biliary strictures can be due to benign or malignant causes. The first experience with endoscopic bdbs seems promising in the treatment of benign biliary strictures. Diagnostics free fulltext benign biliary strictures. Untreated biliary strictures can lead to complications, such as chronic cholestasis, jaundice, recurrent sepsis, and secondary biliary cirrhosis, which can have severe ramifications. In contrast to malignant biliary obstruction, in which shortterm palliation is often the goal of therapy, benign strictures require durable repair because most patients are in otherwise good health and are expected to live for years. Postcholecystectomy partial biliary stricture leading to. Traditionally, biliary strictures have been considered to be indeterminate when a diagnosis cannot be made after basic laboratory workup, abdominal imaging and endoscopic retrograde cholangiopancreatography ercp with biliary sampling. The archimedes stent is a biodegradable biliary and pancreatic stent intended to be used to drain obstructed biliary or pancreatic ducts.
Article pdf available in clinical and experimental. Benign biliary strictures can be difficult to manage. The diagnosis of biliary strictures can be challenging. Endoscopic plastic stent placement has become the firstline therapy for benign biliary strictures bbss, allowing high stricture resolution rates to be achieved. Benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bileduct injury, or at biliary anastomoses following liver transplantation. Primary biliary strictures appear to be less responsive to balloon dilatation alone and require stenting with large catheters 1620 f for several months to permit scarring around the catheter. If a bile duct injury is suspected intraoperatively, cholangiography is essential, and a careful rouxeny biliary enteric anastomosis is often required to achieve the best postoperative result. Classification based on the principles of surgical treatment. Management of benign biliary strictures whether surgical, percutaneoustranshepatic, or by endoscopic means is difficult. Radiological approach to benign biliary strictures sciencedirect. Among the surgical techniques hepaticojejunostomy yields the most favaroble results. Cholecystectomy and orthotopic liver transplantation olt are the.
Effective treatment of benign biliary strictures with a. Endoscopic biodegradable biliary stents in the treatment. Strasbergs classification is most commonly used for bile duct injury while benign. Cholangiocarcinoma and adenocarcinoma of the pancreas are the most common causes of malignant biliary obstruction. May 31, 2001 benign bile duct strictures are usually iatrogenic and result from surgery near the porta hepatis. Management of benign biliary strictures radiology key. Ercp for biliary disease stones cancer benign strictures inflammatory psc post operative. Despite recent developments in imaging techniques endoscopic ultrasound and magnetic resonance imaging, it is often difficult to differentiate benign from malignant biliary strictures.
The chart showing pdf series, word series, html series, scan qr codes. Apr 27, 2008 several conditions may cause benign biliary stricture formation. Successful management of benign biliary strictures with fully. Background biliary strictures bs are an everyday challenge in gastrointestinal clinical practice. Benign anastomotic biliary strictures untreatable by ercp. Possibility of cholangiocarcinoma should always be kept in mind while dealing with patients presenting with delayed biliary stricture. Standard surgical techniques offer a good chance of cure for the majority of patients affected by extrahepatic benign biliary stricture. Conclusion the ability to achieve steady, longterm results confirms hepaticojejunostomy as the best procedure in the treatment of benign biliary strictures, even if endoscopic procedures are gaining a new role in the treatment of a greater number of patients. Most common benign biliary strictures amandable to endoscopic treatment are postcholecystectomy, dominant.
The role of ercp in benign diseases of the biliary tract this is one of a series of statements discussing the use of gi endoscopy in common clinical situations. Patients with a benign biliary stricture after hepatobiliary surgery or liver transplantation, untreatable with endoscopy, underwent a percutaneous treatment cycle consisting of a 20min balloon dilatation session on day one, repeated. Mb management of benign biliary strictures should be aimed at achieving patency of the bile duct or preserving that patency in an attempt to minimize any short or longterm complications such as infection with cholangitis or more chronic changes such as secondary biliary cirrhosis. Benign biliary strictures can now be effectively treated with endoscopic therapy in a variety of clinical situations.
However, the diagnostic yield from conventional endoscopic retrograde cholangiopancreatography tissue sampling is modest. We describe the salient clinical and imaging manifestations of benign biliary strictures that will help radiologists to accurately diagnose these entities. The most common causes of benign biliary strictures include iatrogenic post liver. Recalcitrant embedded biliary selfexpanding metal stents.
Benign biliary strictures bbss have various origins, each with a different natural history and each demonstrating a different response to treatment. In preparing this guideline, a search of the medical litera. These strictures are notoriously difficult to treat and traditionally are managed by resection and fashioning of a choledocho or hepatojejunostomy. Management of benign biliary stenosis and injury springerlink. Benign biliary strictures can be attributable to a large variety of causes, but are commonly iatrogenic after direct or. Fully covered metal stents for benign biliary strictures due. Igg4related disease and igg4related sclerosing cholangitis, however, have been receiving increased recognition. Benign biliary strictures bbs may result from various causes, the most common being intraoperative biliary injury during cholecystectomy. The standards of practice committee of the american society for gastrointestinal endoscopy asge prepared this text.
The most prevalent etiology of benign strictures by far is related to surgery. Three degradation profiles address all biliary and pancreatic drainage indications. Endoscopy has an established role in the diagnosis and therapy of biliary strictures. Role of transforming growth factorbeta signaling pathway in. Historically, these strictures were managed via balloon dilation and plastic stent placement, but plastic stents require frequent maintenance, and their placement side by side can make endoscopic retrograde cholangiopancreatography technically challenging. Imaging plays a key role in differentiating benign from malignant strictures, defining the extent, and directing the biopsy. Cholecystectomy and orthotopic liver transplantation olt are the most common iatrogenic causes of benign biliary stricture. Currently, unnecessary surgery for suspected phcc is unavoidable. In benign strictures, the wire mesh penetrates the submucosa and stimulates mucosal hyperplasia and tissue ingrowth.
A fully covered selfexpandable metal stent with antimigration features for benign biliary strictures. Benign bile duct strictures have varicolored origin and high morbidity. In bbs, promising results of covered selfexpanding metal stent use have been recently published. Biliary stricture can be seen with a wide array of nonneoplastic causes. Endoscopic treatment of postcholecystectomy biliary strictures pcbs with multiple plastic biliary stents placed sequentially is a minimally invasive alternative to surgery but requires multiple interventions. Biliary complications after ldlt, particularly benign biliary strictures, play an. If a bile duct injury is suspected intraoperatively, cholangiography is essential, and a careful rouxeny biliaryenteric anastomosis is often required to achieve the best postoperative result. Management of bile duct injury benign biliary stricture should be done at a biliary. Although the risk of late bile duct cancer complicating biliaryenteric anastomosis has been well documented 1, 2, biliaryenteric anastomosis especially, rouxen y hepaticojejunostomy is frequently used for high biliary injuries and for biliary diversion in benign biliary strictures. We considered for further analysis only patients referred to our institution from january 1, 1988, the date that the endoscopy unit for biliary disease started to operate. Successful management of benign biliary strictures with fully covered selfexpanding metal stents. Further studies are needed to confirm the effectiveness of biodegradable biliary stents in endoscopic management of benign biliary strictures.
Although surgical bypass procedure was the traditional treatment of choice for benign extrahepatic biliary strictures, therapeutic endoscopic retrograde cholangiopancreatography has recently come into favor. The incidence of benign strictures resected as phcc as a proportion of all resections was relatively low, at 31 per cent. Ercp wih biliary sphincterotomy and stenting for palliative purpose duration. Pdf benign biliary strictures surgery or endoscopy. Benign biliary strictures are most commonly iatrogenic in nature and are a consequence of hepatobiliary surgery. The diagnosis and treatment of benign biliary strictures remains a clinical challenge, requiring a multidisciplinary approach. Traditionally, surgery has been used as a means to treat. Alternatively, the patient may be transferred to a tertiary referral center for further management by. When this happens, bile can back up into the liver, causing abdominal pain, nausea, itching, fever, chills, and jaundice. Endoscopic retrograde cholangiopancreatography in the. For example, in patients with sclerosing cholangitis, balloon dilatation alone or shortterm 23 weeks placement of a single stent for a dominant cbd stricture can be sufficient.
Final determination of malignancy in biliary strictures can entail major surgery if preoperative diagnosis of malignancy cannot be made. Longterm results of metallic stents for benign biliary. Nonoperative management of benign postoperative biliary. Jul 16, 2012 benign strictures and types of stents. Patients with mild biliary strictures may not show any symptoms, but the stricture causes abnormalities in the blood and a rise in some of the liver enzymes. Cholangiocarcinoma cca and pancreatic cancer account for the majority of malignant biliary strictures, and are often associated with grave prognosis at the time of diagnosis 1, 2. Endoscopy is a widely used approach for the treatment of benign biliary strictures. The preoperative diagnosis of igg4related sclerosing. Advances in endoscopic procedures have provided alternative options of relieving biliary obstructions, but prolonged length of treatment and. Endoscopic management of benign biliary stricture bbs in patients with chronic pancreatitis cp is challenging. Fully covered metal stents for benign biliary strictures.
In fact, stricture formation can be delayed beyond 5 years in up to onethird of cases. Between january 1, 1975, and july 1, 1998, 163 patients were referred for treatment to our department with diagnoses of benign strictures of the common bile duct. Bile proteomics for differentiation of malignant from benign. Oct 28, 2014 alhough up to 30% of biliary strictures can be benign, the vast majority are malignant, the two major malignancies being pancreatic adenocarcinoma and cholangiocarcinoma. Role of transforming growth factorbeta signaling pathway. Endoscopic management of benign biliary strictures. Pdf current treatment of benign biliary strictures researchgate. Benign biliary strictures bbss are commonly encountered by advanced endoscopists. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures 1, 2. Prognosis and duration of treatment of bbs depends mainly on stricture.
Benign biliary strictures bbs have diverse etiologies. Management of benign biliary strictures with a novel. To evaluate longterm patency rates of a novel percutaneous threefold balloon dilatation protocol in benign anastomotic biliary strictures. Temporary placement of fully covered selfexpandable metal stents. Selected benign biliary strictures can be treated safely and successfully by percutaneous balloon dilatation. Differentiating malignant from benign common bile duct stricture with multiphasic helical ct. Strictures can be caused during surgery on nearby tissues, such as the gallbladder. When the stricture becomes more pronounced, symptoms start to develop. Biliary strictures can be broadly classified as benign or malignant biliary strictures mbss. We performed a large prospective multinational study to study the ability to remove these stents after extended indwell and the frequency and durability of stricture resolution.
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