Percutaneous management of benign biliary disease

Endobiliary Radiofrequency Ablation in the Percutaneous Management of Refractory Benign Bilioenteric Anastomosis Strictures

OBJECTIVE

The purpose of this study is to evaluate the safety and efficacy of endobiliary radiofrequency ablation (RFA) in the percutaneous management of benign bilioenteric anastomosis strictures that are refractory to balloon dilatation and long-term drainage.

MATERIALS AND METHODS

Twenty-one patients (11 men) with a mean age of 47.9 years (range, 26-73 years) underwent percutaneous balloon dilatation and long-term drainage for benign bilioenteric anastomosis strictures. Endobiliary RFA was performed in six patients (four men; mean age, 53.1 years; range, 43-63 years) whose strictures did not respond to balloon dilatation and long-term drainage.

RESULTS

Presenting symptoms were jaundice (n = 21), pain (n = 19), pruritus (n = 17), and cholangitis (n = 15). The symptoms appeared 1384 days (range, 4-7592 days) after surgery. The technical success rate was 100%. The overall clinical success rate was 95.2% (20/21) with a mean follow-up of 67.3 months (range, 9-148 months) after catheter removal. In 15 patients, associated biliary stones were removed. Two patients with recurrent strictures were successfully retreated. Endobiliary RFA was successful and catheter removal could be achieved in all six patients (100%) whose disease did not respond to multiple balloon dilatation sessions and long-term drainage. The mean symptom-free period after endobiliary RFA and catheter removal was 430 days (range, 270-575 days). One patient with refractory disease (4.7%), for whom endobiliary RFA was not performed, underwent surgery. There were no major complications.

CONCLUSION

Endobiliary ablation may be used safely and effectively in the percutaneous management of benign bilioenteric anastomosis strictures that are refractory to balloon dilatation and long-term drainage, with promising results.

IDIOPATHIC BENIGN STRICTURES OF THE EXTRAHEPATIC BILE DUCT: RESULTS OF ENDOSCOPIC THERAPY

Background:  Idiopathic, benign, non‐traumatic, non‐inflammatory strictures of bile ducts are rare. We report cases with benign non‐traumatic, non‐inflammatory strictures of bile ducts diagnosed on histopathology of endoscopic tissue specimens and managed with endoscopic therapy.

Methods:  Eight patients with benign non‐traumatic, non‐inflammatory strictures of bile ducts were studied. Diagnosis of benign stricture was based on imaging studies (ultrasound and CT scanning), normal CA 19–9 levels, negative brush cytology and histopathology, endoscopic retrograde cholangiopancreatography (ERCP) and no evidence of malignancy on follow up. Endoscopic balloon dilatation of stricture was performed and biliary stent was placed.

Results:  Median age was 42 years and five patients were males. Clinical presentation included jaundice (5), abdominal pain (7), fever (2) and pruritus (6). Liver function tests and imaging studies revealed features of obstructive jaundice. ERCP revealed smooth concentric and tapering stricture in all patients. Brush cytology and histopathological specimen revealed cubocolumnar epithelium surrounded by fibrous tissue without inflammation and negative for malignant cells. All patients got relief of fever, jaundice, pain and pruritus after balloon dilatation and stenting. Symptoms completely resolved in a median of 24 days. Liver function tests normalized in a median of 36 days. Follow up ERCP after 6 months did not show evidence of stricture and stent could be removed successfully in all patients. Thereafter, for a median follow up of 19 months, patients remained asymptomatic and their liver function tests and ultrasound were normal.

Conclusions:  Benign strictures of extrahepatic bile ducts can be non‐traumatic and non‐inflammatory without any cause and can be managed successfully with endoscopic balloon dilatation and biliary stenting.

The radiology of jaundice

Ultrasonography is the most useful technique for screening patients with suspected obstructive jaundice. Additional information may be gained with CT when US fails either because of disturbing gas-filled loops of bowel or because the patient is obese. A more specific diagnosis is usually obtained from the ERCP which can be combined with percutaneous biopsy and drainage of obstructed bile ducts. PTC and PTCD are left for those patients in whom ERCP has failed.

Endoscopic biliary prostheses as treatment for benign postoperative bile duct strictures

We evaluated the efficacy of endoscopically placed biliary stents as treatment for 32 benign postoperative biliary strictures in 29 patients. Five patients also had bile fistulas. Stents were inserted for a mean of 162 days and then removed. ERCPs were obtained before stent insertion and again after removal. Responses were followed and categorized as excellent, good, or poor. Stent insertion was successful in 25 patients (86%), 23 of which have a mean follow-up of 19 months (range, 2 to 42 months) after stent removal. Seventy-four percent had an excellent (48%) or good (26%) response. Early postoperative strictures and fistulas responded favorably. We conclude that benign postoperative biliary strictures can be treated successfully by endoscopic prostheses.

Percutaneous creation of a hepaticojejunostomy

A procedure is described whereby a direct anastomosis may be created percutaneously between the biliary system and a Roux-en-Y limb; in effect a percutaneous hepaticojejunostomy. Although it will have limited applications, it represents a further extension of percutaneous techniques in the biliary system for complex problems.

Benign biliary strictures: a proposed combined surgical and radiological management

A combined surgical and radiological approach to the management of complex biliary strictures is described. Radiological access for stricture dilatation or stone extraction is created at the time of surgery either by insertion of a transhepatic U-tube or superficial fixation of the afferent limb of the Roux-en-Y loop. Each of seven patients treated in this way had multiple complicating factors known to adversely affect the outcome of operative repair. Five of the seven have had an excellent outcome at a median follow-up of 15 months (mean 21 months, range 2-39 months).