Endoscopic retrograde cholangiopancreatography in the management of benign biliary strictures

Clinical outcome of single plastic stent treatment of benign iatrogenic biliary strictures: is the outcome predetermined?

Endoscopic retrograde cholangiopancreatography (ERCP) is used for the management of benign iatrogenic biliary strictures after cholecystectomy and liver transplantation. Multiple stents can injure biliary circulation. If resolution of reversible ductal edema and/or ischemia is the mechanism for successful therapy then single stent placement for benign biliary stricture should work. Retrospectively reviewed ERCP records between November 1999 and 2012 provided 25 patients with repeat ERCPs performed at 10-week intervals or if symptoms of stent occlusion were present. If strictures did not improve between stent changes and if removal was not an option, hepaticojejunostomy was used. Strictures resolved in 72% of patients. Seven patients underwent hepaticojejunostomy. Three had ERCP-related complications. No stricture recurrence occurred during the follow-up period. Endoscopic single plastic stent treatment of benign biliary iatrogenic strictures has comparable success to multiple stenting. Many postsurgical strictures may have reversible ischemic/edematous component with stenting to maintain bile drainage.

Endoscopic extraction of large common bile duct stones: A review article

Since therapeutic endoscopic retrograde cholangiopancreatography replaced surgery as the first approach in cases of choledocolithiasis, a plethora of endoscopic techniques and devices appeared in order to facilitate rapid, safe and effective bile duct stones extraction. Nowadays, endoscopic sphincterotomy combined with balloon catheters and/or baskets is the routine endoscopic technique for stone extraction in the great majority of patients. Large common bile duct stones are treated conventionally with mechanical lithotripsy, while the most serious complication of the procedure is “basket and stone impaction” that is predominately resolved surgically. In cases of difficult, impacted, multiple or intrahepatic stones, more sophisticated procedures have been used. Electrohydraulic lithotripsy and laser lithotripsy are performed using conventional mother-baby scope systems, ultra-thin cholangioscopes, thin endoscopes and ultimately using the novel single use, single operator SpyGlass Direct Visualization System, in order to deliver intracorporeal shock wave energy to fragment the targeted stone, with very good outcomes. Recently, large balloon dilation after endoscopic sphincterotomy confirmed its effectiveness in the extraction of large stones in a plethora of trials. When compared with mechanical lithotripsy or with balloon dilation alone, it proved to be superior. Moreover, dilation is an ideal alternative in cases of altered anatomy where access to the papilla is problematic. Endoscopic sphincterotomy followed by large balloon dilation represents the onset of a new era in large bile duct stone extraction and the management of “impaction” because it seems that is an effective, inexpensive, less traumatic, safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists. When complete extraction of large stones is unsuccessful, the drainage of the common bile duct is mandatory either for bridging to the final therapy or as a curative therapy for very elderly patients with short life expectancy. Placing of more than one plastic endoprostheses is better while the administration of Ursodiol is ineffective. The great majority of patients with large stones can be treated endoscopically. In cases of unsuccessful stone extraction using balloons, baskets, mechanical lithotripsy, electrohydraulic or laser lithotripsy and large balloon dilation, the patient should be referred for extracorporeal shock wave lithotripsy or a percutaneous approach and finally surgery.

Large balloon dilation vs. mechanical lithotripsy for the management of large bile duct stones: a prospective randomized study

OBJECTIVES

The removal of large bile duct stones (>12 mm) after endoscopic sphincterotomy (EST) remains a challenging issue in therapeutic endoscopy. The aim of this prospective, randomized, controlled trial was to compare the effectiveness and complications of EST followed by large balloon dilation (LBD) with that of EST followed by mechanical lithotripsy (ML) for the management of large bile duct stones.

METHODS

A total of 90 patients with large bile duct stones (12-20 mm) were randomized to EST followed by LBD (n=45) or EST followed by ML (n=45). Success rate was determined with a final cholangiogram, whereas type and rate of post-procedure complications were assessed prospectively.

RESULTS

Complete bile duct stone removal was accomplished in 97.7% of patients subjected to EST-LBD as compared with 91.1% of those subjected to EST-ML (P=0.36). Post-procedure complications were observed in two (4.4%) patients subjected to EST-LBD and in nine (20%) patients subjected to EST-ML (P=0.049). Rates of pancreatitis were similar between the two groups (one case in each), as was post-endoscopic retrograde cholangio pancreatography (ERCP) hemorrhage (one case in each group). None of the patients subjected to EST-LBD developed cholangitis, while this was seen in six patients subjected to EST-ML (0.0 vs. 13.3%, P=0.026). One patient subjected to EST-ML developed perforation, which was successfully managed conservatively. None of our patients with complications died.

CONCLUSIONS

EST followed by LBD is equally effective as EST followed by ML for the removal of large bile duct stones, although it is associated with fewer complications.

Endotherapy of postoperative biliary strictures with multiple stents: results after more than 10 years of follow-up

BACKGROUND

Endoscopic dilation of postoperative biliary strictures with increasing numbers of stents was first described by our group in 2001 with promising results after a long-term follow-up (mean 4 years).

OBJECTIVE

To verify results of endoscopic treatment of postoperative biliary strictures at a very-long-term follow-up.

DESIGN

Single center, follow-up study.

SETTING

Tertiary-care, academic referral center.

PATIENTS

A group of 42 patients from our 2001 study, who had undergone endoscopic dilation of postoperative biliary strictures with the multiple endoscopic stenting technique, underwent systematic follow-up. The last telephone follow-up was done in September 2009.

INTERVENTION

Clinical conditions and the occurrence of new biliary symptoms during the follow-up period were assessed, and results of the most recent liver function tests and abdominal US were recovered.

MAIN OUTCOME MEASUREMENTS

Occurrence of cholangitis and liver function test evaluation during the follow-up period.

RESULTS

Of the 40 patients who were alive at the end of the study published in 2001, 5 (12.5%) died of unrelated causes after a mean of 6.7 years (range 3-13.3 years) from the end of treatment, without further biliary symptoms. The overall mean follow-up time for the remaining 35 patients (87.5%) was 13.7 years (range 11.7-19.8 years). Seven patients (20%) experienced recurrent acute cholangitis after a mean of 6.8 years (range 3.1-11.7 years) from the end of treatment. All 7 of these patients underwent ERCP. Four of the 7 patients had postoperative biliary stricture recurrence (n = 4/35, 11.4%) that was retreated endoscopically with placement of stents, and the other 3 patients had common bile duct stones (n = 3/35, 8.6%) that were extracted. No stricture or bile duct stone recurrences after retreatment were recorded after a mean follow-up period of a further 7.1 years (range 2.5-12.1 years). Twenty-eight patients remained asymptomatic with normal liver function test results and abdominal US results after a mean follow-up period of 13.7 years (range 11.7-19.8 years).

LIMITATIONS

Telephone follow-up.

CONCLUSION

Results of multiple endoscopic stenting for postoperative biliary strictures remain excellent even after a very-long-term follow-up. The stricture recurrence rate is low, and recurrences can be retreated endoscopically.

Endoscopic biliary plastic stenting and successful intentional stent retrieval in a benign biliary stricture with mural spherical calcification and porcelain gallbladder

We report a very rare case of benign biliary stricture with calcification and porcelain gallbladder, causing difficulty in differential diagnosis. A 64-year-old man was referred for further examination of jaundice. Computed tomography showed calcifications in the gallbladder wall and the common bile duct. Endoscopic retrograde cholangiopancreatography revealed narrowing and a filling defect in the distal common bile duct. Peroral cholangioscopy showed a protruded lesion and stricture, and pathological examinations revealed no evidence of malignancy. The stricture was resolved after temporary insertion of progressively larger of plastic stents. Patients with benign biliary stricture and/or porcelain gallbladder should be followed carefully, because malignancy can occur as a complication, although infrequent.