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Entezari P, Soliman M, Malik A, Moazeni Y, Reiland A, Thornburg B, Rajeswaran S, Salem R, Srinivasa R, Riaz A. How Endoscopic Guidance Augments Nonvascular Image-guided Interventions. Radiographics 2022; 42:1845-1860. [DOI: 10.1148/rg.220013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Entezari P, Aguiar JA, Salem R, Riaz A. Role of Interventional Radiology in the Management of Acute Cholangitis. Semin Intervent Radiol 2021; 38:321-329. [PMID: 34393342 DOI: 10.1055/s-0041-1731370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Acute cholangitis presents with a wide severity spectrum and can rapidly deteriorate from local infection to multiorgan failure and fatal sepsis. The pathophysiology, diagnosis, and general management principles will be discussed in this review article. The focus of this article will be on the role of biliary drainage performed by interventional radiology to manage acute cholangitis. There are specific scenarios where percutaneous drainage should be preferred over endoscopic drainage. Percutaneous transhepatic and transjejunal biliary drainage are both options available to interventional radiology. Additionally, interventional radiology is now able to manage these patients beyond providing acute biliary drainage including cholangioplasty, stenting, and percutaneous cholangioscopy/biopsy.
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Affiliation(s)
- Pouya Entezari
- Division of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Jonathan A Aguiar
- Division of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Riad Salem
- Division of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Ahsun Riaz
- Division of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
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Abstract
We are at an exciting cross-road in biliary interventions. While other services such as surgery and gastroenterology have learned to use imaging guidance to improve the safety and efficacy of their procedures, it is time for interventional radiologist to learn endoscopic interventions to achieve the same. The future of interventional radiologists in managing patients with biliary disease depends on (1) increasing comfort of our procedures, (2) publishing our data on biliary interventions, and (3) increasing collaboration with other services to manage biliary disease. We need to appropriately understand the limitations of interventional radiology to help guide the future directions of our specialty in this very interesting space.
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Affiliation(s)
- Ahsun Riaz
- Division of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Riad Salem
- Division of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
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Riaz A, Entezari P, Ganger D, Gabr A, Thornburg B, Russell E, Ladner D, Katariya N, Caicedo JC, Boike J, Lewandowski RJ, Keswani R, Aadam AA, Abecassis M, Salem R. Percutaneous Access of the Modified Hutson Loop for Retrograde Cholangiography, Endoscopy, and Biliary Interventions. J Vasc Interv Radiol 2020; 31:2113-2120.e1. [PMID: 32948389 DOI: 10.1016/j.jvir.2020.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The purpose of this study was to present the institutional experience of performing endoscopy, cholangiography, and biliary interventions through the modified Hutson loop by interventional radiology. MATERIALS AND METHODS A total of 61 of 64 modified Hutson loop access procedures were successful. This single-center retrospective study included 61 successful procedures of biliary interventions using existing modified Hutson loops (surgically affixed subcutaneous jejunal limb adjacent to biliary anastomosis or anastomoses) for diagnostic or therapeutic purposes in 21 patients. Seventeen of 21 patients (81%) had undergone liver transplantation. Indications included biliary strictures (n = 18) and biliary leaks (n = 3). The clinical success and complications were evaluated. RESULTS There were 3 of 26 modified Hutson loop retrograde biliary intervention failures (12%) before introduction of endoscopy and no failures (0 of 38 [0%]) subsequently (P = .06). Endoscopy or cholangioscopy was performed in 19 procedures by interventional radiologists. Retrograde biliary interventions included diagnostic cholangiography (n = 26), cholangioplasty (n = 25), stent placement (n = 29), stent retrieval (n = 25), and biliary drainage catheter placement (n = 5). No procedure-related mortality occurred. There was 1 major complication (duodenal perforation) (1.6%) and 12 minor complications (19%). In the 9 patients undergoing therapeutic interventions for biliary strictures, there was a significant decrease in median alkaline phosphatase (288.5 to 174.5 U/L; P = .03). There was a trend toward decrease in median bilirubin levels (1.7 to 1 mg/dL; P = .06) at 1 month post-intervention. CONCLUSIONS The modified Hutson loop provided interventional radiologists a safe and effective alternative access to manage biliary complications in patients with biliary-enteric anastomoses. Introduction of the endoscope in interventional radiology has improved the success rate of these procedures.
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Affiliation(s)
- Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois.
| | - Pouya Entezari
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Elliott Russell
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Daniela Ladner
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, Illinois
| | - Nitin Katariya
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, Illinois
| | - Juan Carlos Caicedo
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, Illinois
| | - Justin Boike
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Rajesh Keswani
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Abdul Aziz Aadam
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
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5
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Houghton E. Complex percutaneous biliary procedures: Review and contributions of a high volume team. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii180036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kim D, Bolus C, Iqbal SI, Davison BD, Ahari HK, Flacke S, Molgaard CP. Percutaneous Transjejunal Biliary Access in 60 Patients with Bilioenteric Anastomoses. J Vasc Interv Radiol 2018; 30:76-81.e1. [PMID: 30316675 DOI: 10.1016/j.jvir.2018.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 01/31/2023] Open
Abstract
PURPOSE To determine success and complication rates of percutaneous transjejunal biliary access (PTJBA) in patients with bilioenteric anastomoses. MATERIALS AND METHODS In a single-center, retrospective study, 169 PTJBA procedures were performed over a 13.8-y period in 60 subjects (47 male; mean age, 54.5 y). Indications for biliary interventions were cholangitis (137 cases, 45 subjects) or hyperbilirubinemia (32 cases, 18 subjects). All patients had antecolic bilioenteric anastomoses without surgical fixation to the peritoneum (liver transplantation with hepaticojejunostomy, n = 37; hepatectomy with hepaticojejunostomy, n = 8; hepaticojejunostomy only, n = 12; pancreaticoduodenectomy, n = 3). RESULTS Initial PTJBA was successful in 140 cases (82.8%) in 35 subjects (58.3%). Twenty-one additional PTJBAs (12.4%) in 18 subjects (30.0%) were performed secondarily following a conventional transhepatic approach. Radiographic markers on the Roux-en-Y limb (P = .14, odds ratio [OR] = 2.98) or preprocedural imaging (P = .13, OR = 10.00) did not increase the odds of successful PTJBA. There were 7 major complications (4.3%) in 6 patients (10.0%) requiring hospitalization longer than 5 d, and 37 minor complications (23.0%) in 19 patients (31.7%). No procedure-related mortality was observed. Minor and major complication rates were not affected by time between bilioenteric anastomosis creation and PTJBA (P = .70, OR = 1.00; P = .62, OR = 1.00), longer dwell time of a transjejunal drain (P = .68, OR = 1.02; P = .49, OR = 0.71), or access size (P = .40, OR = 0.85; P = .23, OR = 0.59). CONCLUSIONS PTJBA is a relatively safe technique with a high success rate in patients with bilioenteric loops that are not surgically fixed to the peritoneum.
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Affiliation(s)
- DaeHee Kim
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805.
| | - Christopher Bolus
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Shams I Iqbal
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Brian D Davison
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Heideh K Ahari
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Sebastian Flacke
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Christopher P Molgaard
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
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Severini A, Cozzi G, Salvetti M, Mazzaferro V, Doci R. Management of Complications from Hepatobiliary Surgery Using the Percutaneous Trans Jejunal Approach. TUMORI JOURNAL 2018; 83:912-7. [PMID: 9526583 DOI: 10.1177/030089169708300608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The work was aimed at presenting the indications, techniques and results of the percutaneous transjejunal approach to the biliary tree in patients with hepatobiliary complications due to surgery. Patients and methods Ten patients, 7 males and 3 females, mean age 50 years (range, 10–62) with hepatico-jejunostomy, who developed cholangitis together with jaundice or bile leakage, underwent this procedure, performed through the anastomotic loop that was not surgically anchored to the abdominal wall in all cases but one. The transjejunal approach was chosen because of non-dilated bile ducts in 3 patients, complex pathologic situations in 5 patients and to avoid complications to a transplanted liver in 2 patients. The jejunal loop was identified using CT, US and fluoroscopy in 4 patients and after its opacification in the remaining 6 (by percutaneous transhepatic or intravenous cholangiography or fistulography). Results The procedure was technically and diagnostically successful in all cases. Therapeutic procedures (stenting, dilation, litholysis) were also performed using the transjejunal approach in 7 patients and in 6 of them complete pathological resolution was achieved. There were no complications. Conclusions Different pathologies of the biliary tree, in patients with bilio-enteric anastomoses, have been identified and treated by this technique; they were fistulas, anastomotic and/or multiple segmental benign or malignant stenoses of the bile duct, and diffuse intrahepatic lithiasis. The procedure was safe and reliable.
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Affiliation(s)
- A Severini
- Department of Radiology, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
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8
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Hederström E, Andrén-Sandberg Å, Forsberg L. Gallstones in Bili-Digestive Shunts Diagnosed by Ultrasound. Acta Radiol 2016. [DOI: 10.1177/028418518903000520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In 4 patients treated surgically with a bili-digestive shunt, 2 because of pancreatic carcinoma and 2 because of chronic pancreatitis with cellular atypias, stones (with acoustic shadow) or sludge formation in the common bile duct were observed at postoperative ultrasonography (US) and confirmed by percutaneous transhepatic cholangiography. Clinical signs were abnormal liver function tests occasionally combined with relapsing attacks of cholangitis. All entero-anastomoses were narrow; surgical revision was done in 2 of the patients while 2 were percutaneously dilated. Except for the stones and detritus masses, the ‘typical’ US findings were absence of gas echoes in the periportal structures, normal width of bile ducts, or only a slight dilatation. US seems to be the method of choice for postoperative follow-up.
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Affiliation(s)
- E. Hederström
- Departments of Diagnostic Radiology and Surgery, University Hospital, S-221 85 Lund, Sweden
| | - Å. Andrén-Sandberg
- Departments of Diagnostic Radiology and Surgery, University Hospital, S-221 85 Lund, Sweden
| | - L. Forsberg
- Departments of Diagnostic Radiology and Surgery, University Hospital, S-221 85 Lund, Sweden
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Retrograde Percutaneous Transjejunal Creation of Biliary Neoanastomoses in Patients with Complete Hepaticojejunostomy Dehiscence. J Vasc Interv Radiol 2016; 26:1544-9. [PMID: 26408218 DOI: 10.1016/j.jvir.2015.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 04/27/2015] [Accepted: 06/02/2015] [Indexed: 12/26/2022] Open
Abstract
A technique of percutaneous hepaticojejunostomy (PHJ) was developed to allow creation of a neoanastomosis in cases of hepaticojejunostomy (HJ) dehiscence when endoscopic intervention is unfeasible as a result of postsurgical anatomy. PHJ involves transhepatic biliary catheterization and transjejunal retrograde enterotomy. A rendezvous establishes the communication between the bile ducts and the jejunum. PHJ was performed in five patients, and neoanastomosis creation without residual biliary leak was achieved in all cases, with no procedure-related complications. Bilirubin levels and white blood cell counts quickly decreased after PHJ (median, 1 d; range, 1-4 d). Median survival after PHJ was 210 days (range, 45-540 d).
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Lopera JE, Ramsey GR. Transjejunal biliary interventions: going back to a road less traveled. Acta Radiol 2014; 55:1210-8. [PMID: 24316661 DOI: 10.1177/0284185113515476] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Percutaneous transhepatic biliary interventions are not without risk and potential complications. In patients with bilioenteric anastomosis in whom repeat biliary interventions are expected, percutaneous transjejunal access is a very useful approach that is not frequently used nowadays. We provide a brief review of the history, indications, and current status of transjejunal biliary interventions. Transjejunal biliary access provides a relatively atraumatic pathway to the biliary system in patients that need repeat interventions. Multiple studies have provided convincing data that in appropriately chosen patients receiving a bilioenteric anastomosis, an antecolic limb of jejunum should be placed for subsequent access in biliary intervention.
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Affiliation(s)
- Jorge E Lopera
- Department of Radiology, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Gregory R Ramsey
- Department of Radiology, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
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11
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Morrison JJ, McVinnie DW, Suiter PA, de Quadros NM. Percutaneous jejunostomy: repeat access at the healed site of prior surgical jejunostomy with US and fluoroscopic guidance. J Vasc Interv Radiol 2013. [PMID: 23177111 DOI: 10.1016/j.jvir.2012.08.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
PURPOSE To evaluate the safety and efficacy of ultrasound (US)- and fluoroscopy-guided jejunostomy tube placement in patients with a history of surgical jejunostomy. MATERIALS AND METHODS Between June 2003 and June 2012, percutaneous US-guided jejunostomy placement was attempted 28 times in 26 patients with a history of surgical jejunostomy (14 men and 12 women). Retrospective chart review was performed to determine procedural success, complications, and interval between original jejunostomy and new tube placement. Clinical outcomes were evaluated with a mean follow-up period of 110 days (range, 3-631 d; median, 68 d). RESULTS Successful tube placement was achieved in 26 of 28 attempts (92%). The mean time between removal of the original surgical jejunostomy and percutaneous placement of the new tube was 278 days (range, 3 d to 8 y; median, 88 d). A single minor complication involved a tube site infection 4 days after the procedure. There were no major complications. Mean procedure time was 49 minutes (range, 15-125 min; median, 45 min). CONCLUSIONS Percutaneous jejunostomy access can be reliably and safely reestablished with US and fluoroscopic guidance in patients with a history of surgical jejunostomy.
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Affiliation(s)
- James J Morrison
- Department of Radiology, Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI 48202, USA.
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12
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Two decades of percutaneous transjejunal biliary intervention for benign biliary disease: a review of the intervention nature and complications. Insights Imaging 2011; 2:557-65. [PMID: 23100019 PMCID: PMC3289021 DOI: 10.1007/s13244-011-0119-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Revised: 06/29/2011] [Accepted: 07/11/2011] [Indexed: 12/29/2022] Open
Abstract
Objective To assess outcomes of percutaneous transjejunal biliary intervention (PTJBI) in terms of success and effectiveness in patients with a Roux-en-Y hepaticojejunostomy for benign biliary strictures and stones. Methods Clinical and radiographic records of 63 patients with a Roux-en-Y choledochojejunostomy or hepaticojejunostomy for benign disease who underwent at least one PTJBI between 1986 and 2007 were reviewed. Effectiveness was determined by successful access rate, rates of stricture dilatation and/or stone extraction, morbidity, complications and hospitalisation. Results PTJBI was attempted 494 times. Successful access to the Roux-en-Y was accomplished in 93% of interventions. After access to the Roux-en-Y was granted, all strictures were effectively dilated. Ninety-seven percent of extraction attempts of intrahepatic calculi were successful. The median number of interventions per patient was five. The median interval between interventions was 51.5 weeks (range 2.7–1,279.6 weeks). The early complication rate was 3%. Morbidity, measured in terms of cholangitis episodes was 14%, in 25 out of 63 patients. Mean hospitalisation was 4.1 nights per year. Conclusion PTJBI is safe and effective in treating benign biliary strictures and/or calculi. High success rates and short hospitalisation periods, together with few complications make it a well-accepted and integral part of managing complex biliary problems.
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Amitha Vikrama KS, Keshava SN, Surendrababu NRS, Moses V, Joseph P, Vyas F, Sitaram V. Jejunal access loop cholangiogram and intervention using image guided access. J Med Imaging Radiat Oncol 2010; 54:5-8. [PMID: 20377708 DOI: 10.1111/j.1754-9485.2010.02130.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Jejunal access loop is fashioned in patients who undergo Roux en Y hepaticojejunostomy and biliary intervention is anticipated on follow up. Post-operative study of the biliary tree through the access loop is usually done under fluoroscopic guidance. We present a series of 20 access loop cholangiograms performed in our institution between August 2004 and November 2008. We aimed to evaluate the safety and efficacy of the procedure and to highlight the role of CT guidance in procuring access. Access loop was accessed using CT (n = 13), ultrasound (n = 3) or fluoroscopic guidance (n = 4). Fluoroscopy was used for performing cholangiograms and interventions. Twelve studies had balloon plasty of the stricture at anastomotic site or high up in the hepatic ducts. Seven studies showed normal cholangiogram. Plasty was unsuccessful in one study. Technical success in accessing the jejunal access loop was 100%; in cannulation of anastomotic site and balloon plasty it was 95%. One case required two attempts. Procedure-related complications were not seen. All patients who underwent balloon plasty of the stricture were doing well for variable lengths of time. Access loop cholangiogram and interventions are safe and effective. CT guidance in locating/procuring the access loop is a good technique.
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14
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Köcher M, Cerná M, Havlík R, Král V, Gryga A, Duda M. Percutaneous treatment of benign bile duct strictures. Eur J Radiol 2007; 62:170-4. [PMID: 17383840 DOI: 10.1016/j.ejrad.2007.01.032] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Accepted: 01/19/2007] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate long-term results of treatment of benign bile duct strictures. MATERIALS AND METHODS From February 1994 to November 2005, 21 patients (9 men, 12 women) with median age of 50.6 years (range 27-77 years) were indicated to percutaneous treatment of benign bile duct stricture. Stricture of hepatic ducts junction resulting from thermic injury during laparoscopic cholecystectomy was indication for treatment in one patient, stricture of hepaticojejunostomy was indication for treatment in all other patients. Clinical symptoms (obstructive jaundice, anicteric cholestasis, cholangitis or biliary cirrhosis) have appeared from 3 months to 12 years after surgery. RESULTS Initial internal/external biliary drainage was successful in 20 patients out of 21. These 20 patients after successful initial drainage were treated by balloon dilatation and long-term internal/external drainage. Sixteen patients were symptoms free during the follow-up. The relapse of clinical symptoms has appeared in four patients 9, 12, 14 and 24 months after treatment. One year primary clinical success rate of treatment for benign bile duct stricture was 94%. Additional two patients are symptoms free after redilatation (15 and 45 months). One patient is still in treatment, one patient died during secondary treatment period without interrelation with biliary intervention. The secondary clinical success rate is 100%. CONCLUSION Benign bile duct strictures of hepatic ducts junction or biliary-enteric anastomosis are difficult to treat surgically and endoscopically inaccessible. Percutaneous treatment by balloon dilatation and long-term internal/external drainage is feasible in the majority of these patients. It is minimally invasive, safe and effective.
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Affiliation(s)
- Martin Köcher
- Department of Radiology, University Hospital, I.P.Pavlova 6, 775 20 Olomouc, Czech Republic.
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15
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Nakamura N, Nishida S, Neff GR, Vaidya A, Levi DM, Kato T, Ruiz P, Tzakis AG, Madariaga JR. Intrahepatic biliary strictures without hepatic artery thrombosis after liver transplantation: an analysis of 1,113 liver transplantations at a single center. Transplantation 2005; 79:427-32. [PMID: 15729168 DOI: 10.1097/01.tp.0000152800.19986.9e] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Intrahepatic biliary strictures (IHBS) without hepatic artery thrombosis (HAT) is a serious complication and known to increase the risk of graft failure after liver transplantation. This manuscript describes the incidence, risk factors, clinical pictures, management, and outcomes. METHODS Between 1994 and 2002, 1,113 liver transplantations were performed in 974 adult patients. Data was retrospectively analyzed in terms of incidence, risk factors, clinical pictures (type of strictures), management (radiologic, surgical management), and outcomes. RESULTS Sixteen (1.4%) grafts had IHBS without HAT. Specific risk factors were not identified from donors or recipients. However, ischemic factors from the donors were suspected from non-heart-beating donors (n=1) and cardiac-arrest donors (n=2). Three types of IHBS were identified: (1) diffuse type (n=7), (2) bilateral proximal type (n=7), and (3) unilateral type (n=2). Overall success rate of radiologic interventions was 31.3% (5/16). Of the 11 patients who did not improve, 6 died: diffuse type (3/7, 42.9%), bilateral type (3/7, 42.9%), and unilateral (0/2, 0%). Three patients had retransplantation, and two patients are waiting retransplantation. The majority of the IHBS were diffuse or bilateral (14/16, 87.5%), and rate of the graft failure was high (10/14, 71.4 %). Overall graft survival of IHBS was lower than that without IHBS (P=0.025). CONCLUSIONS The majority of the IHBS without HAT were of a diffuse or bilateral proximal type. Patients with diffuse or bilateral proximal type have a low success rate from radiologic intervention and may benefit from early retransplantation.
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Affiliation(s)
- Noboru Nakamura
- Division of Transplantation, Department of Surgery, University of Miami, 1801 NW 9th Avenue, Miami, FL 33136, USA
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16
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Berkmen T, Echenique A, Russell E. Ultrasound guidance in accessing the afferent limb of a modified Roux-en-Y choledochojejunostomy for percutaneous dilation of biliary strictures. J Vasc Interv Radiol 2001; 12:1219-22. [PMID: 11585890 DOI: 10.1016/s1051-0443(07)61683-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Percutaneous retrograde biliary dilation via the afferent limb of a modified Roux-en-Y choledochojejunostomy is used in the management of chronic biliary strictures. Access to the afferent loop may be challenging in the absence of surgically placed radiopaque markers. Ultrasound (US) guidance was used to access the loop in 10 patients with subcutaneous afferent loops and three patients with subfascial afferent loops. Successful puncture was made in all 10 patients with subcutaneous loops and in one patient with a subfascial loop. Initial fluoroscopically guided attempts failed in five loops, which were then successfully accessed with use of US guidance. US is useful in accessing subcutaneous afferent loops.
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Affiliation(s)
- T Berkmen
- Department of Radiology, Hospital of St. Raphael, New Haven, Connecticut, USA.
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17
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Bathe OF, Pacheco JT, Ossi PB, Franceschi D, Sleeman D, Hutson DG, Russell E, Levi JU, Livingstone AS. A subcutaneous or subfascial jejunostomy is beneficial in the surgical management of extrahepatic bile duct cancers. Surgery 2000; 127:506-11. [PMID: 10819058 DOI: 10.1067/msy.2000.105863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Extrahepatic bile duct cancers are rare tumors with a dismal prognosis. Even after a resection, obstructive cholestasis and other biliary complications are the rule. To facilitate retrograde access to the biliary tree for treatment of such biliary complications, a modified Roux-en-Y hepaticojejunostomy is constructed such that the afferent limb is brought up as a subcutaneous or subfascial jejunostomy (SJ). The safety and utility of construction of an SJ was evaluated in patients with extrahepatic cholangiocarcinoma. METHODS From 1985 to 1997, 24 patients with extrahepatic bile duct cancers received an SJ as part of their management. Demographic data, operative data, tumor characteristics, and postoperative courses were retrospectively reviewed. All but 3 patients were followed to the time of death. RESULTS The average age of the patients was 62 +/- 9 years. The tumor was resected in 17 patients. Major complications occurred in 5 patients (21%). There was 1 operative death (4%). None of the complications could be attributed to construction of the SJ, although 1 patient had a soft tissue infection at the site of the percutaneous access of the SJ. Frequent dilatations of biliary strictures were required in 5 patients, and 1 patient eventually required insertion of an internal biliary stent. These procedures could all be accomplished through the SJ. CONCLUSIONS The SJ is a technically simple and safe addition to the management of resectable and unresectable extrahepatic bile duct cancers, particularly proximal lesions. The procedure facilitates brachytherapy if indicated, and it allows convenient management of postoperative biliary complications, including recurrent strictures.
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Affiliation(s)
- O F Bathe
- Department of Surgery, University of Miami, Fla., USA
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18
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Hutson DG, Russell E, Yrizarry J, Levi JU, Livingstone AS, Guerra J, Reddy R, Jeffers L, Schiff ER, Scagnelli T, Mendez K. Percutaneous dilatation of biliary strictures through the afferent limb of a modified Roux-en-Y choledochojejunostomy or hepaticojejunostomy. Am J Surg 1998; 175:108-13. [PMID: 9515525 DOI: 10.1016/s0002-9610(97)00278-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND This report is a 13-year prospective evaluation of percutaneous balloon dilatation of benign biliary strictures through the subcutaneous or subfascially positioned afferent limb of a choledocho or hepaticojejunostomy in 30 patients. DATA SOURCE Twenty-seven strictures developed after a common duct injury sustained at the time of cholecystectomy, two after hepatectomy reconstruction for trauma and one following a gastrectomy. Twelve injuries (40%) were recognized at operation. Of the 18 patients where the injury was unrecognized at the time of operation, 8 had not been reoperated at the time of referral, 7 had late repairs by the referring physician, and 3 had late repairs at our institution. The follow-up is 1 to 13 years. RESULTS There has been 1 late death and 6 patients are lost alive. The jejunal-limb was accessed 50 times with two minor and no major complications. There have been two parajejunal hernia repairs, but there have not been any reoperations for recurrent biliary strictures. CONCLUSIONS Benign biliary strictures can be effectively managed by repeat balloon dilatations thru the afferent limb of a choledocho or hepaticojejunostomy, thus eliminating the need for repeat surgical interventions.
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Affiliation(s)
- D G Hutson
- Department of Surgery, University of Miami School of Medicine, Florida 33101, USA
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19
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Affiliation(s)
- S M Wu
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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20
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21
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Cameron DC, Frazer CK. The Hutson loop and prosthesis: clinical uses in hepato-biliary intervention. AUSTRALASIAN RADIOLOGY 1995; 39:159-65. [PMID: 7605321 DOI: 10.1111/j.1440-1673.1995.tb00261.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A number of method of making a Roux-en-Y hepaticojejunostomy have been advocated to help the radiologist gain access to the biliary system. We have found markers and rings unsatisfactory and therefore designed and tested our own prosthesis. Reliable rapid access is easily achieved using this device with a much reduced radiation dose to both patient and radiologist. The prosthesis has been used for the past 3 years, and the last 23 patients are reviewed. Seven patients have required repeated interventions via the loop and we present the findings and our results.
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Affiliation(s)
- D C Cameron
- Department of Radiology, Royal Perth Hospital, Western Australia
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22
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Eschelman DJ, Sullivan KL. Retrograde placement of biliary endoprostheses through a Hutson loop. J Vasc Interv Radiol 1994; 5:633-5. [PMID: 7949722 DOI: 10.1016/s1051-0443(94)71568-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- D J Eschelman
- Department of Radiology, Jefferson Medical College, Thomas Jefferson University Hospital, Philadelphia, Pa
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23
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Raute M, Podlech P, Jaschke W, Manegold BC, Trede M, Chir B. Management of bile duct injuries and strictures following cholecystectomy. World J Surg 1993; 17:553-62. [PMID: 8362535 DOI: 10.1007/bf01655124] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
During 7057 conventional cholecystectomies (1972-1991), 16 bile duct injuries occurred, amounting to a risk of 0.22%. A total of 1022 laparoscopic cholecystectomies were performed without such a complication since April 1990. In a retrospective study, 64 patients (16 of our patients and 48 referrals) with an injury or stricture due to conventional cholecystectomy were investigated. In 14 of our 16 patients the injury was recognized and immediately repaired with a good long-term result of 93%, including one successful repair of a subsequent stricture. Two cases of unrecognized injury were managed by nonoperative means. The group of 48 referred patients comprised 10 early postoperative complications (21%) and 38 strictures after an "uneventful" cholecystectomy. Of the 64 total patients, 10 (16%) underwent nonoperative treatment, and 54 required surgery. The mean follow-up period after surgery was 7.4 +/- 4.9 years. Most cases (93%) were repaired by bilioenteric anastomosis (i.e., foremost hepaticojejunostomy) with an 18% restricture rate. Including second and third repairs for restricture, a total of 60 operations (14 primary and 46 secondary reconstructions) were performed without hospital mortality. A good long-term result after stricture repair was achieved in 75% of the patients, whereas 17% had a poor outcome owing to restricture or death (10% had related mortality within 10 years). The other 8% had a moderate result due to recurrent cholangitis. Thus immediate repair of a bile duct injury offers the better chance of a favorable prognosis compared to secondary stricture repair.
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Affiliation(s)
- M Raute
- Department of Surgery, Mannheim Clinic of Heidelberg University, Germany
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24
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Blumgart LH. Invited commentary. World J Surg 1992. [DOI: 10.1007/bf02067096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Ho CS, Yeung EY. The management of problematic biliary calculi. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1992; 6:355-81. [PMID: 1392094 DOI: 10.1016/0950-3528(92)90009-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Recent advances in modern medical technology have significantly reduced the number of patients with 'problematic calculi'. When a patient does present with a difficult bile duct stone, various non-surgical treatment options are now available. In experienced hands, with healthy or high-risk patients, percutaneous treatment is as safe and as efficacious as endoscopy or surgery. Since it does not require general anaesthesia, and patients recover much more quickly than after surgery, the percutaneous approach is preferred when endoscopy fails to achieve ductal clearance. Surgery is indicated for patients with lesions requiring surgical removal or correction, but seldom for removal of biliary calculi alone.
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26
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Lombard M, Farrant M, Karani J, Westaby D, Williams R. Improving biliary-enteric drainage in primary sclerosing cholangitis: experience with endoscopic methods. Gut 1991; 32:1364-8. [PMID: 1752470 PMCID: PMC1379169 DOI: 10.1136/gut.32.11.1364] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Six jaundiced patients with primary sclerosing cholangitis and a dominant biliary stricture were managed by endoscopic placement of endoprostheses. Five showed considerable improvement within weeks of stenting: their serum bilirubin concentration fell from mean (range) 266 mumol/l (63-681) to 65 mumol/l (10-280) after one month. One patient required a liver transplant at five months because of continued deterioration in hepatic function. Follow up of 12-49 months in the remaining five patients shows sustained biochemical improvement, with repeat cholangiograms indicating doubling of the minimum calibre of the extrahepatic bile duct in four patients and considerable shortening of stricture length in three. Three patients developed sepsis at the time of the initial endoprosthesis insertion: surgical drainage was necessary in one. Endoscopic methods of improving biliary-enteric drainage in jaundiced patients with primary sclerosing cholangitis may be preferable to surgical and percutaneous methods, which may complicate subsequent liver transplantation.
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Affiliation(s)
- M Lombard
- Liver Unit, King's College Hospital, London
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27
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Schweizer WP, Matthews JB, Baer HU, Nudelmann LI, Triller J, Halter F, Gertsch P, Blumgart LH. Combined surgical and interventional radiological approach for complex benign biliary tract obstruction. Br J Surg 1991; 78:559-63. [PMID: 2059806 DOI: 10.1002/bjs.1800780514] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In patients with complicated high benign biliary strictures surgical technique alone cannot exclude the possibility of recurrent problems, and hepatic atrophy/hypertrophy, portal hypertension and intrahepatic stones may all complicate surgical management. A multidisciplinary approach to these complex cases, which minimizes the need for repeated surgical interventions, has been pursued. Roux-en-Y hepaticojejunostomy was performed and an extended limb of the jejunum brought to the abdominal wall to allow access for later radiological intervention. Over a 30-month period 58 biliary-enteric anastomoses for benign disease were performed. Seventeen of these 58 patients were managed using the combined approach. Ten of these 17 patients had complex postcholecystectomy strictures and seven had strictures resulting from inflammatory disease, hepatic resection or congenital problems. A new classification of results of management of bile duct strictures is proposed. Seven patients were classified as 'excellent', six 'good', two 'fair' and two 'poor'. Results were obtained at a mean follow-up of 16 months and it seems likely that in some patients major surgical reinterventions were avoided.
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Affiliation(s)
- W P Schweizer
- Department of Visceral and Transplantation Surgery, University of Berne, Switzerland
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28
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Abstract
Bile duct strictures are an uncommon but serious complication of primary operations on the gallbladder or biliary tree. Most strictures occur as a result of injury to the bile duct during cholecystectomy. In addition, strictures can occur at the site of previous biliary anastomoses for reconstruction of the biliary tree. Most patients with benign bile duct strictures present soon after their initial operation; however, in some cases, presentation is delayed for years. Cholangiography is essential for defining the anatomy of the biliary tree prior to management. In many cases, nonoperative biliary drainage is useful to treat sepsis and biliary fistulas. A number of alternatives exist for elective repair of bile duct strictures. Experience would suggest, however, that a choledochojejunostomy or hepaticojejunostomy performed through a Roux-en-Y limb of jejunum is the preferable management in most cases. Postoperative biliary stenting may be valuable in optimizing the results. Nonoperative management by percutaneous transhepatic or endoscopic balloon dilatation has been reported to be successful in a number of small series. Long-term results are limited, however. Comparative data suggest that surgical repair for benign postoperative strictures is associated with fewer long-term problems and with similar overall morbidity and costs.
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Affiliation(s)
- K D Lillemoe
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
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29
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Abstract
The treatment of choice for most retained bile duct stones is by nonoperative means. If a T-tube is in place, percutaneous techniques via the T-tract are indicated. Percutaneous access via puncture of a Roux-en-Y loop is also practical. In the absence of a T-tube, retrograde endoscopic techniques should be used. Both techniques are very effective and safe. Stones in the intrahepatic and extrahepatic ducts also can be treated nonoperatively. Endoscopic sphincterotomy has a role in the treatment of selected patients with gallstone pancreatitis, acute cholangitis, and choledocholithiasis with in situ gallbladders. In difficult cases, endoscopic and percutaneous techniques are employed in combination.
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30
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Morrison MC, Lee MJ, Saini S, Brink JA, Mueller PR. Percutaneous Balloon Dilatation of Benign Biliary Strictures. Radiol Clin North Am 1990. [DOI: 10.1016/s0033-8389(22)02660-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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31
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Rossi P, Salvatori FM, Bezzi M, Maccioni F, Porcaro ML, Ricci P. Percutaneous management of benign biliary strictures with balloon dilation and self-expanding metallic stents. Cardiovasc Intervent Radiol 1990; 13:231-9. [PMID: 2121349 DOI: 10.1007/bf02578024] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Seventy patients with benign biliary strictures were treated by means of percutaneous balloon dilation and stenting. Patients with stenoses relapsing during catheter stenting (18/70) were treated with self-expanding metallic stents. Results were evaluated in 56 patients; in patients without sclerosing cholangitis (n = 47) the patency rate with both modalities of treatment was 96%, while in the patients with secondary sclerosing cholangitis (n = 9), it was 33%, for a total success rate of 86%. The average follow-up was 23 months (range 3-72 months). Major complications included one death for septic shock (1%), three severe hemorrhages (4%), two of which required arterial embolization, two pleural effusions (3%), and one liver abscess following arterial embolization. Moderate fever for 1-2 days was a common finding after percutaneous puncture and balloon dilation. Percutaneous management of benign biliary strictures so far has been attempted only in surgical failures or in complicated cases. In view of our midterm results it may well become the initial treatment in many patients.
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Affiliation(s)
- P Rossi
- Department of General and Dental Radiology, University of Milan, Italy
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32
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Affiliation(s)
- P R Mueller
- Department of Radiology, Harvard Medical School, Boston
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33
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Montalvo BM, Fanney DR, Yrizarry JM, Russell E. Hepaticodochojejunostomy with afferent limb: CT anatomy. GASTROINTESTINAL RADIOLOGY 1989; 14:246-50. [PMID: 2731698 DOI: 10.1007/bf01889208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Hepaticodochojejunostomy with an afferent limb constructed to provide a permanent access route for retrograde biliary dilation has been described. The computed tomographic (CT) scans of 12 patients who had undergone this procedure were reviewed. The appearance of the afferent limb from its position within the subcutaneous tissues to its anastomosis with the biliary tree is described and illustrated. Recognition of the limb as a surgical pathway is important because familiarity with its anatomy will avoid errors in CT interpretation and aid in successful transjejunal catheterization of the bile ducts.
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Affiliation(s)
- B M Montalvo
- Department of Diagnostic Radiology, University of Miami School of Medicine, Jackson Memorial Medical Center, Florida
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34
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Pitt HA, Kaufman SL, Coleman J, White RI, Cameron JL. Benign postoperative biliary strictures. Operate or dilate? Ann Surg 1989; 210:417-25; discussion 426-7. [PMID: 2802831 PMCID: PMC1357913 DOI: 10.1097/00000658-198910000-00001] [Citation(s) in RCA: 155] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
At The Johns Hopkins Hospital from 1979 through 1987, 42 patients had 45 procedures for benign postoperative biliary strictures. Three patients were managed with both surgery and balloon dilatation. Twenty-five patients underwent surgical repair with Roux-Y choledocho- or hepaticojejunostomy with postoperative transhepatic stenting for a mean of 13.8 +/- 1.3 months. Twenty patients had balloon dilatation a mean of 3.9 times and were stented transhepatically for a mean of 13.3 +/- 2.0 months. The two groups were similar with respect to multiple parameters that might have influenced outcome. Mean length of follow-up was 57 +/- 7 and 59 +/- 6 months for surgery and balloon dilatation, respectively. No patients died after any of the procedures. The same definition of a successful outcome was applied to both groups and was achieved in 88% of the surgical and in only 55% of the balloon dilatation patients (p less than 0.02). Significant hemobilia occurred more often with balloon dilatation (20% vs. 4%, p less than 0.02). The total hospital stay and cost of balloon dilatation was not significantly different from surgery. We conclude that surgical repair of benign postoperative strictures results in fewer problems that require further therapy. Nevertheless balloon dilatation is an alternative for patients who are at high risk or who are unwilling to undergo another operation.
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Affiliation(s)
- H A Pitt
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
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35
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Berkelhammer C, Kortan P, Haber GB. Endoscopic biliary prostheses as treatment for benign postoperative bile duct strictures. Gastrointest Endosc 1989; 35:95-101. [PMID: 2714611 DOI: 10.1016/s0016-5107(89)72717-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- C Berkelhammer
- Department of Medicine, Wellesley Hospital, University of Toronto, Ontario, Canada
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36
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Reddy KR, Hutson DG, Russell E, Jeffers LJ, Schiff ER. Combined surgical and radiologic approach to recurrent cholangitis and intrahepatic pigment stones. Gastroenterology 1988; 95:1383-7. [PMID: 3169501 DOI: 10.1016/0016-5085(88)90376-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A 37-yr-old white woman from Australia presented with ascending cholangitis and jaundice and was found to have multiple brown, "earthy" pigment stones in the biliary tree, including the segmental ducts. Removal of these stones was accomplished via a subcutaneously placed afferent jejunal limb of a choledochojejunostomy using balloon dilators. The jejunal conduit also served as an access for periodic removal of newly formed stones. This combined surgical and radiologic approach is an effective way of removing recurring pigment stones. The afferent jejunal limb can also be used to perfuse dissolution agents, if necessary, via catheters placed in the biliary tree.
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Affiliation(s)
- K R Reddy
- Department of Medicine, University of Miami School of Medicine, Florida
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37
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Trambert JJ, Bron KM, Zajko AB, Starzl TE, Iwatsuki S. Percutaneous transhepatic balloon dilatation of benign biliary strictures. AJR Am J Roentgenol 1987; 149:945-8. [PMID: 3499800 PMCID: PMC2972738 DOI: 10.2214/ajr.149.5.945] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Between February 1981 and June 1984, 15 patients with benign biliary strictures were treated with percutaneous transhepatic balloon dilatation. Three of these patients had received liver transplants. The treatment began with a course of balloon dilatation therapy, after which a stent catheter was left across the stricture. Six weeks later, after duct patency had been shown by cholangiography, the stent catheter was removed from all but two patients, both of whom had intrahepatic sclerosing cholangitis. After this procedure, six patients (40%), including two liver-transplant patients, were stricture-free after one treatment for periods ranging from 27 to 56 months, and were considered to be treatment successes. Nine patients (60%) suffered stricture recurrences. In eight of these patients, the stricture was heralded by symptoms of either cholangitis or jaundice; in one patient, who was on permanent catheter drainage, the stricture was discovered only on follow-up cholangiography. All successfully treated patients had only one stricture, while all patients with more than one stricture suffered recurrences. Our data also suggest a greater responsiveness for anastomotic strictures than for non-anastomotic strictures. Of the patients with recurrences, five had symptom-free intervals of 23 months or more (up to 31 months). The fact that strictures recurred after such long periods of time underscores the importance of long-term follow-up. In view of the number of patients helped, the favorable experience with post-liver-transplantation strictures, and the lack of any major complications in our series, percutaneous biliary balloon dilatation offers a viable alternative to surgical management of benign biliary strictures.
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Affiliation(s)
- J J Trambert
- Department of Radiology, Presbyterian University Hospital, Pittsburgh, PA 15213
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