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

Outcomes of percutaneous endobiliary radiofrequency ablation in managing resistant benign biliary strictures: a retrospective analysis

OBJECTIVES

To assess the safety and effectiveness of percutaneous endobiliary radiofrequency ablation (EB-RFA) in the management of refractory benign biliary strictures.

METHODS

Percutaneous EB-RFA was performed in 15 individuals (M/F = 8/7; median age: 57 [33-84]) for benign biliary strictures resistant to traditional methods (transhepatic cholangioplasty and biliary drains). All patients underwent ≥1 unsuccessful cholangioplasty session and upsizing of their transhepatic biliary drains pre-procedure. Technical and clinical success were defined as luminal gain with enhanced flow and a lack of clinically evident recurrent stricture on follow-up after drain/stent removal, respectively.

RESULTS

A total of 16 EB-RFA procedures were performed. Technical success rate was 100% (16/16). Procedure-related complications occurred in 1/16 cases (drain leakage with subsequent cellulitis). Clinical success rate was 87% (13/15) with a median follow-up of 17 (2-24) months. Drain/stent was not removed in one case (1/16) as the patient was lost to follow-up immediately post-procedure. The one-year patency rate was 100%. A significant reduction was observed in the median number of IR visits (8 [1-51] to 1 [0-9]; P = .003) and drain insertion/exchange procedures (5 [1-45] to 0 [0-6]; P = .003) pre- and post-EB-RFA with a median follow-up of 18 (0-26) months.

CONCLUSION

Percutaneous EB-RFA can safely and effectively treat refractory benign biliary strictures. However, larger prospective studies with extended follow-ups are needed to gather more robust data.

ADVANCES IN KNOWLEDGE

This study contributes to the limited evidence on the role of EB-RFA in addressing refractory benign biliary strictures, enhancing the understanding of its clinical utility.

Atlas for Cholangioscopy and Cholecystoscopy: A Primer for Diagnostic and Therapeutic Endoscopy in the Biliary Tree and Gallbladder

Percutaneous endoscopy of the biliary system (cholangioscopy) and gallbladder (cholecystoscopy) has significantly impacted diagnostic and therapeutic approaches to many diseases in interventional radiology, overcoming previous challenges related to scope size and rigidity. The current endoscopes offer enhanced maneuverability within narrow tubular structures such as bile ducts. Before endoscopy, reliance on 2D imaging modalities limited real-time visualization during percutaneous procedures. Percutaneous endoscopy provides 3D perspectives, enabling a better appreciation of normal structures, targeted biopsy of lesions, and accurate deployment of therapeutic interventions. This review aims to explore percutaneous endoscopic findings across various biliary and gallbladder pathologies.

[Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]

Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.

Endobiliary and Pancreatic Radiofrequency Ablations

Radio frequency ablation (RFA) involves use of thermal energy to perform ablation of tissues. It has a wide range of application in gastrointestinal tract. Over the last few years, several studies have reported successful and safe application in the biliary and pancreatic tissues. It is particularly beneficial in patients with biliary malignancies in whom it has shown to improve survival. Additionally, it can be applied in occluded metal stents secondary to tumor ingrowth to prolong the patency of stents. In pancreas, RFA can successfully ablate cystic lesions and neuroendocrine tumors. It has also been applied in unresectable pancreatic cancers. This review discusses the application of endobiliary and pancreatic RFAs.

Research Priorities in Percutaneous Image and Endoscopy Guided Interventions for Biliary and Gallbladder Diseases: Proceedings from the Society of Interventional Radiology Foundation Multidisciplinary Research Consensus Panel

Recent technological advancements including the introduction of disposable endoscopes have enhanced the role of interventional radiology (IR) in the management of biliary/gallbladder diseases. There are unanswered questions in this growing field. The Society of Interventional Radiology Foundation convened a virtual Research Consensus Panel consisting of a multidisciplinary group of experts, to develop a prioritized research agenda regarding percutaneous image and endoscopy guided procedures for biliary and gallbladder diseases. The panelists discussed current data, opportunities for IR and future efforts to maximize IR's ability and scope. A recurring theme throughout the discussions was to find ways to reduce the total duration of percutaneous drains and to improve the patients' quality of life. Following the presentations and discussions, research priorities were ranked based on their clinical relevance and impact. The research ideas ranked top three were as follows: 1- Percutaneous multimodality management of benign anastomotic biliary strictures (Laser vs endobiliary ablation vs cholangioplasty vs drain upsize protocol alone); 2- Ablation of intraductal cholangiocarcinoma with and without stenting; and 3- Cholecystoscopy/choledochoscopy and lithotripsy in non-surgical patients with calculous cholecystitis. Collaborative retrospective and prospective research studies are essential to answer these questions and to improve the management protocols for patients with biliary/gallbladder diseases.

Percutaneous Balloon Dilatation for Hepaticojejunostomy Stricture Following Paediatric Liver Transplantation: Long-Term Results of an Institutional "Three-Session" Protocol

PURPOSE

The aim of this study was to report the long-term results of an institutional protocol of percutaneous biliary balloon dilatation (PBBD) on paediatric patients with benign anastomotic stricture after liver transplantation. As a secondary objective, we evaluated risk factors associated with post-treatment re-stricture.

MATERIALS AND METHODS

Fourteen paediatric, post-liver transplant patients with benign anastomotic stricture of Roux-en-Y hepaticojejunostomy were included. All patients underwent the same treatment protocol of three PBBD procedures with 15-day intervals. Clinical outcome was analysed using the Terblanche classification. Primary patency rate was assessed with the Kaplan-Meier test.

RESULTS

All patients had an initial successful result (Terblanche grade, excellent/good) after PBBD. At the end of the follow-up time of 35.7 ± 21.1 months (CI95%, 23.5-47.9), 10 patients persisted with excellent/good grading, while the remaining 4 had re-stricture, all of the latter occurring within the first 19 months. Patency rate after percutaneous treatment at 1, 3, and 5 years were 85.7%, 70%, and 70%, respectively. History of major complication after liver transplantation was associated with 5 times higher risk of re-stricture, HR 5.48 [95% CI, 2.18-8.78], p = 0.018.

CONCLUSION

In paediatric patients with benign anastomotic stricture of hepaticojejunostomy after liver transplantation, the "Three-session" percutaneous biliary balloon dilatation protocol is associated with a high rate of long-term success. In this limited series, the history of post-liver transplant major complication, defined as complications requiring a reintervention under general anaesthesia or advanced life support, seems to be an independent risk factor for stricture recurrence.

Development of Radiofrequency Ablation Generator and Balloon-Based Catheter for Microendoluminal Thin-Layer Ablation Therapy Using the Rat Duodenum as a Model of Low-Impedance Tissue

Radiofrequency ablation (RFA) is a routinely used, safe, and effective method for the tissue destruction. Often, in case of its application in malignant conditions, the extent of tissue destruction is insufficient due to the size of the target lesion, as well as due to the risk of heat-induced damage to the surrounding organs. Nevertheless, there are conditions requiring superficial precise-depth ablation with preservation of deeper layers. These are represented, for example, by mucosal resurfacing in case of Barrett's esophagus or treatment of recurrent mucosal bleeding in case of chronic radiation proctitis. Recently, new indications for intraluminal RFA use emerged, especially in the pancreatobiliary tract. In the case of intraductal use of RFA (e.g., biliary and pancreatic tract), there are currently available rigid and needle tip catheters. An expandable balloon-based RFA catheter suitable for use in such small-diameter tubular organs could be of benefit due to possible increase of contact between the probe and the target tissue; however, to prevent excessive tissue damage, a compatible generator suitable for low-impedance catheter/tissue is essential. This project aimed to develop a radiofrequency ablation generator and bipolar balloon-based catheter optimized for the application in the conditions of low-impedance tissue and (micro)endoluminal environment. Subsequent evaluation of biological effect in vivo was performed using duodenal mucosa in Wistar rat representing conditions of endoluminal radiofrequency ablation of low-impedance tissue. Experiments confirming the safety and feasibility of RFA with our prototype devices were conducted.

Percutaneous Management of Benign Biliary Strictures

Benign biliary strictures are often due to a variety of etiologies, most of which are iatrogenic. Clinical presentation can vary from asymptomatic disease with elevated liver enzymes to obstructive jaundice and recurrent cholangitis. Diagnostic imaging methods, such as ultrasound, multidetector computed tomography, and magnetic resonance imaging (cholangiopancreatography), are used to identify stricture location, extent, and possible source of biliary obstruction. The management of benign biliary strictures requires a multidisciplinary team approach and include endoscopic, percutaneous, and surgical interventions. Percutaneous biliary interventions provide an alternative diagnostic and therapeutic approach, especially in patients who are not amenable to endoscopic evaluation. This review provides an overview of benign biliary strictures and percutaneous management by interventional radiologists. Diagnostic evaluation with percutaneous transhepatic cholangiography and treatment options, including biliary drainage, balloon dilation, retrievable/biodegradable stents, and other innovative minimally invasive options, are discussed.