May 25, 2014 pathological effects of biliary obstruction fibrosis and scarring biliary fistula biliary stasis liver atrophy repeated cholangitis biliary cirrhosis and phtn 7. Management of benign biliary strictures radiology key. The chart showing pdf series, word series, html series, scan qr codes. Postcholecystectomy bile duct stricture can develop even after several years of index surgery. Intraoperative bile duct injury, most often sustained during laparoscopic cholecystectomy, is the leading cause. 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. Y hepaticojejunostomy, pancreaticoduodenectomy or choledochojejunostomy are increasingly seen. Most common benign biliary strictures amandable to endoscopic. Benign biliary strictures pose difficult management problems. During 6 months of follow up, bdbs seemed sufficient for remodeling and resolution of strictures.
In many instances, benign strictures can be effectively treated by cholangioplasty. Temporary placement of a single fullycovered selfexpanding metal stent fcsems may offer safe and effective treatment with fewer reinterventions. Article pdf available in clinical and experimental. Strasbergs classification is most commonly used for bile duct injury while benign. 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. Endoscopy is a widely used approach for the treatment of benign biliary strictures. 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. 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. Temporary placement of fully covered selfexpandable metal stents. Lap chole multiple factors contribute to stricture formation following laparoscopic cholecystectomy misinterpretation of the cystic duct as the common bile duct mcc. Several conditions may cause benign biliary stricture formation.
Benign biliary stricture authorstream presentation. Endoscopic stent therapy is considered as firstline therapy for benign biliary strictures bbs. 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. Treatment aims to relieve symptoms of biliary obstruction. Negotiation of postoperative biliary strictures may sometimes be much more difficult than malignant. Pdf current treatment of benign biliary strictures researchgate.
Endoscopic management of benign biliary strictures after. The archimedes stent is a biodegradable biliary and pancreatic stent intended to be used to drain obstructed biliary or pancreatic ducts. Biliary strictures can be due to benign or malignant causes. Diagnostics free fulltext benign biliary strictures. A biliary stricture is a narrowing of the common bile duct. Traditionally, surgery has been used as a means to treat. Benign biliary strictures are most commonly iatrogenic in nature and are a consequence of hepatobiliary surgery. Igg4related disease and igg4related sclerosing cholangitis, however, have been receiving increased recognition. Longterm results of metallic stents for benign biliary. Fully covered metal stents for benign biliary strictures. Benign strictures of the biliary tree have different etiologies, each with different natural histories and responses to therapeutic endoscopic retrograde. The management of benign biliary strictures often entails cholangioplasty, internalexternal multihole biliary drain placement, andor subsequent stenting in cases of recalcitrant stenosis. Biliary endoscopy for benign and malignant biliary strictures. 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.
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. Classification based on the principles of surgical treatment. 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. 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. Jul 16, 2012 benign strictures and types of stents. Strictures can be caused during surgery on nearby tissues, such as the gallbladder. Benign biliary strictures can be attributable to a large variety of causes, but are commonly iatrogenic after direct or. 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. Benign biliary strictures bbss are often the consequence of iatrogenic injury during laparoscopic. Successful management of benign biliary strictures with fully covered selfexpanding metal stents. Oct 23, 2018 biliary strictures can be broadly classified as benign or malignant. External metallic circle in hepaticojejunostomy bmc.
Biliary complications after ldlt, particularly benign biliary strictures, play an. 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. The most pertinent and critical differentiation is between benign and. The management landscape is constantly evolving, with the development of modifiable selfexpandable metal stents and biodegradable stents. Sep 18, 2019 biliary strictures due to chronic pancreatitis are among the most difficult to treat. 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. Management of benign biliary strictures with a novel. The role of ercp in benign diseases of the biliary tract. Dr m k chouhan professor and hod of surgery dr snmc,jodhpur candidatedr sumer 2. 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. Despite advances in surgical techniques, benign biliary strictures after living donor liver.
The diagnosis and treatment of benign biliary strictures remains a clinical challenge, requiring a multidisciplinary approach. 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. Bile is a substance that helps in digestion of fatty food and excreting getting rid of harmful substances. Successful management of benign biliary strictures with. Biliary stricture, also known as bile duct stricture, occurs when the bile duct gets smaller or narrower. Pdf benign biliary strictures bbss may form from chronic. In an effort to evaluate the spectrum of these strictures, a retrospective analysis was carried out on 105 consecutive patients with benign duct stricture treated at the department between 1985 and 1994. Fully covered selfexpanding metal stents fcsems are gaining acceptance for the treatment of benign biliary strictures. Current diagnosis and treatment of benign biliary strictures after.
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. Despite recent developments in imaging techniques endoscopic ultrasound and magnetic resonance imaging, it is often difficult to differentiate benign from malignant biliary strictures. Role of mrcp in differentiation of benign and malignant. Endoscopy has an established role in the diagnosis and therapy of biliary strictures.
Possibility of cholangiocarcinoma should always be kept in mind while dealing with patients presenting with delayed biliary stricture. Imaging plays a key role in differentiating benign from malignant strictures, defining the extent, and directing the biopsy. However, the diagnostic yield from conventional endoscopic retrograde cholangiopancreatography tissue sampling is modest. Typical balloon sizes utilized are 810 mm, though this can vary. Endoscopic treatment of benign biliary strictures and cystic. Biliary strictures can be broadly classified as benign or malignant biliary strictures mbss.
Postcholecystectomy partial biliary stricture leading to. Benign biliary strictures bbs may result from various causes, the most common being intraoperative biliary injury during cholecystectomy. A fully covered selfexpandable metal stent with antimigration features for benign biliary strictures. Isolated igg4related sclerosing cholangitis is less common. Benign biliary strictures are most commonly a consequence of injury at laparoscopic cholecystectomy or fibrosis after biliary enteric anastomosis. Role of transforming growth factorbeta signaling pathway in. 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. 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.
Benign biliary strictures bbss are commonly encountered by advanced endoscopists. Currently, unnecessary surgery for suspected phcc is unavoidable. The choice of the type of stent is dependent mainly on the etiology of biliary stricture. Treatment aims to relieve symptoms of biliary obstruction, maintain longterm drainage, and preserve liver function. The first experience with endoscopic bdbs seems promising in the treatment of benign biliary strictures. Biliary strictures frequently present a challenge in terms of diagnosis, which requires a multidisciplinary approach. Benign anastomotic biliary strictures untreatable by ercp. 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. The bile duct is the tube that takes bile from the liver to the small bowel. Benign biliary strictures bbs usually occur as a complication of biliary surgery or secondary to underlying diseases chronic pancreatitis, choledocholithiasis. Fully covered metal stents for benign biliary strictures due.
Endoscopic management of benign biliary stricture bbs in patients with chronic pancreatitis cp is challenging. Management of bile duct injury benign biliary stricture should be done at a biliary. The pathogenesis of benign biliary stricture is still unclear. Ercp wih biliary sphincterotomy and stenting for palliative purpose duration. Benign biliary strictures can be difficult to manage. Among the surgical techniques hepaticojejunostomy yields the most favaroble results. May 31, 2001 benign bile duct strictures are usually iatrogenic and result from surgery near the porta hepatis. Longterm results of metallic stents for benign biliary strictures. The incidence of benign strictures resected as phcc as a proportion of all resections was relatively low, at 31 per cent. Most common benign biliary strictures amandable to endoscopic treatment are postcholecystectomy, dominant. Benign hilar bile duct strictures resected as perihilar. 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. Final determination of malignancy in biliary strictures can entail major surgery if preoperative diagnosis of malignancy cannot be made. Three degradation profiles address all biliary and pancreatic drainage indications.
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. Alternatively, the patient may be transferred to a tertiary referral center for further management by. Benign biliary strictures bbss have various origins, each with a different natural history and each demonstrating a different response to treatment. Iatrogenic causes, such as cholecystectomy and orthotopic liver transplantation, are the most. Pdf benign biliary strictures surgery or endoscopy.
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. Endoscopic management of benign biliary strictures. The most prevalent etiology of benign strictures by far is related to surgery. Progress in the endoscopic management of benign biliary. Apr 27, 2008 several conditions may cause benign biliary stricture formation. Advances in endoscopic procedures have provided alternative options of relieving biliary obstructions, but prolonged length of treatment and. Role of transforming growth factorbeta signaling pathway. Isolated igg4related sclerosing cholangitis misdiagnosed. Biliary strictures due to chronic pancreatitis are among the most difficult to treat.
Radiological approach to benign biliary strictures sciencedirect. The preoperative diagnosis of igg4related sclerosing. Pdf proximal biliary strictures mimicking hilar cholangiocarcinoma. Nonoperative management of benign postoperative biliary. Ercp for biliary disease stones cancer benign strictures inflammatory psc post operative.
Biliary strictures present a diagnostic challenge, especially when no etiology can be. As our understanding of longstanding techniques involving biliary dilation and plastic stent placement evolves, newer therapeutic options such as selfexpandable metal stents. Although surgical bypass procedure was the traditional treatment of choice for benign extrahepatic biliary strictures, therapeutic endoscopic retrograde cholangiopancreatography has recently come into favor. Benign perihilar stricture represents less than 20% of cases.
When the stricture becomes more pronounced, symptoms start to develop. Cholecystectomy and orthotopic liver transplantation olt are the. In fact, stricture formation can be delayed beyond 5 years in up to onethird of cases. The diagnosis of biliary strictures can be challenging.
Further studies are needed to confirm the effectiveness of biodegradable biliary stents in endoscopic management of benign biliary strictures. Detecting malignancies at an earlier stage is of paramount importance for effective management. The existing sems has been designed primarily to palliate malignant biliary obstruction and has a high frequency of stent migration, difficulty in retrieval and stricture recurrence after stent removal. Successful management of benign biliary strictures with fully. 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.
Kortan,11 claudio navarrete,12 joyce peetermans, daniel blero,1. When this happens, bile can back up into the liver, causing abdominal pain, nausea, itching, fever, chills, and jaundice. The intrapancreatic portion of the cbd is most commonly involved due to fibrosis of the periductal pancreatic parenchyma 24. The most common causes of benign biliary strictures include iatrogenic post liver. We describe the salient clinical and imaging manifestations of benign biliary strictures that will help radiologists to accurately diagnose these entities. Cholecystectomy and orthotopic liver transplantation olt are the most common iatrogenic causes of benign biliary stricture. Selected benign biliary strictures can be treated safely and successfully by percutaneous balloon dilatation.
Benign biliary strictures, current treatment options in. In benign strictures, the wire mesh penetrates the submucosa and stimulates mucosal hyperplasia and tissue ingrowth. Prognosis and duration of treatment of bbs depends mainly on stricture. These strictures are notoriously difficult to treat and traditionally are managed by resection and fashioning of a choledocho or hepatojejunostomy.
The standards of practice committee of the american society for gastrointestinal endoscopy asge prepared this text. The main manifestations of benign biliary stricture are scar contracture and stenosis of bile duct, especially at the hepatic hilum or above8. Treatment of postcholecystectomy biliary strictures with. In bbs, promising results of covered selfexpanding metal stent use have been recently published. In preparing this guideline, a search of the medical litera. Cholangiocarcinoma and adenocarcinoma of the pancreas are the most common causes of malignant biliary obstruction. Benign bile duct strictures are usually iatrogenic and result from surgery near the porta hepatis. Benign biliary strictures bbs and postcholecystectomy bile leaks have traditionally been treated endoscopically with plastic stents. 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. Benign biliary strictures can now be effectively treated with endoscopic therapy in a variety of clinical situations. Standard surgical techniques offer a good chance of cure for the majority of patients affected by extrahepatic benign biliary stricture. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures 1, 2.
Differentiating malignant from benign common bile duct stricture with multiphasic helical ct. Management of benign biliary strictures whether surgical, percutaneoustranshepatic, or by endoscopic means is difficult. Effective treatment of benign biliary strictures with a. To evaluate longterm patency rates of a novel percutaneous threefold balloon dilatation protocol in benign anastomotic biliary strictures. Benign bile duct strictures have varicolored origin and high morbidity. Endoscopic plastic stent placement has become the firstline therapy for benign biliary strictures bbss, allowing high stricture resolution rates to be achieved. 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. In a nonrandomized study at centers in 11 countries, 187 patients with benign biliary strictures received fcsems. Improvements in existing technologies as well as the implementation of novel technologies and techniques have the potential to. Management of benign biliary stenosis and injury springerlink.
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