This is done to collect cells that can then be analyzed to rule out malignancy. Patients of 163 patients referred for treatment with diagnoses of benign strictures of the common bile duct between. Six weeks later, after duct patency had been shown by cholangiography. Surgery is a valid option in cases of complete transection or ligation of the common bile duct, in selected patients with benign strictures related to chronic. Benign biliary stricture is regarded as a main factor influencing the efficacy of biliary surgery 1, 2. Biliary stricture is likely to occur in cases without proper management of bdi, may be causing such severe complications as repeated strictures, cholangitis or impairment to liver function. Pdf benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bileduct injury, or at. 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. Most common benign biliary strictures amandable to. Quarterly publication of the hellenic society of gastroenterology, volume 26. Comment surgery achieved excellent or good results in 17 pa tients 77%, and fair or poor results in 5 patients 23%. The primary goal of treatment for benign biliary strictures bbss is to resolve bile duct obstruction, to achieve a longterm ductal patency and to maintain liver guide.
In patients with benign biliary strictures, the use of fully covered selfexpandable metal stents sems has been proposed as an alternative to plastic stenting, but high quality prospective data are sparse. Benign noninflammatory stricture of the common hepatic. Mrcp and mri in the evaluation of bile duct obstruction. Progress in the endoscopic management of benign biliary. Benign biliary strictures comprise a heterogeneous group of diseases. This video, captured via endoscopic retrograde cholangiopancreatography, shows the brushing of a common bile duct stricture using a biliary brush. The purpose of the present study was to determine the short and longterm outcomes of a structured benign biliary stricture treatment protocol, analyze the treatment parameters, and evaluate the protocols effectiveness in relation to other percutaneous protocols and nonpercutaneous treatments. Improvements in existing technologies as well as the implementation of novel technologies and techniques have the potential to. Bile proteomics for differentiation of malignant from. Unfortunately, most benign bile duct strictures biliary strictures are iatrogenic, resulting from operative trauma see images. Whether from a surgical mishap, a cancer scare, or some other source of inflammation or infection, the keys to treating and preventing further bile duct strictures are good health, quick diagnoses, and quality treatment by a specialist experienced in treating bile duct strictures. Instead it arises from severe or prolonged inflammation of the bile duct.
Clinicalbiliary successful management of benign biliary strictures with fully covered selfexpanding metal stents jacques deviere,1 d. Laparoscopic versus open surgery for the management of. Hepaticojejunostomy with external metallic circle were performed in eight male spraguedawley rats. Bile duct strictures are problematic in terms of management and distinction between benign and malignant.
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. Benign biliary strictures bbss have various origins, each with a different natural history and each demonstrating a different response to treatment. May 25, 2014 definition a biliary stricture is an abnormal narrowing of the bile duct, the tube that moves bile a substance that helps in digestion from the liver to the small intestine 4. However, the presence of tumor masses in imaging could not exclude a benign dignity in all cases. Pdf current treatment of benign biliary strictures researchgate. Differentiation between benign and malignant biliary. Possibility of cholangiocarcinoma should always be kept in mind while dealing with patients presenting with delayed biliary stricture.
In march, 2014, a 69yearold man was referred to us with a onemoreyear history of recurrent jaundice and fever after lc. Iatrogenic causes, such as cholecystectomy and orthotopic liver transplantation, are the most. 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. Nageshwarreddy,2 andreas puspok,3 thierry ponchon,4 marco j.
These strictures are characteristically single and short in length patients who develop an anastomotic stricture within the first 12 months after olt have the best response to endoscopic therapy with balloon dilation and stent placement. Management for a complicated biliary stricture after iatrogenic bile duct injury bile duct injury bdi remains to be a serious complication of biliary surgery. Benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bileduct injury, or at biliary. Bourke,6 horst neuhaus,7 andre roy,8 ferran gonzalezhuix llado,9. Eusguided fna of strictures or nodes endobiliary forceps biopsy and cholangioscopydirected biopsy pathological con. Sep 22, 2012 as laparoscopic cholecystectomy and liver transplantation lt have become more common, so has biliary stricture. Pdf current management of postoperative complications. Current treatment of benign biliary strictures ncbi. A case of small in situ perihilar cholangiocarcinoma. If a bile duct injury is suspected intraoperatively. However, hilar biliary stricture where operative management is necessary 3.
The most common strictures amenable to endoscopic treatment are postcholecystectomy, postliver transplantation, related to primary sclerosing cholangitis and to chronic pancreatitis. Amongst the various characteristics of benign strictures, a bile duct wall thickness of less than 7 mm and the absence of external compression have a negative predictive value of 100% for excluding malignancy in patients with biliary obstruction without a. The current diagnosis and treatment of benign biliary stricture. Biliary strictures can be broadly classified as benign or malignant biliary strictures mbss. Detecting malignancies at an earlier stage is of paramount importance for effective management. Most com mon benign biliary strictures amandable to endoscopic treatment are postcholecystectomy, dominant biliary strictures due to primary sclerosing cholangitis, biliary anastomotic strictures occurring after liver transplantation, and common bile duct strictures due to chronic pancreatitis. 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. Management of bile duct problems treatment overview bile duct obstruction bile duct or biliary obstruction occurs for numerous reasons. Here, we present a case of management for complicated biliary stricture after iatrogenic bdi. Biliaryenteric anastomosis especially rouxen y hepaticojejunostomy is frequently used for biliary diversion in benign biliary strictures.
Benign biliary strictures in children can stem from psc. Bile duct obstruction the presence of bile duct obstruction is diagnosed on mrcp when the maximal diameter of the extrahepatic bile duct exceeds 7 mm in patients who have their gallbladder in place and 10 mm in patients who have undergone a cholecystectomy. Thirteen patients had undergone several unsuccessful surgical repairs, and four had not undergone surgery because of their clinical status. 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. Cholecystectomy and orthotopic liver transplantation olt are the most common iatrogenic causes of benign biliary stricture. Lymphadenectomy of the hepatoduodenal ligament is routinely performed in advanced gallbladder carcinoma. This is a pdf file of an unedited manuscript that has been accepted for publication. Different procedures should be performed by experienced surgeons according to the different types of benign biliary strictures, and biliaryenteric anastomosis is the most common used treatment. As a service to our customers we are providing this early version of the manuscript. A bile duct stricture is often caused by injury to the bile ducts during surgery. However, the diagnostic yield from conventional endoscopic retrograde cholangiopancreatography tissue sampling is modest. D, 0% serial incremental endoscopic dilation followed by multiple plastic stent placement is often required for benign, severe fibrotic biliary strictures. The process of operative management can be divided into following steps. The book is uniquely structured in a way that allows areas of controversy to be highlighted through the use of a two chapter format for each topic.
The majority of benign strictures are iatrogenic, secondary to bile duct injury after liver transplantation or laparoscopic cholecystectomy, with. Causes can include cancerous and noncancerous processes as well as injuries from medical procedures or operations. The treatment began with a course of balloon dilatation therapy, after which a stent catheter was left across the stricture. Between february 1981 and june 1984, 15 patients with benign biliary strictures were treated with percutaneous transhepatic balloon dilatation. Successful management of benign biliary strictures with fully. Benign strictures of the bile ducts represent a significant endoscopic biliary stenting was successful excellent or clinical problem. Due to different management algorithms, these conditions need to be diagnosed swiftly and accurately to guide appropriate therapy and optimise outcomes for patients. This is a tube that moves bile from the liver to the small intestine. Pathology etiology there are numerous causes of biliary duct strictures, including 1,2.
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. 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. A technique of biliary tract reconstruction with complete followup in 44 consecutive cases. The wallflex biliary rx fully covered stent system rmv is indicated for use in the palliative treatment of biliary strictures produced by malignant neoplasms, relief of malignant biliary obstruction prior to surgery and for indwell up to 12 months in the treatment of benign biliary strictures secondary to chronic pancreatitis. Benign biliary strictures pose difficult management problems. In this study, we present the results of hepaticojejunostomy with external metallic circle. A bile duct stricture is an abnormal narrowing of the common bile duct. Traditionally, surgery has been used as a means to treat. Benign hilar bile duct strictures resected as perihilar. Ercp wih biliary sphincterotomy and stenting for palliative purpose duration. Anastomotic strictures anastomotic strictures account for up to 80% of biliary strictures after olt.
Postcholecystectomy bile duct stricture can develop even after several years of index surgery. Longterm results of metallic stents for benign biliary strictures. The device is assigned the generic name metallic biliary stent system for benign strictures, and it is identified as a prescription device intended for the treatment of benign biliary strictures. The gore viabil biliary endoprosthesis is indicated for the treatment of malignant biliary strictures. Few therapeutic options are available for biliaryenteric anastomotic site stricture bes including new surgical reconstruction or percutaneous transhepatic biliary drainage followed by balloon dilation of bes or stent placement.
This volume covers the pathophysiology, epidemiology, presentation, diagnosis, medical and surgical management of benign biliary stenosis. Surgical management by a bilioenteric anastomosis is the standard for the repair of postcholecystectomy benign biliary strictures bbs. Benign strictures of the bile ducts represent a significant endoscopic biliary stenting. Irani s, baron th, akbar a, lin os, gluck m, gan i et al. Bile is a substance that helps in digestion of fatty food. In preparing this guideline, a search of the medical litera. He underwent lc for cholecystolithiasis with chronic cholecystitis in november 2012.
Bile duct stricture uf health, university of florida health. Benign biliary stricture, classification, surgery introduction. Department of surgery, catholic university, rome, italy. In this nonrandomized retrospective study, 101 patients with benign biliary strictures were included. Oct 16, 2019 the causes of benign bile duct strictures are usually surgical inexperience, failure to recognize abnormal biliary anatomy and congenital anomalies, acute inflammation, misplacement of clips, excessive use of cautery, and excessive dissection around the major bile ducts, resulting in ischemic injury. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures 1, 2. A cholangiographic pattern of isolated chd stricture and diffuse and uniform intrahepatic biliary dilatation, as seen in our patient, is extremely uncommon in 2% of cases psc. 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. Endoscopic treatment of benign biliary strictures using. Postcholecystectomy partial biliary stricture leading to. Effectiveness and safety of endoscopic treatment of benign. Management of bile duct problems treatment overview. The role of ercp in benign diseases of the biliary tract. Despite recent developments in imaging techniques endoscopic ultrasound and magnetic resonance imaging, it is often difficult to differentiate benign from malignant biliary strictures.
This study compared the results of surgery and endoscopy for benign biliary strictures in one institution, over the same period of time and with the same outcome definitions. Most common benign biliary strictures amandable to endoscopic treatment are postcholecystectomy, dominant biliary strictures due to primary sclerosing cholangitis, biliary anastomotic strictures occurring after liver transplantation, and common bile. The aim of the present study was to describe our experience of laparoscopic bilioenteric anastomosis rouxeny. Insertion of fully covered selfexpanding metal stents in. This expanded indication represents a significant clinical milestone in achieving optimal treatment strategies for chronic pancreatitis patients suffering from. In an effort to determine the role of interventional radiologic and endoscopic techniques in the management of benign biliary strictures, a retrospective analysis was carried out on 194. Patients and methods the records of patients undergoing operation for benign biliary stricture between 1983 and 1992 were re viewed. Pdf endoscopy is a widely used approach for the treatment of benign biliary strictures. External metallic circle in hepaticojejunostomy bmc. The diagnosis of biliary strictures can be challenging.
Original article surgical management of benign biliary. Backgroundhistorically, surgical correction has been the treatment of choice for benign biliary strictures bbs. Endoscopy has an established role in the diagnosis and therapy of biliary strictures. Benign bile duct strictures are usually iatrogenic and result from surgery near the porta hepatis. The biliary stents are intended to be left indwelling for a limited amount of time and subsequently removed.
The removable gore viabil biliary endoprosthesis is indicated for the treatment of benign and malignant biliary strictures and can be removed from such strictures for up to one year post implant. Thirtyfive patients were treated surgically and 66 by endoscopic stenting. Abstract endoscopy is a widely used approach for the treatment of benign biliary strictures. Strictures can be caused during surgery on nearby tissues, such as the gallbladder. Original article surgical management of benign biliary strictures. Benign bile duct strictures near the hepatic duct confluence remains a surgical challenge. Maturation of the ttube tract usually requires six weeks. In fact, stricture formation can be delayed beyond 5 years in up to onethird of cases. Current management of postoperative complications and benign biliary strictures. Selfexpanding metallic stents of a modified gianturco design were used to treat benign strictures of the biliary tree in 17 patients. When this happens, bile can back up into the liver, causing abdominal pain, nausea, itching, fever, chills, and jaundice.
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. Final determination of malignancy in biliary strictures can entail major surgery if preoperative diagnosis of malignancy cannot be made. Management for a complicated biliary stricture after. A biliary stricture is a narrowing of the common bile duct. Biliary strictures can be due to benign or malignant causes. In fact the most common benign causes are not related to any type of mass or growth. Original article elevated serum level of carbohydrate. However, the differentiation of benign and malignant strictures is notoriously difficult.
The endoscopist and malignant and nonmalignant biliary. Biliary stricture occurs when the bile duct the tube that takes bile from the liver to the small bowel gets smaller or narrower. Hepaticojejunostomy is the procedure of choice for repair of a bile duct injury benign biliary stricture. Endoscopic management of benign biliary strictures after. The best time to repair bile duct injury is delayed at least 6 weeks after the injury. Endoscopic treatment of benign biliary strictures using covered selfexpandable metal stents csems. Longterm outcomes of a benign biliary stricture protocol. The classification of biliary strictures used at hopital paul brousse is based on the lowest level at which healthy biliary mucosa is available for anastomosis.
Conclusion the incidence of benign strictures resected as phcc as a proportion of all resections was relatively low, at 31 per cent. Role of endoscopic retrograde cholangiopancreatography in the. Three of these patients had received liver transplants. The main etiology of bile duct strictures closely related to the liver is a malignancy cancer. Endoscopic treatment of benign biliary strictures is widely used as first. This study was performed to evaluate the longterm effectiveness and safety of a new fully covered sems for benign biliary strictures.
The accurate diagnosis of biliary strictures based on imaging alone is frequently challenging, as there is a wide range of benign and malignant aetiologies. There are a few reports describing the procedure by a laparoscopic technique. 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. Fortunately, endoscopic treatment has almost simultaneously been developed. Endoscopic management of benign biliary strictures kavel h visrodia,james h tabibian, todd h baron kavel h visrodia, department of internal medicine, mayo clinic, rochester, mn 55905, united states james h tabibian, division of gastroenterology and hepatology. Pathological effects of biliary obstruction biliary obstruction high local concentratio n of bile salts inflammatio n 6. Dr m k chouhan professor and hod of surgery dr snmc,jodhpur candidatedr sumer 2. However, when preserving the extrahepatic bile duct, this surgical procedure may induce bile duct stricture, and the present case is a case of delayed ischemic stricture.
Obstruction can occur at different levels of the bile duct tree figure 1a. Fully covered selfexpanding metal stents fcsems are gaining acceptance for the treatment of benign biliary strictures. Cause, classification, and clinical manifestations biliary stricture can be seen with a wide array of nonneoplastic causes. Radiological dilation of a postoperative or other benign biliary stricture can be performed via percutaneous thc or through a mature, surgicallyplaced ttube tract. Current treatment of benign biliary strictures 3 annals of gastroenterology 25 which increases costs and may decrease patient compliance, which is of paramount importance for this type of treatment. Our patient had an asymptomatic course and normal liver function tests over a followup period of 2 years. In the end, no one wants to experience a bile duct stricture. Purpose stricture formation at the biliary enteric anastomotic site is a common complication due to fibrotic healing. Wallflex biliary rx fully covered stent system rmv now indicated in the u. Benign biliary strictures can now be effectively treated with endoscopic therapy in a variety of clinical situations. Malignant strictures or benign strictures associ ated with either sclerosing cholangitis or liver trans plantation were excluded. Discrimination of malignant proximal bile duct pbd stricture from a benign lesion is difficult with nonsurgical methods.
Percutaneous transhepatic balloon dilatation of benign. How to differentiate benign from malignant bile duct strictures. Temporary placement of stent grafts in postsurgical benign. The standards of practice committee of the american society for gastrointestinal endoscopy asge prepared this text. However, benign causes of biliary strictures does not mean that it is due to benign noncancerous cause. Patient characteristics, initial trauma, previous repairs, and level of obstruction were comparable in both groups. A narrowed bile duct makes it difficult for bile to pass to the small bowel, causing a buildup of bile. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures 1. Oct 16, 2019 bile duct stricture biliary stricture is an uncommon but challenging clinical condition that requires a coordinated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. Biliary stricture can be seen with a wide array of nonneoplastic causes. Treatment of benign biliary strictures with temporary placement of stentgrafts has a positive effect, but is less successful in patients with strictures developed following a liver transplant. Strictures definition of strictures by medical dictionary.
559 1288 1322 352 735 923 303 669 676 1448 1017 1545 653 1422 1529 1209 1368 1613 230 902 309 871 265 1035 968 369 535 1486