Among the surgical techniques hepaticojejunostomy yields the most favaroble results. Biliary complications after ldlt, particularly benign biliary strictures, play an. Although surgical bypass procedure was the traditional treatment of choice for benign extrahepatic biliary strictures, therapeutic endoscopic retrograde cholangiopancreatography has recently come into favor. 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.
Biliary strictures frequently present a challenge in terms of diagnosis, which requires a multidisciplinary approach. 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. In fact, stricture formation can be delayed beyond 5 years in up to onethird of cases. Treatment aims to relieve symptoms of biliary obstruction.
Pdf benign biliary strictures bbss may form from chronic. Benign biliary stricture authorstream presentation. 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. Postcholecystectomy bile duct stricture can develop even after several years of index surgery. Temporary placement of fully covered selfexpandable metal stents. Benign biliary strictures bbs have diverse etiologies. 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. 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. Biliary endoscopy for benign and malignant biliary strictures.
Role of fully covered selfexpandable metal stent for. Benign bile duct strictures are usually iatrogenic and result from surgery near the porta hepatis. Management of bile duct injury benign biliary stricture should be done at a biliary. As our understanding of longstanding techniques involving biliary dilation and plastic stent placement evolves, newer therapeutic options such as selfexpandable metal stents.
Dr m k chouhan professor and hod of surgery dr snmc,jodhpur candidatedr sumer 2. Selected benign biliary strictures can be treated safely and successfully by percutaneous balloon dilatation. Benign biliary strictures bbs may result from various causes, the most common being intraoperative biliary injury during cholecystectomy. Further studies are needed to confirm the effectiveness of biodegradable biliary stents in endoscopic management of benign biliary strictures. In bbs, promising results of covered selfexpanding metal stent use have been recently published. The most common causes of benign biliary strictures include iatrogenic post liver. The choice of the type of stent is dependent mainly on the etiology of biliary stricture. Jul 16, 2012 benign strictures and types of stents. Effective treatment of benign biliary strictures with a.
Longterm results of metallic stents for benign biliary. Role of transforming growth factorbeta signaling pathway. Currently, unnecessary surgery for suspected phcc is unavoidable. Benign biliary strictures, current treatment options in. Bile proteomics for differentiation of malignant from benign. Successful management of benign biliary strictures with fully. The most pertinent and critical differentiation is between benign and. Biliary stricture, also known as bile duct stricture, occurs when the bile duct gets smaller or narrower. The pathogenesis of benign biliary stricture is still unclear. The bile duct is the tube that takes bile from the liver to the small bowel. Biliary strictures can be due to benign or malignant causes. 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.
Most common benign biliary strictures amandable to endoscopic. 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. The preoperative diagnosis of igg4related sclerosing. Kortan,11 claudio navarrete,12 joyce peetermans, daniel blero,1. Final determination of malignancy in biliary strictures can entail major surgery if preoperative diagnosis of malignancy cannot be made. The diagnosis of biliary strictures can be challenging. Article pdf available in clinical and experimental. Y hepaticojejunostomy, pancreaticoduodenectomy or choledochojejunostomy are increasingly seen. Bile is a substance that helps in digestion of fatty food and excreting getting rid of harmful substances. The most common cause of perihilar obstruction is cholangiocarcinoma, especially in thailand. 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. A biliary stricture is a narrowing of the common bile duct. 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. Benign biliary strictures bbss are commonly encountered by advanced endoscopists.
Current diagnosis and treatment of benign biliary strictures after. Management of benign biliary strictures with a novel. Endoscopic management of benign biliary strictures. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures 1, 2. These strictures are notoriously difficult to treat and traditionally are managed by resection and fashioning of a choledocho or hepatojejunostomy. Progress in the endoscopic management of benign biliary.
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 are most commonly iatrogenic in nature and are a consequence of hepatobiliary surgery. Differentiating malignant from benign common bile duct stricture with multiphasic helical ct. In benign strictures, the wire mesh penetrates the submucosa and stimulates mucosal hyperplasia and tissue ingrowth. Pdf proximal biliary strictures mimicking hilar cholangiocarcinoma. Benign perihilar stricture represents less than 20% of cases. Benign biliary strictures bbss have various origins, each with a different natural history and each demonstrating a different response to treatment. Ercp for biliary disease stones cancer benign strictures inflammatory psc post operative. The chart showing pdf series, word series, html series, scan qr codes. Fully covered metal stents for benign biliary strictures. The most prevalent etiology of benign strictures by far is related to surgery.
Benign bile duct strictures have varicolored origin and high morbidity. 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. When the stricture becomes more pronounced, symptoms start to develop. Management of benign biliary strictures whether surgical, percutaneoustranshepatic, or by endoscopic means is difficult. Role of mrcp in differentiation of benign and malignant.
Three degradation profiles address all biliary and pancreatic drainage indications. Benign biliary strictures can be attributable to a large variety of causes, but are commonly iatrogenic after direct or. Alternatively, the patient may be transferred to a tertiary referral center for further management by. Most common benign biliary strictures amandable to endoscopic treatment are postcholecystectomy, dominant.
We describe the salient clinical and imaging manifestations of benign biliary strictures that will help radiologists to accurately diagnose these entities. Benign anastomotic biliary strictures untreatable by ercp. Imaging plays a key role in differentiating benign from malignant strictures, defining the extent, and directing the biopsy. The standards of practice committee of the american society for gastrointestinal endoscopy asge prepared this text. Iatrogenic causes, such as cholecystectomy and orthotopic liver transplantation, are the most. Treatment aims to relieve symptoms of biliary obstruction, maintain longterm drainage, and preserve liver function. The intrapancreatic portion of the cbd is most commonly involved due to fibrosis of the periductal pancreatic parenchyma 24.
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. May 31, 2001 benign bile duct strictures are usually iatrogenic and result from surgery near the porta hepatis. Cholecystectomy and orthotopic liver transplantation olt are the. Management of bile duct injury benign biliary stricture should be done at a biliary center which has. However, the diagnostic yield from conventional endoscopic retrograde cholangiopancreatography tissue sampling is modest. Isolated igg4related sclerosing cholangitis is less common. Management of benign biliary strictures springerlink. During 6 months of follow up, bdbs seemed sufficient for remodeling and resolution of strictures. Prognosis and duration of treatment of bbs depends mainly on stricture. Biliary strictures can be broadly classified as benign or malignant biliary strictures mbss. Endoscopic retrograde cholangiopancreatography in the. 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.
Endoscopic biodegradable biliary stents in the treatment. 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. Detecting malignancies at an earlier stage is of paramount importance for effective management. Advances in endoscopic procedures have provided alternative options of relieving biliary obstructions, but prolonged length of treatment and. 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. Typical balloon sizes utilized are 810 mm, though this can vary. Radiological approach to benign biliary strictures sciencedirect. Fully covered selfexpanding metal stents fcsems are gaining acceptance for the treatment of benign biliary strictures. Treatment of postcholecystectomy biliary strictures with.
Benign biliary strictures bbs and postcholecystectomy bile leaks have traditionally been treated endoscopically with plastic stents. Benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bileduct injury, or at biliary anastomoses following liver transplantation. When this happens, bile can back up into the liver, causing abdominal pain, nausea, itching, fever, chills, and jaundice. Lap chole multiple factors contribute to stricture formation following laparoscopic cholecystectomy misinterpretation of the cystic duct as the common bile duct mcc. A fully covered selfexpandable metal stent with antimigration features for benign biliary strictures. Successful management of benign biliary strictures with. 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.
Benign biliary strictures can be difficult to manage. 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. The main manifestations of benign biliary stricture are scar contracture and stenosis of bile duct, especially at the hepatic hilum or above8. Benign biliary strictures pose difficult management problems. 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. Benign biliary strictures bbs usually occur as a complication of biliary surgery or secondary to underlying diseases chronic pancreatitis, choledocholithiasis, sclerosing cholangitis. The diagnosis and treatment of benign biliary strictures remains a clinical challenge, requiring a multidisciplinary approach. Several conditions may cause benign biliary stricture formation. 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. Biliary stricture can be seen with a wide array of nonneoplastic causes. Postcholecystectomy partial biliary stricture leading to. The role of ercp in benign diseases of the biliary tract.
Apr 27, 2008 several conditions may cause benign biliary stricture formation. Improvements in existing technologies as well as the implementation of novel technologies and techniques have the potential to. 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. Strictures can be caused during surgery on nearby tissues, such as the gallbladder. The management landscape is constantly evolving, with the development of modifiable selfexpandable metal stents and biodegradable stents. Diagnostics free fulltext benign biliary strictures. In many instances, benign strictures can be effectively treated by cholangioplasty. 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. Possibility of cholangiocarcinoma should always be kept in mind while dealing with patients presenting with delayed biliary stricture. Recalcitrant embedded biliary selfexpanding metal stents. Biliary strictures present a diagnostic challenge, especially when no etiology can be.
The first experience with endoscopic bdbs seems promising in the treatment of benign biliary strictures. 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. Endoscopy is a widely used approach for the treatment of benign biliary strictures. Endoscopic management of benign biliary stricture bbs in patients with chronic pancreatitis cp is challenging. Strasbergs classification is most commonly used for bile duct injury while benign. 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.
Endoscopic treatment of benign biliary strictures and cystic. Benign biliary strictures bbss are often the consequence of iatrogenic injury during laparoscopic. Pdf current treatment of benign biliary strictures researchgate. Role of transforming growth factorbeta signaling pathway in. Endoscopic management of benign biliary strictures after. May 25, 2014 pathological effects of biliary obstruction fibrosis and scarring biliary fistula biliary stasis liver atrophy repeated cholangitis biliary cirrhosis and phtn 7. External metallic circle in hepaticojejunostomy bmc. Removal was scheduled at 1012 months for patients with chronic pancreatitis or cholecystectomy and at 46 months for patients who received liver transplants. 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. Endoscopic plastic stent placement has become the firstline therapy for benign biliary strictures bbss, allowing high stricture resolution rates to be achieved. Temporary placement of a single fullycovered selfexpanding metal stent fcsems may offer safe and effective treatment with fewer reinterventions.
Sep 18, 2019 biliary strictures due to chronic pancreatitis are among the most difficult to treat. The incidence of benign strictures resected as phcc as a proportion of all resections was relatively low, at 31 per cent. Management of benign biliary stenosis and injury springerlink. Benign biliary strictures can now be effectively treated with endoscopic therapy in a variety of clinical situations. Endoscopy has an established role in the diagnosis and therapy of biliary strictures. Endoscopic stent therapy is considered as firstline therapy for benign biliary strictures bbs. The management of benign biliary strictures often entails cholangioplasty, internalexternal multihole biliary drain placement, andor subsequent stenting in cases of recalcitrant stenosis. Benign strictures of the biliary tree have different etiologies, each with different natural histories and responses to therapeutic endoscopic retrograde. Management of benign biliary strictures radiology key. Untreated biliary strictures can lead to complications, such as chronic cholestasis, jaundice, recurrent sepsis, and secondary biliary cirrhosis, which can have severe ramifications. The archimedes stent is a biodegradable biliary and pancreatic stent intended to be used to drain obstructed biliary or pancreatic ducts.
Intraoperative bile duct injury, most often sustained during laparoscopic cholecystectomy, is the leading cause. In preparing this guideline, a search of the medical litera. Background biliary strictures bs are an everyday challenge in gastrointestinal clinical practice. Cholangiocarcinoma and adenocarcinoma of the pancreas are the most common causes of malignant biliary obstruction. Ercp wih biliary sphincterotomy and stenting for palliative purpose duration. Classification based on the principles of surgical treatment. Despite recent developments in imaging techniques endoscopic ultrasound and magnetic resonance imaging, it is often difficult to differentiate benign from malignant biliary strictures. Oct 23, 2018 biliary strictures can be broadly classified as benign or malignant. 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.
Negotiation of postoperative biliary strictures may sometimes be much more difficult than malignant. Benign biliary strictures are most commonly a consequence of injury at laparoscopic cholecystectomy or fibrosis after biliary enteric anastomosis. Benign hilar bile duct strictures resected as perihilar. Standard surgical techniques offer a good chance of cure for the majority of patients affected by extrahepatic benign biliary stricture. Nonoperative management of benign postoperative biliary.
Igg4related disease and igg4related sclerosing cholangitis, however, have been receiving increased recognition. Pdf benign biliary strictures surgery or endoscopy. Cholecystectomy and orthotopic liver transplantation olt are the most common iatrogenic causes of benign biliary stricture. Traditionally, surgery has been used as a means to treat. To evaluate longterm patency rates of a novel percutaneous threefold balloon dilatation protocol in benign anastomotic biliary strictures. Fully covered metal stents for benign biliary strictures due. Successful management of benign biliary strictures with fully covered selfexpanding metal stents. Despite advances in surgical techniques, benign biliary strictures after living donor liver. Benign biliary strictures bbs usually occur as a complication of biliary surgery or secondary to underlying diseases chronic pancreatitis, choledocholithiasis. In a nonrandomized study at centers in 11 countries, 187 patients with benign biliary strictures received fcsems.
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