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Takahashi K, Ozawa E, Miyaaki H, Hara T, Soyama A, Hidaka M, Eguchi S, Nakao K. Fully-Covered Self-Expandable Metal Stent for Hepaticojejunostomy Anastomotic Stricture After Living Donor Liver Transplantation: A Case Series. Transplant Proc 2024; 56:1593-1597. [PMID: 39181765 DOI: 10.1016/j.transproceed.2024.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 08/06/2024] [Indexed: 08/27/2024]
Abstract
INTRODUCTION We prospectively evaluated 3 cases regarding the usefulness of fully-covered self-expandable metal stents (FCSEMSs) for hepaticojejunostomy anastomotic stricture (HAS) after living donor liver transplantation (LDLT), which could not be resolved with conventional treatment using a plastic stent. CASE REPORT All patients underwent LDLT with Roux-en-Y reconstruction; therefore, a short-type double-balloon enteroscope was used for the endoscopic procedures. HAS was observed on enteroscopic view of endoscopy in patients 1 and 2, and cholangiography revealed dilatation of the intrahepatic bile duct. The FCSEMS was successfully placed without the report of adverse events. The FCSEMS was removed after 16 weeks, and the HAS improved in both patients. In addition, stone clearance was also achieved in patient 2. On the other hand, FCSEMS was not placed in patient 3 because there was no indication of FCSEMS placement due to the multiple segmental biliary strictures (pruned-tree appearance on cholangiography). Subsequent deceased-donor liver transplantation confirmed recurrent primary sclerosing cholangitis. In this case, magnetic resonance cholangiopancreatography (MRCP) was not performed prior to cholangiography to rule out PSC recurrence. CONCLUSION FCSEMS placement may be effective and safe for HAS after LDLT, which is not resolved with conventional treatment using a plastic stent. MRCP should be used to identify HAS prior to invasive cholangiography.
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Affiliation(s)
- Kosuke Takahashi
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Eisuke Ozawa
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takanobu Hara
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Masaaki Hidaka
- Department of Digestive and General Surgery, Shimane University, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Rajendran J, Irrinki S, Gupta V, Singh V, Sinha SK, Lal A, Kurdia K, Das A, Yadav TD. Elastography for Evaluation of Regression in Liver Fibrosis After Surgical Biliary Drainage for Benign Biliary Strictures: A Practical Possibility? J Clin Gastroenterol 2024; 58:502-506. [PMID: 37725412 DOI: 10.1097/mcg.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 06/25/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Hepatic fibrosis and secondary biliary cirrhosis are consequences of long-standing benign biliary strictures. Evidence on the reversibility of fibrosis after the repair is incongruous. METHODOLOGY A prospective observational study on patients who underwent Roux-en-Y hepaticojejunostomy for benign biliary stricture. A liver biopsy was performed during repair and correlated with preoperative elastography. The improvement in liver functions and regression of fibrosis was compared with preoperative liver function tests and elastography. RESULTS A Total of 47 patients [mean age-38.9 y (Range: 21 to 66)] with iatrogenic benign biliary stricture were included. A strong female preponderance was noted. High strictures (type III and IV) comprised 72.7% of the study group. The median interval (injury to repair) was 7 months (2 to 72 mo). The median duration of jaundice was 3 months (1 to 20 mo). Both factors had a significant correlation with the stage of fibrosis ( P =0.001 and P =0.03, respectively). Liver biopsy revealed stage I, II, III, and IV fibrosis in 26 (55.3%), 11 (23.4%), 2 (4.3%), and 2(4.3%), respectively. The remaining 6 (12.8%) had no fibrosis. The severity of fibrosis had a good correlation with preoperative liver stiffness measurement-value on FibroScan. Significant improvement in liver function tests (bilirubin-3.55±3.48 vs. 0.59±0.52; Albumin-3.85±0.61 vs. 4.14±0.37; ALP-507.66±300.65 vs. 167±132.07; P value 0.00) and regression of fibrosis (liver stiffness measurement; 10.42±5.91 vs. 5.85±3.01, P value 0.00) was observed after repair of the strictures. CONCLUSION Improved biliary function and regression of liver fibrosis can be achieved with timely repair of benign biliary stricture and it is feasible to be evaluated using elastography.
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Affiliation(s)
| | | | | | | | | | | | | | - Ashim Das
- Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Joo S, Lee SY, Lee SY, Hwang Y, Kim M, Jeong JW, Jang SI, Fang S. Triamcinolone acetonide alleviates benign biliary stricture by ameliorating biliary fibrosis and inflammation. BMB Rep 2024; 57:200-205. [PMID: 38523372 PMCID: PMC11058357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/29/2023] [Accepted: 01/25/2024] [Indexed: 03/26/2024] Open
Abstract
We conducted a comprehensive series of molecular biological studies aimed at unraveling the intricate mechanisms underlying the anti-fibrotic effects of triamcinolone acetonide (TA) when used in conjunction with fully covered self-expandable metal stents (FCSEMS) for the management of benign biliary strictures (BBS). To decipher the molecular mechanisms responsible for the anti-fibrotic effects of corticosteroids on gallbladder mucosa, we conducted a comprehensive analysis. This analysis included various methodologies such as immunohistochemistry, ELISA, real-time PCR, and transcriptome analysis, enabling us to examine alterations in factors related to fibrosis and inflammation at both the protein and RNA levels. Overall, our findings revealed a dose-dependent decrease in fibrosisrelated signaling with higher TA concentrations. The 15 mg of steroid treatment (1X) exhibited anti-fibrosis and anti-inflammatory effects after 4 weeks, whereas the 30 mg of steroid treatment (2X) rapidly reduced fibrosis and inflammation within 2 weeks in BBS. Transcriptomic analysis results consistently demonstrated significant downregulation of fibrosis- and inflammation-related pathways and genes in steroid-treated fibroblasts. Use of corticosteroids, specifically TA, together with FCSEMS was effective for the treatment of BBS, ameliorating fibrosis and inflammation. Our molecular biological analysis supports the potential development of steroid-eluted FCSEMS as a therapeutic option for BBS in humans resulting from various surgical procedures. [BMB Reports 2024; 57(4): 200-205].
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Affiliation(s)
- Seyeon Joo
- Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul 03722, Korea
- Department of Biomedical Sciences, Yonsei University College of Medicine, Seoul 03722, Korea
| | - See Young Lee
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
| | - Su Yeon Lee
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
| | - Yeseong Hwang
- Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul 03722, Korea
- Department of Biomedical Sciences, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Minki Kim
- Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul 03722, Korea
- Department of Biomedical Sciences, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Jae Woong Jeong
- Department of Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Sung Ill Jang
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
| | - Sungsoon Fang
- Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul 03722, Korea
- Department of Biomedical Sciences, Yonsei University College of Medicine, Seoul 03722, Korea
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Suto A, Ishido K, Kimura N, Wakiya T, Kikuchi H, Iino C, Igarashi G, Sato S, Sakuraba H, Hakamada K. A case of hepaticojejunal anastomotic obstruction after a living-donor liver transplantation and recanalization using a high-frequency knife under the rendezvous technique. Clin J Gastroenterol 2023; 16:726-731. [PMID: 37170062 DOI: 10.1007/s12328-023-01812-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023]
Abstract
A 65-year-old woman underwent living-donor liver transplantation (left-lobe graft: GWRW ratio, 0.54) for cirrhosis caused by autoimmune hepatitis. At 68 years, she was diagnosed with obstructive cholangitis due to stricture during a hepaticojejunostomy following impaired liver function. Endoscopic balloon dilation of anastomosis and placement of a plastic stent resulted in improved liver function. However, at 72 years, the patient experienced a flare-up of liver damage. The plastic stent had fallen out, and although endoscopic stenotic dilation was attempted, the anastomotic site was obstructed completely. Therefore, recanalization of the hepaticojejunostomy was attempted using a rendezvous technique. A percutaneous transhepatic biliary drainage tube was inserted through the B3 bile duct, and the complete obstructed anastomosis was confirmed by percutaneous transhepatic and transjejunal approaches. The anastomosis was reopened by excising the scarred tissues from the jejunal side using a 1.5-mm high-frequency knife. A 14-Fr. catheter for the internal fistula tube was percutaneously placed at the opened anastomosis to achieve anastomotic site recanalization. The patient's liver damage improved after the re-internalization, and no symptom recurrence such as obstructive cholangitis developed for 1 year. There are few reports of recanalization of the hepaticojejunostomy with a high-frequency knife. Herein, we report the case with a literature review.
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Affiliation(s)
- Akiko Suto
- Department of Surgery, Odate Municipal General Hospital, 3-1 Yutaka-cho, Odate, Akita, 017-8550, Japan
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Keinosuke Ishido
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan.
| | - Norihisa Kimura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Hidezumi Kikuchi
- Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Chikara Iino
- Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Go Igarashi
- Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Satoshi Sato
- Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Hirotake Sakuraba
- Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
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Ödemiş B, Başpınar B, Tola M, Torun S. Magnetic Compression Anastomosis Is a Good Treatment Option for Patients with Completely Obstructed Benign Biliary Strictures: A Case Series Study. Dig Dis Sci 2022; 67:4906-4918. [PMID: 35050430 DOI: 10.1007/s10620-022-07381-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 01/01/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Completely obstructed benign biliary strictures (BBS) is a difficult-to-treat condition. Surgery is the main treatment modality with high morbidity and mortality. Recently, the magnetic compression anastomosis (MCA) technique was employed in such cases with low complication rates. AIMS To evaluate the effectiveness of the MCA in completely obstructed BBS. METHODS 21 MCA procedures were performed in 19 patients with completely obstructed BBS. All patients had percutaneous biliary access. Magnets were located to the proximal side of the obstruction via percutaneous biliary sheath and the distal side endoscopically. The procedure was terminated as the magnets attracted. Either self-expandable fully covered metallic stent and/or a growing number of plastic stents were introduced after recanalization was achieved. RESULT A total number of 19 patients with completely obstructed BBS resulting from cholecystectomy or liver transplant underwent 21 MCA procedures. Among those, 19 (90.5%) interventions were successful. The median stricture length that had been measured after magnet attraction was 4 mm (range 1-10 mm). The median magnet coupling time in successful cases was 9 days (range 4-27 days). No correlation was found between magnet coupling time and stricture length (p = 0.27). Complications were observed in 6 (cholangitis:1, magnet migration:2, magnet entrapment:3) of 19 successful MCA procedures. Fifteen of the 19 successful procedures had at least a period of stent-free follow-up. Recurrence of stenosis occurred in 7 procedures, of which 4 remained stent-free with retreatment. Eventually, 12 procedures had stent-free last status. CONCLUSIONS MCA is an effective and safe treatment option in completely obstructed BBS. Further studies are required for procedural standardization.
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Affiliation(s)
- Bülent Ödemiş
- Department of Gastroenterology and Hepatology, Ankara City Hospital, Bilkent Avenue Çankaya, 06800, Ankara, Turkey.
| | - Batuhan Başpınar
- Department of Gastroenterology and Hepatology, Ankara City Hospital, Bilkent Avenue Çankaya, 06800, Ankara, Turkey
| | - Muharrem Tola
- Department of Radiology, Division of Interventional Radiology, Ankara City Hospital, Bilkent Avenue Çankaya, 06800, Ankara, Turkey
| | - Serkan Torun
- Faculty of Medicine, Department of Gastroenterology, Düzce University, Konuralp Campus, Beçiyörükler District, 81010, Merkez, Düzce, Turkey
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Jang SI, Fang S, Nahm JH, Cho JH, Do MY, Lee SY, Jeong S, Lee DH, Lee DK. Preclinical evaluation of endoscopic placement of a steroid-eluting metal stent in an in vivo porcine benign biliary stricture model. Sci Rep 2022; 12:8864. [PMID: 35614115 PMCID: PMC9132970 DOI: 10.1038/s41598-022-12957-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/19/2022] [Indexed: 11/28/2022] Open
Abstract
Treatment of benign biliary strictures (BBS) using fully covered self-expandable metal stents (FCSEMS) has a high success rate, but recurrence can occur. Corticosteroids may be useful based on their anti-fibrotic and anti-inflammatory effects. We investigated the safety and efficacy of corticosteroid-eluting FCSEMS in an animal model. BBSs were created by radiofrequency ablation in 12 mini-pigs. Four weeks later, FCSEMS coated with 0 mg (control), 15 mg (steroid 1 × group), or 30 mg (steroid 2 × group) triamcinolone were inserted endoscopically. The in vitro drug release assay revealed that the optimal stent had 15 mg of triamcinolone and a hydrophilic membrane. No transmural necrosis or perforation occurred in any animal. Fibrous wall thickness tended to decrease macroscopically and microscopically in a triamcinolone dose-dependent manner (control vs. steroid 2 × group: 773.1 vs. 468.5 µm, P = 0.037). Thickness also decreased over time in the steroid 2 × group (3 days vs. 4 weeks: 907.9 vs. 468.5 µm, P = 0.025). Blood parameters tended to improve after stent insertion. In a porcine BBS model, steroid-eluting FCSEMS showed potential as a safe and effective treatment modality to reduce fibrotic tissue. Studies are required to confirm their safety and efficacy in humans with refractory BBS.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Sungsoon Fang
- Severance Biomedical Science Institute, BK21 Plus Project for Medical Science, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Hae Nahm
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea.
| | - Min Young Do
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Su Yeon Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
| | - Don Haeng Lee
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
- Utah-Inha DDS & Advanced Therapeutics Research Center, Incheon, Republic of Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea.
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Sasaki K, Ota H, Miyagi S, Tokodai K, Fujio A, Kashiwadate T, Miyazawa K, Matsumura M, Saitoh Y, Kanai N, Nishimaki H, Takase K, Unno M, Kamei T. Novel technique for recanalization of severe hepaticojejunal obstruction using a transseptal needle in a pediatric liver transplant recipient. Pediatr Transplant 2022; 26:e14160. [PMID: 34633121 DOI: 10.1111/petr.14160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 09/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endoscopic and PTB interventions are common nonsurgical interventions for biliary anastomotic strictures that occur after liver transplantation. When these nonsurgical interventions fail, surgical re-anastomosis is considered; however, this is quite invasive and can cause additional injury that may lead to graft loss. We report a case in which conventional nonsurgical interventions failed, but a new method that involve the use of a transseptal needle-a device to create a transseptal left-heart access during cardiac catheter interventions-was successfully used in recanalization of the hepaticojejunal anastomotic obstruction. CASE A 21-year-old man, who had received living-donor liver transplantation for biliary atresia at the age of 23 months presented with recurrent cholangitis and liver dysfunction due to a biliary anastomotic stricture of the hepaticojejunostomy. Therapeutic interventions for biliary stricture, including the PTB approach, double-balloon enteroscopic approach, and rendezvous approach failed. We then performed needle puncture of the anastomotic obstruction using a transseptal needle and succeeded in recanalizing the complete anastomotic obstruction. To perform the procedures safely, we evaluated the organ and needle positions using biplane fluoroscopy and placed a balloon in the afferent jejunal limb as a target for puncture. The 12 Fr catheter via the biliary route was removed 7 months after the procedure, without using a catheter, there was no recurrent stricture or cholangitis for 26 months. CONCLUSION Using a transseptal needle to manage hepaticojejunal anastomotic obstruction can reduce the number of patients who need surgical re-anastomosis.
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Affiliation(s)
- Kengo Sasaki
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hideki Ota
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shigehito Miyagi
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuaki Tokodai
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Atsushi Fujio
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshiaki Kashiwadate
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Koji Miyazawa
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Muneyuki Matsumura
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshikatsu Saitoh
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Norifumi Kanai
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroyasu Nishimaki
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Zhao G, Tian Y, Hua R, Liu Q, Cheng J, Wu G, Zhang Y, Ni Z. A poly(
l
‐lactic acid) braided stent with high mechanical properties during in vitro degradation in bile. J Appl Polym Sci 2022. [DOI: 10.1002/app.51685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Gutian Zhao
- School of Mechanical Engineering, Jiangsu Key Laboratory for Design and Manufacture of Micro‐Nano Biomedical Instruments Southeast University Nanjing China
| | - Yuan Tian
- School of Mechanical Engineering, Jiangsu Key Laboratory for Design and Manufacture of Micro‐Nano Biomedical Instruments Southeast University Nanjing China
| | - Rixin Hua
- School of Mechanical Engineering, Jiangsu Key Laboratory for Design and Manufacture of Micro‐Nano Biomedical Instruments Southeast University Nanjing China
| | - Qingwei Liu
- School of Mechanical Engineering, Jiangsu Key Laboratory for Design and Manufacture of Micro‐Nano Biomedical Instruments Southeast University Nanjing China
| | - Jie Cheng
- School of Mechanical Engineering, Jiangsu Key Laboratory for Design and Manufacture of Micro‐Nano Biomedical Instruments Southeast University Nanjing China
| | - Gensheng Wu
- School of Mechanical and Electronic Engineering Nanjing Forestry University Nanjing China
| | - Yi Zhang
- Center of Interventional Radiology & Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School Southeast University Nanjing China
| | - Zhonghua Ni
- School of Mechanical Engineering, Jiangsu Key Laboratory for Design and Manufacture of Micro‐Nano Biomedical Instruments Southeast University Nanjing China
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Percutaneous Biliary Neo-anastomosis or Neo-duct Creation Using Radiofrequency Wires. Cardiovasc Intervent Radiol 2022; 45:337-343. [PMID: 35106635 DOI: 10.1007/s00270-022-03059-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/04/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE This study aims to report a minimally invasive, percutaneous technique to cross complete biliary occlusions using a radiofrequency wire to create a biliary-enteric neo-anastomosis or biliary neo-duct. METHODS All patients who underwent attempted creation of a neo-anastomosis/neo-duct using an RF wire were included in the study. Patients with non-malignant, complete and non-traversable biliary occlusion were considered for the creation of a neo-anastomosis (4 patients)/neo-duct (1 patient). RESULTS Five patients (4 females, 1 male) with a mean age of 40 years (range: 10-69 years) were included in this study. Percutaneous bowel access was obtained in three of five patients and a snare was placed in the jejunal loop to serve as a target for RF wire advancement. In two patients, an enteral target was provided using a peroral endoscope in collaboration with gastroenterology. The procedure was technically successful in all cases and no intra-operative complications occurred. Patency of the neo-anastomosis was maintained in all patients, with follow-up ranging from 4 to 11 months. CONCLUSION The RF wire was successfully used to create a biliary neo-anastomosis with a minimally invasive approach for the treatment of non-malignant complete biliary occlusion. This technique offers patients with complete biliary occlusion a safe, effective and durable treatment option which avoids the need for a permanent biliary drain and ultimately results in an improved quality of life.
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Lam R, Muniraj T. Fully covered metal biliary stents: A review of the literature. World J Gastroenterol 2021; 27:6357-6373. [PMID: 34720527 PMCID: PMC8517778 DOI: 10.3748/wjg.v27.i38.6357] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/09/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.
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Affiliation(s)
- Robert Lam
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520, United States
| | - Thiruvengadam Muniraj
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520, United States
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Javed A, Shashikiran BD, Aravinda PS, Agarwal AK. Laparoscopic versus open surgery for the management of post-cholecystectomy benign biliary strictures. Surg Endosc 2021; 35:1254-1263. [PMID: 32179999 DOI: 10.1007/s00464-020-07496-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Surgical management by a bilioenteric anastomosis is the standard for the repair of post-cholecystectomy benign biliary strictures (BBS). This is traditionally done as an open operation. There are a few reports describing the procedure by a laparoscopic technique. The aim of the present study was to describe our experience of laparoscopic bilio-enteric anastomosis [Roux-en-Y hepaticojejunostomy (LRYHJ)/laparoscopic hepaticoduodenostomy (LHD)] in the management of post-cholecystectomy BBS and compare the outcomes with our patients operated by the open approach. METHODS Retrospective analysis of prospective data of post-cholecystectomy BBS patients treated by laparoscopic bilio-enteric anastomosis. The outcomes were compared with patients who underwent an open repair. RESULTS Between January 2016 and February 2019, 63 patients underwent surgery for post-cholecystectomy BBS. Twenty-nine patients who underwent laparoscopic bilio-enteric anastomosis (LRYHJ-13, LHD-16) were compared with 34 patients who underwent an open repair. The median age (40 vs 39) years, type of index surgery [laparoscopic cholecystectomy (13 vs 15), laparoscopic converted to open cholecystectomy (10 vs 16), and open cholecystectomy (6 vs 3)], type of injury low stricture (7 vs 5) and high stricture (22 vs 29), preoperative biliary fistula (23 vs 30), and time from injury to repair (6 vs 7 months) were similar in the 2 groups. The median duration of surgery was also similar (210 vs 200 min, p = 0.937); however, the median intraoperative blood loss (50 mL vs 200 mL, p = 0.001), time to resume oral diet (2 vs 4 days p = 0.023),** and median duration of postoperative hospital stay (6 vs 8 days, p = 0.001) were significantly less in the laparoscopy group. Overall morbidity rate (within 30 days post-surgery) was significantly higher in the open repair group (38% vs 20%). In a subgroup analysis of the laparoscopic repair group, the operative time in patients who underwent an LHD was significantly less than LRYHJ (190 vs 230 min, p = 0.034). The other parameters like the mean intraoperative blood loss, time to initiate oral diet, duration of postoperative hospital stay, and incidence of postoperative bile leak were similar. Patients undergoing open repair had a median follow-up of 26 months with two developing anastomotic stenosis and those undergoing laparoscopic repair had a median follow-up for 9 months with one developing anastomotic stenosis. CONCLUSION Laparoscopic surgery for post-cholecystectomy BBS with an LRYHJ or LHD is feasible and safe and compares favourably with the open approach.
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Affiliation(s)
- Amit Javed
- Department of Gastrointestinal Surgery and Liver Transplantation, GB Pant Institute of Post Graduate Medical Education and Research and MAM College, University of Delhi, New Delhi, India.
| | - B D Shashikiran
- Department of Gastrointestinal Surgery and Liver Transplantation, GB Pant Institute of Post Graduate Medical Education and Research and MAM College, University of Delhi, New Delhi, India
| | - P S Aravinda
- Department of Gastrointestinal Surgery and Liver Transplantation, GB Pant Institute of Post Graduate Medical Education and Research and MAM College, University of Delhi, New Delhi, India
| | - Anil K Agarwal
- Department of Gastrointestinal Surgery and Liver Transplantation, GB Pant Institute of Post Graduate Medical Education and Research and MAM College, University of Delhi, New Delhi, India
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12
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Tian Y, Zhang J, Cheng J, Wu G, Zhang Y, Ni Z, Zhao G. A poly(L‐lactic acid) monofilament with high mechanical properties for application in biodegradable biliary stents. J Appl Polym Sci 2021. [DOI: 10.1002/app.49656] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yuan Tian
- School of Mechanical Engineering, Jiangsu Key Laboratory for Design and Manufacture of Micro‐Nano Biomedical Instruments, Southeast University Nanjing China
| | - Jing Zhang
- School of Mechanical Engineering, Jiangsu Key Laboratory for Design and Manufacture of Micro‐Nano Biomedical Instruments, Southeast University Nanjing China
| | - Jie Cheng
- School of Mechanical Engineering, Jiangsu Key Laboratory for Design and Manufacture of Micro‐Nano Biomedical Instruments, Southeast University Nanjing China
| | - Gensheng Wu
- School of Mechanical and Electronic Engineering, Nanjing Forestry University Nanjing China
| | - Yi Zhang
- Center of Interventional Radiology & Vascular Surgery, Department of Radiology Zhongda Hospital, Medical School, Southeast University Nanjing China
| | - Zhonghua Ni
- School of Mechanical Engineering, Jiangsu Key Laboratory for Design and Manufacture of Micro‐Nano Biomedical Instruments, Southeast University Nanjing China
| | - Gutian Zhao
- School of Mechanical Engineering, Jiangsu Key Laboratory for Design and Manufacture of Micro‐Nano Biomedical Instruments, Southeast University Nanjing China
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Dorrell R, Pawa S, Zhou Y, Lalwani N, Pawa R. The Diagnostic Dilemma of Malignant Biliary Strictures. Diagnostics (Basel) 2020; 10:diagnostics10050337. [PMID: 32466095 PMCID: PMC7277979 DOI: 10.3390/diagnostics10050337] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/15/2020] [Accepted: 05/21/2020] [Indexed: 12/13/2022] Open
Abstract
The differential diagnosis for biliary strictures is broad. However, the likelihood of malignancy is high. Determining the etiology of a biliary stricture requires a comprehensive physical exam, laboratory evaluation, imaging, and ultimately tissue acquisition. Even then, definitive diagnosis is elusive, and many strictures remain indeterminant in origin. This literary review examines the diagnostic dilemma of biliary strictures and presents innovations in both histochemical and endoscopic techniques that have increased the diagnostic power of differentiating benign and malignant strictures. The field of tissue biopsy is revolutionizing with the advent of free DNA mutation profiling, fluorescence in situ hybridization (FISH), and methionyl t-RNA synthetase 1 (MARS 1), which allow for greater testing sensitivity. Endoscopic ultrasound, endoscopic retrograde cholangiopancreatography (ERCP), cholangioscopy, confocal laser endomicroscopy, and intraductal ultrasound build upon existing endoscopic technology to better characterize strictures that would otherwise be indeterminate in etiology. This review uses recent literature to insert innovative technology into the traditional framework of diagnostic methods for malignant biliary strictures.
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Affiliation(s)
- Robert Dorrell
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA;
| | - Swati Pawa
- Division of Gastroenterology, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA;
| | - Yi Zhou
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA;
| | - Neeraj Lalwani
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA;
| | - Rishi Pawa
- Division of Gastroenterology, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA;
- Correspondence:
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Biodegradable versus multiple plastic stent implantation in benign biliary strictures: A systematic review and meta-analysis. Eur J Radiol 2020; 125:108899. [DOI: 10.1016/j.ejrad.2020.108899] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
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15
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De Gregorio MA, Criado E, Guirola JA, Alvarez-Arranz E, Pérez-Lafuente M, Barrufet M, Ferrer-Puchol MD, Lopez-Minguez S, Urbano J, Lanciego C, Aguinaga A, Capel A, Ponce-Dorrego MD, Gregorio A. Absorbable stents for treatment of benign biliary strictures: long-term follow-up in the prospective Spanish registry. Eur Radiol 2020; 30:4486-4495. [PMID: 32221684 DOI: 10.1007/s00330-020-06797-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/01/2020] [Accepted: 03/09/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Benign strictures of the bile duct may be difficult to treat endoscopically due to altered bowel anatomy. Furthermore, recurrence of stenosis and symptoms remains high. The aim of the Spanish Prospective Registry BiELLA study was to investigate the safety and efficacy of absorbable stents in the treatment of benign biliary strictures and their outcomes on the medium and long-term follow-up. METHODS A prospective, multicenter, observational, non-randomized study (the BiELLA study) was conducted from January 2014 to September 2018. One hundred fifty-nine patients with benign biliary strictures, mostly postsurgical, were enrolled for implantation of absorbable biliary stents in the 11 participating Spanish tertiary hospitals. The average patient follow-up was 45.4 ± 15.9 months (range, 12-60 months). The follow-up data included symptoms, biochemical parameters, and ultrasound images at 1, 6, and 12 months and then yearly for up to 60 months. RESULTS The immediate technical and clinical success rates were 100%. In all patients, stent placement resulted in improvement of clinical symptoms and biochemical parameters. The primary mean patency for stent was 86.7, 79.6, and 78.9% at 12, 36, and 60 months, respectively (95% CI). Biliary restenosis and occlusion occurred in 40 (26.6%) patients. Of the 40 patients, 18 (12%) patients were treated with a second stent and 22 (14.6%) patients had operative repair of the recurrent strictures. There were no major complications associated with stent implantation. CONCLUSIONS Implantation of an absorbable polydioxanone biliary stent is safe and effective for treatment of benign biliary strictures refractory to balloon dilatation or other biliary intervention. KEY POINTS • Percutaneous implantation of biodegradable prostheses for the treatment of benign postsurgical biliary strictures is a safe and effective procedure. • More than 75% of the patients presented patency of the stented biliary tree at 5 years follow-up. • Absorbable stents improved clinical symptoms and signs (jaundice, itching, fever), and laboratory parameters in a few days after stent placement.
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Affiliation(s)
- Miguel A De Gregorio
- Interventional Radiology Research Group (GITMI), University of Zaragoza, Zaragoza, Spain
| | - Eva Criado
- Interventional Radiology Unit, UDIAT-Centre Diagnòstic, Hospital Universitario Parc Tauli Sabadell, Medicine Department Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Jose A Guirola
- Interventional Radiology Research Group (GITMI), University of Zaragoza, Zaragoza, Spain
| | - Enrique Alvarez-Arranz
- Interventional Radiology Research Group (GITMI), University of Zaragoza, Zaragoza, Spain.
| | | | - Marta Barrufet
- Interventional Radiology Unit, Hospital Clínic i Provincial, Barcelona, Spain
| | - Maria D Ferrer-Puchol
- Interventional Radiology Unit, Hospital Universitario La Ribera, Alzira, Valencia, Spain
| | - Sandra Lopez-Minguez
- Interventional Radiology Research Group (GITMI), University of Zaragoza, Zaragoza, Spain
| | - Jose Urbano
- Interventional Radiology Unit, Hospitales Vithas, Madrid, Spain
| | - Carlos Lanciego
- Interventional Radiology Unit, Hospital Universitario Virgen de la Salud, Toledo, Spain
| | - Alexander Aguinaga
- Interventional Radiology Unit, Hospital Universitario de Cruces, Bilbao, Spain
| | - Antonio Capel
- Interventional Radiology Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | | | - Abel Gregorio
- Interventional Radiology Unit, Hospital de Denia Marina Salud, Alicante, Spain
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The use of a 532-nm laser fitted with a balloon and a cylindrical light diffuser to treat benign biliary stricture: a pilot study. Lasers Med Sci 2020; 36:25-31. [PMID: 32157583 DOI: 10.1007/s10103-020-02992-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 02/26/2020] [Indexed: 01/29/2023]
Abstract
Endoscopic management of benign biliary stricture (BBS) remains challenging. Stenting is currently used for BBS management, but refractory BBS remains problematic. The aim of this study was to assess the safety and feasibility of a dilation balloon-equipped cylindrical light diffuser for BBS in a large animal model. A total of seven mini-pigs were used in the current study. Laser settings were chosen based on the findings of a previous animal study. Five animals were used in a preliminary study to establish process conditions. BBSs were created in the common bile ducts of the other two animals by intraductal radiofrequency ablation (RFA) via endoscopic retrograde cholangiography (ERC). At 4 weeks post-RFA, laser ablation was performed using a customized balloon-equipped cylindrical diffuser at 10 W for 10 s while maintaining balloon inflation for 10 s at 5 atm. A follow-up ERC was performed at 4 weeks post-laser ablation and the animals were sacrificed for histologic evaluation. BBS was observed in all animals by ERC at 4 weeks post-RFA. The mean bile duct stricture diameter in the two animals as determined by ERC was 0.8 mm. Laser ablations were performed without technical difficulty and no adverse event was encountered. At 4 weeks post-laser ablation, mean biliary stricture diameter had dilated to 1.6 mm on cholangiographic finding. On histologic examination, inflammatory cell infiltration in lamina propria and dense collagen deposition were observed, but there was no evidence of bile duct perforation. The devised balloon-equipped cylindrical laser light diffuser appears to be safe and feasible for the treatment of BBS. However, further studies and modifications are required before it can be applied clinically as a monotherapy.
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Kapoor BS, Mauri G, Lorenz JM. Management of Biliary Strictures: State-of-the-Art Review. Radiology 2018; 289:590-603. [PMID: 30351249 DOI: 10.1148/radiol.2018172424] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Biliary strictures can be broadly classified as benign or malignant. Benign biliary strictures are most commonly iatrogenic in nature and are a consequence of hepatobiliary surgery. Cholangiocarcinoma and adenocarcinoma of the pancreas are the most common causes of malignant biliary obstruction. This article reviews state-of-the-art minimally invasive techniques used to manage these strictures. In addition, the roles of (a) recently introduced biodegradable biliary stents in the management of benign biliary strictures and (b) intraprocedural imaging and navigation tools, such as cone-beam CT, in percutaneous reconstruction of the biliary-enteric anastomosis are discussed.
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Affiliation(s)
- Baljendra S Kapoor
- From the Department of Radiology, Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, L10, Cleveland, OH 44195-5243 (B.S.K.); Division of Interventional Radiology, IEO, European Institute of Oncology IRCCS, Milan, Italy (G.M.); and Department of Radiology, University of Chicago Medical Center, Chicago, Ill (J.M.L.)
| | - Giovanni Mauri
- From the Department of Radiology, Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, L10, Cleveland, OH 44195-5243 (B.S.K.); Division of Interventional Radiology, IEO, European Institute of Oncology IRCCS, Milan, Italy (G.M.); and Department of Radiology, University of Chicago Medical Center, Chicago, Ill (J.M.L.)
| | - Jonathan M Lorenz
- From the Department of Radiology, Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, L10, Cleveland, OH 44195-5243 (B.S.K.); Division of Interventional Radiology, IEO, European Institute of Oncology IRCCS, Milan, Italy (G.M.); and Department of Radiology, University of Chicago Medical Center, Chicago, Ill (J.M.L.)
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18
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Jang SI, Lee DK. Anastomotic stricture after liver transplantation: It is not Achilles' heel anymore! INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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19
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Biliary reconstruction with a pedicled gallbladder flap in patients during pancreaticoduodenectomy. J Surg Res 2018; 225:76-81. [DOI: 10.1016/j.jss.2018.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 12/10/2017] [Accepted: 01/03/2018] [Indexed: 11/21/2022]
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20
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Kirkpatrick DL, Hasham H, Collins Z, Johnson P, Lemons S, Shahzada H, Hunt SL, Walter C, Hill J, Fahrbach T. The Utility of a Benign Biliary Stricture Protocol in Preventing Symptomatic Recurrence and Surgical Revision. J Vasc Interv Radiol 2018; 29:688-694. [PMID: 29398411 DOI: 10.1016/j.jvir.2017.10.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 10/30/2017] [Accepted: 10/31/2017] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To determine whether treating benign biliary strictures via a stricture protocol reduced the probability of developing symptomatic recurrence and requiring surgical revision compared to nonprotocol treatment. MATERIALS AND METHODS A stricture protocol was designed to include serial upsizing of internal/external biliary drainage catheters to a target maximum dilation of 18-French, optional cholangioplasty at each upsizing, and maintenance of the largest catheter for at least 6 months. Patients were included in this retrospective analysis if they underwent biliary ductal dilation at a single institution from 2005 to 2016. Forty-two patients were included, 25 women and 17 men, with an average age of 51.9 years (standard deviation ± 14.6). Logistic regression models were used to determine the probability of symptomatic recurrence and surgical revision by stricture treatment type. RESULTS Twenty-two patients received nonprotocol treatment, while 20 received treatment on a stricture protocol. After treatment, 7 (32%) patients in the nonprotocol group experienced clinical or laboratory recurrence of a benign stricture, whereas only 1 patient in the stricture protocol group experienced symptom recurrence. Patients in the protocol group were 8.9 times (95% confidence interval [CI] = 1.4-175.3) more likely to remain symptom free than patients in the nonprotocol group. Moreover, patients in the protocol group had an estimated 89% reduction in the probability of undergoing surgical revision compared to patients receiving nonprotocol treatment (odds ratio = .11, 95% CI = .01-.73). CONCLUSIONS Establishing a stricture protocol may decrease the risk of stricture recurrence and the need for surgical revision when compared to a nonprotocol treatment approach.
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Affiliation(s)
- Daniel L Kirkpatrick
- Department of Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, Kansas, 66160.
| | - Hasnain Hasham
- Department of Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, Kansas, 66160
| | - Zachary Collins
- Department of Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, Kansas, 66160
| | - Philip Johnson
- Department of Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, Kansas, 66160
| | - Steven Lemons
- Department of Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, Kansas, 66160
| | - Hassan Shahzada
- Department of Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, Kansas, 66160
| | - Suzanne L Hunt
- Department of Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, Kansas, 66160
| | - Carissa Walter
- Department of Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, Kansas, 66160
| | - Jacqueline Hill
- Department of Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, Kansas, 66160
| | - Thomas Fahrbach
- Department of Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, Kansas, 66160
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Jang SI, Lee KH, Yoon HJ, Lee DK. Treatment of completely obstructed benign biliary strictures with magnetic compression anastomosis: follow-up results after recanalization. Gastrointest Endosc 2017; 85:1057-1066. [PMID: 27619787 DOI: 10.1016/j.gie.2016.08.047] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 08/27/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although nonsurgical methods produce high clinical success rates in the treatment of benign biliary stricture (BBS), conventional methods are not always successful in cases of severe biliary stricture or complete obstruction. Therefore, the efficacy of magnetic compression anastomosis (MCA) for treatment of refractory BBS was evaluated in a single-center, nonrandomized study. METHODS MCA was performed in patients with BBS that was not resolved by conventional endoscopic or percutaneous treatments. One magnet was delivered through the percutaneous transhepatic biliary drainage tract, and the other advanced through 1 of 3 different routes. After magnet approximation and recanalization, an internal drainage catheter was placed for 6 months. RESULTS This study followed 39 patients who underwent MCA after the development of postoperative or traumatic strictures. Recanalization was achieved successfully in 35 patients. There was an acceptable procedure-related adverse event of mild cholangitis in 1 patient and no procedure-related mortalities. The average elapsed time from magnet approximation to removal was 57.4 days (range, 13-182 days), and the mean follow-up period after recanalization was 41.9 months (range, 7.1-73.4 months). Restenosis after MCA recurred in 1 patient, and partial restenosis occurred in another patient, but recanalization in these patients was successful using a guidewire via the percutaneous and endoscopic tracts. CONCLUSIONS MCA represents an alternative nonsurgical recanalization method for BBSs that cannot be treated by conventional methods. The rate of stricture recurrence after MCA was lower than that after conventional methods, likely because of the creation of a new fistula tract instead of dilation of a previous stricture.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea; Department of Medicine, The Graduate School of Yonsei University, Seoul, Republic of Korea
| | - Kwang-Hun Lee
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hong Jin Yoon
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Mauri G, Michelozzi C, Melchiorre F, Poretti D, Pedicini V, Salvetti M, Criado E, Falcò Fages J, De Gregorio MÁ, Laborda A, Sonfienza LM, Cornalba G, Monfardini L, Panek J, Andrasina T, Gimenez M. Benign biliary strictures refractory to standard bilioplasty treated using polydoxanone biodegradable biliary stents: retrospective multicentric data analysis on 107 patients. Eur Radiol 2016; 26:4057-4063. [DOI: 10.1007/s00330-016-4278-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/23/2015] [Accepted: 02/08/2016] [Indexed: 01/20/2023]
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Hsieh CE, Chou CT, Lin CC, Chen CB, Lin KH, Lin PY, Chen YL. Portal Vein Thrombosis and Arterioportal Shunting Due To Chronic Cholangitis: A Rare Complication of Living-Donor Liver Transplant. EXP CLIN TRANSPLANT 2016; 15:474-476. [PMID: 26790032 DOI: 10.6002/ect.2015.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES We present a patient with portal vein thrombosis due to chronic cholangitis after undergoing a living-donor liver transplant. CASE PRESENTATION A 52-year-old woman with a history of hepatitis B virus-related liver cirrhosis underwent a living-donor liver transplant. After the surgery, the patient had recurrent episodes of cholangitis because of common and intrahepatic bile duct stricture. Biliary stricture because of cholangitis eventually resulted in acute portal vein thrombosis. A stent was inserted by percutaneous transluminal portography. Blood flow through the portal vein progressively improved from the third through the 10th day after stent placement. The anticoagulation regimen was change to acetylsalicylic acid and clopidogrel hydrogen sulfate (Plavix). On poststenting day 10, a follow-up computed tomographic scan showed good patency of the main portal vein and no evidence of arterioportal shunting. CONCLUSIONS Cholangitis after living-donor liver transplant is a rare cause of portal vein thrombosis. Regular follow-up examinations with color Doppler ultrasound are required to monitor portal vein flow in patients with biliary complications after living-donor liver transplant.
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Affiliation(s)
- Chia-En Hsieh
- From the Department of Liver Transplantation, Changhua Christian Hospital, Changhua, Taiwan
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Gupta V, Umapathy L, Gulati A, Singh G. 'O' configuration of biliary-enteric drainage: a preventable surgical error. Indian J Surg 2015; 77:156-8. [PMID: 25972680 DOI: 10.1007/s12262-015-1219-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 01/05/2015] [Indexed: 10/24/2022] Open
Abstract
Surgical errors in Roux limb reconstruction are not reported widely. A young male who underwent hepaticojejunostomy after biliary injury developed acute obstruction of the proximal jejunum. Barium study revealed the O configuration of alimentary limb-'O' sign. At laparotomy, he was found to have the alimentary limb joining on to itself and without any connection with the biliary limb. The O loop complex was resected, and Roux-en-Y construction was refashioned. He made an uneventful recovery and is well at one year follow-up. We have reviewed the literature and propose a classification system for such type of errors. Every effort should be made to prevent this complication.
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Affiliation(s)
- Vikas Gupta
- Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Lohith Umapathy
- Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Ajay Gulati
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gurpreet Singh
- Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012 India
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Mauri G, Mattiuz C, Sconfienza LM, Pedicini V, Poretti D, Melchiorre F, Rossi U, Lutman FR, Montorsi M. Role of interventional radiology in the management of complications after pancreatic surgery: a pictorial review. Insights Imaging 2014; 6:231-9. [PMID: 25516470 PMCID: PMC4376815 DOI: 10.1007/s13244-014-0372-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/01/2014] [Accepted: 11/18/2014] [Indexed: 01/04/2023] Open
Abstract
Pancreatic resections are surgical procedures associated with high incidence of complications, with relevant morbidity and mortality even at high volume centres. A multidisciplinary approach is essential in the management of these events and interventional radiology plays a crucial role in the treatment of patients developing post-surgical complications. This paper offers an overview on the interventional radiological procedures that can be performed to treat different type of complications after pancreatic resection. Procedures such as percutaneous drainage of fluid collections, percutaneous transhepatic biliary procedures, arterial embolisation, venous interventions and fistula embolisation are viable treatment options, with fewer complications compared with re-look surgery, shorter hospital stay and faster recovery. A selection of cases of complications following pancreatic surgery managed with interventional radiological procedure are presented and discussed. Teaching Points • Interventional radiology is crucial to treat complications after pancreatic surgery • Percutaneous drainage of collections can be performed under ultrasound or computed tomography guidance • Percutaneous biliary procedures can be used to treat biliary complications • Venous procedures can be performed effectively through transhepatic or transjugular access • Fistulas can be treated effectively by percutaneous embolisation.
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Affiliation(s)
- Giovanni Mauri
- Servizio di Radiologia, IRCCS Policlinico San Donato, San Donato Milanese, Milano, Italy,
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Sugawara G, Ebata T, Yokoyama Y, Igami T, Mizuno T, Nagino M. Management strategy for biliary stricture following laparoscopic cholecystectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:889-95. [PMID: 25159686 DOI: 10.1002/jhbp.151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Biliary strictures following laparoscopic cholecystectomy (Lap-C), which are often associated with vascular injuries, remain a serious problem to manage. The aim of this study was to review our experiences with postoperative biliary stricture. METHODS This study involved 14 consecutive patients with biliary strictures that resulted from bile duct injuries during Lap-C between 1997 and 2013. Their medical records were retrospectively analyzed. RESULTS Percutaneous transhepatic biliary drainage (PTBD) catheter dilatation was first attempted in eight patients, and five patients were successfully treated. Biliary re-stricture recurred in one patient after 34-month follow-up period. This patient underwent repeated catheter dilatations, which led to recurrent stricture resolution. All five patients maintained biliary tract patency over 72-month follow-up period. The remaining nine patients underwent surgical procedures, including hepaticojejunostomy in two patients, re-hepaticojejunostomy in two patients, and the remaining five patients, with biliary strictures involving the secondary biliary branch and concomitant vascular injuries underwent right hemihepatectomy with cholangiojejunostomy. There were no major postoperative complications. After 80-month follow-up period, all nine patients were alive without biliary stricture. CONCLUSIONS PTBD catheter dilatation is recommended first for postoperative Lap-C-associated biliary strictures. In complicated injury patients with vascular injuries, right hemihepatectomy with cholangiojejunostomy should be indicated.
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Affiliation(s)
- Gen Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Hu B, Leung JW, Gao DJ, Wang TT, Wu J. Management of benign biliary strictures with a novel retrievable self-expandable metal stent. J Dig Dis 2014; 15:146-53. [PMID: 24528634 DOI: 10.1111/1751-2980.12117] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Endoscopic placement of covered self-expandable metal stent (SEMS) has gained popularity in the management of benign biliary strictures (BBS). 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. This study aimed to design a novel retrievable SEMS dedicated to the treatment of extrahepatic BBS and evaluate its clinical efficacy and safety. METHODS A short fully covered SEMS (FCSEMS) with a retrieval lasso was designed for the specific treatment of BBS. A total of 45 patients with segmental extrahepatic BBS were included in this study. The stent was placed entirely inside the bile duct with only the retrieval lasso extending from the papilla. The stents were recommended to be in situ for 6 to 12 months before removal. RESULTS The FCSEMS was successfully placed in all 45 patients. In all, 33 patients had their FCSEMS successfully removed after a mean period of 8.6 ± 3.7 (range 2-15.5) months. Stent migration occurred in 9.1% of the patients. During a mean follow-up of 18.9 months after stent removal, recurrent stricture was found in 2 (6.1%) patients and was successfully treated with a second FCSEMS. Overall, the strictures resolved in 30/33 (90.9%) patients. CONCLUSIONS Intraductal placement of a short FCSEMS is suitable for the treatment of segmental extrahepatic BBS. This new removable design offered prolonged stenting and drainage for BBS for up to one year with minimal complications.
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Affiliation(s)
- Bing Hu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
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Mauri G, Michelozzi C, Melchiorre F, Poretti D, Tramarin M, Pedicini V, Solbiati L, Cornalba G, Sconfienza LM. Biodegradable biliary stent implantation in the treatment of benign bilioplastic-refractory biliary strictures: preliminary experience. Eur Radiol 2013; 23:3304-3310. [PMID: 23842947 DOI: 10.1007/s00330-013-2947-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 05/25/2013] [Accepted: 05/28/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To evaluate feasibility, safety, and outcome of patients treated with biodegradable biliary stents for benign biliary stenosis refractory to other treatments. METHODS Between March 2011 and September 2012, ten patients (seven men, three women; age 59 ± 7 years) with recurrent cholangitis due to postsurgical biliary stricture, previous multiple unsuccessful (two to five) bilioplasties, and unsuitability for surgical/endoscopic repair underwent percutaneous implantation of a biodegradable biliary stent. Patients were followed-up clinically and with ultrasound at 1, 3 and 6 months, and then at 6-month intervals. RESULTS Stent implantation was always feasible. No immediate major or minor complications occurred. In all patients, 48-h cholangiographic control demonstrated optimal stent positioning and stenosis resolution. In a median follow-up time of 16.5 months (25th-75th percentiles = 11-20.25 months) no further invasive treatment was needed. Three patients experienced transient episodes of cholangitis. Neither re-stenosis nor dilatation of the biliary tree was documented during follow-up. No stent was visible at the 6-month follow-up. CONCLUSIONS Percutaneous placement of biodegradable biliary stents represents a new option in treating benign biliary stenoses refractory to treatment with bilioplasty. This technique seems to be feasible, effective and free from major complications. Further investigations are warranted to confirm our preliminary results.
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Affiliation(s)
- Giovanni Mauri
- Servizio di Radiologia, IRCCS Policlinico San Donato, San Donato Milanese, Milano, Italy,
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Nguyen NQ, Schoeman MN, Ruszkiewicz A. Clinical utility of EUS before cholangioscopy in the evaluation of difficult biliary strictures. Gastrointest Endosc 2013; 78:868-874. [PMID: 23800700 DOI: 10.1016/j.gie.2013.05.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 05/13/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biliary tract malignancies can be assessed with either EUS or SpyGlass cholangioscopy (SGC). OBJECTIVE To evaluate the impact of EUS and guided biopsy before considering SGC in patients who had biliary strictures with negative ductal brushing. DESIGN Prospective, observational study. SETTING Tertiary level referral hospital. PATIENTS Forty consecutive patients with biliary strictures. INTERVENTION EUS evaluation and biopsy, where possible, were performed in all patients. If EUS examination failed to provide a definitive diagnosis, SGC and ductal biopsy was performed. Results were compared with surgical specimens or positive histocytology. MAIN OUTCOME MEASUREMENTS Tissue diagnosis, technical success, adverse events, and clinical outcomes. RESULTS On EUS, abnormalities responsible for the biliary strictures were identified in 39 patients (98%), with FNA achievable in 30 patients (75%). EUS-FNA provided positive histocytology in 23 patients (58%). SGC-guided biopsy was performed to evaluate nondiagnostic EUS-FNA (17 patients) and to clarify autoimmune pancreatitis on FNA (2 patients). The procedure was successful in 18 patients (95%) and provided tissue diagnosis in 16 patients (88%), with 2 false-negative results from extrinsic pathologies. When EUS was used before the SGC approach, the need for SGC was avoided in 24 patients (60%), cholangitis was minimized in 2.5%, and a cost saving of U.S.$110,000 was realized. Tissue diagnosis was achieved in 38 patients (94%) with this approach. LIMITATIONS Relatively small sample size. CONCLUSIONS EUS evaluation in patients with difficult biliary stricture prevents the need, cost, and adverse events of SGC in 60% of patients. Together, EUS followed by the SGC approach provides correct clinical diagnosis in 94% of patients with minimal adverse events.
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Affiliation(s)
- Nam Q Nguyen
- Department of Gastroenterology & Hepatology, Royal Adelaide Hospital, Adelaide, South Australia; Department of Medicine, University of Adelaide, Adelaide, South Australia
| | - Mark N Schoeman
- Department of Gastroenterology & Hepatology, Royal Adelaide Hospital, Adelaide, South Australia
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