Endoscopic management of benign biliary strictures. Longterm outcomes of a benign biliary stricture protocol. Only surgeons well trained and experienced in their management should treat this entity. Fraiman and his team of experts and get help right away. Design of a stent for treatment of benign distal biliary strictures endoscopy international open 2016. 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. In patients with benign biliary strictures, the use of fully covered selfexpandable metal stents sems has been proposed as an alternative to plastic stenting, but high quality prospective data are sparse. When this happens, bile can back up into the liver, causing abdominal pain, nausea, itching, fever, chills, and jaundice. Yang z, zheng x, asiapacific consensus guidelines for endoscopic management of benign biliary strictures, gastrointestinal endoscopy 2017, doi. Biliary stricture is likely to occur in cases without proper management of bdi, may be causing such severe complications as repeated strictures, cholangitis or impairment to liver function. The majority of benign strictures are iatrogenic, mainly because of bile duct injury during cholecystectomy, anastomotic healing after orthotopic liver transplantation olt, or biliary bypass.
Successful management of benign biliary strictures with. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures. The stent is fully covered with a silicone polymer to reduce the potential of tissue ingrowth into the stent. Pathological effects of biliary obstruction biliary obstruction high. However, hilar biliary stricture where operative management is necessary 3. Our aim was to analyze our experience with the surgical repair of benign biliary strictures in the decade since the heppcouinaud technique has become an integral component of our surgical management strategy. Endoscopy has an established role in the diagnosis and therapy of biliary strictures. Any information contained in this pdf file is automatically generated from digital material submitted to epos by third parties in the form of scientific presentations. Pathology etiology there are numerous causes of biliary duct strictures, including 1,2. A biliary stricture is a narrowing of the common bile duct. Bile duct stricture biliary stricture is an uncommon but challenging clinical condition that requires a coordinated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. The majority of benign strictures are iatrogenic, secondary to bile duct injury after liver transplantation or laparoscopic cholecystectomy, with.
Genetic abnormalities in biliary brush samples for. If you are in the baltimore region and fear you may have a bile duct stricture, or a related condition that may cause a stricture in the future, contact dr. The injury may be a single acute event, such as damage to the bile ducts during surgery or trauma to the abdomen. Most biliary strictures result from injuries during cholecystectomies, and their initial management is a major determining factor of the longterm outcome. Biliary stricture can be seen with a wide array of nonneoplastic causes. Pdf endoscopy is a widely used approach for the treatment of benign biliary strictures. However, most studies report a poor sensitivity of 27% to 56%1114.
Patients and methods patients selection all patients, who were diagnosed as benign bili ary strictures and underwent surgical treat. Differentiation between benign and malignant biliary stricture. A bile duct stricture is an abnormal narrowing of the common bile duct. Benign strictures develop when the bile ducts are injured in some way. Most common benign biliary strictures amandable to endoscopic treatment are postcholecystectomy, dominant biliary strictures due to primary sclerosing cholangitis, biliary anastomotic strictures occurring after liver transplantation, and common bile. This study has shown that patients with a putative biliary stricture and completely normal lfts are unlikely to have a primary hpb malignancy. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures 1, 2.
Bile duct strictures are problematic in terms of management and distinction between benign and malignant. Benign biliary strictures can now be effectively treated with endoscopic therapy in a variety of clinical situations. Biliary stricture endoscopy pancreatitis biliary stents. Benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bileduct injury, or at biliary. Efficacy of multiple biliary stenting for refractory benign biliary. Progress in the endoscopic management of benign biliary.
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. Current status and future directions mohammed attaya, md1 hosam attaya, md1 ashraf thabet, md1 1division of interventional radiology, department of radiology, massachusetts general hospital, harvard medical school, boston, massachusetts dig dis interv 2017. Common controversies in management of biliary strictures. Ethics documents guidelines for the manuscript publishing process. The process of operative management can be divided into following steps. This study was performed to evaluate the longterm effectiveness and safety of a new fully covered sems for benign biliary strictures. Sems have a larger diameter compared to plastic stents and therefore, higher patency rate. Current endoscopic approach to indeterminate biliary. This is a tube that moves bile from the liver to the small intestine. Bile duct strictures victorian hepatopancreato biliary. This article has an accompanying continuing medical education activity on page e15. Unfortunately, most benign bile duct strictures biliary strictures are iatrogenic, resulting from operative trauma see images. Cholecystectomy and orthotopic liver transplantation olt are the most common iatrogenic causes of benign biliary stricture. Percutaneous management of malignant biliary strictures.
Tight strictures in hilar regions are difficult to treat because it is difficult to pass accessories through the narrow strictures. Testing for genetic abnormalities may increase the diagnostic value of cytology. All fully covered metal stents were removed successfully. Anastomotic strictures anastomotic strictures account for up to 80% of biliary strictures after olt. This is a pdf file of an unedited manuscript that has been accepted for publication.
Detecting malignancies at an earlier stage is of paramount importance for effective management. The most common etiologies of strictures encountered are following surgery and those related to chronic pancreatitis. Current treatment of benign biliary strictures 3 annals of gastroenterology 25 which increases costs and may decrease patient compliance, which is of paramount importance for this type of treatment. Biliary strictures can be due to benign or malignant causes. Intraductal brushing during ercp figure figure1 1 remains the firstline approach for tissue sampling of biliary strictures because of its wide availability and technical ease in most cases.
Benign biliary stricture and its rare associationmirizzi syndrome. Strictures of the bile duct can be benign or malignant. As a biliary stricture can limit the bodys ability to. With years of experience treating bile duct strictures, bile duct injuries, and related diseases that may cause bile duct narrowing, bile duct specialist dr. The current diagnosis and treatment of benign biliary. Pdf benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bileduct injury, or at. Imaging plays a key role in differentiating benign from malignant strictures, defining the extent, and directing the biopsy. We describe the salient clinical and imaging manifestations of benign biliary strictures that will help radiologists to accurately diagnose these entities. Benign biliary strictures managed with the wallflex. Biliary stricture is a term used to describe a constriction of the bile duct, a tube which carries bile from the liver and the gallbladder to the intestines. Endoscopic treatment of benign biliary strictures and. Most common benign biliary strictures amandable to. Management of benign biliary strictures whether surgical, percutaneoustranshepatic, or by endoscopic means is difficult.
Bile is a substance that helps in digestion of fatty food. Endoscopic management has evolved over the last 2 decades as the current standard of care. Surgery is considered the treatment of choice, offering more than 80% longterm success. Fortunately, endoscopic treatment has almost simultaneously been developed. The chart showing pdf series, word series, html series, scan qr codes. Benign biliary strictures were classified according to the bismuths classification with a small modification. As a service to our customers we are providing this early version of the manuscript. However, the diagnostic yield from conventional endoscopic retrograde cholangiopancreatography tissue sampling is modest. Classification based on the principles of surgical treatment article pdf available in world journal of surgery 2510. Bile proteomics for differentiation of malignant from. Any information contained in this pdf file is automatically generated from digital. Highquality crosssectional imaging provides a road map for. The data of surgical management of benign biliary strictures from china remain sparse.
Management for a complicated biliary stricture after iatrogenic bile duct injury bile duct injury bdi remains to be a serious complication of biliary surgery. We have used this method selectively for bile duct reconstruction since 1982. Benign biliary strictures are a common indication for endoscopic retrograde cholangiopancreatography ercp. When adequate biliary drainage was achieved, metal stents were removed. Biliary strictures bile duct narrowing posted by dr. Biliary strictures are considered indeterminate when ba. Wallflex biliary fully covered fc benign stricture study. Original article surgical management of benign biliary. A minor narrowing does not significantly impede bile movement and a. Benign noncancerous bile duct strictures may develop from chronic pancreatitis or injury to the bile duct after a laparoscopic cholecystectomy the most common cause for a benign bile duct stricture is trauma to the bile duct as a complication of a laparoscopic cholecystectomy for gallstone disease. The best time to repair bile duct injury is delayed at least 6 weeks after the injury. Effectiveness and safety of endoscopic treatment of benign. Strictures can be caused during surgery on nearby tissues, such as the gallbladder.
Temporary placement of fully covered metal stents for. Bile duct stricture uf health, university of florida health. Malignant biliary strictures in patients with a normal. Gupta, rao, reddy benign biliary strictures treatment chronic pancreatitisrelated in selected patients. A number of factors can cause the bile duct to become constricted, including gallstones, scar tissue, pancreatitis, tumors, and a condition known as primary sclerosing cholangitis.
Management of hilar strictures poses a difficult challenge to gastroenterologists. Abstract endoscopy is a widely used approach for the treatment of benign biliary strictures. Multiple strategies have been employed to improve the sensitivity. Despite recent developments in imaging techniques endoscopic ultrasound and magnetic resonance imaging, it is often difficult to differentiate benign from malignant biliary strictures. Surgical management of benign strictures of the biliary tract. Resolution of the benign biliary strictures was found in 28 of 36 patients 77. A pilot study of endoscopically inserted biodegradable biliary stents in the treatment of benign biliary strictures and cystic duct leaks. From 2010 to 2011, wallflex biliary rx fully covered metal stents were placed in 36 patients with benign biliary strictures in our hospital.
Biliary stricture occurs when the bile duct the tube that takes bile from the liver to the small bowel gets smaller or narrower. Current treatment of benign biliary strictures ncbi. The most prevalent etiology of benign strictures by far is related to surgery. Benign biliary strictures managed with a wallflex biliary. Benign biliary strictures represent a challenging problem to clinicians and patients as a result of their associated morbidity and difficulty to treat.
Hypoalbuminaemia and isolated intrahepatic duct dilatation on ultrasound were significantly associated with malignancy in patients with normal bilirubin and completely normal lfts. Iatrogenic injuries after cholecystectomy are the most commonly reported and best characterized causes, and they are emphasized in this chapter. A total of 868 patients with benign biliary strictures were included in this study. These strictures are characteristically single and short in length patients who develop an anastomotic stricture within the first 12 months after olt have the best response to endoscopic therapy with balloon dilation and stent placement. Background the heppcouinaud technique is an innovative approach for repair of proximal biliary strictures.
Controversy benign biliary stricture should they be. Hepaticojejunostomy is the procedure of choice for repair of a bile duct injury benign biliary stricture. Endoscopic biliary stenting for benign biliary strictures bbs is. Management for a complicated biliary stricture after. The diagnosis of biliary strictures can be challenging. Biliary strictures frequently present a challenge in terms of diagnosis, which requires a multidisciplinary approach. The idea to use them for bbs has been proposed several.
Anatomyshaped design of a fullycovered, biliary, self. Despite advances in device technology, management of benign biliary stric tures remains. A narrowed bile duct makes it difficult for bile to pass to the small bowel, causing a. We assessed genetic abnormalities for cdkn2a, tp53, erbb2, 20q, myc, and chromosomes 7 and 17 and measures of genetic clonal diversity in brush samples from 29 psc patients with benign biliary strictures and 12 patients with sporadic cca or psc. The areas discussed in this editorial include the role of biliary drainage in resectable malignant strictures and whether such drainage should be performed routinely prior to surgery, the best endoscopic palliation for unresectable hilar strictures and whether unilateral or. If a bile duct injury is suspected intraoperatively. Benign bile duct strictures are usually iatrogenic and result from surgery near the porta hepatis. Cause, classification, and clinical manifestations biliary stricture can be seen with a wide array of nonneoplastic causes. Improvements in existing technologies as well as the implementation of novel technologies and techniques have the potential to. A biliary stricture is any narrowing of the bile duct, the tube that carries bile between the liver, gallbladder and duodenum of the small intestine. Several causes of benign biliary strictures have been described table 42a. This study compared the results of surgery and endoscopy for benign biliary strictures in one institution, over the same period of time and with the same outcome definitions.
Palliation for malignant biliary obstruction with needle. Surgery is a valid option in cases of complete transection or ligation of the common bile duct, in selected patients with benign strictures related to chronic. As laparoscopic cholecystectomy and liver transplantation lt have become more common, so has biliary stricture. So we summarized the causes, types, and surgical outcomes of benign biliary strictures in three tertiary hospitals. Benign biliary stricture is regarded as a main factor influencing the efficacy of biliary surgery 1, 2.
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