Biliary stricture occurs when the bile duct the tube that takes bile from the liver to the small bowel gets smaller or narrower. 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. A bile duct stricture is an abnormal narrowing of the common bile duct. When adequate biliary drainage was achieved, metal stents were removed. Surgical management of benign strictures of the biliary tract. Benign biliary strictures managed with a wallflex biliary. Pdf current treatment of benign biliary strictures. Most common benign biliary strictures amandable to. Cholecystectomy and orthotopic liver transplantation olt are the. Postlt biliary strictures are considered abs or nonabs nabs ie, elsewhere in the biliary tree. Riphaus6 institutions institutions are listed at the end of article. Bile proteomics for differentiation of malignant from. Taking a thorough clinical history into consideration may be beneficial in clarifying the etiology of a biliary stricture. Pdf radiological approach to benign biliary strictures.
Postoperative strictures 1 cholecystectomy or common bile duct exploration accounting 80% of nonmalignant stricture 2 biliaryenteric anastomosis 3 hepatic resection 4 portocaval shunt 5 pancreatic surgery 6 gastrectomy 7 liver. Benign strictures develop due to damage to the bile ducts during surgery or trauma to the abdomen. Thirteen patients had undergone several unsuccessful surgical repairs, and four had not undergone surgery because of their clinical status. As laparoscopic cholecystectomy and liver transplantation lt have become more common, so has biliary stricture. Benign biliary stricture and its rare associationmirizzi syndrome. Pdf benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bileduct injury, or at. Current treatment of benign biliary strictures ncbi. 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. Classification based on the principles of surgical treatment article pdf available in world journal of surgery 2510. Pdf endoscopic management of benign biliary strictures.
Stent deployment was successful in all but onepatient91%inwhomthestentdid notcrossthepapillaand was replacedimmediately. Bile is a substance that helps in digestion of fatty food. A total of 868 patients with benign biliary strictures were included in this study. Strictures can be caused during surgery on nearby tissues, such as the gallbladder. Benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bileduct injury, or at biliary.
Endoscopic management has evolved over the last 2 decades as the current standard of care. Benign biliary strictures can now be effectively treated with endoscopic therapy in a variety of clinical situations. Biliary complications usually occur within the first 3 months. Biliary strictures occur due to a variety of mechanisms including iatrogenic, inflammatory and neoplastic causes.
When this happens, bile can back up into the liver, causing abdominal pain, nausea, itching, fever, chills, and jaundice. Anastomotic strictures anastomotic strictures account for up to 80% of biliary strictures after olt. The idea to use them for bbs has been proposed several. The current diagnosis and treatment of benign biliary. The aim of treatment is to relieve symptoms of biliary obstruction or cholangitis. Background the heppcouinaud technique is an innovative approach for repair of proximal biliary strictures. Bile duct stricture uf health, university of florida health. However, the diagnostic yield from conventional endoscopic retrograde cholangiopancreatography tissue sampling is modest. Benign biliary strictures bbss have various origins, each with a different natural history and each demonstrating a different response to treatment.
Resolution of the benign biliary strictures was found in 28 of 36 patients 77. One patient had an anastomotic stricture after orthotopic liver transplantation that was located in the lower third of the common bile duct cbd. Fortunately, endoscopic treatment has almost simultaneously been developed. Progress in the endoscopic management of benign biliary. A biliary stricture is a narrowing of the common bile duct. Benign biliary strictures represent a challenging problem to clinicians and patients as a result of their associated morbidity and difficulty to treat. A pilot study of endoscopically inserted biodegradable biliary stents in the treatment of benign biliary strictures and cystic duct leaks. Covered metal stent for benign biliary stricture caused by.
Biliary strictures can be broadly classified as benign or malignant biliary strictures mbss. Longterm outcomes of a benign biliary stricture protocol. Endoscopic treatment of benign biliary strictures and. Pdf current treatment of benign biliary strictures researchgate. The diagnosis of biliary strictures can be challenging. Information about previous surgical procedures is very important for making a. Biliary stricture can be seen with a wide array of nonneoplastic causes. Detecting malignancies at an earlier stage is of paramount importance for effective management. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures 1, 2.
Ercp is the firstline treatment modality for abs and in selected cases of nabs. Unfortunately, most benign bile duct strictures biliary strictures are iatrogenic, resulting from operative trauma see images. Important features of our series are 1 the long patient followup. Endoscopy has an established role in the diagnosis and therapy of biliary strictures. Listing a study does not mean it has been evaluated by the u.
Sems have a larger diameter compared to plastic stents and therefore, higher patency rate. Anatomyshaped design of a fullycovered, biliary, self. Until a few years ago, surgery was the only available treatment for biliary strictures. Endoscopic biliary dilatation and stenting is the mainstay of therapy for biliary strictures.
Benign biliary strictures can be attributable to a large variety of causes, but are commonly iatrogenic after direct or vascular injury during laparoscopic cholecystectomy and other biliary. Biliary stricture is the most frequent complication after lt, and incidence ranges from 5%32%. Endoscopic management of benign biliary strictures. Endoscopic management of a benign biliary stricture. 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. Percutaneous transhepatic balloon dilatation of benign. This case report highlights the occurrence of such a stricture 11 years after. Iatrogenic causes, such as cholecystectomy and orthotopic liver transplantation, are the most. A narrowed bile duct makes it difficult for bile to pass to the small bowel, causing a. 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 strictures constitute about 25% of all biliary strictures. Benign biliary strictures may be dilated with hydrostatic balloons or graduated catheters passed over a guidewire. However, most studies report a poor sensitivity of 27% to 56%1114.
Migration may occur spontaneously and can be treated by delivering longer stents. Asiapacific consensus guidelines for endoscopic management of. Ercp wih biliary sphincterotomy and stenting for palliative purpose duration. We have used this method selectively for bile duct reconstruction since 1982. The stricture can then be opened by inserting a biliary stent a metal or plastic tube to open the stricture. Biliary stricture management and treatment cleveland clinic. Covered metal stent for benign biliary stricture caused by chronic pancreatitis the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. This is a tube that moves bile from the liver to the small intestine. Benign biliary stricture is an infrequent condition and the majority occur following cholecystectomy. Current endoscopic approach to indeterminate 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. 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. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures. Multiple strategies have been employed to improve the sensitivity.
Most biliary strictures result from injuries during cholecystectomies, and their initial management is a major determining factor of the longterm outcome. Current treatment of benign biliary strictures 3 annals of gastroenterology 25 which increases costs and may decrease patient compliance, which is of paramount importance for this type of treatment. Our 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. Imaging plays a key role in differentiating benign from malignant strictures, defining the extent, and directing the biopsy. The other procedure that can be done is called pthc percutaceous transhepatic cholangiography, in which a catheter drain is inserted through the right side. Biliary strictures bile duct narrowing posted by dr. Benign biliary strictures are a common indication for endoscopic retrograde cholangiopancreatography ercp. 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. Only surgeons well trained and experienced in their management should treat this entity. 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.
Cause, classification, and clinical manifestations biliary stricture can be seen with a wide array of nonneoplastic causes. Original article surgical management of benign biliary. Benign biliary strictures were classified according to the bismuths classification with a small modification. 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 role of ercp in benign diseases of the biliary tract. The majority of recent studies of benign biliary strictures bbss have reported on treatment of stenotic injuries following cholecystectomy, orthotopic liver transplantation, living donor liver transplantation, chronic pancreatitis, and different inflammatory conditions such as common bileductrelated strictures. Improvements in existing technologies as well as the implementation of novel technologies and techniques have the potential to. Percutaneous management of malignant biliary strictures. Temporary placement of fully covered metal stents for. Benign biliary strictures pose difficult management problems. 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. All fully covered metal stents were removed successfully. The most common etiologies of strictures encountered are following surgery and those related to chronic pancreatitis. Malignant biliary strictures and those refractory to endoscopic therapy may. People with bile duct strictures often experience symptoms including jaundice or pain, or have abnormal blood tests.
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