Operative management to surgically reestablish bile flow within the biliary tree and into the proximal gastrointestinal tract in a manner that prevents cholestasis, cholangitis, sludge and stone formation, restricture, or biliary cirrhosis nonoperative management to correct the increased resistance to biliary flow caused by a reduction in. Classification based on the principles of surgical treatment article pdf available in world journal of surgery 2510. Benign biliary strictures bbs have diverse etiologies. Biliary strictures occur due to a variety of mechanisms including iatrogenic, inflammatory and neoplastic causes. The most common etiologies of strictures encountered are following surgery and those related to chronic pancreatitis. Imaging plays a key role in differentiating benign from malignant strictures, defining the extent, and directing the biopsy. Endoscopic therapy for stenosis of the biliary and pancreatic. Postoperative strictures 1 cholecystectomy or common bile duct exploration accounting 80% of nonmalignant stricture 2 biliary enteric anastomosis 3 hepatic resection 4 portocaval shunt 5 pancreatic surgery 6 gastrectomy 7 liver. Current management of biliary strictures springerlink. Whether from a surgical mishap, a cancer scare, or some other source of inflammation or infection, the keys to treating and preventing further bile duct strictures are good health, quick diagnoses, and quality treatment by a specialist experienced in treating bile duct strictures. Biliary anastomotic stricture occurs in 15% to 20% of patients after deceased orthotopic. For some,such as highrisk or compromised patients or those.
Sep 22, 2012 as laparoscopic cholecystectomy and liver transplantation lt have become more common, so has biliary stricture. Prognosis and duration of treatment of bbs depends mainly on stricture. Benign biliary strictures pose difficult management problems. Biliary stricture can be seen with a wide array of nonneoplastic causes. Oct 16, 2019 bile duct strictures may be asymptomatic but, if ignored, can cause lifethreatening complications, such as ascending cholangitis, 2, 3 liver abscess, and secondary biliary cirrhosis. Currently, up to 20% of biliary strictures remain indeterminate after preoperative evaluation and necessitate surgical intervention for a definitive diagnosis.
Cholecystectomy and orthotopic liver transplantation olt are the most common iatrogenic causes of benign biliary stricture. Pdf transpapillary biliary biopsy for malignant biliary. Despite advances in surgical techniques, benign biliary strictures after. Given the costs associated with sems, plastic stents are still the most commonly. Strictures of the bile duct are a wellrecognized compli. Ercp wih biliary sphincterotomy and stenting for palliative purpose duration. Mb management of benign biliary strictures should be aimed at achieving patency of the bile duct or preserving that patency in an attempt to minimize any short or longterm complications such as infection with cholangitis or more chronic changes such as secondary biliary cirrhosis. A variety of benign conditions, such as primary sclerosing cholangitis psc and igg4related sclerosing cholangitis, frequently mimic malignancies. 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. Unfortunately, most benign bile duct strictures biliary strictures are iatrogenic, resulting from operative trauma see images. Oct 16, 2019 bile duct stricture biliary stricture is an uncommon but challenging clinical condition that requires a coordinated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. If a bile duct injury is suspected intraoperatively, cholangiography is essential, and a careful rouxeny biliary enteric anastomosis is often required to achieve the best postoperative result. Original article surgical management of benign biliary. Improvements in existing technologies as well as the implementation of novel technologies and techniques have the potential to.
There is a wide spectrum of nonneoplastic causes of biliary stricture that can pose a significant challenge to clinicians and radiologists. A total of 868 patients with benign biliary strictures were included in this study. Traditionally, surgery has been used as a means to treat. Treatment of postcholecystectomy biliary strictures with fully. These strictures are notoriously difficult to treat and traditionally are managed by resection and fashioning of a choledocho or hepatojejunostomy. Pdf surgical management of benign strictures of the biliary. With this technique, a roux loop made of healthy, tensionfree jejunum distal to the. Biliary stricture dr n surendra babu jr resident dept. Dr m k chouhan professor and hod of surgery dr snmc. Volatile organic compounds in bile can diagnose malignant. Pathology etiology there are numerous causes of biliary duct strictures, including 1,2. 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. Pdf surgical management of benign strictures of the. In addition, psc and other chronic biliary diseases.
For biliary strictures located in the common hepatic duct or the common bile duct, most interventional radiologists prefer to use the right midaxillary approach, as the majority of the liver is drained by the rightsided ductal system, and the rightsided approach is associated with lower complication rates. Metaanalysis of the long term success rate of different. Benign biliary stricture accounts for significant morbidity and mortality and is difficult to treat. Volatile organic compounds in bile can diagnose malignant biliary strictures in the setting of pancreatic cancer. The goal of this study was to compare the long term disease free survival in benign biliary strictures with various etiology after surgery. Pdf recurrent biliary strictures after initial biliary. Shah, md director of pancreatic biliary endoscopy interventional endoscopy services california pacific medical center director of endoscopy sfvamc associate clinical. Surgery is considered the treatment of choice, offering more than 80% longterm success. Transpapillary biliary biopsy for malignant biliary strictures. Strictures as a result of recurrent cholangiocarcinoma at the biliary enteric anastomosis presented between 7 and 29 months after pancreaticoduodenectomy.
Endoscopic treatment of benign biliary strictures and cystic duct leakages with a novel biodegradable biliary stent the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. However, the diagnostic yield from conventional endoscopic retrograde cholangiopancreatography tissue sampling is modest. In patients with benign biliary strictures, the use of fully covered selfexpandable metal stents sems has been proposed as an alternative to plastic stenting, but high quality prospective data are sparse. Benign biliary strictures are most commonly a consequence of injury at laparoscopic cholecystectomy or fibrosis after biliary enteric anastomosis. The definitive management of benign biliary strictures depends upon numerous factors, including the complexity and location of the stricture, the degree of inflammation and fibrosis, the presence of ongoing infection or sepsis, and the capability and experience of the surgeon and interventional radiologist at the institution. Edwyn harrison, md dr villa is an advanced endoscopy fellow and dr harrison is a professor in the division of gastroenterology and hepatology at the mayo clinic in scottsdale, arizona. The discovery of novel biomarkers, new imaging modalities and advanced endoscopic techniques suggests that a multimodality approach might lead to better diagnostic accuracy. Fortunately, endoscopic treatment has almost simultaneously been developed. Comparison between cholangiocarcinoma and pancreatic cancer. Endoscopic biliary dilatation and stenting is the mainstay of therapy for biliary strictures. Metal versus plastic stents for anastomotic biliary strictures. The current diagnosis and treatment of benign biliary stricture. 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. We describe the salient clinical and imaging manifestations of benign biliary strictures that will help radiologists to accurately diagnose these entities.
Benign bile duct strictures carry the risk of stone formation and ascending cholangitis, which in itself may be lifethreatening but can also lead to subsequent biliary cirrhosis. The most prevalent etiology of benign strictures by far is related to surgery. The diagnosis of biliary strictures can be challenging. Endoscopic treatment of benign biliary strictures and cystic. In the end, no one wants to experience a bile duct stricture. Current diagnosis and treatment of benign biliary strictures after.
Bile duct strictures are problematic in terms of management and distinction between benign and malignant. Management of benign biliary strictures springerlink. Endoscopic management of benign biliary strictures springerlink. Seventeen patients with stenosis of the orifice bile duct 7, bile ductmain pancreatic duct 7, accessory pancreatic duct 3 underwent sphincterotomy andor dilation and stent placement for a median of 140 days range 30 to. Biliary strictures frequently present a challenge in terms of diagnosis, which requires a multidisciplinary approach. Surgical management of benign strictures of the biliary tract article pdf available in world journal of surgery 2510. Effectiveness and safety of endoscopic treatment of benign. The diagnosis of biliary stricture is often missed or delayed because of its indolent course, with up to 20% of patients presenting with subtle clinical manifestations 1 year after the initial injury. In most cases, the bile duct stricture is secondary to biliary tract operations, especially cholecystectomy, with an incidence of major bile duct injury in the open. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures 1, 2. Benign biliary strictures were classified according to the bismuths classification with a small modification. Biliary stricture occurs when the bile duct the tube that takes bile from the liver to the small bowel gets smaller or narrower. Radiological approach to benign biliary strictures. Benign bile duct strictures are usually iatrogenic and result from surgery near the porta hepatis.
Jan 23, 2015 benign biliary strictures are a common indication for endoscopic retrograde cholangiopancreatography ercp. Focal intrahepatic benign bile duct stricture after cholecystectomy. Biliary strictures frequently present a diagnostic challenge during preoperative evaluation to determine their benign or malignant nature. The chart showing pdf series, word series, html series, scan qr codes. A narrowed bile duct makes it difficult for bile to pass to the small bowel, causing a buildup of bile. Management of biliary strictures after liver transplantation nicolas a.
Longterm results showed that biliary strictures occurred in 5 % cases and were associated with sepsis p aug 23, 2015 endoswiss 2015 live case. A novel percutaneous transhepatic treatment of a benign bile duct. This study was performed to evaluate the longterm effectiveness and safety of a new fully covered sems for benign biliary strictures. This study compared the results of surgery and endoscopy for benign biliary strictures in one institution, over the same period of time and with the same outcome definitions. A minor narrowing does not significantly impede bile movement and a person may be asymptomatic. 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. Anastomotic strictures anastomotic strictures account for up to 80% of biliary strictures after olt. Patients who presented initially with obstructive jaundice prior to pancreaticoduodenectomy had a similar incidence of stricture formation compared with patients who did not present with. 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. Highquality crosssectional imaging provides a road map for endoscopic. Manipulation of the duodenal papilla may lead to symptomatic stenosis of the orifices of bile duct, main pancreatic duct or accessory pancreatic duct. Bile is a substance that helps in digestion of fatty food.
Longterm results showed that biliary strictures occurred in 5 % cases and were associated with sepsis p strictures. Diagnosis by ercp, idus,diagnosis by ercp, idus, cholangioscopy, and tissue samplingcholangioscopy, and tissue sampling janak n. Endoscopic management has evolved over the last 2 decades as the current standard of care. The diseasefree survival, calculated after exclud ing the first patient who.