Oct 17, 2018 importantly, the treatment of benign biliary strictures after olt requires a team approach, which includes hepatologists, endoscopists, transplant surgeons, and interventional radiologists. Among biliary aes, biliary strictures after olt present an 4overall incidence of approximately % and are classified as anastomotic biliary strictures abss and nonanastomotic biliary strictures nabss. While overall the most common causes of biliary strictures are malignant, including cholangiocarcinoma and pancreatic adenocarcinoma, benign strictures encompass a wide spectrum of etiologies including iatrogenic, autoimmune, infectious, inflammatory, and congenital. Selfexpandable metallic stents mss have been useful for inoperable malignant biliary strictures. Pdf current treatment of benign biliary strictures researchgate. Postlt strictures can be anastomotic biliary strictures abs or nonanastomotic biliary strictures nabs. The most prevalent etiology of benign strictures by far is related to surgery. This case report highlights the occurrence of such a stricture 11 years after. Benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bileduct injury, or at biliary. Painless jaundice is most frequently caused by obstruction of the extrahepatic bile duct by malignant periampullary neoplasms, but benign tumors and pseudotumors of the biliary tract, although rare, should be included in the differential diagnosis.
The best time to repair bile duct injury is delayed at least 6 weeks after the injury. How to differentiate benign from malignant bile duct. Migration may occur spontaneously and can be treated by delivering longer stents. Abstract endoscopy is a widely used approach for the treatment of benign biliary strictures. Benign biliary strictures can be difficult to manage. Benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bileduct injury, or at biliary anastomoses following liver transplantation. Successful management of benign biliary strictures with fully covered selfexpanding metal stents. Fully covered selfexpanding metal stents fcsems are gaining acceptance for the treatment of benign biliary strictures. Benign biliary strictures bbs can be caused by postoperative injury, anastomotic injury following orthotopic liver transplantation olt, chronic pancreatitis, primary role of fully covered selfexpandable metal stent for treatment of benign biliary strictures and bile leaks nonthalee pausawasadi. Advances in endoscopic procedures have provided alternative options of relieving biliary obstructions, but prolonged. Management of benign esophageal strictures uptodate. Treatment aims to relieve symptoms of biliary obstruction, maintain longterm drainage, and preserve liver function.
Role of fully covered selfexpandable metal stent for. How to differentiate benign from malignant bile duct strictures. Pdf radiological approach to benign biliary strictures. Several conditions may cause benign biliary stricture formation. Benign biliary strictures pose difficult management problems. Asiapacific consensus guidelines for endoscopic management of. Anastomotic strictures anastomotic strictures account for up to 80% of biliary strictures after olt. The standards of practice committee of the american society for gastrointestinal endoscopy asge prepared this text. 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 duct strictures. Oct 28, 2014 alhough up to 30% of biliary strictures can be benign, the vast majority are malignant, the two major malignancies being pancreatic adenocarcinoma and cholangiocarcinoma. Most common benign biliary strictures amandable to. 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.
Endoscopic management of a benign biliary stricture. Benign biliary strictures bbs are most commonly caused by iatrogenic surgical injury, usually after cholecystectomy, or may occur at the site of biliary anastomosis after hepatic resection or liver transplantation. In the first instance, simple balloon dilatation should be attempted, followed by insertion of a largebore catheter. When the stricture becomes more pronounced, symptoms start to develop. In the recent past, the most common cause of benign biliary strictures in western countries appears to be postoperative causes, while in asia it is due to infection such as clonorchis sinensis in parts of southern china 1. Endoscopy has an established role in the diagnosis and therapy of biliary strictures. Olt biliary strictures has become the performance of erc, whereas for strictures occurring in patients with. Although surgical bypass procedure was the traditional treatment of choice for benign extrahepatic biliary strictures, therapeutic endoscopic retrograde cholangiopancreatography.
Endoscopic management of benign biliary strictures after. Pathological effects of biliary obstruction biliary obstruction high local concentratio n of bile salts inflammatio n 6. Benign biliary strictures are secondary to surgery, chronic pancreatitis cp, psc, or. The role of ercp in benign diseases of the biliary tract. Patients with mild biliary strictures may not show any symptoms, but the stricture causes abnormalities in the blood and a rise in some of the liver enzymes. The rate of resteno ary obstructions, the overall chance of cure for patients sis was also determined. Detecting malignancies at an earlier stage is of paramount importance for effective management. Bile leaks biliary stenosis ercp biliary stents cholangioscopy. Importantly, these series demonstrate that with current preoperative staging tools. The main etiology of bile duct strictures closely related to the liver is a malignancy cancer. Cholecystectomy and orthotopic liver transplantation olt are the most common iatrogenic causes of benign biliary stricture. Successful management of benign biliary strictures with fully. Stenting for benign and malignant biliary strictures gastrointestinal. Removal was scheduled at 1012 months for patients with chronic pancreatitis or cholecystectomy and at 46 months for.
Benign biliary stricture is regarded as a main factor influencing the efficacy of biliary surgery 1, 2. Complications of dilation, pneumatic dilation of the lower esophageal sphincter for achalasia, dilation of esophageal rings and webs, and management of malignant esophageal. However, in both bbs and postcholecystectomy bile leak the need of stent therapy is temporary and endoscopic. Longterm results of metallic stents for benign biliary. A total of 868 patients with benign biliary strictures were included in this study. Despite recent developments in imaging techniques endoscopic ultrasound and magnetic resonance imaging, it is often difficult to differentiate benign from malignant biliary strictures. Pdf endoscopy is a widely used approach for the treatment of benign biliary strictures. Biliary strictures can be broadly classified as benign or malignant. Benign tumors and pseudotumors of the biliary tract. Biliary stricture, also known as bile duct stricture, occurs when the bile duct gets smaller or narrower. Cholecystectomy and orthotopic liver transplantation olt are the. Benign biliary strictures bbs have diverse etiologies. Final determination of malignancy in biliary strictures can entail major surgery if preoperative diagnosis of malignancy cannot be made. Management of benign biliary strictures europe pmc.
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 duct strictures due to chronic pancreatitis. The stan dards of practice committee of the american society for gastrointestinal endoscopy asge prepared this text. We performed a large prospective multinational study to study the ability to remove these stents after extended indwell and the frequency and durability of stricture resolution. Biliary stricture may lead to pain, jaundice, cholangitis and secondary biliary cirrhosis. The bile duct is the tube that takes bile from the liver to the small bowel. Progress in the endoscopic management of benign biliary. Pdf benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bileduct injury, or at.
Endoscopic retrograde cholangiopancreatography in the. Benign biliary strictures and leaks gastrointestinal endoscopy. When pseudotumors or nontraumatic inflammatory strictures of the extrahepatic bile duct are included, the incidence increases, with some surgical series reporting up to a 10% to 25% incidence of benign biliary pseudotumors corvera et al, 2005. Management of benign biliary strictures europe pmc article. The management landscape is constantly evolving, with the development of modifiable selfexpandable metal stents and biodegradable. For example, in patients with sclerosing cholangitis, balloon dilatation alone or shortterm 23 weeks placement of a single stent for a dominant cbd stricture can be sufficient. 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.
Benign biliary strictures may be dilated with hydrostatic balloons or graduated catheters passed over a. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures 1, 2. Endoscopic treatment of benign biliary strictures and. Diagnostics free fulltext benign 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. A biliary stricture is a narrowing of the common bile duct.
A fully covered selfexpandable metal stent with antimigration features for benign biliary strictures. May 25, 2014 definition a biliary stricture is an abnormal narrowing of the bile duct, the tube that moves bile a substance that helps in digestion from the liver to the small intestine 4. 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. The management landscape is constantly evolving, with the development of modifiable selfexpandable metal stents and biodegradable stents.
Standard surgical techniques offer a good chance of cure for the majority of patients affected by extrahepatic benign biliary stricture. 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. Traditionally, surgery has been used as a means to treat. 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. Cause, classification, and clinical manifestations biliary stricture can be seen with a wide array of nonneoplastic causes.
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. However, the differentiation of benign and malignant strictures is notoriously difficult. Background historically, surgical correction has been the treatment of choice for benign biliary strictures bbs. Morbidity occurred more frequently in pa tients treated with endoscopic procedures than with sur design. Oct 23, 2018 biliary strictures can be broadly classified as benign or malignant. Benign biliary strictures can now be effectively treated with endoscopic therapy in a variety of clinical situations. The diagnosis of biliary strictures can be challenging. Pdf benign biliary strictures surgery or endoscopy. In bbs, promising results of covered selfexpanding metal stent use have been recently published. Intraoperative bile duct injury, most often sustained during laparoscopic cholecystectomy, is the leading cause. Benign biliary strictures constitute about 25% of all biliary strictures.
Endoscopy is a widely used approach for the treatment of benign biliary strictures. The aetiology of benign biliary strictures is diverse 1. However, the diagnostic yield from conventional endoscopic retrograde cholangiopancreatography tissue sampling is modest. Biliary strictures can be due to benign or malignant causes. Conclusion the ability to achieve steady, longterm results confirms hepaticojejunostomy as the best procedure in the treatment of benign biliary strictures, even if endoscopic procedures are gaining a new role in the treatment of a greater number of patients. Hepaticojejunostomy is the procedure of choice for repair of a bile duct injury benign biliary stricture. Untreated biliary strictures can lead to complications, such as chronic cholestasis, jaundice, recurrent sepsis, and secondary biliary cirrhosis, which can have severe ramifications. Benign biliary strictures bbs usually occur as a complication of biliary surgery or secondary to underlying diseases chronic pancreatitis, choledocholithiasis, sclerosing cholangitis.
Management of benign biliary strictures radiology key. Current treatment of benign biliary strictures ncbi. Patients of 163 patients referred for treatment with diagnoses of benign strictures of the common bile duct between. Benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bileduct injury, or at.
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. Benign biliary stricture is an infrequent condition and the majority occur following cholecystectomy. Benign biliary strictures bbs and postcholecystectomy bile leaks have traditionally been treated endoscopically with plastic stents. Biliary strictures frequently present a challenge in terms of diagnosis, which requires a multidisciplinary approach. There are many causes of benign strictures of the biliary tree, which include inflammation, gall stone disease, infection including parasites, and congenital abnormalities, 1 with iatrogenic strictures becoming more prevalent. In a nonrandomized study at centers in 11 countries, 187 patients with benign biliary strictures received fcsems. Apr 27, 2008 several conditions may cause benign biliary stricture formation.
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. Radiological approach to benign biliary strictures. Biliary stricture formation is one of the most common complications after lt, with an incidence of 5% to 32%. Most common benign biliary strictures amandable to endoscopic treatment are postcholecystectomy, dominant biliary strictures due to primary sclerosing cholangitis, biliary anastomotic strictures occurring. Anastomotic strictures are the most frequent, occurring in approximately 6%12% of cases, and are a conse. The choice of the type of stent is dependent mainly on the etiology of biliary stricture. This is one of a series of statements discussing the use of gi endoscopy in common clinical situations.
This may no longer hold with the growing affluence in asia and the influx of. Improvements in existing technologies as well as the implementation of novel technologies. During cholecystectomy, strictures may be caused by direct trauma to the bile duct, thermal injury from cauterization, ischemia due to. Benign biliary strictures were classified according to the bismuths classification with a small modification. Benign biliary strictures are most commonly iatrogenic in nature and are a consequence of hepatobiliary surgery. Despite recent developments in imaging techniques endoscopic ultrasound and magnetic resonance imaging, it is often difficult to. The classification of biliary strictures used at hopital paul brousse is based on the lowest level at which healthy biliary mucosa is available for anastomosis. In preparing this guideline, a search of the medical litera.
Bile proteomics for differentiation of malignant from. 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. Original article surgical management of benign biliary. Some benign biliary strictures, however, mimic malignant ones. 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. The percutaneous management of benign biliary strictures allows the simultaneous or subsequent application of a number of different treatment strategies. 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. The aim of treatment is to relieve symptoms of biliary obstruction or cholangitis. Mb approximately 15% of biliary strictures in the western world are benign, and there are multiple factors that contribute to stricture formation in the biliary tree. Although surgical bypass procedure was the traditional treatment of choice for benign extrahepatic biliary strictures, therapeutic endoscopic retrograde cholangiopancreatography has recently come into favor. Cholangiocarcinoma and adenocarcinoma of the pancreas are the most common causes of malignant biliary obstruction. Bile is a substance that helps in digestion of fatty food and excreting getting rid of harmful substances. Successful management of benign biliary strictures with.
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