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Vedamurthy A, Krishnamoorthi R, Irani S, Kozarek R. Endoscopic Management of Benign Pancreaticobiliary Disorders. J Clin Med 2025; 14:494. [PMID: 39860499 PMCID: PMC11766296 DOI: 10.3390/jcm14020494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2024] [Revised: 01/09/2025] [Accepted: 01/09/2025] [Indexed: 01/27/2025] Open
Abstract
Endoscopic management of benign pancreaticobiliary disorders encompasses a range of procedures designed to address complications in gallstone disease, choledocholithiasis, and pancreatic disorders. Acute cholecystitis is typically treated with cholecystectomy or percutaneous drainage (PT-GBD), but for high-risk or future surgical candidates, alternative decompression methods, such as endoscopic transpapillary gallbladder drainage (ETP-GBD), and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD), are effective. PT-GBD is associated with significant discomfort as well as variable adverse event rates. EUS-GBD leverages lumen-apposing metal stents (LAMS) for direct access to the gallbladder, providing the ability to treat an inflamed GB internally. Choledocholithiasis is primarily managed with ERCP, utilizing techniques to include balloon extraction, mechanical lithotripsy, or advanced methods such as electrohydraulic or laser lithotripsy in cases of complex stones. Altered anatomy from bariatric procedures like Roux-en-Y gastric bypass may necessitate specialized approaches, including balloon-assisted ERCP or EUS-directed transgastric ERCP (EDGE). Post-operative complications, including bile leaks and strictures, are managed endoscopically using sphincterotomy and stenting. Post-liver transplant anastomotic and non-anastomotic strictures often require repeated stent placements or advanced techniques like magnetic compression anastomosis in refractory cases. In chronic pancreatitis (CP), endoscopic approaches aim to relieve pain and address structural complications like pancreatic duct (PD) strictures and calculi. ERCP with sphincterotomy and stenting, along with extracorporeal shock wave lithotripsy (ESWL), achieves effective ductal clearance for PD stones. When traditional approaches are insufficient, direct visualization with peroral pancreatoscopy-assisted lithotripsy is utilized. EUS-guided interventions, such as cystgastrostomy, pancreaticogastrostomy, and celiac plexus blockade, offer alternative therapeutic options for pain management and drainage of peripancreatic fluid collections. EUS plays a diagnostic and therapeutic role in CP, with procedures tailored for high-risk patients or those with complex anatomy. As techniques evolve, endoscopic management provides minimally invasive alternatives for patients with complex benign pancreaticobiliary conditions, offering high clinical success and fewer complications.
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Affiliation(s)
- Amar Vedamurthy
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason, Franciscan Health, Seattle, WA 98101, USA
| | - Rajesh Krishnamoorthi
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason, Franciscan Health, Seattle, WA 98101, USA
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason, Franciscan Health, Seattle, WA 98101, USA
| | - Richard Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason, Franciscan Health, Seattle, WA 98101, USA
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason, Franciscan Health, 1100 9th Avenue, G-250B, Seattle, WA 98101, USA
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Quintini D, Rizzo GEM, Tarantino I, Sarzo G, Fantin A, Miraglia R, Maruzzelli L, Ligresti D, Carrozza L, Rancatore G, Gruttadauria S, Cillo U, Ferrara F, Traina M. Endoscopic or combined management of post-surgical biliary leaks: a two-center recent experience. Surg Endosc 2024; 38:7233-7242. [PMID: 39384654 PMCID: PMC11615086 DOI: 10.1007/s00464-024-11243-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 08/29/2024] [Indexed: 10/11/2024]
Abstract
BACKGROUND AND AIMS Post-surgical biliary leaks (PSBL) are one of the most prevalent and significant adverse events emerging after liver or biliary tract surgeries. Endoscopic retrograde cholangiopancreatography (ERCP) alone or combined with another approach (Rendez Vous) as treatment of PSBL obtains optimal outcomes due to the possibility of modifying the resistances in the biliary tree. METHODS A retrospective double-center study was conducted in two tertiary centers. Consecutive patients who underwent at least one attempt of PSBL correction by ERCP or Rendez Vous procedure between January 2018 and August 2023 were included. The primary outcome was overall endoscopic clinical success. In contrast, the secondary outcomes were hospital stay exceeding five days and endoscopic clinical success with the first endoscopic procedure at the tertiary center. Both univariate and multivariate analyses were used to assess outcomes. RESULTS 65 patients were included. Patients with one or multiple) leaks had more possibility to achieve the endoscopic clinical success compared to those affected by the association of leaks and stricture (96% vs 67%, p value 0.005). Leaks occurring in the main biliary duct had less probability (67%) to achieve the overall endoscopic clinical success compared to those in the end-to-end anastomosis (90%), in the resection plane or biliary stump (96%) or first or secondary order biliary branches (100%, p value 0.038). A leak-bridging stent positioning had more probability of achieving the endoscopic clinical success than a not leak-bridging stent (91% vs 53%, p value 0.005). CONCLUSIONS ERCP and Rendez Vous procedures are safe and effective for treating PSBL, regardless of the type of preceding surgery, even if technical or clinical success was not achieved on the first attempt. A stent should be placed, if feasible, leak-bridging to enhance treatment efficacy.
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Affiliation(s)
- Dario Quintini
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Palermo, Italy
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Giacomo Emanuele Maria Rizzo
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Palermo, Italy.
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy.
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Palermo, Italy
| | - Giacomo Sarzo
- OSA General Surgery, Padua University Hospital, Padua, Italy
| | - Alberto Fantin
- Gastroenterology Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | | | | | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Palermo, Italy
| | - Lucio Carrozza
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Palermo, Italy
| | - Gabriele Rancatore
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Palermo, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT, UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Umberto Cillo
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Francesco Ferrara
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Palermo, Italy
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Symeonidis D, Tepetes K, Tzovaras G, Samara AA, Zacharoulis D. BILE: A Literature Review Based Novel Clinical Classification and Treatment Algorithm of Iatrogenic Bile Duct Injuries. J Clin Med 2023; 12:3786. [PMID: 37297981 PMCID: PMC10253433 DOI: 10.3390/jcm12113786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/18/2023] [Accepted: 05/28/2023] [Indexed: 06/12/2023] Open
Abstract
PURPOSES The management of patients with iatrogenic bile duct injuries (IBDI) is a challenging field, often with dismal medico legal projections. Attempts to classify IBDI have been made repeatedly and the final results were either analytical and extensive but not useful in everyday clinical practice systems, or simple and user friendly but with limited clinical correspondence approaches. The purpose of the present review is to propose a novel, clinical classification system of IBDI by reviewing the relevant literature. METHODS A systematic literature review was conducted by performing bibliographic searches in the available electronic databases, including PubMed, Scopus, and the Cochrane Library. RESULTS Based on the literature results, we propose a five (5) stage (A, B, C, D and E) classification system for IBDI (BILE Classification). Each stage is correlated with the recommended and most appropriate treatment. Although the proposed classification scheme is clinically oriented, the anatomical correspondence of each IBDI stage has been incorporated as well, using the Strasberg classification. CONCLUSIONS BILE classification represents a novel, simple, and dynamic in nature classification system of IBDI. The proposed classification focuses on the clinical consequences of IBDI and provides an action map that can appropriately guide the treatment plan.
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Affiliation(s)
| | | | | | - Athina A. Samara
- Department of Surgery, University Hospital of Larisa, Mezourlo, 41221 Larisa, Greece
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Giurazza F, Ierardi A, Spinazzola A, Corvino F, Pane F, Carrafiello G, Niola R. Percutaneous Embolization of Biliary Leaks: Initial Experience with Extravascular Application of a PTFE-Covered Microplug. Cardiovasc Intervent Radiol 2023; 46:400-405. [PMID: 36746789 DOI: 10.1007/s00270-023-03368-3] [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: 11/02/2022] [Accepted: 01/16/2023] [Indexed: 02/08/2023]
Abstract
PURPOSE This paper describes the initial experience with a PTFE-covered microplug to perform extravascular embolizations in patients with iatrogenic biliary leaks. MATERIALS AND METHODS A retrospective multicenter analysis has been conducted on seven patients. All were symptomatic for abdominal pain and had an abdominal drainage adjacent to the supposed site of leakage. The biliary output of the drainage was monitored daily. Biliary leak etiology was iatrogenic: four after laparoscopic cholecistectomy for gallstones, one after explorative laparotomy for pancreas head adenocarcinoma with concomitant cholecistectomy for gallstones, and two after long-standing internal-external right biliary drainage for cholangiocarcinoma. In four cases leakage sourced from cystic duct stump, in one from an aberrant bile duct and in two from bilio-cutaneous fistula. Technical success was considered leak resolution at the last cholangiography. Clinical success was defined improvement in the clinical conditions together with progressive resolution of the biliary output from the abdominal drainage until removal. RESULTS Technical and clinical successes were 100%. A 5 mm microplug was adopted in five cases of post-cholecistectomy leaks. A 3 mm microplug and a 9 mm microplug were deployed in the two cases of peripheral leaks related to bilio-cutaneous fistulas. In three patients additional embolics (coils in two cases; spongel slurry in one case) were required. Minor complications occurred in three patients. CONCLUSION This initial experience on seven patients with iatrogenic biliary leaks demonstrated that percutaneous transhepatic PTFE-covered microplug embolization is technically feasible and clinically effective to achieve leak resolution. Future researches with larger samples are needed to confirm these findings.
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Affiliation(s)
- Francesco Giurazza
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy.
| | - Annamaria Ierardi
- Radiology Department, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Via F. Sforza, 35, 20122, Milan, Italy
| | - Angelo Spinazzola
- Interventional Radiology Department, ASST Crema Ospedale Maggiore, Largo U. Dossena 2, 26013, Crema, Italy
| | - Fabio Corvino
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Francesco Pane
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Giampaolo Carrafiello
- Radiology Department, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Via F. Sforza, 35, 20122, Milan, Italy.,Department of Health Sciences, Università Degli Studi Di Milano, Via F. Sforza, 35, 20122, Milan, Italy
| | - Raffaella Niola
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
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Leonor PA, Miley A, Al-Shahrani A, Shah RJ. Endoscopic treatment of a refractory benign biliary stricture using cholangioscopy-guided thulium laser stricturoplasty. VideoGIE 2022; 7:256-258. [PMID: 35815165 PMCID: PMC9264140 DOI: 10.1016/j.vgie.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Loskot J, Jezbera D, Zmrhalová ZO, Nalezinková M, Alferi D, Lelkes K, Voda P, Andrýs R, Fučíková AM, Hosszú T, Bezrouk A. A Complex In Vitro Degradation Study on Polydioxanone Biliary Stents during a Clinically Relevant Period with the Focus on Raman Spectroscopy Validation. Polymers (Basel) 2022; 14:polym14050938. [PMID: 35267761 PMCID: PMC8912347 DOI: 10.3390/polym14050938] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
Biodegradable biliary stents are promising treatments for biliary benign stenoses. One of the materials considered for their production is polydioxanone (PPDX), which could exhibit a suitable degradation time for use in biodegradable stents. Proper material degradation characteristics, such as sufficient stiffness and disintegration resistance maintained for a clinically relevant period, are necessary to ensure stent safety and efficacy. The hydrolytic degradation of commercially available polydioxanone biliary stents (ELLA-CS, Hradec Králové, Czech Republic) in phosphate-buffered saline (PBS) was studied. During 9 weeks of degradation, structural, physical, and surface changes were monitored using Raman spectroscopy, differential scanning calorimetry, scanning electron microscopy, and tensile and torsion tests. It was found that the changes in mechanical properties are related to the increase in the ratio of amorphous to crystalline phase, the so-called amorphicity. Monitoring the amorphicity using Raman spectroscopy has proven to be an appropriate method to assess polydioxanone biliary stent degradation. At the 1732 cm−1 Raman peak, the normalized shoulder area is less than 9 cm−1 which indicates stent disintegration. The stent disintegration started after 9 weeks of degradation in PBS, which agrees with previous in vitro studies on polydioxanone materials as well as with in vivo studies on polydioxanone biliary stents.
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Affiliation(s)
- Jan Loskot
- Department of Physics, University of Hradec Králové, Rokitanského 62, 500 03 Hradec Králové, Czech Republic; (J.L.); (D.J.)
| | - Daniel Jezbera
- Department of Physics, University of Hradec Králové, Rokitanského 62, 500 03 Hradec Králové, Czech Republic; (J.L.); (D.J.)
| | - Zuzana Olmrová Zmrhalová
- Center of Materials and Nanotechnologies, Faculty of Chemical Technology, University of Pardubice, Studentska 95, 530 02 Pardubice, Czech Republic;
| | - Martina Nalezinková
- Department of Biology, University of Hradec Králové, Rokitanského 62, 500 03 Hradec Králové, Czech Republic; (M.N.); (A.M.F.)
| | - Dino Alferi
- Department of Medical Biophysics, Faculty of Medicine in Hradec Králové, Charles University, Šimkova 870, 500 03 Hradec Králové, Czech Republic; (D.A.); (K.L.); (P.V.)
| | - Krisztina Lelkes
- Department of Medical Biophysics, Faculty of Medicine in Hradec Králové, Charles University, Šimkova 870, 500 03 Hradec Králové, Czech Republic; (D.A.); (K.L.); (P.V.)
| | - Petr Voda
- Department of Medical Biophysics, Faculty of Medicine in Hradec Králové, Charles University, Šimkova 870, 500 03 Hradec Králové, Czech Republic; (D.A.); (K.L.); (P.V.)
| | - Rudolf Andrýs
- Department of Chemistry, University of Hradec Králové, Rokitanského 62, 500 03 Hradec Králové, Czech Republic;
| | - Alena Myslivcová Fučíková
- Department of Biology, University of Hradec Králové, Rokitanského 62, 500 03 Hradec Králové, Czech Republic; (M.N.); (A.M.F.)
| | - Tomáš Hosszú
- Department of Neurosurgery, Faculty of Medicine in Hradec Králové, Charles University, Sokolská 581, 500 05 Hradec Králové, Czech Republic;
- Department of Neurosurgery, University Hospital Hradec Králové, Sokolská 581, 500 05 Hradec Králové, Czech Republic
| | - Aleš Bezrouk
- Department of Medical Biophysics, Faculty of Medicine in Hradec Králové, Charles University, Šimkova 870, 500 03 Hradec Králové, Czech Republic; (D.A.); (K.L.); (P.V.)
- Correspondence:
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Zimmer V. Cystic Duct Leakage as Visualized by Novel Digital Single-Operator Cholangioscopy (with Video). GE - PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2022; 29:369-370. [PMID: 36159191 PMCID: PMC9485957 DOI: 10.1159/000516949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/23/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Vincent Zimmer
- Department of Medicine, Marienhausklinik St. Josef Kohlhof, Neunkirchen, Germany
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
- *Vincent Zimmer,
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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: 15] [Impact Index Per Article: 3.8] [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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Ishizaki Y, Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Okubo Y, Nakamura J, Takasumi M, Hashimoto M, Kato T, Kobashi R, Hikichi T, Ohira H. Spontaneous disappearance of common bile duct stones following the insertion of a new dumbbell-shaped, covered self-expandable metallic stent in a patient with benign biliary stricture. Clin Case Rep 2021; 9:e04093. [PMID: 34026137 PMCID: PMC8122123 DOI: 10.1002/ccr3.4093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/04/2021] [Accepted: 03/13/2021] [Indexed: 11/11/2022] Open
Abstract
The new dumbbell-shaped, covered self-expanding metallic stent can efficiently remove the choledocholiths in cases with common bile duct (CBD) strictures; moreover, it may potentially prevent a positional displacement and contribute to the better improvement of the CBD stricture.
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Affiliation(s)
- Yuto Ishizaki
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Mitsuru Sugimoto
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Tadayuki Takagi
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Rei Suzuki
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Naoki Konno
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Hiroyuki Asama
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Yuki Sato
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Hiroki Irie
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Yoshinori Okubo
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
- Department of EndoscopyFukushima Medical University HospitalFukushimaJapan
| | - Jun Nakamura
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
- Department of EndoscopyFukushima Medical University HospitalFukushimaJapan
| | - Mika Takasumi
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Minami Hashimoto
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
- Department of EndoscopyFukushima Medical University HospitalFukushimaJapan
| | - Tsunetaka Kato
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
- Department of EndoscopyFukushima Medical University HospitalFukushimaJapan
| | - Ryoichiro Kobashi
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Takuto Hikichi
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
- Department of EndoscopyFukushima Medical University HospitalFukushimaJapan
| | - Hiromasa Ohira
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
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Bilal M, Chandnani M, McDonald NM, Miller CS, Saperia J, Wadhwa V, Singh S, Cohen JM, Berzin TM, Sawhney MS, Pleskow DK. Use of fully covered self-expanding metal biliary stents for managing endoscopic biliary sphincterotomy related bleeding. Endosc Int Open 2021; 9:E667-E673. [PMID: 33937506 PMCID: PMC8062221 DOI: 10.1055/a-1380-3268] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background and study aims Endoscopic biliary sphincterotomy (EBS) related-bleeding is a common adverse event related to endoscopic retrograde cholangiopancreatography (ERCP). Traditionally, endoscopic modalities such as epinephrine injection, cauterization, and balloon tamponade have been used for management. Recently, use of a fully covered self-expandable metal stent (FCSEMS) to manage EBS-related bleeding has gained popularity. However, data regarding its use are limited to small case series. Therefore, we aimed to evaluate the safety and efficacy of FCSEMS placement for the treatment of EBS-related bleeding. Patients and methods All patients referred to our center from October 2014 to November 2019 who had an FCSEMS placed for EBS-related bleeding were included. FCSEMS was placed either for primary control of bleeding or after failure of other traditional endoscopic hemostasis techniques at the discretion of the endoscopist. Data was collected regarding patient demographics, procedural characteristics, clinical and technical success rates of FCSEMS, as well as adverse events. Results A total of 97 patients underwent placement of FCSEMS for EBS-related bleeding, of which 76.3 % had immediate bleeding and 23.7 % had delayed bleeding. Mean age was 67.2 years and 47.4 % were males. Seven patients who had immediate EBS-related bleeding at index ERCP underwent other endoscopic therapies prior to placement of FCSEMS for rebleeding. The technical success rate for FCSEMS placement was 100 % and the rebleeding rate was 6.2 %. Four patients with FCSEMS placement developed pancreatitis and four had stent migration. Conclusions Our findings suggest that FCSEMS is a highly effective treatment modality for managing EBS-related bleeding and has an acceptable safety profile.
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Affiliation(s)
- Mohammad Bilal
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Madhuri Chandnani
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Nicholas M. McDonald
- Division of Gastroenterology & Hepatology, University of Minnesota Medical Center, Minneapolis, MN
| | - Corey S. Miller
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - James Saperia
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Vaibhav Wadhwa
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | | | - Jonah M. Cohen
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Tyler M. Berzin
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Mandeep S. Sawhney
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Douglas K. Pleskow
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Abstract
Every year approximately 750,000 cholecystectomies are performed in the United States, most of those are performed laparoscopically. Postcholecystectomy complications are not uncommon and lead to increased morbidity and financial burden. Some of the most commonly encountered complications with laparoscopic cholecystectomy include biliary injury (0.08%-0.5%), bile leak (0.42%-1.1%), retained common bile duct stones (0.8%-5.7%), postcholecystectomy syndrome (10%-15%), and postcholecystectomy diarrhea (5%-12%). Endoscopy has an important role in the diagnosis and management of biliary complications and in many cases can provide definitive management. There is no consensus on the best therapeutic approach for biliary complications. Therefore, biliary complications should be approached by an experienced multidisciplinary team. It is important for the gastroenterologist to be familiar with the management of such complications (Visual Abstract, Supplemental Digital content 1, http://links.lww.com/AJG/B544).
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Tringali A, Reddy DN, Ponchon T, Neuhaus H, Lladó FGH, Navarrete C, Bruno MJ, Kortan PP, Lakhtakia S, Peetermans J, Rousseau M, Carr-Locke D, Devière J, Costamagna G. Treatment of post-cholecystectomy biliary strictures with fully-covered self-expanding metal stents - results after 5 years of follow-up. BMC Gastroenterol 2019; 19:214. [PMID: 31830897 PMCID: PMC6909597 DOI: 10.1186/s12876-019-1129-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 11/22/2019] [Indexed: 12/24/2022] Open
Abstract
Background Endoscopic treatment of post-cholecystectomy biliary strictures (PCBS) with multiple plastic biliary stents placed sequentially is a minimally invasive alternative to surgery but requires multiple interventions. Temporary placement of a single fully-covered self-expanding metal stent (FCSEMS) may offer safe and effective treatment with fewer re-interventions. Long-term effectiveness of treatment with FCSEMS to obtain PCBS resolution has not yet been studied. Methods In this prospective multi-national study in patients with symptomatic benign biliary strictures (N = 187) due to various etiologies received a FCSEMS with scheduled removal at 6–12 months and were followed for 5 years. We report here long-term outcomes of the subgroup of patients with PCBS (N = 18). Kaplan Meier analyses assessed long-term freedom from re-stenting. Adverse events were documented. Results Endoscopic removal of the FCSEMS was achieved in 83.3% (15/18) of patients after median indwell of 10.9 (range 0.9–13.8) months. In the remaining 3 patients (16.7%), the FCSEMS spontaneously migrated and passed without complications. At the end of FCSEMS indwell, 72% (13/18) of patients had stricture resolution. At 5 years after FCSEMS removal, 84.6% (95% CI 65.0–100.0%) of patients who had stricture resolution at FCSEMS removal remained stent-free. In addition, at 75 months after FCSEMS placement, the probability of remaining stent-free was 61.1% (95% CI 38.6–83.6%) for all patients. Stent or removal related serious adverse events occurred in 38.9% (7/18) all resolved without sequalae. Conclusions In patients with symptomatic PCBS, temporary placement of a single FCSEMS intended for 10–12 months indwell is associated with long-term stricture resolution up to 5 years. Temporary placement of a single FCSEMS may be considered for patients with PCBS not involving the main hepatic confluence. Trial registration numbers NCT01014390; CTRI/2012/12/003166; Registered 17 November 2009.
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Affiliation(s)
- Andrea Tringali
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy. .,Università Cattolica del Sacro Cuore, Centre for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy.
| | - D Nageshwar Reddy
- Gastroenterology and Therapeutic Endoscopy, Asian Institute of Gastroenterology, Hyderabad, India
| | - Thierry Ponchon
- Service de Gastroentérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Lyon, France
| | - Horst Neuhaus
- Medizinische Klinik, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Ferrán González-Huix Lladó
- Unidad de Endoscopia, Servicio de Aparato Digestivo, Hospital Universitari Doctor Josep Trueta, Girona, Catalunya, Spain
| | - Claudio Navarrete
- Servicio de Endoscopía, Clínica Alemana de Santiago. Jefe de Departamento de Cirugia, Clinica Santa Maria, Santiago, Chile
| | - Marco J Bruno
- Maag-, Darm- en Leverziekten, Erasmus Universitair Medisch Centrum, Rotterdam, The Netherlands
| | - Paul P Kortan
- Division of Gastroenterology, Centre for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sundeep Lakhtakia
- Service de Gastroentérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Lyon, France
| | - Joyce Peetermans
- Boston Scientific Corporation, Marlboro, Massachusetts, United States
| | - Matthew Rousseau
- Boston Scientific Corporation, Marlboro, Massachusetts, United States
| | - David Carr-Locke
- The Center for Advanced Digestive Care, Weill Cornell Medicine, New York Presbyterian Hospital, New York, USA
| | - Jacques Devière
- Gastro-Entérologie et d'Hépato-Pancréatologie, Universite Libre de Bruxelles Hôpital Erasme, Brussels, Belgium
| | - Guido Costamagna
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy.,Università Cattolica del Sacro Cuore, Centre for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
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Haseeb A, Amateau SK. Metal Biliary Stents in Benign Disease. Clin Gastroenterol Hepatol 2019; 17:1029-1032. [PMID: 30557736 DOI: 10.1016/j.cgh.2018.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Abdul Haseeb
- Division of Gastroenterology, Hepatology and Nutrition, Section of Interventional and Advanced Endoscopy, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Stuart K Amateau
- Division of Gastroenterology, Hepatology and Nutrition, Section of Interventional and Advanced Endoscopy, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
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14
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Tandon V, G K A, Jindal SP, Hukkeri V, Madaan V, Govil D. Cholecystoenteric Fistulae—Our Experience. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1744-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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15
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Kwon CI, Gromski MA, Oh HC, Easler JJ, El Hajj II, Watkins J, Fogel EL, McHenry L, Sherman S, Lehman GA. Additional flap on plastic stents for improved antimigration effect in the treatment of post-cholecystectomy bile leak. Endosc Int Open 2018; 6:E489-E494. [PMID: 29607401 PMCID: PMC5876032 DOI: 10.1055/s-0043-125361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 11/22/2017] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND AND STUDY AIMS In plastic stent insertion for treatment of post-cholecystectomy bile leak, stent migration may be more common due to the absence of a shelf to anchor the stent. We evaluated how adding a flap to straight plastic stents for this indication might influence the rate of stent migration when compared to use of conventional plastic stents. PATIENTS AND METHODS This is a retrospective study including patients referred for ERCP for treatment of post-cholecystectomy bile leak. Patients with a customized anti-migration flap stent had the additional flap created on the distal end of straight plastic stents, intended to aid in anchoring in the distal supra-sphincteric biliary duct. The primary endpoint is stent migration events. The secondary endpoint is bile leak resolution after first ERCP session. RESULTS Thirty-two patients were treated with the experimental additional flap stents and 225 patients were treated with standard straight biliary stents. The total failure rate of bile leak resolution after a single endoscopic treatment for all treated was 10.5 % (27/257) and the total stent migration rate for all enrolled was 15.2 % (39/257). Stent migration rate was lower in the additional flap stent group than in the conventional group (3.1 % vs. 16.9 %, respectively, P = 0.04). Furthermore, significantly more patients had resolution of their bile leak after the first ERCP session in the group with the additional flap (100 % vs. 88 %, respectively, P = 0.03). CONCLUSION A plastic biliary stent with an extra flap may have improved performance with regard to stent migration and resolution of bile leak over standard plastic biliary stents.
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Affiliation(s)
- Chang-Il Kwon
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States,Current Affiliation: Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Mark A. Gromski
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Hyoung-Chul Oh
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Jeffrey J. Easler
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Ihab I El Hajj
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - James Watkins
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Evan L. Fogel
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Lee McHenry
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Stuart Sherman
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Glen A. Lehman
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States,Corresponding author Glen A. Lehman, MD Indiana University Hospital550 North University Blvd., Suite 1634Indianapolis, IN 46202-5149+1-317-948-0164
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16
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Lim DZ, Wong E, Hassen S, Al-Habbal Y. Retroperitoneal bile leak after laparoscopic cholecystectomy. BMJ Case Rep 2018; 2018:bcr-2017-222750. [PMID: 29351939 DOI: 10.1136/bcr-2017-222750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Bile duct injury (BDI) is a well-recognised complication of laparoscopic cholecystectomy (LC). Following a BDI, bile usually leaks into the peritoneal space and causes biliary peritonitis. This manifests as non-specific abdominal pain and fever occurring several days after the surgery. It can be managed by laparoscopic washout with or without bile duct repair. We present a rare case of retroperitoneal bile leak post-LC. The mechanism of injury here was likely partial avulsion from excessive traction of the cystic duct during intraoperative cholangiogram. Diagnosing retroperitoneal bile leak can be difficult because it is extremely rare and the presenting symptoms can be similar to an intraperitoneal bile leak. A high index of clinical suspicion is required. In cases of suspected bile leak, any mismatch between the exploratory laparoscopic findings and imaging findings should alert surgeons to consider the rare possibility of a retroperitoneal bile leak.
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Affiliation(s)
- Dee Zhen Lim
- School of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
| | - Enoch Wong
- Department of General Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Sayed Hassen
- Department of General Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Yahya Al-Habbal
- Department of General Surgery, Eastern Health, Box Hill, Victoria, Australia
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17
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Asia-Pacific consensus guidelines for endoscopic management of benign biliary strictures. Gastrointest Endosc 2017; 86:44-58. [PMID: 28283322 DOI: 10.1016/j.gie.2017.02.031] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/23/2017] [Indexed: 12/11/2022]
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18
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Zheng X, Wu J, Sun B, Wu YC, Bo ZY, Wan W, Gao DJ, Hu B. Clinical outcome of endoscopic covered metal stenting for resolution of benign biliary stricture: Systematic review and meta-analysis. Dig Endosc 2017; 29:198-210. [PMID: 27681297 DOI: 10.1111/den.12742] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 09/22/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM Management of benign biliary stricture is challenging. Endoscopic therapy has evolved as the first-line treatment for various benign biliary strictures. However, covered self-expandable metal stents (CSEMS) have not been approved by the United States Food and Drug Administration for the treatment of benign biliary stricture. With this goal, we conducted the present systemic review and meta-analysis to evaluate the efficacy and safety of endoscopic stenting with CSEMS in the treatment of benign biliary stricture. METHODS Systematic review and meta-analysis by searching PubMed, MEDLINE and Embase databases. RESULTS In total, 37 studies (1677 patients) fulfilled the inclusion criteria. Pooled stricture resolutions were achieved in 83% of cases. Median stent dwelling time was 4.4 months, with median endoscopic retrograde cholangiopancreatography sessions of 2.0. Stricture recurrence at 4-year follow up was 11% (95% CI, 8-14%). Pooled complication rate was 23% (95% CI, 20-26%). CONCLUSIONS Placement of CSEMS is effective in the treatment of benign biliary stricture with relatively short stenting duration and low long-term stricture recurrence rate. However, more prospectively randomized studies are required to confirm the results.
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Affiliation(s)
- Xiao Zheng
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Jun Wu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Bo Sun
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Ye-Chen Wu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Yuan Bo
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Wei Wan
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Dao-Jian Gao
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Bing Hu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
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Páramo M, García-Barquín P, Carrillo M, Millor Muruzábal M, Vivas I, Bilbao J. Treatment of benign biliary leaks with transhepatic placement of coated self-expanding metallic stents. RADIOLOGIA 2017. [DOI: 10.1016/j.rxeng.2016.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Páramo M, García-Barquín P, Carrillo M, Millor Muruzábal M, Vivas I, Bilbao JI. Treatment of benign biliary leaks with transhepatic placement of coated self-expanding metallic stents. RADIOLOGIA 2016; 59:47-55. [PMID: 27814912 DOI: 10.1016/j.rx.2016.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 09/01/2016] [Accepted: 09/09/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To analyze the safety and efficacy of percutaneous placement of coated self-expanding metallic stents (SEMS) in patients with biliary leaks. MATERIAL AND METHODS This ethics committee at our center approved this study. We retrospectively reviewed all coated SEMS placed between October 2008 and September 2015. We analyzed patient-related factors such as the primary underlying disease, prior hepatic procedures, and clinical outcome. We evaluated the location, the number and type of leak (anastomotic or non-anastomotic), and the characteristics of the interventional procedure (number of stents deployed, location of the stents, technical success, and primary functionality). We recorded the complications registered. RESULTS We studied 14 patients (11 men and 3 women). The mean follow-up period was 375.5 days (range 15-1920 days). Leaks were postsurgical in 12 patients. One patient developed an arteriobilioportal fistula. In another, the biliary leak occurred secondary to the rupture of the common bile duct after ERCP. A total of 23 coated SEMS were placed, including 21 Fluency® stents (Bard, Tempe, AZ, USA) and 2 Wallflex® stents (Boston Scientific, Galway, Republic of Ireland). The technical success of the procedure was considered total in 11 (78.6%) patients, partial in 2 (14.3%) patients, and null in 1 (7.2%) patient. The clinical outcome was good in 13 of the 14 patients. The mean period of primary functionality of the coated SEMS was 331 days (range 15-1920 days). No major complications were observed in 11 (78.6%) patients. CONCLUSIONS Percutaneous placement of coated SEMS for the treatment of benign biliary leaks is safe and efficacious, with a high rate of technical and clinical success and a moderate rate of complications.
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Affiliation(s)
- M Páramo
- Departamento de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España.
| | - P García-Barquín
- Departamento de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - M Carrillo
- Departamento de Radiología, Hospital Morales Meseguer, Murcia, España
| | - M Millor Muruzábal
- Departamento de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - I Vivas
- Departamento de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - J I Bilbao
- Departamento de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España
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21
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Canena J, Horta D, Coimbra J, Meireles L, Russo P, Marques I, Ricardo L, Rodrigues C, Capela T, Carvalho D, Loureiro R, Dias AM, Ramos G, Coutinho AP, Romão C, Veiga PM. Outcomes of endoscopic management of primary and refractory postcholecystectomy biliary leaks in a multicentre review of 178 patients. BMC Gastroenterol 2015; 15:105. [PMID: 26285593 PMCID: PMC4545536 DOI: 10.1186/s12876-015-0334-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 08/10/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Biliary leaks have been treated with endoscopic management using different techniques with conflicting results. Furthermore the appropriate rescue therapy for refractory leaks has not been established. We evaluated the clinical effectiveness of initial endotherapy for postcholecystectomy biliary leaks using an homogenous approach (sphincterotomy + placement of a 10-French plastic stent) in a large series of patients as well as the optimal and efficacy of rescue endotherapy for refractory biliary leaks. METHODS This was a multicenter, retrospective study of 178 patients who underwent endoscopic management of postcholecystectomy biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore (10-French) plastic stent. Data were collected to analyze the clinical outcomes and technical success, efficacy of the rescue endotherapy and the need for surgery, adverse events and prognostic factors for clinical success of endotherapy. RESULTS Following endotherapy, closure of the leak was accomplished in 162/178 patients (91.0%). The multivariate logistic model showed that the type of leak, namely a high-grade biliary leak, was the only independent prognostic factor associated with treatment failure (OR = 26.78; 95% CI = 6.59-108.83; P < 0.01). The remaining 16 patients were treated with multiple plastic stents (MPSs) with a success rate of 62.5% (10 patients). The use of fewer than 3 plastic stents (P = 0.023) and a high-grade biliary leak (P = 0.034) were shown to be significant predictors of treatment failure with MPSs in refractory bile leaks. The 6 patients in whom the placement of MPSs failed were retreated with a fully cover self-expandable metallic stent (FCSEMS), resulting in closure of the leak in all cases. CONCLUSIONS Endotherapy of biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore plastic stent is associated with a high rate of success (90%). However in our series there were several failures using MPSs as a strategy for rescue endotherapy suggesting that refractory biliary leaks should be treated with FCSEMS especially in patients with high-grade leaks.
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Affiliation(s)
- Jorge Canena
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
- Department of Endoscopy, José Joaquim Fernandes Hospital at Unidade Local de Saúde do Baixo Alentejo, Rua Doutor António Fernandes Covas Lima, 7800-309, Beja, Portugal.
| | - David Horta
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
| | - João Coimbra
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Liliane Meireles
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Pedro Russo
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Inês Marques
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Leonel Ricardo
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
| | - Catarina Rodrigues
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
| | - Tiago Capela
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Diana Carvalho
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Rafaela Loureiro
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - António Mateus Dias
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Gonçalo Ramos
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - António Pereira Coutinho
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Carlos Romão
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Pedro Mota Veiga
- Curva de Gauss - Research, Training and Consulting, Rua Doutor Eduardo Maria dos Santos, Lote 1, Loja 3, 3525-000, Canas de Senhorim, Portugal.
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Mangiavillano B, Pagano N, Baron TH, Luigiano C. Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review. World J Gastroenterol 2015; 21:9038-9054. [PMID: 26290631 PMCID: PMC4533036 DOI: 10.3748/wjg.v21.i30.9038] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/04/2015] [Accepted: 07/08/2015] [Indexed: 02/07/2023] Open
Abstract
Endoscopic stenting has become a widely method for the management of various malignant and benign pancreatico-biliary disorders. Biliary and pancreatic stents are devices made of plastic or metal used primarily to establish patency of an obstructed bile or pancreatic duct and may also be used to treat biliary or pancreatic leaks, pancreatic fluid collections and to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. In this review, relevant literature search and expert opinions have been used to evaluate the outcome of stenting in biliary and pancreatic benign and malignant diseases.
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23
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Canena J, Liberato M, Meireles L, Marques I, Romão C, Coutinho AP, Neves BC, Veiga PM. A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos). Gastrointest Endosc 2015; 82:70-8. [PMID: 25771064 DOI: 10.1016/j.gie.2014.11.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 11/21/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic management of postcholecystectomy biliary leaks is widely accepted as the treatment of choice. However, refractory biliary leaks after a combination of biliary sphincterotomy and the placement of a large-bore (10F) plastic stent can occur, and the optimal rescue endotherapy for this situation is unclear. OBJECTIVE To compare the clinical effectiveness of the use of a fully covered self-expandable metal stent (FCSEMS) with the placement of multiple plastic stents (MPS) for the treatment of postcholecystectomy refractory biliary leaks. DESIGN Prospective study. SETTING Two tertiary-care referral academic centers and one general district hospital. PATIENTS Forty consecutive patients with refractory biliary leaks who underwent endoscopic management. INTERVENTIONS Temporary placement of MPS (n = 20) or FCSEMSs (n = 20). MAIN OUTCOME MEASUREMENTS Clinical outcomes of endotherapy as well as the technical success, adverse events, need for reinterventions, and prognostic factors for clinical success. RESULTS Endotherapy was possible in all patients. After endotherapy, closure of the leak was accomplished in 13 patients (65%) who received MPS and in 20 patients (100%) who received FCSEMSs (P = .004). The Kaplan-Meier (log-rank) leak-free survival analysis showed a statistically significant difference between the 2 patient populations (χ(2) [1] = 8.30; P < .01) in favor of the FCSEMS group. Use of <3 plastic stents (P = .024), a plastic stent diameter <20F (P = .006), and a high-grade biliary leak (P = .015) were shown to be significant predictors of treatment failure with MPS. The 7 patients in whom placement of MPS failed were retreated with FCSEMSs, resulting in closure of the leaks in all cases. LIMITATIONS Non-randomized design. CONCLUSION In our series, the results of the temporary placement of FCSEMSs for postcholecystectomy refractory biliary leaks were superior to those from the use of MPS. A randomized study is needed to confirm our results before further recommendations.
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Affiliation(s)
- Jorge Canena
- Center of Gastroenterology, Cuf Infante Santo Hospital-Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal; Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal; Department of Endoscopy, José Joaquim Fernandes Hospital da Unidade Local de Saúde do Baixo Alentejo, Beja, Portugal
| | - Manuel Liberato
- Center of Gastroenterology, Cuf Infante Santo Hospital-Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Liliane Meireles
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Inês Marques
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Carlos Romão
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - António Pereira Coutinho
- Center of Gastroenterology, Cuf Infante Santo Hospital-Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Beatriz Costa Neves
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Pedro Mota Veiga
- Curva de Gauss-Research, Training and Consulting, Canas de Senhorim, Portugal
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Grolich T, Crha M, Novotný L, Kala Z, Hep A, Nečas A, Hlavsa J, Mitáš L, Misík J. Self-expandable biodegradable biliary stents in porcine model. J Surg Res 2014; 193:606-12. [PMID: 25201575 DOI: 10.1016/j.jss.2014.08.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 07/18/2014] [Accepted: 08/05/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Treatment or prevention of a benign biliary tree stricture is an unresolved problem. A novel self-expandable biodegradable polydioxanon biliary stent in a porcine model was studied. MATERIALS AND METHODS This new stent was used in 23 pigs. Feasibility and safety of surgical stenting, time of biodegradation, and histologic reaction in 2, 8, 13, and 20 wk of a follow-up were studied. All stents were inserted into a common bile duct through a duodenal papilla following small dilatation. After surgical evaluation of abdominal cavities, the pigs were sacrificed to remove common bile ducts with the stents. All bile ducts were assessed by macroscopic and histopathologic examination. RESULTS Self-expansion was correct in all cases. Neither bile duct obstruction nor postsurgical complications were observed. Macroscopic evaluation indicated lightening of the stent color in 2 wk, a partial disintegration in 8 wk, and a complete absorption in 13 and 20 wk. Histologic evaluation in general substantiated a mild-to-moderate inflammatory reaction in the lamina propria during the whole follow up and had no clinical consequences. No cholangitis, necrosis, abscess, or excessive fibroplasia was found in a hepatoduodenal ligament. CONCLUSIONS Our results suggest that polydioxanon biodegradable self-expanding stents seem to be useful for biliary system implantation, offer a good biocompatibility, and completely degrade within 13 wk.
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Affiliation(s)
- Tomáš Grolich
- Department of Surgery, Masaryk University, Brno, Czech Republic.
| | - Michal Crha
- CEITEC - Central European Institute of Technology, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
| | - Ladislav Novotný
- Institute of Pathology and Parasitology, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic; Finn Pathologists, Department of histology, Weybread, United Kingdom
| | - Zdeněk Kala
- Department of Surgery, Masaryk University, Brno, Czech Republic
| | - Aleš Hep
- Department of Hepatogastroenterology, Masaryk University, Brno, Czech Republic
| | - Alois Nečas
- CEITEC - Central European Institute of Technology, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
| | - Jan Hlavsa
- Department of Surgery, Masaryk University, Brno, Czech Republic
| | - Ladislav Mitáš
- Department of Surgery, Masaryk University, Brno, Czech Republic
| | - Jan Misík
- Faculty of Military Health Sciences, Department of Toxicology, University of Defence, Hradec Kralove, Czech Republic
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