Percutaneous transhepatic cholangioscopy-assisted procedures for the management of postoperative benign bilioenteric anastomotic strictures with or without biliary stones

Table 1 Baseline demographic, clinical, and laboratory characteristics of patients with benign biliary anastomotic stricture, n (%)

Characteristics	Value
Age (years), median (range)	53 (25-72)
Sex
Male	16 (40.0)
Female	24 (60.0)
Clinical presentation
Repeated cholangitis	36 (90.0)
Obstructive jaundice	4 (10.0)
Underlying causes of Roux-en-Y bilioenterostomy
LC with intraoperative bile duct injury	14 (35.0)
Choledochal cyst	8 (20.0)
Hepatolithiasis	7 (17.5)
Pancreatic cystic or solid tumor	5 (12.5)
Ampulloma of the papilla of Vater	2 (5.0)
Others1	4 (10.0)
Time interval from bilioenteric anastomosis to BBAS treatment (months), median (range)	66 (2-254)
Abnormal liver function test results (n = 40)
γ-glutamyl transferase (IU/L) (upper normal limit 50 IU/L)	38 (95.0)
Alkaline phosphatase (IU/L) (upper normal limit 112 IU/L)	34 (85.0)
Total bilirubin (mmol/L) (upper normal limit 17.1 mmol/L)	19 (47.5)
Tumor marker level increased (n = 36)
CA19-9 (U/L) (normal limit 37 U/L)	14 (38.9)
CEA (ng/mL) (upper normal limit 5 ng/mL)	2 (5.6)

¹Including 2 chronic pancreatitis, 1 pancreaticobiliary maljunction, and 1 benign biliary stricture.

LC: Laparoscopic cholecystectomy; BBAS: Benign bilioenteric anastomotic stricture; CA19-9: Carbohydrate antigen; CEA: Carcinoembryonic antigen.

Table 2 Characteristics of benign biliary anastomotic stricture in 40 patients after Roux-en-Y bilioenterostomy, n (%)

Characteristics	n (%)
Location of BBAS1
Common bile duct	4 (10.0)
Common hepatic duct	19 (47.5)
Hilar bifurcation	15 (37.5)
RHD and LHD	2 (5.0)
Severity of BBAS
Mild	10 (25.0)
Moderate	11 (27.5)
Severe2	19 (47.5)
Length of BBAS (mm)
≤ 5	20 (76.9)
6-9	6 (23.1)
≥ 10	0 (0.0)
Complexity of BBAS
Simple	32 (80.0)
Complex3	8 (20.0)
Strictures opposite of PTBD	4 (10.0)

¹Two or more strictures existed in different locations in some cases.

²In 19 cases of severe benign bilioenteric anastomotic stricture, including the presence of a pinhole-like stricture (n = 4), sharp angulation and/or looping stricture (n = 2), and complete occlusion (n = 2).

³The complex strictures were located in the left hepatic duct (n = 4), left intrahepatic duct (n = 1), right hepatic duct (n = 1), right intrahepatic duct (n = 1), and both left hepatic duct and right intrahepatic duct (n = 1).

BBAS: Benign bilioenteric anastomotic stricture; RHD: Right hepatic duct; LHD: Left hepatic duct; PTBD: Percutaneous transhepatic biliary drainage.

Table 3 Outcomes of percutaneous transhepatic cholangioscopy-assisted procedures in patients with a benign biliary anastomotic stricture, n (%)

Outcomes	Value
Primary outcomes
Anastomotic patency rate
Initial patency rate after stricture dilation (n = 31)
1 year (3-11 months)	18 (58.1)
2 years (3-21 months)	13 (41.9)
Cumulative patency rate after catheter removal (n = 29)
1 year (%)	(74.3)
2 years (%)	(69.7)
3 years (%)	(59.7)
5 years (%)	(49.8)
7 years (%)	(34.8)
8 years (%)	(21.8)
9 years (%)	(14.5)
Treatment success (n = 32)	29 (90.6)
Secondary outcomes
Technical success for PTCS-assisted stricture dilation (n = 31)	31 (100.0)
Simple stricture for mean 1.2 BD sessions (n = 19)	19 (100.0)
Complex stricture for mean 1.4 BD sessions (n = 8)	8 (100.0)
Simple strictures for bougie dilation (n = 4)	4 (100.0)
Initial technical success without a prior recanalization technique (n = 32)	24 (75.0)
Technical success of PTCS-assisted recanalization (n = 8)	7 (87.5)
With guidewire (n = 4)	4 (100.0)
With microcatheter system (n = 2)	2 (100.0)
With needle knife (n = 2)	1 (50.0)
Overall technical success with or without a recanalization technique (n = 32)	31 (96.9)
Technical success of PTCS-assisted lithotripsy/stone removal (n = 36)	34 (94.4)
Stones recurred (n = 28)	3 (10.7)
Successful removal of indwelling PTCS catheter (n = 32)	291 (90.6)
Duration of indwelling PTCS catheter, median months (range), (n = 29)	6 (2-109)

¹3 patients with the catheter unable to be removed, including due to repeated recurrence of the stricture and/or stones (n = 2) and unsuccessful recanalization (n = 1).

PTCS: Percutaneous transhepatic cholangioscopy; BD: Balloon dilation.

Table 4 Adverse events during percutaneous transhepatic biliary drainage, sinus tract dilation as well as percutaneous transhepatic cholangioscopy-assisted procedures, n (%)

	PTBD (n = 40)	Percutaneous sinus tract dilation (n = 40)	PTCS-assisted anastomotic stricture dilation (n = 31)1	PTCS-assisted anastomotic recanalization (n = 8)	PTCS-assisted stone therapy (n = 36)2
Cholangitis	5 (12.5)	2 (5.0)	2 (6.5)	0 (0.0)	2 (5.6)
Bacteremia	4 (10.0)	2 (5.0)	1 (3.3)	0 (0.0)	0 (0.0)
Right pleural effusion	2 (5.0)	1 (2.5)	0 (0.0)	0 (0.0)	0 (0.0)
Hemobilia	0 (0.0)	1 (2.5)3	1 (3.3)	0 (0.0)	0 (0.0)
Catheter migration	0 (0.0)	1 (2.5)4	0 (0.0)	0 (0.0)	1 (2.8)4
Overall	11 (27.5)	7 (17.5)	4 (12.9)	0 (0.0)	3 (8.3)

¹Including 19 patients with a simple stricture and 8 patients with a complex stricture using balloon dilation and 4 patients with a simple stricture using bougie dilation.

²Including removal using a basket or pushing through the anastomosis by a cholangioscope for small or fragmented stones or electrohydraulic lithotripsy and laser lithotripsy for impacted bile duct stones, or stones unremovable via the sinus tract or anastomosis (e.g., > 1 cm stones).

³Acute bleeding occurred from the sinus tract likely due to a biliovenous fistula caused by blood vessel injury when the catheter was removed and the planned second sinus tract dilation session, bleeding was quickly stopped by compression using another larger catheter.

⁴The catheter was successfully reinserted under ultra-thin cholangioscopy in one case, and with a repeated percutaneous transhepatic biliary drainage procedure in the other.

PTCS: Percutaneous transhepatic cholangioscopy; PTBD: Percutaneous transhepatic biliary drainage.