The major causes of benign biliary strictures include surgery, chronic pancreatitis, primary sclerosing cholangitis, and autoimmune cholangitis. Biliary leaks mainly occur after surgery and, rarely, abdominal trauma. These conditions may benefit from a nonsurgical approach in which endoscopic retrograde cholangiopancreatography (ERCP) plays a pivotal role in association with other minimally invasive approaches. This approach should be evaluated for any injury before deciding about the method for repair. ERCP, associated with peroral cholangioscopy, plays a growing role in characterizing undeterminate strictures, avoiding both unuseful major surgeries and palliative options that might compromise any further management.
Key points
- •
Endoscopic approach plays a major role in the management of a vast majority of bile duct injuries (BDIs), including the most severe ones.
- •
These patients should be managed in highly specialized centers with a multidisciplinary environment and availability of multitechnical approaches.
- •
Biliary stricture calibration is successfully obtained with multiple plastic stents placement and serial exchanges for 1 year.
- •
Fully covered self-expandable metal stents (FCSEMS) represent a reasonable alternative to multiple plastic stents, particularly for biliary stenosis associated with chronic pancreatitis. Uncovered self-expandable metal stents (SEMS) are strictly contraindicated for any benign biliary stenosis.
- •
Autoimmune cholangiopathy (AIC) and primary sclerosing cholangitis (PSC) represent major diagnostic challenges whereby endoscopic retrograde cholangiopancreatography (ERCP) and cholangioscopy play a pivotal role.
Introduction
Benign biliary strictures are secondary to surgery, chronic pancreatitis (CP), PSC, or autoimmune cholangitis. Biliary leaks mainly occur after surgery and, rarely, abdominal trauma.
BDIs occurring during surgery represent a major clinical problem associated with significant morbidity and mortality. Laparoscopic cholecystectomy is the leading cause of iatrogenic BDIs occurring in 0.3% to 0.5% of the cases. They can also develop after hepatic surgery, such as hepatic resection and liver transplant, or follow nonbiliary surgery or nonoperative procedures in areas located close to the biliary tract. Less frequently, abdominal trauma can also result in BDIs.
BDIs can range from nonsevere bile duct leaks or strictures to more severe injuries including complete transection or occlusion of the main ducts. Different classifications described in this article have been developed to evaluate their severity and guide physicians in planning the most appropriate medical or surgical therapeutic intervention for each patient. ERCP and associated nonsurgical techniques play a pivotal and still growing role in their management.
Benign strictures due to CP may also benefit from endoscopic therapy, whereas those associated with PSC or AIC represent, in addition to potential therapy, one of the few diagnostic indications of ERCP (and cholangioscopy) for characterization of undetermined strictures and differential diagnosis from malignancy.
This article covers the current indications and capabilities of ERCP (and associated nonsurgical techniques) for the management of benign biliary strictures and leaks.
Introduction
Benign biliary strictures are secondary to surgery, chronic pancreatitis (CP), PSC, or autoimmune cholangitis. Biliary leaks mainly occur after surgery and, rarely, abdominal trauma.
BDIs occurring during surgery represent a major clinical problem associated with significant morbidity and mortality. Laparoscopic cholecystectomy is the leading cause of iatrogenic BDIs occurring in 0.3% to 0.5% of the cases. They can also develop after hepatic surgery, such as hepatic resection and liver transplant, or follow nonbiliary surgery or nonoperative procedures in areas located close to the biliary tract. Less frequently, abdominal trauma can also result in BDIs.
BDIs can range from nonsevere bile duct leaks or strictures to more severe injuries including complete transection or occlusion of the main ducts. Different classifications described in this article have been developed to evaluate their severity and guide physicians in planning the most appropriate medical or surgical therapeutic intervention for each patient. ERCP and associated nonsurgical techniques play a pivotal and still growing role in their management.
Benign strictures due to CP may also benefit from endoscopic therapy, whereas those associated with PSC or AIC represent, in addition to potential therapy, one of the few diagnostic indications of ERCP (and cholangioscopy) for characterization of undetermined strictures and differential diagnosis from malignancy.
This article covers the current indications and capabilities of ERCP (and associated nonsurgical techniques) for the management of benign biliary strictures and leaks.
Postoperative biliary strictures and leaks
Although most BDIs occur after cholecystectomy, other liver surgeries such as hepatectomies and liver transplant represent sources of major injuries. The early injury often results from complex dissection, poorly defined anatomy, or management of preoperative bleeding by clipping or diathermy.
Delayed injury may arise from ischemia of the bile ducts, and stenoses may develop clinically up to decades after the original insult. Whatever their cause and timing and even if endoscopy has become pivotal in their management, these patients should be initially managed in tertiary referral centers and referred to multidisciplinary teams of endoscopists, radiologists, and surgeons having extensive experience. “Don’t further mess the biliary system” by inappropriate attempts to repair should be the rule, keeping in mind that these complications often occur in young patients undergoing a minor surgery and that inappropriate management may affect at long term their quality of life.
Even if multiple classifications have been published, the most useful for endoscopists is the one described by the group of Amsterdam, which is particularly relevant for postcholecystectomy injuries. BDIs were classified into 4 groups defined as follows:
Type A: Cystic duct leaks or leakages from aberrant or peripheral hepatic radicles
Type B: Major bile duct leaks with or without concomitant biliary stricture
Type C: Bile duct strictures without leakage
Type D: Complete transection of the duct with or without excision of a portion of the biliary tree
Type A leaks arise from the cystic duct and the ducts of Luschka after cholecystectomy. They are usually associated with low output and may require complete filling of the biliary tree with contrast to be demonstrated.
They respond favorably to biliary decompression achieved (and preferably) by transient stent placement (4–8 weeks), endoscopic sphincterotomy (recommended in case of associated common bile duct [CBD] stones), or placement of a nasobiliary catheter, often associated with an endoscopic sphincterotomy (ES). The last is less comfortable for the patient but may be useful, particularly when leaks occur from peripheral radicles, the nasobiliary catheter (NBC) being inserted into the segment from which the leak originates. As for any leak, percutaneous drainage of biloma may be required in addition to endoscopic therapy. These treatments, combining biliary decompression and removal of a persisting obstacle or drainage of a biloma in selected cases, allow resolution of the leak in more than 90% of the cases.
Leakages from major bile ducts (type B), at the level of the CBD after cholecystectomy or choledocal anastomosis or of the intrahepatic ducts after liver surgery, trauma, or in case of anatomic variants, are more challenging to treat endoscopically. They usually are high-output leaks, readily visible at opacification and associated with a biloma in most of the cases when not recognized or suspected and drained preoperatively. These leaks should always benefit from a multidisciplinary therapeutic plan before starting any treatment (mainly attempts at surgical repair), which may further compromise the chances of success. Drainage of collection comes first, usually followed, after proper imaging (preferably with MRI to delineate biliary anatomy), by an ERCP during which the first goal is to reach the intrahepatic ducts proximal to the leak and to evaluate the integrity of all hepatic segments. An ES is always performed in these cases, and stents and/or NBCs are inserted to bypass the leak. At the level of the hilum, multiple stents, usually longer, are implanted in both liver lobes to bypass the leak and ensure stability. In some cases, this endoscopic drainage of the biliary tree can be associated with drainage of the leak itself using transpapillary pigtail stent or NBC to accelerate closure of the external fistula. Another feature of these major leaks is their propensity to be associated with the development of a biliary stricture after healing, another reason why stenting is important not only to favor closure but also to prevent the development of strictures ( Fig. 1 ).
Unlike in minor leaks, stents should be left in place for 6 to 12 months, with exchange when appropriate, similar to what is done for postoperative strictures.
Postoperative biliary strictures (type C) may follow any surgery affecting the biliary system and may also occur at the level of an anastomosis after liver resection or liver transplant (OLTx). When secondary to a direct trauma, they are usually recognized early in the postoperative period and respond more favorably to endoscopic treatment. Delayed presentation may occur up to years (or even decades) after surgery. In this case, their cause most probably involves ischemia and resulting fibrosis. Their treatment usually involves serial placement of multiple stents over a 1-year period. It is now widely accepted that a more aggressive approach including the placement of increasing number of stents over a 6- to 12-month period, with the aim to obtain an anatomic resolution of the stricture, yields more durable results with a success rate more than 80% and an incidence of relapse within 10 years after removal less than 12%. A similar approach is also recommended for choledococholedocal anastomotic strictures after OLTx. Strictures located at the level of the hilum are more difficult to calibrate and technically more demanding because the stents have to be implanted in both lobes or even segmental branches to ensure their stability and allow proper calibration ; this is also true for strictures affecting the upper third of the CBD.
Nonanastomotic strictures occurring after OLTx result from ischemia and are often associated with hepatic artery thrombosis. They are much less responsive to endoscopic therapy with long-term response rate equal to or less than 50%, and a significant proportion of patients may ultimately require transplant. These strictures are often located at the hilum, and their treatment includes placement of multiple plastic stents with serial exchanges. In addition, they are often associated with the formation of bile duct casts or mucocele, which must be repeatedly cleared endoscopically or by combined endoscopic-percutaneous approaches.
ERCP can also be effective for calibration of bilioenteric anastomoses after duodenopancreatectomy or hepaticojejunostomy. Access to the anastomosis in these cases may require the use of device-assisted enteroscopes, and the alternative percutaneous approach should always be considered because it may be less invasive when using dedicated percutaneous (Yamakawa/Munchener) stents.
Whatever the approach, endoscopic or percutaneous, uncovered SEMS are strictly contraindicated for management of benign strictures. Not only is their long-term patency, due to tissue hyperplasia, almost nil but also they cannot be removed in most cases and would compromise any further treatment and chance for cure.
FCSEMS are increasingly being investigated as a treatment option in benign strictures. They could provide more ample and prompt dilation than plastic stents and eliminate the need for multiple sequential ERCP stent exchanges and their attendant costs. A recent multicentric study confirmed the primary requisite of these stents, that is, removability in all cases (with, however, the need for more than 1 procedure in 5%), and showed that a 6-month indwell was able to provide stricture resolution in approximately 70% of patients with postcholecystectomy or anastomotic post-OLTx strictures. These results are surely not better than those reported with multiple plastic stents in these indications, a feature probably related to the high spontaneous migration rate of FCSEMS (around 17% in both groups). Even if technically easier to insert than multiple plastic stents and safe in terms of removability, FCSEMS have not been proved to have a similar efficacy than multiple plastic stents in postoperative and anastomotic strictures.
Complex bile duct injuries, with complete transection and possible excision of a portion of the bile ducts (type D), have been considered not amenable to endoscopic therapy. These are highly complex cases where multidisciplinarity is the rule. Surgical reconstruction may be associated with high morbidity, and percutaneous drainage is usually performed to allow biliary decompression and symptomatic relief while waiting for a surgical procedure performed in stable conditions.
However, successful nonsurgical management of these patients with complex BDI using combined endoscopic/percutaneous or endoscopic ultrasound (EUS)-guided approaches has been described. They consist in rendezvous technique with recanalization through a biloma ( Fig. 2 ) or percutaneous puncture of a distal transected segment using a transjugular intrahepatic portosystemic shuntset (usually used for performing transjugular intrahepatic shunts and puncturing the portal branch through the liver, from a sus-hepatic vein). What has been reported to date is that if stenting can be performed through an excised virtual segment, it effectively results in biliary recanalization and reepithelialization and can offer long-term outcomes similar to those obtained after calibration of a postoperative stricture. Another approach is the EUS-guided drainage of a biloma, which may restore the biliary drainage of a transected part of the bile duct to the gastrointestinal tract or the direct EUS-guided drainage of the proximal transected part of the biliary system through a hepaticogastrostomy or (preferably if feasible) a hepaticobulbostomy ( Fig. 3 ). The place of these techniques in the armamentarium for managing these complex cases still has to be defined, but they represent an option not to be neglected when dealing with patients for whom surgical repair encompasses major surgery with high morbidity.
Related posts:
Difficult Biliary Access
Endoscopic Retrograde Cholangiopancreatography for the Management of Common Bile Duct Stones and Gallstone Pancreatitis
Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Anatomy
Endoscopic Treatment of Recurrent Acute Pancreatitis and Smoldering Acute Pancreatitis
Sphincter of Oddi Dysfunction
Innovations in Intraductal Endoscopy
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
