In the end, no one wants to experience a bile duct stricture. Strictures have a range of benign causes, but can also be a. Differentiating malignant from benign common bile duct. Management of biliary strictures after liver transplantation nicolas a. The areas discussed in this editorial include the role of biliary drainage in resectable malignant strictures and whether such drainage should be performed routinely prior to surgery, the best endoscopic palliation for unresectable hilar strictures and whether unilateral or bilateral stenting should be. Ercp wih biliary sphincterotomy and stenting for palliative purpose duration. Biliary endoscopy for benign and malignant biliary strictures.
Biliary strictures are typically referred to as indeterminate in cases with nondiagnostic lab work, crosssectional imaging, and brushings andor intraductal biopsies obtained during endoscopic retrograde cholangiopancreatography ercp or in cases of benign results but a strong clinical. This is a free, online tool for merging combining multiple pdf files into one, single file. Bile duct strictures are problematic in terms of management and distinction between benign and malignant. Only surgeons well trained and experienced in their management should treat this entity. Pathology etiology there are numerous causes of biliary duct strictures, including 1,2. Benign biliary strictures pose difficult management problems.
Focal strictures occurring at the hepatic duct confluence, or within the common hepatic duct or common bile duct in patients without a history of prior surgery in that region or stone disease, are usually thought to represent cholangiocarcinoma until proved otherwise. Biliary complications are still the major source of morbidity for liver transplant recipients. The miami classification system has been proposed to characterize pcle findings for biliary strictures. Listing a study does not mean it has been evaluated by the u. Classification based on the principles of surgical treatment article pdf available in world journal of surgery 2510. A nonanastomotic stricture is defined as 1 or more focal areas of narrowing of the bile ducts proximal to a biliary anastomosis, 11, 12 and often occurs at multiple sites. Ercp is the firstline treatment modality for abs and in selected cases of nabs. Prospective study of biliary strictures to determine the predictors of malignancy. Convert pdf files online without software installation. Cause, classification, and clinical manifestations biliary stricture can be seen with a wide array of nonneoplastic causes. Pathological effects of biliary obstruction biliary obstruction high local concentratio n of bile salts inflammatio n 6.
Biliary stricture is a term used to describe a constriction of the bile duct, a tube which carries bile from the liver and the gallbladder to the intestines. Improvements in existing technologies as well as the implementation of novel technologies and techniques have the potential to. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures. Katia papalezova, bryan clary, in blumgarts surgery of the liver, pancreas and biliary tract fifth edition, 2012.
Pdf candy provides you with a unique tool to merge pdf files and it is absolutely free for everyone. Endoscopic biliary dilatation and stenting is the mainstay of therapy for biliary strictures. With the advent of laparoscopic biliary surgery, the use of the ttube has become less common, eliminating methods for accessing the biliary tree postoperatively without an invasive procedure. Temporary placement of fully covered metal stents for benign biliary strictures is safe and efficacious. Whether from a surgical mishap, a cancer scare, or some other source of inflammation or infection, the keys to treating and preventing further bile duct strictures are good health, quick diagnoses, and quality treatment by a specialist experienced in treating bile duct strictures. It opens into the part of the intestine called the duodenum via the ampulla of vater segments. Strictures definition of strictures by medical dictionary.
It is only with a severe degree of obstruction or even complete blockage that symptoms arise. Knowledge of the key imaging and clinical findings will aid in facilitating the diagnosis and treatment. While biliary endoscopy has been more commonly utilized for treatment of gallstones with documented excellent results, 1 its role can be expanded for the treatment of benign and malignant biliary strictures, particularly in cases where endoscopic retrograde cholangiopancreatography ercp fails or is not feasible due to surgicallyaltered anatomy. However, there are several congenital, infectious, inflammatory, autoimmune, iatrogenic, and neoplastic etiologies that should also be considered in the differential diagnosis. Postlt biliary strictures are considered abs or nonabs nabs ie, elsewhere in the biliary tree. The stricture can then be opened by inserting a biliary stent a metal or plastic tube to open the stricture. Endoscopy has an established role in the diagnosis and therapy of biliary strictures. Aetiology prior local surgery, pancreatitis, trauma, gallstones. Common controversies in management of biliary strictures. Biliary strictures are a wellknown and common complication of both living donor liver transplant ldlt and deceased donor liver transplant ddlt and account for more than 50% of all biliary complications of liver transplant. The other procedure that can be done is called pthc percutaceous transhepatic cholangiography, in which a catheter drain is inserted through the right side of the abdominal wall, inside the liver to the biliary tree. The presence of thick white bands 20 micrometer, thick dark bands 40 micrometer, dark clumps, epithelial structures and contrast. Some biliary strictures cannot be readily classified as benign or malignant on the basis of noninvasive imaging studies, erc, andor conventional tissue sampling methods i. Evaluation of indeterminate biliary strictures nature.
Prompt diagnosis and management of these strictures are therefore recommended in spite of their benign nature. Classification based on the principles of surgical treatment. Current diagnosis and treatment of benign biliary strictures after. Pancreatic cancer, surrounding and compressing the distal bile duct, is the most common cause of malignant biliary strictures 90%.
Hypothesis the heppcouinaud approach to biliary enteric reconstruction for laparoscopic bile duct injuries provides a durable, longterm result in most patients. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures 1, 2. The diagnosis of biliary strictures can be challenging. Biliary strictures following liver transplantation. Despite advances in surgical techniques, benign biliary strictures after. Pdf on mar 31, 2018, hyun jik lee and others published diagnosis of. Differentiation of benign biliary strictures bbs from malignant biliary strictures mbs. If you need to develop your own application for merging andor splitting. Endoscopic management of biliary obstruction abdominal key. 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.
Management endoscopic surgery with insertion of selfexpanding metal mesh stents. This online pdf merge function is completely cost free and easy to use. We dont put any watermarks on documents you create. A minor narrowing does not significantly impede bile movement and a person may be asymptomatic. 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. Management of biliary strictures after liver transplantation.
A prospective comparison of the diagnostic accuracy of ercp, mrcp, ct, and eus in biliary strictures. Biliary strictures frequently present a diagnostic challenge during preoperative evaluation to determine their benign or malignant nature. Most biliary strictures result from injuries during cholecystectomies, and their initial management is a major determining factor of the longterm outcome. The biliary tree see below is the whole network of various sized ducts branching. Postoperative biliary injuries mainly postcholecystectomy, dominant biliary strictures in the setting of primary sclerosing cholangitis psc, biliary strictures occurring after liver transplantation, and.
Combinedcemri,and mrcp play an important role incharacterizationof benign and malignant biliary stricture. Oct 16, 2019 biliary enteric anastomosis is a safe, effective, and lasting therapy for biliary strictures. The reported incidence of biliary strictures is 5%15% after deceased donor liver transplantation and 28%32% after rightlobe live donor surgery. Alhough up to 30% of biliary strictures can be benign 1, the vast majority are malignant, the two major malignancies being pancreatic adenocarcinoma and cholangiocarcinoma. Apr 12, 2020 biliary stricture is a term used to describe a constriction of the bile duct, a tube which carries bile from the liver and the gallbladder to the intestines. No subscriptions are needed and what is not less important there are no annoying ads on the whole website. You reached the maximum number of files for this function. Combining both modalities modestly increased sensitivity 59. Malignant biliary strictures in patients with a normal. Operative management to surgically reestablish bile flow within the biliary tree and into the proximal gastrointestinal tract in a manner that prevents cholestasis, cholangitis, sludge and stone formation, restricture, or biliary cirrhosis nonoperative management to correct the increased resistance to biliary flow caused by a reduction in. Preoperative diagnosis of biliary strictures often presents as a challenge to clinicians. Biliary stricture management and treatment cleveland clinic.
Pdf benign biliary strictures bbss may form from chronic inflammatory pancreaticobiliary. Indeterminate biliary strictures can easily be mischaracterized which may dramatically affect patients outcome. Oct 16, 2019 bile duct strictures may be asymptomatic but, if ignored, can cause lifethreatening complications, such as ascending cholangitis, 2, 3 liver abscess, and secondary biliary cirrhosis. Management of benign biliary strictures journal article. Biliary strictures occur due to a variety of mechanisms including iatrogenic, inflammatory and neoplastic causes. This is a tube that moves bile from the liver to the small intestine. Postoperative strictures 1 cholecystectomy or common bile duct exploration accounting 80% of nonmalignant stricture 2 biliary enteric anastomosis 3 hepatic resection 4 portocaval shunt 5 pancreatic surgery 6 gastrectomy 7 liver. Biliary strictures are considered indeterminate when basic workup, including transabdominal imaging and endoscopic retrograde cholangiopancreatography with routine cytologic brushing, are nondiagnostic. Benign biliary strictures were classified according to the bismuths classification with a small modification. Original article surgical management of benign biliary. Biliary strictures after liver transplantation article pdf available in gut and liver 52. The current diagnosis and treatment of benign biliary stricture.
These strictures are notoriously difficult to treat and traditionally are managed by. Biliary strictures frequently present a challenge in terms of diagnosis, which requires a multidisciplinary approach. Fortyseven patients with benign biliary strictures were enrolled in the protocol, including 25 53% after olt. The top half of the common bile duct is associated with the liver, while the bottom half of the common bile duct is associated with the pancreas, through which it passes on its way to the intestine. Bile duct stricture uf health, university of florida health. Its purpose is to provide for drainage of bile past obstructed bile ducts and into the small intestine, where it. Surgery of the biliary tree the extent of surgery of the biliary tree is dictated by the location of the disease, and whether the lesion is benign, malignant or premalignant.
A read is counted each time someone views a publication summary such as the title, abstract, and list of authors, clicks on a figure, or views or downloads the fulltext. Biliary stricture is the most frequent complication after lt, and incidence ranges from 5%32%. Bile duct stricture definition of bile duct stricture by. Sep 22, 2012 as laparoscopic cholecystectomy and liver transplantation lt have become more common, so has biliary stricture. No standard definition for indeterminate biliary stricture exists.
Biliary stricture dr n surendra babu jr resident dept. Reasons for hepatobiliary surgery complicated by anastomotic strictures. However, not uncommonly, patients undergo surgical exploration for a preoperative diagnosis. Pdf radiofrequency and malignant biliary strictures.
Dec 28, 2014 biliary strictures and masses are commonly a result of cholangiocarcinoma. The endoscopic treatment of benign biliary strictures bbs has become widely used in the last decade. When this happens, bile can back up into the liver, causing abdominal pain, nausea, itching, fever, chills, and jaundice. Patients baseline characteristics in both groups are presented in table 1.
Current endoscopic approach to indeterminate biliary. Ptc can accurately depict thelocation and characteristics of biliary strictures in most patients. Type i choledochal cysts may mimic biliary strictures on imaging and may also induce biliary stricture formation due to recurrent infection and stone formation. 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. The presence of moderatetosevere fusiform dilatation of the cbd without intrahepatic biliary dilatation is the key imaging finding that helps in differentiating a type i choledochal cyst from a distal cbd stricture fig. A bile duct stricture is often caused by injury to the bile ducts during surgery.
Prospective study of biliary strictures to determine the. Endoscopic management of benign biliary strictures trepo. Approach to management of indeterminate biliary stricture. A bile duct stricture is an abnormal narrowing of the common bile duct. Strictures can be caused during surgery on nearby tissues, such as the gallbladder. The majority of patients initially underwent olt for viral hepatitis 28%, hepatocellular carcinoma 20%, and psc 20%. A biliary stricture is any narrowing of the bile duct, the tube that carries bile between the liver, gallbladder and duodenum of the small intestine. Malignant biliary strictures are usually linked to different types of tumors, mainly cholangiocarcinoma, pancreatic and hepatocellular carcinomas. Pancreatic carcinoma cholangiocarcinoma ampullary carcinoma gallbladder cancer metastatic disease. Focal intrahepatic benign bile duct stricture after cholecystectomy. Called a bile duct stricture, this narrowing of the bile duct dramatically reduces the amount of bile delivered to the small intestine for digestive purposes.
Shah, virendra joshi, michel kahaleh, adam slivka, paul r. Edwyn harrison, md dr villa is an advanced endoscopy fellow and dr harrison is a professor in the division of gastroenterology and hepatology at the mayo clinic in scottsdale, arizona. It can be improved by combining fine needle aspiration biopsy with. Benign biliary strictures managed with a wallflex biliary rx. However, before definitive operative therapy for bile duct strictures is performed, patients must be stabilized and, if possible, biliary drainage should be achieved either endoscopically or percutaneously. A narrowed bile duct makes it difficult for bile to pass to the small bowel, causing a buildup of bile. A total of 868 patients with benign biliary strictures were included in this study. Cholecystectomy and orthotopic liver transplantation olt are the most common iatrogenic causes of benign biliary stricture. Biliary tract surgery an overview sciencedirect topics.
Bain vg, abraham n, jhangri gs, alexander tw, henning rc, hoskinson me et al. Bile is a substance that helps in digestion of fatty food. Benign biliary strictures have a broad spectrum of etiologies. The rendezvous technique is an approach combining ptc and erc. These strictures are longer and occur less frequently and earlier than anastomotic strictures, with a mean time to stricture formation of 3 to 6 months. Evaluation of indeterminate biliary strictures uc davis.
A variety of benign conditions, such as primary sclerosing cholangitis psc and igg4related sclerosing cholangitis, frequently mimic. Diagnosis of bile duct strictures the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. A biliary stricture is a narrowing of the common bile duct. Biliary surgery is one of the biggest and most involving surgeries in the abdomen, and that is due to the proximity of the bile ducts to vital organs. The chart showing pdf series, word series, html series, scan qr codes. Surgical management of benign strictures of the biliary tract. There is no need to install special software and uploaded files can be in various formats like doc, xls, ppt and so on. Final determination of malignancy in biliary strictures can entail major surgery if preoperative diagnosis of malignancy cannot be made. Endoscopic management of biliary strictures sammy ho, md director of pancreaticobiliary services and endoscopic ultrasound montefiore medical center. Strictures of the bile duct are a wellrecognized compli.
Percutaneous management of benign and postoperative. Design retrospective study of patients who underwent operative repair of laparoscopic bile duct injuries from january 1990 through december 1997. Multicenter, prospective registry study utilizing probebased confocal laser endomicroscopy pcle to distinguish benign from malignant dominant biliary strictures in patients with primary sclerosing cholangitis raj j. Unfortunately, most benign bile duct strictures biliary strictures are iatrogenic, resulting from operative trauma see images. Fortunately, endoscopic treatment has almost simultaneously been developed. A number of factors can cause the bile duct to become constricted, including gallstones, scar tissue, pancreatitis, tumors, and a condition known as primary sclerosing cholangitis. Improvements in existing technologies as well as the implementation of novel technologies and techniques have. All fully covered metal stents were removed successfully. Malignant biliary strictures and those refractory to endoscopic therapy may require surgical intervention. Biliary stricture occurs when the bile duct the tube that takes bile from the liver to the small bowel gets smaller or narrower. And, as you might guess, this reduced amount of bile can create many health issues if not treated properly by an experienced bile duct specialist. Simply upload all the files you need to merge you select multiple files for upload at once by pressing and holding ctrl or command button and clicking on. Patients with a putative biliary stricture and a normal bilirubin level whose final diagnoses were pancreatic cancer, ampullary cancer, distal cholangiocarcinoma and hilar cholangiocarcinoma represented 21%, %, 7% and 9% of individuals diagnosed with these pathologies, respectively.
However, the diagnostic yield from conventional endoscopic retrograde cholangiopancreatography tissue sampling is modest. 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. Percutaneous management of benign biliary strictures with. Resolution of the benign biliary strictures was found in 28 of 36 patients 77. Additional techniques that can be used to evaluate indeterminate strictures include 1 eus, 2 intraductal ultrasonography, 3 probebased.