Novel Non-Surgical Interventions for Benign Inflammatory Biliary Strictures in Infants: A Report of Two Cases and Review of Current Pediatric Literature / 대한소아소화기영양학회지

Benign biliary strictures are uncommon in children. Classically, these cases are managed surgically, however less invasive approaches with interventional radiology and or endoscopy may have similar results and improved safety profiles While benign biliary strictures have been described in literature on several occasions in young children, (most older than 1 year and once in an infant 3 months of age), all reported cases were managed surgically. We present two cases of benign biliary strictures in infants less than 6 months of age that were managed successfully with novel non-invasive procedures and a review of all current pediatric cases reported in the literature. Furthermore, we describe the use of a Rendezvous procedure, which has not been reported as a treatment approach for benign biliary strictures.

A clinical observation of percutaneous balloon dilation and maintenance percutaneous transhepatic cholangial catheter drainage for treatment of 21 patients with benign biliary strictures and difficult endoscopy / 中华内科杂志

Objective To investigate the value of percutaneous balloon dilation and percutaneous transhepatic cholangial drainage (PTCD) catheter maintenance in the treatment of benign biliary strictures.Methods The clinical data of 21 patients with benign biliary strictures at Peking Union Medical College Hospital from June 2005 to June 2011 were retrospectively studied,in which 12 patients in severe stricture (stenosis ＞ 70％ ) were treated with percutaneous balloon dilation and PTCD catheter placed across the stricture,while another 9 patients in median stricture( stenosis ＜ 70％ ) were only treated with PTCD catheter maintenance.Results Of the 12 patients underwent balloon dilation and 6-12 months ( median:9 months)of PTCD catheter placement,11 patients had the catheter successfully removed.In the follow-up of 6-24months ( median:10 months),patency of bile duct was preserved in 9 of 11 patients,and recurrent stenosis was seen in 2 patients.A severe complication with biliary artery branch rupture and massive hemobilia was seen in 1 patient during balloon dilation.Of the 9 patients only treated with 1-12 months (median:6months) of PTCD catheter placement,7 patients had the catheter successfully removed.In the follow-up of 5-18 months (median:8 months),patency of bile duct was preserved in 5 of 7 patients,and recurrent stenosis was seen in 2 patients.No severe complication occurred.Conclusions When endoscopy therapy is failed or the patient can't undergo endoscopy therapy,the percutaneous balloon dilation and PTCD catheter maintenance method is an effective alternative therapeutic approach in the treatment of benign biliary strictures.The moderate benign biliary stricture may be effectively treated only by the PTCD catheter maintenance method.

Temporary placement of fully covered metal stent for benign biliary strictures / 中华消化内镜杂志

ObjectiveTo explore the efficacy and safety of temporary placement of fully covered metal stent in the treatment of benign biliary strictures.MethodsFully covered metal stents were placed in 36 patients with benign biliary strictures.All patients were followed up every 1-2 months and the stents were removed when adequate biliary drainage was achieved.ResultsResolution of the benign biliary strictures was achieved in 28 of 36 patients (77.8％ ).All fully covered metal stents were removed successfully.Complications were observed in 3 patients (8.3％) after stent placement and in 1 (2.8％ ) after stent removal.ConclusionTemporary placement of fully covered metal stents for benign biliary strictures is safe and efficacious.Further investigation is required to longer follow-up.

Molecular mechanism of benign biliary stricture and biological therapy / 中华肝胆外科杂志

Benign biliary strictures(BBS) have different etiologies, and the most common causes are strictures secondary to iatrogenic and ischemic injury after hepatobiliary and transplantation surgery. Fibroblast proliferating activity, extracellular matrix overdeposition and scar proliferation are closely related to BBS. The mechanism of development of BBS involves a variety of cells, cytokines and extracellular matrix. In recent years, biological treatment is emerging as an effective option for BBS, but the clinical application is not yet mature and the curative effect needs to be evaluated further in the future.

The Efficacy and Safety of Fully Covered Self-expandable Metal Stents in Benign Extrahepatic Biliary Strictures / 대한소화기내시경학회지

BACKGROUND/AIMS: For the endoscopic treatment of benign biliary strictures (BBS), it has been a drawback to use plastic stents or uncovered self-expandable metal stents. We investigated the efficacy and safety of temporary placing fully covered self-expandable metal stents (FCSEMS) in BBS. METHODS: We enrolled 12 cases that followed up more than 6 months after insertion of a FCSEMS in BBS via ERCP. The cohort consisted of 9 patients with recurrent cholangitis, 2 patients with postcholecystectomy and 1 patient with chronic pancreatitis. The efficacy was assessed according to the resolution of strictures and also the restricture after stent removal, and the safety was evaluated according to the complications associated with stent placement. Finally, the removability of FCSEMSs was assessed. RESULTS: The median time of FCSEMS placement was 6.0 months. Resolution of the BBS was confirmed in 8 cases (67%) after a median post-removal follow-up of 8.5 months. Restricture after stent removal happened in 4 cases (33%). The complications were severe abdominal pain (n=2), pancreatic abscess (n=1) and stent migration (n=6). In 7 cases, all the FCSEMSs were successfully removed by grasping them with forceps. CONCLUSIONS: Temporary placement of a FCSEMS in BBS showed good therapeutic effects, relative safety and easy removability. Further evaluation is needed for determining the causes of restricture and for developing a new stent with antimigration features.

Estenoses biliares benignas: reparação e resultados com o uso de silastic transhepático transanastomótico / Benign biliary strictures: repair and outcome with the use of silastic transhepatic transanastomotic stents

RACIONAL: Os avanços da medicina nem sempre estão relacionados a bons resultados homogêneos para todos os pacientes. Este é o caso de colecistectomia laparoscópica, cujas vantagens são amplamente reconhecidos na literatura médica. No entanto, ela pode trazer consigo temida e grave complicação que é lesão iatrogênica da via biliar extra-hepática. Ela vem aumentando nos últimos anos, apesar da curva de aprendizagem já estar ultrapassada na maioria dos centros. Está estabilizada em nível mais elevado do que o registrado nas colecistectomias laparotômicas. Na reparação das grandes lesões bom resultado pode ser alcançado com a utilização de tubos transanastomóticos em associação à hepaticojejunostomias. OBJETIVOS: Relatar 20 anos de experiência na reconstrução das vias biliares por lesão ductal com o uso de tubos transanastomóticos. MÉTODOS: Foram analisados os dados de 338 pacientes que se submeteram à operação para as principais lesões do ducto biliar entre janeiro de 1988 e dezembro de 2009. RESULTADOS: Todos os 338 pacientes foram submetidos à hepaticojejunostomias com anastomoses em Y-de-Roux (Hepp-Couinaud) ou colangiojejunostomias, todos com o uso de tubos de silastic transanastomóticos. A longo prazo, bom resultado foi obtido em 240 (92,9 por cento) dos 338 pacientes, incluindo aqueles que necessitaram de procedimentos subsequentes. CONCLUSÃO: Estenoses biliares benignas próximas à confluência dos ductos hepáticos permanece sendo desafio cirúrgico. O uso de tubos de silastic transhepáticos transanastomóticos na reconstrução biliar alta é opção que pode proporcionar boa reparação biliar com baixos índices de complicações.

BACKGROUND: The medical advances is not always related to homogeneous good results for all the patients. This is the case of laparoscopic cholecystectomy, whose advantages are largely recognized in the medical literature. However, this operation most dreaded complication, iatrogenic major bile duct injury, is rising in the last years, despite the learning curve, and stabilized in a level higher than that experienced in open cholecystectomy. Among the features which can bring to this event a good outcome is the use of transhepatic transanastomotic tubes in association with the corrective hepaticojejunostomy. AIM: To report a 20 years experience on biliary reconstruction of bile duct injuries with the use of transhepatic transanastomotic tubes. METHODS: Data were analysed from 338 patients who underwent operation for major bile duct injuries between January 1988 and December 2009. RESULTS: All the 338 patients were submitted to Roux-en-Y hepaticojejunostomy (Hepp-Couinaud approach) or distinct cholangiojejunostomies, all with the use of transhepatic transanastomotic silastic tubes. A successful long-term result was achieved in 240 (92,9 percent) of 338 patients, including those who required subsequent procedures. CONCLUSION: Benign bile duct strictures near the hepatic duct confluence remains a surgical challenge. The use of silastic transhepatic transanastomotic tubes in high biliary tract reconstruction is an option which can provides a successful repair of bile duct injuries with low complication rates.

Estenosis biliares benignas: experiencia 77 casos / Benign biliary strictures: experience 77 cases

Se presenta la experiencia de los autores con 77 casos de estenosis biliares benignas tratadas en Unidad de Cirugía Hepática, Biliar y trasplante de hígado del Hospital Universitario de Maracaibo. Desde agosto de 1989 hasta diciembre de 2009, fueron registrados 77 casos de estenosis biliares benignas. Se tipificaron según la clasificación de Bismuth. 83,12% (64) de los pacientes habían sido colecistectomizados (estenosis post-iatrogenia durante este procedimiento): 41 (53,25%) abiertas y 23 (29,87%) laparoscópicas. 89,61 (69) de los pacientes consultaron por ictericia, 62,34% fiebre y 58,44% dolor abdominal. 9% (7) presentó estenosis Bismuth I, 22% (17) tipo II, 44,16% (34) tipo III y 24,68% (19) tipo IV. A todos se les realizó exploración biliar quirúrgica y anastomosis mucosa-mucosa con Y-Roux, tipo Hepp-Couinaud en 70 (87,5%) de los pacientes. La mortalidad fue 2,6% (2) paciente en el transoperatorio. Se presentaron en el peri-operatorio 19 (24,39%) complicaciones en 17 (22%) pacientes: 12 (15,6%) mayores y 7 (8,79%) menores. En un seguimiento promedio de 49 meses, 7-79% (6) pacientes presentaron re-estenosis de la derivación bilioentérica. El mayor porcentaje de estenosis biliares benignas son posteriores a procedimientos quirúrgicos, principalmente colecistectomia. La anastomosis bilioentérica tipo Hepp-Couinaud se realizó en el mayor número de pacientes con excelentes resultados.

Present experience of the authors with 77 cases of bening biliary strictures. From August of 1989 to December of 2009, 77 patients were recorded. Classification of Bismuth was used to classificate the strictures 64 (83,12%) patients were cholecistectomizated (stricture by iatrogenia during this procedure): 41 (53,25%) open and 23 (29,87%) laparoscopic. 89,61% (69) consulted by jaundice, 62,34 by fever and 58,44% by abdominal pain. 9%(7) had stricture Bismuth 1,22% (17) type II, 44,16% (34) type III and 24,68% (19) type IV. All patients were summated to surgical biliary exploration and mucous-mucous biliary anastomosis with Y-Roux. Hepp-Couinaud type in 70 (87,7%) of the patients. Perioperative mortality was 2,6% (2). Perioperative complications were 19 (24,39%) in 17 (22%) patients: 12 (15,6%) mayor and 7(8,79%) minors. In medial following of 49 months, 7,79% (6) presented re-stricture of bilio-enteric anastonosis. The majority of the strictures were due to surgical procedures. Hepp-Couinaud anastomosis was performed in almost all the patients with excellent outcome.

Clinical Use of Gianturco Expandable Metallic Stent in Benign Biliary Stricture: Result of Longterm Follow-up / 한국간담췌외과학회지

BACKGROUND: Self-expandable metallic stent is an effective method in palliative treatment of malignant biliary stricture. However, it is controvesial in benign biliary stricture due to recurrent jaundice, cholangtitis, and finally, obstruction of stent. The purpose of this study was to determine the long-term effectiveness of Gianturco expandable metallic stents in benign biliary strictures. METHODS: We inserted Gianturco self-expandable metallic stent in 13 patients (42~69 years old, 6 men and 7 women) with benign biliary stricture between November 1991 and September 1994 in Wonkwang University Hospital. All patients had a previous history of biliary surgery and underwent balloon dilatation procedure for management of strictures. Insertion routes were percutaneous transhepatic biliary drainage tracks in 8 cases and T-tube tracks in 5 cases. The insertion site was the right intrahepatic duct in 5 cases, the left intrahepatic duct in 2 cases, both intrahepatic ducts in 1 case, common hepatic duct in 1 case, and distal common bile ducts in 4 cases. The stents used were 2~6cm in length and 8~12mm in diameter. The follow-up period was 46months to 81months(mean, 67months). RESULTS: The initial technical success rate was 100% with good immediate patency in all patients. Nine patients(69.2%) had no recurrence of the initial strictures during the follow-up period and 4 patients(30.7%) had further symptoms of biliary obstruction caused by recurrent cholangitis or intrahepatic duct stone formation. These 4 recurrent biliary strictures were treated by surgical methods. The recurrent stricture sites were distal common bile duct(1case), left intrahepatic duct(1case), both intrahepatic ducts(1case), and Roux-en-Y hepaticojejunostomy site(1case). CONCLUSIONS: According to the results of long-term follow-up, expandable metallic stent is a useful method in recurrent biliary strictures, especially in the case where operation is not feasible; poor risk patients, patients refusing operation, multiple biliary operation.