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ENDOSCOPIC MANAGEMENT OF BENIGN BILIARY OBSTRUCTION
PVJ SRIRAM, GV RAO, D NAGESHWAR REDDY
Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad.
The most common causes of benign biliary obstruction are choledocholithiasis and biliary strictures (Table 1). The first line of treatment for calcular obstruction is endotherapy, which by itself merits a comprehensive description and is beyond the scope of the present discussion. Amongst the benign biliary strictures, post-surgical biliary trauma is the leading cause followed by chronic pancreatitis-related and sclerosing cholangitis. The importance of discussion on benign biliary obstruction lies in the fact that almost always, this condition is treatable by one of the 3 main therapeutic approaches namely, endoscopic, radiological, surgical or a combination of the three and delayed or left untreated it almost always leads to a sequence of events starting from cholestasis, recurrent overt or sub-clinical cholangitis, secondary biliary cirrhosis and secondary stone formation. Over the past 2 decades, the advances in ERCP, particularly in the endotherapeutic accessories now allow endoscopic treatment of even the most complicated of the strictures. The results of these techniques are comparable to percutaneous radiological methods and are competing with often-complicated surgical methods. The main advantages of endoscopic approach being its relatively less invasive nature with less morbidity and mortality, while leaving the door open to other methods, should the need arise. The following review initially outlines the technical considerations in the endoscopic management of benign biliary obstructions followed by a brief discussion on the individual conditions.
Stones Choledocholithiasis Strictures Post-operative trauma following
biliary tract surgery
Chronic pancreatitis
Sclerosing cholangitis: AIDS
Infections and InfestationsMiscellaneous Papillary adenoma
Choledochal varices,[1,2]
Crohn's disease,[3]
Peptic ulcer disease,[4,5]
Haemobilia,[6]
Sarcoidosis,[8]
Eosinophilic cholangiopathy[9,10]
TECHNICAL CONSIDERATIONS
Cholangiography : Two most important prerequisites for biliary endotherapy of benign biliary obstruction are an accurate definition of the biliary anatomy and a deep access to the bile duct to facilitate exchange of accessories. Although the aetiology of the biliary obstruction is often evident by the clinical presentation (such as history of trauma or surgery), and other available investigations such as CT or MRCP (chronic pancreatitis, sclerosing cholangitis, etc), a complete delineation of biliary anatomy by performing a cholangiogram is mandatory before proceeding for endoscopic management. We prefer to use a 30% dilute contrast initially for cholangiography so as not to miss any calculi, followed by concentrated solution, to define the stricture and to look for any associated leaks.
Access to proximal biliary tree : Following cannulation, a hydrophilic guide wire is negotiated across the obstruction prior to performing a biliary sphincterotomy. We routinely use one of the hybrid guide wires like Zag wire or Metro wire initially to gain access proximal to the stricture. While the hydrophilic part upfront facilitates easy manoeuvring across the tortuous stricture, the stiffer body of the guide-wire allows subsequent endotherapeutic measures such as sphincterotomy, balloon dilatation and/or stenting over a single guide wire without the need for exchange. However, if the stricture turns out to be very tight and tortuous, we proceed to perform biliary sphincterotomy over the hybrid wire, keeping it as deep as possible below the obstruction and then exchange it for a conventional cannula loaded with one of the 250 cms, J-tipped, hydrophilic Terumo wires (0.018", 0.021" or 0.025") as is appropriate. The advantage of these later guide wires is that due to their shorter length, it is easy to apply torque by twirling movements holding the wire with the index finger and the thumb while gently pushing and pulling the guide wire in the cannula keeping the tip of the guide wire at the mouth of the stricture. Once the guide wire is negotiated across the stricture, it is exchanged for a stiffer Teflon-coated wire to enable subsequent procedures like dilatation and stenting.
Dilatation of strictures : The primary aim of endotherapy in biliary strictures is to relieve obstruction and maintain the patency of the biliary tract. Main problem in treating benign biliary strictures is to maintain the patency of the lumen since re-stenosis due to fibrosis is very common. Hence the need for prior dilatation followed by stenting for a period of time. The extent or grade of dilatation and the frequency varies from case to case and so is the duration. Biliary strictures are routinely dilated using either endoscopic biliary dilating catheters (4 to 10 Fr.) or balloons (9.5 Fr.) and occasionally using a Soehendra stent retriever in case of very tight strictures. Biliary stents of different calibers are used in a graded fashion (initially a single 10 Fr. Stent, which is later exchanged for two 10 Fr. Stents at 6-8 weeks interval) to ensure luminal patency following dilation.[1] Once complete dilatation is achieved, the schedule for subsequent exchanges differs from centre to centre, ranging from a need based stent-exchange to 3 monthly exchange, whether or not symptomatic. A complete success is defined as one, where the biliary lumen is maintained patent for at least one year after the removal of the stents.
CHOLECYSTECTOMY RELATED STRICTURES
The majority of benign bile duct strictures occur as a complication of cholecystectomy.[2] Most are short (< 10 mm), and distal to the confluence of right and left hepatic ducts, as described by the Bismuth classification.[3,4] Laparoscopic cholecystectomy has largely replaced open cholecystectomy because of shorter hospital stay, faster recovery, and lower overall morbidity. Unfortunately, however, the morbidity due to bile duct injury has increased with the advent of laparoscopic approach. While open cholecystectomy is associated with injury to the common bile duct (CBD) in 0.5% of cases,[5,6] Macintyre and Wilson[7] found bile duct injuries following laparoscopic cholecystectomy in 0 to 2% of published, and 0.5 to 0.9% of audited reports. Usually ductal damage, whether leakage, stricture formation, or complete occlusion is not recognized at the time of surgery, but presents some days to years later with abdominal pain, icterus, cholangitis, anorexia, vomiting or nausea, and ileus.[8-12] Elevated alkaline phosphatase and bilirubin accompany all such injuries however, the presence of a biliary leak proximal to a complete ductal obstruction or the development of a fistula may distort this picture.[13]
Most bile duct injuries associated with laparoscopic cholecystectomy result from poorly defined biliary anatomy.[8,14] Intraoperative bleeding near the porta hepatis is potentially risky as attempts are made to secure haemostasis with clips, laser, or diathermy.[15] Inadvertent injury may result from the use of diathermy (stray current, coupling, and sparking) and laser.[15-18] Delayed injuries arise from ischaemia of the bile ducts, especially the right hepatic duct.[19] The distribution of bile duct strictures after laparoscopic cholecystectomy are mid CBD (42 - 50%), confluence area (22 - 41%), common hepatic duct (28%), and distal CBD (15%). Lesions at the level of the cystic duct account for about 20% of cases.[20]
Benign biliary strictures have been classified by Bismuth[21] in relation to distance from the confluence of the right and left hepatic ducts. Strasberg initially classified the biliary injuries following laparoscopic cholecystectomy.[22] Bergman et al modified this classification according to the patients referred for ERCP into four major types: Type A, leakage from cystic duct or peripheral hepatic radicles; Type B, leakage from a major bile duct; Type C, isolated ductal stricture; and Type D, complete transection of the bile duct.[23] ERCP has been shown to be an effective method of diagnosis and treatment in many patients who sustain bile duct injuries during surgery. Types A and B are most amenable to endoscopic therapy while Type D invariably require surgical correction whereas Type C fall in a gray zone where some of them can be salvaged endoscopically. We have further modified this classification based on the associated features that have an impact on the outcome of endoscopic or surgical treatment such as presence, nature and location of obstruction with or without associated biliary leak based on our experience in treating such injuries (Table 2 and Figs. 1-10).
Bergman Rao and Reddy modification Treatment approach A1: Cystic duct leak (CDL) A1: Cystic duct leak
A2: CDL + distal biliary calcular obstruction
A3: CDL + distal malignant obstruction, previously undetected
Endoscopic sphincterotomy (ES) + Stenting
ES + Endoscopic stone extraction
ES + Stenting evaluation for surgery
A2: Injury to accessory hepatic duct A4: Injury to accessory hepatic duct
ES +/- Stenting
B: Partial CBD injury B: Partial CBD injury ES + Stenting Surgery (Sx)
C: Main ductal stricture
C1: Chronic -stricture
C2: Acute obstruction -clip or ligature
ES + BD + Stenting
ES + Balloon dilatation (BD) +
Stenting Versus Laparoscopic or open SxD1: Main ductal transection or ligation D1: Main ductal transection with distal (on ERC) and proximal leaks (on PTC/MRC) Percutaneous bilioma drainage
Closure of distal stumpD2: Ligation of right hepatic or aberrant right hepatic duct D2: Main ductal transection with distal leak (on ERC) and a proximal leak (on PTC/MRC) Percutaneous bilioma drainage
D3: Main ductal transection with distal cut off (on ERC) and proximal cut off (on PTC/MRC) Reconstructive surgery +
Closure of distal stumpD4: Main ductal transection with distal (on ERC) and proximal cut off (on PTC/MRC) Reconstructive surgery D5: Litigation of right hepatic or aberrant right hepatic duct Reconstructive surgery
The treatment of bile duct injury following laparoscopic cholecystectomy depends on the nature and extent of injury. While small to moderate bile duct leaks at the cystic duct stump or peripheral ducts may be cured by non-surgical methods (percutaneous US-guided external drainage of bilioma combined with temporizing endoscopic biliary drainage) alone, larger leaks or transection of the main ducts often requires surgery. The role of ERCP in the management of patients post-laparoscopic cholecystectomy is well defined.[24-26] Endoscopic balloon dilation, with or without stent placement has met with some success.[28-31] Davids et al[32] evaluated the efficacy of endoscopic stenting in 70 patients with incomplete strictures after cholecystectomy and showed that stent placement could be achieved in 94% of patients, with good or excellent clinical response noted in 83%. Early complications (minor bleeding from sphincterotomy site, cholangitis, and pancreatitis) occurred in 9% of patients. A retrospective study comparing surgical with endoscopic therapy concluded that surgery and endoscopy have similar long-term success rates, with recurrences being seen in 17% of patients.[33] This data suggests that surgery should be reserved for those patients with complete duct transection, failed previous repairs, and failed endoscopic therapy. Draganov et al confirmed these findings in another retrospective study with long term follow up data in 29 patients with benign biliary strictures (19 post-operative, 9 chronic pancreatitis related and 1 idiopathic) who were treated with sequential insertion of multiple biliary stents.[34] 62% could be successfully treated (mean follow up of 48 months after stent removal) and 38% failed (mean follow up of 11.6 months). The failed groups included those with hilar strictures or those related to chronic pancreatitis.
according to reasibility of endoscopic treatment.
(B) endoscopic sphincterotomy and stenting.
before (A) and after (B) endoscopic treatment.
ligature Type C2 before (A), during (B) and
after (C) successful treatment.
and proximal leaks
cut off (A) and a proximal leak (B).
leak (A) and proximal cut off (on B).
distal (A) and proximal cut off (B).
right hepatic duct.
SCLEROSING CHOLANGITIS
The treatment of sclerosing cholangitis depends on the location and extent of biliary involvement. Patients with predominantly extrahepatic disease are benefited by hepaticoenteric anastomosis. Recently orthotopic liver transplantation is being advocated as the treatment of choice in patients with PSC and cirrhosis. The disappointing results of surgery and emergence of liver transplantation led to increased use of nonsurgical therapy in symptomatic patients prior to liver transplantation. Percutaneous techniques include balloon dilatation and stenting. Results of several large series have shown short-term clinical benefit from stricture dilatation in up to 90% of cases.[35] Endoscopic balloon dilatation may be beneficial for patients with jaundice secondary to dominant extrahepatic strictures.[36] Additionally, endoscopic sphincterotomy can be used to relieve back-pressure and facilitate bile flow through a fixed stricture. Dilatation of a dominant stricture should be preceded by cytologic brushing to exclude a neoplasm.[37] The long-term benefits of biliary dilatation are uncertain in patients with this progressive disease.
Chronic Pancreatitis related biliary strictures
Initial studies suggested a favourable response of these strictures to endoscopic treatment.[38] Vitale et al treated 25 patients with endoscopic sphincterotomy, balloon dilatation and stenting and the stents were exchanged over 3-4 months. All patients achieved a good biliary decompression; in 20 patients stents could be removed completely after a mean stenting period of 13 months with no recurrence over a follow up period of 32 months while 3 patients continued to require stenting whereas another 2 were operated. However, these findings were refuted in a recent long-term follow up study on endotherapy of benign biliary strictures using multiple stents.[34] As a group, all patients with chronic pancreatitis related distal biliary strictures fared poorly on long term following endotherapy.
BILIARY INFECTIONS AND INFESTATIONS
Suppurative Cholangitis :
Biliary sepsis is the result of biliary obstruction and infection. The severity of this condition varies from mild fever and slight chills, which can be treated temporarily with antibiotics, to the full-blown picture of suppurative cholangitis, which requires immediate biliary decompression. Since emergency surgical decompression is associated with a high mortality rate (up to 50%), nonsurgical approaches are preferred. The treatment of biliary sepsis requires experience, judgment, and skill in establishing drainage.[39,40] Endoscopic biliary decompression is best achieved by a combination of endoscopic biliary sphincterotomy and stent placement. Sphincterotomy provides immediate drainage, and stent placement prevents obstruction of the papillary orifice by any debris or stones. It is advisable not to perform complete cholangiography at the time of ERCP to avoid flare up of cholangitis due to bilio-venous reflux of bacterial flora. A nasobiliary catheter can be used as a temporizing measure following sphincterotomy in severely ill hospitalized patients, in whom the biliary tree can be evaluated for cause of obstruction at a later time once the patient's general medical condition improves.
Biliary Ascariasis : ERCP is a highly sensitive method to demonstrate the worm in the biliary and pancreatic ducts. Worms can be seen in the duodenum on endoscopy and very often they are seen across the ampulla of Vater during endoscopy. Endoscopy is the main stay of treatment for biliary ascariasis.[41-44] The extraction of the worm is easy when it is protruding out of the ampulla of Vater. Holding with a grasping forceps, the worm can be brought out by withdrawing the endoscope out of the patient. A Dormia basket could also be used for the purpose by gently manoeuvring the outer end of the worm in to the strings of the basket to hold it gently before being brought out (Fig. 11). It is better to avoid using a polypectomy snare as it tends to cut the worm and the remnant might be retained. The worm should be extracted completely since remnants can lead to stone formation. Endoscopic sphincterotomy should be avoided, as far as possible, in the endemic areas since a patulous biliary sphincter facilitates easy entry of the Fig.11: Biliary ascariasis. One end of the worm is being gently enganged in to the Dormia basket before extraction worms into the biliary tree should re-infection occur. Endoscopic balloon dilation of the biliary sphincter (sphincteroplasty) is an alternative to sphincterotomy to retrieve the parasite and associated calculi.[44] Extraction of the worm is usually associated with rapid relief of symptoms. However, infection may be associated with calculi or strictures, which can also be dealt endoscopically, during the same session. Following endotherapy, patients should receive anti-helminthic therapy in the form of a single oral dose of albendazole (400 mg) or mebendazole (500 mg), to eradicate remaining worms. In endemic areas periodic de-worming may have role in preventing recurrences.
gently enganged in to the Dormia basket before extraction.
Echinococcus Granulosus : The most common site of hydatid cyst formation is the liver. In approximately one-fourth of the cases, due to higher pressure in the cyst, it ruptures into the biliary tree causing obstructive jaundice.[45] In patients presenting with obstructive jaundice or cholangitis, endoscopic biliary sphincterotomy facilitates extraction of the cysts and membranes using a Dormia basket or a biliary occlusion balloon.[46] Saline irrigation of the bile duct may be necessary to flush out the hydatid sand and small daughter cysts. Life-threatening episodes of acute cholangitis can be managed by an initial naso-biliary drainage as a temporizing method, followed by extraction of hydatid cysts and membranes with or without sphincterotomy.[47,48] In presence of a frankly communicating hydatid cyst with the biliary ductal system, a hydrophilic guide-wire can be negotiated across the communication in to the cyst and a naso-biliary catheter could be inserted to facilitate emptying of the cyst contents. Irrigating the cyst using hypertonic saline solution through the NBD ensures sterilization of the germinal layers and the remaining daughter cysts[49] Biliary communication sometimes manifests in the early post-operative period as jaundice within two to four weeks of surgery or as persistent biliary drainage through the T-tube or an external biliary fistula. Endoscopic biliary sphincterotomy and ductal clearance followed by internal biliary stenting for approximately four to six weeks is usually sufficient to achieve fistula closure.[51] Late post-operative complications, including sphincter of Oddi stenosis and sclerosing cholangitis, are most commonly seen in patients in whom formalin was used to sterilize the cysts during surgery, where seepage of formalin in to the bile ducts through minor communications causes inflammatory changes and stricture formation. Most of these complications can be treated endoscopically by sphincterotomy and stenting with or without dilatation of the stricture using biliary balloons.
Clonorchis Sinensis : The infective metacercariae adhering to the common bile duct migrate along the epithelial lining of the duct in to the intra hepatic ducts, where they mature into flat, elongated, 10 to 23 mm long adult worms. The migration of the immature worm causes trauma to the bile duct epithelium leading to ulceration, desquamation of the epithelium followed by adenomatous hyperplasia and goblet cell metaplasia leading to encapsulating fibrosis of the bile duct. Most of the infected patients are asymptomatic while those with symptoms present with cholangitis, cholangiohepatitis, or intrahepatic calculi. The mechanical effect of the worm blocks flow of bile and stasis predisposes to cholangitis that results in the death of the worm. Ductal irregularities are due to adenomatous hyperplasia, which vary from small indentations to hemispherical filling defects that give a scalloped appearance when these indentations or defects occur in series. The individual Clonorchis worms may be visible as filamentous, wavy, and elliptical shaped filling defects. Emergency biliary decompression following sphincterotomy is the treatment of choice for patients presenting with acute cholangitis.[51] Endoscopic biopsies are indicated during ERCP, whenever cholangiocarcinoma is suspected. Along with endotherapy, patient must also receive praziquantel (75 mg/kg per day in three divided doses) for complete eradication of the infection. Surgical intervention is indicated in patients with hepatolithiasis complicated by multiple biliary strictures.
Type Intrinsic (Intramural) Extrinsic (Nodal) Type 1:
Extrahepatic
CBD stricture
Compression by enlarged pericholedochal lymph nodes.
Type 2:
IntrahepaticIntrahepatic strictures
Compression by enlarged perihilar lymph nodes. Type 2:
CombinedExtrahepatic and intrahepatic biliary strictures Combination of biliary strictures and lymph nodal compression.
Fasciola Hepatica : Fasciola hepatica, also known as the sheep liver fluke, is frequently seen in sheep rearing areas of the world. Human infection occurs after eating raw vegetables that are infested with metacercariae which penetrate the duodenal wall, migrate across the peritoneal cavity, and enter the biliary passages through the capsule and parenchyma of liver. Inflammation due to toxic metabolites and mechanical effects of the larvae in the bile ducts leads to epithelial necrosis and adenomatous changes eventually leading to biliary fibrosis. Infestation of bile duct and/or gallbladder with the adult worm results in the chronic phase of fascioliasis, usually 3 to 4 months after the ingestion of contaminated meal. Eggs or the dead parasites can form a nidus for calculus formation, potentially leading to intra or extra hepatic biliary lithiasis. The worms can be extracted by using a balloon catheter or Dormia basket following biliary sphincterotomy.[52,53] Simultaneous pharmacotherapy using Bithionol, a dichlorophenol, is recommended in a dose of 30 to 50 mg/kg on alternate days for 10 to 15 doses. Irrigating the biliary system with povidone iodine solution during ERCP was used effectively for resistant cases.[54]
Biliary Tuberculosis : Biliary tuberculosis presents as a triad of fever, jaundice (due to extra or intrahepatic strictures, or hepatolithiasis) and hepatic calcifications.[55] Based on the location (intra / extra hepatic or both), and nature of obstruction (intramural, extrinsic, or combined), we have classified tubercular biliary strictures in to Type I or extra hepatic [I (i): Intrinsic; I (e): extrinsic]; Type II or Intrahepatic [II (i): Intrinsic; II (e): Extrinsic] and Type III or Both extra and intra hepatic [III (i): Intrinsic; III (e): Combined] (Table 3 and Fig. 12). The diagnosis can be confirmed by endoscopic biliary brush cytology / biopsy or guided cytology from the enlarged lymph nodes. While presence of acid-fast bacilli (AFB) in the smear is pathognomonic, prior treatment with antibiotics like fluoroquinolones, often makes it impossible to demonstrate AFB. Polymerase chain reaction (PCR) on the endoscopic specimens to demonstrate mycobacterial DNA may be extremely helpful to establish the diagnosis.[56] 4-drug antitubercular regime is the main stay of treatment, coupled with endoscopic sphincterotomy and stenting in presence of biliary obstruction.[56]
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