ORIGINAL ARTICLE
Clinical Outcome of Single Plastic Stent Treatment of Benign Iatrogenic Biliary Strictures: Is the Outcome Predetermined? Murad A. Rajab, MD,* Jorge Go, MD,* and William B. Silverman, MD, FACG, AGAF, FASGEw
Abstract: Endoscopic retrograde cholangiopancreatography (ERCP) is used for the management of benign iatrogenic biliary strictures after cholecystectomy and liver transplantation. Multiple stents can injure biliary circulation. If resolution of reversible ductal edema and/or ischemia is the mechanism for successful therapy then single stent placement for benign biliary stricture should work. Retrospectively reviewed ERCP records between November 1999 and 2012 provided 25 patients with repeat ERCPs performed at 10-week intervals or if symptoms of stent occlusion were present. If strictures did not improve between stent changes and if removal was not an option, hepaticojejunostomy was used. Strictures resolved in 72% of patients. Seven patients underwent hepaticojejunostomy. Three had ERCP-related complications. No stricture recurrence occurred during the follow-up period. Endoscopic single plastic stent treatment of benign biliary iatrogenic strictures has comparable success to multiple stenting. Many postsurgical strictures may have reversible ischemic/edematous component with stenting to maintain bile drainage. Key Words: postsurgical biliary stricture, single plastic stent, cholecystectomy, liver transplantation
(Surg Laparosc Endosc Percutan Tech 2014;24:e221–e223)
P
ostoperative bile duct injuries are a well-recognized complication following cholecystectomy and liver transplantation. Those complications can be divided into 2 broad categories: early complication, which involves bile duct transection leading to bile leaks, and late complications as in benign iatrogenic biliary stricture (BIBS). BIBS is a common complication with an incidence of 10% to 35% and 0.1% to 0.5% following liver transplantation and laparoscopic cholecystectomy, respectively.1–3 These complications are mainly related to surgical technique, which may result in local inflammation and edema or prolonged ischemia leading to fibrosis and stricture.4 Two treatment strategies have been used with comparable success rates: surgical biliary diversion and endoscopic intervention with and without stent placement.2,5–7 The present guidelines recommend proceeding with endoscopic intervention as the first line of approach in managing biliary complications.8 Received for publication May 28, 2013; accepted January 4, 2014. From the *Division of Gastroenterology/Hepatology; and wDepartment of Internal Medicine, Division of Gastroenterology/ Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA. The authors declare no conflicts of interest. Reprints: William B. Silverman, MD, FACG, AGAF, FASGE, Department of Internal Medicine, Division of Gastroenterology/ Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 4553 A JCP, Iowa City, IA 52242 (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
However, there is no standard endoscopic approach in managing benign biliary strictures. Some endoscopists have followed a more aggressive approach by using multiple parallel biliary plastic stents and have had good stricture resolution success rate ranging between 80% and 90%.3,9,10 That approach is technically more demanding and may be potentially injurious to the biliary circulation by way of compressive radial expansive forces at the level of the stricture. Instead, we reasoned that the mechanism for successful stent therapy is simply to maintain biliary ductal drainage during the time period that spontaneous resolution of stricture-related reversible ductal edema and/or ischemia occurs. If this reasoning is correct, then the type of stenting (or dilation) would not be critical to treatment success. Keeping that in mind, we conducted a retrospective study to evaluate the success rate of single stent placement in patients with BIBS at our institution.
MATERIALS AND METHODS An Institute Review Board study was conducted at the University of Iowa Hospitals and clinics using data collected between November 1999 and November 2012 from our endoscopic retrograde cholangiopancreatography (ERCP) database and electronic medical record system. All ERCPs were performed by one experienced therapeutic endoscopist (W.B.S.). We included patients who had a biliary stricture secondary to orthotopic liver transplantation (OLT) or postcholecystectomy. We excluded patients who had complete ductal transection or total obstruction of the common duct allowing no passage of contrast across it. Also excluded were biliary strictures due to chronic pancreatitis or malignancy. Twenty-five patients were eligible for the study. Eighteen patients had OLT with end-to-end donor duct-torecipient duct biliary anastomoses and 7 patients had recent cholecystectomy with presumed thermal injury to the common duct. ERCP was performed to evaluate possible biliary obstruction that was suggested by elevation in liver enzymes, clinical presentation, and, if present, abnormal imaging studies. High-grade biliary stricture at ERCP was defined as narrowing of >50% of the ductal lumen visualized during cholangiography that involved the anastomotic area in patients with OLT, or mid common bile duct adjacent to the gall bladder fossa, in patients with recent cholecystectomy. ERCP-related therapeutic intervention included sphincterotomy, with and without balloon dilatation, and placement of a single 10-FG plastic stent. After the initial endoscopic intervention, repeat ERCPs were scheduled to be performed at 10-week intervals for stent exchange and stricture evaluation. ERCP was performed earlier if there were signs or symptoms of stent occlusion. Successful
Volume 24, Number 6, December 2014 www.surgical-laparoscopy.com |
e221
Surg Laparosc Endosc Percutan Tech
Rajab et al
endoscopic management was defined as stricture resolution on cholangiography with improvement on liver enzymes. Patients were referred for surgical hepaticojejunostomy (HJ) if there was absence of stricture improvement between stent changes and stent removal without subsequent replacement was deemed not possible. After successful resolution of the biliary strictures, patients were followed by way of clinical and laboratory evaluation. Complications were graded according to the classification of Cotton.11 Time to stricture was defined as the time between the index surgery and the time of first ERCP. Time to stricture resolution was defined as the time between the first ERCP to the time of last ERCP where the stricture had resolved and the final stent was removed. As the continuous data was not normally distributed, we presented them as medians and interquartile (IQR) range and used the Wilcoxon Rank Sum test to detect statistical significance. For categorical variables, w2 test was used. Statistical significance was set at P < 0.05. All statistical analyses were performed using SAS version 9.3 for Windows (SAS Institute, Cary, NC).
RESULTS Of the 25 patients who were eligible for the study, 13 were men (52%). Mean (SD) age was 59 ± 13 years (range, 30 to 81 y). Eighteen patients (72%) had liver transplantation and 7 patients (28%) underwent recent cholecystectomy. The indications for liver transplantation are shown in Table 1. Twenty-five patients underwent a total of 79 ERCPs. Biliary access was successful in all patients. All strictures were located at the anastomotic site in patients with OLT and at the mid common hepatic duct in postcholecystectomy patients. Fourteen patients (56%) had balloon dilation with stent placement. Eleven patients (44%) had only single stent placed across the stricture, as shown in Table 2. Balloon diameter was determined at the time of ERCP and ranged between 6 and 8 mm. All strictures were single and focal with lengths
Clinical Outcome of Single Plastic Stent Treatment of Benign Iatrogenic Biliary Strictures: Is the Outcome Predetermined? Murad A. Rajab, MD,* Jorge Go, MD,* and William B. Silverman, MD, FACG, AGAF, FASGEw
Abstract: Endoscopic retrograde cholangiopancreatography (ERCP) is used for the management of benign iatrogenic biliary strictures after cholecystectomy and liver transplantation. Multiple stents can injure biliary circulation. If resolution of reversible ductal edema and/or ischemia is the mechanism for successful therapy then single stent placement for benign biliary stricture should work. Retrospectively reviewed ERCP records between November 1999 and 2012 provided 25 patients with repeat ERCPs performed at 10-week intervals or if symptoms of stent occlusion were present. If strictures did not improve between stent changes and if removal was not an option, hepaticojejunostomy was used. Strictures resolved in 72% of patients. Seven patients underwent hepaticojejunostomy. Three had ERCP-related complications. No stricture recurrence occurred during the follow-up period. Endoscopic single plastic stent treatment of benign biliary iatrogenic strictures has comparable success to multiple stenting. Many postsurgical strictures may have reversible ischemic/edematous component with stenting to maintain bile drainage. Key Words: postsurgical biliary stricture, single plastic stent, cholecystectomy, liver transplantation
(Surg Laparosc Endosc Percutan Tech 2014;24:e221–e223)
P
ostoperative bile duct injuries are a well-recognized complication following cholecystectomy and liver transplantation. Those complications can be divided into 2 broad categories: early complication, which involves bile duct transection leading to bile leaks, and late complications as in benign iatrogenic biliary stricture (BIBS). BIBS is a common complication with an incidence of 10% to 35% and 0.1% to 0.5% following liver transplantation and laparoscopic cholecystectomy, respectively.1–3 These complications are mainly related to surgical technique, which may result in local inflammation and edema or prolonged ischemia leading to fibrosis and stricture.4 Two treatment strategies have been used with comparable success rates: surgical biliary diversion and endoscopic intervention with and without stent placement.2,5–7 The present guidelines recommend proceeding with endoscopic intervention as the first line of approach in managing biliary complications.8 Received for publication May 28, 2013; accepted January 4, 2014. From the *Division of Gastroenterology/Hepatology; and wDepartment of Internal Medicine, Division of Gastroenterology/ Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA. The authors declare no conflicts of interest. Reprints: William B. Silverman, MD, FACG, AGAF, FASGE, Department of Internal Medicine, Division of Gastroenterology/ Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 4553 A JCP, Iowa City, IA 52242 (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
However, there is no standard endoscopic approach in managing benign biliary strictures. Some endoscopists have followed a more aggressive approach by using multiple parallel biliary plastic stents and have had good stricture resolution success rate ranging between 80% and 90%.3,9,10 That approach is technically more demanding and may be potentially injurious to the biliary circulation by way of compressive radial expansive forces at the level of the stricture. Instead, we reasoned that the mechanism for successful stent therapy is simply to maintain biliary ductal drainage during the time period that spontaneous resolution of stricture-related reversible ductal edema and/or ischemia occurs. If this reasoning is correct, then the type of stenting (or dilation) would not be critical to treatment success. Keeping that in mind, we conducted a retrospective study to evaluate the success rate of single stent placement in patients with BIBS at our institution.
MATERIALS AND METHODS An Institute Review Board study was conducted at the University of Iowa Hospitals and clinics using data collected between November 1999 and November 2012 from our endoscopic retrograde cholangiopancreatography (ERCP) database and electronic medical record system. All ERCPs were performed by one experienced therapeutic endoscopist (W.B.S.). We included patients who had a biliary stricture secondary to orthotopic liver transplantation (OLT) or postcholecystectomy. We excluded patients who had complete ductal transection or total obstruction of the common duct allowing no passage of contrast across it. Also excluded were biliary strictures due to chronic pancreatitis or malignancy. Twenty-five patients were eligible for the study. Eighteen patients had OLT with end-to-end donor duct-torecipient duct biliary anastomoses and 7 patients had recent cholecystectomy with presumed thermal injury to the common duct. ERCP was performed to evaluate possible biliary obstruction that was suggested by elevation in liver enzymes, clinical presentation, and, if present, abnormal imaging studies. High-grade biliary stricture at ERCP was defined as narrowing of >50% of the ductal lumen visualized during cholangiography that involved the anastomotic area in patients with OLT, or mid common bile duct adjacent to the gall bladder fossa, in patients with recent cholecystectomy. ERCP-related therapeutic intervention included sphincterotomy, with and without balloon dilatation, and placement of a single 10-FG plastic stent. After the initial endoscopic intervention, repeat ERCPs were scheduled to be performed at 10-week intervals for stent exchange and stricture evaluation. ERCP was performed earlier if there were signs or symptoms of stent occlusion. Successful
Volume 24, Number 6, December 2014 www.surgical-laparoscopy.com |
e221
Surg Laparosc Endosc Percutan Tech
Rajab et al
endoscopic management was defined as stricture resolution on cholangiography with improvement on liver enzymes. Patients were referred for surgical hepaticojejunostomy (HJ) if there was absence of stricture improvement between stent changes and stent removal without subsequent replacement was deemed not possible. After successful resolution of the biliary strictures, patients were followed by way of clinical and laboratory evaluation. Complications were graded according to the classification of Cotton.11 Time to stricture was defined as the time between the index surgery and the time of first ERCP. Time to stricture resolution was defined as the time between the first ERCP to the time of last ERCP where the stricture had resolved and the final stent was removed. As the continuous data was not normally distributed, we presented them as medians and interquartile (IQR) range and used the Wilcoxon Rank Sum test to detect statistical significance. For categorical variables, w2 test was used. Statistical significance was set at P < 0.05. All statistical analyses were performed using SAS version 9.3 for Windows (SAS Institute, Cary, NC).
RESULTS Of the 25 patients who were eligible for the study, 13 were men (52%). Mean (SD) age was 59 ± 13 years (range, 30 to 81 y). Eighteen patients (72%) had liver transplantation and 7 patients (28%) underwent recent cholecystectomy. The indications for liver transplantation are shown in Table 1. Twenty-five patients underwent a total of 79 ERCPs. Biliary access was successful in all patients. All strictures were located at the anastomotic site in patients with OLT and at the mid common hepatic duct in postcholecystectomy patients. Fourteen patients (56%) had balloon dilation with stent placement. Eleven patients (44%) had only single stent placed across the stricture, as shown in Table 2. Balloon diameter was determined at the time of ERCP and ranged between 6 and 8 mm. All strictures were single and focal with lengths
