The endoscopist and malignant and non-malignant biliary obstruction

Patients with biliary strictures often represent a diagnostic and therapeutic challenge, due to the site and complexity of biliary obstruction and wide differential diagnosis. Multidisciplinary decision making is required to reach an accurate and timely diagnosis and to plan optimal care. Developments in endoscopic ultrasound and peroral cholangioscopy have advanced the diagnostic yield of biliary endoscopy, and novel optical imaging techniques are emerging. Endoscopic approaches to biliary drainage are preferred in most scenarios, and recent advances in therapeutic endoscopic ultrasound allow drainage where the previous alternatives were only percutaneous or surgical. Here we review recent advances in endoscopic practice for the diagnosis and management of biliary strictures. This article is part of a Special Issue entitled: Cholangiocytes in Health and Diseaseedited by Jesus Banales, Marco Marzioni and Peter Jansen.     

Metallic endoprostheses in the treatment of benign strictures of the biliary tract

Nine original nitinol self-smoothing-out stents and 3 Gianturco stents were implanted to treat benign strictures of biliary ducts and biliodigestive anastomosis after ineffective repeated attempts to make balloon dilatation. There were no complications associated with the implantation procedure. The follow-up of patients varied from 3 to 26 months. After 4 months, reobturation was revealed at the site of repair in one case, which required implantation of an additional stent coated with polytetrafluoroethylene. The patency of the biliary tract was preserved in the remaining patients in the above period.     

胆道镜结合微爆破碎石治疗复杂性胆道结石

目的:探讨微爆破碎石用于治疗复杂胆道结石的治疗体会。方法:在胆道镜直视下,分别在术中和术后对158例复杂的胆道结石患者进行微爆破碎石,然后用取石网取出碎石,泥沙状结石随液体流出或让其自行流入肠道。结果:158例患者156例取石成功。取石成功率98.73%。明显提高了胆道取石的成功率。无1例出现胆道穿孔、瘘道穿孔及胆道出血等严重并发症。结论:在胆道镜下,采用微爆破碎石术治疗复杂的胆道结石是一种安全、可靠、高效的方法,可以明显提高结石的取净率。     

Methodologic aspects of evaluating brush samples from biliary strictures by cytology and DNA flow cytometry

OBJECTIVE: To present a method of increasing the cell yield from brush samples of the biliary tree for measurement of DNA content by flow cytometry (FCM). STUDY DESIGN: One hundred eight cell specimens from 86 patients were studied by FCM for DNA ploidy and cell cycle composition. All specimens were cytologically classified into benign, suspicious for malignancy and malignant. Two methods for preparation of the cell material were compared. RESULTS: Enzymatic treatment of formalin-fixed brushes for release of cell nuclei was superior to mechanical removal of the cells. The fraction of samples not possible to assess was reduced from 27% to 4%, and good quality histograms increased from 21% to 62%. Aneuploidy was detected in 7% of benign and 57% of suspicious malignant samples. Using DNA analysis in addition to cytology as a diagnostic marker for cancer, the sensitivity increased from 12% to 31%. CONCLUSION: FCM of cells from biliary strictures can be used routinely as an adjunct to cytology for DNA analysis.     

Decompression of malignant biliary obstruction by duodenoscopic intubation of bile duct.

Interest is increasing in non-operative methods of relieving malignant obstruction of the bile duct, and drainage tubes and prostheses may be placed in the bile duct via the percutaneous transhepatic route. Two cases are described, however, in which a duodenoscope was used and the approach was via the papilla of Vater. This method allows temporary or permanent drainage tubes to be placed through malignant strictures. This endoscopic approach is less invasive and should be safer than that by the transhepatic route; furthermore, removing and replacing a blocked endoprosthesis should be easier. Further study is needed, as the procedure is technically more difficult and its role in managing biliary strictures has yet to be defined.     

Bacterial biofilm and clogging of biliary stents

Endoscopic biliary stenting has become a standard palliative treatment for obstructive jaundice due to malignancies of the pancreas and the hepatobiliary system. Despite the high initial success rate in achieving biliary drainage, durable endoscopic stenting has been limited by the clogging of biliary stents, usually after 4–5 months, due to formation of an adherent bacterial biofilm. Various methods have been investigated for the prevention of bacterial adhesion and prolongation of stent patency. These include: 1) prophylactic use of antimicrobial agents and bile salts; 2) testing of new stent material and new designs for these biliary stents; and 3) the recent introduction of self-expandable metal stents. Each method has its own merits as well as specific problems. This article reviews the pathogenesis of biofilm formation on the biliary stents and the latest status of research in avoiding the problem of stent occlusion.     

胆道镜结合微爆破碎石治疗复杂性胆道结石

目的：探讨微爆破碎石用于治疗复杂胆道结石的治疗体会。方法：在胆道镜直视下,分别在术中和术后对158例复杂的胆道结石患者进行微爆破碎石,然后用取石网取出碎石,泥沙状结石随液体流出或让其自行流入肠道。结果：158例患者156例取石成功。取石成功率98.73%。明显提高了胆道取石的成功率。无1例出现胆道穿孔、瘘道穿孔及胆道出血等严重并发症。结论：在胆道镜下,采用微爆破碎石术治疗复杂的胆道结石是一种安全、可靠、高效的方法,可以明显提高结石的取净率。     

Reclassification of "atypical" diagnoses in endoscopic retrograde cholangiopancreaticography-guided biliary brushings

OBJECTIVE: To evaluate the usefulness of reclassifying "atypical" diagnoses in reporting biliary cytology using strict morphologic criteria. STUDY DESIGN: Cytologic specimens from 139 patients (direct, alcohol-fixed smears or cytocentrifuge preparations) were evaluated. Diagnoses were benign (70), atypical (36) and malignant (33). Using strict criteria--major (nuclear contour, chromatin pattern) and minor (polarity, cell types, nuclear size, nuclear grooves, nucleoli, mitosis, nuclear/cytoplasmic [N/C] ratio)--atypical cases were reevaluated and reclassified. Follow-up (F/U) was available on all cases. RESULTS: Atypical cases, (36) were reclassified as malignant (26), atypical favor benign (2)/reactive (3) and atypical, not otherwise specified (NOS) (5). Cases reclassified as malignant showed irregular nuclear contours, chromatin irregularities and rare mitosis. Nuclear enlargement, nucleoli and cellularity varied widely in all groups. N/C ratio was increased in most reclassified malignant cases. All 26 malignant reclassifications correlated with F/U of malignancy. Benign and reactive cases (5) were negative for malignancy on F/U (4), and in 1 case a metastatic carcinoma involving the biliary tree was found. In the 5 atypical (NOS) cases, F/U showed malignancy (3) and pancreatitis (2). Cytocentrifuge preparations made in our laboratory were of superior quality when compared to other methods of cell preparation. CONCLUSION: Irregularities in nuclear membrane and abnormal chromatin pattern were the most consistently useful features correlating with malignancy. The sensitivity and specificity of biliary brush cytology can be enhanced by using strict cytomorphologic criteria and proper collection and fixation, all of which decrease atypical diagnoses.     

RECONSTRUCTIVE OPERATIONS ON THE BILIARY TRACT

Fifty cases in which reconstruction of the biliary system was carried out were reviewed. In 25 cases the operation was done during the treatment of malignant neoplasms. The other 25 patients were treated for benign conditions. Delayed stricture of the biliary anastomosis occurs more frequently following operation for benign post-traumatic obstruction than following reconstruction for other conditions. This is probably a result of: (1) greater regional scarring, (2) local infection, and (3) technical imperfections in the reconstituted biliary anastomosis.Certain primary malignant tumors may be difficult to recognize by both gross and microscopic examination. In six cases of biliary obstruction resulting from malignant neoplasms in the present series, exploration had been carried out some time previously, and in four of them an erroneous diagnosis of benign biliary obstruction was made.End-to-end anastomosis of the duct above and below the point of obstruction is the method preferred in the treatment of benign biliary stricture. Intrahepatic and extrahepatic biliary-enteric anastomoses have been used successfully in selected cases.     

Endoscopic papillotomy and removal of gall stones.

Endoscopic papillotomy was attempted in 59 patients with extrahepatic obstruction of the biliary duct system and was actually performed in 50 patients. A special high-frequency diathermy knife was introduced via a duodenoscope into the terminal common bile duct and the roof of the papilla was incised. In 33 out of 39 patients with choledocholithiasis the stones passed into the duodenum spontaneously or were removed endoscopically. Papillary stenosis without ductal stones was successfully treated with this method in eight out of 11 patients. One perforation of the duodenocholedochal junction occurred and was repaired surgically. Endoscopic papillotomy and stone extraction is a relatively safe and effective method of treating extrahepatic jaundice.     

Fibreoptic endoscopic palliative intubation of inoperable oesophagogastric neoplasms.

Palliative intubation for inoperable malignant strictures at the cardia was done on 16 occasions in 13 patients using fiberoptic endoscopy. Preliminary dilatation was performed, and the Celestin tube was mounted on an introducer and passed over a guide wire inserted with a fiberoptic endoscope. Only one death resulted from the procedure and all the 12 patients who left hospital were swallowing satisfactorily on discharge. The method provided a simple and relatively safe means of relieving dysphagia and improving nutrition.     

Increased incidence of menstrual abnormalities and hysterectomy preceding primary biliary cirrhosis.

A study was performed to assess the incidence of previous hysterectomy and dilatation and curettage among women with primary biliary cirrhosis. In 87 patients with primary biliary cirrhosis hysterectomy or dilatation and curettage had been performed significantly more often than among 100 age matched normal controls and 80 age matched patients with chronic active hepatitis or alcoholic liver disease. Among the 47 patients with primary biliary cirrhosis who had undergone hysterectomy or dilatation and curettage operations had been performed at a mean of 10.7 years and 13.2 years, respectively, before the onset of disease. The main indication for hysterectomy among patients with primary biliary cirrhosis and controls was menorrhagia. These menstrual disorders may be a consequence of high concentrations of oestrogens in patients with primary biliary cirrhosis.     

An elderly man with cholestatic jaundice due to biliary hydatidosis

Hydatid disease is found throughout the world, with a higher prevalence in the Mediterranean area. In Spain, the most endemic regions are Rioja and Aragon, with rates above 10 cases/100,000 inhabitants, followed by Castilla-La Mancha and Castilla y Leon (5-10 cases/100,000 inhabitants). This parasitic disease is caused by the larval stage of Echinococcus granulosus (EG) and the main organs affected are the liver and the lung (85 % cases). We present a case of obstructive jaundice and secondary cholangitis due to a biliary hydatidosis. Abdominal computed tomography scan showed dilatation of the entire biliary tract. The technique used for diagnosis and treatment was endoscopic retrograde cholangiopancreatography.     

General surgery: biliary surgery.

The management of biliary tract disease has changed completely as a result of minimally invasive treatment. For most patients with gallstones that cause symptoms a laparoscopic cholecystectomy will treat the condition with minimal morbidity and a short recovery period. If complications are encountered, conversion to a mini-cholecystectomy gives results that are nearly as good. Acute cholecystitis can be treated by percutaneous drainage followed either by percutaneous cholecystolithotomy or a laparoscopic cholecystectomy. Gallstones in the bile duct are best treated by endoscopic sphincterotomy with duct clearance. The day of the large cholecystectomy scar with its subsequent incisional hernia has gone.     

Manometric changes during retrograde biliary infusion in mice

The manometric, ultrastructural, radiographic, and physiological consequences of retrograde biliary infusion were determined in normostatic and cholestatic mice. Intraluminal biliary pressure changed as a function of infusion volume, rate, and viscosity. Higher rates of constant infusion resulted in higher peak intraluminal biliary pressures. The pattern of pressure changes observed was consistent with biliary ductular and/or canalicular filling followed by leakage at a threshold pressure. Retrograde infusion with significant elevations in pressure led to paracellular leakage of lanthanum chloride, radiopaque dye, and [(14)C]sucrose with rapid systemic redistribution via sinusoidal and subsequent hepatic venous drainage. Chronic extrahepatic bile duct obstruction resulted in significantly smaller peak intrabiliary pressures and lower levels of paracellular leakage. These findings indicate that under both normostatic and cholestatic conditions elevated intrabiliary volumes/pressures result in an acute pressure-dependent physical opening of tight junctions, permitting the movement of infusate from the intrabiliary space into the subepithelial tissue compartment. Control of intraluminal pressure may potentially permit the selective delivery of macromolecules >18-20 A in diameter to specific histological compartments.     

恶性胆道梗阻患者所行经皮穿刺肝内胆管引流术中成功置入金属支架的术前影响因素分析

目的:探讨恶性胆道梗阻患者行PTBD(Percutaneous Transhepatic Biliary Drainage)术中金属支架置入成功率的影响因素。方法:回顾性搜集2010年10月-2017年1月上海市第一人民医院收治的因患有近端恶性胆道梗阻行PTBD术患者的相关临床资料。比较不同原发病因患者支架置入情况。根据患者支架置入是否成功将其分为支架组和非支架组,比较患者的一般临床特征。结果:胰腺癌、胃癌和胆囊癌为本研究中数量上前3位的肿瘤,将以上3组分别按照支架置入数行x~2检验,其中胰腺癌(n=18,支架=6)和胃癌(n=14,支架=11)有统计学意义。将50例患者分为支架组(n=28)和非支架组(n=22),组间比较差异有统计学意义的因素包括:白细胞计数(支架组=6.40±3.40×10~9/L,非支架组=10.74±6.41×10~9/L),中性粒细胞计数(支架组=4.90±3.06×10~9/L,非支架组=8.92±6.25×10~9/L),胆道感染(支架组=9,非支架组=15)。进一步将该50例患者分为6组:胰腺癌-胆道感染组、胃癌-胆道感染组、其他肿瘤-胆道感染组、胰腺癌+胆道感染组、胃癌+胆道感染组、其他肿瘤+胆道感染组。将以上6组分别按照支架置入数行x~2检验,胰腺癌+胆道感染组(n=11,支架=1,P=0.001)有统计学意义。结论:PTBD术对于恶性胆道梗阻是一种有效的姑息治疗手段。胆道感染是PTBD术中支架置入成功的不利因素,胰腺癌合并胆道感染会显著降低PTBD术中支架置入成功率。     

Percutaneous Transhepatic Balloon Dilation of Biliary-Enteric Anastomotic Strictures after Surgical Repair of Iatrogenic Bile Duct Injuries

Purpose

To evaluate the efficacy of percutaneous balloon dilation of biliary-enteric anastomotic strictures resulting from surgical repair of laparoscopic cholecystectomy-related bile duct injuries.

Material and Methods

A total of 61 patients were referred to our institution from 1995 to 2010 for treatment of obstruction at the biliary-enteric anastomosis following surgical repair of laparoscopic cholecystectomy-related bile duct injuries. Of these 61 patients, 27 underwent surgical revision upon stricture diagnosis, and 34 patients were managed using balloon dilation. Of these 34 patients, 2 were lost to follow up, leaving 32 patients for analysis. The primary study objective was to determine the clinical success rate of balloon dilation of biliary-enteric anastomotic strictures. Secondary study objectives included determining anastomosis patency, rates of stricture recurrence following treatment, and morbidity.

Results

Balloon dilation of biliary-enteric anastomotic strictures was clinically successful in 21 of 32 patients (66%). Anastomotic stricture recurred in one of 21 patients (5%) after an average of 13.1 years of follow-up. Patients who were unsuccessfully managed with balloon dilation required significantly more invasive procedures (6.8 v. 3.4; p = 0.02) and were left with an indwelling biliary catheter for a significantly longer period of time (8.8 v. 2.0 months; p = 0.02) than patients whose strictures could be resolved by balloon dilation. No significant differences in the number of balloon dilations performed (p = 0.17) or in the maximum balloon diameter used (p = 0.99) were demonstrated for patients with successful or unsuccessful balloon dilation outcomes.

Conclusion

Percutaneous balloon dilation of anastomotic biliary strictures following surgical repair of laparoscopic cholecystectomy-related injuries may result in lasting patency of the biliary-enteric anastomosis.     

Role of biliary brush cytology in primary sclerosing cholangitis

OBJECTIVE: To assess the role of brush cytology in the routine evaluation of patients with primary sclerosing cholangitis (PSC). STUDY DESIGN: From January 1995 to June 2000, 64 brush cytology specimens were obtained from 21 patients who had at least one cytologic sample obtained during endoscopic retrograde cholangiography. All patients had a diagnosis of primary sclerosing cholangitis. Cases were classified as benign, atypical or malignant according to major cytologic criteria (nuclear contour and chromatin irregularities) and minor cytologic criteria (polarity, cellularity, nuclear enlargement, mitosis, increased nuclear/cytoplasmic ratio) used by us to diagnose biliary brush cytology. Follow-up was available in all cases. RESULTS: Diagnoses were benign (13), atypical (5) and malignant (3) on cytology. Follow-up of the 13 benign cases showed bile duct stones (2), gallbladder adenocarcinoma at cholecystectomy (1), ascending cholangitis (1) and clinically/cytologically by benign follow-up (9). Five of 13 benign cases had subsequent liver transplantation for liver failure, with explants showing changes of primary sclerosing cholangitis. Of the 3 malignant cases, 1 had carcinoma in situ on biopsy, with the explanted liver showing high grade dysplasia; the second patient had cholangiocarcinoma on explant; and the third had hepatocellular carcinoma on liver five needle aspiration. The 5 patients with atypical cytology were reclassified on review as reactive (3) and atypical not otherwise specified (2). Follow-up showed benign disease in 3 of 3 atypical cases reclassified as reactive; 2 of 2 reclassified as atypical not otherwise specified showed low grade dysplasia in the explant. CONCLUSION: The overall incidence of malignancy was low (3 of 21) in patients with PSC. Bile duct brushing is a sensitive method of detecting neoplasia in the setting of PSC when well-defined cytologic criteria are applied.     

Usefulness of bile cytology in the diagnostic management of patients with biliary tract obstruction

Eighteen patients with evidence of biliary tract obstruction had a total of 29 satisfactory bile samples submitted for diagnostic cytology during a two-year period. These 29 specimens were reviewed in order to determine if bile cytology is useful in the diagnostic management of patients with obstructive biliary tract disease. Twenty-one of the bile specimens were from patients with malignant biliary stricture, and eight were from patients with benign biliary obstruction. Bile cytology was positive for carcinoma in eight samples from patients with malignant stricture and was inconclusive for malignancy in two. There were no false positives. The diagnostic specificity of bile cytology was 100%, the diagnostic sensitivity was 48%, and the diagnostic accuracy was 62%. When carefully collected and promptly processed, bile proved an excellent specimen for cytologic evaluation and was a valuable adjunct to other diagnostic procedures for the detection of carcinoma causing biliary tract obstruction.     

内镜下萨氏扩张器扩张联合局部注射曲安奈德治疗食管良性吻合口狭窄的疗效及安全性研究

目的:探讨食管良性吻合口狭窄经内镜下萨氏扩张器扩张联合局部注射曲安奈德治疗的临床疗效及安全性。方法:选取79例食管良性吻合口狭窄患者作为研究对象,根据数字表法将其随机分为对照组(n=38)和研究组(n=41),对照组给予内镜下萨氏扩张器扩张治疗,研究组在对照组基础上联合局部注射曲安奈德治疗,比较两组患者临床疗效、术后恢复情况以及安全性。结果:研究组治疗后总有效率为85.37%(35/41),高于对照组患者的65.79%(25/38)(x~2=4.138,P=0.002)。研究组持续症状缓解时间、再次进行内镜下扩张治疗的间隔时间均长于对照组(t=21.573、27.209,P=0.000、0.000),两组患者治疗前Stooler评分比较差异无统计学意义(t=0.266,P=0.791),两组患者治疗后Stooler评分均降低(t=16.606、25.962,P=0.000、0.000),且研究组低于对照组(t=7.407,P=0.000)。研究组术后并发症总发生率为19.51%(8/41),低于对照组患者的42.11%(16/38)(x~2=4.760,P=0.009)。结论:食管良性吻合口狭窄经内镜下萨氏扩张器扩张联合局部注射曲安奈德治疗后,可获得较好的疗效,患者临床症状得到改善,同时还可减少并发症发生率,临床应用价值较高。