Clinical Endoscopy

Original Article

Prophylactic endoscopic transpapillary gallbladder stenting to prevent acute cholecystitis induced after metallic stent placement for malignant biliary strictures: a retrospective study in Japan: Fumisato Kozakai, Yoshihide Kanno, Shinsuke Koshita, Takahisa Ogawa, Hiroaki Kusunose, Toshitaka Sakai, Keisuke Yonamine, Kazuaki Miyamoto, Haruka Okano, Yuto Matsuoka, Kento Hosokawa, Hidehito Sumiya, Kei Ito; Clin Endosc 2024;57(5):647-655. Published online May 17, 2024; DOI: https://doi.org/10.5946/ce.2023.284

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Background
/Aims: Endoscopic biliary drainage using self-expandable metallic stents (SEMSs) for malignant biliary strictures occasionally induces acute cholecystitis (AC). This study evaluated the efficacy of prophylactic gallbladder stents (GBS) during SEMS placement.
Methods
Among 158 patients who underwent SEMS placement for malignant biliary strictures between January 2018 and March 2023, 30 patients who attempted to undergo prophylactic GBS placement before SEMS placement were included.
Results
Technical success was achieved in 21 cases (70.0%). The mean diameter of the cystic duct was more significant in the successful cases (6.5 mm vs. 3.7 mm, p<0.05). Adverse events occurred for 7 patients (23.3%: acute pancreatitis in 7; non-obstructive cholangitis in 1; perforation of the cystic duct in 1 with an overlap), all of which improved with conservative treatment. No patients developed AC when the GBS placement was successful, whereas 25 of the 128 patients (19.5%) without a prophylactic GBS developed AC during the median follow-up period of 357 days (p=0.043). In the multivariable analysis, GBS placement was a significant factor in preventing AC (hazard ratio, 0.61; 95% confidence interval, 0.37–0.99; p=0.045).
Conclusions
GBS may contribute to the prevention of AC after SEMS placement for malignant biliary strictures.

Citations

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Risk Factors for Cholecystitis After Self-expandable Metallic Stent Placement for Malignant Distal Biliary Obstruction
Hashem Albunni, Azizullah Beran, Nwal Hadaki, Mark A. Gromski, Mohammad Al-Haddad
Journal of Clinical Gastroenterology.2025;[Epub] CrossRef
Technical challenges and safety of prophylactic gallbladder stenting with metallic biliary stenting
Masood Muhammad Karim, Om Parkash
Clinical Endoscopy.2024; 57(6): 841. CrossRef

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Case Report

Refractory benign biliary stricture due to chronic pancreatitis in two patients treated using endoscopic ultrasound-guided choledochoduodenostomy fistula creation: case reports: Sho Ishikawa, Nozomi Okuno, Kazuo Hara, Nobumasa Mizuno, Shin Haba, Takamichi Kuwahara, Yasuhiro Kuraishi, Takafumi Yanaidani; Clin Endosc 2024;57(1):122-127. Published online May 16, 2023; DOI: https://doi.org/10.5946/ce.2022.149

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Benign biliary stricture (BBS) is a complication of chronic pancreatitis (CP). Despite endoscopic biliary stenting, some patients do not respond to treatment, and they experience recurrent cholangitis. We report two cases of CP with refractory BBS treated using endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) fistula creation. A 50-year-old woman and a 60-year-old man both presented with obstructive jaundice secondary to BBS due to alcoholic CP. They underwent repeated placement of a fully covered self-expandable metal stent for biliary strictures. However, the strictures persisted, causing repeated episodes of cholangitis. Therefore, an EUS-CDS was performed. The stents were eventually removed and the patients became stent-free. These fistulas have remained patent without cholangitis for more than 2.5 years. Fistula creation using EUS-CDS is an effective treatment option for BBS.

Citations

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Forward viewing liner echoendoscopy for therapeutic interventions
Kazuo Hara, Nozomi Okuno, Shin Haba, Takamichi Kuwahara
Clinical Endoscopy.2024; 57(2): 175. CrossRef
Successful sequential management of traumatic choledochal leak and stenosis in children using ERCP: a case report and literature review
Cuo Leng, Yu Zou, Zhoujian Yang, Xinhua Zhao
Frontiers in Medicine.2024;[Epub] CrossRef

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Review

Intraductal ultrasonography for biliary strictures: Young Koog Cheon; Clin Endosc 2023;56(2):164-168. Published online February 17, 2023; DOI: https://doi.org/10.5946/ce.2022.184

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When diagnosing the nature of biliary strictures, it is sometimes difficult to perform non-invasive methods such as ultrasound, spiral computed imaging, magnetic resonance imaging, or endoscopic ultrasonography. Thus, treatment decisions are usually based on biopsy results. However, brush cytology or biopsy, which is widely used for biliary stenosis, has limitations owing to its low sensitivity and negative predictive value for malignancy. Currently, the most accurate method is bile duct tissue biopsy under direct cholangioscopy. On the other hand, intraductal ultrasonography administered under the guidance of a guidewire has the advantages of easy administration and being less invasive, allowing for adequate examination of the biliary tract and surrounding organs. This review discusses the usefulness and drawbacks of intraductal ultrasonography for biliary strictures.

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Abdominal Radiology.2024;[Epub] CrossRef

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Systematic Review and Meta-Analysis

Confocal Laser Endomicroscopy in the Diagnosis of Biliary and Pancreatic Disorders: A Systematic Analysis: Do Han Kim, Somashekar G. Krishna, Emmanuel Coronel, Paul T. Kröner, Herbert C. Wolfsen, Michael B. Wallace, Juan E. Corral; Clin Endosc 2022;55(2):197-207. Published online November 29, 2021; DOI: https://doi.org/10.5946/ce.2021.079

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Background
/Aims: Endoscopic visualization of the microscopic anatomy can facilitate the real-time diagnosis of pancreatobiliary disorders and provide guidance for treatment. This study aimed to review the technique, image classification, and diagnostic performance of confocal laser endomicroscopy (CLE).
Methods
We conducted a systematic review of CLE in pancreatic and biliary ducts of humans, and have provided a narrative of the technique, image classification, diagnostic performance, ongoing research, and limitations.
Results
Probe-based CLE differentiates malignant from benign biliary strictures (sensitivity, ≥89%; specificity, ≥61%). Needlebased CLE differentiates mucinous from non-mucinous pancreatic cysts (sensitivity, 59%; specificity, ≥94%) and identifies dysplasia. Pancreatitis may develop in 2-7% of pancreatic cyst cases. Needle-based CLE has potential applications in adenocarcinoma, neuroendocrine tumors, and pancreatitis (chronic or autoimmune). Costs, catheter lifespan, endoscopist training, and interobserver variability are challenges for routine utilization.
Conclusions
CLE reveals microscopic pancreatobiliary system anatomy with adequate specificity and sensitivity. Reducing costs and simplifying image interpretation will promote utilization by advanced endoscopists.

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Woo Hyun Paik
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Focused Review Series: Endoscopic Management for Biliary Stricture after Liver Transplantations

Magnetic Compression Anastomosis for the Treatment of Post-Transplant Biliary Stricture: Sung Ill Jang, Jae Hee Cho, Dong Ki Lee; Clin Endosc 2020;53(3):266-275. Published online May 29, 2020; DOI: https://doi.org/10.5946/ce.2020.095

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A number of different conditions can lead to a bile duct stricture. These strictures are particularly common after biliary operations, including living-donor liver transplantation. Endoscopic and percutaneous methods have high success rates in treating benign biliary strictures. However, these conventional methods are difficult to manage when a guidewire cannot be passed through areas of severe stenosis or complete obstruction. Magnetic compression anastomosis has emerged as an alternative nonsurgical treatment method to avoid the mortality and morbidity risks of reoperation. The feasibility and safety of magnetic compression anastomosis have been reported in several experimental and clinical studies in patients with biliobiliary and bilioenteric strictures. Magnetic compression anastomosis is a minimally traumatic and highly effective procedure, and represents a new paradigm for benign biliary strictures that are difficult to treat with conventional methods.

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Unilateral Versus Bilateral Biliary Drainage for Post-Transplant Anastomotic Stricture: Jin Ho Choi, Woo Hyun Paik; Clin Endosc 2020;53(3):255-260. Published online May 22, 2020; DOI: https://doi.org/10.5946/ce.2020.079

Abstract PDF PubReader ePub

Living donor liver transplantation is the most common type of liver transplantation in Asia. Post-transplant biliary stricture is frequent in living donor liver transplantation, and endoscopic management is considered to be the treatment of choice. However, endoscopic management is still challenging in patients who undergo right lobe living donor liver transplantation because of the anatomical alteration. In this article, we reviewed the recently updated results for proper endoscopic biliary drainage in post-living donor liver transplantation anatomical biliary stricture and compared unilateral and bilateral drainage.

Citations

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Digital single-operator cholangioscopy for difficult anastomotic biliary strictures in living donor liver transplant recipients after failure of standard ERCP: SPYPASS-2 study (with videos)
In Rae Cho, Sang Hyub Lee, Joongyu Kang, Junyeol Kim, Tae Seung Lee, Myeong Hwan Lee, Min Woo Lee, Jin Ho Choi, Woo Hyun Paik, Ji Kon Ryu, Yong-Tae Kim, Suk Kyun Hong, YoungRok Choi, Nam-Joon Yi, Kwang-Woong Lee, Kyung-Suk Suh
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Review

The Role of Peroral Cholangioscopy in Evaluating Indeterminate Biliary Strictures: Nasim Parsa, Mouen A. Khashab; Clin Endosc 2019;52(6):556-564. Published online July 16, 2019; DOI: https://doi.org/10.5946/ce.2019.011

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Biliary strictures are considered indeterminate when the initial radiologic evaluation and endoscopic retrograde cholangiopancreatography with brush cytology and/or forceps biopsy do not reveal diagnostic findings. Evaluation of these strictures is challenging and often requires a multidisciplinary approach and multiple procedures. Peroral cholangioscopy allows direct visualization of these lesions and targeted tissue acquisition using miniature biopsy forceps. In the past decade, there have been significant improvements in the field of cholangioscopy. These advances have allowed higher-quality image acquisition, easy setup, operation by a single operator, easy maneuverability, and excellent targeted tissue sampling performance. However, the interpretation of cholangioscopic visual findings remains challenging. In this review, we discuss the role of peroral cholangioscopy in the evaluation of indeterminate biliary strictures.

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Original Articles

Endoscopic Ultrasonography-Guided Gallbladder Drainage as a Treatment Option for Acute Cholecystitis after Metal Stent Placement in Malignant Biliary Strictures: Fumisato Kozakai, Yoshihide Kanno, Kei Ito, Shinsuke Koshita, Takahisa Ogawa, Hiroaki Kusunose, Kaori Masu, Toshitaka Sakai, Toji Murabayashi, Keisuke Yonamine, Yujiro Kawakami, Yuki Fujii, Kazuaki Miyamoto, Yutaka Noda; Clin Endosc 2019;52(3):262-268. Published online March 15, 2019; DOI: https://doi.org/10.5946/ce.2018.183

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Background
/Aims: It is often difficult to manage acute cholecystitis after metal stent (MS) placement in unresectable malignant biliary strictures. The aim of this study was to evaluate the feasibility of endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) for acute cholecystitis.
Methods
The clinical outcomes of 10 patients who underwent EUS-GBD for acute cholecystitis after MS placement between January 2011 and August 2018 were retrospectively evaluated. The procedural outcomes of percutaneous transhepatic gallbladder drainage (PTGBD) with tube placement (n=11 cases) and aspiration (PTGBA) (n=27 cases) during the study period were evaluated as a reference.
Results
The technical success and clinical effectiveness rates of EUS-GBD were 90% (9/10) and 89% (8/9), respectively. Severe bile leakage that required surgical treatment occurred in one case. Acute cholecystitis recurred after stent dislocation in 38% (3/8) of the cases. Both PTGBD and PTGBA were technically successful in all cases without severe adverse events and clinically effective in 91% and 63% of the cases, respectively.
Conclusions
EUS-GBD after MS placement was a feasible option for treating acute cholecystitis. However, it was a rescue technique following the established percutaneous intervention in the current setting because of the immature technical methodology, including dedicated devices, which need further development.

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Risk factors and treatment strategies for cholecystitis after metallic stent placement for malignant biliary obstruction: a multicenter retrospective study
Akihiro Matsumi, Hironari Kato, Taiji Ogawa, Toru Ueki, Masaki Wato, Masakuni Fujii, Tatsuya Toyokawa, Ryo Harada, Yuki Ishihara, Masahiro Takatani, Hirofumi Tsugeno, Naoko Yunoki, Takeshi Tomoda, Toshiharu Mitsuhashi, Motoyuki Otsuka
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The updated Asia-Pacific consensus statement on the role of endoscopic management in malignant hilar biliary obstruction
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Endoscopy International Open.2024; 12(09): E1065. CrossRef
Prophylactic endoscopic transpapillary gallbladder stenting to prevent acute cholecystitis induced after metallic stent placement for malignant biliary strictures: a retrospective study in Japan
Fumisato Kozakai, Yoshihide Kanno, Shinsuke Koshita, Takahisa Ogawa, Hiroaki Kusunose, Toshitaka Sakai, Keisuke Yonamine, Kazuaki Miyamoto, Haruka Okano, Yuto Matsuoka, Kento Hosokawa, Hidehito Sumiya, Kei Ito
Clinical Endoscopy.2024; 57(5): 647. CrossRef
Endoscopic Transpapillary Gallbladder Drainage for Recurrent Cholecystitis after Covered Self-expandable Metal Stent Placement for Unresectable Malignant Biliary Obstruction
Akinori Maruta, Takuji Iwashita, Kaori Banno, Takuya Koizumi, Soichi Iritani, Kensaku Yoshida, Shogo Shimizu, Masahito Shimizu
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Takahisa Ogawa, Yoshihide Kanno, Shinsuke Koshita, Hiroaki Kusunose, Toshitaka Sakai, Keisuke Yonamine, Kazuaki Miyamoto, Fumisato Kozakai, Haruka Okano, Hideyuki Anan, Kento Hosokawa, Kei Ito
DEN Open.2023;[Epub] CrossRef
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Hyung Ku Chon, Chan Park, Dong Eun Park, Tae Hyeon Kim
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Sean Bhalla, Ryan Law
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Factors Associated with Malignant Biliary Strictures in Patients with Atypical or Suspicious Cells on Brush Cytology: Ji Young Park, Tae Joo Jeon; Clin Endosc 2019;52(2):168-174. Published online January 9, 2019; DOI: https://doi.org/10.5946/ce.2018.105

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Background
/Aims: Pathological diagnosis of biliary strictures with atypical or suspicious cells on endoscopic retrograde brush cytology and indeterminate strictures on imaging is challenging. The aim of this study was to identify markers for malignant strictures in such cases.
Methods
We retrospectively analyzed data collected from 146 consecutive patients with indeterminate biliary strictures on imaging who underwent endoscopic retrograde brush cytology from 2007 to 2013. Factors associated with malignant strictures in patients with atypical or suspicious cells on brush cytology were identified.
Results
Among the 67 patients with a malignant disease (48 cholangiocarcinoma, 6 gallbladder cancer, 5 pancreatic cancer, 5 ampulla of Vater cancer, and 3 other types), 36 (53.7%) had atypical or suspicious cells on brush cytology. Among these, the factors that independently correlated with malignant strictures were stricture length (odds ratio [OR], 5.259; 95% confidence interval [CI], 1.802– 15.294) and elevated carbohydrate antigen 19-9 (CA19-9) (OR, 3.492; 95% CI, 1.242–9.815), carcinoembryonic antigen (CEA) (OR, 4.909; 95% CI, 1.694–14.224), alkaline phosphatase (ALP) (OR, 3.362; 95% CI, 1.207–9.361), and gamma-glutamyl transpeptidase (rGT) (OR, 4.318; 95% CI, 1.512–12.262).
Conclusions
Elevated levels of CA19-9, CEA, ALP, and rGT and stricture length are associated with malignant strictures in patients with indeterminate biliary strictures on imaging and atypical or suspicious cells on brush cytology.

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High Diagnostic Yield of Endoscopic Retrograde Cholangiopancreatography Brush Cytology for Indeterminate Strictures
Abdulsemed M Nur, Misbah Salim, Scott Boerner, Suqing Li, Cindy C Y Law, Leanne Edwards, Kaitlin Ryan, Paul D James
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Digital Image Analysis has an Additive Beneficial Role to Conventional Cytology in Diagnosing the Nature of Biliary Ducts Stricture
Ahmed Helmy, Heba Mohamed Saad Eldien, Gehan Sayed Seifeldein, Ahmed Mohammed Abu-Elfatth, Adnan Ahmed Mohammed
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Yizhen Zhang, Qingwei Jiang, Qiang Wang, Yunlu Feng, Dongsheng Wu, Tao Guo, Shengyu Zhang, Xi Chen, Yingyun Yang, Wen Shi, Xi Wu, Aiming Yang
Cancer Management and Research.2021; Volume 13: 7735. CrossRef
Tips and tricks for the diagnosis and management of biliary stenosis-state of the art review
Giovanna Del Vecchio Blanco, Michelangela Mossa, Edoardo Troncone, Renato Argirò, Andrea Anderloni, Alessandro Repici, Omero Alessandro Paoluzi, Giovanni Monteleone
World Journal of Gastrointestinal Endoscopy.2021; 13(10): 473. CrossRef
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Eui Joo Kim, Jae Hee Cho
Clinical Endoscopy.2019; 52(2): 95. CrossRef

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Review

A Review of Probe-Based Confocal Laser Endomicroscopy for Pancreaticobiliary Disease: Kunal Karia, Michel Kahaleh; Clin Endosc 2016;49(5):462-466. Published online September 19, 2016; DOI: https://doi.org/10.5946/ce.2016.086

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Confocal laser endomicroscopy (CLE) is a novel in vivo imaging technique that can provide real-time optical biopsies in the evaluation of pancreaticobiliary strictures and pancreatic cystic lesions (PCLs), both of which are plagued by low sensitivities of routine evaluation techniques. Compared to pathology alone, CLE is associated with a higher sensitivity and accuracy for the evaluation of indeterminate pancreaticobiliary strictures. CLE has the ability to determine the malignant potential of PCLs. As such, CLE can increase the diagnostic yield of endoscopic retrograde cholangiopancreatography and endoscopic ultrasound, reducing the need for repeat procedures. It has been shown to be safe, with an adverse event rate of ≤1%. Published literature regarding its cost-effectiveness is needed.

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David J. Restrepo, Chris Moreau, Cyrus V. Edelson, Ameesh Dev, Shreyas Saligram, Hari Sayana, Sandeep N. Patel
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Robert Dorrell, Swati Pawa, Yi Zhou, Neeraj Lalwani, Rishi Pawa
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Jie Wu, Yu-Chen Wang, Wen-Jie Luo, Bo Dai, Ding-Wei Ye, Yi-Ping Zhu
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Aleksey Novikov, Thomas E. Kowalski, David E. Loren
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Kedi Xiong, Wei Wang, Ting Guo, Zhen Yuan, Sihua Yang
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Enrique Pérez-Cuadrado-Robles, Pierre H. Deprez
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Filipe Vilas-Boas, Guilherme Macedo
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Luca Barresi, Stefano F. Crinò, Carlo Fabbri, Fabia Attili, Jan W. Poley, Silvia Carrara, Ilaria Tarantino, Laura Bernardoni, Silvia Giovanelli, Milena Di Leo, Erminia Manfrin, Matteo Tacelli, Marco J. Bruno, Mario Traina, Alberto Larghi
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Original Article

The Clinical Usefulness of Simultaneous Placement of Double Endoscopic Nasobiliary Biliary Drainage: Hong Jun Kim, Sung Koo Lee, Choong Heon Ryu, Do Hyun Park, Sang Soo Lee, Dong Wan Seo, Myung-Hwan Kim; Clin Endosc 2015;48(6):542-548. Published online November 30, 2015; DOI: https://doi.org/10.5946/ce.2015.48.6.542

Abstract PDF PubReader ePub

Background
/Aims: To evaluate the technical feasibility and clinical efficacy of double endoscopic nasobiliary drainage (ENBD) as a new method of draining multiple bile duct obstructions.
Methods
A total of 38 patients who underwent double ENBD between January 2004 and February 2010 at the Asan Medical Center were retrospectively analyzed. We evaluated indications, laboratory results, and the clinical course.
Results
Of the 38 patients who underwent double ENBD, 20 (52.6%) had Klatskin tumors, 12 (31.6%) had hepatocellular carcinoma, 3 (7.9%) had strictures at the anastomotic site following liver transplantation, and 3 (7.9%) had acute cholecystitis combined with cholangitis. Double ENBD was performed to relieve multiple biliary obstruction in 21 patients (55.1%), drain contrast agent filled during endoscopic retrograde cholangiopancreatography in 4 (10.5%), obtain cholangiography in 4 (10.5%), drain hemobilia in 3 (7.9%), relieve Mirizzi syndrome with cholangitis in 3 (7.9%), and relieve jaundice in 3 (7.9%).
Conclusions
Double ENBD may be useful in patients with multiple biliary obstructions.

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High-throughput metabolomics reveals the perturbed metabolic pathways and biomarkers of Yang Huang syndrome as potential targets for evaluating the therapeutic effects and mechanism of geniposide
Heng Fang, Aihua Zhang, Xiaohang Zhou, Jingbo Yu, Qi Song, Xijun Wang
Frontiers of Medicine.2020; 14(5): 651. CrossRef
Can Endoscopic Nasobiliary Drainage Involving Two Catheters Be Used to Treat Various Conditions?
Dong Wook Lee, Ho Gak Kim
Clinical Endoscopy.2015; 48(6): 464. CrossRef

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Focused Review Series: Advanced Endoscopic Treatment For Pancreaticobiliary Diseases

Preoperative Drainage for Malignant Biliary Strictures: Is It Time for Self-Expanding Metallic Stents?: Jason Roque, Shiaw-Hooi Ho, Khean-Lee Goh; Clin Endosc 2015;48(1):8-14. Published online January 31, 2015; DOI: https://doi.org/10.5946/ce.2015.48.1.8

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Palliation of jaundice improves the general health of the patient and, therefore, surgical outcomes. Because of the complexity and location of strictures, especially proximally, drainage has been accompanied by increased morbidity due to sepsis. Another concern is the provocation of an inflammatory and fibrotic reaction around the area of stent placement. Preoperative biliary drainage with self-expanding metallic stent (SEMS) insertion can be achieved via a percutaneous method or through endoscopic retrograde cholangiopancreatography. A recently published multicenter randomized Dutch study has shown increased morbidity with preoperative biliary drainage. A Cochrane meta-analysis has also shown a significantly increased complication rate with preoperative drainage. However, few of these studies have used a SEMS, which allows better biliary drainage. No randomized controlled trials have compared preoperative deployment of SEMS versus conventional plastic stents. The outcomes of biliary drainage also depend on the location of the obstruction, namely the difficulty with proximal compared to distal strictures. Pathophysiologically, palliation of jaundice will benefit all patients awaiting surgery. However, preoperative drainage often results in increased morbidity because of procedure-related sepsis. The use of SEMS may change the outcome of preoperative biliary drainage dramatically.

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Michael Xiang Ma, Marcus Woon Soon Chin, Melissa Jennings, Chiang Siah, Simon Edmunds
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Special Issue Article of IDEN 2013

Endoscopic Guided Biliary Drainage: How Can We Achieve Efficient Biliary Drainage?: Prashant Kedia, Monica Gaidhane, Michel Kahaleh; Clin Endosc 2013;46(5):543-551. Published online September 30, 2013; DOI: https://doi.org/10.5946/ce.2013.46.5.543

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Currently, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary drainage for various pancreatico-biliary disorders. ERCP is successful in 90% of the cases, but is unsuccessful in cases with altered anatomy or with tumors obstructing access to the duodenum. Due to the morbidity and mortality associated with surgical or percutaneous approaches in unsuccessful ERCP cases, biliary endoscopists have been using endoscopic ultrasound-guided biliary drainage (EUS-BD) more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that incorporates various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS-BD techniques. Indications for EUS-BD include failed conventional ERCP, altered anatomy, tumor preventing access into the biliary tree and contraindication to percutaneous access (i.e., ascites, etc.). EUS-BD utilizing EUS-guided rendezvous technique is conducted by creating a tract from either the stomach or the duodenum into the bile duct. Although EUS-BD has rapidly been gaining attraction and popularity in the endoscopic world, the indications and methods have yet to be standardized. There are several access routes and techniques that are employed by advanced endoscopists throughout the world for BD. This article reviews the indications and currently practiced EUS-BD techniques, including indications, technical details (intrahepatic or extrahepatic approach), equipment, patient selection, complications, and overall advantages and limitations.

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Case Report

Fracture of Self-Expandable Metal Stent during Endoscopic Removal in Benign Biliary Stricture: Kyu Re Joo, Chang Nyol Paik, Woo Chul Chung, Kang-Moon Lee, Jin Mo Yang; Clin Endosc 2013;46(1):95-97. Published online January 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.1.95

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The endoscopic insertion of the self-expandable metal stent (SEMS) in benign biliary stricture has become an alternative to surgery. Fracture or migration of SEMS can occur rarely as complications. We report a case of fracture of SEMS during endoscopic retrieval in patients with chronic pancreatitis. In this case, broken stent was successfully removed with endoscopic ballooning of bile duct and with a snare device.

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Endoscopy.2021; 53(01): E11. CrossRef
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Internal Medicine.2018; 57(3): 329. CrossRef

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A Case of Benign Biliary Stricture as a Complication of Photodynamic Therapy for Biliary Papillomatosis: Mun Ki Choi, M.D., Dong Uk Kim, M.D., Gwang Ha Kim, M.D., Geun Am Song, M.D., Hyung Seok Nam, M.D., Yang Seon Yi, M.D., Kang Hee Ahn, M.D. and Jung Seop Eom, M.D.; Korean J Gastrointest Endosc 2011;42(5):327-333. Published online May 28, 2011

Abstract PDF: Biliary papillomatosis is a rare disease with a high risk of recurrence and malignant transformation. Therapeutic options include partial hepatectomy, Whipple's procedure and liver transplantation. If there is no surgical option left due to several reasons, local palliative procedures such as biliary stenting and drainage for the treatment of cholestasis are considered, but tumor growth cannot be influenced. Photodynamic therapy might be a new additional, palliative option for patients with biliary papillomatosis who are not eligible for surgery. Benign biliary stricture is a rare complication of photodynamic therapy. We report here a case of a 63-year-old male who developed benign biliary stricture after photodynamic therapy using the photosensitizer photofrin. (Korean J Gastrointest Endosc 2011;42:327-333)

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The Efficacy and Safety of Fully Covered Self-expandable Metal Stents in Benign Extrahepatic Biliary Strictures: Byeong Uk Kim, M.D., Ja Chung Goo, M.D., Young Shim Cho, M.D., Jung Ho Han, M.D., Soon Man Yoon, M.D., Hee Bok Chae, M.D., Seon Mee Park, M.D. and Sei Jin Youn, M.D.; Korean J Gastrointest Endosc 2011;42(1):11-19. Published online January 30, 2011

Abstract PDF

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. (Korean J Gastrointest Endosc 2011;42:11-19)

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Bilateral Biliary Approach in Patients with Hepatolithiasis: Dong Uk Kim, M.D., Geun Am Song, M.D., Kwang Ha Kim, M.D., Suk Kim, M.D.*, Hyung Wook Kim, M.D. and Dae Hwan Kang, M.D.; Korean J Gastrointest Endosc 2010;41(5):273-279. Published online November 30, 2010

Abstract PDF: Background
/Aims: Percutaneous procedures for treating patients with hepatolithiasis associated with intrahepatic biliary stricture (IHBS) have been shown to have a relatively lower rate of successful stone removal than without IHBS. The reason is tight stenosis or acute angulation of intrahepatic bile ducts (IHDs). We suggest that a bilateral approach to IHDs would improve the success rate of stone removal in patients with complicated IHBS.
Methods
Conventional cholangioscopic electrohydrolithotripsy (EHL) was performed in 82 patients without IHBS. Percutaneous transhepatic stricture dilation and cholangioscopic EHL through unilateral access was performed to treat 41 patients with hepatolithiasis with IHBS. In 21 patients with complicated stricture and multiple stones, removal of hepatolithiasis was achieved by a bilateral approach. The rate of complete stone clearance and complication was reviewed retrospectively.
Results
Complete stone clearance was achieved in 92.7% (76/82) of patients using a unilateral approach without IHBS, in 61.0% (25/41) of cases using a unilateral approach with IHBS, and in 85.7% (18/21) of cases using a bilateral approach with IHBS (p＜0.05). The number of sessions of PTCS was 2.7±0.3, 3.9±0.3, and 2.7±0.5 respectively. The overall complication rate was 14.6% (21/144), and didn't differ between groups.
Conclusions
A bilateral approach to IHDs may be a useful alternative treatment in unresectable patients with multiple hepatolithiasis associated with complicated IHBS. (Korean J Gastrointest Endosc 2010;41:273-279)

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Pancreatic and Biliary Strictures Associated with Cholangitis and Bile Reflux Following Endoscopic Papillectomy of Ampullary Adenoma: Dae-Geun Song, M.D., Jei So Bang, M.D., Won Hyeong Park, M.D., Tae Gyoon Kim, M.D., Hyun Gyung Park, M.D., Bo Young Min, M.D., Su Hyun Yang, M.D. and Jong Hoon Byun, M.D.; Korean J Gastrointest Endosc 2009;39(1):50-54. Published online July 30, 2009

Abstract PDF: Ampullary adenoma is rare but clinically important because it is a premalignant lesion. Use of endoscopic gastroduodenoscopy has increased detection of adenoma of the major duodenal papilla. Endoscopic papillectomy is a promising technique to supplant surgical ampullectomy, because it is less aggressive and more stable. However, various complications include bleeding, perforation, pancreatitis and cholangitis. We describe pancreatic and biliary strictures associated with cholangitis, and bile reflux through the pancreatic duct to the minor duodenal papilla after endoscopic papillectomy. Pancreatic and biliary strictures have not been hitherto reported complications. We performed endoscopic papillary balloon dilatation, minor papilla papillotomy and inserted a drain tube through the accessory pancreatic duct. (Korean J Gastrointest Endosc 2009;39: 50-54)

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A Case of Biliary Cast Syndrome with a Biliary Stricture and Suppurative Cholangitis after Liver Transplantation: Jung Pil Suh, M.D., In Seok Lee, M.D., Jae Hyuck Chang, M.D., Jung Hyun Kwon, M.D., Won Haing Hur, M.D., Si Hyun Bae, M.D., Myung Gyu Choi, M.D., In Sik Chung, M.D. and Dong Goo Kim, M.D.*; Korean J Gastrointest Endosc 2007;35(4):281-286. Published online October 30, 2007

Abstract PDF: Biliary complications after liver transplantation occur in 13∼35% of patients. Biliary cast syndrome, cast formation of biliary sludge along the bile duct, can develop in 4∼18% of liver transplant recipients, although the incidence rate is significantly decreasing due to the improvement of graft harvesting and preservation. It is very important that early diagnosis and effective management of biliary cast syndrome be performed when there is a bile duct stricture or dilatation associated with jaundice and cholangitis in the recipient after liver transplantation, due to the possibility of retransplantation and death of the patient from graft loss. We report a case of a biliary cast formed with suppurative cholangitis and extracted incidentally with a plastic biliary stent during an endoscopic procedure after cadaveric liver transplantation, in which the ERCP findings revealed a stricture at the anastomosis site of the common bile duct and cholangitis. (Korean J Gastrointest Endosc 2007;35:281-286)

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Analysis of Factors Influencing the Long Term Outcome after Endoscopic Stenting for Benign Biliary Stricture: Seok Young Lee, M.D., Hyung Suk Lee, M.D., Won Jae Yoon, M.D., Jun Kyu Lee, M.D., Kwang Hyuck Lee, M.D., Jin-Hyeok Hwang, M.D.*, Ji Bong Jeong, M.D.^†, Ji Kon Ryu, M.D., Yong-Tae Kim, M.D. and Yong Bum Yoon, M.D.; Korean J Gastrointest Endosc 2006;32(1):21-26. Published online January 30, 2006

Abstract PDF: Background
/Aims: The problem with endoscopic management for benign biliary stricture is the occurrence of restenosis after removal of biliary stents. However the factors that influence the rate of restenosis have not yet been identified. The aim of this study was to identify the factors that affect patency of the bile duct after removal of an endoscopic stent for management of benign biliary stricture. Methods: The medical records and potential factors that influence biliary restenosis were analyzed in 19 patients with benign biliary stricture. Results: At the time of stent removal, successful stricture resolution was noted in 13 out of 19 patients. Among these 13 patients, good biliary patency, without restenosis, was observed in 10 patients during a mean follow-up of 24 months. The time interval, from biliary surgery to stricture, tended to be shorter in the group with good results compared to the group with poor results (6.2±3.3 months vs. 80.2±139.3 months respectively: p=0.07). Other factors did not affect the rate of restenosis after removal of the stent. Conclusions: The time interval, from biliary surgery to stricture, tends to influence restenosis after endoscopic management for benign biliary stricture. (Korean J Gastrointest Endosc 2006;32:21⁣26)

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악성 담도폐쇄 환자에서 내시경적 배액관 삽입 후 단기합병증 발생에 대한 연구: Korean J Gastrointest Endosc 2003;27(5):417-417. Published online November 20, 2003

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내시경적 경유두 조직생검의 진단적 의의 ( Endoscopic Transpapillary Biopsy for the Diagnosis of Patients with Pancreaticobiliary Ductal Strictures ): Korean J Gastrointest Endosc 1999;19(3):405-413. Published online November 30, 1998

Abstract PDF: Background
/Aims: Many diseases and conditions are responsible for pancreaticobiliary ductal strictures. In such patients, histologic diagnosis is crucial to determine therapeutic modalities and to predict their outcomes, as well as to avoid unnecessary operations for tissue diagnosis. To evaluate the diagnostic role of endoscopic transpapillary biopsys (ETPB), this technique was performed in patients with pancreaticobiliary ductal strictures suggestive of malignancy. Methods: After visualization of the pancreaticobiliary tree and the lesion by endoscopic retrograde cholangiopancreatography (ERCP), an ETPB of the lesion was conducted with or without an endoscopic sphincterotomy (EST) in sixty-four patients with pancreaticobiliary ductal strictures. The biopsy results were analysed according to the morphology of the lesion, site of the stricture, number of biopsys and whether or not an EST was done. Results: The final diagnoses of the sixty-four patients included forty bile duct cancers (62.5%), nine pancreatic cancers (14.1%), four metastatic cancers (6.3%), and eleven benign ductal strictures (17.2%) such as biliary stones, cholangitis, etc. The sites of the strictures were located in the upper bile duct in thirty-two patients (50.0%), the middle bile duct in twenty-two (34.4%), the lower bile duct in three (4.7%), the pancreatic head in four (6.3%), and the pancreatic body in three (4.7%). Adequate tissue specimens for pathologic examination were obtained in fifty-four cases (84.4%). An ETPB was possible without an EST in nineteen cases (29.7%). The ETPB results revealed sensitivity of 60.4% (32/53), specificity of 100% (6/6), positive predictive value of 100% (32/32), and negative predictive value of 34.4% (11/32). The sensitivity of the ETPB was higher in the EST group than in group without an EST. There was no statistical significance however, according to tumor morphology, site, or number of biopsys. Conclusions: It is recommended that an ETPB, being a safe and effective method, should be performed as a diagnostic procedure during an ERCP for patients with pancreaticobiliary ductal strictures of unknown causes. (Korean J Gastrointest Endosc 19: 405∼413, 1999)

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Expandable Metallic Stent 를 이용한 담도협착 치료의 추적 성적 ( Biliary Endoprosthese by the Use of Expandable Metallic Stents ): Korean J Gastrointest Endosc 1992;12(1):65-70. Published online November 30, 1991

Abstract PDF: Expandable metallic stents(EMS) were implanted in 7 patients with malignant (4 cholangio- carcinnoma, 1 pancreatic cancer, 1 ampullary carcinoma and 1 lymph node metastasis) biliary stricutres and 17 patients with benign(13 intrahepatic strictures of primary intrahepatic stone patients, 2 postoperative stricutres, 1 ampullary stenosis followed by endoscopic sphineterotomy and 1 bilioenteric anastomosis) biliary stricutures. In the fifteen patients out of 17 patients with benign biliary stricture, relief of cholangitis, improvement of liver function or loss of pruritus was observed. But in the 2 patients with.biliary cirrhosis, no clinical improvement was noted. In the malignant strictures with cholangio-carcinoma, the occlusion of EMS occurred in 3 patients and the duration of stent patency was average 2 months in those patients.

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