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Background: Most benign biliary strictures nowadays are managed endoscopically with plastic stents or with a insertion of a fully covered self-expandable metal stent (fcSEMS). The paradigm for the treatment of benign hilar strictures precludes the use of an fcSEMS because it obstructs the intrahepatic bile ducts, in particular, the contralateral hepatic duct. It is unknown whether use of a plastic stent in the opposite hepatic duct after deployment of an fcSEMS across the liver hilum provides an adequate solution for this problem., Objective: To evaluate the use of an fcSEMS in combination with a contralateral plastic stent in the treatment of benign hilar strictures., Design: Case series., Setting: Tertiary referral hospital., Patients: Two consecutive patients with benign hilar strictures., Interventions: Placement of an intrahepatically deployed fcSEMS in conjunction with a contralateral 10F plastic stent for 4 to 5 months followed by stent removal and cholangiogram., Main Outcome Measurements: Clinical and laboratory follow-up of at least 9 months., Results: In both patients, the indwelling period of the stents was uneventful as was stent removal. Both strictures resolved, and there were no clinical or biochemical signs of a recurrent stricture., Limitations: Small number of patients., Conclusions: Treatment of benign hilar strictures with an fcSEMS deployed across the liver hilum in conjunction with a contralateral plastic stent placement is feasible without ensuing cholangitis caused by bile duct occlusion., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Palliation of patients with malignant hilar stenoses, especially advanced lesions, by stent insertion poses particular difficulties. This study assessed the efficacy of endoscopically inserted unilateral metallic stents for complex malignant hilar obstruction., Methods: A prospective, uncontrolled, single-center study was conducted by using a cohort of 61 patients with malignant hilar obstruction. A single, unilateral metallic stent was inserted across the stricture into the duct that technically was easiest to access. Patients were evaluated 1 month after stent placement and, thereafter, every 3 months., Results: Successful stent insertion was achieved in 59 of 61 (96.7%) patients. In 3 of 61 (4.9%) cases, stent malfunction occurred. Successful drainage was achieved in 59 of 61 (96.7%) patients and complete resolution of jaundice in 86% of cases. Early complications included cholangitis in 3 of 61 (4.9%) patients and stent occlusion in 2 of 61 (3.2%). Late stent occlusion occurred in 14 of 61 (22.9%) patients, including 10 (16.3%) cases of cholangitis and one of liver abscess. Median stent patency was 169 days. Median patient survival was 140 days., Conclusions: Unilateral metallic stent insertion is safe, feasible, and achieves adequate drainage in the great majority of patients with nonresectable hilar cholangiocarcinoma.

Background: Endoscopic management of malignant hilar biliary obstruction is controversial with respect to optimal types of stents and extent of drainage. This study evaluated outcomes of selective MRCP and CT-targeted drainage with self-expanding metallic stents., Methods: Consecutive patients undergoing attempted palliative ERCP for malignant hilar biliary obstruction were prospectively followed. Whenever possible, management strategy included evaluation and staging for potential resectability before ERCP, with primary placement of metallic stents at the first ERCP in nonsurgical candidates, and early conversion to a metallic stent when a tumor proved to be unresectable. MRCP and/or CT were used to plan selective guidewire access, opacification, and drainage only of the largest intercommunicating segmental ducts. Unilateral stent placement was intended in all cases except for selected patients with Bismuth II cholangiocarcinoma., Results: Thirty-five patients were included. Bismuth classification was I, 10; II, 6; III, 8; and IV, 11. Tumor origin was bile duct (17), gallbladder (5), and metastatic (13). Metallic stents were placed in 27 patients as the initial stent, and in 8 after plastic stent placement. Initial stents were placed endoscopically in 33 patients and percutaneously in 2 patients in whom lumenal tumor precluded ERCP. Stent placement was unilateral in 31 patients and bilateral in 4 patients. There were no episodes of cholangitis or other complications within 30 days after any procedures. Initial metallic stents were clinically effective in 27 (77%) of the 35 patients. Additional percutaneous drainage in 3 patients who did not respond to initial stent placement did not resolve jaundice. Median patency of first metallic stents was 8.9 months for patients with primary bile duct tumors and 5.4 months for all patients, and was not related to Bismuth classification. No further intervention was needed in 25 (71%) patients., Conclusions: Unilateral metallic stent placement by using MRCP and/or CT to selectively target drainage provides safe and effective palliation in most patients with malignant hilar biliary obstruction.

Background: Some patients who undergo endoscopic insertion of biliary metallic stents for malignant biliary stenosis later develop symptomatic duodenal stenosis due to tumor invasion., Methods: We compared the development of symptomatic duodenal stenosis in patients who had undergone endoscopic biliary metallic stent insertion (metallic stent group) with that in patients who had undergone either endoscopic biliary drainage or percutaneous transhepatic biliary drainage with a plastic stent (nonmetallic stent group). Fourteen patients in the metallic stent group were matched with 14 patients in a nonmetallic stent group. All patients had a Karnofsky performance status score of greater than 90% and were clinical stage IV when they underwent biliary decompression., Results: Although there was no difference in survival time between the 2 groups, 5 of 14 patients in the metallic stent group developed symptomatic duodenal stenosis due to tumor invasion during the observation period whereas this occurred in only 1 of 14 patients in the nonmetallic stent group. Multiple logistic regression analysis indicates that the type of stent (p = 0.022) and survival time (p = 0.002) are 2 independent prognostic factors for the development of symptomatic duodenal stenosis., Conclusions: Patients treated with endoscopic biliary metallic stent insertion are prone to develop symptomatic duodenal stenosis due to tumor invasion compared with those treated with either endoscopic retrograde biliary drainage or percutaneous transhepatic biliary drainage with a plastic stent.

Background: The management of bile leaks has evolved in the laparoscopic era. This study characterizes risk factors for their developmental and their clinical course and management., Methods: Data on a cohort of patients who developed bile leaks after cholecystectomy in the laparoscopic era were gathered prospectively and retrospectively from an ongoing surgical database and following a review of hospital charts., Results: Sixty-four patients (mean age 56 +/- 17.1 years, 72% women) were included over a 5-year study period. The incidence of leaks was 1.1% among patients entered in a laparoscopic cholecystectomy database. Intraoperative complications were encountered in 36%. Rates of intraoperative complication and conversion to open surgery were greater among patients who developed leaks (5.2% vs 0.6% and 33% vs 6.3%, respectively, p < 0.00001). Patients presented 5.3 +/- 4.2 days following surgery with abdominal pain (89%), fever (74%), and tenderness (81%). Ultrasound diagnosed a suspected leak in 73%, which ERCP showed as originating from the cystic duct stump in 77%. Biliary obstruction was noted in 20 (31%) patients (14 with stones). Treatments included percutaneous (13%), endoscopic (28%), primary or secondary operative procedures (14%), or a combination thereof (45%)., Conclusion: A complication at laparoscopic cholecystectomy increases the likelihood of a subsequent bile leak. Most patients present early with a patent cystic duct stump in the absence of biliary obstruction. Endoscopic therapy is successful in the majority of cases, but otherwise percutaneous or operative procedures may be needed.

A prospective study was undertaken to evaluate the long-term results of percutaneous trans-hepatic cholangioscopic lithotomy in 48 patients with hepatolithiasis during a 4- to 10-year follow-up period. Complete clearance of the intrahepatic stones was achieved in 40 patients (83.3%). In these 40 patients, long-term results during the follow-up period were as follows: free of symptoms and without evidence of recurrent stones, 22 patients (55%); free of symptoms with recurrent stones, 2 patients; recurrent stones with cholangitis, 14 patients (35%); symptoms of cholangitis without evidence of recurrent stones, 2 patients. Of those patients with recurrent stones, secondary biliary cirrhosis developed in 1, and in 9 of the patients in whom secondary cholangitis developed, subsequent laparotomy or percutaneous drainage was required. Three of the 40 patients (7.5%) died within the 4- to 10-year follow-up period. The procedural failure rate in terms of stone retention was 20.5% for patients with bile duct strictures. No stones were retained in patients without strictures. The postprocedural rate of stone recurrence for patients with bile duct strictures was 51.6%; no recurrence was seen in patients without strictures.

Forty-five patients with malignant hilar obstruction were treated with a total of 68 percutaneously inserted metallic self-expandable endoprostheses (Wallstents) for palliative biliary drainage. The stent diameter was 1 cm; the length was 3.5 to 10.5 cm. Early complications occurred in seven patients (16%), including cholangitis in four patients (9%). The 30-day mortality rate was 9%, with two procedure-related deaths (4%). Of the 45 patients, 29 died between 10 and 550 days (median, 126 days) after stent insertion. Reobstruction occurred in 13 of these patients after 26 to 184 days (median, 105 days). Sixteen patients were alive 44 to 737 days (median, 305 days) after stent insertion. Reobstruction occurred in four patients after 142 to 279 days (median, 246 days). The cause of reobstruction was proximal overgrowth in seven patients; distal overgrowth in four patients; and tumor ingrowth and proximal overgrowth, tumor ingrowth, hemobilia, and angling of the stent in one patient each. The cause of reobstruction was not established in two patients. Reintervention was performed in 14 patients (31%). Because reobstruction of Wallstent endoprostheses is primarily not stent-related but rather is caused by tumor progression, and because insertion and reintervention is easier, we consider the use of the Wallstent in malignant hilar biliary obstruction advantageous in comparison with plastic stents.