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Purpose: To report on the use of biliary manometry for determining treatment completion in living donor liver transplant recipients., Materials and Methods: Twenty of 85 patients (24%) who underwent living donor liver transplantation developed postoperative anastomotic biliary strictures. Fifteen patients underwent transhepatic biliary drainage and percutaneous dilation. In 10 patients, biliary stress manometry was used to assess treatment adequacy after a mean of 2.5 dilation sessions occurring during a mean period of 62 days (range, 5-55 days). An intrabiliary pressure of less than 20-cm H2O after an escalating intrabiliary infusion to 1,200 mL per hour for 3 minutes was defined as the success threshold (in lieu of a capped external catheter "clinical trial")., Results: There were no complications during the infusion study. In all 10 patients in whom manometry was successful, biliary catheters were removed. One patient (who underwent manometry and catheter removal after only one dilation session) required repeat intubation 7 weeks later. The remaining nine patients (90%) remained free of evidence of biliary obstruction at a mean of 8.4 months. With Kaplan-Meier survival analysis, the probability of biliary patency at 3, 6, and 12 months was 90%., Conclusions: This biliary stress manometry protocol offers a promising alternative to the catheter "clinical trial" for determining endpoints for multisession anastomotic biliary stricture dilation in living donor transplant recipients.

Purpose: To determine the significance of hepatic artery steno-occlusive disease on the patency of anastomotic biliary strictures in liver transplant recipients after transhepatic balloon dilation., Materials and Methods: A retrospective review of records of all patients undergoing transhepatic balloon dilation for anastomotic biliary strictures after orthotopic liver transplantation was performed over an 8-year period. Patency of the anastomosis was based on subsequent cholangiography. The presence of hepatic artery steno-occlusive disease was determined by Doppler ultrasound and/or angiography. The anastomotic biliary stricture patency rates were calculated by the Kaplan-Meier method., Results: Thirty-eight patients who had undergone liver transplants underwent 53 balloon dilations for anastomotic biliary strictures (nine patients for arterial disease, 26 patients had patent arteries and three patients had arteries of indeterminate patency). Eight of the 53 strictures treated (15%) were refractory to balloon dilation: 10.5% of first comers and 27% of restenotic lesions. Two of the 53 strictures treated (4%) had significant complications: hemobilia requiring blood transfusion and ductal rupture. One-year cumulative primary patency rates for anastomotic biliary strictures for patients with arterial disease, patent hepatic arteries, and all-comers were: 0%, 45% (P = .01), and 36%, respectively. One-year cumulative primary patency rates for choledocho-choledocal and choledocho-jejunal anstomoses in patients with patent arteries were 43% and 48%, respectively (P = .10)., Conclusions: In the presence of hepatic artery disease there is a lower patency of anastomotic biliary strictures after balloon dilation. Imaging of the hepatic artery should be considered to stratify patients who will have a successful outcome.

Purpose: To determine the technical efficacy and safety of a flared polyurethane-covered self-expandable nitinol stent in the management of malignant biliary obstruction and to evaluate its clinical efficacy by estimating stent patency and patient survival rates., Materials and Methods: Thirteen patients with common bile duct strictures (nonhilar) caused by malignant disease were treated by placement of 13 nitinol stents. The stents used include a flared section in the proximal portion (12 mm in diameter and 10 mm in length) and a section in the remnant portion that is fully covered with high-elasticity polyurethane, with an unconstrained diameter of 10 mm and a total length of 50-80 mm. Patient survival and stent patency rates were calculated with use of Kaplan-Meier survival analysis. The follow-up bilirubin and serum amylase and lipase levels were calculated, and the differences in means were evaluated with use of a Wilcoxon signed-rank test. The average follow-up duration was 22.9 weeks (range, 8-56 weeks)., Results: Placement was successful in all cases. The 30-day mortality rate was 0%. The survival rates were 38% and 24% at 20 and 50 weeks, respectively. Seventy-seven percent of study patients had adequate palliative drainage during their the remainder of their lives. The stent patency rates were 71% and 48% at 20 and 50 weeks, respectively. Three patients (23%) presented with stent occlusion requiring repeat intervention. There were no procedure-related complications such as proximal or distal migration. No complications occurred other than stent occlusion. One patient's stent was removed under endoscopic guidance 15 weeks after its insertion. Bilirubin levels had significantly decreased 1 week after stent insertion (P <.001)., Conclusion: Preliminary results suggest that placement of a flared polyurethane-covered self-expandable nitinol stent is feasible and effective in achieving biliary drainage. The stents do not migrate, but there is tumor ingrowth into the flared portion of the stent. Treatment of a larger group of patients will be mandatory to validate these long-term results.

Purpose: Extrahepatic biliary obstruction can be managed endoscopically or percutaneously. When endoscopic therapy fails, percutaneous drainage with or without endoscopic assistance may be performed. However, transhepatic drainage may itself be unsuccessful. In such patients, a transcholecystic approach combined with endoscopic therapy was used to achieve biliary drainage., Materials and Methods: After attempts at transhepatic biliary drainage failed, a percutaneous cholecystostomy was performed in four patients, with subsequent cannulation of the common bile duct, endoprosthesis insertion, or papillotomy., Results: The success rate was 100%, with no major complication or procedure-related mortality. Slight bleeding from a sphincterotomy was the only minor complication., Conclusion: When percutaneous transhepatic access to the bile duct fails, the transcholecystic route can be safely used with care to successfully achieve biliary drainage.

Purpose: The authors analyzed the follow-up data of 58 patients with malignant obstructive jaundice who underwent percutaneous palliative treatment with Wallstents over a 4-year period., Patients and Methods: Thirty-nine patients had obstruction at the hilar level, and 19 patients had common bile duct obstruction without hilar involvement. Stent patency and survival were calculated with the Kaplan-Meier method., Results: Early complications occurred in 14 patients (24%) and were managed conservatively. There were two procedure-related deaths (3.4%) due to sepsis and pancreatitis, and the overall 30-day mortality was 14%. Forty-eight patients have died, nine patients are surviving (average, 11 months), and one patient was lost to follow-up. Forty-four patients (77%) experienced relief of their initial symptoms, with bilirubin levels returning to normal in 63%. The 12-month patency rate of the endoprostheses was 46% in patients with hilar obstruction and 89% in patients with non-hilar obstruction (P = .029). Late biliary complications were documented in 20 patients (35%). Thirteen patients with hilar obstruction and two patients with common duct obstruction required at least one reintervention; stent patency was restored in all patients but one. The overall 6-month survival rate was 50%, and the 12-month survival rate, 36%; no significant difference was found between patients with hilar and non-hilar obstruction., Conclusion: The long-term patency of the Wallstent endoprosthesis was excellent if common duct obstruction was treated but was significantly lower in the presence of hilar involvement. Use of the Wallstent did not result in a lower complication rate compared with the reported results of plastic endoprostheses. Reinterventions to restore stent patency were successful in almost all cases. The survival of patients with hilar and with non-hilar obstruction was similar.

Purpose: Coated and noncoated Wallstents were implanted in dogs with experimental benign common bile duct stenoses to monitor the long-term patency of self-expanding stents in the biliary system., Materials and Methods: Experimental common bile duct stenoses were induced with a thermal laser in 12 dogs. Three silicone-coated and 14 noncoated stents were implanted. The animals were followed up from 3 to 25 months by means of cholangiography, cholangioscopy, measurements of liver enzyme levels, autopsy, and histology., Results: Silicone coated stents failed in all cases, resulting in two total occlusions and one stent dislodgment to the bowel. Noncoated stents led to marked mucosal hyperplasia and stent narrowing in most cases, but with follow-up of more than 12 months, hyperplasia underwent regression and--except in one case--neither an increase in liver enzyme levels nor stent occlusion occurred. Histologically, the extent of hyperplasia was related to the stent position within the duct wall. With stents in the mucosal layer, hyperplasia was excessive. Once the stent entered the submucosal layer, hyperplasia was decreased., Conclusion: In an experimental setting, mucosal hyperplasia did not compromise patency of noncoated stents in benign bile duct stenosis and regressed with late follow-up after 12 months.