Tips and tricks for the diagnosis and management of biliary stenosis-state of the art review

Biliary stenosis may represent a diagnostic and therapeutic challenge resulting in a delay in diagnosis and initiation of therapy due to the frequent difficulty in distinguishing a benign from a malignant stricture.In such cases,the diagnostic flowchart includes the sequential execution of imaging techniques,such as magnetic resonance,magnetic resonance cholangiopancreatography,and endoscopic ultrasound,while endoscopic retrograde cholangiopancreatography is performed to collect tissue for histopathological/cytological diagnosis or to treat the stenosis by insertion of stent.The execution of percutaneous transhepatic drainage with subsequent biopsy has been shown to increase the possibility of tissue diagnosis after failure of the above techniques.Although the diagnostic yield of histopathology and imaging has increased with improvements in endoscopic ultrasound and peroral cholangioscopy,differential diagnosis between malignant and benign stenosis may not be easy in some patients,and strictures are classified as indeterminate.In these cases,a multidisciplinary workup including biochemical marker assays and advanced technologies available may speed up a diagnosis of malignancy or avoid unnecessary surgery in the event of a benign stricture.Here,we review recent advancements in the diagnosis and management of biliary strictures and describe tips and tricks to increase diagnostic yields in clinical routine.

Cutting balloon treatment of anastomotic biliary stenosis after liver transplantation: Report of two cases

Biliary stenosis is a common complication after liver transplantation,and has an incidence rate ranging from4.7%to 12.5%based on our previous study.Three types of biliary stenosis(anastomotic stenosis,nonanastomotic peripheral stenosis and non-anastomotic central hilar stenosis)have been identified.We report the outcome of two patients with anastomotic stricture after liver transplantation who underwent successfulcutting balloon treatment.Case 1 was a 40-year-old male transplanted due to subacute fulminant hepatitis C.Case 2 was a 57-year-old male transplanted due to hepatitis B virus-related end-stage cirrhosis associated with hepatocellular carcinoma.Both patients had similar clinical scenarios:refractory anastomotic stenosis after orthotopic liver transplantation and failure of balloon dilation of the common bile duct to alleviate biliary stricture.

Post-trans-arterial chemoembolization hepatic necrosis and biliary stenosis: Clinical charateristics and endoscopic approach

Liver cancer is the fifth most common tumor and the second highest death-related cancer in the world.Hepatocarcinoma(HCC)represents 90%of liver cancers.According to the Barcelona Clinic Liver Cancer group,different treatment options could be offered to patients in consideration of tumor burden,liver function,pa-tient performance status and biochemical marker serum concentration such as alpha-fetoprotein.Trans-arterial chemoembolization(TACE)is the treatment of choice in patients with diagnosis of unresectable HCC not eligible for liver trans-plantation,and preserved arterial supply.TACE is known to be safe and its com-plications are generally mild such as post-TACE syndrome,a self-resolving adverse event that occurs in about 90%of patients after the procedure.However,albeit rarely,more severe adverse events such as biloma,sepsis,hepatic failure,chemoagents induced toxicities,and post-TACE liver necrosis can occur.A prompt diagnosis of these clinical conditions is fundamental to prevent further complications.As a result,biliary stenosis could be a rare post-TACE necrosis complication and can be difficult to manage.Complications from untreated biliary strictures include recurring infections,jaundice,chronic cholestasis,and secon-dary biliary cirrhosis.

Application of DynaCT biliary soft tissue reconstruction technology in diagnosis and treatment of hepatolithiasis

BACKGROUND Hepatobiliary stone disease involves an intrahepatic bile duct stone that occurs above the confluence of the right and left hepatic ducts.One-step percutaneous transhepatic cholangioscopic lithotripsy(PTCSL)using the percutaneous transhepatic one-step biliary fistulation(PTOBF)technique enables the clearing of intrahepatic stones and the resolution of strictures.However,hepatolithiasis with associated strictures still has high residual and recurrence rates after one-step PTCSL.DynaCT can achieve synchronized acquisition with a flat-panel detector during C-arm rotation.The technical approach and application value of DynaCT biliary soft tissue reconstruction technology for the diagnosis and treatment of hepatolithiasis with bile duct stenosis were evaluated in this study.AIM To explore the value of DynaCT biliary soft tissue reconstruction technology for the diagnosis and treatment of hepatolithiasis with bile duct stenosis,and to assess the feasibility and effectiveness of the PTOBF technique guided by DynaCT biliary soft tissue reconstruction technology.METHODS The clinical data of 140 patients with complex biliary stenosis disease combined with bile duct stenosis who received PTOBF and were admitted to the First Affiliated Hospital of Guangzhou Medical University from January 2020 to December 2024 were collected.The patients were divided into two groups:DynaCT-PTOBF group(70 patients)and conventional PTOBF group(70 patients).These groups were compared in terms of the preoperative bile duct stenosis,location of the liver segment where the stone was located,intraoperative operative time,immediate stone retrieval rate,successful stenosis dilatation rate,postoperative complication rate,postoperative reoperation rate,stone recurrence rate,and stenosis recurrence rate.RESULTS DynaCT biliary soft tissue reconstruction technology was successfully performed in 70 patients.The DynaCTPTOBF group had a higher detection rate of target bile ducts where bile duct stones and biliary strictures were located than the PTOBF group.Compared with the PTOBF group,the DynaCT-PTOBF group was characterized by a significantly greater immediate stone removal rate(68.6%vs 50.0%,P=0.025),greater immediate stenosis dilatation success rate(72.9%vs 55.7%,P=0.034),greater final stenosis release rate(91.4%vs 75.7%,P=0.012),shorter duration of intraoperative hemorrhage(3.14±2.00 vs 26.5±52.1,P=0.039),and lower incidence of distant cholangitis(2.9%vs 11.4%,P=0.49).There were no significant differences between the two groups in terms of the final stone removal rate,reoperation rate,or long-term complication incidence rate.CONCLUSION DynaCT biliary soft tissue reconstruction technology guiding the PTOBF technique in patients with hepatolithiasis with bile duct stenosis is feasible and accurate.It may be beneficial for optimizing the preoperative evaluation of the PTOBF technique.