Characteristics of fecal microbial communities in patients with non-anastomotic biliary strictures after liver transplantation

AIM To explore the possible relationship between fecal microbial communities and non-anastomotic stricture(NAS) after liver transplantation(LT).METHODS A total of 30 subjects including 10 patients with NAS, 10 patients with no complications after LT, and 10 nonLT healthy individuals were enrolled. Fecal microbial communities were assessed by the 16 S r RNA gene sequencing technology.RESULTS Different from the uncomplicated and healthy groups, unbalanced fecal bacterium ratio existed in patients with NAS after LT. The results showed that NAS patients were associated with a decrease of Firmicutes and Bacteroidetes and an increase of Proteobacteria at the phylum level, with the proportion-ratio imbalance between potential pathogenic families including Enterococcaceae, Streptococcaceae, Enterobacteriaceae, Pseudomonadaceae and dominant families including Bacteroidaceae. CONCLUSION The compositional shifts of the increase of potential pathogenic bacteria as well as the decrease of dominant bacteria might contribute to the incidence of NAS.

Still elusive: Developments in the accurate diagnosis of indeterminate biliary strictures

Indeterminate biliary strictures pose a significant diagnostic dilemma for gastroenterologists.Despite advances in endoscopic techniques and instruments,it is difficult to differentiate between benign and malignant pathology.A positive histological diagnosis is always preferred prior to high risk hepatobiliary surgery,or to inform other types of therapy.Endoscopic retrograde cholangiopancreato-graphy with brushings has low sensitivity and despite significant improvements in instruments there is still an unacceptably high false negative rate.Other methods such as endoscopic ultrasound and cholangioscopy have improved diagnostic quality.In this review we explore the techniques available to aid accurate diagnosis of indeterminate biliary strictures and obtain accurate histology to facilitate clinical management.

Diagnosis and Management of Biliary Strictures after Deceased-Donor Liver Transplantation Based on Clinical Practice

Biliary complications are still the main complications for liver transplantation recipients. Biliary strictures comprise the major part of all biliary complications after deceased-donor liver transplantation (LT). Biliary strictures following LT are divided into anastomotic strictures (AS) and non-anastomotic strictures (NAS). A Limitation of current published researches is that most studies aren’t based on clinical practice. The aim of this review is to summarize risk factors, clinical presentation, diagnosis and management in post-LT biliary strictures.

Clinical approach to indeterminate biliary strictures:Clinical presentation,diagnosis,and workup

Despite advances in cross-sectional imaging and endoscopic technology,bile duct strictures remain a challenging clinical entity.It is crucial to make an early determination of benign or malignant nature of biliary strictures.Early diagnosis not only helps with further management but also minimizes mortality and morbidity associated with delayed diagnosis.Conventional imaging and endoscopic techniques,particularly endoscopic retrograde cholangiopancreatography(ERCP)and tissue sampling techniques play a key in establishing a diagnosis.Indeterminate biliary strictures(IDBSs)have no definite mass on imaging or absolute histopathological diagnosis and often warrant utilization of multiple diagnostics to ascertain an etiology.In this review,we discuss possible etiologies,clinical presentation,diagnosis,and management of IDBSs.Based on available data and expert opinion,we depict an evidence based diagnostic algorithm for management of IDBSs.Areas of focus include use of traditional tissue sampling techniques such as ERCP with brush cytology,intraductal biopsies,fluorescence in situ hybridization and flow cytometry.We also describe the role of endoscopic ultrasound(EUS)-guided fine needle aspiration and biopsies,cholangioscopy,confocal laser endomicroscopy,and intraductal EUS in management of IDBSs.

Older liver grafts from donation after circulatory death are associated with impaired survival and higher incidence of biliary non-anastomotic structure

Background:Grafts from older donors after circulatory death were associated with inferior outcome in liver transplants in the past.But it has seemed to remain controversial in the last decade,as a result of modified clinical protocols,selected recipients,and advanced technology of organ perfusion and preservation.The present study aimed to examine the impact of older donor age on complications and survival of liver transplant using grafts from donation after circulatory death(DCD).Methods:A total of 944 patients who received DCD liver transplantation from 2015 to 2020 were included and divided into two groups:using graft from older donor(aged≥65 years,n=87)and younger donor(age<65 years,n=857).Propensity score matching(PSM)was applied to eliminate selection bias.Results:A progressively increased proportion of liver transplants with grafts from older donors was observed from 1.68%to 15.44%during the study period.The well-balanced older donor(n=79)and younger donor(n=79)were 1:1 matched.There were significantly more episodes of biliary nonanastomotic stricture(NAS)in the older donor group than the younger donor group[15/79(19.0%)vs.6/79(7.6%);P=0.017].The difference did not reach statistical significance regarding early allograft dysfunction(EAD)and primary non-function(PNF).Older livers had a trend toward inferior 1-,2-,3-year graft and overall survival compared with younger livers,but these differences were not statistically significant(63.1%,57.6%,57.6%vs.76.9%,70.2%,67.7%,P=0.112;64.4%,58.6%,58.6%vs.76.9%,72.2%,72.2%,P=0.064).The only risk factor for poor survival was ABO incompatible transplant(P=0.008)in the older donor group.In the subgroup of ABO incompatible cases,it demonstrated a significant difference in the rate of NAS between the older donor group and the younger donor group[6/8(75.0%)vs.3/14(21.4%);P=0.014].Conclusions:Transplants with grafts from older donors(aged≥65 years)after circulatory death are more frequently associated with inferior outcome compared to those from younger donors.Older grafts from DCD are more likely to develop NAS,especially in ABO incompatible cases.

Minimally invasive surgery for post cholecystectomy biliary stricture:current evidence and future perspectives

Postcholecystectomy bile duct injury(BDI)remains a devastating iatrogenic complication that adversely impacts the quality of life with high healthcare costs.Despite a decrease in the incidence of laparoscopic cholecystectomy-related BDI,the absolute number remains high as cholecystectomy is a commonly performed surgical procedure.Open Roux-en-Y hepaticojejunostomy with meticulous surgical technique remains the gold standard surgical procedure with excellent longterm results in most patients.As with many hepatobiliary disorders,a minimally invasive approach has been recently explored to minimize access-related complications and improve postoperative recovery.Since patients with gallstone disease are often admitted for a minimally invasive cholecystectomy,laparoscopic and robotic approaches for repairing postcholecystectomy biliary stricture are attractive.While recent series have shown the feasibility and safety of minimally invasive post-cholecystectomy biliary stricture management,most are retrospective analyses with small sample sizes.Also,long-term follow-up is avail-able only in a limited number of studies.The principles and technique of minimally invasive repair resemble open repair except for the extent of adhesiolysis and the suturing technique with continuous sutures commonly used in minimally invasive approaches.The robotic approach overcomes key limitations of laparoscopic surgery and has the potential to become the preferred minimally invasive approach for the repair of postcholecystectomy biliary stricture.Despite increasing use,lack of prospective studies and selection bias with available evidence precludes definitive conclusions regarding minimally invasive surgery for managing postcholecystectomy biliary stricture.High-volume prospective studies are required to confirm the initial promising outcomes with minimally invasive surgery.

Endoscopic management of benign biliary strictures:Looking for the best stent to place

Benign biliary strictures(BBS)might occur due to different pancreaticobiliary conditions.The etiology and location of biliary strictures are responsible of a wide array of clinical manifestations.The endoscopic approach endoscopic retrograde cholangiopancreatography represents the first-line treatment for BBS,considering interventional radiology and surgery when endoscopic treatment fails or it is not suitable.The purpose of this review is to provide an overview of possible endoscopic treatments for the optimal management of this subset of patients.

Endoscopic ultrasonography can diagnose distal biliary strictures without a mass on computed tomography

AIM:To assess the diagnostic ability of endoscopic ultrasonography(EUS)for evaluating causes of dista biliary strictures shown on endoscopic retrograde chol angiopancreatography(ERCP)or magnetic resonance cholangiopancreatography(MRCP),even without iden tifiable mass on computed tomography(CT). METHODS:The diagnostic ability of EUS was retro spectively analyzed and compared with that of routine cytology(RC)and tumor markers in 34 patients with distal biliary strictures detected by ERCP or MRCP a Dokkyo Medical School Hospital from December 2005 to December 2008,without any adjacent mass or ec centric thickening of the bile duct on CT that could cause biliary strictures.Findings considered as benign strictures on EUS included preservation of the normasonographic layers of the bile duct wall,irrespective of the presence of a mass lesion.Other strictures were considered malignant.Final diagnosis of underlying diseases was made by pathological examination in 18 cases after surgical removal of the samples,and by clinical follow-up for>10 mo in 16 cases. RESULTS:Seventeen patients(50%)were finally di- agnosed with benign conditions,including 6"normal" subjects,while 17 patients(50%)were diagnosed with malignant disease.In terms of diagnostic ability,EUS showed 94.1%sensitivity,82.3%specificity,84.2% positive predictive value,93.3%negative predictive value(NPV)and 88.2%accuracy for identifying ma- lignant and benign strictures.EUS was more sensi- tive than RC(94.1%vs 62.5%,P=0.039).NPV was also better for EUS than for RC(93.3%vs 57.5%,P= 0.035).In addition,EUS provided significantly higher sensitivity than tumor markers using 100 U/mL as the cutoff level of carbohydrate antigen 19-9(94.1%vs 53%,P=0.017).On EUS,biliary stricture that was fi- nally diagnosed as malignant showed as a hypoechoic, irregular mass,with obstruction of the biliary duct and invasion to surrounding tissues. CONCLUSION:EUS can diagnose biliary strictures caused by malignant tumors that are undetectable on CT.Earlier detection by EUS would provide more therapeutic options for patients with early-stage pancreaticobiliary cancer.

Digital single-operator cholangioscopy for biliary stricture after cadaveric liver transplantation

BACKGROUND Biliary strictures after liver transplantation(LT)remain clinically arduous and challenging situations,and endoscopic retrograde cholangiopancreatography(ERCP)has been considered as the gold standard for the management of biliary strictures after LT.Nevertheless,in the treatment of biliary strictures after LT with ERCP,many studies show that there is a large variation in diagnostic accuracy and therapeutic success rate.Digital single-operator peroral cholangioscopy(DSOC)is considered a valuable diagnostic modality for indeterminate biliary strictures.AIM To evaluate DSOC in addition to ERCP for management of biliary strictures after LT.METHODS Nineteen patients with duct-to-duct biliary reconstruction who underwent ERCP for suspected biliary complications between March 2019 and March 2020 at Beijing Chaoyang Hospital,Capital Medical University,were consecutively enrolled in this observational study.After evaluating bile ducts using fluoroscopy,cholangioscopy using a modern digital single-operator cholangioscopy system(SpyGlass DS^(TM))was performed during the same procedure with patients under conscious sedation.All patients received peri-interventional antibiotic prophylaxis.Biliary strictures after LT were classified according to the manifestations of choledochoscopic strictures and the manifestations of transplanted hepatobiliary ducts.RESULTS Twenty-one biliary strictures were found in a total of 19 patients,among which anastomotic strictures were evident in 18(94.7%)patients,while non-anastomotic strictures in 2(10.5%),and space-occupying lesions in 1(5.3%).Stones were found in 11(57.9%)and loose sutures in 8(42.1%).A benefit of cholangioscopy was seen in 15(78.9%)patients.Cholangioscopy was crucial for selective guidewire placement prior to planned intervention in 4 patients.It was instrumental in identifying biliary stone and/or loose sutures in 9 patients in whom ERCP failed.It also provided a direct vision for laser lithotripsy.A spaceoccupying lesion in the bile duct was diagnosed by cholangioscopy in one patient.Patients with biliary stricture after LT displayed four types:(A)mild inflammatory change(n=9);(B)acute inflammatory change edema,ulceration,and sloughing(n=3);(C)chronic inflammatory change;and(D)acute suppurative change.Complications were seen in three patients with post-interventional cholangitis and another three with hyperamylasemia.CONCLUSION DSOC can provide important diagnostic information,helping plan and perform interventional procedures in LT-related biliary strictures.

Endoscopic pancreatic duct and biliary duct stenting in treatment of chronic pancreatitis with distal benign biliary stricture: a single-center experience

BACKGROUND: The development of endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and stenting are relatively new alternatives to surgery for the treatment of benign lesions in the biliary duct and pancreas. The objective of this study was to assess the value of stenting in the endoscopic pancreatic duct and biliary duct in the treatment of chronic pancreatitis with distal benign biliary stricture. METHODS: Twenty-two patients diagnosed with chronic pancreatitis with distal benign biliary stricture underwent endoscopic treatment in our center, with ERCP, EST, endoscopic retrograde biliary drainage (ERBD) and endoscopic retrograde pancreatic drainage (ERPD) with stents. A numeric rating scale was used to assess pain intensity. The clinical data on endoscopic therapies and recovery of the patients were recorded and compared. RESULTS: ERCPs were successfully performed in 21 patients and 1 (4.5%) failed because of pancreatic ductal variation. A total of 68 ERCPs were performed with 47 pancreatic duct stents and 39 biliary duct stents. The rate of complications was 13.2% (9/68). The abdominal pain score after endoscopic treatment was significantly reduced. The levels of bilirubin and alanine transaminase in all 21 patients were improved compared to those before endoscopic treatment.CONCLUSION: Endoscopic stent drainage of the pancreatic duct and biliary duct for chronic pancreatitis with distal biliary benign stricture can be selected as a safe, effective and minimally invasive therapeutic method.

Portal vein stenting as a significant risk factor for biliary stricture in adult living donor liver transplantation

BACKGROUND: Although perioperative portal vein (PV) stent implantation is an effective treatment for steno-occlusive disease in adult living donor liver transplantation (LDLT) re-cipients, we experienced high incidence of biliary anastomotic strictures (BAS) after PV stenting. In this study, we sought to clarify the relation between BAS and PV stenting and to suggest the possible mechanism of BAS and measures to reduce its in-cidence. METHODS: We retrospectively analyzed 44 LDLT recipients who underwent PV stent implantation across the line of PV anastomosis regardless of the location of steno-occlusion (stent group) and their matched controls (non-stented LDLT recipients, n=131). RESULTS: The incidence of BAS was higher in patients in the stent group than that in the control group (43.2% vs 17.6%, P=0.001). Cumulative 6-month and 1-, 2- and 5-year BAS rates were 31.8%, 34.1%, 41.4% and 43.2%, respectively, in the stent group and 13.0%, 13.8%, 16.1% and 17.8%, respectively, in the control group (P=0.001). Multivariate analysis revealed that PV stenting was an independent risk factor for BAS. CONCLUSIONS: Although PV stent implantation is a reliable treatment modality for steno-occlusive PV in adult LDLT recipients, innovative methods to prevent the PV stent from crossing the line of PV anastomosis may be necessary to reduce the incidence of postoperative BAS.

New anti-reflux plastic stent to reduce the risk of stent-related cholangitis in the treatment of biliary strictures

BACKGROUND There is little data available on the role of new anti-reflux plastic stents(ARPSs).AIM To compare the use of ARPSs with that of traditional plastic stents(TPSs)for patients with biliary strictures.METHODS Consecutive patients with biliary strictures who underwent first endoscopic biliary stenting between February 2016 and May 2019 were included.The onset of stent-related cholangitis,stent patency,clinical success,and other adverse events were evaluated.RESULTS Sixty-seven patients in the ARPS group and 66 patients in the TPS group were included in the final analyses.Fewer patients experienced stent-related cholangitis in the ARPS group than that in the TPS group(8 patients vs 18 patients;P=0.030).The median time till the onset of first stent-related cholangitis was later in the ARPS group than that in the TPS group(128.5 d vs 76 d;P=0.039).The cumulative median stent patency in the ARPS group was 185 d,which was significantly longer than that in the TPS group(133 d;P=0.001).The clinical success rates and other adverse events did not significantly differ between both groups.CONCLUSION Placement of new ARPS might be a safe and effective optional therapeutic strategy to reduce the risk of stent-related cholangitis and prolong stent patency.

Recovery from a biliary stricture of a common bile duct ligature injury:A case report

BACKGROUND Cholecystectomy is a common elective procedure for cholecystic diseases,including cholecystitis and cholelithiasis.Common bile duct injury is a major complication in both open and laparoscopic cholecystectomy(LC).The number of cholecystectomies performed has increased due to popularization and application of the laparoscopic technique,which has led to an increase in the number of bile duct injuries.CASE SUMMARY A 65-year-old man presented to the General Surgery Department with a complaint of repeated right upper quadrant pain for 2 years that had worsened over the previous day.The patient had a history of gallstones and hypertension.A LC was performed;it was found that a biliary stricture of 53 h duration was caused by a ligature injury of the common bile duct during the LC.Another laparoscopic exploration was performed,and the stricture was released.CONCLUSION LC is a common surgical procedure,but if a complication occurs,it is important for the surgeon to consider another exploratory surgery.

Endoscopic therapy using a self-expandable metallic stent with an anti-migration system for postorthotopic liver transplantation anastomotic biliary stricture

BACKGROUND Endoscopic therapy using multiple plastic stents(MPSs)is the standard therapy for postorthotopic liver transplantation(p-OLT)anastomotic biliary stricture(ABS).However,this approach demands repeated procedures.Recent studies us-ing fully covered self-expandable metallic stents(FCSEMS)have shown en-couraging results,but migration occurs in 10%to 40%of cases.The objective of this retrospective study was to evaluate the efficacy of endoscopic treatment using FCSEMS with an anti-migration system(Am-FCSEMS)in patients with p-OLT ABS.AIM To evaluate the efficacy of endoscopic treatment using an Am-FCSEMS in patients with p-OLT ABS.METHODS This study was conducted in a private tertiary care centre in S?o Paulo,Brazil and was approved by our institution's Human Research Committee.From April 2018 to October 2020,regardless of previous endoscopic treatment(MPS or FCSEMS),17 patients with p-OLT ABS and indications for endoscopic therapy were included in this study.The exclusion criteria were pregnancy,nonanastomotic biliary or hilar stricture,hepatic artery stenosis/thrombosis,isolated biliary fistulae,a distance shorter than 2 cm from the stricture to the hepatic hilum,and patient refusal.The primary endpoint was the efficacy of p-OLT ABS endoscopic treatment using an Am-FCSEMS that re-mained in place for a 12-mo period.Biliary sphincterotomy was performed in patients with native papilla,and an Am-FCSEMS(10 mm in final diameter and 60 or 80 mm in length)was placed(Hanarostent TM MI Tech,Co).Balloon stricture dilation was performed only if necessary to introduce the stent.RESULTS Three patients were excluded due to loss to follow-up before stent removal.Among the 14 patients included and followed,7 were women,and the average age was 56 years(range:28-76).The average period of Am-FCSEMS placement was 362±109 d.Technical success occurred in all 14 patients(100%).There were no cases of distal stent migration.Complete resolution of the stricture occurred in 13/14 patients(92.85%).Adverse events occurred in 3/14 patients(21.42%):2 patients with mild acute pancreatitis(14.28%)and 1 patient(7.14%)with stent dysfunction(occlusion by biliary sludge and stones,which was treated endoscopically without the need for stent removal).No deaths occurred related to therapy.All stents were removed using foreign body forceps or snares without difficulty.After Am-FCSEMS removal,all 13 patients who had ABS resolution were followed-up for an average of 411±172 d,and there was no stricture recurrence or need for further endoscopic therapy.CONCLUSION In this retrospective study,endoscopy therapy using an Am-FCSEMS for p-OLT ABS was safe and effective,with a high stricture re-solution rate that was probably due to the absence of stent migration.

Cholangioscopy-assisted guidewire placement in a malignant biliary stricture: A case report

BACKGROUND Cholangioscopy has been described in case reports and series to facilitate guidewire placement in difficult benign biliary strictures.Specifically,it has been infrequently used in difficult benign anastomotic liver transplant biliary strictures to visualize the stricture orifice for guidewire placement.Here we describe a case of guidewire placement through a difficult malignant biliary stricture using single operator cholangioscopy.CASE SUMMARY A 74-year-old female presented with jaundice and weight loss.Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography(ERCP)by other endoscopists demonstrated pancreatic adenocarcinoma with a dilated cystic duct(CD)and proximal common bile duct(CBD).The associated distal CBD stricture was dilated and stented with a plastic stent.However she subsequently developed cholangitis,prompting referral for a repeat ERCP.The stent was found to have migrated distally to the confluence of the dilated CD and CBD stricture.Despite using multiple hydrophilic guidewires,the stricture could not be traversed due to preferential wire passage into the dilated CD.SpyGlass DS(Boston Scientific Corp,Marlborough,MA,United States)was then used to visualize the orifices of the CD and CBD stenosis,enabling the guidewire to be placed directly through the stricture into the proximal CBD.A WallFlex covered metal stent(Boston Scientific Corp,Marlborough,MA,United States)was successfully placed,resulting in resolution of her cholangitis.CONCLUSION To our knowledge,this is one of the first cases to describe successful cholangioscopic guidewire placement for malignant biliary strictures.

Percutaneous interventional therapy for anastomotic biliary strictures after orthotopic liver transplantation

Objective To describe the technique,efficacy, and safety of percutaneous interventional therapy for anastomotic biliary strictures after orthotopic liver transplantation ( OLT) . Methods From May 2004 to December 2009,25 patients with anastomotic biliary stric-

Current diagnosis and treatment of benign biliary stricturesafter living donor liver transplantation

Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation(LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.

Biliary strictures complicating living donor liver transplantation:Problems,novel insights and solutions

Biliary stricture complicating living donor liver transplantation(LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT than in deceased donor liver transplantation. Endoscopic management is the mainstay for biliary strictures complicating LDLT and includes endoscopic retrograde cholangiography, sphincterotomy and stent placement(with or without balloon dilatation). The efficacy and safety profiles as well as outcomes of endoscopic management of biliary strictures complicating LDLT is an area that needs to be viewed in isolation, owing to its unique set of problems and attending complications; as such, it merits a tailored approach, which is yet to be well established. The diagnostic criteria applied to these strictures are not uniform and are over-reliant on imaging studies showing an anastomotic narrowing. It has to be kept in mind that in the setting of LDLT, a subjective anastomotic narrowing is present in most cases due to a mismatch in ductal diameters. However, whether this narrowing results in a functionally significant narrowing is a question that needs further study. In addition, wide variation in the endotherapy protocols practised in most centres makes it difficult to interpret the results and hampers our understanding of this topic. The outcome definition for endotherapy is also heterogenous and needs to be standardised to allow for comparison of data in this regard and establish a clinical practice guideline. There have been multiple studies in this area in the last 2 years, with novel findings that have provided solutions to some of these issues. This review endeavours to incorporate these new findings into the wider understanding of endotherapy for biliary strictures complicating LDLT, with specific emphasis on diagnosis of strictures in the LDLT setting, endotherapy protocols and outcome definitions. An attempt is made to present the best management options currently available as well as directions for future research in the area.

Evaluation of fully covered self-expanding metal stents in benign biliary strictures and bile leaks

AIM: To investigate the use of fully covered metal stents in benign biliary strictures (BBS) and bile leaks. METHODS: We studied 17 patients, at Harbor-UCLA Medical center (Los Angeles), with BBS (n=12) and bile leaks (n=5) from July 2007 to February 2012 that had received placement of fully covered self-expanding metal stents (FCSEMs). Fourteen patients had endoscopic placement of VIABIL (Conmed, Utica, New York, United States) stents and three had Wallflex (Boston Scientific, Mass) stents. FCSEMS were 8 mm or 10 mm in diameter and 4 cm to 10 cm in length. Patients were followed at regular intervals to evaluate for symptoms and liver function tests. FCSEMS were removed after 4 or more weeks. Resolution of BBS and leak was documented cholangiographically following stent removal. Stent patency can be defined as adequate bile and contrast flow from the stent and into the ampulla during endoscopic retrograde cholangiopancreatography (ERCP) without clinical signs and/or symptoms of biliary obstruction. Criterion for bile leak resolution at ERCP is defined as absence of contrast extravasation from the common bile duct, cystic duct remanent, or gall blad-der fossa. Rate of complications such as migration, and instent occlusion were recorded. Failure of endoscopic therapy was defined as persistent biliary stenosis or continuous biliary leakage after 12 mo of stent placement. RESULTS: All 17 patients underwent successful FC- SEMS placement and removal. Etiologies of BBS included: cholecystectomies (n=8), cholelithiasis (n=2), hepatic artery compression (n=1), pancreatitis (n=2), and Whipple procedure (n=1). All bile leaks occurred following cholecystectomy. The anatomic location of BBS varied: distal common bile duct (n=7), common hepatic duct (n=1), hepaticojejunal anastomosis (n=2), right intrahepatic duct (n=1), and choledochoduo-denal anastomatic junction (n=1). All bile leaks were found to be at the cystic duct. Twelve of 17 patients had failed prior stent placement or exchange. Resolution of the biliary strictures and bile leaks was achieved in 16 of 17 patients (94%). The overall median stent time was 63 d (range 27-251 d). The median stent time for the BBS group and bile leak group was 62 ± 58 d (range 27-199 d) and 92 ± 81 d (range 48-251 d), respectively. All 17 patients underwent successful FCSEMS removal. Long term follow-up was obtained for a median of 575 d (range 28-1435 d). Complications occurred in 5 of 17 patients (29%) and included: migration (n=2), stent clogging (n=1), cholangitis (n=1), and sepsis with hepatic abscess (n=1). CONCLUSION: Placement of fully covered self-expanding metal stents may be used in the management of benign biliary strictures and bile leaks with a low rate of complications.

Bilateral vs unilateral placement of metal stents for inoperable highgrade hilar biliary strictures: A systemic review and meta-analysis

BACKGROUND Bilateral vs unilateral biliary stenting is used for palliation in malignant biliary obstruction.No clear data is available to compare the efficacy and safety of bilateral biliary stenting over unilateral stenting.AIM To assess the efficacy and safety of bilateral vs unilateral biliary drainage in inoperable malignant hilar obstruction.METHODS PubMed,Embase,Scopus,and Cochrane databases,as well as secondary sources(bibliographic review of selected articles and major GI proceedings),were searched through January 2019.The primary outcome was the re-intervention rate.Secondary outcomes were a technical success,early and late complications,and stent malfunction rate.Pooled odds ratio(OR)and 95%confidence interval(CI)were calculated for each outcome.RESULTS A total of 9 studies were included(2 prospective Randomized Controlled Study,5 retrospective studies,and 2 abstracts),involving 782 patients with malignant hilar obstruction.Bilateral stenting had significantly lower re-intervention rate compared with unilateral drainage(OR=0.59,95%CI:0.40-0.87,P=0.009).There was no difference in the technical success rate(OR=0.7,CI:0.42-1.17,P=0.17),early complication rate(OR=1.56,CI:0.31-7.75,P=0.59),late complication rate(OR=0.91,CI:0.58-1.41,P=0.56)and stent malfunction(OR=0.69,CI:0.42-1.12,P=0.14)between bilateral and unilateral stenting for malignant hilar biliary strictures.CONCLUSION Bilateral biliary drainage had a lower re-intervention rate as compared to unilateral drainage for high grade inoperable malignant biliary strictures,with no significant difference in technical success,and early or late complication rates.