Endoscopic Management of the Iatrogenic CBD Injury
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1 The Liver Week 2014, Jeju, Korea Endoscopic Management of the Iatrogenic CBD Injury Jong Ho Moon, MD, PhD Department of Internal Medicine Soon Chun Hyang University School of Medicine Bucheon/Seoul, KOREA
2 Management of the Iatrogenic CBD Injury Surgery The mainstay of therapy in the past Possible morbidity and mortality Endoscopic therapy Can be the first therapeutic option in selected patients Primary effective nonoperative treatment Percutaneous intervention Reserved for failed endoscopic procedures DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
3 Causes of the Iatrogenic CBD Injury -Endoscopic View- Postoperative injury most common Post-ERCP injury Abdominal trauma Ischemic Radiation
4 Advantages Endoscopic Management of the Iatrogenic CBD Injury Immediate therapy combined with diagnostic evaluation Minimally invasive Not affected to further surgical, radiologic intervention Disadvantages Need experienced endoscopist Need high cost equipment / proper accessories Need multiple trials with long stenting period Not always successful Relatively high recurrence rate ; Should be done with surgical, or radiological backcover DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
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10 Endoscopic Therapy of the Iatrogenic Biliary Tract Injury Principles Elimination of transpapillary pressure gradient To Allow the flow of bile juice into the duodenum Prevent strictures Procedures ERCP EUS DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
11 ERCP for the Iatrogenic Biliary Tract Injury Endoscopic sphincterotomy Followed by stone extraction Endoscopic drainage Biliary stent 5-10F plastic stent (PS) Fully covered self expandable metal stent (SEMS) Nasobiliary drainage DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
12 EUS for the Iatrogenic Biliary Tract Injury Linear EUS with needle puncture Transmural drainage Transgastric, transduodenal Stents 5-10F plastic stent Fully covered self expandable metal stent (SEMS) Drainage catheter DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
13 Outcomes of Endoscopic Therapy for Postoperative Biliary Leaks Endotherapy n=105 EBS + NBD 78 (68.0%) EBS + stent 21 (20.4%) EBS alone 12 (11.6%) Success rate 98% Complication rate 2% Mortality 0% (EBS; endoscopic biliary sphincterotomy, NBD; nasobiliary drainage) Costamagna G, et al. Gastrointest Endosc Clin N Am 2003;13:635
14 Common Iatrogenic Biliopancreatic Tract Injuries for Endotherapy Benign biliary strictures Bile leak Bile leak with biloma Pancreatic leak Pancreatic leak with peripancreatic fluid collection DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
15 Endoscopic Management of Benign Biliary Stricture Endoscopic biliary sphincterotomy Dilatation Bougie Balloon Stenting - main management Single plastic stent Multiple plastic stents Self expandable metal stent (SEMS) DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
16 Bismuth Classification of Benign Biliary Stricture Zepeda-Gomez S, Baron TH. Nat Rev Gastroenterol Hepatol 2011;8:573 DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
17 Considering Factors of Stenting for Benign Biliary Stricture (BBS) Long survival patients Short strictured segment with otherwise normal bile duct Wick phenomenon Benign biliary stricture>malignant biliary stricture Anatomic stricture Functional stricture Bile duct remodeling High late recurrence DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
18 Results of Biliary Plastic Stenting for BBS Successful stent placement; 100% Immediate clinical success; near 100% Permanent resolution of stricture;15-35% Deviere J, et al. GIE 1990;36:96 Kahl S, et al. Am J GE 2003;98:2448 Cahen DL, et al. Eur J GE H 2005;17:103 DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
19 Problems of Biliary Plastic Stenting Stent clogging Disappointing long-term results Stent migration Unclear stenting period / exchange time Smits ME, et al. Br J Surg 1996;83:764 Kiehne K, et al. Endoscopy 2000;32:377 Farnbacher MJ, et al. Am J GE 2000;95:1466 DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
20 Multiple Biliary Stenting for Benign Biliary Stricture Sequentially increasing plastic stents number During 1 year (3 months interval) 3-5 plastic stents Larger cumulative diameter Overall clinical success rate; 62-92% Better long-term results than single stent Progressive dilatation Tissue remodeling Costamagna G, et al. GIE 2001;54:272 Catalano MF, et al. GIE 2004;60:945
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22 Advantages of Multiple Biliary Stenting Slowly, gently dilatation of the fibrotic scar No damage the normal bile duct mucosa Normal CBD below the stricture; progressively increase in diameter Easily removable without impairment Costamagna, G. GIE 2008;67:455 DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
23 Problems of Multiple Biliary Stenting Need for multiple sessions Technical difficulties How many stents? Stenting period? Which stent? (diameter, etc) Interval between stent placement? Lack of controlled, long-term follow-up data Poor outcomes for hilar stricture, biliary stricture by chronic pancreatitis Draganov P, et al. GIE 2002;55:680 DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
24 Retrieval, Fully Covered Metal Stent for Benign Biliary Stricture Longer patency than plastic stent, uncovered MS More effective, fewer procedures Safely removable stent Benefits of plastic stent + metal stent - Can be an ideal stent for benign biliary stricture Kaffes AJ, et al., Gastrointest Endosc 2013;78:13 Van Berkel AM, et al., Endoscopy, 2004;36:381 Cantu P, et al., Endoscopy, 2005;37:735 DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
25 Retrieval, Fully Covered Metal Stent S & G Biotech Inc, Korea
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28 Problems of Current Fully Covered SEMS for Benign Biliary Strictures Migration Foreign body reaction; de novo stricture formation Reflux of duodenal contents Always guarantee for removal of stent? Stenting duration? Kaffes AJ, et al., Gastrointest Endosc 2013;78:13 Kiehne K, et al. Endoscopy 2000;32:377 Farnbacher MJ, et al. Am J Gastroenterol 2000;95:1466 DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
29 Ideal Fully Covered SEMS for Benign Biliary Strictures 100% stent removal rate Minimal foreign body reaction or tissue hyperplasia Preventing reflux of duodenal contents Preventing migration DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
30 Prevention of Stent Migration Conformable Biliary Stent Bumpy, fully covered metal stent HANAROSTENT biliary flap BONASTENT M-Intraductal DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
31 Bumpy, Fully Covered Metal Stent (Taewoong Medical Co., Korea) Moon SH, et al. Gastrointest Endosc 2010;72:86
32 HANAROSTENT Biliary Flap Anti Migration: Anchorable flaps on stent distal reduce risk of migration Large Flare Proximal End Easy Removal: Less invasive and foldable flaps allow easy stent removal (MI Tech, Co.,Ltd, Korea) Park Do H, et al. Gastrointest Endosc 2011;73:64
33 Prevention of Reflux of Duodenal Contents Metal stent with anti-reflux valve Intra-ductal deployment
34 Anti-Reflux Biliary Stent in Distal Malignant Biliary Strictures Kaplan-Meier curve of cumulative patency of the stents HU B, et al. Endoscopy 2014;46:120 HU B, et al. Gastrointest Endosc 2011;73:143
35 Anti-Reflux Biliary Stent (Wine-glass-shaped tubular valve using silicon) (Hanarostent, M.I. Tech., KOREA) Kim DU, Kwon CI, et al. Dig Endosc 2013:25;60 DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
36 Covered Metal Stent with Windsock Type Anti-Reflux Valve Bare portion with flared stent proximal end e-polytetrafluoroethylene (e-ptfe) covered body portion Windsock type anti-reflux valve EGIS Biliary Stent M-Valve (S & G Biotech Inc, Korea)
37 EGIS Biliary Stent M-Valve (S & G Biotech Inc, Korea)
38 Foreign Body Reaction of Covered SEMS in Benign Biliary Strictures The tip or flange of SEMS potentially damage normal bile duct mucosa Tissue hyperplasia at margin of stent Whole covering and abrupt stretching on normal CBD below stricture by SEMS Inflammatory reaction by expansion, covering materials Abrupt dilatation of scar induce inflammation, lead to stricture recurrence DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
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40 New Fully Covered, Intraductal Metal Stent BONASTENT M-Intraductal (Standard Sci.Tech, KOREA) Moon JH, et al. Gastrointest Endosc 2012;75:1080
41 Features of BONASTENT M-Intraductal (ID) Fully covered using silicone preventing any tissue ingrowth Convex margin without flange at both ends to preventing de novo stricture by tissue hyperplasia Moon JH, et al. Gastrointest Endosc 2012;75:1080 DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
42 Features of BONASTENT M-Intraductal (ID) Inside placement of short length stent - Preventing duodenal reflux - Minimizing the stenting effect to the normal bile duct Moon JH, et al. Gastrointest Endosc 2012;75:1080 DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
43 Insertion and Deployment of BONASTENT M-ID
44 Removal of BONASTENT M-ID
45 Anastomotic Biliary Stricture after LRLT Most problematic benign biliary stricture The location of the stricture; usually the most proximal bile duct Difficult to locate center of stent within the strictured bile duct segment Short strictured segment DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
46 51/F, Benign biliary stricture after LRLT ; Total bilirubin 7.4 mg/dl
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56 Complete Obstruction of the Bile Duct
57 Magnetic Compression Anastomosis by PTCS Jang SI, Lee DK, et al. Gastrointest Endosc 2011;74:1040
58 Courtesy of Dr. Lee DK, Seoul, Korea
59 Courtesy of Dr. Lee DK, Seoul, Korea
60 Endoscopic Therapy for Bile Leak Endoscopic biliary sphincterotomy Endoscopic biliary drainage Biliary stent 5-10F plastic stent Fully covered metal stent Bypass injury site/ good bilioduodenal flow Prevent stricture at injured bile duct site Nasobiliary drainage (ENBD) Allow serial cholangiograms, and avoid repeat ERCP DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
61 Strasberg Classification of Laparoscopic Bile Duct Injury and Bile Leak A B C D > 2 cm E1 < 2 cm E2 E3 E4 E5 Strasberg SM, et al. J Am Coll Surg 1995;180:101 DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
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70 Endoscopic Therapy for Bile Leak with Biloma ERCP Endoscopic biliary sphincterotomy Endoscopic biliary drainage Linear EUS Transmural drainage of biloma DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
71 INSTITUTE FOR DIGESTIVE RESEARCH SOONCHUNHYANG UNIVERSITY HOSPITAL
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83 Endoscopic Therapy for Pancreatic Leak with Peripancreatic Fluid Collection Endoscopic pancreatic sphincterotomy Endoscopic pancreatic drainage Transmural drainage of peripancreatic fluid collection Linear EUS DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
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89 Conclusions of Endoscopic Management for the Iatrogenic CBD Injury Primary effective Generally safe Can be repeated Stepwise approach Classical plastic stents Multiple plastic stenting Fully covered SEMS DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
90 Conclusions of Endoscopic Management of the Iatrogenic CBD Injury Surgery Interventional radiology - still as important management option in failed patients with endosocopic Tx DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
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92 Features of BONASTENT M-Intraductal Long lasso at distal end to easy removal of stent DIGESTIVE DISEASE CENTER SOON CHUN HYANG UNIVERSITY HOSPITAL
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102 28, Woman C/C Jaundice, Abdominal pain (1 week) P/I Laparoscopic cholecystectomy, 2 weeks ago INSTITUTE FOR DIGESTIVE RESEARCH SOONCHUNHYANG UNIVERSITY HOSPITAL
103 Laboratory Findings CBC Total bilirubin Direct bilirubin AST / ALT ALP / rgtp Amylase / Lipase 6.78 mg/dl 5.28 mg/dl 257 / 373 IU/L 251 / 698 IU/L 2593 / 1880 IU/L INSTITUTE FOR DIGESTIVE RESEARCH SOONCHUNHYANG UNIVERSITY HOSPITAL
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STRICTURES OF THE BILE DUCTS Session No.: 5. Andrea Tringali Digestive Endoscopy Unit Catholic University Rome - Italy
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