Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline - Updated October 2017.

ESGE recommends against routine preoperative biliary drainage in patients with malignant extrahepatic biliary obstruction; preoperative biliary drainage should be reserved for patients with cholangitis, severe symptomatic jaundice (e. g., intense pruritus), or delayed surgery, or for before neoadjuvant chemotherapy in jaundiced patients. Strong recommendation, moderate quality evidence. ESGE recommends the endoscopic placement of a 10-mm diameter self-expandable metal stent (SEMS) for preoperative biliary drainage of malignant extrahepatic biliary obstruction. Strong recommendation, moderate quality evidence.ESGE recommends SEMS insertion for palliative drainage of of extrahepatic malignant biliary obstruction. Strong recommendation, high quality evidence. ESGE recommends against the insertion of uncovered SEMS for the drainage of extrahepatic biliary obstruction of unconfirmed etiology. Strong recommendation, low quality evidence. ESGE suggests against routine preoperative biliary drainage in patients with malignant hilar obstruction. Weak recommendation, low quality evidence.ESGE recommends uncovered SEMSs for palliative drainage of malignant hilar obstruction. Strong recommendation, moderate quality evidence.ESGE recommends temporary insertion of multiple plastic stents or of a fully covered SEMS for treatment of benign biliary strictures. Strong recommendation, moderate quality evidence.ESGE recommends endoscopic placement of plastic stent(s) to treat bile duct leaks that are not due to transection of the common bile duct or common hepatic duct. Strong recommendation, moderate quality evidence.

Single-balloon enteroscopy for treating Roux-en-Y choledochojejunostomy stenosis after liver transplantation: a case report.

Endoscopic treatment of biliary tract complications after Roux-en-Y surgery is still a challenge. With balloon enteroscopy, we can reach previously inaccessible areas changing the management of biliopancreatic diseases in patients with surgically altered anatomy. We report a case of single-balloon enteroscopy plus endoscopic retrograde cholangiopancreatography for the treatment of a pinpoint stricture in a hepaticojejunal anastomosis after liver transplantation.

Effects of albumin administration in serum liver enzymes of rats in the presence of extrahepatic biliary obstruction.

PURPOSE: To study the influence of albumin on changes of liver function in the extrahepatic biliary obstruction through an experimental model in rats. METHODS: Sixty rats were divided into four groups: Group C (Control): 6 animals. Group M (Fictitious Operation): 18 rats underwent laparotomy and handling of the bile ducts; Groups O (extrahepatic biliary obstruction) and A (Treated with 2% albumin): 18 animals in each group underwent ligation of the ductus liver; The animals in groups M, O and A were divided into three subgroups of 6 animals each to be killed in the 7, 14 and 21 days postoperative (POD). Blood was drawn for determination of total bilirubin (TB), indirect bilirubin (IB), direct bilirubin (DB), alkaline phosphatase (ALP), aspartate aminotransferase (AST) and alanine aminotransferase (ALT). RESULTS: On POD 7, BI levels were 4.5 mg / dl in group O and 2.1 mg / dl in group A (p = 0.025). On the 14th POD, the levels of PA were 1185.2 U / l in the group and O 458.3 U / l in group A (p = 0.004). ALT levels were 101.7 U / l in the group O and 75.7 U / l in group A (= 0.037). On POD 21, the levels of ALP were 1069.5 U / l in the group O and 468.3 U / l in group A (p = 0, 004). CONCLUSION: The administration of albumin reduced the serum levels of bilirubin in the 7th day of supplementation.

Effects of albumin administration in serum liver enzymes of rats in the presence of extrahepatic biliary obstruction / Efeitos da administração de albumina nos níveis séricos de enzimas hepáticas em ratos com obstrução biliar extra-hepática

PURPOSE: To study the influence of albumin on changes of liver function in the extrahepatic biliary obstruction through an experimental model in rats. METHODS: Sixty rats were divided into four groups: Group C (Control): 6 animals. Group M (Fictitious Operation): 18 rats underwent laparotomy and handling of the bile ducts; Groups O (extrahepatic biliary obstruction) and A (Treated with 2 percent albumin): 18 animals in each group underwent ligation of the ductus liver; The animals in groups M, O and A were divided into three subgroups of 6 animals each to be killed in the 7, 14 and 21 days postoperative (POD). Blood was drawn for determination of total bilirubin (TB), indirect bilirubin (IB), direct bilirubin (DB), alkaline phosphatase (ALP), aspartate aminotransferase (AST) and alanine aminotransferase (ALT). RESULTS: On POD 7, BI levels were 4.5 mg / dl in group O and 2.1 mg / dl in group A (p = 0.025). On the 14th POD, the levels of PA were 1185.2 U / l in the group and O 458.3 U / l in group A (p = 0.004). ALT levels were 101.7 U / l in the group O and 75.7 U / l in group A (= 0.037). On POD 21, the levels of ALP were 1069.5 U / l in the group O and 468.3 U / l in group A (p = 0, 004). CONCLUSION: The administration of albumin reduced the serum levels of bilirubin in the 7th day of supplementation.

OBJETIVO: Estudar a influência da albumina em alterações funcionais do fígado na obstrução biliar extra-hepática por meio de um modelo experimental desenvolvido em ratos. MÉTODOS: 60 ratos distribuídos em quatro grupos: Grupo C (Controle): 6 animais. Grupo M (Operação Fictícia): 18 ratos submetidos à laparotomia e manuseio das vias biliares; Grupos O (Obstrução Biliar Extra-hepática) e A (Tratados com albumina a 2 por cento): 18 animais, em cada grupo, submetidos à ligadura do ducto hepático; Os animais dos grupos M, O e A foram distribuídos em três subgrupos de 6 animais cada, para serem mortos nos 7°, 14° e 21° dias pós- operatórios (DPO). Foi colhido sangue para dosagem de bilirrubina total (BT), bilirrubina indireta (BI), bilirrubina direta (BD), fosfatase alcalina (FAL), aspartato aminotransferase (AST) e alanina aminotransferase (ALT). RESULTADOS: no 7º DPO, os níveis de BI foram 4,5 mg/dl no grupo O e 2,1mg/dl no grupo A (p=0,025). No 14º DPO, os níveis de FAL foram 1185,2 U/l no grupo O e 458,3 U/l no grupo A (p=0,004). Os níveis de ALT foram de 101,7 U/l no grupo O e 75,7 U/l no grupo A (=0,037). No 21º DPO, os níveis de FAL foram de 1069,5 U/l no grupo Oe de 468,3 U/l no grupo A (p =0, 004). CONCLUSÃO: a administração de albumina reduziu os níveis séricos de bilirrubina indireta no 7°dia de suplementação.

[Endoscopic treatment of postcholecystectomy biliary strictures]. / Tratamiento endoscópico de las estenosis biliares post-colecistectomía.

INTRODUCTION: Biliary strictures are a serious complication of biliary surgery. Historically, surgery was the treatment of choice. Then appeared the endoscopic treatment with results comparable with those achieved by the surgery. MATERIAL AND METHODS: Twenty-two patients underwent endoscopic treatment for postcholecystectomy benign biliary stricture between 1990 and 2006. After pneumatic dilation with ballons, stents were inserted. Stents were exchanged between 3 and 8 months and ultimately removed from all patients at 12 months. RESULTS: Endoscopic treatment was successful in 16 cases (72%): in 14 was excellent (63%), in 2 good (10%) and in 6 bad (27%). These cases required surgery. Early complications were cholangitis in 2 cases and pancreatitis in 3; late complications developed in 3 cases, with 2 o more cholangitis episodes. There was no mortality. CONCLUSIONS: Endoscopic treatment of biliary strictures with dilation and stent insertion was successful in 72% of the 22 cases in our series, with low morbility and no mortality.

[Prognostic factors of mortality in the malignant biliary obstruction unresectable after the insertion of an endoscopic stent]. / Factores pronósticos de mortalidad en la estenosis biliar distal maligna irresecable después de la colocación de una prótesis endoscópica.

OBJECTIVE: To determine the factors prognostics of early mortality in the malignant billary estenosis after the endoscopic derivation. BACKGROUND DATA: The surgical, percutaneous or endoscopic derivation is the alternative of palliative treatment in the biliary obstruction unresectable. The factors prognostic the early mortality after surgical derivation are: hemoglobin < 10 g/dL, serum bilirubin > 10 mg/dL and serum albumin < 2.5 g/dL; for the percutaneous derivation they are the sanguineous urea more of 4.3 mmol/L and hemoglobin < 10.9 g/dL; whereas in the single endoscopic derivation type 3 of Bismuth and the infectious complications after the endoscopic colangiography and the absence of the clinical success were factors prognoses of early mortality. METHODS: Descriptive and retrospective analysis of 97 cases with malignant biliary obstruction. The factors were evaluated prognoses of early mortality. Univariated and bivaried analysis and of survival by the method of Kaplan-Meier was made curved. RESULTS: 97 cases were included that presented/displayed unresectable disease and had a biochemical control subsequent to the drainage. They were 58 women and 39 men. More frequent symptoms: ictericia, pain and prurito. 61 cases of distal obstruction and 36 with proximal obstruction. Twenty deaths (25.9%) happened within the 30 later days to the treatment. The bilirubin > 14 mg/dL and the proximal location were like predicting of early mortality. CONCLUSIONS: The obstruction biliary more frequent is located in choledocho distal and is of pancreatic origin. The main factors associated to early mortality are: the bilirubin > of 14 mg/dL and the proximal location reason why is important the suitable selection of patient candidates to endoscopic derivation. The survival is better in the distal obstruction.

Estado actual del intervencionismo en la vía biliar: aspectos técnicos / Techniques in the practice of the minimally invasive procedures

Introducción: Un cirujano moderno debe comprender no sólo los distintos procesos patológicos, interpretar y utilizar correctamente las imágenes, sino también conocer los adelantos técnicos aplicables a diversas enfermedades. Objetivo: El motivo del presente trabajo es comentar aspectos técnicos de la práctica invasiva mínima sobre la vía biliar. Población: Práctica hospitalaria y extrahospitalaria. Material y Métodos: Se analizan los últimos 200 pacientes que requirieron drenaje percutáneo de la vía bibliar en la práctica hospitalaria y extrahospitalaria. La edad de los mismos osciló entre los 24 y 92 años, con una media de 56; pertenecían al sexo femenino 111. La obstrucción biliar fue, en 154 pacientes, por patología maligna. Se observaron 35 estenosis por lesión quirúrgica de la vía bibliar. Resultados: Se colocaron 268 drenajes percutáneos en la vía biliar en 200 pacientes consecutivos. Se decidió colocar prótesis metálicas expandibles en 50 enfermos, siendo en 5 (10 por ciento), como primer gesto. La morbimortalidad dentro de los 30 días, en relación a la técnica fue de 24 casos complicados (12 por ciento) y 4 pacientes fallecidos (2 por ciento). Conclusión: El drenaje percutáneo de la vía bibliar es una técnica segura y efectiva. La colocación de prótesis expandibles metálicas como primer gesto o luego de un drenaje es factible (AU)

Video-endoscopia biliar percutánea (VEB): aporte diagnóstico y terapéutico / Percutaneous biliary videoendoscopy (PBVE) for the etiological diagnosis and treatment

Antecedentes: El diagnóstico imagenológico de la estenosis biliar alcanza una sensibilidad del 85 por ciento y una especificidad del 98 por ciento. En cerca del 15 por ciento de las estenosis biliares no se llega al diagnóstico etiológico, lo que conduce a dificultades para proponer terapéuticas o elaborar pronósticos. Objetivo: Evaluar el aporte de la Video-Endoscopia Biliar Percutánea (VEB) para el diagnóstico etiológico de la estenosis biliar cuando fracasan los procedimientos corrientes, previo a la indicación de laparotomía. Lugar de aplicación: Institución privada. Diseño: Análisis retrospectivo de la casuística registrada en una ficha por paciente y volcada en una base de datos. Población: 22 VEB practicadas en 13 pacientes, 8 mujeres y 5 varones, edad promedio 51 años, portadores de ictericia obstructiva de origen incierto e imagenología no concluyente, entre febrero de 1993 y febrero de 2004. Método: Estudio retrospectivo descriptivo. Descripción detallada del instrumental y de la técnica. Resultados: Todos los procedimientos fueron técnicamente exitosos. Se realizaron 22 veces en 13 pacientes. 5 biopsias se hicieron a nivel de la confluencia, 3 en el canal hepático común, 1 en colédoco distal y 4 en anastomosis bilio-digestivas estenosadas. La biopsia informó "maligno" en 5 casos y "benigno" en 8. Hubo un falso negativo, resultando sensibilidad del 92 por ciento y especificidad del 100 por ciento. El endoscopio de 9F fue insuficiente en casi todos los casos, en tanto que el 15F alcanzó el diagnóstico en cada caso. La morbilidad vinculada al procedimiento se tradujo en 2 hemobilias de resolución espontánea. Todos los casos fueron confirmados por cirugía o control alejado, con seguimiento máximo de 9 años y promedio de 24 meses. Conclusiones: La VEB es un procedimiento que alcanza el diagnóstico cuando los métodos clásicos fallan. La técnica es relativamente sencilla, la morbilidad reducida, el costo bajo y los resultados alentadores cuando el algoritmo clásico no consigue diagnóstico de certeza. Permite visión directa de lesiones sin diagnóstico, facilitando la toma de muestras para examen histopatológico. El endoscopio de 15F es el instrumento ideal (AU)

Estado actual del intervencionismo en la vía biliar: aspectos técnicos / Techniques in the practice of the minimally invasive procedures

Introducción: Un cirujano moderno debe comprender no sólo los distintos procesos patológicos, interpretar y utilizar correctamente las imágenes, sino también conocer los adelantos técnicos aplicables a diversas enfermedades. Objetivo: El motivo del presente trabajo es comentar aspectos técnicos de la práctica invasiva mínima sobre la vía biliar. Población: Práctica hospitalaria y extrahospitalaria. Material y Métodos: Se analizan los últimos 200 pacientes que requirieron drenaje percutáneo de la vía bibliar en la práctica hospitalaria y extrahospitalaria. La edad de los mismos osciló entre los 24 y 92 años, con una media de 56; pertenecían al sexo femenino 111. La obstrucción biliar fue, en 154 pacientes, por patología maligna. Se observaron 35 estenosis por lesión quirúrgica de la vía bibliar. Resultados: Se colocaron 268 drenajes percutáneos en la vía biliar en 200 pacientes consecutivos. Se decidió colocar prótesis metálicas expandibles en 50 enfermos, siendo en 5 (10 por ciento), como primer gesto. La morbimortalidad dentro de los 30 días, en relación a la técnica fue de 24 casos complicados (12 por ciento) y 4 pacientes fallecidos (2 por ciento). Conclusión: El drenaje percutáneo de la vía bibliar es una técnica segura y efectiva. La colocación de prótesis expandibles metálicas como primer gesto o luego de un drenaje es factible

Video-endoscopia biliar percutánea (VEB): aporte diagnóstico y terapéutico / Percutaneous biliary videoendoscopy (PBVE) for the etiological diagnosis and treatment

Antecedentes: El diagnóstico imagenológico de la estenosis biliar alcanza una sensibilidad del 85 por ciento y una especificidad del 98 por ciento. En cerca del 15 por ciento de las estenosis biliares no se llega al diagnóstico etiológico, lo que conduce a dificultades para proponer terapéuticas o elaborar pronósticos. Objetivo: Evaluar el aporte de la Video-Endoscopia Biliar Percutánea (VEB) para el diagnóstico etiológico de la estenosis biliar cuando fracasan los procedimientos corrientes, previo a la indicación de laparotomía. Lugar de aplicación: Institución privada. Diseño: Análisis retrospectivo de la casuística registrada en una ficha por paciente y volcada en una base de datos. Población: 22 VEB practicadas en 13 pacientes, 8 mujeres y 5 varones, edad promedio 51 años, portadores de ictericia obstructiva de origen incierto e imagenología no concluyente, entre febrero de 1993 y febrero de 2004. Método: Estudio retrospectivo descriptivo. Descripción detallada del instrumental y de la técnica. Resultados: Todos los procedimientos fueron técnicamente exitosos. Se realizaron 22 veces en 13 pacientes. 5 biopsias se hicieron a nivel de la confluencia, 3 en el canal hepático común, 1 en colédoco distal y 4 en anastomosis bilio-digestivas estenosadas. La biopsia informó "maligno" en 5 casos y "benigno" en 8. Hubo un falso negativo, resultando sensibilidad del 92 por ciento y especificidad del 100 por ciento. El endoscopio de 9F fue insuficiente en casi todos los casos, en tanto que el 15F alcanzó el diagnóstico en cada caso. La morbilidad vinculada al procedimiento se tradujo en 2 hemobilias de resolución espontánea. Todos los casos fueron confirmados por cirugía o control alejado, con seguimiento máximo de 9 años y promedio de 24 meses. Conclusiones: La VEB es un procedimiento que alcanza el diagnóstico cuando los métodos clásicos fallan. La técnica es relativamente sencilla, la morbilidad reducida, el costo bajo y los resultados alentadores cuando el algoritmo clásico no consigue diagnóstico de certeza. Permite visión directa de lesiones sin diagnóstico, facilitando la toma de muestras para examen histopatológico. El endoscopio de 15F es el instrumento ideal

Biliary stricture caused by portal biliopathy: case report and literature review.

Portal biliopathy is a rare condition that is usually not diagnosed and only in few cases causes symptoms. Those symptoms are caused by vascular obstruction of the biliary tree in patients with portal hypertension. We report a case of a 29 years man who presented with history of intermittent jaundice, persistent elevation of hepatic function test and hematemesis as a manifestation of portal hypertension without liver damage. We present the clinical, radiological and pathological characteristics and literature review of the cases that had been reported, their diagnoses, treatment and clinical implication.

[Portal biliopathy]. / Biliopatía portal.

Portal biliopathy is a rare condition that is usually not diagnosed. It is associated with presence of varix around bile duct with concomitant ischemic damage and structural alterations of bile duct wall; this produces obstructive phenomena. There are scarce reports on the literature this entity. In the present paper, we report two cases in which obstruction of extrahepatic bile duct was associated with cholecystitis with well-documented extrahepatic portal hypertension. Both cases were managed with cholecystectomy and endoscopic placement of endoprothesis. Treatment of portal biliopathy should be adjusted to the individual patient's characteristics. It is focused on the one hand on management of portal hypertension and on the other hand to management of obstructive jaundice. When cholecistitis is found, cholecistectomy should to be performed. If the patient develops concomitant gastrointestinal bleeding due to portal hypertension, management of the problem could require surgical devascularization, shunting procedures, or endoscopic variceal ligature.

[Postoperative biliary stenosis: long-term results of endoscopic treatment]. / Estenosis biliar postoperatoria: resultados del tratamiento endoscópico a largo plazo.

BACKGROUND: Endoscopic stent placement is often the initial therapy in symptomatic patients with postoperative strictures because patients are usually diagnosed at the time of ERCP. Although stent insertion rapidly relieves symptoms of biliary obstruction and can even be live-saving in patients with cholangitis, all stents eventually clog, necessitating regular stent changes every 3 to 4 months. Results from several groups suggested that placing multiple stents for months to years could dilate the stricture permanently and thus also treat patients with postoperative biliary strictures palliatively. OBJECTIVE: The outcome of temporary biliary stent placement for postoperative bile duct stenosis was retrospectively evaluated. This is a review of our experience with endoscopic dilation and stent placement in postoperative biliary strictures. PATIENTS AND METHODS: Thirty patients with postoperative strictures diagnosed with ERCP were treated with long-term endoscopic stent placement. One 10 Fr stent was placed at first whenever possible, and stents were exchanged every 3 months for a total of 18 months as median. RESULTS: Four men and 26 women with mean age 42 years (range 16-69 years), and laparoscopic cholecystectomy in six and cholecystectomy (open procedure) in 24; surgical history was reviewed retrospectively. Five patients were lost to follow-up and 25 patients were followed for a median of 18 months. In all 25 patients, previous to stent placement, 8.5 or 10 Fr, a mechanical or hydrostatic dilation was necessary. Stents were exchanged every 3 months to avoid cholangitis caused by clogging. Three 10 Fr stents were inserted in one patient, two 10 Fr stents in 14 patients, one 10 Fr and one 8.5 Fr stent in nine patients, and in one patient, one 10 Fr stent. Six patients (24%) developed recurrent stenosis and required surgery. CONCLUSIONS: Endoscopic treatment with mechanical or hydrostatic dilation and stent insertion may improve long-term results for patients with postoperative biliary strictures.