Long-term outcome of percutaneous transhepatic therapy for benign bilioenteric anastomotic strictures.

PURPOSE: To evaluate the long-term outcomes of a percutaneous transhepatic approach in benign bilioenteric anastomoses with calibration of the stenosis to 15 F and extended internal/external drainage. MATERIALS AND METHODS: Between February 2000 and May 2007, the efficacy of this percutaneous transhepatic procedure was retrospectively studied in 39 patients with benign postoperative bilioenteric anastomotic strictures. The main purpose of the protocol was to repair the anastomosis by calibration of the stenosis to 15 F with a silicone drain and perform internal/external drainage for at least 1 year. The follow-up period ranged from 12 to 65 months (mean, 34.4 months), and outcomes were classified according to the patient's clinical symptoms and laboratory parameters and the need for further interventions. RESULTS: The procedure was successful in 38 of 39 patients. Four patients were lost to follow-up during or after drainage. The duration of drainage (41 internal catheters in 34 patients) ranged from 126 days to 488 days (mean, 346 d). Twenty-seven patients had positive outcomes during the mean follow-up of 34 months, and six patients had negative outcomes. The bile duct patency probability according to the Kaplan-Meier method was and 70.6% at 34 months after drain removal. CONCLUSIONS: Percutaneous treatment of benign biliary strictures with calibrated stent implantation and extended drainage has good long-term results and may be an effective alternative to surgery. Advantages over surgery are its minimal invasiveness and reduced risk of complications.

Central pancreatectomy: single-center experience of 50 cases.

Central pancreatectomy is a nonstandard operation for unusual lesions. This study reports a single-center experience of central pancreatectomy. Thirty-eight women and 12 men with a mean age of 49.4 years (range, 13.4-79.2 years) underwent central pancreatectomy from January 1987 to October 2005. Indications included 18 neuroendocrine tumors (11 nonfunctioning), 10 serous and 10 mucinous cystadenomas, 5 intraductal papillary mucinous neoplasms, 3 main pancreatic duct strictures, 2 solid cystic papillary tumors, 1 hydatid cyst, and 1 acinar cell carcinoma. The proximal pancreatic remnant was suture ligated. The distal pancreatic end was anastomosed to a Roux-en-Y jejunal loop (n = 6) or to the stomach (n = 44). Three patients had associated procedures, 1 each for metastatic liver cytoreduction (VIPoma), hydatid liver disease, and pancreatic resection for multifocal mucinous cystadenoma. The median operative time was 3 hours 21 minutes (range, 1 hour 50 minutes to 6 hours). The mean length of the resected pancreas was 45 mm (range, 20-80 mm) and the mean tumor size was 23 mm (5-60 mm). The perioperative mortality was nil. Complications included the following: 4 patients (8%) had pancreatic anastomotic leak, 5 patients (10%) had acute pancreatitis, 7 patients (14%) had intra-abdominal collection, and 3 patients (6%) had bleeding. Six patients (12%) required a reoperation during the postoperative period. Eight patients (16%) required endoscopic (1 with biliary endoscopic stent) or radiological (7 with percutaneous drainage) intervention. No patients developed de novo diabetes. On long-term follow-up, 2 patients with invasive intraductal papillary mucinous neoplasia had recurrence; one was treated successfully by completion pancreatectomy and the other died at 20 months. One patient with serous cystadenoma died at 16.8 years without recurrence. One patient with metastatic VIPoma had a liver transplant 9 years postoperatively and is alive. The median follow-up was 55 months (range, 2 months to 16.8 years). The actuarial 5-year patient and pancreatic remnant survival rates were 98% and 95%, respectively. In our series, central pancreatectomy led to effective preservation of both cephalic and distal pancreatic remnants without a significant increase in postoperative morbidity compared with conventional pancreatectomy.

Value of magnetic resonance cholangiography in benign and malignant biliary stenosis: comparative study with direct cholangiography.

PURPOSE: Magnetic resonance cholangiography (MRC) is currently under investigation for imaging of biliary stenosis. The purpose of this study was to evaluate the diagnostic value of MRC compared with direct cholangiography in biliary duct diseases, with the exception of biliary-enteric anastomosis. METHOD: Forty-nine patients (26 men, 23 women; median age 60 years) with clinically suspected bile duct stenosis were prospectively included. Magnetic resonance cholangiography was performed within 7 days before direct cholangiography, considered to be the gold standard. Stenosis location, extension, and type according to Bismuth classification as well as diagnostic presumed causes were determined by 2 radiologists and 1 endoscopist. RESULTS: Magnetic resonance cholangiography correctly identified the level of biliary ductal obstruction compared with direct cholangiography findings in 96% patients. Excellent agreement between MRC and direct cholangiography was found for the stenosis location (kappa value, 0.89). Sensitivity and specificity of MRC to detect common bile duct stenosis were 88% and 100%, respectively. Sensitivity and specificity of MRC to detect biliary confluence stenosis were 96% and 93%, respectively. Precise location of the lesion according to Bismuth classification was correctly evaluated on MRC in 74% of patients (kappa value, 0.64). The overall interobserver concordance between radiologists for the level of stenosis was good (kappa value, 0.625). In 35 patients with intrahepatic bile ducts dilation identified on direct cholangiography, 97% of patients were identified on MRC. Moderate concordance between MRC and direct cholangiography was confirmed in the evaluation of the surgical management (kappa value, 0.55). CONCLUSION: Magnetic resonance cholangiography is able to replace diagnostic direct cholangiography to restrict the use of invasive procedures to cases in which therapeutic procedures are anticipated or MRC findings are equivocal, especially in biliary tract diseases.