Original ArticlePercutaneous transhepatic cholangioplasty: An effective treatment in patients with benign biliary stricture
Introduction
Percutaneous Transhepatic Biliary Drainage (PTBD) was first undertaken in the early 1970s in an attempt to prevent the complications of bile leakage after percutaneous transhepatic cholangiography in patients with biliary obstruction. Benign biliary stricture has multiple etiologies. Most common cause is iatrogenic in nature from inadvertent damage to the biliary tree during surgical procedures like after cholecystectomy, biliary-enteric anastomoses and anastomoses after hepatic transplantation. Additionally, benign biliary obstruction may be associated with trauma, inflammatory processes due to stone disease or pancreatitis, post surgical sphincter of Oddi dysfunction, and as a late complication of the treatment of other intra-abdominal processes.
The estimated incidence of major bile duct injuries, which was 0.1%–0.3%1, 2 during the open cholecystectomy era, has risen to an estimated incidence 0.4%–0.6%3, 4 for laparoscopic cholecystectomy. Incidence following biliary-enteric anastomoses, which is a common surgical technique for bile drainage to gastrointestinal tract after resection of benign or malignant diseases, is approximately 10–40%. Postoperative anastomotic biliary strictures are not an uncommon occurrence after liver transplantation. They occur after 2.5–13% of liver transplantations and they represent atleast one-half of biliary complications encountered after liver transplantation.5 Stricture is caused by an ischemic insult of the biliary wall secondary to dissection or thermal injury causing fibrosis.
In general iatrogenic injuries if not treated surgically, endoscopy is treatment of choice. Endoscopic treatment is usually successful in stricture near or involves ampulla of water. Stricture involving hepatic ducts and hila or patient with biliary-enteric anastomoses where endoscopy is not feasible, PTBD with balloon dilatation is the treatment of choice (Fig. 1).
Pre procedural magnetic resonance cholangiopancreatography (MRCP) and ultrasonography may be helpful in determining the level of block and optimal transhepatic access route. Fluoroscopy and ultrasonography is the chief imaging tool used during PTBD. Real time ultrasonographic guidance is often used to target the biliary tree. More recently, real-time CT fluoroscopy and magnetic resonance imaging (MRI) have been used.
Section snippets
Materials and method
This study was conducted from May 2008 to May 2010 on patients with benign biliary stricture in whom ERCP had failed and referred for PTBD. The follow-up of patients was done until May 2013. History, investigations and operative details of all patients will be noted before and after the procedure and regular follow-up at 1 week, 1 month, 3 months, 6 months and then every 6 months.
Patient demographics/clinical features
In present study we evaluated 14 patients (6 male and 8 female) with mean age was 44.2 years. Majority of patients presented jaundice (80.5%), pain (80.5%) (Table 1) and pruritus (60.4%). Other clinical features were recurrent fever, abdominal distension, weight loss, nausea and vomiting. Major causes of stricture were HJ stricture related to hepato-biliary surgery other than liver transplant (n = 8), post LDLT biliary stricture (n = 2), post cholecystectomy CBD injury (n = 2), post LDLT HJ
Discussion
Benign anastomotic stricture after Major Hepato-biliary Surgery presents a difficult management problem. Treatment options for these types of stricture are either surgical reconstruction or dilation by a minimally invasive approach.7, 8
Previously surgical reconstruction is considered to be the most definitive treatment9 Surgical treatment carries the morbidity approximately 25%, with reported mortality rates of 2%–13%.10 In addition, 25% of patients develops recurrent stricture as observed on
Conflicts of interest
All authors have none to declare.
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