Endoscopic interventions in the biliary tract

  • Adolf Stiehl
Article
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Opinion statement

In patients with common bile duct stones, the endoscopic removal of such stones has become the standard therapy. The surgical approach is indicated only for stones that cannot be extracted endoscopically. In biliary obstruction due to pancreaticobiliary malignancy, endoscopic interventions represent the first-line therapy in the palliative situation. If endoscopic access is not possible, the percutanous approach often represents an alternative, followed by palliative surgical options. Biliary strictures or bile leaks after liver transplantation very often may be treated effectively by endoscopic dilatation or temporary stenting. In most cases, endoscopic therapy of such problems represents the first option before the percutaneous or surgical approach is indicated. In primary sclerosing cholangitis, dominant biliary strictures develop frequently and endoscopic treatment allows their opening in most cases. There is no real alternative to endoscopy in this situation. The situation is more complex in postoperative biliary strictures and chronic pancreatitis. In these conditions, advantages and disadvantages of the endoscopic versus the surgical approach have to be evaluated to find the most effective form of treatment in the individual situation. The surgical intervention often represents the better alternative.

Keywords

Bile Duct Primary Sclerosing Cholangitis Biliary Obstruction Common Bile Duct Stone Biliary Stricture 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
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References and Recommended Reading

  1. 1.
    Hellerhoff K, Petzold V, Born P, et al.: MRCP versus ERCP in the evaluation of patients with suspected biliopancreatic disease: can ERCPs be saved [abstract]? Gastrointest Endosc 2001, 53:AB 97.Google Scholar
  2. 2.
    Angulo P, Pearce DH, Johnson CD, et al.: Magnetic resonance cholangiography in patients with biliary disease: its role in primary sclerosing cholangitis. J Hepatol 2000, 33:520–527.PubMedCrossRefGoogle Scholar
  3. 3.
    Rosch T, Meining A, Fruhmorgen S, et al.: A prospective comparison of the diagnostic accuracy of ERCP, MRCP, CT, and EUS in biliary strictures. Gastrointest Endosc 2002, 55:870–876. Critical evaluation of the sensitivity and specificity of ERCP, MRCP, CT, and endoscopic ultrasound, indicating that the accuracy of MRCP is lower than was previously anticipated.PubMedCrossRefGoogle Scholar
  4. 4.
    Connor P, Hawes RH: DDW reports 2001. ERCP topics. Endoscopy 2001, 33:930–939.PubMedCrossRefGoogle Scholar
  5. 5.
    Dutta SK, Cox M, Williamy RB, et al.: Prospective evaluation of the risk of bacteriemia and the role of antibiotics in ERCP. J Clin Gastroenterol 1983, 5:325–329.PubMedCrossRefGoogle Scholar
  6. 6.
    Sauter G, Grabein B, Huber G, et al.: Antibiotic prophylaxis of infectious complications with endoscopic retrograde cholangio-pancreaticography. A randomized controlled study. Endoscopy 1990, 22:164–167.PubMedGoogle Scholar
  7. 7.
    Niederau C, Pohlmann U, Lübke H, et al.: Prophylactic antibiotic treatment in therapeutic or complicated diagnostic ERCP: results of a randomized controlled clinical study. Gastrointest Endosc 1994, 40:533–537.PubMedCrossRefGoogle Scholar
  8. 8.
    Olson R, Björnsson E, Bäckman L, et al.: Bile duct bacterial isolates in primary sclerosing cholangitis: a study of explanted livers. J Hepatol 1998, 28:426–432. Study of bacterial isolates in explanted livers showing a high rate of bacterial infections in livers of patients with primary sclerosing cholangitis patients. The infection rate may be reduced by treatment with antibiotics at the time of the ERCP.CrossRefGoogle Scholar
  9. 9.
    Classen M, Demling L: Endoskopische Sphinkterotomie der Papilla Vateri und Steinextraktion aus dem Ductus Choledochus. Dtsch Med Wochenschr 1974, 99:496–497.PubMedCrossRefGoogle Scholar
  10. 10.
    Kawai K, Akasaka Y, Mrakami K, et al.: Endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1974, 20:148–151.PubMedGoogle Scholar
  11. 11.
    Riemann JF, Seuberth K, Demling L: Mechanical lithotripsy of common bile duct stones. Gastrointest Endosc 1985, 31:207–213.PubMedGoogle Scholar
  12. 12.
    Sauerbruch T, Stern M: Study group for shock wave lithotripsy of bile duct stones. Fragmentation of bile duct stones by extracorporeal shock waves: a new approach to biliary calculi after failure of routine endoscopic measures. Gastroenterology 1989, 96:146–152.PubMedGoogle Scholar
  13. 13.
    Freeman M, Nelson D, Sherman S, et al.: Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996, 335:909–918.PubMedCrossRefGoogle Scholar
  14. 14.
    Saito M, Tsuyuguchi T, Yamaguchi T, et al.: Long-term outcome of endoscopic papillotomy for choledocholithiasis with cholecystolithiasis. Gastrointest Endosc 2000, 51:540–545. Follow-up study of patients with common duct stones who had their bile duct stones removed but in whom the gallbladder was left in situ. The outcome indicates that there is no need for routine cholecystectomy in such patients.PubMedCrossRefGoogle Scholar
  15. 15.
    Sharma VK, Howden CW: Meta-analysis of randomized controlled trials of endoscopic retrograde cholangiography and endoscopic sphincterotomy for the treatment of acute biliary pancreatitis. Am J Gastroenterol 1999, 94:3211–3214. A meta-analysis in patients with gallstone pancreatitis comparing complication rates after treatment with sphincterotomy with those after conservative treatment. The pooled data of four randomized trials indicate a significant reduction of the mortality in the endoscopy group.PubMedCrossRefGoogle Scholar
  16. 16.
    Chang L, Lo S, Stabile BE, et al.: Preoperative versus postoperative endoscopic retrograde cholangiopancreaticography in mild to moderate gallstone pancreatitis. Ann Surg 2000, 231:82–87.PubMedCrossRefGoogle Scholar
  17. 17.
    Fogel EL, Sherman S, Devereaux BM, Lehman GA: Therapeutic biliary endoscopy. Endoscopy 2001, 33:31–38.PubMedCrossRefGoogle Scholar
  18. 18.
    Vitale GC, Reed DN Jr, Nguyen CT, et al.: Endoscopic treatment of distal bile duct stricture from chronic pancreatitis. Surg Endosc 2000, 14:227–231.PubMedCrossRefGoogle Scholar
  19. 19.
    Born P, Rösch T, Bruhl K, et al.: Long-term results of endoscopic and percutaenous transhepatic treatment of benign biliary strictures. Endoscopy 1999, 31:725–731.PubMedCrossRefGoogle Scholar
  20. 20.
    Theilmann L, Kuppers B, Kadmon M, et al.: Biliary tract strictures after orthotopic liver transplantation. Endoscopy 1994, 26:517–522.PubMedGoogle Scholar
  21. 21.
    Hintze R, Adler A, Veltzke W, et al.: Endoscopic management of biliary complications after orthotopic liver transplantation. Hepatogastroenterology 1997, 44:258–262.PubMedGoogle Scholar
  22. 22.
    Pfau PR, Kochman ML, Lewis JD, et al.: Endoscopic management of postoperative biliary complications in orthotopic liver transplantation. Gastrointest Endosc 2000, 52:55–63. A study in patients with biliary complications after liver transplantation, indicating that the majority of complications can effectively be treated by endoscopic measures.PubMedCrossRefGoogle Scholar
  23. 23.
    Schwartz DA, Petersen BT, Poterucha JJ, et al.: Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation. Gastroinest Endosc 2000, 51:169–174.CrossRefGoogle Scholar
  24. 24.
    Lee JG, Schutz SM, England RE, et al.: Endoscopic therapy of sclerosing cholangitis. Hepatology 1995, 21:661–667.PubMedGoogle Scholar
  25. 25.
    Ponsioen CY, Lam K, van Milligen de Wit AWM, et al.: Four years’ experience with short-term stenting in primary sclerosing cholangitis. Am J Gastroenterol 1999, 94:2403–2407. A study indicating that dominant stenoses may effectively be treated by short-time stenting.PubMedCrossRefGoogle Scholar
  26. 26.
    Stiehl A, Rudolph G, Klöters-Plachky P, et al.: Development of dominant bile duct stenoses in patients with primary sclerosing cholangitis treated with ursodeoxycholic acid: outcome after endoscopic treatment. J Hepatol 2002, 26:151–156. A 13-year prospective study indicating that the majority of patients with time develop dominant stenoses that may successfully be treated by endoscopic dilatations. Combined treatment with ursodeoxycholic acid and dilatations of dominant stenoses led to a significant improvement of survival compared with the predicted survival.CrossRefGoogle Scholar
  27. 27.
    Smith AC, Dowsett JF, Russel RC, et al.: Randomised trial of endoscopic stenting versus surgical bypass in malignant low bile duct obstruction. Lancet 1994, 344:1655–1660.PubMedCrossRefGoogle Scholar
  28. 28.
    Andersen JR, Sorensen SM, Kruse A, et al.: Randomised trial of endoscopic endoprostheses versus operative bypass in malignant obstructive jaundice. Gut 1989, 30:1132–1135.PubMedGoogle Scholar
  29. 29.
    Speer AG, Cotton PB, Russel RC, et al.: Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987, II:57–62.CrossRefGoogle Scholar
  30. 30.
    Davids PH, Groen AK, Rauws EA, et al.: Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant bile duct obstruction. Lancet 1992, 340:1488–1492.PubMedCrossRefGoogle Scholar
  31. 31.
    Shepherd HA, Royle G, Ross AP, et al.: Endoscopic biliary endoprostheses in the palliation of malignant obstruction of the distal common bile duct: a randomised trial. Br J Surg 1998, 75:1166–1168.CrossRefGoogle Scholar
  32. 32.
    Knyrim K, Wagner HJ, Pausch J, Vakil N: A prospective, randomized controlled trial of metal stents for malignant obstruction of the common bile duct. Endoscopy 1993, 25:207–212.PubMedCrossRefGoogle Scholar
  33. 33.
    Dumoceau JM, Cremer M, Auroux J, et al.: A comparison of Ultraflex Diamond stents and Wallstents for palliation of distal malignant biliary strictures. Am J Gastroenterol 2000, 95:670–676.CrossRefGoogle Scholar
  34. 34.
    Ssayama H, Komatsu Y, Tsijino T, et al.: A prospective randomized study of ‘covered’ vs ‘uncovered’ metallic stent for distal malignant biliary obstruction [abstract]. Gastrointest Endosc 2000, 51:191.CrossRefGoogle Scholar
  35. 35.
    Ortner,MA, Liebetruth J, Schreiber ST, et al.: Photodynamic therapy of nonresectable cholangiocarcinoma. Gastroenterology 1998, 114:536–542.PubMedCrossRefGoogle Scholar
  36. 36.
    Berr F, Liebetruth J, Caca K, et al.: Photodynamic therapy for advanced bile duct cancer: evidence for improved palliation and extended survival. Hepatology 2000, 31:291–298. A study in patients with advanced bile duct cancer showing that palliative photodynamic treatment is accompanied by a local tumor response rate of up to 67% after five photodynamic therapies, which leads to an apparent benefit in survival time.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2003

Authors and Affiliations

  • Adolf Stiehl
    • 1
  1. 1.Department of MedicineUniversity of Heidelberg, Medizinische UniversitätsklinikHeidelbergGermany

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