Percutaneous intervention for bilioenteric anastomotic strictures: Current strategies and future directions

Abstract

Postoperative bilioenteric anastomotic strictures are encountered in a significant number of patients after primary biliary repair, hepatopancreaticobiliary tumor resection, and liver transplantation. Due to difficulties with repeat surgery and endoscopic access, percutaneous dilation has become the accepted treatment in these cases. While the overall paradigm of percutaneous access, balloon dilation, and catheter stenting remains consistent, institutional protocols differ in several technical variables including balloon sizes, inflation techniques, catheter sizing, and overall time course of treatment, amongst others. The current review aims to discuss various treatment protocols and their relative efficacy, as well as touch on emerging techniques.

The Utility of Biliary Manometry in Assessing Early Catheter Removal After Percutaneous Balloon Dilatation of Hepaticojejunostomy Strictures

“…Percutaneous management includes percutaneous transhepatic biliary drainage (PTBD) followed by balloon dilatation of the HJ stricture(s) [5][6][7]. The anastomotic site is kept patent by the placement of internal-external biliary catheters (IEBCs), which have varied in caliber from 8 to 18 Fr in different studies [8][9][10][11]. Thereafter, repeat cholangiography with or without balloon dilatation along with catheter exchange/upsizing is done at intervals of weeks to months (one week to three months in different studies) [8][9][11][12].…”

“…The anastomotic site is kept patent by the placement of internal-external biliary catheters (IEBCs), which have varied in caliber from 8 to 18 Fr in different studies [8][9][10][11]. Thereafter, repeat cholangiography with or without balloon dilatation along with catheter exchange/upsizing is done at intervals of weeks to months (one week to three months in different studies) [8][9][11][12]. These biliary catheters have been placed for varying periods (mean duration of 1.1-19.9 months) in previous studies [13][14].…”

“…These biliary catheters have been placed for varying periods (mean duration of 1.1-19.9 months) in previous studies [13][14]. The endpoint of the treatment is considered to be reached when cholangiography shows the free flow of contrast across the HJ anastomosis into the jejunum and the patient passes a "clinical test" [8,15].…”

“…If the LFTs are not elevated (total bilirubin: <1.3 mg/dl, conjugated bilirubin: <0.4 mg/dl, alkaline phosphatase: <150 U/L) and the obstructive symptoms do not recur, the treatment is considered a success and the catheter is withdrawn. If the LFTs are deranged, then either repeat balloon dilatation is performed with placement of IEBCs or the patient is referred for surgical management [8,[15][16].…”