ERCP and Related Technologies: A Clinical Update

David L. Carr-Locke, MD, FRCP, FACG, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

Disclosures

May 22, 2000

In This Article

Biliary Strictures

This session discussed the use of single or multiple plastic stents for hilar strictures, plastic or metal stents for hilar strictures, and long-term stents for benign biliary strictures.

Dr. Haber began his presentation by emphasizing that the endoscopic therapy of complex hilar strictures remains challenging and controversial. The challenges include difficulties in interpreting intrahepatic ductal anatomy, difficulties in selecting patients for possible resection with the accepted low resectability rate, and in general, the relatively short life expectancy of most patients with lesions in this area. Some of the "bad press" associated with endoscopic therapy of hilar obstruction can be attributed to the inability to provide adequate drainage and the resulting high septic complication rate.

Dr. Haber subsequently discussed the diagnostic aspect of ERCP technique in defining the stricture anatomy and its extent in terms of the Bismuth classification. He stressed the importance of making an immediate differential diagnosis based on ERCP appearances and prior noninvasive imaging, and further emphasized the care necessary in filling segments of obstructed intrahepatic ducts relative to the endoscopist's ability to provide a subsequent drainage. Dr. Haber also mentioned some important principles of endoscopic tissue sampling, such as the relation of sensitivity to site of tissue sampling (ie, whether the sample is taken from the duct in which the tumor arises), the high yield if the malignant stricture is disrupted or abraded, and the cumulative yield of using more than 1 sampling technique.

He discussed at some length the technical aspects of gaining access across a hilar stricture and the accessories most likely to achieve success, including: a straight or J-tipped hydrophilic guidewire used with a double lumen papillotome to enable tip deflection or an extraction balloon that can be used to change the orientation of a guidewire by various degrees of inflation. Dr. Haber further advocated consideration of routine dilation of hilar strictures prior to stent placement with low compliance hydrostatic balloons or catheter dilators, because stent placement is always more difficult in this area when compared with distal bile duct strictures.

Lastly, Dr. Haber summarized results of endoscopic drainage. The Brussels group published their results of Bismuth type II and III malignant strictures. They reported that survival in 24 patients treated with a single stent was significantly less than that achieved with bilateral stents.[81] However, a contrary view was presented by a London group[82] that successfully used single stents in this patient population without a high septic complication rate or high early mortality. A French group[83] further reported different success rates depending on how the setting involving a single stent was defined and recommended against drainage altogether in patients with Bismuth type III strictures. Indeed, Dr. Haber's own group published their work involving a series of 98 patients with type II and III strictures, which addressed the issue of infectious complications. These investigators found that patients with a unilateral stent without contamination of the contralateral side survived almost as well as patients treated with bilateral stents when both sides had been pacified. Both patient groups were found to be significantly better than patients in whom 1 side of an obstructed system had been contaminated but could not be drained.[84] The latter finding suggests that all pacified intrahepatic ducts should be drained whenever possible.

Dr. Huibregtse introduced the topic by asserting that 85% of bifurcation tumors can only be treated for palliation, and that the primary aim of therapy is therefore biliary drainage.

He discussed the Bismuth classification and commented that the complication of cholangitis was found to be much higher in types III and IV when stent therapy was attempted. He also highlighted some of the difficulties of placing metallic stents in bifurcation tumors, particularly the difficulty of achieving sufficient proximal access to the stricture before deployment. Placement of multiple metallic stents was also difficult, Dr. Haber reported, particularly when access to a contralateral side was attempted after placement of the first stent. Most endoscopists preferred to place 2 guidewires initially, and dilation either immediately prior to metallic stent placement or by the placement of plastic stents for a period was often necessary. Access through the side of a Wallstent was found to be possible with available guidewires, dilating balloons, or a Soehendra stent retriever, but often percutaneous access was required.

Whether metallic stents perform better than plastic stents for hilar tumors remains unclear, but Wallstent placement is feasible in over 90% of patients. Some studies have shown longer patency and lower complication rates than plastic stents[85] and a reduced number of subsequent interventions for metallic stents.[86]

Dr. Binmoeller reviewed the classification of benign bile duct strictures as published by Bismuth, with the type I - V nomenclature still representing a useful system for description and comparison.

Because more than 80% of benign strictures are postoperative in etiology,[87] Dr. Binmoeller focused on the pathogenic mechanisms -- mechanical, thermal, and ischemic -- for ductal injury. Endoscopic therapy of such strictures with the goal of placing two 10-Fr stents for up to 1 year has been shown to provide a success rate of 38%.[88] As Dr. Binmoeller emphasized, strictures associated with chronic pancreatitis can be effectively treated in the short term by endoscopic stenting, but stricture resolution in the long term is rare and cannot be recommended. For strictures associated with sclerosing cholangitis, aggressive endoscopic therapy was shown to reduce the number of symptomatic episodes and admissions to hospital.[89] The Amsterdam group has had moderately good success with a short-term stent therapy after dilation, with an apparent effect on the natural history of the disease.[90]

He stressed that the role of expandable metal stents for benign bile duct strictures remains controversial and currently cannot be recommended in view of the high occlusion rate and lack of long-term success.[91,92]

Lastly, Dr. Binmoeller pointed out that no controlled studies have so far compared endoscopic stent therapy with surgical treatment, although a retrospective study from the Amsterdam group did suggest very similar long-term outcomes.[93] It should be realized, however, that the results of surgical repair have improved in recent years as demonstrated by a series of 130 patients[94] predominantly treated by hepaticojejunostomy, in which good results were achieved in 76% of cases over a 7-year follow-up.

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