Introduction
Endoscopy is considered the first-line modality for treatment of benign biliopancreatic
stenosis. Benign biliary strictures (BBSs) are more frequently the consequence of
postoperative injury (i. e., post-cholecystectomy, liver transplantation, bilioenteric
anastomosis), but they can be also due to chronic pancreatitis, chronic cholangiopathies
(i. e., primary sclerosing cholangitis, immunoglobulin G4-related cholangiopathy)
and trauma. Clinical manifestations vary from incidental elevation on liver function
testing in asymptomatic patients to a more severe clinical course such as jaundice
and cholangitis. If left untreated, BBS can lead to chronic cholestasis, recurrent
sepsis, and secondary biliary cirrhosis.
Benign pancreatic strictures (BPSs) can be caused by chronic pancreatitis, trauma,
and surgical injury. Relevant stricture of the main pancreatic duct can increase the
intraluminal pressure and cause injury to the gland with abdominal pain and pancreatitis.
Many treatment options (endoscopy, percutaneous, surgery) are currently available
for treatment of biliopancreatic strictures [1]
[2]. Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred option for
most patients because it is effective, safe, and minimally invasive [3]. The final goal of endoscopic treatment is permanent resolution of the stricture
with mechanical or balloon dilatation and/or stent placement [4]
[5]. However, deep access of the duct above the stricture can be challenging, depending
on stricture severity and anatomic location.
In this study, a novel procedure for recanalization of challenging biliopancreatic
strictures is reported.
Patients and methods
Case 1
A 60-year-old man underwent orthotopic liver transplantation (OLT) due to alcohol-related
liver cirrhosis in April 2020. Postoperative follow-up visits were uneventful until
February 2021, when the patient complained of the onset of itching. Laboratory testing
showed elevation in liver function tests. Magnetic resonance cholangiography (MRC)
revealed a stricture from the choledocho-choledochostomy. ERCP was attempted to treat
the anastomotic biliary stricture (ABS) ([Fig. 1a]); however, deep biliary access with 0.035-inch hydrophilic guidewires (Terumo Radiofocus,
Japan) failed, due to the tightness of the stricture. Cholangioscopic-assisted (SpyGlass
DS, Boston Scientific, United States) guidewire placement was attempted: only a 0.020-inch
angled hydrophilic guidewire (Terumo Radiofocus, Japan) passed the ABS ([Fig. 1b]). However, mechanical (GT 5-4-3, Cook Endoscopy, United States) and pneumatic (Max
Force, Boston Scientific, United States) dilation catheters failed to cross the stricture
due to the softness of the 0.020-inch guidewire. Therefore, electroincision of the
stricture was successfully performed using a small pulse of pure cut current (ERBE
VIO3, Tubingen, Germany – High Cut, Effect 1) with an over-the wire 6Fr cystotome
([Fig. 1c]) (Cysto Gastro set, Endoflex, Germany), obtaining effective recanalization as shown
on cholangioscopy ([Fig. 1d], [Video 1]). After stricture incision, a larger 0.035-inch wire was placed through the cystotome,
6-mm balloon dilatation was performed, and two 8.5Fr plastic stents were placed through
the ABS for biliary drainage; the postoperative course was uneventful. Multiple plastic
stents were inserted up to six 10Fr diameter during the subsequent ERCPs. Stents were
removed 12 months later due to ABS resolution.
Fig. 1 a Tight anastomotic biliary stricture (arrow). b Passage of the stricture under cholangioscopic view. c Electroincision of the stricture with a 6Fr cystotome over 0.020-inch guidewire under
fluoroscopic control. d Cholangioscopy shows good stricture recanalization.
Video 1 Electroincision of a tight anastomotic biliary stricture following liver transplantation
using a 6Fr cystotome.
Case 2
A 29-year-old man with a medical history of OLT due to Wilson’s disease at age 10
years was discovered incidentally to have anicteric cholestasis during follow-up laboratory
tests. Clinical and hepatological follow-ups were regular until that time. MRC diagnosed
an ABS. Deep cannulation of the ABS using different types of 0.035-inch hydrophilic
guidewire (straight, angled – Terumo Radiofocus, Japan) under fluoroscopic control
was unsuccessful. Cholangioscopy (SpyGlass DSII, Boston Scientific, United States)
showed that ABS was very tight and angled. Under direct vision, a 0.020-inch angled
hydrophilic guidewire (Terumo Radiofocus, Japan) passed the stenosis. However, even
in this case mechanical (GT 5-4-3, Cook Endoscopy, United States) and a pneumatic
(Max Force, Boston Scientific, United States) dilatation catheter failed to cross
the stricture due to the softness of the guidewire. Electroincision of the stricture
was successfully performed using the 6Fr cystotome (Cysto Gastro set, Endoflex, Germany)
and pure cut current setting (ERBE VIO3, Tubingen, Germany – High Cut, Effect 1),
as described above. A 0.035-inch hydrophilic guidewire (Terumo Radiofocus, Japan)
was placed and 6-mm balloon dilatation was performed, allowing insertion of two 10Fr
plastic stents across the stricture. Patient was discharged from the hospital after
24 hours without any adverse events (AEs). After insertion of a maximum of five 10Fr
plastic stents, the ABS was resolved; the stents were removed 9 months later.
Case 3
A 9-year-old boy suffered abdominal trauma due to a traffic accident with bike handlebar
compression. Computed tomography scan and magnetic resonance pancreatography (MRP)
showed pancreatic trauma with rupture of the main pancreatic duct. Due to the patient’s
spontaneous clinical improvement, a “watch and wait” strategy was chosen and he was
discharged after 2 weeks. Three months later, he was admitted for acute pancreatitis;
MRP was repeated and showed main pancreatic duct dilatation above a tight and fibrotic
stricture in the head of the pancreas. After multidisciplinary discussion, the decision
was made to perform ERCP for pancreatic drainage. During the procedure, the pancreatic
stricture ([Fig. 2a]) was passed only with a small 0.020-inch angled hydrophilic guidewire (Terumo Radiofocus,
Japan). However, the 3Fr mechanical dilatator (GT 5-4-3, Cook Endoscopy, United States)
and the 7Fr Sohendra stent retriever (SSR-7, Cook Endoscopy, United States) ([Fig. 2b]) failed to pass the stricture. An over-the-wire needle-knife (HPC 3, Cook Endoscopy,
United States) ([Fig. 2c]) was used to -cut the stricture using pure cut current (ERBE VIO3, Tubingen, Germany
– High Cut, Effect 1), allowing passage of a 4-mm balloon dilator, before insertion
of a 7Fr pancreatic stent. The patient’s hospital stay was uneventful he was discharged
48 hours after ERCP. Six months later, the patient was asymptomatic; ERCP showed pancreatic
stricture improvement and the 7Fr stent was replaced with one with an 8.5Fr diameter.
Fig. 2 a Tight pancreatic duct stricture on pancreatography (arrow). b Failed dilatation with the Soehendra stent retriever. c Over-the-wire needle knife was used for electrosurgical incision of the stricture.
Endoscopic revision of the treatment of ABS and pancreatic strictures were approved
by the local Ethics Committee of the Catholic University of Rome (447/12, 1136/1).
Results
Electrosurgical incision of benign biliopancreatic strictures was successful in the
three cases reported, without related AEs ([Table 1]).
Table 1
Results of electrosurgical incision for benign biliopancreatic strictures.
|
Patient no.
|
Stricture site
|
Stricture etiology
|
Guidewire diameter
|
Electrosurgical device
|
Type of current
|
No. days after discharge
|
|
1
|
Biliary
|
Anastomotic (following liver transplantation)
|
0.020-inch
|
6F cystotome
|
Pure cut
|
1
|
|
2
|
Biliary
|
Anastomotic (following liver transplantation)
|
0.020-inch
|
6F cystotome
|
Pure cut
|
1
|
|
3
|
Pancreatic
|
Abdominal trauma
|
0.020-inch
|
Needle-knife
|
Pure cut
|
2
|
Discussion
Endoscopic treatment of benign biliopancreatic strictures can be challenging. Achieving
deep cannulation of the duct above the stenotic tract may be difficult, even after
papillary cannulation. The difficulty depends on the severity of the stricture (i. e.,
pinpoint strictures, hard fibrosis, complete obliteration of the lumen) or anatomical
issue (i. e., ductal angulation) [6]. Powerful advancement of the guidewire should always be avoided due to the risk
of false tract or perforation.
Cholangioscopy-assisted guidewire placement has been described in the literature.
Despite the cost, it can be an option in selected cases [7]
[8]
[9]
[10]. However, cholangioscopy-assisted guidewire placement is not a guarantee of treatment
success. In fact, in case of hard stenosis, the usual 0.035-inch wire may not pass
the stricture even under direct cholangioscopic vision. Smaller-diameter (0.018-,
0.020-, or 0.025-inch) guidewires are available and can be more effective for luminal
passage and stricture penetration. However, these wires are softer and may be unsupportive
for over-the-wire devices placement, such as dilatators (hydrostatic, mechanical).
An effective dilation technique was described using the Soehendra stent retriever
[11], but its use can be limited by small-diameter guidewires.
Hence, there is a need for a new strategy for treatment of severe BBS and BPS. Assuming
that benign and especially anastomotic strictures do not usually involve a long segment,
but they are more frequently short fibrotic rings, we borrowed the concept of endoscopic
incisional therapy (EIT) described in the literature for treatment of benign esophageal
[12] or colorectal anastomotic strictures [13].
Limited literature exists on this topic. Since its introduction by Raskin et al [14] for Schatzki’s ring in 1985, EIT has been used to treat a wide variety of diseases,
including benign and refractory esophageal anastomotic strictures [15]
[16]
[17], post-endoscopic submucosal dissection or endoscopic mucosal resection-related esophageal
stenosis [18]
[19], esophageal corrosive strictures [20], and colorectal anastomotic stricture [13]
[21].
Conclusions
In the present series, EIT was successfully applied to pass difficult biliopancreatic
strictures in selected cases without the occurrence of AEs. However, it is a blind
procedure because cutting of the strictures is performed only under fluoroscopic guidance
and it is based on the endoscopist’s expertise. Probing with a hand while advancing
the electrocautery device is important because prompt interruption of the EIT is mandatory
to avoid perforation of and/or injury to surrounding structures.
The introduction of dedicated devices that fit the cholangioscope working channel
to perform this procedure under direct vision would eliminate this issue in the future.
