Table Of ContentAdvanced ERCP for
Complicated and Refractory
Biliary and Pancreatic
Diseases
Dong Ki Lee
Editor
123
Advanced ERCP for Complicated
and Refractory Biliary
and Pancreatic Diseases
Dong Ki Lee
Editor
Advanced ERCP for
Complicated and
Refractory Biliary
and Pancreatic Diseases
Editor
Dong Ki Lee
Department of Internal Medicine
Gangnam Severance Hospital
Yonsei University College of Medicine
Seoul
South Korea
ISBN 978-981-13-0607-5 ISBN 978-981-13-0608-2 (eBook)
https://doi.org/10.1007/978-981-13-0608-2
© Springer Nature Singapore Pte Ltd. 2020
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It is with great admiration, respect, and love that I dedicate
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my wife, Kyung Won, who is truly the “wind beneath my wings.”
Contents
1 High-Level Biliary Strictures After Living-Donor Liver
Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Young Min Kim, Tae Ryong Chung, and Dong Ki Lee
2 Totally Obstructed Biliary Stricture I: Concept and
Methods of Magnetic Compression Anastomosis . . . . . . . . . . . . . 17
Yool Lae Kim, Sung Ill Jang, and Dong Ki Lee
3 Totally Obstructed Biliary Stricture II:
Clinical Applications and Results of Magnetic
Compression Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Sung Ill Jang, Mo Jin Won, and Dong Ki Lee
4 Percutaneous Intervention for Refractory
Benign Biliary Strictures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Hans-Ulrich Laasch, Shofiq Al-Islam, and Raman Uberoi
5 SEMS Insertion for Hilar Stricture: Who, When, and Why? . . . 69
Osman Ahmed and Jeffrey H. Lee
6 SEMS Insertion for Hilar Stricture: Which Stent,
How and Why? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Hiroyuki Isayama, Toshio Fujisawa, Shigeto Ishii, Hiroaki
Saito, Akinori Suzuki, Yusuke Takasaki, Sho Takahashi,
Hirofumi Kogure, and Yousuke Nakai
7 SEMS Insertion for Malignant Hilar Stricture:
ERCP Versus the Percutaneous Approach . . . . . . . . . . . . . . . . . . 87
Yonsoo Kim, Sung Ill Jang, and Dong Ki Lee
8 Palliative Therapy for Malignant Biliary Obstruction . . . . . . . . 109
Woo Hyun Paik, Dongwook Oh, and Do Hyun Park
9 Differentiation of Indeterminate Biliary Stricture . . . . . . . . . . . 127
Hong Jin Yoon, Sung Ill Jang, and Dong Ki Lee
10 Characteristics of Benign Pancreatic Duct Stricture . . . . . . . . . . 143
Resheed Alkhiari and Michel Kahaleh
vii
viii Contents
11 Management of Benign Pancreatic Strictures . . . . . . . . . . . . . . . 147
Resheed Alkhiari and Michel Kahaleh
12 Functional Biliary Stents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Jin-Seok Park, Seok Jeong, and Don Haeng Lee
1
High-Level Biliary Strictures After
Living-Donor Liver
Transplantation
Young Min Kim, Tae Ryong Chung,
and Dong Ki Lee
Introduction and management of high-level biliary stricture
after living-donor LT (LDLT).
Biliary complications after surgery, such as liver
transplantation (LT) and cholecystectomy,
include biliary stricture and leakage and forma- Definition
tion of a biliary cast, sludge, and/or stone. The
incidence of biliary complications after LT is Biliary strictures after LT are classified as anasto-
10–35% [1, 2]. Despite advances in surgical tech- motic (AS) or non-anastomotic (NAS) strictures
niques and the development of immunosuppres- according to location. AS occurs at the site of
sants, biliary complications after LT remain a anastomosis between the choledochal duct of the
major cause of morbidity and, in severe cases, donor and the choledochal duct of the jejunal
mortality. Roux limb of the recipient. NAS also occurs in
Biliary stricture is the most common compli- other parts of the biliary system [9, 10] and
cation after LT, accounting for ~40% of all biliary patients with both types of strictures have been
complications [3–8]. The symptoms of biliary reported. In this chapter, we will discuss high-
stricture range from none to pruritus and abdomi- level biliary strictures, which occur at or around
nal pain. If biliary stricture is overlooked, severe the bifurcation of the left and right hepatic ducts
complications such as ascending cholangitis, [11]. Endoscopic retrograde cholangiopancrea-
liver abscess, and secondary biliary cirrhosis can tography (ERCP) images of high- and low-level
result. Therefore, high-risk patients should be biliary strictures are shown in Fig. 1.1.
monitored closely. Moreover, in patients with
high-level biliary stricture, the intrahepatic duct
is narrow, and the distal part of the stent has a Incidence
high rate of migration over the stricture.
In this chapter, we focus on the definition, Benign biliary stricture (BBS) is a common com-
incidence, etiology, pathophysiology, risk factors, plication after LT. The incidence of biliary stric-
ture after LDLT is 25–32% [3, 12–15] compared
with <15% after deceased-donor LT (DDLT) [14,
16, 17]. In LDLT, anastomosis between the right
Y. M. Kim · T. R. Chung · D. K. Lee (*) hepatic duct of the donor and the bile duct of the
Department of Internal Medicine, Gangnam recipient is highly complex. The right hepatic
Severance Hospital, Yonsei University College of
duct has many anatomic variations, including
Medicine, Seoul, South Korea
e-mail: [email protected] multiple bile ducts, poor blood supply, and a
© Springer Nature Singapore Pte Ltd. 2020 1
D. K. Lee (ed.), Advanced ERCP for Complicated and Refractory Biliary and Pancreatic Diseases,
https://doi.org/10.1007/978-981-13-0608-2_1
2 Y. M. Kim et al.
a b
Fig. 1.1 Two types of benign biliary stricture (BBS) hand, (b) shows high-level BBS and is observed mainly in
according to the location of stricture. (a) Shows low-level patients who have undergone living donor liver
BBS and is mainly observed in patients who have under- transplantation
gone a deceased donor liver transplantation. On the other
short stump [6, 14, 15, 18]. Also, hypertrophy of disease. A 68-year-old female underwent laparo-
the received liver aggravates ASs. Biliary stric- scopic cholecystectomy 25 years prior and had
ture is more common after LDLT (33.3%) than BBS due to recurrent common hepatic duct
after DDLT (9.6%) [7, 19–22]. LDLT is the treat- (CHD) and common bile duct stones. An ERCP
ment of choice for end-stage liver disease, par- cholangiogram showed a stricture of, and a stone
ticularly in East Asia, including South Korea, in, the left intrahepatic duct (Fig. 1.2). A 44-year-
because it is more difficult to obtain organs from old female underwent left hemihepatectomy for
deceased donors than is the case in Western intrahepatic cholangiocarcinoma. An ERCP
nations. In Asia, the incidence of biliary stricture cholangiogram showed a stricture of the CHD,
has decreased from 30% to 15–25% due to accu- and abdominal computed tomography (CT)
mulation of experience with LDLT [6, 23–27]. showed bile leakage due to postoperative injury
In a prospective study of 531 patients who (Fig. 1.3).
underwent LT from 1979 to 2003, AS occurred in We will focus on the etiology of biliary stric-
47 (42 duct-to-duct anastomosis and 5 hepatico- tures after LDLT (Table 1.1). AS can be caused by
jejunal Roux-en-Y anastomosis) patients, and the the surgical technique and local ischemia, whereas
cumulative risks of AS at 1, 5, and 10 years were NAS can be caused by, for example, hepatic artery
6.6%, 10.6%, and 12.3%, respectively [1]. thrombosis or immunological factors, prolonged
cold ischemia, and vascular insufficiency [10,
28–30]. Biliary strictures early after LT are caused
Etiology by technical factors. In contrast, those occurring
late after LT are typically caused by hepatic artery
The causes of biliary strictures include LT, post- thrombosis, preservation-i nduced injury, pro-
operative injury after cholecystectomy, pancre- longed cold and warm ischemia, altered bile com-
atitis, primary sclerosing cholangitis, and stone position, and immunological injury.
1 High-Level Biliary Strictures After Living-Donor Liver Transplantation 3
a b
Fig. 1.2 Benign biliary stricture due to intrahepatic bile duct stone. An ERCP cholangiogram shows a stone (a) and
stricture (b) in the left hepatic duct
a b
Fig. 1.3 Benign biliary stricture due to postoperative injury after hemihepatectomy. An ERCP cholangiogram shows
stricture of the common hepatic duct (a), and abdominal CT shows bile leakage (b)
Pathophysiology Also, chemokine ligand (CCL) 2, CCL5, and
fractalkine (CX3CL1) induce transendothelial
Biliary tract injury such as surgery induces an migration of leukocytes, resulting in induction
inflammatory response, resulting in fibrosis and of an inflammatory cascade [32]. Genetic poly-
narrowing of the lumen of the bile duct. morphisms in the chemokine receptors (CCRs)
Cytokines and chemokines are key media- that mediate leukocyte trafficking alter their
tors of hepatobiliary inflammation [31]. Pro- expression and function, affecting hepatobili-
inflammatory cytokines such as interleukin-6, ary inflammation after LT [33, 34]. The associ-
tumor necrosis factor-alpha, and interferon- ation between a loss- of- function mutation in
gamma induce a cell-mediated immune CC chemokine receptor 5 delta 32 and occur-
response and promote hepatobiliary injury. rence of ischemic-type biliary lesions has been
