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Copyright 2012 ACG
ACG 2012 Postgraduate Course
Benign and Malignant Biliary
Strictures: How to Evaluate and
Manage
g
Michel Kahaleh, M.D.
Chief Endoscopy
Professor of Clinical Medicine
Division of Gastroenterology and Hepatology
ERCP

Diagnostics
– Forced to function as radiologists
– Reading shadows

Therapeutics
– Trial and error for wire placement
– “Shooting
Shooting in the dark”
dark
“Clinical correlation required”
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ERCP

Clinical correlation
– Brush cytology
– Fluoroscopically-guided forceps biopsies
– Intraductal FNA
ERCP with Brush Cytology
Patients
N
Sensitivity
(%)
Ponchon, 1995
233
35%
97%
Lee, 1995
149
37%
100%
Ornellas, 2006
50
40%
100%
Jailwala, 1999
133
30%
100%
Author/Yr
Total
565
36%
Specificity
(%)
99%
Fukuda - Gastrointestinal Endoscopy
Volume 62, No. 3, 2005
October 2012
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ERCP with Biopsy
Author/year
Patients
N
Ponchon, 1995
Schoefl, 1997
Jailwala, 2000
128
103
133
Total
Sensitivity
((%))
364
Specificity
(%)
( )
43%
65%
37%
48%
97%
100%
100%
99%
Ponchon - Gastrointestinal Endoscopy
December; 42(6):565-72
Cholangiopancreatoscopy
–
–
–
–
Choledocholithiasis
Biliary strictures
Biliary stones
Mucosal irregularity attributed to primary
duct tumors
– Villous tumors of the biliary epithelium
Duodenoscope-Assisted Cholangiopancreatoscopy
Gastrointest Endosc 1999;50:943-945
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Mother baby scope
Two operators needed
 Two-way steering only
 Only one channel
 Scope fragility, high
repair costs
 Limited
tools/accessories

Single Operator System
 Single-operator system
 Four-way
F
steering
i capability
bili
 Independent irrigation channels
 Diagnostic and therapeutic
capabilities
 Single-use components for reliable,
p
consistent performance
 Improved therapeutic options
 Daily accessibility to technology
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Single Operator System - Registry
Gastrointest Endosc 2011;74:805-14.
Single Operator System - Registry
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Sites of interest were
CBD 55%
 CHD and hilum 53%
 Main hepatic ducts 23%
 Intrahepatic 7%
 Ampulla 4%

Gastrointest Endosc 2011;74:805-14.
Indeterminate Biliary Strictures:
Gastrointest Endosc 2011;74:805-14.
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Criteria For SOC
Stricture (location/grade)
 Ulceration
 Inflammation
 Growth
 Vascular pattern
 Quality
Final diagnosis ?

Peroral Cholangioscopy
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FISH vs KRAS
Kipp BR et al: J Mol Diagn 2010, 12:780–786
FISH vs KRAS
Kipp BR et al: J Mol Diagn 2010, 12:780–786
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Indeterminate biliary strictures
Normal reticular pattern
Irregular large white vessels
Meining: CGH 2008
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Suspicious Lesion
Benign biliary strictures
Benign biliary strictures:
 Chronic pancreatitis
 Biliary calculi
 Trauma
 Surgery
 Cholangiopathies
October 2012
Stahl TJ : Ann Surg 1988
Smits ME: Br J Surg 1996
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Background
Plastic stents are frequently used, but
associated with
 Occlusion (8-36%)
 Migration (1-23%)
 Multiple
M l i l sessions/stents
i /
requirement
i

Deviere J : Ann Surg 1990
Farnbacher MJ: Am J Gastro 2000
Eickhoff A: Eur J Gastroenterol Hep 2001
Multiple Plastic Stents
Success rate: 89% (40/45)
with no recurrence at mean f/u 48.8 mos
Costamagna G: GIE 2001
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Background
- Uncovered self-expanding
self expanding metal stents
(SEMS) failed long-term therapy due to
intraluminal mucosal hyperplasia and the
inability to remove them
- Typically
yp
y offered to patient
p
in whom surgery
g y
is not an option
Deviere J: Gut 1994
Hausegger KA: Radiology 1994
Van Berkel AM: Endoscopy 2004
UVA Experience: GIE 2008, 67: 446-54
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Biliary sphincterotomy in all
p
patients
CSEMS
10 mm x 40, 60 or 80 below
cystic
Multivariate analysis of
factors predictive of success
was performed
f
d (eg,
( patient
i
age, time in place, CSEMS
length and etiology)
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Results: GIE 2008



CSEMS in pplace median 4 months (1-28)
(
)
Removal in 65 patients
Follow-up post removal: median of 12 months (3-26)
 Stricture in the uncovered portion (3)
 Failure (3)
uode a edema
ede a preventing
p eve t g removal
e ova (2)
( )
 Duodenal
Success rate of 59/67 (88%)
No predictor of success by logistic regression
Failure ?
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Choledochoscopy

Several groups thus far studied the temporary placement with
planned retrieval FCSEMSs
Study
Number of
patients
Etiology
Stent type
Success
Cahen et al1
6
CP
Hanaro
3–6 mo (predefined
interval)/66%
Mahajan et al2
44
CP, BDS, OLT, AIP,
PSC
Viabil
Tringali et al3
17
CP
Niti-S
Unflared (7)
Flared (10)
3.3 mo (3–
4.8mo)/83%
Predefined removal at
6mo/43% (Unflared)
87% (Flared)
Park, et al4
43
CP, BDS, OLT,
postsurgical
2.
FCMS with 4
anchoring fins;
FCMS with
both ends flared
6 mo- 91% with
AF; 88% with flared
ends
1.
Cahen DL et al. Endoscopy 2008
Mahajan A et al. Gastrointest Endosc 2009;70(2):303–9
Tringali A et al. Gastrointest Endosc 2010
4.
Park D et al. Gastrointest Endosc 2011
3.
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Recurrent Stricture
Metal Biliary Stents and Malignant
Strictures
Levy MJ : CHG 2004;2:273
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Metal Biliary Stents
Wilson Cook: Zilver®
Olympus: X-Suit NIR®
Metal Biliary Stents
Stainless
steel or Nitinol
Self expandable
p
from 8 Fr to 30 Fr
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Fully Covered SEMS
Conmed: Viabil®
Fully Covered SEMS
The WallFlex Biliaryy RX Stent,, introduced in 2008 & 2009
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Covered versus Uncovered

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Better patency of covered SEMS ?
Migration of covered SEMS ?
Cholecystitis with covered SEMS ?
Bridge to surgery ?
-Short uncovered SEMS
-Covered SEMS
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Covered versus Uncovered
Better patency Covered
 Identical risk of Cholecystitis
 Mild increased risk of Migration with
Covered

Partially Covered SEMS Regardless
of Resectability ?
Kahaleh et al: Endoscopy 2007
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Cost effective analysis: SEMS vs
DoubleLayer vs Plastic ?
Kahaleh et al: Endoscopy 2007
Cost effective analysis: CSEMS vs
DoubleLayer vs Plastic ?
SEMS placement 4384 $
 DoubleLayer stent 4449 $
 Polyethylene stent 4926 $
------------------------------------------------- Readmission not taken into account

Kahaleh et al: Endoscopy 2007
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ACG 2012 Postgraduate Course
 Metal Stents for Benign strictures will be a future option
Metal stents are efficacious and safe in Malignant biliary
strictures.
 They provide longer periods of patency and better QOL
 SEMS dysfunction due to stent ingrowth seems to be lower with
cSEMS.
Thank you for your attention
Questions: [email protected]
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