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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1209_Библиотеки_им_академика_М_И_Перельмана.pdf
297© Springer International Publishing Switzerland 2016
J.M. Millis, J.B. Matthews (eds.), Diffi cult Decisions in Hepatobiliary
and Pancreatic Surgery, Diffi cult Decisions in Surgery: An Evidence-Based
Approach, DOI 10.1007/978-3-319-27365-5_26
Chapter 26
Surgery or Endoscopy for Bile Duct Strictures
Secondary to Chronic Pancreatitis?
Katherine A. Morgan , Gregory A. Cote , and David B. Adams
Abstract A terminal benign biliary stricture (BBS) is a common complication of
chronic pancreatitis (CP). Historically, BBS was a surgical disease, treated with
operative biliary bypass. With the advent of endoscopic retrograde cholangiopancreatography and endoscopic stenting, therapeutic endoscopy has become the primary approach to BBS. Endoscopic management has limitations, however, including
unsatisfactory long term durability. Improvements in stent technology and technique are promising. Surgery can often concomitantly best address other CP related
complications including pain. Surgery has higher short term morbidity but may be
more durable long-term. Minimally invasive techniques in biliary bypass are
feasible.
Keywords Chronic pancreatitis • Biliary stricture • Bile duct stricture • Jaundice •
ERCP • Endoscopic stent • Choledochoduodenostomy • Choledochojejunostomy
K. A. Morgan
Department of Surgery , Medical University of South Carolina ,
114 Doughty Street, Ste 249, MSC 295 , Charleston , SC 29425 , USA
e-mail:
morganka@musc.edu
G. A. Cote
Division of Gastroenterology and Hepatology , Medical University of South Carolina ,
25 Courtenay Drive , Charleston , SC 29425 , USA
e-mail:
cotea@musc.edu
D. B. Adams (
*)
Department of Surgery , Medical University of South Carolina ,
114 Doughty Street, Ste 249, MSC 295 , Charleston , SC 29425 , USA
e-mail:
adamsdav@musc.edu
298
Introduction
Chronic pancreatitis (CP) is a debilitating and morbid disease marked by the progressive replacement of healthy pancreatic parenchyma with fi brotic tissue. In
severe disease, 10–30 % of patients will develop a symptomatic benign biliary stricture (BBS). At greatest risk are those patients with an infl ammatory pseudotumor in
the head of the pancreas due to extrinsic compression of the intrapancreatic portion
of the bile duct . Timely and effective treatment of a BBS in CP is essential to avoid
the signifi cant consequences of chronic cholestasis, recurrent cholangitis , and secondary biliary cirrhosis . Patients with a persistent symptomatic stricture despite
resolution of acute infl ammation do well with intervention. A stricture is considered
symptomatic when it causes jaundice , pain , or cholangitis.
Historically, BBS in CP was a surgical disease. Surgical options include primarily choledochoduodenostomy (side-to-side or end-to side) and choledochojejunostomy (Roux-en-Y), but also reinsertion of the common bile duct into the resection
bed after local resection of the pancreatic head. With the advent of endoscopic retrograde cholangiopancreatography ( ERCP ) and endobiliary stents, endoscopic
drainage has been increasingly utilized as a fi rst-line intervention for patients with
a symptomatic BBS secondary to CP, as it is less morbid than the surgical approach.
Endoscopic drainage is traditionally accomplished by performance of a biliary
sphincterotomy , dilation of the stricture using graduated catheters or hydrostatic
balloons, and placement of multiple plastic stents in parallel. The short-term effi cacy of endoscopic drainage is high, but its durability is suboptimal and requires an
average of 3–4 ERCPs to achieve maximal dilation. The advent of fully covered,
self-expanding metallic stents (SEMS)—not currently FDA approved for BBS—
may improve the short- and long-term effi cacy of endoscopic therapy by providing
sustained radial expansion of the stricture during stent indwell. Additionally, SEMS
may reduce the resource intensity of endoscopic therapy by lowering the number of
ERCPs required to treat a BBS. There have been no randomized, comparative effectiveness trials of endoscopy versus surgery for CP-induced BBS, so the decision to
proceed with either alternative is often based on local expertise and additional clinical factors (e.g., medical comorbidities, concomitant pancreatic pathology). The
available evidence is worth consideration.
Search Strategy
A systematic review of the literature for pertinent studies was undertaken utilizing
Ovid/Medline databases from 1990 to present. Search terms included: chronic pancreatitis (as a Medical Subject Heading, MeSH) AND biliary stricture OR bile duct
stricture OR jaundice OR ERCP OR biliary bypass OR choledochoduodenostomy
OR choledochojejunostomy OR hepaticojejunostomy . Search was restricted to
K.A. Morgan et al.
299
articles written in English. We only included clinical trial s and cohort studies; case
reports or series were excluded. In addition, the references from relevant studies
were reviewed to identify any potential studies missed using this method.
Patients Surgical intervention
Endoscopic
intervention Outcomes
Patients with
chronic
pancreatitis
and associated
biliary stricture
Choledochoduodenostomy,
choledochojejunostomy, or
Frey procedure
Endoscopic
stenting
Therapeutic success ( stricture
resolution), stricture recurrence,
morbidity, number of procedures,
length of hospitalization
Results
Studies Comparing Endoscopic and Surgical Intervention
There are no randomized trials comparing the effi cacy of endoscopic and surgical
therapies for BBS in CP. Multiple single institution cohort studies of endoscopic
and surgical approaches and few prospective trials of endoscopic therapy are available for review.
Regimbeau and colleagues compared the outcomes of endoscopy and surgery in
39 patients undergoing management for CP-related BBS. Thirty-three patients
underwent endoscopic therapy (ET) initially and six surgery (ST). Patients undergoing ET required a mean of three ERCPs, including SEMS (35 %) and multiple
plastic stents (65 %) for a mean duration of 11 months. ST included choledochoduodenostomy (CDD, 4), choledochojejunostomy (CDJ, 1), and insertion of the
CBD into the pancreatic head [ 1 ], combined with Frey [ 5 ] and pancreaticojejunos-
tomy [ 1 ]. The complication rate was high in the surgical group (83 % vs. 21 %,
p = 0.01), although much of the morbidity was related to the associated pancreatic
procedure. Length of stay was similar. Initial success was similar between groups,
obtained in 74 % of ST and 75 % of ET, but long-term success (24 months) was
signifi cantly greater in the ST group as compared to the ET group (65 % vs 12 %,
p = 0.01). Seventeen of 33 patients (52 %) initially treated with ET ultimately underwent surgery for recurrent BBS [ 1 ].
Outcomes of Surgical Intervention
Multiple retrospective single institution reports of surgical outcomes in management of CP BBS have been undertaken. Notably, R.L. Sanders reported his experience with 25 patients undergoing CDD to the Southern Surgical Association in
1946. There were two (8 %) perioperative deaths and the remaining patients did
26 Surgery or Endoscopy for Bile Duct Strictures Secondary to Chronic Pancreatitis?
300
well long-term [ 2 ]. Many other similar and important series are reported. We limit
our review to the more modern era since 1990, as endoscopic stent therapy was
widely available at that point. In 2011, our group reported experience with 79
patients undergoing CDD for CP related BBS, with a morbidity rate of 19 % and
long-term success in 77/79 patients, with one requiring endoscopic management of
anastomotic stricture (Fig. 26.1 ). “Sump syndrome,” which refers to a clinical diathesis of fever, elevated hepatic chemistries, cholangitis , or hepatic abscess due to
biliary stasis in the terminal bile duct and refl ux of duodenal contents, is a reported
complication after CDD. With adequate anastomotic size, however, sump syndrome
is a rare event, occurring in 2.5 % of patients in the authors’ series [ 3 ]. Several other
retrospective series of CDD for CP related BBS have been reported over the past
two decades with morbidity rates of 9.8–28 %, mortality rates of 0–6 %, and longterm success rate s of 90–100 % [ 4 – 6 ].
While CDD has been the classic operative approach to biliary bypass in CP in
order to avoid circumferential dissection of the bile duct in an infl ammatory fi eld,
CDJ is a reasonable alternative approach. CDJ can be undertaken particularly when
a fi brotic duodenum is not suitable for anastomosis and is some surgeons’ preference to avoid the sump syndrome. Blankensteijn and Terpstra presented 113 patients
who underwent operative biliary bypass (64 CDD and 49 CDJ). Perioperative morbidity and mortality following CDD were 10.9 % and 4.7 % and following CDJ
were 28.6 % and 12.2 % respectively. Recurrent cholangitis was not seen after CDD
but occurred in three patients after CDJ (6.1 %) [ 7 ]. Nealon and Urrutia described
their series of 64 patients undergoing CDJ for CP associated BBS. Length of stay
was 12 days and long-term outcomes were excellent with no episodes of clinically
apparent jaundice or cholangitis [ 8 ].
Fig. 26.1 A side to side
choledochoduodenostomy
is performed with generous
mobilization of the
duodenum to allow for a
tension free anastomosis at
least 2 cm in length
K.A. Morgan et al.
301
Minimally invasive surgical approaches to CP related BBS have more recently
been reported. In 2012, Khajanchee and colleagues reported on 20 cases of laparoscopic CDD, with 25 % conversion to open surgery , morbidity of 30 %, and longterm success in 95 % [ 9 ]. Jeyapalan and colleagues described their experience with
laparoscopic CDD in six patients in 2002. Length of stay was 6 days, and one patient
died. No patient required re-intervention at short-term follow-up [ 10 ].
In patients with other complications of CP in addition to BBS such as debilitating pain , surgery is often the primary approach in the physiologically fi t patient. In
patients with dilated duct pancreatitis (main duct diameter >6 mm), drainage with a
lateral pancreaticojejunostomy, combined with a CDD, may be undertaken.
Alternatively, in these patients with typically head-dominant infl ammatory disease,
and duodenal stenosis a pancreatoduodenectomy (PD) is indicated [ 11 ]. In patients
with biliary stricture and CP related pain, a PD or a duodenal preserving pancreatic
head resection can be benefi cial. Frey suggested in 1990 that his local pancreatic
head resection combined with lateral pancreaticojejunostomy (LR-LPJ) could often
relieve biliary obstruction by releasing the constrictive fi brotic tissue in the pancreatic head [ 12 ]. In 1994, Izbicki and colleagues described a similar effect with their
duodenal preserving pancreatic head resection (DPPHR) in 37 patients, with excellent long-term results [ 13 ]. In 1997 the same group reported on a subset of patients
with persistent biliary obstruction despite DPPHR. They described successful management of seven such patients with reinsertion of the common bile duct into the
pancreatic head resection cavity [ 14 ]. In 2008, the group described their experience
with now 82 such patients, with 30 % morbidity (similar to DPPHR without biliary
reinsertion), but signifi cant biliary anastomotic stricture rate of 18 % [ 15 ]. Recently,
in 2013, Rebibo and colleagues presented their experience with LR-LPJ and biliary
bypass , performing concomitant CDD in eight patients, CDJ in four patients and
reinsertion of the CBD into the pancreatic head resection cavity in three patients.
The perioperative morbidity was high (73 %) but primarily related to pancreatic
head resection. Two of the three patients with biliary reinsertion did develop strictures in long-term follow-up [ 16 ].
Outcomes of Endoscopic Intervention
The basic principal of endoscopic treatment of chronic pancreatitis -induced biliary
stricture is to maximally dilate the stricture using graduated catheters or hydrostatic
balloons, followed by placement of multiple plastic (typically polyethylene) stents
in parallel (Figs. 26.2 and 26.3 ). Since stent occlusion rates begin to rise after 3–4
months, patients typically return for repeat ERCP and upsizing of stents to the
extent possible. Most experts advocate maintaining patency of the stricture for up to
12 months after embarking upon endoscopic treatment, so patients can assume an
average of 3–4 ERCPs and up to 1 year of therapy in order to achieve stricture resolution. This “aggressive stenting” approach evolved from high recurrence rates
26 Surgery or Endoscopy for Bile Duct Strictures Secondary to Chronic Pancreatitis?
302
Fig. 26.2 Endoscopic
image of multiple parallel
endoscopically placed
plastic transampullary
biliary stent s
Fig. 26.3 Fluoroscopic
image of multiple parallel
endoscopically placed
plastic transampullary
biliary stent s
K.A. Morgan et al.
303
(nearly 20 %), predominantly in the setting of postoperative strictures, when treatment was limited to dilation alone or with placement of only two plastic stents in
parallel [ 17 , 18 ].
The short-term effi cacy of endoscopic biliary drainage is well established, but
most experts would agree that the long-term durability (typically defi ned, albeit
arbitrarily, of >1 year follow-up after all stents have been removed) of endoscopic
treatment in the setting of chronic pancreatitis is approximately 65 %. This is signifi cantly lower than postoperative biliary stricture s, where long-term resolution
rates of >80 % are considered the norm [ 19 ].
Given the need for multiple procedures and the poor long-term effi cacy of plastic
stents, there is substantial interest in using removable, fully-covered, self- expandable
metallic stents (SEMS) to treat benign biliary stricture s. SEMS have superior
patency to plastic stents, and so may require fewer ERCPs to resolve a stricture .
Furthermore, SEMS radially expand within the duct, potentially achieving a more
sustained dilation of the stricture and lower recurrence rates; there are no data confi rming this hypothesis to date. Potential negatives of SEMS include diffi culty with
removal and SEMS-specifi c complications such as acute pancreatitis (via compression of the pancreatic orifi ce), cholecystitis (via occlusion of the cystic duct insertion), and secondary bile duct injury usually when the stent is oversized (larger than
the diameter of the bile duct itself). There are no comparative effectiveness studies
of SEMS and plastic stents for treating benign biliary strictures, but a growing body
of literature favors their safety and effi cacy of SEMS in appropriately selected
patients.
Comparative study of surgery and endoscopy for chronic pancreatitis related biliary stricture s
First
author year Design N Outcome Surgery Endoscopy P
Quality of
evidence
Regimbeau
[
1 ]
Retrospective
review
39
Initial success 74 % 75 % NS
Low
Success at 24
months
65 % 12 % 0.01
Morbidity 83 % 21 % 0.01
Length of stay,
days
16 24 NS
Results of surgery for chronic pancreatitis related biliary stricture s
First author year Design N Type of surgery Morbidity
Longterm
success
Quality
of
evidence
Blankenstein
1990 [
7 ]
Retrospective 113 CDD (64), CDJ
(49)
CDD 10.9
%, CDJ
28.6 %
CDD 100
%, CDJ
94 %
Low
Escuadera Fabre
1991 [
6 ]
Retrospective 71 CDD 28 % 96 % Low
Mendes de
Almeida 1996 [
5 ]
Retrospective 125 CDD NR 90 % Low
(continued)
26 Surgery or Endoscopy for Bile Duct Strictures Secondary to Chronic Pancreatitis?
304
First author year Design N Type of surgery Morbidity
Longterm
success
Quality
of
evidence
Leppard 2011 [
3 ] Retrospective 79 CDD 19 % 99 % Low
Cataldegirmen
2008 [
15 ]
Retrospective 82 Frey + CBD
resertion
15 % 82 % Low
Rebibo 2013 [
16 ] Retrospective 15 Frey + CDD
[
8 ], Frey + CDJ
[
4 ], Frey +
CBD
reinsertion [
3 ]
73 % 80 % Low
Jeyapalan 2002
[
10 ]
Retrospective 6 Lap CDD Low
Bosanquet 2012 Retrospective 37 CDD 14 % Low
Khajanchee 2012
[
9 ]
Retrospective 20 Laparoscopic
CDD
30 % 95 % Low
Nealon 1996 [
8 ] Retrospective 64 CDJ NR 100 % Low
Results of endoscopy for chronic pancreatitis associated biliary stricture s (Adapted and modifi ed
from Dumonceau et al. (2012) [
40 ])
First author, year n
Longterm
success,
%
Stenting
duration,
months
Stent
dysfunction
of any cause
per patient, %
Follow-up
post stent
removal,
months
Patients who
underwent
surgical
drainage, %
Quality of
evidence
Single plastic stent
Deviere 1990 [
20 ] 25 12 n.a. 72 14 24 Low
Barthet 1994 [
21 ] 19 10 10 NA 18 21 Low
Smits 1996 [ 22 ] 58 28 10 64 49 28 Low
Vitale 2000 [
23 ] 25 80 13 20 32 8 Low
Farnbacher 2000
[ 24 ]
31 32 10 52 28 6 Low
Eickoff 2001 [
25 ] 39 31 9 43 58 28 Low
Kahl 2003 [
26 ] 61 26 12 34 40 49 Low
Catalano 2004
[ 27 ]
34 24 21 41 50 41 Low
Cahen 2005 [ 28 ] 58 38 9 48 45 28 Low
Multiple plastic stents
Draganov 2002
[
29 ]
9 44 14 n.a. 48 n.a. Low
Pozsar 2004 [ 30 ] 29 60 21 n.a. 12 13 Low
Catalano 2004
[ 27 ]
12 92 14 8 47 8 Very low
Weber 2014 [
31 ] 61 (89 %
plastic)
31 12 n.a. n.a. 28 Very low
(continued)
K.A. Morgan et al.
305
First author, year n
Longterm
success,
%
Stenting
duration,
months
Stent
dysfunction
of any cause
per patient, %
Follow-up
post stent
removal,
months
Patients who
underwent
surgical
drainage, %
Quality of
evidence
Covered, self-expandable metallic stents
Cahen 2008 [
32 ] 6 50 5 33 28 17 Low
Behm 2009 [
33 ] 20 80 5 5 22 0 Low
Mahajan 2009
[
34 ]
19 n.a. 3 11 4 n.a. Low
Poley 2012 [ 35 ] 13 46 4–8 n.a. 12 n.a. Very low
Perri 2012 [ 36 ] 17 71 6 n.a. 24 n.a. Low
Kahaleh 2013 [ 37 ] 31 80 3 22 n.a. n.a. Low
Deviere 2014 [ 38 ] 127 80 % 8 10 24 <1 Moderate
Recommendations Based on the Data
Recommendations based upon interpretation of the evidence at hand are summarized in Fig. 26.4 .
Therapeutic endoscopy is a reasonable primary approach to the CP related BBS.
(Strength of recommendation: Strong; Quality of evidence: Moderate)
Endoscopy can potentially avoid the high reported surgical morbidity . This recommendation is supported by high initial endoscopic success rate s (67–100 %).
While the durability of endoscopic therapy is inferior to surgery , with long-term
success rates of approximately 25 % and some 25–50 % of patients requiring salvage surgery by current strategies, a substantial number of patients will avoid surgery altogether. When analyzed based on intention-to-treat, as per Regimbeau and
colleagues, long-term outcomes of surgery are not compromised.
Endoscopic strategy should include balloon cholangioplasty with placement of mul-
tiple plastic stents in order to maintain a larger ductal diameter and to avoid
premature stent occlusion during therapy . (Strength of recommendation: Strong;
Quality of evidence: Moderate)
Fully covered SEMS appear promising based on initial data; comparative effectiveness studies of SEMS versus multiple plastic stents are needed to determine the
potential advantages of this technique.
In patients with complications from CP other than biliary tract obstruction requir-
ing surgery (pancreatic duct obstruction with pain , pancreatolithiasis, duodenal
obstruction) surgery is a reasonable primary approach. (Strength of recommen-
dation: Strong; Quality of evidence: Low)
26 Surgery or Endoscopy for Bile Duct Strictures Secondary to Chronic Pancreatitis?
306
Surgery is an effective treatment for CP related BBS. Biliary bypass can be
included with pancreatic duct drainage (lateral pancreaticojejunostomy, Frey) with
choledochoduodenostomy , Roux-en-Y choledochojejunostomy , or reinsertion of
the common bile duct into the pancreatic head resection cavity as described by
Izbicki. Generally, choledochoduodenostomy (side-to-side or end-to side) is the
most common method of operative biliary bypass for BBS in CP and is safe and
durable long term, with minimal morbidity . “Sump syndrome” is an unusual long
term complication of CDD and can be avoided by an adequate anastomotic diameter. Roux-en-Y choledochojejunostomy and reinsertion of the CBD into the pancreatic head resection bed are reasonable approaches as well with good outcomes .
Laparoscopic biliary bypass is feasible and effective.
Personal View of the Data
Chronic pancreatitis is a heterogenous disease with different clinical and morphological presentations that depend on environmental, genetic, and anatomic factors.
There is great geographic variation in the presentation of the disease as exemplifi ed
by the calcifi c chronic pancreatitis of Southern India and the infl ammatory head
mass reported in studies from Germany [
39 ]. Thus it is hard to classify and directly
compare different management strategies for biliary obstruction associated with
chronic pancreatitis. Also unanswered is the risk of cholangitis and biliary cirrhosis
associated with terminal biliary stenosis. Certainly the patient with cholangitis and
Fig. 26.4 Summary of evidence based recommendations for management of chronic pancreatitis
related biliary stricture s
K.A. Morgan et al.