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318
rate was 74 % using indocyanine green, 70 % using IOC with conventional contrast
fl uid, and 26 % with conventional visual inspection [ 24 ].
Recommendations
The literature regarding the routine use of intraoperative cholangiogram is confl icting. Most of the studies are non-experimental comparative data and not Level 1
data. This is due to the fact that bile duct injury occurs rarely and a large multicenter
randomized controlled trial is not feasible. Routine IOC is associated with similar
rates of bile injury, increased rate of detecting retained stones (though it is unclear
if this is clinically signifi cant), longer operative time, increased cost , and low rate of
false positives. There is unclear evidence regarding secondary procedures and overall cost-effectiveness. Therefore, the use of routine intraoperative cholangiogram
during laparoscopic cholecystectomy should be left to the discretion of the operating surgeon. This is a weak recommendation in light of low-quality data.
There is currently inadequate evidence to suggest replacement of routine IOC
with near-infrared fl uorescence cholangiography . Additional large volume studies
are needed to show protective effect.
A Personal View of the Data
There likely will never be a consensus on the routine versus selective use of intraoperative cholangiogram in elective laparoscopic cholecystectomy . Most recent
studies show there is no signifi cant difference in bile duct injury . The more compelling argument is the additional cost of IOC, with a wide variety described in the
literature ranging from $77 to $930. The two nationwide analyses reviewed found
higher costs ($739–$930) than the values stated in earlier regional studies. In order
to ever recommend routine IOC, the cost must be minimal. This is not currently the
case.
We eagerly await the results of larger studies of newer techniques such as fl uorescence cholangiogram which may facilitate identifi cation of biliary structures
with reduced cost and operative time.
Recommendations
1. The safety of laparoscopic cholecystectomy requires correct identifi cation of rel-
evant anatomy (evidence quality low; strong recommendation).
2. The routine use of intraoperative cholangiogram should be used at the discretion
of the surgeon (evidence quality low; weak recommendation).
S. Svoboda and B.L. Bello
319
3. Fluorescence cholangiography is a feasible alternative to contrast-dye cholangi-
ography yet larger studies need to be reviewed (evidence quality low; weak
recommendation).
References
1. Flum DR, Cheadle A, Prela C, Dellinger EP, Chan L. Bile duct injury during cholecystectomy
and survival in Medicare benefi ciaries. JAMA. 2003;289(13):1639–44.
2. Nuzzo G, Giuliante F, Giovannini I, Ardito F, D’Acapito F, Vellone M, Murazio M, Capelli
G. Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey
on 56 591 cholecystectomies. Arch Surg. 2005;140(10):986–92.
3. Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates JA. Open chole-
cystectomy. A contemporary analysis of 42,474 patients. Ann Surg. 1993;218(2):129–37.
4. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparo-
scopic cholecystectomy. J Am Coll Surg. 1995;180(1):101–25.
5. Avgerinos C, Kelgiorgi D, Touloumis Z, Baltatzi L, Dervenis C. One thousand laparoscopic
cholecystectomies in a single surgical unit using the “critical view of safety” technique.
J Gastrointest Surg. 2009;13(3):498–503.
6. Sanjay P, Fulke JL, Exon DJ. ‘Critical view of safety’ as an alternative to routine intraoperative
cholangiography during laparoscopic cholecystectomy for acute biliary pathology.
J Gastrointest Surg. 2010;14(8):1280–4.
7. Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunter JG. Causes and prevention
of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive
psychology perspective. Ann Surg. 2003;237(4):460–9.
8. Massarweh NN, Devlin A, Elrod JA, Symons RG, Flum DR. Surgeon knowledge, behavior,
and opinions regarding intraoperative cholangiography. J Am Coll Surg.
2008;207(6):821–30.
9. Soper NJ, Dunnegan DL. Routine versus selective intra-operative cholangiography during
laparoscopic cholecystectomy. World J Surg. 1992;16(6):1133–40.
10. Nies C, Bauknecht F, Groth C, Clerici T, Bartsch D, Lange J, Rothmund M. Intraoperative
cholangiography as a routine method? A prospective, controlled, randomized study. Chirurg.
1997;68(9):892–7.
11. Khan OA, Balaji S, Branagan G, Bennett DH, Davies N. Randomized clinical trial of routine
on-table cholangiography during laparoscopic cholecystectomy. Br J Surg.
2011;98(3):362–7.
12. Amott D, Webb A, Tulloh B. Prospective comparison of routine and selective operative chol-
angiography. ANZ J Surg. 2005;75(6):378–82.
13. Flum DR, Flowers C, Veenstra DL. A cost-effectiveness analysis of intraoperative cholangiog-
raphy in the prevention of bile duct injury during laparoscopic cholecystectomy. J Am Coll
Surg. 2003;196(3):385–93.
14. Giger U, Ouaissi M, Schmitz SF, Krähenbühl S, Krähenbühl L. Bile duct injury and use of
cholangiography during laparoscopic cholecystectomy. Br J Surg. 2011;98(3):391–6.
15. Törnqvist B, Strömberg C, Persson G, Nilsson M. Effect of intended intraoperative cholangi-
ography and early detection of bile duct injury on survival after cholecystectomy: population
based cohort study. BMJ. 2012;345:e6457.
16. Ragulin-Coyne E, Witkowski ER, Chau Z, Ng SC, Santry HP, Callery MP, Shah SA, Tseng
JF. Is routine intraoperative cholangiogram necessary in the twenty-fi rst century? A national
view. J Gastrointest Surg. 2013;17(3):434–42.
17. Buddingh KT, Weersma RK, Savenije RA, van Dam GM, Nieuwenhuijs VB. Lower rate of
major bile duct injury and increased intraoperative management of common bile duct stones
27 Routine or Selective Cholangiography for Elective Laparoscopic Cholecystectomy?
320
after implementation of routine intraoperative cholangiography. J Am Coll Surg.
2011;213(2):267–74.
18. Nickkholgh A, Soltaniyekta S, Kalbasi H. Routine versus selective intraoperative cholangiog-
raphy during laparoscopic cholecystectomy: a survey of 2,130 patients undergoing laparoscopic cholecystectomy. Surg Endosc. 2006;20(6):868–74.
19. Brown LM, Rogers SJ, Cello JP, Brasel KJ, Inadomi JM. Cost-effective treatment of patients
with symptomatic cholelithiasis and possible common bile duct stones. J Am Coll Surg.
2011;212(6):1049–60.
20. Livingston EH, Miller JA, Coan B, Rege RV. Costs and utilization of intraoperative cholangi-
ography. J Gastrointest Surg. 2007;11(9):1162–7.
21. Schols RM, Bouvy ND, Masclee AA, van Dam RM, Dejong CH, Stassen LP. Fluorescence
cholangiography during laparoscopic cholecystectomy: a feasibility study on early biliary tract
delineation. Surg Endosc. 2013;27(5):1530–6.
22. Osayi SN, Wendling MR, Drosdeck JM, Chaudhry UI, Perry KA, Noria SF, Mikami DJ,
Needleman BJ, Muscarella 2nd P, Abdel-Rasoul M, Renton DB, Melvin WS, Hazey JW,
Narula VK. Near-infrared fl uorescent cholangiography facilitates identifi cation of biliary anatomy during laparoscopic cholecystectomy. Surg Endosc. 2015;29(2):368–752.
23. Dip FD, Asbun D, Rosales-Velderrain A, Lo Menzo E, Simpfendorfer CH, Szomstein S,
Rosenthal RJ. Cost analysis and effectiveness comparing the routine use of intraoperative fl uorescent cholangiography with fl uoroscopic cholangiogram in patients undergoing laparoscopic
cholecystectomy. Surg Endosc. 2014;28(6):1838–43.
24. Prevot F, Rebibo L, Cosse C, Browet F, Sabbagh C, Regimbeau JM. Effectiveness of intraop-
erative cholangiography using indocyanine green (versus contrast fl uid) for the correct assessment of extrahepatic bile ducts during day-case laparoscopic cholecystectomy. J Gastrointest
Surg. 2014;18(8):1462–8.
S. Svoboda and B.L. Bello
321© 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_28
Chapter 28
When Is Bile Duct Resection Indicated
for Biliary Strictures in Primary Sclerosing
Cholangitis?
J. Camilo Barreto and J. Michael Millis
Abstract Primary sclerosing cholangitis (PSC) has a variable clinical course, but
often becomes a progressive disease that leads to chronic cholestasis, cirrhosis and
liver failure. In addition, PSC is the most common risk factor for cholangiocarcinoma in western countries. The etiology is unclear, and as a result there are no
specifi c medical therapies that change long-term outcomes. Liver transplantation
offers the only potentially curative therapy but it is usually reserved for patients with
advanced stage or cirrhosis. Earlier stages require alternative invasive treatment
modalities to manage symptoms and address dominant strictures, which can be
benign or malignant. The distinction between these may be extremely challenging,
and has an infl uence on the treatment options, which include endoscopic dilatation,
stenting, or surgery, either biliary bypass or extrahepatic bile duct resection.
Endoscopic therapy has less morbidity, but surgical treatment has the advantage of
not leaving potentially malignant or dysplastic strictures in place and may be associated with longer survival. When cholangiocarcinoma develops, it tends to appear at
an advanced stage and prognosis is poor.
Keywords Primary sclerosing cholangitis • Stricture • Cancer • Endoscopy •
Resection • Morbidity
J. C. Barreto
Section of General Surgery , University of Chicago Medicine , Chicago , IL , USA
J. M. Millis (
*)
Department of Surgery , University of Chicago Hospitals ,
5841 S. Maryland Ave, MC 5027 , Chicago , IL 60637 , USA
e-mail:
mmillis@surgery.bsd.uchicago.edu
322
Introduction
Primary sclerosing cholangitis is a chronic disease characterized by multifocal bile
duct stricture s secondary to idiopathic infl ammation and fi brosis of intra and extrahepatic bile ducts. It is associated in 75 % of patients with concomitant infl ammatory bowel disease. PSC has a variable course, and some patients may be
asymptomatic, whereas progressive infl ammation and obliteration leads to secondary biliary cirrhosis and liver failure in 50 % of cases, with a median survival of
11–18 years [ 1 ]. Patients with cirrhosis should be considered for transplant upfront,
since their surgical mortality is higher and have poorer survival with non-transplant
surgical therapy [ 2 ]. The role of transplantation in PSC is well established and out
of the scope of this chapter.
For non-cirrhotic patients at earlier stages, treatment options are variable and
more controversial. Knowledge of the etiology of PSC is still very limited, likely
involving genetic components in a setting of persistent infl ammation. Currently,
there is no effective targeted therapy, and available medical treatment options
(immunosuppressive agents and ursodeoxycholic acid) have limited value and have
not proven to halt disease progression. In the absence of specifi c treatment, a signifi cant aspect in the care of patients with PSC involves managing biliary stricture s for
symptomatic relief. Dominant strictures happen in 10–20 % of patients [ 3 , 4 ]. They
have been defi ned in cholangiography as strictures of the common bile duct with a
diameter ≤1.5 mm and/or strictures of a hepatic duct ≤1 mm within 2 cm of the
hepatic duct bifurcation [ 5 ]. Cholangiocarcinoma is a complication occurring in
10–20 % of patients. This should be factored in when deciding what is the best
approach for biliary strictures, since at the time of presentation, up to 25 % of strictures are malignant [ 6 ]. In previous decades, before the advent of advanced endo-
scopic interventions and the wider availability of liver transplant ation , surgical
resection or bypass was the mainstay therapy for dominant strictures. In more recent
times, due to its lower complication rate, endoscopic treatment has generally been
the fi rst line of treatment, in the form of sphincterotomy followed by stricture dilatation with or without stent placement. The low incidence of PSC makes it diffi cult to
obtain high quality evidence, and there are no randomized trials to identify the best
approaches for operative management of strictures.
Search Strategy
A literature search of English language publications was used to identify data on
endoscopic and surgical management of dominant biliary stricture s, outcomes in
terms of complications and survival , as well as risk of cholangiocarcinoma . Data
was assessed and processed according to the categories in Table 28.1 .
J.C. Barreto and J.M. Millis
323
Endoscopic Therapy
Endoscopic therapies have the advantages of lower complication rates, and not
altering the biliary anatomy in case patients undergo a liver transplant . Endoscopic
dilatation of PSC patients with a dominant stricture can achieve clinical and biochemical response in 80 % of cases [ 3 , 5 , 7 , 8 ]. Most patients will require more than
one session. Baluyut et al. also showed an increase in survival at 5 years in 63
patients with endoscopic therapy, which primarily consisted of repeated balloon
dilatations (83 % vs. 65 % by using the Mayo Survival Model). They concluded that
endoscopic attempts to maintain biliary patency are associated with improved survival [ 8 ]. Stiehl et al. reported their experience with 106 patients [ 5 ], 52 of which
developed dominant strictures while also receiving ursodeoxycholic acid. They
were managed endoscopically with repeated balloon dilatations, and fi ve patients
had a temporary biliary stent . The actuarial survival free of liver transplant at 5 years
was 94 %, compared to the Mayo multicenter survival model of 77 %. Another
prospective observational study from Germany of 96 patients undergoing endoscopic dilatation showed an actuarial survival free of liver transplant of 68 % at
5 years and 44 % at 10 years when patients had a serum bilirubin greater than 2 mg/
dL. With serum bilirubin levels less than 2 mg/dL, the survival was 83 % at 5 years
and 56 % at 10 years [ 9 ]. A National Institutes of Health panel concluded that bal-
loon dilatation of high grade strictures is benefi cial [ 10 ].
Stents offer the theoretical advantage of improving patency rates after dilatation.
However, some studies have reported an association with increased risk of cholangitis [ 3 , 5 , 7 ]. The difference in stenting protocols and small number of subjects
complicate the interpretation of outcomes after stent therapy. A retrospective study
[ 11 ] compared patients undergoing balloon dilatation alone with a group treated
with balloon dilatation plus stenting. Stent placement did not provide additional
benefi ts after dilatation and increased the infectious complication rate.
Biliary Resection and Biliary Bypass
Before liver transplant became a viable option, surgical treatment was the mainstay
of treatment for PSC. Non-transplant surgical therapies for patients with PSC are
extrahepatic biliary resection or bypass with bilioenteric anastomosis. The
Table 28.1 PICO table for surgery or endoscopic therapy for PSC
P (patients) I (intervention)
C (comparator
group)
O ( outcomes
measured)
Patients with primary sclerosing
cholangitis and dominant stricture
Resection Endoscopic
treatment
Survival
Cancer risk
Morbidity
28 When Is Bile Duct Resection Indicated for Biliary Strictures in Primary…
324
disadvantage of the latter is leaving in situ the strictured area at risk of malignant
transformation. Resection entails excision of the entire extrahepatic biliary duct
including the confl uence, since it is frequently involved with a dominant stricture .
This is followed by bilateral hepaticojejunostomies and some authors recommend
transhepatic stenting for 1 year [ 12 ]. Pitt et al. have reported outcomes with differ-
ent variants of bypass surgery in 22 patients, with an overall survival of 82 % with
a median follow-up of 5 years [ 13 ]. Johns Hopkins has reported one of the largest
experiences with patients undergoing non-transplant surgical therapy. Extrahepatic
biliary resection was performed with long term transhepatic stenting. In those
patients managed with resection surgical, 50 non-cirrhotic patients had a 5-year
survival of 85 % [ 14 ]. Operative mortality in cirrhotic patients was 20 %, compared
to 2.5 % in non-cirrhotics. The complication rate was 32 %, most commonly from
cholangitis . None of the resected patients developed cholangiocarcinoma during a
median follow-up of 62 months. Among 35 patients who underwent endoscopic
therapy (dilatation with or without stenting), overall 5-year survival was 58 %.
Although survival was lower than the 85 % survival achieved with resection, the
complication rate associated to endoscopic therapy was lower (14 %, mostly mild
pancreatitis). Three patients of 35 (8 %) in the endoscopic group developed cholangiocarcinoma [ 14 ]. One of the arguments in favor of endoscopic therapy as fi rst-line
treatment quotes that patients who had biliary tract surgery have increased morbidity and mortality should they need liver transplantation [ 15 – 18 ]. In the Johns
Hopkins experience, although operative time for liver transplant was shorter in
patients with no previous biliary tract surgeries, the estimated blood loss and operative mortality was not statistically different [ 14 ]. A more recent report from Johns
Hopkins has confi rmed the outcomes of extrahepatic bile duct resection including
the confl uence, with a 5 and 10-year survival of 76 % and 52 % respectively. No
patients developed cholangiocarcinoma. Cirrhotic patients had a 10-year survival of
only 12 %, compared to 57 % for patients who undergo liver transplant, underscoring that adequate candidate selection is key for good outcomes [ 19 ].
The other alternative in surgical therapy is bypass without resection . Pitt et al.
reported a survival of 82 % at 5 years with different bypass techniques [ 13 ]. Myburgh
reported a survival of 100 % in 16 non-cirrhotic patients with a median survival of
6.5 years, managed with hepaticojejunostomy without resection [ 20 ]. Another
approach involves a choledochojejunostomy with a subcutaneously placed afferent
limb, to allow for serial dilatations of the biliary tree [ 21 ].
Risk of Malignancy
Patients with PSC have a risk of cholangiocarcinoma of 10–20 % over their lifetime,
and PSC is the most common risk factor for its occurrence in Western countries.
Half of patients are diagnosed within 1 year of diagnosis of PSC [ 22 ]. When it
occurs, most tumors develop at the bifurcation (70 % hilar vs. 11 % intrahepatic)
[
23 ]. Cholangiocarcinoma tends to be diagnosed at an advanced, unresectable stage.
J.C. Barreto and J.M. Millis
325
This is, in part, due to the diffi culty in differentiating benign from malignant lesions,
and the fact that early strictures are often asymptomatic [ 24 ]. Several clinical fi nd-
ings seem to be predictive of malignant transformation, such as rapid clinical and
biochemical deterioration, weight loss, marked proximal ductal dilatation [ 25 ].
Unfortunately, both screening for the disease and diagnostic confi rmation after cancer has appeared can be challenging. Cholangiography alone may not be able to
distinguish between benign and malignant strictures. CA 19-9 elevation is nonspecifi c, as there is considerable overlap with elevation secondary to benign strictures. As a consequence, it lacks enough sensitivity and positive predictive values
for the diagnosis of cholangiocarcinoma in patients with PSC [ 2 ]. In general, endo-
scopic ultrasound (EUS) guided FNA in suspected cholangiocarcinoma has specifi city, sensitivity and positive predictive value of 86, 100 and 100 % respectively
[ 26 ]. However, these results come from patients without PSC. Tissue-diagnosis is
challenging because tumors tend to be highly desmoplastic, with small aggregations
of cancer cells in a rich fi brous tissue, and biliary cytology studies are positive in
only 30 % of patients. Other modalities, like fl uorescent in situ hybridization (FISH)
have been used to improve sensitivity, but it still remains low at 34 % [ 27 ].
Some reports have suggested that there is an increased risk for cholangiocarcinoma when patients with dominant strictures are treated without resection [ 14 , 28 ].
In the Johns Hopkins experience, none of the patients that underwent extrahepatic
biliary resection later developed cholangiocarcinoma [ 14 ], and in contrast, malig-
nancy has been reported in most series of patients treated with endoscopic therapy.
In Stiehl et al. series, 3 % were diagnosed with cholangiocarcinoma [ 5 ], and 8 % of
patients in Baluyut’s study developed it [ 8 ]. Proponents of endoscopic therapy have
argued that the risk of cholangiocarcinoma is still low in their series and that endoscopic therapy is not a risk factor per se for cholangiocarcinoma [ 8 , 29 ]. However,
there is currently a lack of high quality evidence to support either hypothesis. As
mentioned before, there are no randomized trials comparing outcomes of endoscopic vs. surgical treatment.
Recommendations
• Liver transplantation provides better survival in cirrhotic patients with PSC
(Evidence quality high, strong recommendation).
• Non-cirrhotic patients with PSC and symptomatic, benign-appearing dominant
strictures may be treated initially with endoscopic therapy given its lower mor-
bidity , and can be managed with repeated dilatations if needed. (Evidence quality
low, weak recommendation)
• Surgical therapy should be performed for non-cirrhotic patients with dominant
strictures suspicious for malignancy, equivocal fi ndings on cancer screening , or
when endoscopic therapy has failed. (Evidence quality moderate, strong
recommendation).
28 When Is Bile Duct Resection Indicated for Biliary Strictures in Primary…
326
• Extrahepatic bile duct resection should be preferred to biliary bypass in appro-
priate surgical candidates given the underlying risk of cholangiocarcinoma in
unresected bile ducts. (Evidence quality low, weak recommendation)
References
1. Koro NS, Alkaade S. Role of endoscopy in primary sclerosing cholangitis. Curr Gastroenterol
Rep. 2003;15:361.
2. Aljiffry M, Renfrew PD, Walsh MJ, Laryea M, Molinari M. Analytical review of diagnosis and
treatment strategies for dominant bile duct strictures in patients with primary sclerosing cholangitis. HPB (Oxf). 2011;13:79–90.
3. Van Milligen de Wit AW, Rauws EA, van Bracht J, et al. Endoscopic stent therapy for domi-
nant extrahepatic bile duct strictures in primary sclerosing cholangitis. Gastrointest Endosc.
1996;44:293–9.
4. Olsson RG, Asztely MS. Prognostic value of cholangiography in primary sclerosing cholangi-
tis. Eur J Gastroenterol Hepatol. 1995;7:251–4.
5. Stiehl A, Rudolph G, Kloters-Plachky P, Sauer P, Walker S, et al. Development of dominant
bile duct stenoses in patients with primary sclerosing cholangitis treated with ursodeoxycholic
acid: outcome after endoscopic treatment. J Hepatol. 2002;36:151–6.
6. Tischendorf JJ, Kruger M, Trautwein C, et al. Cholangioscopic characterization of dominant
bile duct stenoses in patients with primary sclerosing cholangitis. Endoscopy.
2006;38:665–9.
7. Ponsloen CY, Lam K, van Milligen de Witt AW, Hulbregtse K, Tytgat GN. Four years experi-
ence with short-term stenting in primary sclerosing cholangitis. Am J Gastroenterol.
1999;94:2403–7.
8. Baluyut AR, Sherman S, Lehrman GA, Hoen H, Chalasani N. Impact of endoscopic therapy
on the survival of patients with primary sclerosing cholangitis. Gastrointest Endosc.
2001;53:308–12.
9. Gotthardt DN, Rudolph G, Kloters-Plachky P, Kulaksiz H, Stiehl A. Endoscopic dilation of
dominant stenoses in primary sclerosing cholangitis: outcome after long-treatment. Gastrointest
Endosc. 2010;71:527–34.
10. LaRusso NF, Shneider BL, Black D, et al. Primary sclerosing cholangitis: summary of a work-
shop. Hepatology. 2006;44:746–64.
11. Kaya M, Petersen BT, Angulo P, et al. Balloon dilation compared to stenting of dominant
strictures in primary sclerosing cholangitis. Am J Gastroenterol. 2001;96:1059–66.
12. Domanjko B, Ahrendt SA. Indications for non-transplant surgery in primary sclerosing chol-
angitis. HPB. 2005;7:292–7.
13. Pitt HA, Thompson HH, Tompkins RK, Longmire WP. Primary sclerosing cholangitis: results
of an aggressive surgical approach. Ann Surg. 1982;196:259–68.
14. Ahrendt SA, Pitt HA, Kalloo AN, et al. Primary sclerosing cholangitis. Resect, dilate or trans-
plant? Ann Surg. 1998;227:412–23.
15. Martin FM, Rossi RL, Nugent FW, et al. Surgical aspects of sclerosing cholangitis. Results in
178 patients. Ann Surg. 1990;212:551–6.
16. Ismail T, Angrisani L, Powell JE, et al. Primary sclerosing cholangitis: surgical options, prog-
nostic variables and outcome. Br J Surg. 1991;78:564–7.
17. Farges O, Malassagne B, Sebaugh M, Bismuth H. Primary sclerosing cholangitis: liver trans-
plantation or biliary surgery. Surgery. 1995;117:146–55.
18. Brandsaeter B, Friman S, Broome U, et al. Outcome following liver transplantation for pri-
mary sclerosing cholangitis in the Nordic countries. Scand J Gastroenterol.
2003;38:1776–83.
J.C. Barreto and J.M. Millis
327
19. Pawlik TM, Olbrecht VA, Pitt HA, et al. Primary sclerosing cholangitis: role of extrahepatic
biliary resection. J Am Coll Surg. 2008;206:822–32.
20. Myburgh JA. Surgical biliary drainage in primary sclerosing cholangitis. The role of the Hepp-
Couinaud approach. Arch Surg. 1994;129:1057–62.
21. Hutson DG, Russell E, Levi JU, et al. Dilatation of biliary strictures through the afferent limb
of a Roux-en-Y choledochojejunostomy in patients with sclerosing cholangitis. World J Surg.
2001;25:1251–3.
22. Bergquist A, Ekbom A, Olsson R, et al. Hepatic and extrahepatic malignancies in primary
sclerosing cholangitis. J Hepatol. 2002;36:321–7.
23. Abu-Elmagd KM, Selby R, Iwatsuki S, et al. Cholangiocarcinoma and sclerosing cholangitis:
clinical characteristics and effect on survival after transplantation. Transplant Proc.
1993;25:1124–9.
24. Lee JG, Schutz SM, England RE, Leung JW, Cotton PB. Endoscopic therapy of sclerosing
cholangitis. Hepatology. 1995;21:661–7.
25. Rosen CB, Nagorney DM, Wiesner RH, Coffey RJ, LaRusso NF. Cholangiocarcinoma com-
plicating primary sclerosing cholangitis. Ann Surg. 1991;213:21–5.
26. Eloubeidi MA, Chen VK, Jhala NC, et al. Endoscopic ultrasound-guided fi ne needle aspiration
biopsy of suspected cholangiocarcinoma. Clin Gastroenterol Hepatol. 2004;2:209–13.
27. Kipp BR, Stadheim LM, Halling SA, et al. A comparison of routine cytology and fl uorescence
in situ hybridization for the detection of malignant bile duct strictures. Am J Gastroenterol.
2004;99:1675–81.
28. Linder S, Soderlund C. Endoscopic therapy in primary sclerosing cholangitis: outcome of
treatment and risk of cancer. Hepatogastroenterology. 2001;48:387–92.
29. Chalasani N, Baluyut A, Ismail A, et al. Cholangiocarcinoma in patients with primary scleros-
ing cholangitis: a multicenter case-control study. Hepatology. 2000;31:7–11.
28 When Is Bile Duct Resection Indicated for Biliary Strictures in Primary…