Endoscopic treatment of common bile duct strictures complicating chronic pancreatitis

Endoscopic Treatment of Common Bile Duct Strictures Complicating Chronic Pancreatitis Evan L. Fogel, MD, and Stuart Sherman, MD

Distal common bile duct (CBD) strictures frequently complicate chronic pancreatitis. These strictures may be noted incidentally at cholangiography or may present as persistent cholestasis, jaundice, or cholangitis. Evaluation of endoscopic biliary stenting for CBD strictures in chronic pancreatitis has been addressed in several studies. These suggest that endoscopic therapy may be a useful alternative to surgery for short-term treatment of these strictures, because immediate relief of jaundice and cholangitis is achieved in nearly all patients. Complete stricture resolution, however, occurs in a minority of patients after final stent removal. Surgical biliary-enteric bypass remains the long-term treatment of choice for average-risk individuals. The role of expandable metallic stents requires further study in this benign condition, Copyright 9 1999 by W.B. Saunders Company

tent marker. 4-6,8,9,13-15 Biliary decompression has been recommended in this group of patients, generally when the ALP level is greater than twice the upper limit of normal. 16 Surgical therapy has been the traditional approach. However, these procedures are associated with considerable morbidity and mortality, especially in the alcoholic, debilitated patient with portal hypertension. 4"6,8,9,15,~7Based on the excellent outcome (with low morbidity) from endoscopic biliary stenting in benign postoperative strictures, evaluation of similar techniques for CBD strictures complicating chronic pancreatitis has been addressed in several studies.

Polyethylene Stents hronic pancreatitis is a chronic, often progressive, inflammatory condition characterized by fibrosis of the pancreas and its surrounding tissue. The distal portion of the common bile duct (CBD) in most individuals is enclosed within the posterior portion of the head of the pancreas. In a small percentage, it lies within a groove on its posterior surface} This anatomic relationship allows for compression or obstruction in chronic pancreatitis or other pancreatic disease processes such as a pseudocyst or neoplasm (Fig 1). Intrapancreatic CBD strictures have been reported to occur in 2.7% to 45.6% of patients with chronic pancreatitis. 2 Most patients with chronic pancreatitis and distal CBD strictures are alcoholic. 3-9 It is important, therefore, to distinguish whether abnormal liver function tests are secondary to the stenotic CBD, alcoholic liver disease, or other biliary tract or intrinsic liver disease. However, there is a broad spectrum of liver test derangements secondary to a CBD stricture. Results of liver tests may be normal, with the stricture identified coincidentally at cholangiography. There is general agreement that such patients require no intervention. Alternatively, the patient may have an elevated serum alkaline phosphatase (ALP), which may serve as a marker for significant biliary obstruction. 9-n In 1 series, a CBD stricture was seen in 30% of patients and was associated with persistent cholestasis, jaundice, or cholangitis in 9%. 12 The serum bilirubin is a less reliable parameter, because it may transiently rise during an acute inflammatory episode and return to normal once this subsides, leaving the persistently raised ALP as a more consis-

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From the Department of Medicine, Indiana University Medical Center, Indianapolis, IN. Address reprint requests to Evan L. Fogel, MD, 550 N University Blvd, Suite 2300, Indianapolis, IN 46202. Copyright 9 1999 by W.B. Saunders Company 1096-2883/99/0104-0006510.00/0

Deviere et a112 evaluated the use of biliary stenting (1 or 2 Biotrol [Biotrol-Guerbet, Paris, France] 10F C-shaped stents) in 25 chronic pancreatitis patients with bile duct obstruction and significant cholestasis (alkaline phosphatase > 2 times the upper limits of normal) (Figs 2, 3). Nineteen patients had jaundice, and 7 presented with cholangitis. Cholestasis, hyperbilirubinemia, and cholangitis resolved in all patients after stent placement. Late follow-up (mean, 14 months; range, 4 to 72 months) of 22 patients was much less satisfactoW. One patient died of acute cholecystitis and postsurgical complications, whereas a second died 10 months after stenting of sepsis, which was believed to be caused by stent blockage or dislodgment. Stent migration occurred in 10 patients and stent occlusion in 8, resulting in cholestasis with or without jaundice (n = 12), cholangitis (n = 4), or no symptoms (n --- 2). These patients were treated with stent replacement, surgery, or both (n = 7). Ten patients continued to have a stent in place (mean follow-up, 8 months) and remained asymptomatic. Only 3 patients required no further stems because of resolution of their biliary stricture. The salient point of this study is that biliary drainage is an effective therapy for resolving cholangitis or jaundice in patients with chronic pancreatitis and a biliary stricture. However, the long-term efficacy of this treatment is much less satisfactory because stricture resolution rarely occurs. Barthet et al is also found that biliary stenting is not a definitive therapy for chronic pancreatitis patients with a distal CBD stricture. In their series of 19 patients, 9F to 12F polyethylene endoprostheses were used, with endoscopic retrograde cholangiopancreatography (ERCP) performed every 4 months for evaluation of the stricture and elective stent exchange. The mean duration of stenting was 10 months (range, 4 to 22 months). Only 2 patients had complete clinical (resolution of symptoms), biological (normalization of cholestatic liver tests), and radiological (resolution of biliary stricture and upstream dilation) recovery. Six of 10 (60%) possible

Techniques in Gastrointestinal Endoscopy, Vol 1, No 4 (October), 1999: pp 175-179

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obstructive symptoms underwent endoscopic therapy: 21 had single stent placement with elective exchange at 3- to 6-month intervals over an 18-month period, and 4 had multiple simultaneous 10F stents placed every 3 months (single stents added sequentially) over a mean of 13 months. Mean follow-up after final stent removal was 4.2 years for the single-stent group and 2.4 years for the multiple-stent group. Near normalization of liver function tests was seen in all 4 patients who had simultaneous stents, a trend not observed in the single-stent group. The distal CBD stricture diameter increased from 1.2 mm to 2.5 mm after simultaneous stent therapy. There were no episodes of cholangitis in the multiple stented group (5 episodes occurred before stenting), in contrast to 9 episodes in the single-stented group (15 episodes occurred before stenting). The investigators concluded that multiple simultaneous stents may provide better long-term resolution of strictures. Larger series are awaited to confirm these results.

Self-Expanding Metal Stents

Fig 1. This 45-year-old man has chronic pancreatitis and a smooth, tapered distal common bile duct stricture within the pancreatic head, associated with proximal dilation. The pancreatogram showed an irregular, dilated main pancreatic duct with ectatic side branches (not shown). Note the extensive pancreatic calcifications (arrows).

clinical successes, 8 of 19 (42%) possible biological successes, and 3 of 19 (16%) possible radiological successes were obtained. Smits et aP 9 reported 58 patients with chronic pancreatitis who underwent long-term polyethylene biliary stenting. Median follow-up was 4.1 years. A 10F Amsterdam-type stent was placed at the initial ERCE and patients had stents replaced every 3 to 9 months if the stricture persisted. Successful outcome of biliary stenting was defined as clinical improvement with persistence of stricture regression after final stent removal. All 58 patients improved clinically (reduced jaundice or serum ALP) within 2 weeks, but complete normalization of ALP was noted in only 42%. In 16 patients (28%), the stricture resolved and required no further intervention. However, 26 patients (44%) had persistent stricturing throughout follow-up and continued with stenting either because they preferred to or because there was a contraindication to surgery. The remaining 16 patients had surgical bypass for persistent strictures. Five procedure-related (9%) and 37 late stent-related (64%) complications occurred, with stent occlusion observed in 36 patients. The investigators concluded that a trial of biliary stenting should be pursued in patients with symptoms of biliary obstruction caused by chronic pancreatitis, with surgical bypass remaining the treatment of choice for long-term management. Table 1 summarizes this and the above-published series of endoscopic therapy of chronic pancreatitis-induced CBD strictures with polyethylene stents. The Milwaukee group 2~ has presented limited data examining the role of multiple simultaneous biliary endoprostheses in the treatment of symptomatic distal CBD strictures in patients with chronic pancreatitis. In their series, 25 patients with

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Because of the largely disappointing long-term results with plastic stents and the concern for the high morbidity associated with surgically performed biliary drainage procedures in alcoholic patients, the group from Brussels evaluated the use of uncoated expandable metal stents for this indication. 2~ Twenty patients were treated with a 34-ram-long metal stent, which becomes 10 mm in diameter when fully expanded. The short length of the stent was chosen so surgical bypass (eg, choledochoduodenostomy) would still be possible if necessary. Cholestasis (n = 20), jaundice (n = 7), and cholangitis (n = 3) resolved in all patients. Eighteen patients had no further biliary problems during a follow-up period of 33 months (range, 24 to 42 months). Two patients (10%) developed epithelial hyperplasia within the stent, resulting in recurrent cholestasis in 1 and jaundice in the other. These patients were treated endoscopically with standard plastic stents with 1 of these patients ultimately requiring surgical drainage. The investigators concluded that this therapy could be an effective alternative to surgical biliary diversion, but longer follow-up and controlled trials will be necessary to confirm these results.

Biliary Pain and Chronic Pancreatitis Patients with chronic pancreatitis and distal CBD strictures may present with pain of pancreatic or biliary origin. It has been postulated that symptomatic improvement after bile duct stenting would support a biliary source as the site of pain and predict which patients would respond to operative biliary decompression. = This theory was tested in 8 patients presenting with pain with and without cholestasis. Seven of 8 (88%) patients stented had pain relief. Operative biliary drainage (without pancreatic surgery) was performed in 5, with continued pain relief. Although more patients and a longer follow-up are needed, these preliminary data suggest that nonoperative biliary drainage will predict surgical outcome.

Discussion Distal common bile duct strictures frequently complicate chronic pancreatitis. Although most patients are asymptomatic

FOGEL AND SHERMAN

A

Fig 2. Schematic view of the technique of biliary stenting for a common bile duct stricture due to chronic pancreatitis. (A) The cholangiogram shows a distal CBD stricture in the pancreatic head with proximal dilation. A guidewire has been advanced through the stricture. (B,C) The stricture is dilated with a hydrostatic balloon, with obliteration of the balloon waistline. (D) A polyethylene straight stent is placed across the stricture.

and may demonstrate only periodic elevations of the serum alkaline phosphatase, biliary drainage is indicated in patients with cholangitis, jaundice, or persistent cholestasis, in hopes of preventing secondary biliary cirrhosis and recurrent cholangitis. The incidence of secondary biliary cirrhosis is uncertain in this patient population, but has been reported to be as high as 29.2%. 4-9,11,13,15,23 Cholangitis may occur spontaneously in patients with chronic pancreatitis, but is often seen in association with choledocholithiasis proximal to the CBD stricture. The incidence of cholangitis has been reported as 2.6% to 25%. 4,5,7-9,15 When pancreatic decompression is indicated as well, there is general agreement that a surgical biliary-enteric bypass procedure is the treatment of choice to prevent these late complications. The studies presented here indicate that plastic biliary stents placed endoscopically are a useful alternative to surgery for short-term treatment of chronic pancreatitisinduced common bile duct strictures complicated by cholestasis, jaundice, and cholangitis. Immediate relief of jaundice and

ENDOSCOPY OF COMMON BILE DUCT STRICTURES

cholangitis is achieved in nearly all patients. However, complete and persistent stricture resolution occurs in a minority of patients after final stent removal. This lack of response may be secondary to the extrinsic compression and fibrotic nature of the stricture in chronic pancreatitis, in contrast to postoperative biliary strictures, where stricture resolution occurs after a period of stenting in more than 80% of patients. Stent dysfunction (occlusion, migration) continues to be a major limitation, and stents should therefore be exchanged electively every 3 to 6 months to decrease the likelihood of cholangitis. Simultaneous placement of multiple biliary stents may be more beneficial than single stents, but further study is necessary. However, because the long-term efficacy of endoscopic therapy has been unsatisfactory, operative intervention seems to be a better long-term solution in average-risk patients. More data on the long-term outcome, preferably in controlled trials, are necessary before the expandable stents can be advocated for this indication.

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Fig 3. A 38-year-old man with chronic calcific pancreatitis caused by alcohol presented with jaundice. He had previously undergone a Puestow procedure. (A) The cholangiogram shows a distal common bile duct stricture in the pancreatic head with proximal dilation. (B) The stricture was dilated with an 8-mm hydrostatic balloon. (C) A 10F (straight) stent was placed, bridging the stricture. After initial relief of jaundice and an interval of abstinence from alcohol, a surgical choledochoduodenostomy was performed.

Conclusion In chronic pancreatitis patients with persistent cholestasis, jaundice, or cholangitis secondary to a distal common bile duct stricture, endoscopic biliary stenting has a definite role. It is

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useful in the short-term management of complications, but surgical biliary-enteric bypass remains the long-term treatment of choice for average-risk individuals. Stent placement also should be considered for high-risk surgical patients. The role

FOGEL AND SHERMAN

TABLE 1. Selected Series Reporting the Results of Endoscopic Therapy of Chronic Pancreatitis-lnduced CBD Strictures With Polyet.hylene Stents

Author/yr Deviere et al, 199012 Barthet et al, 199418 Smits et al, 199619 Total

n 25 19 58 102

Median Duration of Stenting (m)

Median Follow-up After Stent Removal (m)

Not mentioned 10 (4-22) 10 (1-31)

14 (4-72)* 18 (13-48)1 49 (3-113):1:

Stent Dysfunction Clinical Improvement

Stricture Resolution

Occlusion

Migration

25 (100%) 19 (100%) 58 (100%) 102 (100%)

3 (12%) 2 (11%) 16 (28%) 21 (21%)

8 (32%) 0 (0%) 36 (62%) 44 (43%)

10 (40%) 1 (5%) 4 (7%) 15 (15%

NOTE. Number of patients with final stent removal: *3; 13; :1:16.

of metallic stents requires further study in this benign condition. Trials of membrane-coated metal stents and removable coil spring stents are awaited.

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ENDOSCOPY OF COMMON BILE DUCT STRICTURES

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