Endoscopic Treatment of Biliary Stenosis in Patients with Alveolar Echinococcosis--Report of 7 Consecutive Patients with Serial ERC Approach

Abstract

Background and aims: Biliary vessel pathology due to alveolar echicococcosis (AE) results in variable combinations of stenosis, necrosis and inflammation. Modern management strategies for patients with cholestasis are desperately needed. The aim is proof of principle of serial ERC (endoscopic retrograde cholangiography) balloon dilation for AE biliary pathology.

Methods: Retrospective case series of seven consecutive patients with AE-associated biliary pathology and ERC treatment in an interdisciplinary endoscopy unit at a University Hospital which hosts a national echinococcosis treatment center. The AE patient cohort consists of 106 patients with AE of the liver of which 13 presented with cholestasis. 6/13 received bilio-digestive anastomosis and 7/13 patients were treated by ERC and are reported here. Biliary stricture balloon dilation was performed with 18-Fr balloons at the initial and with 24-Fr balloons at subsequent interventions. If indicated 10 Fr plastic stents were placed.

Results: Six patients were treated by repeated balloon dilation and stenting, one by stenting only. After an acute phase of 6 months with repeated balloon dilation, three patients showed "sustained clinical success" and four patients "assisted therapeutic success," of which one has not yet reached the six month endpoint. In one patient, sustained success could not be achieved despite repeated insertion of plastic stents and balloon dilation, but with temporary insertion of a fully covered self-expanding metal stent (FCSEMS). There was no loss to follow up. No major complications were observed.

Conclusions: Serial endoscopic dilation is a standard tool in the treatment of benign biliary strictures. Serial endoscopic intervention with balloon dilation combined with benzimidazole treatment can re-establish and maintain biliary duct patency in AE associated pathology and probably contributes to avoid or postpone bilio-digestive anastomosis. This approach is in accordance with current ERC guidelines and is minimally disruptive for patients.

Fig 1. timing of stent insertion and balloon dilation in individual patients.

Please note the change of scale at the top of the figure from monthly to yearly after 24 months. At the beginning there is monthly follow-up spacing for 24 months and changes to yearly intervals thereafter. Clinically stable patients are usually followed-up in yearly intervals. Patient 3 shows “sustained clinical success” after FCSEMS removal although biliary duct stenosis is still demonstrable on MRCP (Fig 3). Patient 5 was initially treated in our clinic. In the interval of nearly 2 years without follow-up the patient had non curative liver resection in another hospital.

Fig 2. Imaging and ERC findings patient 1.

CT scans in axial orientation show multifocal hypovascular calcified mass lesions and obstructive cholestasis with predominance on the left side (A). Minimum intensity projection in oblique coronary orientation visualizes the central occlusion of both bile ducts (B, arrow head). With ERC and initial placement of a plastic stent (which becomes occluded early) and subsequent serial balloon dilation (C, D) patency of bile ducts was regained (E). MRCP confirms sustained clinical success of bile duct recovering (F).

Fig 3. Imaging and ERC findings patient 2.

Contrast-enhanced MRI in coronal orientation shows a peripheral liver mass with contiguous perivascular infiltration towards the liver hilum (A). MRCP shows central bilateral bile duct stenosis due to a mass lesion of the liver hilum with micro vesicular appearance (B, arrow head). ERC before (C) und during (D) balloon dilation confirms central stenosis of main and right hepatic ducts (arrows). After serial ERC with balloon dilatation satisfactory remodeling of bile ducts is visible at ERC (E) and MRCP (F).

Fig 4. Imaging and ERC findings patient 3.

CT scan in axial (A) and coronal (B) orientation and ERC (C) show bilateral obstructive cholestasis with dilatation of intrahepatic bile ducts as well as calcified mass lesions in the periphery and hilum of the liver. Infiltration of the liver hilum with stenosis of the main bile duct (arrow head). Balloon dilation of stenosis and insertion of plastic stents (D). Temporary placement of a FCSEMS (E). MRCP shows persistent stenosis of the main bile duct after extraction of FCSEMS (F) clinically there was”assisted clinical success” (see Fig 1).