Biliary Interventions

Biliary strictures have a relatively wide spectrum of benign to malignant causes. Endoscopic interventions, percutaneus interventions, and surgery could be selected by multidisciplinary teams for treatment of these patients. Ultrasound, CT, MRI, ERCP, and PET-CT are used for diagnosing the type of stricture, localization and also staging of malignant causes. In this lecture, we discuss image guided percutaneus methods like external biliary drainage, high pressure balloons, external-internal biliary drainage for benign biliary stenosis and also stenting, external- internal biliary drainage with brachytherapy for malignant causes like cholangiocarcinoma (Klatskin tumors) which represents the most common form of malignancy in the biliary tract and is inoperable in the majority of cases. Moreover, other tumors like adenocarcinoma of gallbladder, stomach, etc. can invade extra or intrahepatic bile ducts directly. The same protocols for external-internal biliary drainage and brachytherapy may apply. Sometimes, metastatic lymphadenopathies in hilum of liver cause billiary stenosis due to compression of CBD, in these cases we only do biliary drainage or stenting is performed as a measure to decrease billirubin level and make chemotherapy possible. In benign causes, the most frequent causes are ligation or traumatization of CBD, CHD, or RHD in open or laparoscopic cholecystectomy. Inevitable hepatojejunostomy or choledocojejunostomy are needed in these patients, and the most common complication of this surgery is narrowing of anastomosis which may lead to raising of billirubin and LFTs. intervention of choice in these complications is PTC and ballooning. As part of an ongoing study, patients have been treated with high pressure balloon for the past 3 years and more than 90% of these patient have remained asymptomatic so far.