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, 7 (11), E1410-E1418

Validity and Safety of Endoscopic Biliary Stenting for Biliary Stricture Associated With IgG4-related Pancreatobiliary Disease During Steroid Therapy

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Validity and Safety of Endoscopic Biliary Stenting for Biliary Stricture Associated With IgG4-related Pancreatobiliary Disease During Steroid Therapy

Yasuhiro Kuraishi et al. Endosc Int Open.

Abstract

Background Patients with IgG4-related sclerosing cholangitis and autoimmune pancreatitis frequently develop obstructive jaundice, which requires endoscopic biliary stenting (EBS) during steroid therapy to prevent bile duct infection from cholestasis and adverse steroid effects. However, it is controversial whether EBS during steroid therapy is advisable, because the procedure itself carries a risk of cholangitis and procedure-related adverse events. This study aimed to clarify the validity and safety of EBS for patients with biliary stricture associated with IgG4-related pancreatobiliary disease (IgG4-PBD) during steroid therapy. Methods We enrolled 59 patients who presented with biliary stricture exhibiting jaundice or liver dysfunction and who were treated with EBS. The incidences of recurrent biliary obstruction and acute cholangitis were compared for EBS cases with and without steroid administration. Results EBS was present in 55 periods with steroid administration and 110 periods without. The incidence of recurrent biliary obstruction was significantly lower in cases with steroids than in those without (1-month no obstruction rate: 100 % vs. 82 %; log-rank test P = 0.0015). The incidence of acute cholangitis related to stenting was significantly lower in cases with steroids than in those without (1-month no acute cholangitis rate: 100 % vs. 90 %; log-rank test P = 0.0278). Biliary stents could be removed without acute cholangitis, liver dysfunction, or stent replacement in 96 % of patients who underwent endoscopic retrograde cholangiopancreatography 1 month after commencing steroid administration. Conclusions EBS during steroid administration was both valid and safe in patients with biliary stricture associated with IgG4-PBD. Stents could be safely removed 1 month after steroid initiation.

Conflict of interest statement

Competing interests None

Figures

Fig. 1
Fig. 1
Inclusion criteria for this study and flow diagram. A total of 104 patients with biliary stricture associated with IgG4-related pancreatobiliary disease were identified. Among them, 63 patients underwent endoscopic biliary stenting (EBS) and 59 patients were ultimately evaluated in this study.
Fig. 2
Fig. 2
Endoscopic retrograde cholangiopancreatography (ERCP) and its related procedures in patients with biliary stricture associated with IgG4-related pancreatobiliary disease. a Cholangiography showed biliary strictures with a smooth surface and dilatation of the proximal bile duct that mimicked cholangiocarcinoma and pancreatic carcinoma of the head. Biliary stricture of the distal common bile duct was observed more frequently among patients with biliary stricture associated with IgG4-related pancreatobiliary disease. b Pancreatography showed diffuse irregular narrowing, a specific feature of autoimmune pancreatitis. c Intraductal ultrasonography disclosed a smooth inner margin and homogeneous internal echo in the stricture despite the bile duct appearing normal in the cholangiogram. d Transpapillary forceps biopsy was useful to distinguish from pancreatobiliary carcinoma. Abundant IgG4-positive cells were often observed. e A biliary stent (7-Fr double pig-tail plastic stent) was placed into the intrahepatic bile duct across the biliary stricture. f Cholangiography 1 month after starting steroid therapy revealed improvement in the biliary stricture such that the biliary stent could be removed in almost all patients.
Fig. 3
Fig. 3
Representative cases of endoscopic biliary stenting (EBS) with and without steroid therapy in this study. a A period of EBS without steroids was defined as the time from the insertion of a biliary stent to that of its removal or the commencement of steroids. An EBS period with steroids was defined as the time from the start of steroid administration to that of stent removal or from exchanging a stent to its removal during steroid therapy. For typical cases receiving steroid administration, treatment consisted of periods without steroids, after which the stent was not exchanged, and with steroids. b For cases receiving ERCP-related procedures, stent exchange was performed every time. c For cases of stent dysfunction, stent exchange was performed every time.
Fig. 4
Fig. 4
Improvement of biliary strictures in patients with biliary stricture associated with IgG4-related pancreatobiliary disease after steroid therapy. a Location for diameter measurements of the bile duct at the biliary stricture and distal side of the bile duct that appeared normal on cholangiography. b Comparison of the ratio of bile duct diameters before and at 4 ± 2 weeks after starting steroid remission induction therapy. In all patients, improvements in biliary strictures were observed. The ratio of the diameter of the bile duct after steroid therapy was significantly improved over that before therapy (median ratio: 0.67 vs. 0.18, P  < 0.0001).
Fig. 5
Fig. 5
Kaplan-Meier curves. a The time to recurrent biliary obstruction between stenting with and without steroid administration. The incidence of recurrent biliary obstruction with steroids was significantly lower than without (1-month no obstruction rate: 100 % vs. 82 %; log-rank test P  = 0.0015). b The time to acute cholangitis for stenting. The incidence of acute cholangitis during stenting with steroids was significantly lower than without (1-month no acute cholangitis rate: 100 % vs. 90 %; log-rank test P  = 0.0278).

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