الفهرس 
Anatomy of biliary treeOnly 14 pages are availabe for public view
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Abstract
SUMMARY AND CONCLUSION
Biliary stricture is a narrowing of the bile duct. This narrowing can cause blockage of the bile into small intestine. The management of recurrent biliary strictures presents a significant challenge to surgeons. If not recognized promptly or if managed improperly, severe complications may result; including cholangitis, portal hypertension, and biliary cirrhosis.
Benign strictures of the biliary tract are associated with a broad spectrum of signs and symptoms, ranging from subclinical disease with mild elevation of liver enzymes to complete obstruction with jaundice, pruritus, cholangitis and ultimately biliary cirrhosis
Initial imaging techniques employed regarding the evaluation of patients with postoperative biliary stricture include abdominal ultrasound and CT scan. The gold standard for the evaluation of patients with recurrent biliary stricture is cholangiography. Recently, magnetic resonance cholangiography has become the method of choice for the diagnosis and delineation of biliary stricture because of its high sensitivity and low complication rates.
Treatment of recurrent biliary stricture requires multidisciplinary approach including endoscopy, interventional radiology and surgery. Whenever surgery is indicated, the procedure of choice is a Roux- en-Y hepaticojejunostomy. PTC interventional therapy could be effective but is invasive. Endoscopic management is not only the least invasive but also very effective via either balloon dilatation or stenting of the stricture. The main obstacle for endoscopic approach is the
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extremely difficult access of the endoscope to the bilioenteric shunt due to the altered anatomy of the Roux-en-Y construction. Some authors advocated the use of double or single balloon enterostomy to overcome this difficulty. Others construct surgical access loop to be used by the endoscopist to reach the HJ stoma. These access loops could be jejunocutaneous , jejunal loop interposition, jejunoduodenostomy or gastric access loop.
Balloon dilatation of biliary stricture with stent of the anastomosis is less invasive than re-do hepaticojejunostomy and has the advantage of conserving bile duct tissue. This combined procedure carries an acceptable morbidity and very low rate of stricture recurrence.
Fully covered self-expanding metal stents are now being used to treat several benign biliary conditions. Advantages include small pre deployment and large post expansion diameters in addition to an easy insertion technique. Lack of imbedding of the metal into the bile duct wall enables removability.
The recently developed technique of balloon-assisted enteroscopy allows deep and even complete intubation of the Roux-en-Y afferent limb to perform ERCP although with variable success rates.
The rendezvous technique in combination with SpyGlass® direct visualization system (SDVS) will expand the possibilities of endoscopic approaches for extremely difficult cases
Successful EUS-guided rendezvous procedures performed for pancreatobiliary obstructions have been reported in the literature. Success rates vary between 35% and 98% in the largest cases series. Failure is mainly due to inability to steer a guidewire across the stricture. When
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combining attempted EUS-guided rendezvous and upstream drainage in cases of failure, the overall drainage success rate is 87%.
Roux-en-Y hepatico-porto-jejunostomy (RYHJ) is now a well-accepted biliary drainage procedure for benign biliary strictures.
Modified biliary reconstruction using a access loop, facilitates endoscopic access of the biliary anastomosis, offers management option for its future complications, and, therefore, could be considered as an advantageous option for reconstruction of benign biliary stricture
short-limb RYHJ appears to be a safe method for biliary reconstruction. The rate of biliary complications of 13%, which includes both early and late complications, compares favorably with the literature in which biliary complications following standard RYHJ ranges from 7% to 38%. Equally important, this short-limb construction has allowed for 100% endoscopic success in patients who have required postoperative biliary intervention., the high success rate was significant.
The management of patients with recurrent biliary strictures is to correct the increased resistance to biliary flow caused by a reduction in lumen diameter. Three options for the management of recurrent biliary strictures are currently available: endoscopic dilation and stenting, The rendezvous technique and surgical biliary drainage by a Roux enY hepaticojejunostomy with surgical access loop that could be used by the endoscopist to reach the HJ stoma. These access loops could be jejunocutaneous, jejunal loop interposition, jejunoduodenostomy or gastric access loop.