Clinical Approach Strategy in Managing Complex Biliary Cases: Lesson Learnt from a Tertiary Referral Private Hospital

Cosmas Rinaldi Adithya Lesmana(1), Maria Satya Paramitha(2), Yulia Estu Pratiwi(3), Laurentius Adrianto Lesmana(4),

(1) - Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia - Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia - Gastrointestinal Cancer Center, MRCCC Siloam Semanggi Hospital, Jakarta, Indonesia
(2) Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
(3) Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia
(4) - Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia - Gastrointestinal Cancer Center, MRCCC Siloam Semanggi Hospital, Jakarta, Indonesia
Corresponding Author


Introduction: In the era of laparoscopic procedure, there are innovations on non-surgical management approaches for managing biliary tract disorders, such as therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and interventional endoscopic ultrasound (EUS). There is still no clear consensus yet in step-approach for managing difficult  biliary disorders. Method: A retrospective endoscopy database study was conducted. Complex biliary cases which included in this study, where multi-management approach is needed, biliary obstruction accompanied with cholangitis or biliary sepsis, difficult CBD stone, recurrent CBD stone, or advanced progressive malignant biliary obstruction. Results: Sixty-one subjects in this retrospective database study were considered as complex biliary cases. In this study, 16.4% of the subjects underwent combination of therapeutic ERCP and EUS in one session based on the complexity of the case; and 8.2% of the subjects underwent therapeutic ERCP with additional single operator cholangioscopy procedure. One subject underwent rendezvous ERCP procedure through percutaneous approach. Around 4.9% of the subjects underwent EUS-guided biliary drainage procedure. Conclusion: Complex biliary cases require a good clinical approach algorithm to decide which procedure comes first based on comprehensive evaluation consists of patient’s factor, expertise, cost, and the risk of complications.


Keywords: biliary tract; endoscopic retrograde cholangiography; endoscopic ultrasound; laparoscopic procedure


Everhart JE, Khare M, Hill M, et al. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology. 1999; 117: 632-639. DOI: 10.1016/s0016-5085(99)70456-7. PMID: 10464139.

Aerts R, Penninckx F. The burden of gallstone disease in Europe. Alimentary Pharmacology and Therapeutics. 2003; 18 Suppl 3: 49-53. DOI: 10.1046/j.0953-0673.2003.01721.x. PMID: 14531741.

Boberg KM. The clinical burden of biliary disease: A global perspective. In: Hirschfield G, Adams D, Liaskou E, editors. Biliary disease: From science to clinic. Switzerland: Springer International Publishing; 2017.

Gourgiotis S, Kocher HM, Solaini L, et al. Gallbladder cancer. Am J Surg. 2008; 196(2): 252-264. DOI: 10.1016/j.amjsurg.2007.11.011. PMID: 18466866.

Kiran RP, Pokala N, Dudrick SJ. Incidence pattern and survival for gallbladder cancer over three decades – An analysis of 10301 patients. Ann Surg Oncol. 2007; 1492): 827-832. DOI: 10.1245/s10434-006-9224-4. PMID: 17109082.

Randi G, Franceschi S, La Vecchia C. Gallbladder cancer worldwide: Geographical distribution and risk factors. Int J Cancer. 2006; 118(7): 1591-1602. DOI: 10.1002/ijc.21683. PMID: 16397865.

Shaib Y, El-Serag HB. The epidemiology of cholangiocarcinoma. Semin Liver Dis. 2004; 24(2): 115-125. DOI: 10.1055/s-2004-828889. PMID: 15192785.

Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part III: Liver, biliary tract, and pancreas. Gastronterology. 2009; 136(4): 1134-1144. DOI: 10.1053/j.gastro.2009.02.038. PMID: 19245868.

Costi R, Gnocchi A, Mario FD, et al. Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy, and laparoscopy. World J Gastroenterol. 2014; 20(37): 13382-13401. DOI: 10.3748/wjg.v20.i37.13382. PMID: 25309071.

Herrera-Ramirez MA, Acevedo HL, Pena GAG, et al. Efficiency of laparoscopic vs endoscopic management in cholelithiasis and choledocholithiasis. Is there any difference? Cir Cir. 2017; 85(4): 306-311. DOI: 10.1016/j.circir.2016.10.008. PMID: 28024730.

Ainsworth AP, Adamsen S, Rosenberg J. Surgical versus endoscopic treatment of bile duct stones. Ugeskr Laeg. 2007; 169: 1671-1674.

Manes G, Paspatis G, Aabakken L, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2019; 51. DOI: 10.1055/a-0862-0346. PMID: 30943551.

Balik E, Eren T, Keskin M, et al. Parameters that may be used for predicting failure during Endoscopic Retrograde Cholangiopancreatography. J Oncol. 2013. DOI: 10.1155/201681. PMID: 23861683.

Patel JA, Patel NA, Shinde T, et al. Endoscopic retrograde cholangiopancreatography after laparoscopic Roux-en-Y gastric bypass: A case series and review of the literature. Am Surg. 2008; 74: 689;693. PMID: 18705568.

Buxbaum JL, Fehmi SMA, Sultan S, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019; 1:31. DOI: 10.1016/j.gie.2018.10.001. PMID: 30979521.

Hindryckx P, Degroote H, Tate DJ, et al. Endoscopic ultrasound-guided drainage of the biliary system: Techniques, indications, and future perspectives. World J Gastrointest Endosc. 2019; 11(2): 103-114. DOI: 10.4253/wjge.v11.i2.103. PMID: 30788029.

O’Rourke RW, Lee NN, Cheng J, et al. Laparoscopic biliary reconstruction. Am J Surg. 2004; 187: 621-624. DOI: 10.1016/j.amjsurg.2004.01.006. PMID: 15135678.

Wang X, Dai C, Jiang Z, et al. Endoscopic retrograde cholangiopancreatography versus laparoscopic exploration for common bile duct stones in post-cholecystectomy patients: A retrospective study. Oncotarget. 2017; 8(47): 82114-82122. DOI: 10.18632/oncotarget.18839. PMID: 29137249.

Khan SA, Tavolari S, Brandi G. Cholangiocarcinoma: Epidemiology and risk factors. Liver Int. 2019; 39(Suppl.1): 19-31. DOI: 10.1111/liv.14095. PMID: 30851228.

Rahib L, Smith BD, Aizenberg R, et al. Projecting cancer incidence and deaths to 2030: The unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer Res. 2014; 74(11): 2913-2921. DOI: 10.1158/0008-5472. PMID: 24840647.

Viesca MFY, Arvanitakis M. Early diagnosis and management of malignant distal biliary obstruction: A review on current recommendations and guidelines. Clin Exp Gastroenterol Hepatol. 2019; 12: 415-432. DOI: 10.2147/CEG.S195714. PMID: 31807048.

Dumonceau JM, Tringali A, Papanikolaou I, et al. Endoscopic biliary stenting: Indications, choice of stents, and results. European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2018; 50(09): 910-930. DOI: 10.1055/a-0659-9864. PMID: 30086596.

Lima LA, Bustamante AC, Moura GH, et al. Endoscopic palliative treatment versus surgical bypass in malignant low bile duct obstruction: A systematic review and meta-analysis. Int J Hepatobiliary Pancreat Dis. 2015; 5: 35-46. DOI: 10.5348/ijhpd-2015-32-CR-7.

Lesmana CRA, Gani RA, Hasan I, et al. Palliative endoscopic ultrasound biliary drainage for advanced malignant biliary obstruction: Should it replace the percutaneous approach? Case Rep Gastroenterol. 2019; 13: 385-397. DOI: 10.1159/000502835. PMID: 31616233.

Sharaiha RZ, Khan MA, Kamal F, et al. Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: A systematic review and meta-analysis. Gastrointest Endosc. 2017; 85(5): 904-914. DOI: 10.1016/j.gie.2016.12.023. PMID: 28063840.

Rustagi T, Aslanian HR. Endoscopic management of biliary leaks after laparoscopic cholecystectomy. J Clin Gastroenterol. 2014; 48: 674-678. DOI: 10.1097/MCG.000000000000000044. PMID: 24296422.

Abraham S, Rivero HG, Erlikh IV, et al. Surgical and non-surgical management of gallstones. American Academy of Family Physicians. 2014; 89(10): 795-802. PMID: 24866215.

Full Text: PDF

Article Metrics

Abstract View : 92 times
PDF Download : 48 times

DOI: 10.24871/25120242-10


  • There are currently no refbacks.