The use of endoscopic retrograde cholangiopancreatography for treating benign biliary strictures has become the standard of practice, with surgery and percutaneous therapy reserved for selected patients. The gold-standard endoscopic therapy is dilation of the stricture followed by placing and exchanging progressively larger and more numerable plastic stents over a 1-year period. Newer modalities, including the use of fully covered metal stents, are currently under investigation in an effort to improve the treatment of benign biliary strictures.
Key points
- •
This article discusses the diverse causes of benign biliary strictures, including strictures caused by postoperative adverse events, primary sclerosing cholangitis, chronic pancreatitis, ischemia, and autoimmune cholangiopathy.
- •
Endoscopic evaluation and treatment are the standard of practice, with specific management based on correctly identifying the underlying cause, characteristics, and location of the stricture(s). The relative merits of endoscopic retrograde cholangiopancreatography (ERCP) with dilation, plastic stents, and self-expandable metal stents are discussed.
- •
The most common therapy for benign biliary strictures involves ERCP with balloon dilation and placement of multiple plastic stents in a side-by-side fashion, followed by the periodic exchange of these stents for approximately 1 year to allow for expansion and remodeling of the stricture(s).
- •
The use of covered, self-expandable, removable metal stents for the treatment of benign biliary strictures is under investigation; clinical trials are underway to determine the best management approach.
Introduction
Benign biliary strictures (BBS) are rarely encountered in the general population and require coordinated care between medical, surgical, pathologic, and radiologic specialties for appropriate evaluation and management. Differentiation of BBS from malignant causes of biliary stricture and obstruction is not always straightforward, with malignant causes being more common. BBS have diverse causes, each with different natural histories and management strategies, most of which incorporate the use of endoscopic retrograde cholangiopancreatography (ERCP). The causes of BBS are shown in Box 1 . Depending on the severity of the obstruction, the clinical presentation of a biliary stricture may vary from subclinical disease with mild increase of liver function tests alone to complete biliary obstruction with resultant jaundice, with or without cholangitis. In some cases, symptoms may not develop until years after the initial insult, with delayed presentation mostly commonly seen with ischemic causes of bile duct injury. The most common cause of BBS in the Western world is surgical injury to the bile duct, particularly during cholecystectomy (CCY). Inflammatory injuries to the biliary ducts are the second most common cause of BBS, and include diseases such as chronic pancreatitis, primary sclerosing cholangitis, and autoimmune cholangiopathy. Complete occlusion or transection of the common bile duct (CBD) generally requires surgical management.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
