Skip to main content

Advertisement

SpringerLink
Log in

Multidisciplinary approach to benign biliary strictures

  • Published:
Current Treatment Options in Gastroenterology Aims and scope Submit manuscript

Opinion statement

The various approaches used for the management of patients with benign biliary strictures are justified by the diverse nature, clinical presentation, and severity of these strictures. Benign biliary strictures are most commonly postoperative, a consequence of injury during laparoscopic cholecystectomy or fibrosis after biliary duct-to-duct or bilioenteric anastomoses (ie, liver transplantation). Less frequently, benign strictures are due to chronic pancreatitis or other nonmalignant diseases, including external compression, parasites, stone perforation, and infections. Because of their peculiar pathogenesis, localization, and short extension into the bile duct, the majority of these strictures can be approached by operative treatments such as surgical bypass and endoscopic—or radiological—dilation. In contrast, primary sclerosing cholangitis (PSC) is a systemic disease with immunemediated inflammation and subsequent fibrosis of the bile ducts with the development of multiple strictures due to an “intrinsic” liver disease; thus, medical therapy and pharmacologic research are mainly focused on the treatment of PSC rather than other benign biliary strictures. However, none of the previously mentioned benign strictures has a univocal and sole treatment. Any attempt to identify a standard treatment for all the strictures is questionable, inconclusive, and most likely useless due to the diversity of patients and diseases. Gastroenterologists, radiologists, and surgeons work in tight collaboration, not in competition, to individualize the patients’ treatment. The morphology and extension of the stricture, its location, the theoretical pathogenesis (eg, intrinsic strictures, strictures due to inflammation and fibrosis after bile leak, ischemic lesions), the patients’ specific characteristics (comorbidity and history of prior surgery, including enterobiliary anastomoses and gastric resection), and preferences should indicate the treatment that may offer the patient major benefits with a lower complication rate. Unfortunately, in most of the cases, choosing between different treatments is more likely based on local availability than their actual effectiveness and indication.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. Nuzzo G, Giuliante F, Giovannini I, et al.: Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56 591 cholecystectomies. Arch Surg 2005, 140:986–992.

    Article  PubMed  Google Scholar 

  2. MacFadyen BV, Jr, Vacchio R, Ricardo AE, Mathis CR: Bile duct injury after laparoscopic cholecystectomy. The United States experience. Surg Endosc 1998, 12:315–321.

    Article  PubMed  Google Scholar 

  3. Pascher A, Neuhaus P: Bile duct complications after liver transplantation. Transpl Int 2005, 18:627–642.

    Article  PubMed  Google Scholar 

  4. Zoepf T, Maldonado-Lopez EJ, Hilgard P, et al.: Balloon dilatation vs. balloon dilatation plus bile duct endoprostheses for treatment of anastomotic biliary strictures after liver transplantation. Liver Transpl 2006, 12:88–94.

    Article  PubMed  Google Scholar 

  5. Thuluvath PJ, Pfau PR, Kimmey MB, Ginsberg GG: Biliary complications after liver transplantation: the role of endoscopy. Endoscopy 2005, 37:857–863.

    Article  PubMed  CAS  Google Scholar 

  6. Cahen DL, van Berkel AM, Oskam D, et al.: Long-term results of endoscopic drainage of common bile duct strictures in chronic pancreatitis. Eur J Gastroenterol Hepatol 2005, 17:103–108.

    Article  PubMed  Google Scholar 

  7. Kahl S, Zimmermann S, Genz I, et al.: Risk factors for failure of endoscopic stenting of biliary strictures in chronic pancreatitis: a prospective follow-up study. Am J Gastroenterol 2003, 98:2448–2453.

    Article  PubMed  Google Scholar 

  8. Berstad AE, Aabakken L, Smith HJ, et al.: Diagnostic accuracy of magnetic resonance and endoscopic retrograde cholangiography in primary sclerosing cholangitis. Clin Gastroenterol Hepatol 2006, 4:514–520.

    Article  PubMed  Google Scholar 

  9. Kaya M, Petersen BT, Angulo P, et al.: Balloon dilation compared to stenting of dominant strictures in primary sclerosing cholangitis. Am J Gastroenterol 2001, 96:1059–1066.

    Article  PubMed  CAS  Google Scholar 

  10. Ponsioen CY, Lam K, van Milligen de Wit AW, et al.: Four years experience with short term stenting in primary sclerosing cholangitis. Am J Gastroenterol 1999, 94:2403–2407.

    Article  PubMed  CAS  Google Scholar 

  11. Stiehl A, Rudolph G, Sauer P, et al.: Efficacy of ursodeoxycholic acid treatment and endoscopic dilation of major duct stenoses in primary sclerosing cholangitis. An 8-year prospective study. J Hepatol 1997, 26:560–566.

    Article  PubMed  CAS  Google Scholar 

  12. Maheshwari A, Yoo HY, Thuluvath PJ: Long-term outcome of liver transplantation in patients with PSC: a comparative analysis with PBC. Am J Gastroenterol 2004, 99:538–542.

    Article  PubMed  Google Scholar 

  13. Greaves MW: Itch in systemic disease: therapeutic options. Dermatol Ther 2005, 18:323–327.

    Article  PubMed  Google Scholar 

  14. MacFaul GR, Chapman RW: Sclerosing cholangitis. Curr Opin Gastroenterol 2006, 22:288–293.

    Article  PubMed  Google Scholar 

  15. LaRusso NF, Shneider BL, Black D, et al.: Primary sclerosing cholangitis: summary of a workshop. Hepatology 2006, 44:746–764.

    Article  PubMed  Google Scholar 

  16. Wolfhagen FH, Sternieri E, Hop WC, et al.: Oral naltrexone treatment for cholestatic pruritus: a doubleblind, placebo-controlled study. Gastroenterology 1997, 113:1264–1269.

    Article  PubMed  CAS  Google Scholar 

  17. Bergasa NV: The pruritus of cholestasis. J Hepatol 2005, 43:1078–1088.

    PubMed  Google Scholar 

  18. Lazaridis KN, Gores GJ, Lindor KD: Ursodeoxycholic acid ‘mechanisms of action and clinical use in hepatobiliary disorders’. J Hepatol 2001, 35:134–146.

    Article  PubMed  CAS  Google Scholar 

  19. Beuers U: Drug insight: mechanisms and sites of action of ursodeoxycholic acid in cholestasis. Nat Clin Pract Gastroenterol Hepatol 2006, 3:318–328.

    Article  PubMed  CAS  Google Scholar 

  20. Mitchell SA, Bansi DS, Hunt N, et al.: A preliminary trial of high-dose ursodeoxycholic acid in primary sclerosing cholangitis. Gastroenterology 2001, 121:900–907.

    Article  PubMed  CAS  Google Scholar 

  21. Costamagna G, Pandolfi M, Mutignani M, et al.: Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc 2001, 54:162–168.

    PubMed  CAS  Google Scholar 

  22. Lee YM, Kaplan MM: Primary sclerosing cholangitis. N Engl J Med 1995, 332:924–933.

    Article  PubMed  CAS  Google Scholar 

  23. Stiehl A, Rudolph G, Kloters-Plachky P, et al.: Development of dominant bile duct stenoses in patients with primary sclerosing cholangitis treated with ursodeoxycholic acid: outcome after endoscopic treatment. J Hepatol 2002, 36:151–156.

    Article  PubMed  Google Scholar 

  24. Verdonk RC, Buis CI, Porte RJ, Haagsma EB: Biliary complications after liver transplantation: a review. Scand J Gastroenterol Suppl 2006, 243:89–101.

    Article  PubMed  Google Scholar 

  25. Davidson BR, Rai R, Nandy A, et al.: Results of choledo-chojejunostomy in the treatment of biliary complications after liver transplantation in the era of nonsurgical therapies. Liver Transpl 2000, 6:201–206.

    PubMed  CAS  Google Scholar 

  26. Freeman ML, Nelson DB, Sherman S, et al.: Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996, 335:909–918.

    Article  PubMed  CAS  Google Scholar 

  27. Bergman JJ, van den Brink GR, Rauws EA, et al.: Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut 1996, 38:141–147.

    Article  PubMed  CAS  Google Scholar 

  28. Morelli J, Mulcahy HE, Willner IR, et al.: Long-term outcomes for patients with post-liver transplant anastomotic biliary strictures treated by endoscopic stent placement. Gastrointest Endosc 2003, 58:374–379.

    Article  PubMed  Google Scholar 

  29. Rauws EA, Gouma DJ: Endoscopic and surgical management of bile duct injury after laparoscopic cholecystectomy. Best Pract Res Clin Gastroenterol 2004, 18:829–846.

    PubMed  CAS  Google Scholar 

  30. Bergman JJ, Burgemeister L, Bruno MJ, et al.: Long-term follow-up after biliary stent placement for postoperative bile duct stenosis. Gastrointest Endosc 2001, 54:154–161.

    PubMed  CAS  Google Scholar 

  31. Kassab C, Prat F, Liguory C, et al.: Endoscopic management of post-laparoscopic cholecystectomy biliary strictures. Long-term outcome in a multicenter study. Gastroenterol Clin Biol 2006, 30:124–129.

    Article  PubMed  Google Scholar 

  32. Draganov P, Hoffman B, Marsh W, et al.: Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple stents. Gastrointest Endosc 2002, 55:680–686.

    Article  PubMed  Google Scholar 

  33. Rerknimitr R, Sherman S, Fogel EL, et al.: Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy. Gastrointest Endosc 2002, 55:224–231.

    Article  PubMed  Google Scholar 

  34. Thuluvath PJ, Atassi T, Lee J: An endoscopic approach to biliary complications following orthotopic liver transplantation. Liver Int 2003, 23:156–162.

    Article  PubMed  Google Scholar 

  35. Mahajani RV, Cotler SJ, Uzer MF: Efficacy of endoscopic management of anastomotic biliary strictures after hepatic transplantation. Endoscopy 2000, 32:943–949.

    Article  PubMed  CAS  Google Scholar 

  36. van Milligen de Wit AW, van Bracht J, Rauws EA, et al.: Endoscopic stent therapy for dominant extrahepatic bile duct strictures in primary sclerosing cholangitis. Gastrointest Endosc 1996, 44:293–299.

    Article  PubMed  Google Scholar 

  37. Catalano MF, Linder JD, George S, et al.: Treatment of symptomatic distal common bile duct stenosis secondary to chronic pancreatitis: comparison of single vs. multiple simultaneous stents. Gastrointest Endosc 2004, 60:945–952.

    Article  PubMed  Google Scholar 

  38. Smits ME, Rauws EA, van Gulik TM, et al.: Long-term results of endoscopic stenting and surgical drainage for biliary stricture due to chronic pancreatitis. Br J Surg 1996, 83:764–768.

    Article  PubMed  CAS  Google Scholar 

  39. Siriwardana HP, Siriwardena AK: Systematic appraisal of the role of metallic endobiliary stents in the treatment of benign bile duct stricture. Ann Surg 2005, 242:10–19.

    Article  PubMed  Google Scholar 

  40. Familiari P, Bulajic M, Mutignani M, et al.: Endoscopic removal of malfunctioning biliary self-expandable metallic stents. Gastrointest Endosc 2005, 62:903–910.

    Article  PubMed  Google Scholar 

  41. Cantu P, Hookey LC, Morales A, et al.: The treatment of patients with symptomatic common bile duct stenosis secondary to chronic pancreatitis using partially covered metal stents: a pilot study. Endoscopy 2005, 37:735–739.

    Article  PubMed  Google Scholar 

  42. van Berkel AM, Cahen DL, van Westerloo DJ, et al.: Self-expanding metal stents in benign biliary strictures due to chronic pancreatitis. Endoscopy 2004, 36:381–384.

    Article  PubMed  Google Scholar 

  43. Pitt HA, Kaufman SL, Coleman J, et al.: Benign postoperative biliary strictures. Operate or dilate? Ann Surg 1989, 210:417–425.

    Article  PubMed  CAS  Google Scholar 

  44. Lee MJ, Mueller PR, Saini S, et al.: Percutaneous dilatation of benign biliary strictures: single-session therapy with general anesthesia. AJR Am J Roentgenol 1991, 157:1263–1266.

    PubMed  CAS  Google Scholar 

  45. Delhaye M, Matos C, Deviere J: Endoscopic technique for the management of pancreatitis and its complications. Best Pract Res Clin Gastroenterol 2004, 18:155–181.

    Article  PubMed  Google Scholar 

  46. Lillemoe KD, Melton GB, Cameron JL, et al.: Postoperative bile duct strictures: management and outcome in the 1990s. Ann Surg 2000, 232:430–441.

    Article  PubMed  CAS  Google Scholar 

  47. Bismuth H, Majno PE: Biliary strictures: classification based on the principles of surgical treatment. World J Surg 2001, 25:1241–1244.

    Article  PubMed  CAS  Google Scholar 

  48. Rothlin MA, Lopfe M, Schlumpf R, Largiader F: Long-term results of hepaticojejunostomy for benign lesions of the bile ducts. Am J Surg 1998, 175:22–26.

    Article  PubMed  CAS  Google Scholar 

  49. Sutcliffe R, Maguire D, Mroz A, et al.: Bile duct strictures after adult liver transplantation: a role for biliary reconstructive surgery? Liver Transpl 2004, 10:928–934.

    Article  PubMed  Google Scholar 

  50. Ahrendt SA, Pitt HA: Surgical therapy of iatrogenic lesions of biliary tract. World J Surg 2001, 25:1360–1365.

    Article  PubMed  CAS  Google Scholar 

  51. Schlitt HJ, Meier PN, Nashan B, et al.: Reconstructive surgery for ischemic-type lesions at the bile duct bifurcation after liver transplantation. Ann Surg 1999, 229:137–145.

    Article  PubMed  CAS  Google Scholar 

  52. Gouma DJ, Obertop H: Management of bile duct injuries: treatment and long-term results. Dig Surg 2002, 19:117–122.

    Article  PubMed  CAS  Google Scholar 

  53. Hirai I, Ishiyama S, Fuse A, et al.: Primary sclerosing cholangitis successfully treated by resection of the confluence of the hepatic duct. J Hepatobiliary Pancreat Surg 2001, 8:169–173.

    Article  PubMed  CAS  Google Scholar 

  54. Brandsaeter B, Isoniemi H, Broome U, et al.: Liver trans-plantation for primary sclerosing cholangitis; predictors and consequences of hepatobiliary malignancy. J Hepatol 2004, 40:815–822.

    Article  PubMed  CAS  Google Scholar 

  55. Sagmeister M, Mullhaupt B, Kadry Z, et al.: Cost-effectiveness of cadaveric and living-donor liver transplantation. Transplantation 2002, 73:616–622.

    Article  PubMed  Google Scholar 

  56. Carmiel-Haggai M, Fiel MI, Gaddipati HC, et al.: Recurrent hepatitis C after retransplantation: factors affecting graft and patient outcome. Liver Transpl 2005, 11:1567–1573.

    Article  PubMed  Google Scholar 

  57. Roayaie S, Schiano TD, Thung SN, et al.: Results of retransplantation for recurrent hepatitis C. Hepatology 2003, 38:1428–1436.

    PubMed  Google Scholar 

  58. Crocenzi FA, Roma MG: silymarin as a new hepatoprotective agent in experimental cholestasis: new possibilities for an ancient medication. Curr Med Chem 2006, 13:1055–1074.

    Article  PubMed  CAS  Google Scholar 

  59. Mezawa S, Homma H, Sato T, et al.: A study of carboplatin-coated tube for the unresectable cholangiocarcinoma. Hepatology 2000, 32:916–923.

    Article  PubMed  CAS  Google Scholar 

  60. Ginsberg G, Cope C, Shah J, et al.: In vivo evaluation of a new bioabsorbable self-expanding biliary stent. Gastrointest Endosc 2003, 58:777–784.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Digestive Endoscopy Unit, “A. Gemelli” University Hospital, Università Cattolica del Sacro Cuore, Largo “A. Gemelli” 8, 00168, Rome, Italy

    Guido Costamagna

Authors
  1. Guido Costamagna
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Pietro Familiari
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andrea Tringali
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Massimiliano Mutignani
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Guido Costamagna.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Costamagna, G., Familiari, P., Tringali, A. et al. Multidisciplinary approach to benign biliary strictures. Curr Treat Options Gastro 10, 90–101 (2007). https://doi.org/10.1007/s11938-007-0061-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11938-007-0061-8

Keywords

Search

Navigation