Management of Benign Biliary Strictures

Management of Benign Biliary Strictures

Wael E.A. Saad


Management of benign biliary strictures (whether surgical, percutaneous-transhepatic, or by endoscopic means) is difficult.14 These lesions are formed of cicatricial fibrosis and are recalcitrant to many minimally invasive techniques.13 They can be a contributing factor to recurrent cholangitis, hepatic segmental atrophy, hepatic graft dysfunction (in cases of transplanted livers), and in the long-run, obstructive biliary cirrhosis.24

Benign biliary strictures are a heterogenous group of lesions that differ in demographics (patient types), locations within the biliary tract, etiology, and disease process (pathology). Firstly, there are pediatric transplant recipients, adult transplant recipients, and adult non-transplant patients with native livers. Pediatric transplant recipients have smaller ducts than adults (transplanted or native livers), and transplant recipients (pediatric or adults) have transplanted livers that have a relatively compromised arterial supply compared to most patients with native livers (see Outcomes for relevance). Secondly, they vary in morphology and location (Fig. 135-1). Thirdly, they vary in etiology and pathogenesis, including inflammatory processes, infectious processes, inflammatory-ischemic processes, thermal injuries from laparoscopic complications, surgical-technical complications at surgical anastomoses (scarring), and (less commonly) radiation injury.1,511 Many key studies amalgamate disease processes, and/or transplant versus non-transplants, and/or stricture locations (peripheral vs. anastomotic), and/or types of anastomoses (duct-to-duct vs. biliary-enteric anastomoses (see Fig. 135-1).4,1213 As a result, it is difficult to discuss anatomic and functional (clinical) outcomes specific to a uniform population or a particular pathologic-anatomic biliary stricture.

The types and locations of benign biliary strictures that are encountered vary depending on the referral pattern and expertise of the institution. However, overall, the vast majority of benign biliary strictures are either (1) peripheral intrahepatic (the ones that are solitary and treatable), commonly related to liver transplantation, and/or (2) anastomotic biliary strictures (whether in transplanted or native livers). For the purpose of this chapter (with its limited scope), these two lesions will be discussed. Non-anastomotic central (hilar or common hepatic bile duct) lesions are treated similarly to anastomotic benign biliary strictures, and they will be discussed as one entity.


Peripheral Intrahepatic Benign Biliary Strictures

The limited indications for managing peripheral intrahepatic benign biliary strictures are confined to cholangitis with or without biliary stones. The primary issue when contemplating the management of peripheral intrahepatic benign biliary strictures is to make sure this is not a diffuse hepatobiliary process that will develop multiple lesions. Diffuse hepatobiliary processes include primary sclerosing cholangitis and diffuse hepatic graft ischemia. Percutaneous transhepatic biliary management of multiple lesions is futile and probably requires several transhepatic biliary drains. The risks versus benefit of managing multiple lesions tilts heavily toward the risks. Furthermore, treat the patient and not the lesion. If the patient is asymptomatic and has no cholangitis, leave the biliary stricture alone, which will probably cause segmental atrophy of the hepatic segment being drained by the constricted biliary duct segment, with compensatory hypertrophy of adjacent hepatic segments. The only exception is an undersized hepatic graft (usually a pediatric recipient) with involvement of a relatively large hepatic segment. In this case, the involved hepatic segment may not be dispensable.

Central Benign Biliary Strictures (Anastomotic and Nonanastomotic)

Indications include cholangitis with or without biliary stones, biliary stones, cholestasis with pruritus, abnormal liver function tests with concern for developing biliary cirrhosis, and hepatic graft dysfunction. The most definitive treatment of central strictures is a hepaticojejunostomy.4,1416 However, redo hepaticojejunostomies have a lower clinical success rate.4,17 Difficult hepaticojejunostomy candidates (candidates for percutaneous or endoscopic management) include poor surgical candidates owing to comorbidities, patients refusing surgery, numerous adhesions and inflammatory process in the porta hepatis, and short biliary stumps in patients with preexisting hepaticojejunostomies.4


Peripheral Intrahepatic Benign Biliary Strictures

Non-candidacy includes asymptomatic patients and/or patients with diffuse hepatobiliary processes with multiple lesions (see earlier). General contraindications include active sepsis, uncorrected coagulopathy, hemobilia, and possibly ascites. Ascites may have a higher risk for bleeding and may cause leakage of ascitic fluid around the internal-external percutaneous transhepatic biliary drain (PTBD) (high morbidity). However, it is not an absolute contraindication in the author’s opinion.


Peripheral Intrahepatic Benign Biliary Strictures

This includes standard internal-external as well as external PTBDs to establish and maintain percutaneous transhepatic access to the biliary tract. Small-caliber, high-pressure (>12 atm), noncompliant balloons are used. The balloon is sized 100% to 110% of the target biliary duct and probably does not exceed 5 to 6 mm.2,13 Remember that right or left main bile duct (hilar) strictures are included in central benign biliary strictures (see later).

Central Benign Biliary Strictures (Anastomotic and Non-anastomotic)

This includes standard internal-external as well as external PTBDs to establish and maintain percutaneous transhepatic access to the biliary tract. High-pressure (>12 atm) noncompliant balloons are used. The balloon is sized 100% to 125% of the target biliary duct and usually ranges from 6 to 15 mm (Table 135-1).23,13,18 Pediatric and adult split-graft transplant recipients usually require smaller balloons (6-10 mm) compared to whole grafts or native livers (7-15 mm).2

Unconventional balloons that have been used include the cutting balloon (Boston Scientific, Natick, Mass.). This is a noncompliant balloon with four microsurgical blades (atherotomes) mounted longitudinally along the outer surface of the balloon. The atherotomes are 1.5 to 2.0 centimeters in length and are 0.127 in depth for all balloon sizes.3 The cutting balloon comes in diameters from 5 to 8 mm and requires use of a coaxial 0.018-inch wire. The 7- and 8-mm diameters require a 7F introducer sheath.3 A drawback is that available diameters of this balloon are limited; 40% of lesions have been found to require balloon sizes greater than 8 mm, which are not available for cutting balloons.3 The PolarCath (for cryoplasty) from Boston Scientific has been mentioned as a potential tool for managing benign biliary strictures,23 but to the best of our knowledge, its use has not been published.

Covered stents (stent-grafts) can also be used.19 There are two commercially available stent-grafts that can be placed percutaneously or endoscopically but are mostly removed by endoscopic means. However, they can be removed transhepatically, but not by design. These two stents-grafts are the VIABIL (W.L. Gore & Associates, Flagstaff, Ariz.) and the WallFlex (Boston Scientific).


The primary step of percutaneous transhepatic management of benign biliary strictures is establishing transhepatic access by an initial percutaneous transhepatic cholangiogram (PTC) followed by PTBD placement.20 The details of the procedure(s) required for access will not be discussed in this chapter. Only the focus of transhepatic management is described.

There are two schools of managing benign biliary stricture. The traditional/historical school is to chronically place a large-bore (14F-16F) internal-external biliary drain to “splinter” (author’s term) the stricture and keep it opened/stented for an extended period of time that usually requires a PTBD in place for months (4-12 months). Occasionally balloon dilation can also be an adjunct to chronic drain placement. The second school relies on a relatively “fast-track” sequential balloon dilation (see later) and ridding the patient of the PTBD sooner rather than later. There are no studies (randomized controlled or retrospective) comparing the effectiveness of these two approaches to managing benign biliary strictures.

The traditional school has an admirable thought process, but it has two problems. The first is the high patient morbidity (patient discomfort) of a chronically indwelling large drain in patients who are otherwise healthy and active.24

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Dec 23, 2015 | Posted by in INTERVENTIONAL RADIOLOGY | Comments Off on Management of Benign Biliary Strictures

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