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Management of Benign Biliary Strictures
Management of benign biliary strictures, whether surgical, percutaneous-transhepatic, or by endoscopic means, is difficult. These lesions are formed of cicatricial fibrosis and are recalcitrant to many minimally invasive techniques. 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.
Benign biliary strictures are a heterogenous group of lesions that differ in demographics, locations within the biliary tract, etiology, and disease process. Benign biliary strictures 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. Many key studies combine disease processes (e.g., transplant vs. nontransplant), varied stricture locations (e.g., peripheral vs. anastomotic), and/or types of anastomoses (e.g., duct-to-duct vs. biliary-enteric anastomoses [ Fig. 93.1 ]). As a result, it is difficult to discuss anatomic, functional, and clinical outcomes.
Flow chart demonstrating classification of benign biliary strictures based on transplant vs. native livers and based on lesion location. Another dimension of variation not included in the flow chart is the etiology of the benign stricture. Nonanastomotic extrahepatic lesions are in the common hepatic duct. Hilar intrahepatic lesions are lesions at the confluence of main right and main left biliary ducts or in the main right or left biliary ducts. The only exception is if a surgical anastomosis is at the confluence (almost no biliary stump). In this case, we would consider it anastomotic (extrahepatic).
The types and locations of benign biliary strictures encountered vary depending on the referral pattern and expertise of the institution. Overall, most benign biliary strictures are either (1) peripheral intrahepatic (i.e., strictures that are generally solitary, treatable, and not infrequently related to liver transplantation), or (2) anastomotic biliary strictures. For the purpose of this chapter, these two lesion types are discussed.
Indications
Peripheral Intrahepatic Benign Biliary Strictures
An indication for managing peripheral intrahepatic benign biliary strictures is cholangitis with or without associated biliary stones. An important issue when approaching the management of peripheral intrahepatic benign biliary strictures is to make certain that this is not a diffuse hepatobiliary process with multiple lesions. Diffuse hepatobiliary disease processes include primary sclerosing cholangitis and diffuse hepatic graft ischemia. Percutaneous transhepatic biliary management of multiple lesions is challenging and may require several transhepatic biliary drainage catheters. Biliary strictures may cause segmental atrophy of the hepatic segment drained by the narrowed biliary duct segment, and one may see compensatory hypertrophy of adjacent hepatic segments. However, if the patient is clinically asymptomatic and has no cholangitis, the biliary stricture may not require intervention.
Central Benign Biliary Strictures (Anastomotic and Nonanastomotic)
Indications for intervention include (1) biliary stones, (2) cholangitis with or without biliary stones, (3) cholestasis with pruritus, (4) abnormal liver function tests with a concern for the development of biliary cirrhosis, and (5) hepatic graft dysfunction. The most definitive treatment of central strictures is a surgical hepaticojejunostomy. In contrast, redo surgical hepaticojejunostomies have a lower clinical success rate. Patients who are not optimal surgical candidates for a hepaticojejunostomy include those with significant medical comorbidities, those refusing surgery, and those with challenging anatomy such as adhesions and inflammatory processes in the porta hepatis, and short biliary stumps due to prior hepaticojejunostomies.
Contraindications
Peripheral Intrahepatic Benign Biliary Strictures
In general, patients who are not candidates for stricture intervention include asymptomatic individuals and/or those with diffuse hepatobiliary processes with multiple lesions. Other contraindications include active sepsis, uncorrected coagulopathy, hemobilia, and possibly ascites. Ascites may have a higher risk for bleeding and morbidity and may result in leakage of ascitic fluid around the internal-external percutaneous transhepatic biliary drain (PTBD). However, in the authors’ opinion, there is no absolute contraindication to treatment.
Central Benign Biliary Strictures (Anastomotic and Nonanastomotic)
General contraindications for treatment of central benign biliary strictures are the same as those outlined earlier. In addition, an active biliary leak from a surgical anastomosis is a contraindication to transhepatic balloon dilation, which may increase the leak or rupture the surgical anastomosis.
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