Elsevier

Gastrointestinal Endoscopy

Volume 72, Issue 3, September 2010, Pages 551-557
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
Endotherapy of postoperative biliary strictures with multiple stents: results after more than 10 years of follow-up

https://doi.org/10.1016/j.gie.2010.04.052Get rights and content

Background

Endoscopic dilation of postoperative biliary strictures with increasing numbers of stents was first described by our group in 2001 with promising results after a long-term follow-up (mean 4 years).

Objective

To verify results of endoscopic treatment of postoperative biliary strictures at a very-long-term follow-up.

Design

Single center, follow-up study.

Setting

Tertiary-care, academic referral center.

Patients

A group of 42 patients from our 2001 study, who had undergone endoscopic dilation of postoperative biliary strictures with the multiple endoscopic stenting technique, underwent systematic follow-up. The last telephone follow-up was done in September 2009.

Intervention

Clinical conditions and the occurrence of new biliary symptoms during the follow-up period were assessed, and results of the most recent liver function tests and abdominal US were recovered.

Main Outcome Measurements

Occurrence of cholangitis and liver function test evaluation during the follow-up period.

Results

Of the 40 patients who were alive at the end of the study published in 2001, 5 (12.5%) died of unrelated causes after a mean of 6.7 years (range 3-13.3 years) from the end of treatment, without further biliary symptoms. The overall mean follow-up time for the remaining 35 patients (87.5%) was 13.7 years (range 11.7-19.8 years). Seven patients (20%) experienced recurrent acute cholangitis after a mean of 6.8 years (range 3.1-11.7 years) from the end of treatment. All 7 of these patients underwent ERCP. Four of the 7 patients had postoperative biliary stricture recurrence (n = 4/35, 11.4%) that was retreated endoscopically with placement of stents, and the other 3 patients had common bile duct stones (n = 3/35, 8.6%) that were extracted. No stricture or bile duct stone recurrences after retreatment were recorded after a mean follow-up period of a further 7.1 years (range 2.5-12.1 years). Twenty-eight patients remained asymptomatic with normal liver function test results and abdominal US results after a mean follow-up period of 13.7 years (range 11.7-19.8 years).

Limitations

Telephone follow-up.

Conclusion

Results of multiple endoscopic stenting for postoperative biliary strictures remain excellent even after a very-long-term follow-up. The stricture recurrence rate is low, and recurrences can be retreated endoscopically.

Section snippets

Patients and methods

The study group consisted of 42 patients1 who underwent aggressive endoscopic treatment of POBS by use of an increasing number of large-bore plastic stents between December 1987 and December 1997. POBS were classified according to the Bismuth and Lazorthes6 method: 36% had type I strictures, 21% type II, 17% type III, 19% type IV, and 7% type V.

The 42 patients underwent systematic follow-up: all were asked to undergo liver function tests (total and direct bilirubin, aspartate aminotransferase,

Results

No patients were lost to follow-up. Five patients (12.5%) died from unrelated causes (thyroid cancer, pharynx cancer, prostate cancer, heart failure, motorbike accident) after a mean of 6.7 years (range 3-13.3 years, median 6 years, IQR 3-8) from the end of treatment. These patients did not experience further episodes of cholangitis during their lives, and the last liver function test results and abdominal US results were within normal ranges.

The mean follow-up period for the remaining 35

Discussion

POBS need a multidisciplinary approach from diagnosis to treatment. With the advent of laparoscopic cholecystectomy, the incidence of bile duct lesions has increased significantly.7 Patients with POBS are usually healthy and young, but this “benign” event can affect quality of life significantly.8, 9

Three kinds of treatment are available: surgical, endoscopic, and percutaneous. Surgical treatment of POBS should be performed in referral hepatobiliary surgical units because surgical repair may be

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      Citation Excerpt :

      Endoscopic therapy of ABS usually requires biliary sphincterotomy, balloon dilatation and stent placement. The use of balloon dilatation alone in early onset anastomotic strictures (the first 2 months following LT) may be effective, but it leads to a high rate of recurrent stricture formation [22,23]. Multiple 10-Fr plastic stents are usually maintained until stricture resolution or for a minimum of 12 months, with stent exchange scheduled every 3–4 months to reduce the chance of stent blockage and cholangitis; this was our main strategy.

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    DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

    See CME section; p. 600

    If you would like to chat with an author of this article, you may contact Dr Costamagna at [email protected].

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