Benign Billiary Stricture By Dr Dhaval Mangukiya https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

1. Benign Biliary Stricture
Dr Dhaval Mangukiya

2. Clinical Presentation
• Subclinical disease with mild elevation of liver
enzymes to complete obstruction with
jaundice, pruritus and cholangitis, and
ultimately biliary cirrhosis
Warshaw AL, Schapiro RH, Ferrucci Jr JT, Galdabini JJ. Persistent obstructive jaundice,
cholangitis, and biliary cirrhosis due to common bile duct stenosis in chronic pancreatitis.
Gastroenterology. 1976;70(4):562-567

3. Etiology
• Postoperative injury after
cholecystectomy (80%)
• Pancreatitis (10%)
• PSC
• Orthotopic liver
transplantation (OLT)
• Mirizzi syndrome (1%)
• Radiation
• Blunt abdominal trauma
• Portal biliopathy
• Polyarteritis nodosa and systemic
lupus erythematosus (SLE)
• Tuberculosis and histoplasmosis
• Chemotherapeutic drugs
• Sphincter of Oddi dysfunction or
papillary stenosis
• Choledochal cysts
• Recurrent pyogenic cholangitis
• Inflammatory strictures
• Endoscope-related strictures
• HIV cholangiopathy
• Idiopathic
• Miscellaneous

4. • Costamagna G, Tringali A, Mutignani M, et al. Endotherapy of postoperative biliary
strictures with multiple stents: results after more than 10 years of follow-up.
Gastrointest Endosc 2010;72:551-7.
• De Palma GD, Persico G, Sottile R, et al. Surgery or endoscopy for treatment of
postcholecystectomy bile duct strictures? Am J Surg 2003;185:532-5.
• Kuzela L, Oltman M, Sutka J, et al. Prospective follow-up of patients with bile duct
strictures secondary to laparoscopic cholecystectomy, treated endoscopically with
multiple stents. Hepatogastroenterology 2005;52:1357-61.
• Tuvignon N, Liguory C, Ponchon T, et al. Long-term follow-up after biliary stent
placement for postcholecystectomy bile duct strictures: a multicenter study.
Endoscopy 2011;43:208-16.

5. Long-term follow-up after biliary stent placement for
postcholecystectomy bile duct strictures: a multicenter study
• Background and study aims: Endoscopic stenting is a recognized treatment of postcholecystectomy
biliary strictures. Large multicenter reports of its long-term efficacy are lacking. Our aim was to
analyze the long-term outcomes after stenting in this patient population, based on a large experience
from several centers in France.
• Methods: Members of the French Society of Digestive Endoscopy were asked to identify patients
treated for a common bile duct postcholecystectomy stricture. Patients with successful stenting and
follow-up after removal of stent(s) were subsequently included and analyzed. Main outcome
measures were long-term success of endoscopic stenting and related predictors for recurrence (after
one stenting period) or failure (at the end of follow-up).
• Results: A total of 96 patients were eligible for inclusion. The mean number of stents inserted at the
same time was 1.9 ± 0.89 (range1 – 4). Stent-related morbidity was 22.9 % (n = 22). The median
duration of stenting was 12 months (range 2 – 96 months). After a mean follow-up of 6.4
± 3.8 years (range 0 – 20.3 years) the overall success rate was 66.7 % (n = 64)
after one period of stenting and 82.3 % (n = 79) after additional treatments.
The mean time to recurrence was 19.7 ± 36.6 months. The most significant independent predictor of
both recurrence and failure was a pathological cholangiography at the time of stent removal.
• Conclusion: Endoscopic stenting helps to avoid surgery in more than 80 % of patients bearing
postcholecystectomy common bile duct strictures. However, a persistent anomaly on
cholangiography at the time of stent removal is a strong predictor of recurrence and may lead to
consideration of surgery.

6. Type
Bismuth H, Majno PE. Biliary strictures: classification based on the principles of surgical treatment.
World J Surg. 2001;25:1241e1244

7. Strasberg system
Strasberg SM, Herd M, Soper NJ. An analysis of biliary injury during laparoscopic
cholecystectomy. J Am Coll Surg. 1995;180:101–105

9. Good long-term results have been reported by endoscopists
• Born P, R¨osch T, Br¨uhl K, et al. Long-term results of endoscopic and percutaneous transhepatic treatment of benign biliary strictures.
Endoscopy. 1999;31:725–731
• Davids PHP, Rauws EAJ, Coene PPLO, et al. Endoscopic stenting for postoperative biliary strictures. Gastrointest Endosc. 1992;38:12–
18.
• Davids PHP, Tanka AKF, Rauws EAJ, et al. Benign biliary strictures: surgery or endoscopy? Ann Surg. 1993;217:237–243.
• Smith MT, Sherman S, Lehman GA. Endoscopic management of benign strictures of the biliary tree. Endoscopy. 1995;27:253–266.
• Tocchi A,Mazzoni G, Liotta G, et al.Management of benign biliary strictures: biliary enteric anastomosis vs endoscopic stenting. Arch
Surg. 2000;135:153– 157.
• 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.
• Gouma DJ, Obertop H. Management of bile duct injuries: treatment and longterm results. Dig Surg. 2002;19:117–122.
• de Reurer PR, Rauws EA, Vermeulen M, et al. Endoscopic treatment of postsurgical bile duct injuries: long-term outcome and
predictors of success. Gut. 2007;56:1599–1605.
• Fatima J, Burton JG, Grotz TE, et al. Is there a role for endoscopic therapy as a definitive treatment for post-laparoscopic bile duct
injuries? J Am Coll Surg. 2010;211:495–502.
• Karoda Y, Tsuyuguchi T, Sakai Y, et al. Long-term follow-up evaluation for more than 10 years after endoscopic treatment for
postoperative bile duct strictures. Surg Endosc. 2010;24:834–840.
• Moon JH, Choi JH, Koo HC, et al. Feasibility of placing a modified fully covered self-expanding metal stent above the papilla to
maximize stent-induced bile duct injury in patientswith refractory benign biliary strictures. Gastrointest Endosc. 2012;25:1080–1085.

10. Good long-term results have been
reported by radiologists
• Pitt HA, Kaufman SL, Coleman JA, et al. Benign postoperative biliary strictures: operate or dilate? Ann Surg.
1989;210:417–425.
• Lillemoe KD, Melton GB, Cameron JL, et al. Postoperative bile duct strictures: management and outcomes
in the 1990s. Ann Surg. 2000;232:430–441.
• Lillemoe KD, Martin SA, Cameron JL, et al. Major bile duct injuries during laparoscopic
cholecystectomy. Ann Surg. 1997;225:459–471.
• Misra S, Melton GB, Geshwind JF, et al. Percutaneous management of bile duct strictures and injuries
associated with laparoscopic cholecystectomy: a decade of experience. J Am Coll Surg. 2004;198:218–226.

11. • Pitt HA, Myamoto T, Parapatis SK, et al. Factors influencing outcome in patients
with postoperative biliary strictures. Am J Surg. 1982;144:14–21
• Lillemoe KD, Martin SA, Cameron JL, et al. Major bile duct injuries during
laparoscopic cholecystectomy. Ann Surg. 1997;225:459–471.
• Ahrendt SA, Pitt HA. Surgical therapy of iatrogenic lesions of the biliary tract. World
J Surg. 2001;25:1360–1365
• Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy: factors
that influence the results of treatment. Arch Surg. 1995;130:1123–1128.
• 25. Murr MM, Gigot J-F, Najorney DM, et al. Long-term results of biliary
reconstruction after laparoscopic bile duct injuries. Arch Surg. 1999;134:604–610.
• 26. Johnson SR, Koehler A, Pennington LK, et al. Long-term results of surgical repair
of bile duct injuries following laparoscopic cholecystectomy. Surgery.
2000;128:668–677.
• Schmidt SC, Langrehr M, Hintze RE, et al. Long-term results and risk factors
influencing outcome of major bile duct injuries following cholecystectomy. Br J
Surg. 2005;92:76–82.
• de Santiba˜nes E, Palavecino M, ArdilesV, et al. Bile duct injuries: management of
late complications. Surg Endosc. 2006;20:1648–1653.
Good long-term results have been
reported by surgeons

12. Patient Classification
• Bile leaks (type A, n = 239, 45%) or Bile duct injuries
(types B-E, n = 289, 55%) (Table 1).
• Type A - 239 patients with bile leaks
– 229 (95.8%) were managed primarily by endoscopists
– 9 (3.8%) were treated exclusively by interventional
radiologists
– 1 required surgery.
• Type B – E - 289 patients with bile duct injuries
– 70 (24%) were managed by interventional radiologists
– 115 (40%) by endoscopists
– 104 (36%) by surgeons
• 33 patients who were managed by more than 1
modality
– Twenty patients were managed by both interventional
radiologists and surgeons.
– Nine patients were treated by both endoscopists and
surgeons.
– Three patients were managed by both interventional
radiologists and endoscopists
– 1 patient was managed by all 3 specialists.
Management by time (Strasberg B→E).

14. The mean stent time for interventional radiology, endoscopy, and surgery
patients was 9.1, 10.6, and 5.8 months, respectively.

15. Outcomes
Strasberg A bile leaks, who were
managed predominantly by
endoscopists, 96% had a successful
outcome.
50% 76% 88%

16. Multivariable analysis
• Type of management (surgery, endoscopy, or
interventional radiology) and the length of
time that stents were employed remained
statistically significant (each P < 0.001).
Outcomes were worse in (a) endoscopically managed patients who
presented relatively late (2–6 months) and (b) patients who underwent
surgery 2 to 4 weeks after the injury
Surgical management and stenting for 6 to 12
months remained significant predictors of a
successful outcome in a multivariable analysis
(P < 0.001)

17. CONCLUSIONS
• Bile leaks from the cystic duct or a duct of
Lushka were managed almost exclusively by
endoscopists with excellent results. In patients
with bile duct injuries, results were best for
those managed by surgeons, and a successful
outcome was achieved in 95% of these
patients in recent years

18. • Temporary placement
of multiple plastic
stents is recommended.
• Placement of uncovered
SEMS is strongly
discouraged.
• Covered SEMS in
selected patients.

19. Bile Duct Arterial supply

20. SIDS Data – Surgery (30 Patients)
• Biliary Stricture (19)
– HJ (14)
– CBD Exploration (2)
– Redo HJ (1)
– Left Hepatectomy (1)
– CBD stitch removal (1)
• Bile Duct Injury (11)
– Endobiliary stent and
drainage
– External drainage
• Either Laparoscopic or
open
Outside SIDS Elective HJ - 15

21. • Bile duct injury after laparoscopic
cholecystectomy: New classification and
Novel approach for the management in
emergency situations.
• Presented at DDW June 2018
• Dr Pankaj Desai, Dr Keyur Bhatt, Dr Dhaval Mangukiya
SIDS Data

22. SIDS Data Endoscopy
• Strasberg A (102)
– 91 patients had drains
kept during surgery
– 11 patients had Biloma
& pigtail was done
• Strasberg B – E (76)
– 39 HJ (Avg 62nd day)
– 34 Multiple Stenting
Type of injury Number of
patients
Type I 102
Type II 34
Type IIIA 19
Type IIIB 15
Type IIIC 4
Type IIID 2
Type IV 2

24. Chronic Pancreatitis
• Frey’s procedure
• Frey’s procedure + choledochojejunostomy
• Frey’s procedure + opening of the bile duct in
the cored-out head of the pancreas
• Frey’s procedure + choledochoduodenostomy
• Whipple’s operation

25. 341 THE MAJORITY OF PATIENTS REMAIN STENT-FREE 5 YEARS AFTER TEMPORARY
INDWELL OF A SINGLE FULLY COVERED SELF-EXPANDING METAL STENT FOR
TREATMENT OF BENIGN BILIARY STRICTURES SECONDARY TO CHRONIC
PANCREATITIS - RESULTS OF A MULTI-CENTER STUDY
• Jacques Deviere , Nageshwar R. Duvvur, Andreas Püspök et al
• 78% of pts remained stent-free 5 years after stenting
• A randomized comparison to treatment using multiple plastic stents is
warranted
• June 2018 Volume 87, Issue 6, Supplement, Pages AB72–AB73
Chronic Pancreatitis

26. Portal Biliopathy

27. Portal Biliopathy
In patients with extensive thrombosis and non-
shuntable vein or blocked shunt, patients must
be managed with continued endoscopic stents.
Such patients may be candidates for
placement of self-expanding metal stents.
World J Gastroenterol 2016 Sep 21; 22(35): 7973–7982

28. Etiology
• Postoperative injury after
cholecystectomy (80%)
• Pancreatitis (10%)
• PSC
• Orthotopic liver
transplantation (OLT)
• Mirizzi syndrome (1%)
• Radiation
• Blunt abdominal trauma
• Portal biliopathy
• Polyarteritis nodosa and systemic
lupus erythematosus (SLE)
• Tuberculosis and histoplasmosis
• Chemotherapeutic drugs
• Sphincter of Oddi dysfunction or
papillary stenosis
• Choledochal cysts
• Recurrent pyogenic cholangitis
• Inflammatory strictures
• Endoscope-related strictures
• HIV cholangiopathy
• Idiopathic
• Miscellaneous

29. Benign Biliary Stricture
• Only Endoscopic management for Cystic duct
stump blowout with or without retained CBD
stone
• Combination of ERC stent with Surgery at
optimum time interval for Type B,D,E1,E2 BBS
• Only Surgical management for bile duct injury
with peritonitis and Type C,E3,E4,E5 BBS
• Interventional radiology utilised for bilioma, post
bilioenteric anastomotic stricture and Acute
cholangitis with non faesible scenario for
Endoscopist

30. THANK YOU