Synopsis  

Although most centres performing laparoscopic cholecystectomy may now be well beyond the 'learning-curve' phase, the incidence of postsurgical bile duct injuries will probably stay higher than in the era before laparoscopic cholecystectomy. In addition, with surgeons embarking on more complex laparoscopic biliary interventions, such as laparoscopic duct exploration, a further increase in the incidence of surgical bile duct injuries may be expected in the near future. Adequate management of these injuries requires an early postoperative diagnosis with a low threshold for performing an ERCP.

Patients with a complete ductal transection require an elective surgical repair, 6–8 weeks after diagnosis and drainage. Most of the other bile duct injuries (minor leaks from the cystic stump or peripheral hepatic radicals, major bile duct leaks, and isolated bile duct strictures) can in general be managed endoscopically.

Patients who require long-term stenting for bile duct strictures should be treated with at least two 10 Fr plastic stents that are electively exchanged every 3 months. If possible, more than two stents should be inserted. There is currently no place for self-expandable metal stents for this indication.

Optimal management of patients with bile duct injuries requires a multidisciplinary team approach of interventional radiology, therapeutic endoscopy, and reconstructive surgery.

 Introduction   

The majority of surgical bile duct injuries occur during cholecystectomy, but any surgical procedure involving the liver and/or bile ducts may cause these lesions. Over the last decade laparoscopic cholecystectomy has gained widespread acceptance among surgeons and the public and has replaced conventional 'open' cholecystectomy as treatment of choice for symptomatic cholecystolithiasis. Compared with 'open' cholecystectomy, laparoscopic cholecystectomy is associated with less postoperative pain, shorter stay in hospital and recovery, earlier return to work, and a better cosmetic outcome [1]. Laparoscopic cholecystectomy does, however, carry an increased risk for biliary tract injury [2]. These injuries occur in 0.2–0.5% of patients undergoing open cholecystectomy and in 0.5–2.7% after laparoscopic cholecystectomy [3–6]. The injury often results from poorly defined anatomy or from attempts to stop hilar bleeding by means of clipping or thermal devices. Besides direct injury due to clipping and diathermy, delayed injury may arise from ischemia of the bile ducts [7]. The presence of acute cholecystitis, and a low case volume of the surgeon, are accepted risk factors for bile duct injury during laparoscopic cholecystectomy [8,9]. Intraoperative cholangiography does not seem to reduce the frequency of these complications [9]. Management of patients with postsurgical bile duct injuries requires a multidisciplinary approach of radiologists, endoscopists, and surgeons. In general, multiple invasive procedures are required and, although the functional outcome is usually good, postsurgical bile duct injuries have a marked influence on the patients' physical and mental quality of life, even at long-term follow-up [10].

 Classification of bile duct injuries   

In general, four types of bile duct injury can be recognized.

• Type A Cystic duct leaks or leakage from aberrant or peripheral hepatic radicles (Figs 1 and 2).
  
• Type B Major bile duct leaks with or without concomitant biliary strictures (Figs 3 and 4).
  
• Type C Bile duct strictures without bile leakage (Figs 4 and 5).
  
• Type D Complete transections of the duct with or without excision of some portion of the biliary tree (Fig. 6) [11].
  

Presentation   

The majority of bile duct lesions during cholecystectomy are not recognized during the procedure. The postoperative clinical presentation varies widely and is mainly influenced by the type of injury [11]. The diagnosis is usually straightforward in patients with an isolated ductal stricture (type C). These lesions present with jaundice, cholestatic liver function tests, and dilated bile ducts on ultrasound and have a relatively long symptom-free interval after the cholecystectomy (median of 2 months in our series) [11]. In contrast to isolated strictures, bile leaks due to minor bile duct lacerations (type A lesions), major bile duct lacerations (type B lesions), or complete transections (type D lesions), present in a less uniform way. Here, symptoms are frequently absent or non-specific in the early postoperative phase (general malaise, low grade fever, marginally increased liver function tests). However, the patient's clinical condition may rapidly deteriorate after 3–5 days when ileus, peritonitis, and sepsis develop. Early aggressive investigation in patients with diffuse abdominal pain, fever, malaise, or liver function abnormalities after laparoscopic cholecystectomy is therefore mandatory [12,13].

 Diagnostic protocol   

The first step is to perform an abdominal ultrasound to investigate the presence of ductal dilatation or fluid collections [14]. Biliary dilatation is often absent (in our series in 71% of cases) [11] because the biliary system is decompressed by the leak. In the event of fluid collections, percutaneous needle aspiration may differentiate an abscess from a biloma [15]. When ductal dilatation is present or needle aspiration yields bile, an ERCP should be the next diagnostic procedure [11]. At ERCP, care should be taken that the whole biliary system is visualized. Bile leaks associated with the anatomical variant of a low-inserting right segmental hepatic duct can be particularly difficult to diagnose and ERCP results are often interpreted falsely as 'normal', with no leaks demonstrated (Fig. 7).

 Management of bile duct leakage after cholecystectomy   

Spontaneous resolution of bile leakage has been described in patients with external drains [16]. Some have therefore advocated a 'wait-and-see' policy in these patients and this seems justified in clinically stable patients without evidence of sepsis or peritonitis. However, if percutaneous bile leakage persists or the patient's clinical condition deteriorates, an ERCP is indicated. This will establish the diagnosis in all patients with types A, B, and C lesions and will allow for effective therapeutic intervention in most of them [11].

Type A injury (peripheral leaks)   

Patients with bile leakage from the cystic duct or peripheral hepatic radicles are treated by insertion of a short biliary stent to lower the pressure of the biliary system by bypassing the biliary sphincter (Fig. 8). The stent is preferably inserted without endoscopic sphincterotomy unless this is necessary to extract bile duct stones or gain biliary access. Endoscopic treatment is effective in 90% of the patients with type A lesions, although 15–20% will require additional percutaneous drainage of a biloma[11]. Insertion of a stent does give the patient the burden of a second endoscopic intervention for removal of the stent but prevents a sphincterotomy that may cause acute and late complications. Placement of a nasobiliary tube is another option in treating leakage from minor bile ducts: closure of the leak can be monitored by repeating cholangiography, low pressure suction can be applied, and drain removal does not require an additional endoscopy [17,18]. However, nasobiliary tubes are not well tolerated by patients and long-term drainage may require recirculation of bile to prevent electrolyte disturbances [19].

Type B injury (main duct leaks)   

Bile leakage from major bile ducts may be more challenging to treat endoscopically. Extensive duct damage and leakage can make it difficult to pass a guidewire into the proximal biliary system (Fig. 9). The presence of clips and stenoses (due to inflammatory reactions in the hepatoduodenal ligament) may also hamper passage into the proximal hepatic system or insertion of stent. In case ERCP fails, PTC and rendezvous procedure should be the next step (Fig. 10). Endoscopic treatment is successful in approximately 75% of patients with leakage from major bile ducts [8,11,20]. An important late complication of bile leakage from major bile ducts is a secondary stenosis at the site of the leak (Fig. 4). Insertion of a stent not only adequately seals the bile leakage but also allows for prevention or treatment of secondary ductal stenosis.

Type C injuries (postoperative biliary strictures)   

Most postoperative bile duct strictures are short (less than 10 mm in length) and situated distal to the confluence of right and left hepatic ducts. Postoperative strictures are usually classified according to Bismuth by their position relative to the hepatic confluence [23].

Options for therapy include surgery, percutaneous balloon dilation and stenting, and endoscopic stenting, if necessary combined with balloon dilation. The different treatment options will be discussed below.

Type D injury (transections)   

Patients with complete transection of the bile duct are not amenable to endoscopic treatment because the distal and proximal biliary systems are not in continuity (Fig. 6). These patients should undergo reconstructive surgery: Roux-en-Y-hepaticojejunostomy is the procedure of choice. The outcome of surgical management of these lesions is influenced by a variety of factors including: proximal extent of the injury, type of reconstructive procedure performed, experience of the performing surgeon, timing of intervention, presence of proximal dilation and local inflammation at the time of the procedure, condition of the patient, and the length of follow-up. The timing of the procedure is a key factor determining the outcome of reconstructive surgery.

Delayed reconstruction   

We observed that early complications and late anastomotic stenoses occurred in 80% of patients treated with early reconstructive surgery whereas these complications were observed in only 17% of patients who underwent elective surgery after 8–12 weeks [11]. Reconstructive surgery in the acute postoperative phase, often started as a diagnostic procedure in a patient with peritonitis, ileus, or sepsis, is at risk for leakage and stenosis because of the absence of proximal dilatation and the presence of severe inflammatory changes of the tissue. Adequate drainage for 8–12 weeks through percutaneously placed drains allows for the acute local inflammatory reaction to subside and enables the surgeon to establish the exact proximal extent of the injury before surgery [21]. In most patients a percutaneous transhepatic cholangiography and drainage (PTCD) is performed for this purpose and to delineate the proximal anatomy prior to the reconstruction [22]. The biliary system in these patients is often not dilated because it is decompressed by leak. A PTC may therefore be technically difficult and one may choose to drain the biloma by subhepatic and/or abdominal drains and to use MRCP and/or fistulography through these drains to delineate the proximal extent of the injury (Fig. 7).

 Surgical treatment of postoperative biliary strictures   

The outcome of surgery for benign biliary strictures is good in 75–93% of patients [21,24,25]. The treatment of choice is usually a Roux-en-Y-hepaticojejunostomy. Anastomotic strictures develop later in approximately 20% of patients [24,26], and when a subsequent repair is undertaken, a further recurrence develops in 26% [27,28]. The majority of anastomotic stenoses develop within 7 years of surgery [28]. Reported surgical mortality rates are in the range of 3.2–27%, the higher rate being related to patients with coexisting pathology such as portal hypertension [24,25,27]. Factors that are associated with a favorable outcome include greater distance from the hepatic confluence, early referral, no previous repair, and the quality of the proximal duct.

It is important to note that there are only a few reports on surgical treatment of patients with postoperative biliary strictures, and that most reports describe surgical treatment of more than a decade ago. Since then, surgeons have benefited by the improvement in endoscopic and invasive radiographic techniques. Nowadays ultrasound, CT-scanning, ERCP, and PTC provide surgeons with accurate preoperative information and allow for the optimal timing of the reconstructive procedure. Combined with improved surgical techniques, this may have resulted in an improved outcome of surgical treatment. Lillemoe et al. [22] have reported on a series of 156 patients undergoing surgical reconstruction for postoperative bile duct strictures. Two patients died of unrelated disease before completion of treatment, 12 patients had biliary stents in place at the time of the report. Of the 142 patients who completed treatment (mean follow-up 58 months) 91% were considered to have a successful outcome without the need for further interventional procedures.

 Percutaneous treatment of postoperative strictures   

Percutaneous dilation via transhepatic puncture or T-tube has an associated morbidity of less than 7% [29], but the reported success rates vary widely from 33 to 100% [29,30]. In general, percutaneous therapy requires several sessions to obtain a satisfactory outcome. In our hospital, patients undergo a PTC on the first day to obtain a diagnostic cholangiogram and to decompress the biliary system. The next day a percutaneous balloon dilatation (8–10 mm balloon) is performed and an internal–external PTC-drain is inserted through the anastomosis. This drain is left in situ for 6 weeks and then removed after a second balloon dilatation procedure. Misra et al. recently reported their results in 51 patients. The success rate of percutaneous management without the need for subsequent interventions was 59% [31].

The major concerns with the transhepatic approach are the attendant risks of hemorrhage and bile leakage associated with liver puncture. Additionally, two-thirds of patients may have a non-dilated biliary tract, making ductal puncture technically difficult [32]. A further disadvantage is the requirement for long-term transhepatic intubation. In our unit, the percutaneous approach is mainly reserved for patients with postsurgical anastomotic stenoses (usually after hepaticojejunostomy) and as part of a rendezvous procedure with ERCP after failed prior endoscopic approach (Fig. 10).

 Endoscopic treatment of postoperative biliary strictures   

Endoscopic management of patients with postoperative biliary strictures comprises endoscopic balloon dilation, placement of biliary stents, or a combination of the two.

Endoscopic balloon dilation can be performed with 4–8 mm diameter balloons that are passed over a prepositioned guidewire (Fig. 11). In case of very tight strictures, dilating catheters can be used to facilitate advancement of the balloon catheter. Under fluoroscopic control the balloons are then inflated to 4–10 atmospheric pressures. The optimum duration of the maximum insufflation and the number of dilation cycles during one procedure are not well established. Usually balloon dilation does not result in complete disappearance of the waist in the balloon at the first procedure and thus multiple procedures are necessary for radiological resolution. Some preliminary data for endoscopic balloon dilation alone appeared favorable, but this was not confirmed in other studies [33].

Reported results   

Many reports have been published on the outcome of endoscopic treatment in patients with postoperative strictures, but it is difficult to extrapolate general figures for success and complication rates and to determine what factors influence these outcome parameters. Virtually all series are retrospective single-center reports on treatment of a heterogeneous group of patients: isolated strictures and leaks, different mixtures of Bismuth localizations, with or without secondary cirrhosis at the time of treatment, with and without prior treatment before referral to expert centers, etc. Most series have included patients during a period of many years in which endoscopic protocols have changed. Many studies, therefore, describe study populations that have not been uniformly treated. Series with a relatively short follow-up period may reliably report early success and complication rates but will lack the rate of restenosis after stent removal. For this, long-term follow-up studies are required but these may suffer from the same drawbacks as the aforementioned antiquated surgical reports (e.g. the rate of early complications may be an overestimation of the current practice). In Fig. 14 the different phases of endoscopic management of postoperative bile duct stenoses are shown, as well as the outcome parameters of interest. This flow-chart should preferably be used as guidance for further reports on the endoscopic management of patients with postoperative bile duct stenoses.

An early study by our group found that a combination of balloon dilation and insertion of a 10 Fr polyethylene stent, yielded satisfactory results in 21 of 27 patients during a follow-up period of 18 months [34]. Other investigators obtained similar results with this combination therapy [33,35–38]. The standard endoscopic technique nowadays involves placement of usually two stents during a maximum treatment period of 12 months (Figs 12 and 13). To prevent cholangitis due to clogging stents are exchanged at 3 month intervals. The treatment protocol therefore consists of three phases: a stent insertion phase, a stenting phase with stents in situ and trimonthly stent exchange, and a follow-up phase after removal of the stents (Fig. 14).

One of the most comprehensive studies comes from Dumonceau and colleagues, who treated 48 patients with postoperative biliary strictures [39]. Endoscopic dilation of the strictures by means of dilating catheters or balloons was successful in 47 (98%). Four patients had self-expandable metal stents inserted and 43 received plastic stents that were electively exchanged every 6 months. Complications occurred in 6/48 patients (13%) after the initial ERCP. Stenting was maintained for a mean of 8.3 months (0.3–32 months) during which complications occurred in 20% of patients (mainly cholangitis or mild fever after elective stent exchange). Five patients discontinued the stenting phase but in only one patient was this due to complications. In 38 patients the endoscopic treatment was completed: 36 had stricture dilation judged satisfactory during a stent exchange and had no new stents inserted. In two patients plastic stents were replaced by Wallstents. After removal of the stents, the 36 patients were followed up for a mean period of 44 months (1–130 months). In 7 patients (19%) the strictures recurred, with all but one of these occurring within 1 year of stent removal.

Our group has performed a retrospective analysis of 63 patients with incomplete biliary strictures [40]. Stent insertion was successful in 59 (94%). After the initial ERCP early complications occurred in 13 patients (20%), whereas 19 patients (33%) suffered from complications during the stenting phase (mainly cholangitis). Stents were eventually removed in 44 patients after a median period of 12 months (3–37 months). During a median follow-up period of 109 months (2–180 months) restenosis occurred in 9 patients (20%) and all cases of restenosis occurred within 2 years of follow-up.

In Fig. 15 the results of endoscopic treatment of postoperative biliary strictures are summarized.

Phases of endoscopic treatment   

Stent insertion phase   

Stent insertion is successful in about 95% of patients with incomplete ductal strictures [39,40]. In patients with a total ductal obstruction endoscopic treatment is not possible. Since an ERCP is required to make this diagnosis, these patients are inevitably failures of endoscopic treatment. In a strict sense these patients do not have a true stenosis and most studies have therefore limited the inclusion to patients with incomplete ductal stenosis [39,41]. Early complications are mainly sphincterotomy-related or reflect the patient's condition (e.g. pre-existent fever in case of bile leakage). Dumonceau et al. reported early complications in 6 of their 48 patients (12.5%) whereas Costamagna observed 4 complications in 45 patients (9%) [41]. In our series an early complication rate as high as 19% was observed. This study, however, was performed to evaluate the long-term outcome of endoscopic treatment, and patients were treated 10–15 years ago [40]. With the current endoscopic standards, early complications should not be observed in more than 10% of patients.

Stenting phase   

Since the stenting period covers a period of up to 1 year, complications are not uncommon (33% and 20% in the aforementioned studies, respectively). Dumonceau et al. used an interval of 6 months between elective ERCPs and this may be too long given the average time to stent occlusion as reported in other studies [39]. In our retrospective study, complications during the stenting period mainly occurred in patients in whom the patients and/or referring physicians did not adhere to treatment protocol [40]. Many years have passed since then, and the endoscopic treatment of patients with benign biliary strictures has become more accepted. Currently, in patients in whom elective trimonthly ERCPs are performed, complications due to stent dysfunction are mild and occur at a maximum of 10–15% during a stenting period of 1 year. With this regimen 90–95% of patients will have their stenosis adequately dilated within 1 year.

Follow-up phase   

Studies have reported a recurrence rate of 20% after removal of the stents [39,40]. In the series of Dumonceau et al. 36 patients were followed for a mean period of 44 months after removal of the stents, whereas our group followed 44 patients for a median period of 9.1 years after stent removal. It is important to note that almost all cases of restenosis occurred relatively early after removal of the stents: only one patient was diagnosed with recurrent stenosis after more than 6 months and all cases occurred within 2 years of stent removal. This suggests that endoscopic treatment of postsurgical stenoses is not associated with a high rate of long-term restenosis after stent removal, as suggested by antagonists of this treatment regimen. This is in contrast to the anastomotic recurrences after hepaticojejunostomy, which may occur after many years [28]. It also implies that strict follow-up after stent removal is necessary, especially during the first 6–12 months in order to diagnose restenosis at an early stage.

It is important to note that, apart from recurrence of the initial stenosis, other late complications may also occur after stent removal, e.g. cholangitis from bile duct stones or symptoms associated with (pre-existing) liver failure [40,41]. Bile duct stones may develop because of impeded bile flow due to a relative stenosis; however, since all patients initially underwent biliary surgery for stone disease, the underlying stone disease may also be held responsible [42].

 Postoperative biliary strictures: surgery or endoscopy [43]?   

Prospective randomized studies comparing surgical and endoscopic treatment of postoperative biliary strictures are not available. We have performed a retrospective study comparing surgical with endoscopic therapy (Fig. 16) [26]. Both approaches were found to have a similar long-term success rate, with recurrences being seen in 17% of patients.

Since there appear to be no clear differences in the primary outcomes between surgical and endoscopic management, the choice between the two is determined by other factors: the two most important ones are different characteristics of restenosis, and patients' preference.

Recurrent strictures after surgery   

The diagnosis of anastomotic stenosis after hepaticojejunostomy may be difficult since most patients already have mild liver function abnormalities and dilatation of the biliary tree on ultrasound is often absent [44]. After Roux-en-Y-hepaticojejunostomy, endoscopic approach to the biliary tree is usually not possible. Most physicians are reluctant to perform a PTC in these patients because of the risk of hemorrhage and bile leakage, especially in case of non-dilated bile ducts [32]. In patients with prior endoscopic treatment of bile duct strictures, diagnosis of recurrent stenosis is easier, safer, and therefore associated with less medical delay (which may cause secondary biliary cirrhosis). Furthermore, restenosis after endoscopic treatment occurs relatively early after stent removal (less than 1–2 years) [40,45] whereas anastomotic recurrences after surgery may develop after more than 10 years [28].

Treatment of recurrent stenosis after hepaticojejunostomy involves either percutaneous balloon dilation, often supplemented with internal–external stenting, or repeated surgery. Nowadays, most patients with anastomotic stenosis are initially managed by percutaneous treatment, but multiple sessions are often required and the cumulative morbidity due to bleeding and bile leakage may be as high as 30%. Repeat surgery will eventually be required in 20–30% of these patients. Compared to primary hepaticojejunostomy, repeated reconstructive surgery is associated with a higher complication and failure rate [27,28].

Whereas endoscopic treatment is impossible once a Roux-en-Y loop has been constructed, prior endoscopic treatment does not preclude further surgical treatment. In addition, recurrent strictures after prior endoscopic therapy can also be successfully treated by repeated stenting. Finally, although endoscopic treatment requires multiple ERCPs, many patients and their referring doctors prefer endoscopic treatment to surgery.

Therefore, we feel that surgery should be reserved for patients with failed endoscopic therapy or for patients who refuse endoscopic therapy.

 Metal stents for benign strictures   

The use of metal expandable stents in benign biliary disease remains controversial. Initially, several groups reported favorable results in the management of postoperative strictures. Gianturco–Rösch Z stents were placed percutaneously in 43 such patients by Coons [46]. All patients had previously undergone an unsuccessful balloon cholangioplasty. The 1-year reocclusion rate was 13%. Maccioni et al. report long-term patency in 100% in patients with a CBD stricture [47]. Foerster et al., reporting on endoscopic Wallstent placement in four patients, identified no stent-related complications and no cases of occlusion during a follow-up period of 53 weeks [48]. More recent follow-up studies, however, have obtained less satisfactory results. Hausegger et al. reported that the patency rate rapidly decreased to 19% at 57 months follow-up [49]. Dumonceau et al. reported a 100% occlusion rate of Wallstents inserted in six patients with postoperative strictures within 48 months of follow-up [45]. Lopez et al. reported a good clinical result, arbitrarily defined as the need for two or fewer invasive interventions, in only 5 out of 15 patients. The remaining 10 patients underwent multiple interventions, including surgery in five with a poor general outcome [50].

Studies in dogs have demonstrated marked bile duct narrowing related to extensive fibrosis after insertion of Wallstents but only minimal changes after insertion of plastic or covered metal stents [51]. An important disadvantage of metallic stents is that they cannot be removed once they become obstructed. Because of these results we do not advise inserting metallic stents in this context. The advent of removable expandable stents may, however, alter this situation in the future [52].

 A more aggressive treatment protocol?   

Currently, the standard protocol for patients with benign strictures involves placement of two stents during a maximum treatment period of 12 months. Recently, a more aggressive treatment protocol has been suggested in which there is no maximum period of stenting and as many stents as possible are inserted in order to obtain maximum dilatation. Costamagna and colleagues treated 45 patients with such an aggressive protocol [41]. They inserted as many stents as possible according to the downstream duct diameter (Fig. 17). Endoscopic treatment was discontinued only if the stricture was considered to be adequately dilated on fluoroscopy. A mean number of 3.2 stents were inserted (range 1–6 stents) for a mean duration of 12 months (range 2–24 months). Forty-two patients completed the treatment protocol; all stenoses resolved and none of the 42 patients suffered from restenosis during a median period of follow-up of 29 months (range 24 months to 11.3 years). These impressive results suggest that a more prolonged and aggressive endoscopic approach may be justified in more difficult cases.

 Conclusions   

Although most centres performing laparoscopic cholecystectomy may now be well beyond the 'learning-curve' phase, the incidence of postsurgical bile duct injuries will probably stay higher than in the era before laparoscopic cholecystectomy. In addition, with surgeons embarking on more complex laparoscopic biliary interventions, such as laparoscopic duct exploration, a further increase in the incidence of surgical bile duct injuries may be expected in the near future. Adequate management of these injuries requires an early postoperative diagnosis with a low threshold for performing an ERCP. Patients with type D lesions (complete ductal transection) require an elective surgical repair, 6–8 weeks after diagnosis and drainage. Most of the other bile duct injuries (minor leaks from the cystic stump or peripheral hepatic radicals, major bile duct leaks, and isolated bile duct strictures) can in general be managed endoscopically.

Patients who require long-term stenting for bile duct strictures should be treated with at least two 10 Fr plastic stents that are electively exchanged every 3 months. If possible, more than two stents should be inserted. There is currently no place for self-expandable metal stents for this indication.

Optimal management of patients with bile duct injuries requires a multidisciplinary team approach of interventional radiology, therapeutic endoscopy, and reconstructive surgery.

 Outstanding issues and future trends   

Most controversies connected to the management of postsurgical bile duct lesions relate to the treatment of biliary stenoses. There are still many questions concerning the optimal endoscopic management of these patients. Should stent placement always be preceded by balloon dilation? How many stents should be inserted? What is the optimal period of stenting? Some groups treat patients only for a relatively short time (e.g. 6 months) before deciding on success or failure. Others do not have a maximum period of stenting and attempt to insert as many stents as possible in order to obtain maximum dilatation.

With such an aggressive endoscopic treatment protocol, however, the question arises of what the long-term effects of stenting are on the biliary system. Studies using intraductal ultrasonography have shown that stenting induces profound thickening and fibrosis of the bile duct wall that occurs as short as 2 weeks after insertion of a single plastic endoprosthesis [53]. Placing multiple stents for a period of over 1 year might thus reduce the chances of a successful surgical reconstruction in case endoscopic treatment should fail. In the near future, use of biodegradable self-expandable stents that gradually dissolve after 1–2 years, or insertion of covered self-expandable stents that can be removed, might be options.

Which subset of patients will most likely benefit from endoscopic management? The impression exists that patients in whom the stricture is diagnosed relatively early after surgery have a better prognosis than patients who present a long time after surgery, but this has not been substantiated in follow-up studies. Patients with more proximal lesions are more difficult to treat and some experts have advised primary surgical treatment in patients with hilar strictures [54]. Multivariate analysis of large cohorts of patients will be necessary to solve these issues.

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