Endoscopic management of postcholecystectomy bile duct strictures

BACKGROUND: Review of 1.6 million cholecystectornies, from 1992 to 1999, demonstrated a 0.5% incidence of bile duct injury, despite increasing experience with laparoscopy. The incidence has not decreased after the "learning curve." The management of major bile duct injuries has traditionally been by hepaticojejunostomy. Endoscopy has been increasingly used to treat these injuries. This study reviews the senior author's endoscopic treatment of bile duct injuries. STUDY DESIGN: This is a retrospective study, from 1991 to 2006, examining data on 292 patients who were referred for postcholecystectomy problems; 1.99 had cholecystectomy-related injuries and 93 had other pathologies. Sixty-seven patients had bile duct injuries (Amsterdam Academic Medical Center Classification, types B, C, and D). Nineteen patients underwent billoenteric bypass for complete bile duct occlusion or transection. In the remaining 48, endoscopic retrograde cholangiopancreatography (ERCP) evaluation and treatment were possible. Our protocol called for biliary stenting for 11 to 14 months, with stent changes at 3-month intervals. Short- and longterm results were evaluated by clinical, radiologic, and laboratory studies. RESULTS: Forty-six patients were selected for endoscopic management by balloon dilation and biliary stent placement. The mean +/- SD duration of endoscopic stenting was 12 +/- 9.8 months and followup was 30 +/- 24 months after stent removal. During the followup period, 10 of 46 patients (22%) had recurrent stricture: 6 (13%) responded to endoscopic biliary stenting and 4 (9%) required hepaticojejunostomy. Complications included pancreatitis (8%). There were no deaths in the endoscopic group. CONCLUSIONS: ERCP intervention is a safe, effective, minimally invasive treatment for bile duct strictures after cholecystectomy and can be an alternative to hepaticojejunostomy.