Plastic and metal stents for postoperative benign bile duct strictures:: the best and the worst

Background: Endoscopic treatment of postoperative benign bile duct strictures (BEDS) is technically challenging, and the long-term outcome after stricture dilation remains poorly defined. Methods: Forty-eight cases of postoperative BEDS with attempted endoscopic treatment (either transient plastic stenting or definitive metal stent insertion) were reviewed. Results: Endoscopic stricture dilation succeeded in 47 of 48 cases (98%). No procedure-related mortality was observed; 16 (33%) procedure-related or stent-associated complications were observed during treatment. Endoscopic treatment was interrupted in five patients. Stricture relapse occurred in 6 of 6 (100%) and 7 of 36 (19%) patients after metal stent insertion and plastic stent removal, respectively (p < 0.001) (mean follow-up periods 50 +/- 12 and 44 +/- 34 months, respectively). After plastic stent removal, stricture relapses were more frequent among patients with strictures related to liver transplantation as opposed to other surgical procedures (p < 0.05); these recurrent strictures were successfully treated by repeated insertion of plastic stents on a temporary basis. At the end of follow-up, all but one patient treated with plastic stents had normal serum alkaline phosphatase values. Conclusion: Metal stents proved to be inadequate for treating postoperative BEDS. Temporary insertion of a plastic stent (possibly repeated) provided long-term results equal or superior to those reported for surgical biliary drainage. Repeated insertion of plastic stents was more frequently indicated for strictures related to liver transplantation compared with other surgical procedures.