Endoscopic management of benign biliary strictures has significantly changed in recent years. Excluding a malignant etiology remains the first, critical, step; significant progress is being made to increase diagnostic accuracy of bile duct stricture sampling, although negative predictive value does not reach 100%. The currently preferred treatment consists of stricture dilation followed by placement of multiple temporary plastic stents. Drawbacks of this technique include repetition of endoscopic procedures and a small risk of cholangitis. Larger diameter covered self-expandable metal biliary stents seem to be a promising alternative. In this review, we will discuss the various etiologies of benign biliary strictures, their clinical presentation, the diagnostic tools and the endoscopic treatment.

Self-expanding metal stents are claimed to prolong biliary-stent patency, although no formal comparative trial between plastic and expandable stents has been done. In a prospective randomised trial, we assigned 105 patients with irresectable distal bile-duct malignancy to receive either a metal stent (49) or a straight polyethylene stent (56). Median patency of the first stent was significantly prolonged in patients with a metal stent compared with those with a polyethylene stent (273 vs 126 days; p = 0.006). The major cause of stent dysfunction was tumour ingrowth in the metal-stent group and sludge deposition in the polyethylene-stent group. Treatment after any occlusion included placement of a polyethylene stent. In the metal-stent group none of 14 second stents occluded, whereas 11 of 23 (48%) second stents clogged in the polyethylene-stent group (p = 0.002). Overall median survival was 149 days and did not differ significantly between treatment groups. Incremental cost-effectiveness analysis showed that initial placement of a metal stent results in a 28% decrease of endoscopic procedures. Self-expanding metal stents have a longer patency than polyethylene stents and offer adequate palliation in patients with irresectable malignant distal bile-duct obstruction.

The development of non-surgical techniques for the relief of malignant low bileduct obstruction has cast doubt on the best way of relieving jaundice, particularly in patients fit for surgery whose life expectancy is more than a few weeks. We did a randomised prospective controlled trial comparing endoscopic stent insertion and surgical biliary bypass in patients with malignant low bileduct obstruction. 204 patients were randomised (surgery 103, stent 101); 3 subsequently proved to have benign disease and were excluded, leaving 101 surgical and 100 stented patients for assessment. Technical success was achieved in 94 surgical and 95 stented patients, with functional biliary decompression obtained in 92 patients in both groups. In stented patients, there was a lower procedure-related mortality (3% vs 14%, p = 0.01), major complication rate (11% vs 29%, p = 0.02), and median total hospital stay (20 vs 26 days, p = 0.001). Recurrent jaundice occurred in 36 stented patients and 2 surgical patients. Late gastric outlet obstruction occurred in 17% of stented patients and 7% of the surgical group. Despite the early benefits of stenting there was no significant difference in overall survival between the two groups (median survival: surgical 26 weeks; stented 21 weeks; p = 0.065). Endoscopic stenting and surgery are effective palliative treatments with the former having fewer early treatment-related complications and the latter fewer late complications.

The effectiveness of surgical palliation for pancreatic cancer has been reviewed. Jaundice should be relieved early as this eliminates distressing pruritus, improves the quality of life, and avoids the sequelae of prolonged extrahepatic obstruction. The procedure may prolong survival, but this has not been proved. Biliary obstruction is managed best by a simple loop cholecystojejunostomy. If the gallbladder is unavailable, a choledochojejunostomy is equally effective. Nonsurgical techniques such as percutaneous or endoscopically placed biliary stents may be appropriate in patients who are not candidates for surgery. A gastrojejunostomy should be done in all patients who have gastroduodenal obstruction by tumor. Most patients who undergo surgical biliary bypass also should have a gastrojejunostomy, even if gastroduodenal obstruction has not yet developed. Otherwise, more than 20 per cent of patients may need a second operation if gastroduodenal obstruction develops later. Pain, a problem in more than half of patients, is best relieved by an intraoperative celiac ganglion block with 50 per cent ethanol. Laparotomy is desirable in most of these patients with pancreatic cancer, because it provides tissue for diagnosis, allows a definite assessment of resectability, and produces effective palliation.

One hundred and twenty consecutive deeply jaundiced patients undergoing surgery for bile duct obstruction were analysed. Diagnosis by either ultrasound or percutaneous transhepatic cholangiography was correct in 84 per cent and 86 per cent of patients respectively. Combination of the two procedures resulted in a diagnostic accuracy of 96.5 per cent. Despite pre-operative antibiotics and intravenous fluids, including Mannitol, infective complications and renal failure were common. Gastrointestinal haemorrhage was a major cause of postoperative morbidity and mortality. The operative mortality in this series was 14.2 per cent and was related to the depth of jaundice in patients with benign disease. The same relationship did not appear to occur in those with malignant disease. The median survival after palliative bypass surgery in patients with malignant obstruction was 6.5 months.

The role of preoperative endoscopic drainage for patients with malignant obstructive jaundice was evaluated in a randomized controlled trial. A total of 87 patients were assigned to either early elective surgery (44 patients) or endoscopic biliary drainage followed by exploration (43). Thirty-seven patients underwent successful stent insertion and 25 had effective biliary drainage. Complications related to endoscopy occurred in 12 patients. After endoscopic drainage significant reductions of hyperbilirubinaemia, indocyanine green retention and serum albumin concentration were observed. Patients with hilar lesions had a significantly higher incidence of cholangitis and failed endoscopic drainage after stent placement. The overall morbidity rate (18 patients versus 16) and mortality rate (six patients in each group) were similar in the two treatment arms irrespective of the level of biliary obstruction. Despite the improvement of liver function, routine application of endoscopic drainage had no demonstrable benefit. Endoscopic drainage is indicated only when early surgery is not feasible, especially for patients with distal obstruction.

At The Johns Hopkins Hospital from 1979 through 1987, 42 patients had 45 procedures for benign postoperative biliary strictures. Three patients were managed with both surgery and balloon dilatation. Twenty-five patients underwent surgical repair with Roux-Y choledocho- or hepaticojejunostomy with postoperative transhepatic stenting for a mean of 13.8 +/- 1.3 months. Twenty patients had balloon dilatation a mean of 3.9 times and were stented transhepatically for a mean of 13.3 +/- 2.0 months. The two groups were similar with respect to multiple parameters that might have influenced outcome. Mean length of follow-up was 57 +/- 7 and 59 +/- 6 months for surgery and balloon dilatation, respectively. No patients died after any of the procedures. The same definition of a successful outcome was applied to both groups and was achieved in 88% of the surgical and in only 55% of the balloon dilatation patients (p less than 0.02). Significant hemobilia occurred more often with balloon dilatation (20% vs. 4%, p less than 0.02). The total hospital stay and cost of balloon dilatation was not significantly different from surgery. We conclude that surgical repair of benign postoperative strictures results in fewer problems that require further therapy. Nevertheless balloon dilatation is an alternative for patients who are at high risk or who are unwilling to undergo another operation.

To identify individual risk factors and to establish an index of risk in biliary tract surgery, data on 16 potential predictive factors were compiled from a series of 186 biliary tract operations excluding simple cholecystectomy. Eight factors had a significant association with postoperative mortality. Linear discriminant analysis showed that serum creatinine, serum albumin and serum bilirubin levels in the week before surgery had independent significance in predicting postoperative mortality. The discriminant function derived identified a high risk group of patients and the predictive value was confirmed in an independent series of 54 biliary tract operations carried out in another surgical unit. The discriminant function derived for patients jaundiced before surgery also defined a high and low risk group and was similarly validated. Identification of high risk patients undergoing surgery for obstructive jaundice may be useful in defining a group of patients to be considered for trials of preliminary biliary drainage.

Percutaneous transhepatic biliary decompression is a safe and potentially helpful procedure. If done correctly, it will accomplish adequate decompression of the biliary tree and permit hepatic function to return to a more normal state preoperatively. The time gained while waiting for the bilirubin level to decrease can be used for adequate preoperative preparation of the patient. Use of this technique may make it possible for operative treatment of obstructive jaundice to return to a two-stage procedure, the first stage being percutaneous transhepatic biliary decompression.

BACKGROUND: The necessity for drainage of both liver lobes in tumors arising at the biliary bifurcation is controversial. The aim of this study was to compare the outcome of unilateral versus bilateral drainage in patients with biliary obstruction at the hilum. METHODS: One hundred fifty-seven consecutive patients with primary cholangiocarcinoma, gallbladder cancer, or periportal lymph node metastases were randomly allocated to unilateral (group A) or bilateral (group B) hepatic duct drainage. RESULTS: In intention-to treat analysis, group A had a significantly higher rate of successful endoscopic stent insertion than group B (88.6% vs. 76.9%, p = 0.041). Group B had a significantly higher rate of complications than group A (26.9% vs. 18.9%, p = 0.026) because of the higher rate of early cholangitis (16.6% vs. 8.8%, p = 0.013). In per-protocol analysis the rate of successful drainage, complications, and mortality did not differ between the two groups. Median survival did not differ between the two groups but was significantly different for patients with cholangiocarcinoma and those with gallbladder cancer versus patients with metastatic tumors (p = 0.0247). CONCLUSION: The insertion of more than one stent would not appear justified as a routine procedure in patients with biliary bifurcation tumors.