Long term outcomes in patients with benign biliary stricture treated endoscopically with multiple stents

Background: There is no firmly established strategy for management of benign biliary strictures. The long term efficacy of endoscopic therapy with multiple stents is unknown. Aim: To evaluate the long term outcome in patients with benign biliary strictures treated with multiple biliary stents. Study design: Retrospective review. Methods: Over 12 years 34 patients were treated endoscopically for benign biliary stricture (Primary Sclerosing Cholangitis excluded) with sequential insertion of stents with increasing number and/or size. Two patients were lost to follow up and two died with stents in place from unrelated causes. The remaining 30 (17 male, 13 female, mean age 55.1 years, range 18 to 81) were followed and long term outcome after stents removal was evaluated. The average number of ERCPs was 2 to 5 (mean 4). Etiology of the strictures were: Post operative-16 (13 cholecystectomies, 3 Ortotopic Liver Transplant (OLT), Chronic pancreatitis (CP)-10 (6 calcine, 4 non calcine), Trauma-3, Idiopathic-1. The level of stricture was: 1) Level I (CHD/CBD)-23 2) Level II (bifurcation)-2 3) Level III (IHD)-5. The maximum number and size of stents was: 3/10 French Gauge (FG)-19, 2/10 FG-8, 2/11.5 FG-1 and 2/11.5 FG+1/10 FG-2. The total period of stenting ranged from 4 to 36 months (mean 13.9, median 10.5). Results: 12 patients (40%) failed therapy and required restenting or surgery. Of those 4 had level III stricture and 8 level I. The etiology of the level I stricture therapy failures was CP-6 (5 calcific, 1 noncalcific), post lap chole-1 and post OLT-1. The interval to "failure" was 0 to 30 months (mean 10.8). The multiple stents therapy was successful in 18 patients (60%) and they remained asymptomatic during the follow up period after the stents were removed (range 2.9 to 5.8 years, mean 3.4). The level of stricture of the "success" group was level I-15, level II-2 and level III-1. The underlying etiology in the group with level I stricture was post operative-9 (7 cholecystectomies, 2 OLT), chronic pancreatitis-4 (1 calcific, 3 noncalcific) and trauma-2. Only 1 out of 5 patients with level III stricture was treated successfully. The level I strictures were analyzed and post op/trauma had significantly better outcome than chronic calcific pancreatitis related strictures (P<0.05). Conclusion: Sequential endoscopic insertion of multiple biliary stents as therapy for benign biliary stricture leads to long term success in majority of the patients. Level III stricture and chronic calcific pancreatitis as underlying etiology of the stricture predict treatment failure.