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Endotherapy of postcholecystectomy biliary strictures with multiple plastic stents: long-term results in a large cohort of patients

  • Guido Costamagna
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia. Digestive Endoscopy Unit

    Università Cattolica del Sacro Cuore, Roma, Italia. Centre for Endoscopic Research Therapeutics and Training—CERTT
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  • Andrea Tringali
    Correspondence
    Reprint requests: Andrea Tringali, MD, PhD, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia. Università Cattolica del Sacro Cuore, Roma, Italia.
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia. Digestive Endoscopy Unit

    Università Cattolica del Sacro Cuore, Roma, Italia. Centre for Endoscopic Research Therapeutics and Training—CERTT
    Search for articles by this author
  • Vincenzo Perri
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia. Digestive Endoscopy Unit

    Università Cattolica del Sacro Cuore, Roma, Italia. Centre for Endoscopic Research Therapeutics and Training—CERTT
    Search for articles by this author
  • Pietro Familiari
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia. Digestive Endoscopy Unit

    Università Cattolica del Sacro Cuore, Roma, Italia. Centre for Endoscopic Research Therapeutics and Training—CERTT
    Search for articles by this author
  • Ivo Boškoski
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia. Digestive Endoscopy Unit

    Università Cattolica del Sacro Cuore, Roma, Italia. Centre for Endoscopic Research Therapeutics and Training—CERTT
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  • Federico Barbaro
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia. Digestive Endoscopy Unit

    Università Cattolica del Sacro Cuore, Roma, Italia. Centre for Endoscopic Research Therapeutics and Training—CERTT
    Search for articles by this author
  • Rosario Landi
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia. Digestive Endoscopy Unit

    Università Cattolica del Sacro Cuore, Roma, Italia. Centre for Endoscopic Research Therapeutics and Training—CERTT
    Search for articles by this author

      Background and Aims

      Endoscopic therapy of benign biliary strictures with multiple plastic stent (MPS) placement has shown satisfactory results. However, the literature describes various benign biliary stricture etiologies. The aim of this study was to evaluate long-term MPS results in patients with postcholecystectomy biliary strictures (PCBSs).

      Methods

      PCBS patients without complete bile duct transection were included. ERCP consisted of placing an increasing plastic stent number over time, exchanged at regular intervals (3-4 months), until complete morphologic stricture disappearance. After stent removal, patient follow-up comprised liver function tests and clinical assessment.

      Results

      One hundred fifty-four patients (43.5% men; mean age, 53 years) were enrolled; in 43% of the cases, PCBSs were involved or were close to the main hepatic confluence. PCBS resolution rate was 96.7% (n = 149). A mean maximum number of 4.3 ± 1.6 stents were placed side-by-side; a mean of 4.2 ± 1.5 ERCPs per patient was needed to obtain PCBS resolution during a mean treatment period of 11.8 ± 6.4 months. Unscheduled stent exchange because of cholangitis, jaundice, or pain occurred in 7.4% of cases. Procedure-related mortality was absent. Follow-up data were available in 85.2% of cases. After a mean follow-up of 11.1 ± 4.9 years, stricture recurrence rate was 9.4% (n = 12). Subsequent to retreatment, 83.3% of patients (n = 10) were asymptomatic after a mean time of 9 years, whereas 2 patients underwent hepaticojejunostomy because of failed retreatment. Statistical analysis revealed no risk factors for PCBS recurrence after MPS.

      Conclusions

      Endoscopic therapy of PCBSs with MPSs is safe and effective at long-term follow-up. PCBSs involving or close to the main hepatic confluence were successfully treated with MPSs. PCBS recurrence rate is low and can be successful endoscopically retreated without precluding possible surgical treatment.

      Graphical abstract

      Abbreviations:

      BBS (benign biliary stricture), BDI (bile duct injury), FC-SEMS (fully covered self-expandable metal stent), LFT (liver function test), MPS (multiple plastic stent), PCBS (postcholecystectomy biliary stricture)
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      Linked Article

      • Endoscopic plastic stents: Still the preferred option of treatment for benign biliary stenosis?
        Gastrointestinal EndoscopyVol. 90Issue 6
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          We read with great interest the article by Costamagna et al,1 recently published in Gastrointestinal Endoscopy, reporting the long-term results of multiple endoscopically placed plastic stents for the treatment of postcholecystectomy biliary stricture. The article is of considerable relevance because it provides robust evidence of the efficacy of large-bore plastic stents in the treatment of benign biliary stenosis. However, since the time of treatment of the last patient in the series (2010), several advances have been made in the treatment of benign biliary stenosis, mainly aimed at reducing the invasiveness of the treatment.
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      • Endotherapy of postcholecystectomy biliary strictures: Should we do as Romans do?
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          Laparoscopic cholecystectomy is currently the standard treatment for symptomatic cholelithiasis. Bile duct injury (BDI) after cholecystectomy is uncommon and encompasses anatomically and clinically heterogenous situations, ranging from cystic duct leaks to major duct transections, in patients ranging from asymptomatic to critically ill. When BDI happens, a multidisciplinary approach involving surgeons, interventional radiologists, and pancreatobiliary endoscopists is required. The feasibility of endoscopic therapy is largely dependent on the continuity of the bile duct.
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