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Several benign biliary strictures causes include chronic inflammation of the pancreas and bile duct, traumatic injury to the liver and bile duct, bile duct injury following cholecystectomy, or bilioenteric anastomosis following Whipple operation or liver transplantation. Benign biliary stricture evolves gradually over a period of time after the initial insult. Most patients present with jaundice, dark urine, skin itchiness, generalized weakness, loss of appetite, fever, or chills. Blood work shows elevated liver function test, most specifically bilirubin level.

Most patients present to their primary care doctor or gastroenterologist for a medical evaluation. Benign biliary stricture rarely causes pain. Right upper quadrant ultrasound shows a dilated intrahepatic biliary tree. Further imaging with MRI and MRCP shows a unilateral or bilateral dilated intrahepatic biliary tree leading to the location of the biliary stricture. It is essential to rule out occult/early-stage bile duct cancer causing biliary duct obstruction. Further workup with ERCP (Endoscopic retrograde cholangiopancreatography) by an interventional gastroenterologist may be necessary to investigate and potentially treat the biliary stricture. Endoscopic biopsies should be obtained for any suspicious lesions within the bile duct during ERCP to rule out occult bile duct cancer.

Once the diagnosis is confirmed, biliary stricture treatment aims to relieve the biliary obstruction, maintain long-term biliary drainage from the liver to the intestine, and preserve liver function. Endoscopic and percutaneous techniques, including biliary stricture dilatation followed by placement of an endobiliary stent(s), are the first line of treatment. Most benign biliary strictures can be managed this way. The biliary stents are usually left in place about 6-8 weeks prior to removal. The patients do not need to stay in the hospital during this time. A prophylactic antibiotic is given to prevent biliary infection, sepsis (cholangitis), or liver abscess.

In a small number of patients (15%), Endoscopic and percutaneous techniques fail to resolve benign biliary stricture. Surgical treatment is needed for patients whose strictures are refractory to Endoscopic and percutaneous interventions. Biliary duct surgery is best performed utilizing minimally invasive surgical techniques when expertise is available. Understanding complex biliary anatomy is vital to avoid postoperative complications, such as a leak, recurrence stricture, or chronic biliary fistula. Referral to see an experienced biliary surgeon/bile duct surgeon/liver surgeon is crucial due to the complex nature of biliary tract operations.

Robotic biliary resection and reconstruction using a segment of the intestine called Roux-en-Y hepaticojejunostomy is one of the biliary stricture treatments. Robotic technology allows for highly precise dissection, cutting, and suturing of the biliary duct compared to conventional laparoscopy. An abdominal drain is usually placed after biliary surgery. The drain is then later removed once no evidence of bile leak is confirmed. Only very few centers in the United States perform this operation routinely. A high-volume bile duct surgeon or biliary center achieves superior outcomes when compared to a low-volume bile duct surgeon or biliary center.

Dr. Iswanto Sucandy offers biliary tract surgery on a routine basis using the robotic technique. We have achieved significant experience in biliary tract surgery over the years. Our team works collaboratively with our interventional radiologists and interventional endoscopists to achieve the best long-term outcomes.