Benign Biliary Stricture
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Benign biliary strictures may occur from 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 strictures evolve 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. 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 very important to rule out occult/early stage bile duct cancer causing the 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 of benign biliary stricture is confirmed, the goal of treatment is to relieve the biliary obstruction, maintain a 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 treatment. Most benign biliary strictures can be managed this way. The biliary stents are usually left in place in about 6-8 weeks prior to removal. The patients do not need to stay in hospital during this time. Prophylactic antibiotic is given to prevent development of biliary infection, sepsis (cholangitis), or liver abscess.
In 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 technique when expertise is available. Understanding of complex biliary anatomy is important to avoid postoperative complications, such as leak, recurrence stricture, or chronic biliary fistula. Referral to see an experienced biliary surgeon/bile duct surgeon/liver surgeon is crucial, due to complex nature of biliary tract operations.
Robotic biliary resection and reconstruction using a segment of intestine called Roux-en-Y hepaticojejunostomy is one way of treating a benign biliary stricture. Robotic technology allows for a highly precise dissection, cutting, and suturing of the biliary duct, when 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 work collaboratively with our interventional radiologists and interventional endoscopists to achieve the best long-term outcomes.