J. Citron,
Steven
MD
#{149} Louis
C. Martin,
Benign Biliary with Percutaneous
Strictures: Treatment Cholangioplasty’
Results of percutaneous balloon cholangioplasty of 17 patients with 28 benign biliary strictures were compared with those of published radiologic and surgical series to determine whether stricture location was related to therapeutic success and whether a patient should undergo percutaneous or surgical therapy. Treatment was considered successful if there was no anatomic evidence of recurrent stricture or need for surgery (mean follow-up, 32 months). Treatment was successful in all nine (100%) intrahepatic (zone 1) strictures, 11 of 12 (92%) extrahepatic-extrapancreatic (zone 2) strictures, one of three (33%) intrapancreatic (zone 3) strictures, and three of four (75%) bilienteric anastomotic (zone 4) strictures. Restenosis occurred in five patients; cholangioplasty was ultimately successful in two of those patients after redilaHon and stent placement. On the basis of these results and those of published radiologic and surgical series, the authors believe that cholangioplasty is the treatment of choice for zone 1 strictures gery for
and
is as effective
as sur-
zone 2 and 4 strictures. Patients with zone 2 and 4 strictures with concomitant portal hypertension or a history of multiple previous biliary surgical procedures should be considered good candidates for cholangioplasty. Zone 3 strictures may be better treated surgically than percutaneously. Index dure, tion,
76.45
terms:
Bile ducts,
76.1229 76.289,
Bile
#{149}
76.291,
#{149} Catheters
Radiology
interventional
ducts, 76.45
and
stenosis Bile
#{149}
catheterization
1991; 178:339-341
proceor obstruc-
ducts,
MD
surgery
N
percent of benign ductal strictures are due to iatrogenic trauma caused by routine cholecystectomy. The injury is unrecognized in 68% of those patients because the common hepatic duct can be mistaken for the cystic duct due to incomplete dissection or inflammation (1). Surgical repair is successful in relieving the subsequent stricture in 63%-92% of patients, but 10%-30% experience a stricture recurrence, usually within 1-3 years (1-6). Surgical repair becomes less successful with each additional attempt (6). Concomitant biliary cirrhosis and portal hypertension increase operative time and mortality rates (3). Percutaneous cholangioplasty perINETY-SEVEN
biliary
formed
by means
of a T-tube
tract
was
first described by Burhenne (7) in 1975. In 1978, Molnar and Stockum (8) described the percutaneous transhepatic technique. Results of percutaneous dilation techniques developed in the last decade rival those of surgical series (912). We report our experience using balloon catheters to dilate these strictunes and compare our results with those of several radiologic and surgical series. We have reviewed our experience in an attempt to answer these questions pertaining to percutaneous dilation of benign biliary strictures: (a) Does stricture location affect dilation success? and (b) Are there patients who should be treated surgically rather than percutaneously?
17 patients with a total of 28 benign biliary strictures made up our study population. Ten patients had primary postoperative strictures, affecting the hepatic or cornmon bile duct in six and affecting bilientenic anastomoses in four. (A primary
stricture
quired
AND
METHODS
Between April 1982 and March 1988, 43 patients with benign biliary strictures were treated in our department by means of percutaneous cholangioplasty. Twentysix patients with sclerosing cholangitis have been reported elsewhere (13) and were excluded from this study. Therefore,
I From the Department of Radiology, Emory University Hospital, 1364 Clifton GA 30322. Received April 24, 1990; revision requested June 14; revision received cepted September 12. Address reprint requests to L.G.M. RSNA, 1991
Rd. NE, Atlanta, September 11; ac-
as an iatrogenic
or id-
to return
for repeat
dilations
on
successive days prior to final stent placement and hospital discharge. More recently, the patients return about 48 hours after initial biliary drainage for stricture dilation and stent placement under general anesthesia. At this time, a large-bore (10-16-F) stent with side holes above and below the stenosis is placed across the dilated bile duct. A stent was not placed in one patient, a 71-year-old Laotian woman with Oriental cholangiohepatitis, after stricture
dilation;
stents
were
placed
in all
other patients. We drain the bile externally until the patient is afebnile for 24-48 hours and then internalize bile flow by capping the drainage tube. Broad-spectrum antibiotics,
PATIENTS
is defined
iopathic postoperative narrowing in the bile duct.) The remaining seven patients had inflammatory strictures. These strictunes were due to chronic pancreatitis (three patients), cholelithiasis (two patients), and Oriental cholangiohepatitis (two patients). The locations of the bile duct strictures were divided into four zones (Fig 1): intrahepatic (zone 1), extrahepatic-extrapancreatic (zone 2), intrapancreatic (zone 3), and bilientenic anastomotic (zone 4). The current treatment protocol is as follows: Early in our study, patients were re-
usually
cephalosponins,
tered intravenously tial biliary drainage ready for discharge Antibiotics are also
istered
prior
are
adminis-
from the time of miuntil the patient is from the hospital. intravenously admin-
to all stent
changes
and ma-
nipulations. Three patients had indwelling T tubes through which manipulations were performed. After approximately 3-6 months (average, 20 weeks; range, 1-68 weeks), the stent was withdrawn proximal to the stricture and cholangiognaphy was performed to assess patency. If the duct was judged to be patent (normal drainage and subjective lack of significant luminal narrowing), the stent was removed and the patient was followed up
339
clinically
by the
casionally,
referring
a 4-F catheter
physician.
was placed
the
bile duct proximal to the stnictured for 1-3 months after stent removal in the event repeat cholangioplasty was necessary because of early restenosis. The 4-F catheter was removed if there were no signs of restenosis. All dilations were performed on an inpatient basis. Dilation was performed with standard balloon catheters. Balloon diameters were at least that of the adjacent duct. Inflation pressures and duration were 6-15 atm and 3-10 minutes, respectively. Biliary pressures obtained aften a saline infusion were occasionally used to assess patency; a manometnic pressure of less than 20 cm of saline proximal to the stricture was considered normal as per vanSonnenberg et al (14). Follow-up information was obtained by means of questionnaires and telephone interviews with both patients and referring physicians. Long-term follow-up results were not available in one patient; that patient was 94 years old and was not successfully treated with cholangioplasty. Treatment was considered successful if all stents were removed, the patient was symptom-free, laboratory values (eg, bilirubin, alkaline phosphatase, aspartate aminotransferase) were near normal, and sungery was avoided. Restenosis was defined as the need for redilation, stent placement, and stent removal. Cholangioplasty was considered unsuccessful if surgical repair was required. Postprocedural fever was defined as an oral temperature greater than 100.5#{176}F(38.1#{176}C)within 24 hours after dilation. Postprocedural bleeding was defined as a fall in hematocnit greater than 2% (>0.02). Sepsis during or after the stent was placed was defined as fever, night upper quadrant pain, and leukocytosis with or without positive biliary cultures. Postprocedural hospitalization included all hospital days required during the followup period. The mean follow-up period was 32 months (range, 11-61 months). To evaluate the difference in the need for postprocedural hospitalization after percutaneous cholangioplasty and after surgical repair of benign biliary stnictunes, we reviewed the records of 12 patients treated by means of surgery alone at our institution during the period of our study. This study group consisted of three men and nine women (mean age, 54 area
years).
One
patient
had
a zone
1 stricture;
five had zone 2, four had zone 3, and two had zone 4 strictures. Seven patients underwent choledochojejunostomy, two underwent
hepaticojejunostomy,
two
under-
went ampullary sphincteroplasty, and one underwent choledochoduodenostomy. Eleven patients required only one surgical procedure; one patient required four. The mean follow-up period for this group was 28 months. The number of postsurgical hospital days was totaled for each patient. These included any readmissions for cholangitis, wound infection, restenosis, and reoperation. Data were compared with those of our cholangioplasty study population.
340
Radiology
#{149}
RESULTS
Oc-
in
Twenty-four of 28 strictures (86%) in 14 of our 17 patients (82%) were successfully treated by means of pencutaneous cholangioplasty. One hundred percent of zone 1 strictures, 92% of zone 2 strictures, 33% of zone 3 stnictunes, and 75% of zone 4 strictures were treated successfully (Fig 2). Restenosis occurred in five of the 17 patients (29%). Percutaneous cholangioplasty was ultimately successful in two of those patients at 12 and 51/2 months, respectively. Both of those patients had inflammatory strictures with laboratory evidence of biliary obstruction. Both patients underwent redilation and stent placement and were doing well 23 and 60 months later, respectively. Cholangioplasty was
unsuccessful
in three
patients,
Figure 1. Location of benign biliary strictures. Zone 1 four patients, nine strictures; zone 2 = eight patients, 12 strictures; zone = three patients, three strictures; and zone =
four
patients,
four
3
4
strictures.
all of
whom required alternate therapy. A 48year-old woman with neurofibromatosis had had a bilenteric anastomosis and developed both a zone 2 and zone 4 stricture. Both strictures responded to dilation and stent placement, but the patient developed cholangitis after stent removal. The zone 2 stricture could not be recrossed percutaneously. She underwent a hepaticojejunostomy and was doing well at 29 months follow-up. The other two patients in whom cholangioplasty was unsuccessful, a 58-year-old woman and a 94-yearold man, had zone 3 strictures due to chronic pancreatitis. Both had delayed ductal drainage demonstrated at cholangiography 2 and 4 weeks after cholangioplasty, respectively, but neither had signs of cholangitis during the follow-up period. The former underwent choledochoduodenostomy and was doing well 18 months after surgery; the latter underwent endoscopic sphincteroplasty and was lost to follow-up 4 weeks later. Fever immediately following the cholangioplasty was common, occurring in 47% of patients; none had positive blood cultures, possibly because of pretreatment with broad-spectrum antibiotics. Five of the patients who underwent successful cholangioplasty had complications during or after the stenting period. After stent removal, two patients had a total of five episodes of presumed cholangitis; each episode was managed with antibiotics alone. One patient had a night-sided hepatic abscess that was drained percutaneously during the stenting period; the abscess did not recur. One patient had two episodes of cholangitis during the stenting period; both episodes resolved with intravenously administened antibiotics. One patient with zone 1 strictures developed intrahepatic stones during the follow-up period that were successfully removed by means of percutaneous tnanshepatic
Figure
2.
Results
gioplasty
for
strictures
(86%)
and
14 of the
fully
of percutaneous
each
zone.
were
Overall,
successfully
17 patients
cholan24
of
the
28
dilated,
(82%)
were
success-
treated.
methods; however, there was no cholangiographic evidence of ductal restenosis in this patient. Total postprocedural hospital days (including readmissions for complications occurring during the follow-up period) were similar regardless of treatment regimen. Readmission after suc-
cessful
cholangioplasty
was
most
often
due to sepsis that occurred during the stenting period or after stent changes; the average total number of postcholangioplasty hospital days was 17 days. Two patients in whom cholangioplasty was not successful and who required surgical repair averaged 1 1 hospital days after their surgical procedure duning the follow-up period; neither required readmission after surgery. The third patient in whom cholangioplasty was not successful was lost to followup 4 weeks after discharge after undergoing endoscopic sphincteroplasty. The 12 patients treated by means of surgery alone averaged 15 total hospital days after their procedure during
follow-up; two
of whom
three
were
required
rehospitalized, 41 hospital
February
days
1991
each during follow-up. Both of these patients had undergone previous biliany tract surgery at other institutions within 4 months of their surgery at our institution.
DISCUSSION Only about one in 400-500 cholecystectomy procedures is complicated by biliary stricture, which can quickly lead to cirrhosis, cholangitis, and death (12). Since surgical repair of postoperative strictures carries the risk of operative mortality and recurrence, percutaneous treatment, at first only an attnactive concept, is now a viable alternative to surgery. The four largest nadiologic series to date (Williams et al [12], Gallachen et al [10], Mueller et al [9], and Moore et al [11]) had overall success rates of 67%85% in 177 patients with sclerosing cholangitis and primary postoperative and bilientenic anastomotic strictures. Follow-up periods ranged from a mean of 15 months (10) to at least 3 years (9). Our results compare favorably with those from the published surgical and radiologic series. If zone 3 strictures are excluded, 23 of 25 (92%) extrapancreatic strictures were successfully treated with percutaneous cholangioplasty. Our restenosis rate of 29% is similar to those of the surgical series of Kalman et al (20%) (4) and Pellegrini et al (22%) (2) and the radiologic series of Williams et a! (2.2%) (12), Gallacher et al (31%) (10), and Mueller et al (34%) (9); it is higher than those of the surgical series of Way et al (10%) (5) and Blumgant et al (10%) (3). Mueller et al (9) studied 17 patients with sclerosing cholangitis, whom they found to have the highest recurrence rate (58%); such patients were excluded from our study. In our study, patients who underwent successful cholangioplasty had previously undergone surgery an average of nearly 4 years before balloon dilation was attempted. One patient who had a primary postoperative stricture and in whom cholangioplasty was unsuccessful had undergone surgery only 6 months earlier. The two patients who developed nestenosis and required nedilation did so within 1 year of the initial cholangioplasty. This may underscore the importance of the fibrotic maturation process that occurs after biliary manipulation; Braasch (15) notes that this process occurs mainly within the first year after surgical repair and is largely completed within three years. All zone 1 strictures were successfully treated. Surgical treatment of zone 1 strictures is very difficult, requiring hepaticojejunostomy and prolonged
Volume
178
Number
#{149}
2
placement of stents with U tubes (5,15). Because of these difficulties and the excellent results obtained with interventional radiologic methods, we believe that the initial treatment should be performed percutaneously. Our 92% and 75% success rates in achieving longterm patency after cholangioplasty in zone 2 and 4 strictures, respectively, is
similar
to previous
radiologic
and
sun-
gical results. Patients with zone 2 or 4 strictures should, therefore, be treated by means of surgical or percutaneous techniques according to the presence or absence of comorbid conditions and a history of previous biliary tract sungery, as well as patient preferences. Three patients in our series had intrapancreatic biliary strictures; only one was successfully treated with balloon cholangioplasty. Mueller et al (9) liken these strictures to malignant stenoses due to the intense fibrosis surrounding the biliary ducts. Moore et al (11) suc-
cessfully
dilated
a stricture
caused
There
were
number
of total
The authors in preparing
thank Dana the manuscript.
References 1.
2.
postproce-
dural hospital days (17 vs 15) were required for the patients treated by means of nadiologic techniques and those treated surgically. In the patients treated percutaneously, the number of hospital days was largely due to readmissions required for treatment of sepsis caused by stent changes. The physician and hospital resources necessary for these neadmissions and the physician and technical charges required for routine stent maintenance may negate the initial cost savings of the percutaneous procedure.
Warren agement
KW, Mountain of strictures
Clin North Pellegrini
JC, Midell of the biliary
Am 1971; CA. Thomas
51:711-730. MJ. Way
Al. Mantract. Surg LW.
Recur-
rent biliary stricture: patterns of recurrence and outcome of surgical therapy. Am J Surg 1984; 147:175-180. 3.
4.
Blumgart LH, Kelly CJ, Benjamin IS. Benign bile duct stricture following cholecystectomy: critical factors in management. Br J Surg
1984; 71:836-843. Kalman PG. Taylor bile-duct
strictures.
BR. Langer Can J Surg
B. latrogenic 1982; 25:321-
Bernhoft Surg Clin
RA, Thomas North Am
MJ. 1981;
324. 5.
Way LW, stricture. 972.
6.
Pitt HA,
RK,
Miyamoto
Longmire
come
no procedure-nelat-
ed deaths in these series. Immediate postprocedunal sepsis was our most common complication, occurring in 47% of patients. This caused prolonged hospitalization after initial stricture dilation and required readmission for control of sepsis during the stenting period and after tube exchanges. Although we did not perform a direct cost analysis, it is unlikely that percutaneous cholangioplasty is more costeffective than surgical stricture repair.
A similar
Acknowledgment: Hall for assistance
by
chronic pancreatitis in this region but found that strictures of the ampulla of Vater were the least responsive to dilation. Yadegan et a! (16) successfully bypassed intnapancreatic common biliary duct strictures in 21 patients with no periopenative mortality. Further investigation of these lesions is required before balloon cholangioplasty can be recommended for their treatment. Published complication rates associated with percutaneous cholangioplasty vary from none (10) to 24.3% (12). The most common complications are postprocedural fever, chills, and
sepsis.
The number of patients treated in our study is too small to be used alone as a basis to recommend the best mode of therapy; however, our results agree with those of other radiologic series and, when viewed in conjunction with them, suggest that percutaneous treatment is as effective as surgical treatment for all strictures except those in the intrapancreatic bile duct. Stricture location and maturity can be used to predict the likelihood of treatment success and to identify patients who should be treated either percutaneously or surgically. Because of lower monbidity and mortality, patients with concomitant portal hypertension, multiple previous or recent biliary surgeries, and contraindications for general anesthesia may best be treated by means of percutaneous cholangioplasty. U
8.
11. 12.
13.
Transhepatic
of choledochoenterostomy 1978;
dilata-
strictures.
plasty.
with
Radiology
vanSonnenberg
percutaneous
1989;
cholangio-
170:199-206.
E. Ferrucci
JT, Neff
CC,
Mueller PR, Simeone JF, Wittenberg J. ary pressure: manometric and perfusion ies at percutaneous
15. 16.
Ra-
129:59-64.
Mueller PR, vanSonnenberg E, Ferrucci JT, et al. Biliary stricture dilatation: multicenter review of clinical management in 73 patients. Radiology 1986; 160:17-22. Gallacher DJ, Kadir S. Kaufman SL, et al. Nonoperative management of benign postoperative biliary strictures. Radiology 1985; 156:625-629. Moore AV, Illescas FF, Mills SR. et al. Percutaneous dilation of benign biliary strictures. Radiology 1987; 163:625-628. Williams HJ, Bender CE. May GR. Benign postoperative biliary strictures: dilation with fluoroscopic guidance. Radiology 1987; 163:629-634. Skolkin MD, Alspaugh JP. Casarella WJ, Chuang VP, Galambos JT. Sclerosing cholangitis: palliation
14.
out-
Am
diol Clin 1975; 44:153-159. Molnar W, Stockum AE. diology
10.
SK, Tompkins influencing
with post-operative biliary J Surg 1982; 144:14-21. Burhenne HJ. Dilatation of biliary tract strictures: a new roentgenologic technique. Ra-
tion 9.
Factors
in patients
strictures.
7.
T. Parapatis
WP.
Biliary 61:963-
transhepatic
Bilistud-
cholangiog-
raphy and percutaneous biliary drainage. Radiology 1983; 148:41-50. Braasch JW. Current considerations in the repair of bile duct strictures. Surg Clin North Am 1973; 53:423-433. Yadegar J, Williams RA, Passaro E, Wilson SE. Common duct stricture from chronic pancreatitis.
Arch
Surg
1980;
115:582-586.
Radiology
341
#{149}
Steven
MD
#{149} Louis
C. Martin,
Benign Biliary with Percutaneous
Strictures: Treatment Cholangioplasty’
Results of percutaneous balloon cholangioplasty of 17 patients with 28 benign biliary strictures were compared with those of published radiologic and surgical series to determine whether stricture location was related to therapeutic success and whether a patient should undergo percutaneous or surgical therapy. Treatment was considered successful if there was no anatomic evidence of recurrent stricture or need for surgery (mean follow-up, 32 months). Treatment was successful in all nine (100%) intrahepatic (zone 1) strictures, 11 of 12 (92%) extrahepatic-extrapancreatic (zone 2) strictures, one of three (33%) intrapancreatic (zone 3) strictures, and three of four (75%) bilienteric anastomotic (zone 4) strictures. Restenosis occurred in five patients; cholangioplasty was ultimately successful in two of those patients after redilaHon and stent placement. On the basis of these results and those of published radiologic and surgical series, the authors believe that cholangioplasty is the treatment of choice for zone 1 strictures gery for
and
is as effective
as sur-
zone 2 and 4 strictures. Patients with zone 2 and 4 strictures with concomitant portal hypertension or a history of multiple previous biliary surgical procedures should be considered good candidates for cholangioplasty. Zone 3 strictures may be better treated surgically than percutaneously. Index dure, tion,
76.45
terms:
Bile ducts,
76.1229 76.289,
Bile
#{149}
76.291,
#{149} Catheters
Radiology
interventional
ducts, 76.45
and
stenosis Bile
#{149}
catheterization
1991; 178:339-341
proceor obstruc-
ducts,
MD
surgery
N
percent of benign ductal strictures are due to iatrogenic trauma caused by routine cholecystectomy. The injury is unrecognized in 68% of those patients because the common hepatic duct can be mistaken for the cystic duct due to incomplete dissection or inflammation (1). Surgical repair is successful in relieving the subsequent stricture in 63%-92% of patients, but 10%-30% experience a stricture recurrence, usually within 1-3 years (1-6). Surgical repair becomes less successful with each additional attempt (6). Concomitant biliary cirrhosis and portal hypertension increase operative time and mortality rates (3). Percutaneous cholangioplasty perINETY-SEVEN
biliary
formed
by means
of a T-tube
tract
was
first described by Burhenne (7) in 1975. In 1978, Molnar and Stockum (8) described the percutaneous transhepatic technique. Results of percutaneous dilation techniques developed in the last decade rival those of surgical series (912). We report our experience using balloon catheters to dilate these strictunes and compare our results with those of several radiologic and surgical series. We have reviewed our experience in an attempt to answer these questions pertaining to percutaneous dilation of benign biliary strictures: (a) Does stricture location affect dilation success? and (b) Are there patients who should be treated surgically rather than percutaneously?
17 patients with a total of 28 benign biliary strictures made up our study population. Ten patients had primary postoperative strictures, affecting the hepatic or cornmon bile duct in six and affecting bilientenic anastomoses in four. (A primary
stricture
quired
AND
METHODS
Between April 1982 and March 1988, 43 patients with benign biliary strictures were treated in our department by means of percutaneous cholangioplasty. Twentysix patients with sclerosing cholangitis have been reported elsewhere (13) and were excluded from this study. Therefore,
I From the Department of Radiology, Emory University Hospital, 1364 Clifton GA 30322. Received April 24, 1990; revision requested June 14; revision received cepted September 12. Address reprint requests to L.G.M. RSNA, 1991
Rd. NE, Atlanta, September 11; ac-
as an iatrogenic
or id-
to return
for repeat
dilations
on
successive days prior to final stent placement and hospital discharge. More recently, the patients return about 48 hours after initial biliary drainage for stricture dilation and stent placement under general anesthesia. At this time, a large-bore (10-16-F) stent with side holes above and below the stenosis is placed across the dilated bile duct. A stent was not placed in one patient, a 71-year-old Laotian woman with Oriental cholangiohepatitis, after stricture
dilation;
stents
were
placed
in all
other patients. We drain the bile externally until the patient is afebnile for 24-48 hours and then internalize bile flow by capping the drainage tube. Broad-spectrum antibiotics,
PATIENTS
is defined
iopathic postoperative narrowing in the bile duct.) The remaining seven patients had inflammatory strictures. These strictunes were due to chronic pancreatitis (three patients), cholelithiasis (two patients), and Oriental cholangiohepatitis (two patients). The locations of the bile duct strictures were divided into four zones (Fig 1): intrahepatic (zone 1), extrahepatic-extrapancreatic (zone 2), intrapancreatic (zone 3), and bilientenic anastomotic (zone 4). The current treatment protocol is as follows: Early in our study, patients were re-
usually
cephalosponins,
tered intravenously tial biliary drainage ready for discharge Antibiotics are also
istered
prior
are
adminis-
from the time of miuntil the patient is from the hospital. intravenously admin-
to all stent
changes
and ma-
nipulations. Three patients had indwelling T tubes through which manipulations were performed. After approximately 3-6 months (average, 20 weeks; range, 1-68 weeks), the stent was withdrawn proximal to the stricture and cholangiognaphy was performed to assess patency. If the duct was judged to be patent (normal drainage and subjective lack of significant luminal narrowing), the stent was removed and the patient was followed up
339
clinically
by the
casionally,
referring
a 4-F catheter
physician.
was placed
the
bile duct proximal to the stnictured for 1-3 months after stent removal in the event repeat cholangioplasty was necessary because of early restenosis. The 4-F catheter was removed if there were no signs of restenosis. All dilations were performed on an inpatient basis. Dilation was performed with standard balloon catheters. Balloon diameters were at least that of the adjacent duct. Inflation pressures and duration were 6-15 atm and 3-10 minutes, respectively. Biliary pressures obtained aften a saline infusion were occasionally used to assess patency; a manometnic pressure of less than 20 cm of saline proximal to the stricture was considered normal as per vanSonnenberg et al (14). Follow-up information was obtained by means of questionnaires and telephone interviews with both patients and referring physicians. Long-term follow-up results were not available in one patient; that patient was 94 years old and was not successfully treated with cholangioplasty. Treatment was considered successful if all stents were removed, the patient was symptom-free, laboratory values (eg, bilirubin, alkaline phosphatase, aspartate aminotransferase) were near normal, and sungery was avoided. Restenosis was defined as the need for redilation, stent placement, and stent removal. Cholangioplasty was considered unsuccessful if surgical repair was required. Postprocedural fever was defined as an oral temperature greater than 100.5#{176}F(38.1#{176}C)within 24 hours after dilation. Postprocedural bleeding was defined as a fall in hematocnit greater than 2% (>0.02). Sepsis during or after the stent was placed was defined as fever, night upper quadrant pain, and leukocytosis with or without positive biliary cultures. Postprocedural hospitalization included all hospital days required during the followup period. The mean follow-up period was 32 months (range, 11-61 months). To evaluate the difference in the need for postprocedural hospitalization after percutaneous cholangioplasty and after surgical repair of benign biliary stnictunes, we reviewed the records of 12 patients treated by means of surgery alone at our institution during the period of our study. This study group consisted of three men and nine women (mean age, 54 area
years).
One
patient
had
a zone
1 stricture;
five had zone 2, four had zone 3, and two had zone 4 strictures. Seven patients underwent choledochojejunostomy, two underwent
hepaticojejunostomy,
two
under-
went ampullary sphincteroplasty, and one underwent choledochoduodenostomy. Eleven patients required only one surgical procedure; one patient required four. The mean follow-up period for this group was 28 months. The number of postsurgical hospital days was totaled for each patient. These included any readmissions for cholangitis, wound infection, restenosis, and reoperation. Data were compared with those of our cholangioplasty study population.
340
Radiology
#{149}
RESULTS
Oc-
in
Twenty-four of 28 strictures (86%) in 14 of our 17 patients (82%) were successfully treated by means of pencutaneous cholangioplasty. One hundred percent of zone 1 strictures, 92% of zone 2 strictures, 33% of zone 3 stnictunes, and 75% of zone 4 strictures were treated successfully (Fig 2). Restenosis occurred in five of the 17 patients (29%). Percutaneous cholangioplasty was ultimately successful in two of those patients at 12 and 51/2 months, respectively. Both of those patients had inflammatory strictures with laboratory evidence of biliary obstruction. Both patients underwent redilation and stent placement and were doing well 23 and 60 months later, respectively. Cholangioplasty was
unsuccessful
in three
patients,
Figure 1. Location of benign biliary strictures. Zone 1 four patients, nine strictures; zone 2 = eight patients, 12 strictures; zone = three patients, three strictures; and zone =
four
patients,
four
3
4
strictures.
all of
whom required alternate therapy. A 48year-old woman with neurofibromatosis had had a bilenteric anastomosis and developed both a zone 2 and zone 4 stricture. Both strictures responded to dilation and stent placement, but the patient developed cholangitis after stent removal. The zone 2 stricture could not be recrossed percutaneously. She underwent a hepaticojejunostomy and was doing well at 29 months follow-up. The other two patients in whom cholangioplasty was unsuccessful, a 58-year-old woman and a 94-yearold man, had zone 3 strictures due to chronic pancreatitis. Both had delayed ductal drainage demonstrated at cholangiography 2 and 4 weeks after cholangioplasty, respectively, but neither had signs of cholangitis during the follow-up period. The former underwent choledochoduodenostomy and was doing well 18 months after surgery; the latter underwent endoscopic sphincteroplasty and was lost to follow-up 4 weeks later. Fever immediately following the cholangioplasty was common, occurring in 47% of patients; none had positive blood cultures, possibly because of pretreatment with broad-spectrum antibiotics. Five of the patients who underwent successful cholangioplasty had complications during or after the stenting period. After stent removal, two patients had a total of five episodes of presumed cholangitis; each episode was managed with antibiotics alone. One patient had a night-sided hepatic abscess that was drained percutaneously during the stenting period; the abscess did not recur. One patient had two episodes of cholangitis during the stenting period; both episodes resolved with intravenously administened antibiotics. One patient with zone 1 strictures developed intrahepatic stones during the follow-up period that were successfully removed by means of percutaneous tnanshepatic
Figure
2.
Results
gioplasty
for
strictures
(86%)
and
14 of the
fully
of percutaneous
each
zone.
were
Overall,
successfully
17 patients
cholan24
of
the
28
dilated,
(82%)
were
success-
treated.
methods; however, there was no cholangiographic evidence of ductal restenosis in this patient. Total postprocedural hospital days (including readmissions for complications occurring during the follow-up period) were similar regardless of treatment regimen. Readmission after suc-
cessful
cholangioplasty
was
most
often
due to sepsis that occurred during the stenting period or after stent changes; the average total number of postcholangioplasty hospital days was 17 days. Two patients in whom cholangioplasty was not successful and who required surgical repair averaged 1 1 hospital days after their surgical procedure duning the follow-up period; neither required readmission after surgery. The third patient in whom cholangioplasty was not successful was lost to followup 4 weeks after discharge after undergoing endoscopic sphincteroplasty. The 12 patients treated by means of surgery alone averaged 15 total hospital days after their procedure during
follow-up; two
of whom
three
were
required
rehospitalized, 41 hospital
February
days
1991
each during follow-up. Both of these patients had undergone previous biliany tract surgery at other institutions within 4 months of their surgery at our institution.
DISCUSSION Only about one in 400-500 cholecystectomy procedures is complicated by biliary stricture, which can quickly lead to cirrhosis, cholangitis, and death (12). Since surgical repair of postoperative strictures carries the risk of operative mortality and recurrence, percutaneous treatment, at first only an attnactive concept, is now a viable alternative to surgery. The four largest nadiologic series to date (Williams et al [12], Gallachen et al [10], Mueller et al [9], and Moore et al [11]) had overall success rates of 67%85% in 177 patients with sclerosing cholangitis and primary postoperative and bilientenic anastomotic strictures. Follow-up periods ranged from a mean of 15 months (10) to at least 3 years (9). Our results compare favorably with those from the published surgical and radiologic series. If zone 3 strictures are excluded, 23 of 25 (92%) extrapancreatic strictures were successfully treated with percutaneous cholangioplasty. Our restenosis rate of 29% is similar to those of the surgical series of Kalman et al (20%) (4) and Pellegrini et al (22%) (2) and the radiologic series of Williams et a! (2.2%) (12), Gallacher et al (31%) (10), and Mueller et al (34%) (9); it is higher than those of the surgical series of Way et al (10%) (5) and Blumgant et al (10%) (3). Mueller et al (9) studied 17 patients with sclerosing cholangitis, whom they found to have the highest recurrence rate (58%); such patients were excluded from our study. In our study, patients who underwent successful cholangioplasty had previously undergone surgery an average of nearly 4 years before balloon dilation was attempted. One patient who had a primary postoperative stricture and in whom cholangioplasty was unsuccessful had undergone surgery only 6 months earlier. The two patients who developed nestenosis and required nedilation did so within 1 year of the initial cholangioplasty. This may underscore the importance of the fibrotic maturation process that occurs after biliary manipulation; Braasch (15) notes that this process occurs mainly within the first year after surgical repair and is largely completed within three years. All zone 1 strictures were successfully treated. Surgical treatment of zone 1 strictures is very difficult, requiring hepaticojejunostomy and prolonged
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2
placement of stents with U tubes (5,15). Because of these difficulties and the excellent results obtained with interventional radiologic methods, we believe that the initial treatment should be performed percutaneously. Our 92% and 75% success rates in achieving longterm patency after cholangioplasty in zone 2 and 4 strictures, respectively, is
similar
to previous
radiologic
and
sun-
gical results. Patients with zone 2 or 4 strictures should, therefore, be treated by means of surgical or percutaneous techniques according to the presence or absence of comorbid conditions and a history of previous biliary tract sungery, as well as patient preferences. Three patients in our series had intrapancreatic biliary strictures; only one was successfully treated with balloon cholangioplasty. Mueller et al (9) liken these strictures to malignant stenoses due to the intense fibrosis surrounding the biliary ducts. Moore et al (11) suc-
cessfully
dilated
a stricture
caused
There
were
number
of total
The authors in preparing
thank Dana the manuscript.
References 1.
2.
postproce-
dural hospital days (17 vs 15) were required for the patients treated by means of nadiologic techniques and those treated surgically. In the patients treated percutaneously, the number of hospital days was largely due to readmissions required for treatment of sepsis caused by stent changes. The physician and hospital resources necessary for these neadmissions and the physician and technical charges required for routine stent maintenance may negate the initial cost savings of the percutaneous procedure.
Warren agement
KW, Mountain of strictures
Clin North Pellegrini
JC, Midell of the biliary
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Recur-
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4.
Blumgart LH, Kelly CJ, Benjamin IS. Benign bile duct stricture following cholecystectomy: critical factors in management. Br J Surg
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Pitt HA,
RK,
Miyamoto
Longmire
come
no procedure-nelat-
ed deaths in these series. Immediate postprocedunal sepsis was our most common complication, occurring in 47% of patients. This caused prolonged hospitalization after initial stricture dilation and required readmission for control of sepsis during the stenting period and after tube exchanges. Although we did not perform a direct cost analysis, it is unlikely that percutaneous cholangioplasty is more costeffective than surgical stricture repair.
A similar
Acknowledgment: Hall for assistance
by
chronic pancreatitis in this region but found that strictures of the ampulla of Vater were the least responsive to dilation. Yadegan et a! (16) successfully bypassed intnapancreatic common biliary duct strictures in 21 patients with no periopenative mortality. Further investigation of these lesions is required before balloon cholangioplasty can be recommended for their treatment. Published complication rates associated with percutaneous cholangioplasty vary from none (10) to 24.3% (12). The most common complications are postprocedural fever, chills, and
sepsis.
The number of patients treated in our study is too small to be used alone as a basis to recommend the best mode of therapy; however, our results agree with those of other radiologic series and, when viewed in conjunction with them, suggest that percutaneous treatment is as effective as surgical treatment for all strictures except those in the intrapancreatic bile duct. Stricture location and maturity can be used to predict the likelihood of treatment success and to identify patients who should be treated either percutaneously or surgically. Because of lower monbidity and mortality, patients with concomitant portal hypertension, multiple previous or recent biliary surgeries, and contraindications for general anesthesia may best be treated by means of percutaneous cholangioplasty. U
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Mueller PR, vanSonnenberg E, Ferrucci JT, et al. Biliary stricture dilatation: multicenter review of clinical management in 73 patients. Radiology 1986; 160:17-22. Gallacher DJ, Kadir S. Kaufman SL, et al. Nonoperative management of benign postoperative biliary strictures. Radiology 1985; 156:625-629. Moore AV, Illescas FF, Mills SR. et al. Percutaneous dilation of benign biliary strictures. Radiology 1987; 163:625-628. Williams HJ, Bender CE. May GR. Benign postoperative biliary strictures: dilation with fluoroscopic guidance. Radiology 1987; 163:629-634. Skolkin MD, Alspaugh JP. Casarella WJ, Chuang VP, Galambos JT. Sclerosing cholangitis: palliation
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tion 9.
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