Long-term results of metallic stents for benign biliary strictures

Background: Historically, surgical correction has been the treatment of cho ice for benign biliary strictures (BBS). Self-expandable metallic stents (M Ss) have been useful for inoperable malignant biliary strictures; however, their use for BBS is controversial and their natural history unknown. Hypothesis: To test our hypothesis that MSs provide only short-term benefit , we examined the long-term outcome of MSs for the treatment of BBS. Our go al was to develop a rational approach for treating BBS. Data Extraction: Between July 1990 and December 1995, 15 patients had MSs p laced for BBS and have been followed up for a mean of 86.3 months (range, 5 5-120 months). The mean age of the patients was 66.6 years and 12 were wome n. Stents were placed for surgical injury in 5 patients and underlying dise ase in 10 patients (lithiasis, 7; pancreatitis, 2; and primary sclerosing c holangitis, 1). One or more MSs (Gianturco-Rosch "Z" for 4 patients and Wal lstents for 11 patients) were placed by percutaneous, endoscopic, or combin ed approaches. We considered patients to have a good clinical outcome if th e stent remained patent, they required 2 or fewer invasive interventions, a nd they had no biliary dilation on subsequent imaging. Data Synthesis: Metallic stents were successfully placed in all 15 patients , and the mean patency rate was 30.6 months (range, 7-120 months). Five pat ients (33%) had a good clinical result with stent patency from 55 to 120 mo nths. Ten patients (67%) required more than 2 radiologic and/or endoscopic procedures for recurrent cholangitis and/or obstruction (range, 7-120 month s). Five of the 10 patients developed complete stent obstruction at 8, 9, 1 0, 15, and 120 months and underwent surgical removal of the stent and bilio enteric anastomosis. Four of these 5 patients had strictures from surgical injuries. The patient who had surgical removal 10 years after MS placement developed cholangiocarcinoma. Conclusions: Surgical repair remains the treatment of choice for BBS. Metal lic stents should only be considered for poor surgical candidates, intrahep atic biliary strictures, or failed attempts at surgical repair. Most patien ts with MSs will develop recurrent cholangitis or stent obstruction and req uire intervention. Chronic inflammation and obstruction may predispose the patient to cholangiocarcinoma.