Role of endoscopic retrograde cholangiopancreatography in the management of benign biliary strictures: What’s new?

Table 1 Etiology of benign biliary strictures

Post-operative injuries
	Cholecystectomy
	Liver transplantation
	Hepatic resection
	Biliary anastomosis
	Biliary reconstruction
	Biliary enteric anastomosis
Inflammatory
	Chronic pancreatitis
	Primary sclerosing cholangitis
	Autoimmune pancreatitis
	Choledocholithiasis
	Immunoglobulin G4 cholangiopathy
	Infections (recurrent bacterial cholangitis, tuberculosis, histoplasmosis, schistosomiasis, HIV, parasites)
	Postradiation therapy
Others
	Ischemic (hypotension, hepatic artery thrombosis, portal biliopathy)
	Trauma
	Mirizzi syndrome
	Postbiliary sphincterotomy
	Endoscopic sclerotherapy for duodenal ulcer bleeding

HIV: Human immunodeficiency virus.

Table 2 Classification for benign biliary strictures

Bismuth classification
I	Low CHD stricture, > 2 cm distal to hilum
II	Proximal CHD stricture, < 2 cm distal do hilum
III	Hilar involvement up to proximal extent of CHD, but confluence preserved
IV	Confluence involved, no communication between left and right ducts
V	Type I, II or III plus stricture of an isolated (aberrant) right duct
Strasberg classification
A	Small duct injury in continuity with biliary system, with cystic duct leak
B	Injury to sectoral duct with consequent obstruction
C	Injury to sectoral duct with consequent bile leak from a duct not in continuity with biliary system
D	Injury lateral to extrahepatic ducts
E1	Stricture located > 2 cm from bile duct confluence
E2	Stricture located < 2 cm from bile duct confluence
E3	Stricture located at bile duct confluence
E4	Stricture involving right and left bile ducts
E5	Complete occlusion of all bile ducts

CHD: Common hepatic duct.

Table 3 Studies reporting on the treatment of benign biliary strictures with multiple plastic stent

Ref.	Etiology	Total number (completed treatment) (n)	ERCP number	Balloon dilation	Maximal number of stents	Stenting duration (mo)	Follow-up after stent removal (mo)	Success after end of follow-up (%)
Bourke et al[99]	Sphincterotomy	6 (6)	5.2	-	2.2	13	27	100
Costamagna et al[51]	Various surgical procedures	45 (42)	4.1	40% of patients	3.2	12	164	89
Draganov et al[44]	Surgery (n = 19)	29 (27)	4	-	2.7	14	48	Surgery 68
	Chronic pancreatitis (n = 9)							Chronic pancreatitis 44
	Idiopathic (n = 1)
Pozsár et al[69]	Chronic pancreatitis	29 (24)	4.2	-	2.4	21	12	62
Catalano et al[68]	Chronic pancreatitis	12 (12)	4.7	-	4.3	14	47	92
Kuzela et al[100]	Cholecystectomy	43 (43)	6	In some	3.4	12	16	100
Morelli et al[101]	OLT	38 (38)	3.5	+	2.5	3.6	12	87
Tabibian et al[102]	OLT	83 (69)	4.1	+	NA	15	11	91

ERCP: Endoscopic retryrade cholangio pancreatograph; NA: Not available; OLT: Orthotopic liver transplantation.

Table 4 Prospective trials reporting placement of self-expandable metal stents in benign biliary strictures

Ref.	No. patients	Etiology	Type of stent	Clinical success (%)	Adverse events (%)	Migration rate (%)	Median follow-up
Park do et al[90]	33	CP, BDS, OLT, postsurgical	FCSEMS with 4 AF; FCSEMS with both FE	91 with AF; 88 with FE	3	0 with AF; 33 with FE	6 mo (IQR 4-6)
Wagh et al[82]	23	CP, BDS, OLT, idiopathic	Wallflex	96-short term 83-long term	4.3	39	18.8 mo (IQR 14.1-21.3)
Kahaleh et al[72]	133	CP, OLT	FCSEMS flared	67	3.1	10.5	95.5 ± 48.7 d
Devière et al[87]	187	CP, OLT, CCY	Wallflex	76.3	27.3	29.4	20.3 mo (IQR 12.9 -24.3)
Kaffes et al[65]	32	OLT	10 FCSEMS; 10 plastic stent	100 in FCSEMS; 80 in plastic stent	1 in FCSEMS, 5 in plastic stent	0 in FCSEMS	24.5 mo (range 4-38) in FCSEMS; 23 (range 1-42) in pastic stent
Haapamäki et al[70]	60	CP	30 FCSEMS; 30 plastic stent	92 in FCSEMS; 90 in plastic sten	29	10 in FCSEMS; 7 in plastic stent	40 mo (range-66)

AF: Anchoring fins; BDS: Bile duct stones; CCY: Cholecystectomy; CP: Chronic pancreatitis; FE: Fared ends; FCSEMS: Fully covered self-expandable metal stents; IQR: Interquartile range; OLT: Orthotic liver transplantation.