Benign biliary strictures

Benign bile duct strictures are usually iatrogenic and result from surgery near the porta hepatis. If a bile duct injury is suspected intraoperatively, cholangiography is essential, and a careful Roux-en-Y biliary-enteric anastomosis is often required to achieve the best postoperative result. Alternatively, the patient may be transferred to a tertiary referral center for further management by dedicated biliary surgeons, endoscopists, and radiologists. If transfer is contemplated, a catheter should be passed surgically into the bile duct for postoperative cholangiography with a second drain located alongside the injured bile duct to prevent bilious peritonitis. Benign strictures recognized in the office setting require operative intervention and should be thoroughly investigated by cholangiography and cross-sectional imaging to define the lesion and exclude malignancy. Because indwelling catheters help the surgeon to identify the injured bile duct, we favor the combination of percutaneous transhepatic cholangiography and CT scan or magnetic resonance imaging during the preoperative evaluation. The stenotic bile duct should be resected to exclude malignancy, after which an end-to-side biliary-enteric anastomosis is created by the Roux-en-Y technique. Balloon dilation and percutaneous stent placement are acceptable alternatives to surgical therapy in patients with significant medical comorbidities and may be used successfully as primary therapy for postoperative anastomotic strictures.