ADVANCES IN DIAGNOSIS AND TREATMENT OF BILIARY STRICTURES AND STENOSIS

Benign stenoses and strictures of the biliary tract are uncommon and usually result from iatrogenic injuries of the bile duct occurred during surgical procedures like cholecystectomy, hepatic resection or biliary-enteric anastomosis. They may also complicate liver transplantation. Other causes are chronic inflammation like chronic pancreatitis, choledocholithiasis, parasitic infection and primary sclerosing cholangitis. Rarely benign bile duct stenosis may be congenital (for example biliary atresia), develop as a complication of an acute cholecystitis (Mirizzi's syndrome) or be secondary to trauma or spontaneous biliary rupture which is an exceptional event. Benign strictures can sometimes mimic a malignant disease that has to be ruled out. Cholestasis is usually the clinical feature that leads to the diagnosis. Once a biliary damage is suspected at surgery, intraoperative cholangiography allows an early detection of the lesion and is therefore advisable. Biliary damages that go unnoticed at surgery can be diagnosed through a percutaneous on endoscopic cholangiography. An inadequate experience of the surgeon is often the underlying cause of the biliary damage; cholecystectomy should be performed by fully-trained surgeons. Treatment of biliary stenoses can be non-surgical (percutaneous or endoscopic balloon catheter dilatation) or surgical. In this latter case the choice of the surgical strategy will depend on the site and the length of the stenosis. After resection of the stenotic tract, the biliary-enteric anastomosis should be as wide as possible, which is best achieved by performing a hepatico-jejunostomy proximal to the liver. In all benign strictures of the biliary tract, the outcome depends on the experience and competence of all the teams involved (surgeons, radiologists and endoscopists) in selecting and performing