title: Post-cholecystectomy biliary strictures: not always benign.
abstract: BACKGROUND
  Post-cholecystectomy malignant biliary obstruction masquerading as benign biliary stricture (BBS) has not been reported in the literature; it presents a diagnostic and management challenge.
  
  
  METHODS
  Of the 349 post-cholecystectomy BBS managed at a tertiary care hospital in northern India between 1989 and 2004, 11 patients were found to have biliary malignancy. Records of these 11 patients were analyzed retrospectively for the purpose of this study.
  
  
  RESULTS
  Mean age of patients with malignant biliary strictures was significantly higher (52 vs 38 years, P = 0.000); they were more likely to have jaundice (100% vs 78%, P = 0.008) and pruritus (82% vs 48%, P = 0.03). Unlike most patients with BBS referred from elsewhere to us, they had had a smooth postoperative course uncomplicated by bile leak, had a longer cholecystectomy-presentation interval, and were more likely to have high strictures ((Bismuth type III/IV) 91% vs 49%, P = 0.008).
  
  
  CONCLUSIONS
  Post-cholecystectomy biliary obstruction is not always benign. High bilirubin levels and hilar strictures, especially after an uneventful cholecystectomy, in a middle-aged patient should raise a suspicion of underlying missed malignancy.
authors.affiliation: Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India. asharmasgpgi@rediffmail.com
authors.forename: Ajay
authors.initials: A
authors.lastname: Sharma
authors.forename: Anu
authors.initials: A
authors.lastname: Behari
authors.forename: Sadiq S
authors.initials: SS
authors.lastname: Sikora
authors.forename: Ashok
authors.initials: A
authors.lastname: Kumar
authors.forename: Rajan
authors.initials: R
authors.lastname: Saxena
authors.forename: Vinay K
authors.initials: VK
authors.lastname: Kapoor
mesh_terms: D000328:Adult; D001661:Biliary Tract Neoplasms / Q000150:complications / Q000175:diagnosis* / Q000378:metabolism / Q000628:therapy; D001663:Bilirubin / Q000097:blood; D002758:Cholangiography; D002763:Cholecystectomy / Q000009:adverse effects*; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects; D002779:Cholestasis / Q000209:etiology* / Q000378:metabolism / Q000473:pathology / Q000601:surgery; D003937:Diagnosis, Differential; D006801:Humans; D007194:India; D041781:Jaundice, Obstructive / Q000209:etiology; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D011537:Pruritus / Q000209:etiology; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D001663:Bilirubin