title: Predictive value of cholangioscopy after endoscopic management of early postcholecystectomy bile duct strictures with an increasing number of plastic stents: a prospective study (with videos).
abstract: BACKGROUND
  Endotherapy of postcholecystectomy bile duct stricture (PCBS) has been established as an alternative treatment to surgery. Several studies have reported conflicting results regarding the predictors of success or failure of endotherapy.
  
  
  OBJECTIVE
  To evaluate the different cholangioscopic appearances of PCBS after endotherapy with an increasing number of plastic stents and the predictive values of these appearances for the outcome.
  
  
  METHODS
  Prospective study with a long-term follow-up.
  
  
  METHODS
  Two academic tertiary referral centers.
  
  
  METHODS
  Twenty consecutive patients with major bile duct injury, with a bile leak, and a PCBS who underwent therapeutic ERCP.
  
  
  METHODS
  Closure of the leak followed by temporary placement of multiple plastic stents for the treatment of PCBS, followed by cholangioscopy at the end of endotherapy.
  
  
  METHODS
  To analyze the predictive value of cholangioscopy, other predictors of stricture recurrence after endotherapy, and long-term clinical success.
  
  
  RESULTS
  Closure of the leak was achieved in all patients. The median duration of endotherapy was 12 months (range 7-18 months). After endoscopic stenting, the PCBS was considered to be appropriately dilated in all patients. After endotherapy, 3 different findings were noted on cholangioscopy: (1) no lesion or minor defect (n = 10), (2) minor stricture with a fibrous ring (n = 6), and (3) presence of tissue hyperplasia (n = 4). During follow-up, stricture recurrence developed in 4 of 20 patients. All 4 patients were successfully retreated by an additional period of stenting and remained free of cholestasis after a median follow-up period of 44 months. By Kaplan-Meier (log-rank) and univariate analyses, the cholangioscopic pattern of tissue hyperplasia was significantly associated with stricture recurrence (P < .01).
  
  
  CONCLUSIONS
  Small sample size.
  
  
  CONCLUSIONS
  Endoscopic stenting should be regarded as the primary treatment of choice because of the successful long-term outcome after 1 or more additional periods of treatment. However, the cholangioscopic pattern of tissue hyperplasia at the time of stent removal is a strong predictor of stricture recurrence, and this observation may lead to an additional period of endotherapy or other treatment modalities.
authors.affiliation: Department of Gastroenterology, Pulido Valente Hospital, Faculty of Medical Sciences - Nova Medical School, Lisbon, Portugal; Center of Gastroenterology, Cuf Infanto Santo Hospital, Faculty of Medical Sciences - Nova Medical School, Lisbon, Portugal.
authors.forename: Jorge
authors.initials: J
authors.lastname: Canena
authors.affiliation: Center of Gastroenterology, Cuf Infanto Santo Hospital, Faculty of Medical Sciences - Nova Medical School, Lisbon, Portugal.
authors.forename: Manuel
authors.initials: M
authors.lastname: Liberato
authors.affiliation: Department of Gastroenterology, Pulido Valente Hospital, Faculty of Medical Sciences - Nova Medical School, Lisbon, Portugal; Center of Gastroenterology, Cuf Infanto Santo Hospital, Faculty of Medical Sciences - Nova Medical School, Lisbon, Portugal.
authors.forename: António Pereira
authors.initials: AP
authors.lastname: Coutinho
authors.affiliation: Department of Gastroenterology, Pulido Valente Hospital, Faculty of Medical Sciences - Nova Medical School, Lisbon, Portugal.
authors.forename: Inês
authors.initials: I
authors.lastname: Marques
authors.affiliation: Department of Gastroenterology, Pulido Valente Hospital, Faculty of Medical Sciences - Nova Medical School, Lisbon, Portugal.
authors.forename: Carlos
authors.initials: C
authors.lastname: Romão
authors.affiliation: Curva de Gauss, Research, Training and Consulting, Canas de Senhorim, Portugal.
authors.forename: Pedro Mota
authors.initials: PM
authors.lastname: Veiga
authors.affiliation: Department of Gastroenterology, Pulido Valente Hospital, Faculty of Medical Sciences - Nova Medical School, Lisbon, Portugal.
authors.forename: Beatriz Costa
authors.initials: BC
authors.lastname: Neves
mesh_terms: D000328:Adult; D000368:Aged; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods*; D002763:Cholecystectomy / Q000009:adverse effects*; D002779:Cholestasis / Q000175:diagnosis* / Q000209:etiology / Q000601:surgery; D003251:Constriction, Pathologic; D020878:Device Removal / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011446:Prospective Studies; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome
keywords: BBS; CI; FCSEMS; PCBS; benign biliary stricture; confidence interval; fully cover self-expandable metal stent; postcholecystectomy bile duct stricture