1Naveen Kumar Condati, 1Salil Karkhanis, 1Homoyoon Mehrzad, 1Robert Briard, 1Qazi Jehanzeb

1Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, United Kingdom

Background:

Percutaneous trans-hepatic balloon dilatation (PTBD) is a well-known treatment strategy for benign biliary strictures (BBS), to avoid surgical revision of biliary enteric anastomoses. However, there are several parameters involved in the procedure that influence successful long term outcome. The aims of this study were to evaluate the clinico-radiological parameters affecting the successful outcome of PTBD in BBS and to identify the cohort benefiting from PTBD over surgical management.

Material(s) and Method(s):

A retrospective record-based analysis was carried out at our tertiary hospital, of patients treated with PTBD for BBS during the reference period from 1st January 2013 to 31st December 2019. 60 patients (median age-60 years, M:F 33:27) were identified as diagnosed with BBS, on imaging and histopathology, following to biliary enteric anastomosis secondary to liver transplant or tumour resection. Patients with malignant or inflammatory biliary strictures and biliary stone disease were excluded. Radiological success (satisfactory patency on cholangiogram and removal of biliary drain) and clinical success (normal clinical and liver function at 1 year follow up after removal of drain) were considered as primary endpoints.

Result(s):

Of the 60 patients studied by univariate and multivariate analysis, clinico-radiological success in 43 patients (72%) was noted at 1 year follow up. Of the 17 cases with radiological failure, about 60% proceeded to surgical revision with 7 cases not suitable for surgery due to biliary sepsis/ ischemic cholangiopathy.

On comparing the individual clinico-radiological parameters in both the groups, cholangioplasty balloon size of > 10 mm (up to 14 mm) and > 12F (up to 14F) diameter of the internal-external biliary catheter was associated with a successful outcome.

Post-transplant patients formed most of the failure cohort, suggesting this etiology is more likely to fail. Other parameters such as catheter dwell time, number of cholangioplasty sessions, and the time interval between cholangioplasty sessions were not statistically significant. Recurrence of stricture was seen in 6 patients after 1 year follow up, which was successfully treated with repeat cholangioplasty sessions.

Conclusion(s):

The use of larger size cholangioplasty balloon and internal-external biliary catheter early in the course of treatment was associated with significantly improved outcomes. Longer catheter dwell time and the number of cholangioplasty sessions, which are associated with patients’ poor quality of life and increased cost-resource utilization, had no significant effect on the outcome. Post-transplant patients seem to have a higher chance of radiological failure post-PTBD.

Percutaneous trans-hepatic balloon dilatation of benign biliary stricture if optimized by focusing on the parameters described, can provide long-term patency rates, obviating the need for surgical revision in the appropriate clinical setting.