What are the treatment options for stenosis of the common bile duct (CBD)?

From the Guidelines

Treatment for stricture of the common bile duct typically involves endoscopic retrograde cholangiopancreatography (ERCP) with balloon dilation and stent placement as the first-line approach, with fully covered self-expandable metal stents (FCSEMS) favored over multiple plastic stents whenever feasible due to similar efficacy but significantly reduced need for stent exchange procedures during the treatment course 1.

Key Considerations

• The choice of treatment depends on the stricture etiology (benign versus malignant), location, and patient factors.
• Benign strictures often result from surgical injury, chronic pancreatitis, or primary sclerosing cholangitis, while malignant strictures require oncologic management alongside biliary drainage.
• Prompt treatment is essential as bile duct obstruction can lead to cholangitis, jaundice, and liver damage.

Treatment Approach

• ERCP with stent insertion is the preferred treatment for benign biliary stricture due to chronic pancreatitis.
• FCSEMS placement is favored over multiple plastic stents whenever feasible, given similar efficacy but significantly reduced need for stent exchange procedures during the treatment course.
• If endoscopic management fails, surgical options include hepaticojejunostomy or choledochojejunostomy to bypass the stricture.

Important Considerations

• Patients should receive prophylactic antibiotics (such as ciprofloxacin 400mg IV or oral equivalent) before invasive biliary procedures to prevent infection.
• The most recent guidelines recommend FCSEMS placement as the preferred treatment for benign biliary stricture due to chronic pancreatitis, as it reduces the need for stent exchange procedures and has similar efficacy to multiple plastic stents 1.

From the Research

Treatment Options for Stricture of the Common Bile Duct

• Endoscopy is a widely used approach for the treatment of benign biliary strictures, including those of the common bile duct 2
• Endoscopic treatment consists of passing the stricture and placement of at least one large bore plastic stent, followed by further sessions of stenting with multiple plastic stents 2
• Temporary placement of multiple plastic stents is the recommended approach in patients with benign biliary strictures 2
• Covered self-expandable metal stents can be safely placed in selected patients, but placement of uncovered metal stents in patients with benign biliary strictures is strongly discouraged 2

Alternative Treatment Approaches

• Surgery is a valid option in cases of complete transection or ligation of the common bile duct, in selected patients with benign strictures related to chronic pancreatitis, and in noncompliant patients 2
• Percutaneous transhepatic papillary balloon dilation (PTPBD) is an alternative to endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct stone removal, with a similar technical success rate and fewer perioperative complications 3
• PTPBD may be recommended in patients with low cardiopulmonary reserve or definitive anatomic abnormalities of the upper GI tract 3

Specific Patient Populations

• In patients with biliary strictures after liver transplantation, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred initial therapy, with good short and long-term results 4
• Biliary sphincterotomy plus balloon dilation with placement of multiple plastic stents has been the classic endoscopic approach for treating anastomotic biliary strictures, although fully-covered metallic stents have emerged as an alternative 4
• In patients with postcholecystectomy bile duct strictures, endoscopic management by balloon dilation and biliary stent placement is a safe and effective treatment option, with a low complication rate 5