Endoscopic ostium incision at non-malignant post-surgical bilioenteric anastomotic stricture after complex abdominal surgery

Background and aims: Bilioenteric anastomotic stricture is a well-known complication after bile duct surgery or liver transplantation. This study reports our experience with endoscopic ostium incision of high-grade or subtotal stricture at the non-malignant biliary enteroanastomosis.

Patients: Over a 7-yr period among more than 7500 ERCPs, 38 patients (0.50%) after complex abdominal surgery were identified with high-grade/subtotal bilioenteric anastomotic stricture with failed cannulation or inaccessible ostium.

Interventions: DBE enteroscopy (n = 19), push enteroscopy (n = 7) or transstomal endoscopy via jejunostomy (n = 12) were used to reach the bilioenteric anastomotic stricture and to intervene at the postsurgical stricture by ostium incision, guidewire canulation or dilation.

Results: From 38 patients with endoscopically identified high-grade or subtotal bilioenteric anastomotic stricture ostium incision was necessary in 23 patients (60.5%) to access the biliary tree, while in the remaining 15 patients (39.4%) guidewire probing or blunt bouginage/dilation was successful.

The ostium incision in 23 patients was made by either snare, needle knife and/or papillotome in 4 (17.3%), 3 (13.0%) and 18 patients (78.2%), respectively. Sucessful ostium incision was achieved in 20 of 23 patients (86.9%), allowing all further ERCP interventions successfully. Major complications included 1 perforation (5.2%) and 2 cholangitis (10.5% after transstomal approach).

Conclusions: Ostium incision at the strictured bilioenteric anastomosis may be required in a minority of postop patients. It represents a somewhat risky procedure, which should be performed only in experienced centers to avoid percutaneous transhepatic biliary approaches or re-operation.