Multidisciplinary approach to benign biliary strictures.

The various approaches used for the management of patients with benign biliary strictures are justified by the diverse nature, clinical presentation, and severity of these strictures. Benign biliary strictures are most commonly postoperative, a consequence of injury during laparoscopic cholecystectomy or fibrosis after biliary duct-to-duct or bilioenteric anastomoses (ie, liver transplantation). Less frequently, benign strictures are due to chronic pancreatitis or other nonmalignant diseases, including external compression, parasites, stone perforation, and infections. Because of their peculiar pathogenesis, localization, and short extension into the bile duct, the majority of these strictures can be approached by operative treatments such as surgical bypass and endoscopic--or radiological--dilation. In contrast, primary sclerosing cholangitis (PSC) is a systemic disease with immune-mediated inflammation and subsequent fibrosis of the bile ducts with the development of multiple strictures due to an "intrinsic" liver disease; thus, medical therapy and pharmacologic research are mainly focused on the treatment of PSC rather than other benign biliary strictures. However, none of the previously mentioned benign strictures has a univocal and sole treatment. Any attempt to identify a standard treatment for all the strictures is questionable, inconclusive, and most likely useless due to the diversity of patients and diseases. Gastroenterologists, radiologists, and surgeons work in tight collaboration, not in competition, to individualize the patients' treatment. The morphology and extension of the stricture, its location, the theoretical pathogenesis (eg, intrinsic strictures, strictures due to inflammation and fibrosis after bile leak, ischemic lesions), the patients' specific characteristics (comorbidity and history of prior surgery, including enterobiliary anastomoses and gastric resection), and preferences should indicate the treatment that may offer the patient major benefits with a lower complication rate. Unfortunately, in most of the cases, choosing between different treatments is more likely based on local availability than their actual effectiveness and indication.