A benign biliary duct stricture:

C. Is prone to recur after treatment with biliary-enteric anastomosis.

D. When due to chronic pancreatitis should be treated by side-to-side choledochoduodenostomy.

DISCUSSION: Even a minor obstructing lesion in the extrahepatic duct system can produce cirrhosis over time, and the development of portal hypertension, ascites, and esophageal varices. Therefore, all biliary strictures should be treated unless this is not possible or there is no chance for success. The presence or absence of jaundice is of no significance.

Often, the only biochemical abnormality is mild elevation of alkaline phosphatase. The long-term results of percutaneous balloon dilatation are not yet known, but short-term results are good. Although some argue that balloon dilatation should be the initial treatment, its role is ill-defined, and it should not be viewed as standard therapy at this time. Biliary-enteric anastomoses are predisposed to stricture, for reasons that are ill-understood. A mucosa-to-mucosa anastomosis, large size of the anastomosis, a normal duct at the point of anastomosis, and stenting appear to be elements that work against stricture. About 70% of anastomoses are not complicated by strictures. Common duct strictures caused by chronic pancreatitis are located in the distal portion of the duct and are easily treated by side-to-side choledochoduodenostomy. A wide anastomosis is usually possible, and because of this stenting often is not necessary. Although a Roux-en-Y biliary-enteric reconstruction is acceptable treatment, no advantage over choledochoduodenostomy has been demonstrated.