Endoscopic therapy with multiple plastic stents for benign biliary strictures due to chronic calcific pancreatitis: the good, the bad, and the ugly.

Since the bile duct passes through the pancreatic head, the fibrosing process involved with chronic pancreatitis (CP) encasing the distal bile duct may result in the formation of a biliary stricture. Complications that may occur from the resultant biliary obstruction include hepatic fibrosis and cholangitis. As with many diseases, the fibrosing process of CP is extremely variable. At one end of the spectrum, the process may be mild. On the other end of the spectrum, the process may be severe with a large fibrotic head of pancreas, occasionally mimicking pancreatic cancer. In my own experience, there have been patients with moderate chronic pancreatitis and biliary strictures associated with hyperbilirubinemia and dramatic response to even one temporary biliary stent, while others have failed to respond at all to prolonged stenting using multiple large-bore plastic stents. Additionally, some patients may have acute pancreatitis inflammatory changes superimposed on chronic fibrosis. One would expect that if the acute inflammatory process resolves during biliary stent placement, the stricture may improve or resolve. Therefore, the heterogeneity of the fibrosis and presence or absence of acute inflammation may explain the variability of the results of endoscopic therapy using plastic stents. Nearly 14 years ago, Deverie et al described using 10 F biliary stents for strictures due to CP and were only able to resolve the strictures in 3 of 25 (12%) patients on an intention to treat basis after a follow-up interval of 1 to 6 years following stent removal. Similarly, Barthet et al achieved complete (clinical, radiologic, and biochemical) “longterm” resolution (mean follow-up of 18 months) of biliary strictures in 2 of 19 (11%) patients with chronic calcific pancreatitis. Conversely, Smits et al found “complete regression” of strictures using endoscopic therapy for dilation and single stents in 16 of 58 patients (28%) at a median follow-up of 40 months. In the latter study, stent-related complications occurred in 37 of 58 (64%) patients, although there were no deaths. Other studies have produced similar results. All of these studies are retrospective and have differed in patient selection, method of dilation, stent number and diameter, length of follow-up, and definition of success. Recent data suggest that endoscopic insertion of multiple plastic stents across benign postoperative biliary strictures is superior to single stents for stricture resolution. This concept has been applied to patients with other benign strictures. Draganov et al evaluated the long-term outcome and identified predictors of outcome in benign biliary strictures using endoscope insertion of sequential plastic stent insertion in progressively increasing numbers and/or of increasing diameters. Of 29 patients, 9 were due to chronic pancreatitis (3 noncalcific, 6 calcific). Resolution of the stricture was seen in all 3 noncalcific pancreatitis CP patients, but therapy failed in 5 of 6 patients with calcific CP. This suggests that patients with calcific pancreatitis and distal bile duct stricture probably have more advanced