How We Do It: Treatment of Refractory Benign Anastomotic Strictures with Endobiliary Ablation Guided by Percutaneous Endoscopy

Learning Objectives: Techniques Regarding Endobiliary Ablation of Refractory Benign Anastomotic Stricture

Background: Treatment of benign biliary strictures have been performed by IR through various protocols. Most benign biliary stricture protocol last 9-12 months. Endobiliary ablation provides a relatively safe, effective, and efficient treatment of benign biliary strictures with the aid of percutaneous endoscopy utilizing the Spyglass Discover. Here we discuss the process by which refractory bening biliary strictures undergo treatment with endobiliary ablation.

Clinical Findings/Procedure Details: Candidates for benign biliary stricture are identified by interventional radiology, most commonly from failure of conventional benign biliary stricture treatment protocol. Endobiliary ablation is discussed in a formal clinic visit. Depending on the degree of discomfort felt during biliary drain exchange, cases are scheduled with either moderate sedation or monitored anesthesia care (MAC). A sheath cholangiogram (typically through 12Fr sheath) is performed to highlight and confirm the area of interest for treatment. The Spyglass Discover is then used to evaluate and endoscopically confirm the site of interest for ablation. At this time, a biopsy may be obtained if desired to document benign stricture. The Spyglass Discovery is subsequently removed, and a bipolar radiofrequency catheter is advanced to the area of interest. Ablation is performed. After ablation, a balloon sweep is performed to pass any debris into the small intestine. The Spyglass is re-inserted to evaluate post ablation changes and to determine if further ablation or subsequent balloon dilation is necessary. A telescoping dual catheter is placed for post ablation drainage and dilation as this provides a 22Fr (14Fr + 8Fr) dilation at the site of ablation and a 14Fr at the percutaneous entry site. Cases are typically performed outpatient with follow up scheduled in ~6 weeks. Evaluation of strictures post ablation with drain removal may be performed at the 6-week mark or at subsequent follow up 2-week intervals after downsizing/capping trials.

Conclusion and/or Teaching Points:

1. Considerations for endobiliary ablation when dealing with refractory benign biliary stricture


2. Techniques for safe, effective, and efficient endobiliary ablation


3. Maximizing post ablation dilation of the benign biliary stricture