A novel approach in benign biliary stricture - balloon dilation combined with cholangioscopy-guided steroid injection.

The first-line endoscopic strategy for the treatment of benign biliary stricture (BBS) consists of balloon dilation combined with the placement of multiple plastic stents, which has a success rate of more than 80%. Nevertheless, stricture may recur in 10% to 30% of cases after initial resolution [1,2]. Cholangioscopy is a useful adjunct to endoscopic retrograde cholangiopancreatography (ERCP) for the evaluation and treatment of refractory BBS [3,4]. A 58-year-old male patient with BBS after receiving an orthotopic liver transplant was treated with dilation and progressive stent placement, but the response after five ERCP procedures was poor. Cholangiography showed a stricture 3mm in diameter with a sharp and angulated axis and multiple stones proximally (●" Fig.1). Therefore, the patient was treated with a novel technique in which a single-operator direct visualization system (SpyGlass DS Direct Visualization System; Boston Scientific, Natick, Massachusetts, USA) was used. Initially, balloondilationof the strictureup to 10mmwas performed, and stoneswere partially removed. After it had been accurately positioned at the level of the stricture, a prototype 26-gauge sclerotherapy needle (Montag, São Paulo, SP, Brazil) was introduced through the SpyGlass working channel, and 4mL (40mg) of triamcinoFig.2 Spyglass cholangioscopy. a Direct view of the benign biliary stricture. b Cholangioscopy-guided steroid injection.