Long-term Outcomes of Fully Covered Metallic Stent for Refractory Benign Hilar Biliary Strictures

Background: Plastic stents (PS) are the standard treatment for benign biliary strictures, but some cases remain refractory. Fully covered self-expandable metallic stents (FCSEMS) have shown efficacy, though their use in hilar strictures is limited due to the risk of side branch occlusion.
Methods: We analyzed 21 patients who underwent FCSEMS placement between May 2017 and December 2024 after failed repeated PS placement. The median age was 60 years, with 12 males and 9 females. The underlying causes included living donor liver transplantation (n=14), deceased donor liver transplantation (n=3), hepatic resection (n=1), cholecystectomy (n=1), biliary-enteric anastomosis (n=1), and transarterial chemoembolization (n=1). The median number of prior PS exchanges was 5 (IQR: 3-13), and the median PS duration was 12 months (IQR: 4-34). FCSEMS placement was basically performed with PS placed in side branches to maintain drainage. Stents were removed after 4 months.
Results: Stent placement was successful in all cases, with side-branch PS placement in 90%. The stricture resolution rate was 86% (18/21). One case (5%) of procedure-related complications involved bile leakage due to guidewire-induced biliary injury. The median follow-up after stent removal was 5.5 years (IQR: 2.0-6.9), with recurrence in two cases. The 1-year, 3-year, and 5-year stricture-free rates were 94%, 88%, and 88%, respectively.
Conclusion: FCSEMS placement with side-branch PS can safely treat refractory hilar strictures, demonstrating good long-term outcomes.