SSAT - REGRESSION OF LIVER FIBROSIS AFTER SURGICAL BILIARY DRAINAGE IN BENIGN BILIARY STRICTURES: A THEORETICAL FEASIBILITY OR A PRACTICAL POSSIBILITY?

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REGRESSION OF LIVER FIBROSIS AFTER SURGICAL BILIARY DRAINAGE IN BENIGN BILIARY STRICTURES: A THEORETICAL FEASIBILITY OR A PRACTICAL POSSIBILITY?
Jayapal Rajendran^*, Thakur Deen Yadav, Vikas Gupta
GENERAL SURGERY, PGIMER, Chandigarh, Chandigarh, India

BACKGROUND: Hepatic fibrosis, secondary biliary cirrhosis and portal hypertension can occur as a result of long standing benign biliary stricture (BBS). Reversibility of fibrosis after biliary enteric anastomosis is a matter of debate. Fibrosis in the setting of biliary stricture occurs secondary to cholestasis. Hence, decompression of biliary system should theoretically be able to reverse the fibrosis. This study was designed to assess the factors predicting the outcome of surgical biliary drainage in BBS on liver function and regression of fibrosis using noninvasive methods like Fibroscan.
MATERIALS AND METHODS: A prospective analysis of forty seven patients who underwent Roux-en-Y hepaticojejunostomy and intraoperative liver biopsy for benign biliary strictures from July 2014 to December 2015 was performed. All patients underwent Fibroscan, ultrasound, magnetic resonance cholangiopancreaticography and LFT (liver function test) preoperatively and were reassessed anytime after three months using Fibroscan and LFT. Pre-operative liver stiffness measurement (LSM) values derived using Fibroscan were compared with intraoperative liver biopsy.
RESULTS: High strictures (type III and IV) comprised of ~ 72.3% as compared to 27.7 % low strictures (type I and II) following iatrogenic bile duct injury. The interval between biliary injury and surgical repair (range: 2 to 72 months) and duration of jaundice (range: 1 to 20 months) had significant impact on severity of fibrosis. Six (12.8%) patients had no fibrosis, 26 (55.3%) patients had stage 1 fibrosis, 11 (23.4%) patients had stage 2 fibrosis, two (4.3%) patients had stage 3 fibrosis and one (2.1%) patient had stage 4 fibrosis in liver biopsy. We found high correlation between Fibroscan scores done preoperatively and intraoperative liver biopsy (Pearson and Spearmans’s rho correlation coefficient + 0.648). Patients with early repair (6 weeks to 3 months) showed greater regression in fibrosis indicated by greater fall in mean LSM values as compared to patients who underwent late repairs (>3 months). Fall in mean level of parameters of LFT and LSM were found to be statistically significant in stage 0, 1 and 2 fibrosis post surgery (P-0.03). Though there was a fall in liver enzymes and mean LSM values in stage 3 and 4 fibrosis, it was not statistically significant (P-0.3).
Conclusion: Normal biliary function and regression of liver fibrosis can be achieved following timely bilio-enteric anastomosis in patients with BBS. Fibroscan is a novel modality to assess the grade of fibrosis in patients of BBS noninvasively thereby avoiding liver biopsy and its complications.

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