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Gastroenterology. 2018 Sep;155(3):752-759.e5. doi: 10.1053/j.gastro.2018.05.034. Epub 2018 May 24.

No Superiority of Stents vs Balloon Dilatation for Dominant Strictures in Patients With Primary Sclerosing Cholangitis.

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Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, the Netherlands. Electronic address:
Department of Gastroenterology & Hepatology, Karolinska University Hospital, Huddinge, Karolinska Institutet, Sweden.
Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, the Netherlands.
Department of Gastroenterology & Hepatology, Rikshospitalet, Oslo, Norway.
Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
Department of Hepatology, Hôpital Saint Antoine, Paris, France.
Department of Gastroenterology & Hepatology, Helsinki University Hospital, Helsinki, Finland.
Department of Gastroenterology & Hepatology, Universiteitsziekenhuis Leuven, Leuven, Belgium.
Department of Hepatology, Sahlgrenska University, Gothenburg, Sweden.
Institute of Liver & Digestive Health, University College London and Sheila Sherlock Liver Centre, Royal Free Hospital, London, United Kingdom.



Dominant strictures occur in approximately 50% of patients with primary sclerosing cholangitis (PSC). Short-term stents have been reported to produce longer resolution of dominant strictures than single-balloon dilatation. We performed a prospective study to compare the efficacy and safety of balloon dilatation vs short-term stents in patients with non-end-stage PSC.


We performed an open-label trial of patients with PSC undergoing therapeutic endoscopic retrograde cholangiopancreatography (ERCP) at 9 tertiary-care centers in Europe, from July 2011 through April 2016. Patients found to have a dominant stricture during ERCP were randomly assigned to groups that underwent balloon dilatation (n = 31) or stent placement for a maximum of 2 weeks (n = 34); patients were followed for 24 months. The primary outcome was the cumulative recurrence-free patency of the primary dominant strictures.


Study recruitment was terminated after a planned interim analysis because of futility and differences in treatment-related serious adverse events (SAEs) between groups. The cumulative recurrence-free rate did not differ significantly between groups (0.34 for the stent group and 0.30 for the balloon dilatation group at 24 months; P = 1.0). Most patients in both groups had reductions in symptoms at 3 months after the procedure. There were 17 treatment-related SAEs: post-ERCP pancreatitis in 9 patients and bacterial cholangitis in 4 patients. SAEs occurred in 15 patients in the stent group (45%) and in only 2 patients in the balloon dilatation group (6.7%) (odds ratio, 11.7; 95% confidence interval, 2.4-57.2; P = .001).


In a multicenter randomized trial of patients with PSC and a dominant stricture, short-term stents were not superior to balloon dilatation and were associated with a significantly higher occurrence of treatment-related SAEs. Balloon dilatation should be the initial treatment of choice for dominant strictures in patients with PSC. This may be particularly relevant to patients with an intact papilla. no. NCT01398917.


Biliary; Drainage; Surgery; Temporary Stent

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