Percutaneous Repair of an Iatrogenic Laceration of the Left Bile Duct with a Covered Stent

The echoendoscopic biliary drainage is an option to treat obstructive jaundices when ERCP drainage fails. These procedures compose alternative methods to the side of surgery and percutaneous transhepatic biliary drainage, and it was only possible by the continuous development and improvement of echoendoscopes and accessories. The development of linear setorial array echoendoscopes in early 1990 brought a new approach to diagnostic and therapeutic dimenion on echoendoscopy capabilities, opening the possibility to perform punction over direct ultrasonographic view. Despite of the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty could be found at the presence of stent tumor ingrown, tumor gut compression, periampulary diverticula, and anatomic variation. The echoendoscopic technique starts performing punction and contrast of the left biliary tree. When performed from gastric wall, the access is made through hepatic segment III. From duodenum, direct common bile duct punction. Dilatation is required before stent introduction, and a plastic or metallic stent is introduced. This phrase should be replaced by: diathermic dilatation of the puncturing tract is required using a 6F cystostome. The technical success of hepaticogastrostomy is near 98%, and complications are present in 36%: pneumoperitoneum, choleperitoneum, infection, and stent disfunction. To prevent bile leakage, we have used the 2 stent techniques, the first stent introduced was a long uncovered metallic stent (8 or 10 cm), and inside this first stent a second fully covered stent of 6 cm was delivered to bridge the bile duct and the stomach. Choledochoduodenostomy overall success rate is 92% and described complications include, in frequency order, pneumoperitoneum and focal bile peritonitis, present in 19%. By the last 10 years, the technique was especially performed in reference centers, by ERCP experienced groups, and this seems to be a general guideline to safer procedure execution.

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Temporary endobiliary stenting of distal strictures of the common bile duct due to chronic pancreatitis

Annaly khirurgicheskoy gepatologii = Annals of HPB surgery ◽

10.16931/1995-5464.2018331-36 ◽

2018 ◽

Vol 23 (3) ◽

pp. 31-36

Author(s):

O. I. Okhotnikov ◽

M. V. Yakovleva ◽

S. N. Grigoriev

Keyword(s):

Chronic Pancreatitis ◽

Bile Duct ◽

Common Bile Duct ◽

Minimally Invasive ◽

Covered Stent ◽

Internal Drainage ◽

Metal Stent ◽

Invasive Treatment ◽

Benign Biliary Strictures ◽

Endoscopic Extraction

Aim.To determine the possibility, necessity and safety of self-expanding covered endobiliary stents in benign biliary strictures caused by chronic pancreatitis.Material and methods.Nine patients with painless chronic pancreatitis complicated by obstructive jaundice syndrome were enrolled. Minimally invasive treatment included stage-by-stage percutaneous transhepatic cholangiostomy by pigtail 8Fr drain followed by its transformation to temporary transpapillary external-internal drainage. Then we performed antegrade endobiliary stenting of stricture with self-expanding metal stent 9 mm. There were no symptoms of acute pancreatitis. External-internal drainage in within bile duct lumen has been kept for 2–4 weeks to control position and patency of the stent.Results.Technical success of antegrade deployment of self-expanding covered stent into transpapillary position was achieved in all patients. The time of complete opening of the stent was 2 days. Ultrasonic control every 2 months was applied since stent has been installed. All 9 stents were successfully and uneventfully extracted endoscopically after 6–12 months. There were no cases of recurrent mechanical jaundice. Mean disease-free follow-up was 22.8 months.Conclusion.Covered stent opening followed by stricture dilation up to 8-10 mm within distal common bile duct confidently eliminates biliary hypertension. Stenting of this area is followed by formation of stable periductal carcass within 6–9 months which is preserved even after endoscopic extraction of the stent. Minimally invasive management of biliary hypertension using covered self-expanding metal stent in transpapillary position may be an alternative to traditional surgery in selected patients with chronic pancreatitis and mechanical jaundice as predominant clinical syndrome.

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