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Mind the gap! Extraluminal percutaneous-endoscopic rendezvous with a self-expanding metal stent for restoring continuity in major bile duct injury: A case series.

ABSTRACT: INTRODUCTION:Treatment of major iatrogenic and non-iatrogenic bile duct injury (BDI) often requires delayed surgery with interim external biliary drainage. Percutaneous transhepatic cholangiography (PTC) with biliary catheter placement and endoscopic retrograde cholangiography (ERC) with stent placement have been used to bridge defects. In some patients, bridging the defect cannot be achieved through ERC or PTC alone. MATERIALS AND METHODS:Two patients with major BDIs, one iatrogenic and one non-iatrogenic underwent an extraluminal PTC/ERC rendezvous with placement of a fully covered self-expandable metal stent (SEMS) for the acute management of BDI with substantial loss of bile duct length. RESULTS:In both patients the intraperitoneal PTC/ERC rendezvous with SEMS placement was successful with no complications after 12 and 18 months follow-up, respectively. DISCUSSION:This study is the first to report a standardized approach to the acute management of iatrogenic and non-iatrogenic major BDIs using extraluminal intraperitoneal PTC/ERC rendezvous with placement of a fully covered SEMS. The described technique may serve as a "bridge to surgery" strategy for patients where definitive management of BDIs are deferred. However, long-term data of the success of this technique, specifically the use of a SEMS to bridge the defect, are lacking and further investigation is required to determine its role as a definitive treatment of BDIs with substance loss. CONCLUSION:PTC/ERC rendezvous with restoration of biliary continuity and internalization of bile flow is particularly useful for patients who have previously failed ERC and/or PTC alone, and in whom immediate surgical repair is not an option.

SUBMITTER: Lindemann J

PROVIDER: S-EPMC6612668 | biostudies-other | 2019

REPOSITORIES: biostudies-other

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Mind the gap! Extraluminal percutaneous-endoscopic rendezvous with a self-expanding metal stent for restoring continuity in major bile duct injury: A case series.

Lindemann Jessica J Kloppers Christo C Burmeister Sean S Bernon Marc M Jonas Eduard E

International journal of surgery case reports 20190628

<h4>Introduction</h4>Treatment of major iatrogenic and non-iatrogenic bile duct injury (BDI) often requires delayed surgery with interim external biliary drainage. Percutaneous transhepatic cholangiography (PTC) with biliary catheter placement and endoscopic retrograde cholangiography (ERC) with stent placement have been used to bridge defects. In some patients, bridging the defect cannot be achieved through ERC or PTC alone.<h4>Materials and methods</h4>Two patients with major BDIs, one iatroge ...[more]

PMID: 31279238

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Project description:Conventional endoscopic duct clearance may not be possible in up to 10%-15% of common bile duct stones (CBDS). Sphincterotomy and biliary drainage by endoprosthesis have for many years been the mainstay of management in irretrievable stones. Recent years have seen the advent of sphincteroplasty or cholangioscopically-guided electrohydraulic lithotripsy (EHL) permitting duct clearance in majority of cases. However, when bile duct clearance is not possible, options include long-term stenting followed by elective stent exchange (ESE) 6-12 monthly or permanent stent insertion (PSI) in selected cases, but it is not clear which management strategy among ESE and PSI is preferable.A retrospective review of all patients in Leeds Teaching Hospitals NHS Trust who underwent plastic stent insertion for biliary access for difficult CBDS from January 2006 to December 2011 was undertaken. Adult patients with irretrievable CBDS who had plastic stent insertions throughout the follow-up period were included. Patients who underwent PSI and ESE annually were retrospectively reviewed to determine the long-term outcomes. A detailed systematic review was also performed, examining the outcomes of CBDS managed with stents.During the study period, 674 patients underwent 1769 biliary-stent-related procedures; of which, 246 patients met our inclusion criteria. 201 patients had subsequent duct clearance. 45 patients were, therefore, included in the final analysis, 28 of whom underwent annual ESEs and 17 PSIs. Patients in the PSI group had higher American Society of Anesthesiologists (ASA) scores compared with the ESE group. In the PSI group, 9/17 patients presented acutely with blocked stents, 5 of whom presented within 12 months. 2/9 patients were severely ill and died within a fortnight following the repeat endoscopic retrograde cholangiopancreatography (ERCP). In the ESE group, 4/28 patients had duct clearance in subsequent ERCPs, 1/28 patient presented with a blocked stent, and no biliary-related deaths were observed. The mean numbers of ERCPs performed were 0.52 and 1.95 in the PSI and ESE groups, respectively.Over 50% of patients treated with long-term stenting re-presented acutely with stent blockage, though many of these were before 12 months, meaning planned stent exchange would not have affected the outcome. Duct clearance using all possible modalities is the preferred option, but where not possible, management with biliary stenting either with elective exchange or permanent stenting remains a possibility for carefully selected patients, though maybe best suited to those with limited life expectancy.

Project description:BackgroundAnomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases.MethodsThe data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening.ResultsA total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty-seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient).ConclusionThe opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality.

Dataset Information

Mind the gap! Extraluminal percutaneous-endoscopic rendezvous with a self-expanding metal stent for restoring continuity in major bile duct injury: A case series.

Publications

Mind the gap! Extraluminal percutaneous-endoscopic rendezvous with a self-expanding metal stent for restoring continuity in major bile duct injury: A case series.

Similar Datasets

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