Resolution of a refractory severe biliary stricture using a diathermic sheath

Endoscopic treatment of postoperative bile duct strictures (BDSs) is safe and effective [1]. However, when the BDS is severe and only the guide wire can be passed through it, stent placement is not possible. We describe a case of refractory, severe postoperative hilar BDS that was successfully treated using a diathermic sheath.

A 47-year-old man was admitted to our department with recurrent cholangitis. He had previously undergone surgical treatment for gallbladder cancer in 2009, which was followed by regular placement of 7-Fr tube stents for BDS, until the stent was removed at the request of the patient, despite the fact that endoscopic retrograde cholangiopancreatography (ERCP) still revealed a BDS. As a result, 17 months later he developed cholangitis. An ERCP following admission revealed severe hilar BDSs ([Fig. 1 a]). Although a 0.035-inch guide wire was successfully advanced across the left hepatic BDS ([Fig. 1 b]), it was not possible to pass a tapered catheter, Soehendra biliary dilation catheter, or stent retriever (Wilson-Cook, Winston-Salem, North Carolina, USA; [Video 1]).

Fig. 1 Radiographic images showing: a a severe hilar bile duct stricture in a 47-year-old man previously treated for gallbladder cancer; b the hydrophilic, 0.035-inch guide wire that was successfully advanced across the left hepatic bile duct stricture.

Video showing that catheters could not be advanced over the 0.035-inch guide wire; therefore, a 6-Fr diathermic sheath is advanced to the level of the left hepatic bile duct stricture and an incision is made using an electrosurgical generator.

It was therefore decided to incise the BDS using a 6-Fr diathermic sheath (Cysto-Gastro-Set; Endo-Flex, Voerde, Germany; [Fig. 2]), which was advanced over the guide wire to the level of the left hepatic BDS ([Fig. 3 a]; [Video 1]). An incision was made in the BDS using an electrosurgical generator ([Fig. 3 b, ] [Video 1]) and a 5-Fr nasobiliary tube was placed. The patient experienced no serious complications. An ERCP 5 days later revealed resolution of the left hepatic BDS ([Fig. 4 a]), and 7-Fr plastic stents were successfully placed ([Fig. 4 b]).

Fig. 2 Photograph of a 6-Fr guide wire-introducible diathermic sheath (Cysto-Gastro-Set; Endo-Flex, Voerde, Germany).

Fig. 3 Radiographic images showing: a the diathermic sheath being advanced over the guide wire to the level of the bile duct stricture (inset: endoscopic view of the diathermic sheath being advanced over the guide wire into the bile duct); b the diathermic sheath after its passage through the stricture in the left hepatic bile duct.

Fig. 4 Radiographic images taken during an endoscopic retrograde cholangiopancreatography (ERCP) performed 5 days after treatment showing: a resolution of the left hepatic bile duct stricture; b the multiple 7-Fr plastic stents that were successfully placed.

Diathermic sheaths have been used previously to enlarge the channel between the stomach or duodenum and a pancreatic pseudocyst, the pancreatic duct or the gallbladder [2] [3] [4] [5]. To our knowledge, this is the first report of a refractory, severe postoperative BDS successfully treated using a diathermic sheath. Although further study is required, this approach has great potential for selected patients with refractory BDS.

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• References

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