Biliary stenting and successful intentional stent retrieval after 6 months in a benign stricture following hepaticojejunostomy

The management of benign biliary strictures remains a challenge for interventional endoscopists. Surgery, still the mainstay of treatment, is associated with nonnegligible morbidity and mortality. Recently, new techniques and devices for endoscopic therapy have become available [1] [2].

A 45-year-old woman was referred to our clinic because of recurrent fever of unknown origin. She had a history of hepaticojejunostomy due to bile duct injury following laparoscopic cholecystectomy. Ultrasound, laboratory, and MRI studies led to the discovery of a circular stenosis of the anastomosis ([Fig. 1]). Biopsies ruled out a malignant stenosis. Percutaneous transhepatic cholangiography (PTC) showed a filiform and complex stenosis. Multiple unsuccessful balloon dilatations were carried out and a temporary Yamakawa drain was placed. PTC after removal of the drain showed a residual stenosis of more than 50 %. Hence percutaneous transhepatic cholangiographic drainage with stenting was considered. In order to allow the stent to be withdrawn 6 months later, a polytetrafluoroethylene (ePTFE)-covered stent (Viabil; Gore, Flagstaff, AZ, USA) was chosen. The patient was asymptomatic during the following 6 months. The stent was removed percutaneously through a 12 F introduction sheath with an endoscopic grasping forceps ([Fig. 2], [3], [Video 1]). The patient was discharged 3 days after stent removal.

Fig. 1 Magnetic resonance cholangiopancreatography T₂-sequence showing stenosis of the anastomosis after hepaticojejunostomy.

Fig. 2 Sequence of stent extraction through a 12 F introduction sheath using an endoscopic grasping forceps.

Fig. 3 Stent and introduction sheath after removal.

Video 1 Extraction of the stent through a 12 F introduction sheath using an endoscopic grasping forceps.

Percutaneous treatment of benign biliary stenosis is still a challenging issue for endoscopists. Poor long-term patency of metallic stents in the biliary system and the near-impossibility of removing them limits their range of use in benign stenoses [1] [3]. Because of its exoskeleton structure ([Fig. 4]), the Viabil stent is able to collapse during withdrawal and seems a feasible option when balloon dilatation of a benign stricture is not sufficient [1]. Coated stents have proven good long-term patency in malignant stenoses and carry a low risk of tissue ingrowth and sludge accumulation [1] [4] [5]. This supports the feasibility of intentional retrieval and allows the endoscopist greater latitude when extended time periods of stent placement are necessary [1].

Fig. 4 Viabil stent and its exoskeleton structure.

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References

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• 2 Born P, Rosch T, Bruhl K. et al . Long-term results of endoscopic and percutaneous transhepatic treatment of benign biliary strictures.  Endoscopy. 1999;  31 725-731
• 3 Wadhwa R P, Kozarek R A, France R E. et al . Use of self-expandable metallic stents in benign GI diseases.  Gastrointest Endosc. 2003;  58 207-212
• 4 Soderlund C, Linder S. Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial.  Gastrointest Endosc. 2006;  63 986-995
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