Recently, the use of partially or fully covered self-expandable
metal stents (FCSEMSs) has been described for the treatment of complex bile
leaks after laparoscopic or open cholecystectomy [1]
[2].
A 72-year-old woman developed a bile leak after an open
cholecystectomy ([Fig. 1]).
Fig. 1 Cholangiographic image
showing a large leak of contrast due to bile duct damage.
An initial attempt at closure with plastic stents was unsuccessful
([Fig. 2]).
Fig. 2 Cholangiographic images
showing: a placement of two 10-Fr plastic stents;
b persistent leakage after removal of the plastic
stents.
Therefore, it was decided to use a 10-mm diameter, 8-cm long FCSEMS
(WallFlex; Boston Scientific, Natick, Massachusetts, USA), which was
successfully placed ([Fig. 3]), and the bile
output into the external drain decreased.
Fig. 3 a The WallFlex fully
covered self-expandable metal stent (FCSEMS). b
Radiological image of the FCSEMS placed in the bile duct.
Unfortunately, 1 week later a large amount of bile reappeared in the
external drain. A third endoscopic retrograde cholangiogram (ERC) showed
shortening of the stent with the proximal end now below the bile duct defect,
and therefore leakage of contrast ([Fig. 4 a]); therefore, another 8-cm FCSEMS was
placed partly inside the first, completely covering the area of damaged bile
duct with complete resolution of the leakage ([Fig. 4 b]).
Fig. 4 Cholangiographic images
showing: a shortening of the fully covered
self-expandable metal stent (FCSEMS) with a large leakage of contrast;
b the second FCSEMS placed partly inside the first.
A follow-up ERC was performed 6 weeks later, and the stents were
removed using the following technique. The mesh of the nearest FCSEMS was
grasped with a rat-toothed forceps, but the other FCSEMS was sticking within
the bile duct. A 10-mm diameter through-the-scope CRE balloon dilator (Boston
Scientific) was therefore positioned inside the stents and inflated ([Fig. 5 a]), after which, the stents were
easily pulled out of the bile duct and drawn into the gastric cavity ([Fig. 5 b]).
Fig. 5 a – c Cholangiographic images showing: a the CRE balloon
inflated inside the fully covered self-expandable metal stents (FCSEMSs);
b removal of the stents from the bile duct;
c the stents finally withdrawn with the rat-tooth
forceps. d The two FCSEMSs after their removal.
The FCSEMSs were grasped with a forceps ([Fig. 5 c]) and withdrawn along with the
endoscope ([Fig. 5 d]). Finally,
cholangiography confirmed the resolution of the bile leak ([Fig. 6]).
Fig. 6 Cholangiographic image
showing resolution of the bile leak.
To the best of our knowledge, this case is the first reported use of
a fully covered WallFlex stent for closure of a complex biliary leak secondary
to open cholecystectomy. In this case, with a large area of damage in the
proximal bile duct, we have shown that the placement of two overlapping FCSEMs
is an effective method of lining the bile duct lumen and covering the site of
leakage. The technique of inflating a balloon inside a stent to assist its
removal has been previously used [3], but this case is
also the first report in which the technique has been successfully used for the
simultaneous removal of two FCSEMSs, so avoiding the risk of the second stent
dislocating during removal.
Endoscopy_UCTN_Code_TTT_1AR_2AG
