Covered Metal Stents Straight-Arm Benign Biliary Stricture

Patrick S. Yachimski, MD; David L. Carr-Locke, MD, FRCP, FACG, FASGE

Disclosures

August 10, 2009

Introduction and Case Presentation

Introduction

Benign biliary strictures secondary to chronic pancreatitis can prove refractory to long-term biliary stenting, frequent endoscopic re-interventions, and corrective surgery. This case discusses a promising endoscopic approach that corrects benign biliary strictures using covered, removable metal stents.

Case Presentation

A 52-year-old man who has chronic pancreatitis is referred for endoscopic management of a biliary stricture. He previously required multiple interventions -- both surgical and endoscopic -- for management of pancreatic disease. About 5 years ago, he was diagnosed as having pancreaticolithiasis and underwent multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures that resulted in unsuccessful pancreatic duct stone extraction. Subsequently, he underwent gastrojejunostomy and Roux-en-Y choledochojejunostomy to correct chronic calcific pancreatitis in the head of the pancreas that had caused both biliary and duodenal obstruction. After surgery, his choledochojejunostomy closed, and he was left with the original obstructing bile duct stricture. The relapsed stricture was initially treated by an ERCP procedure that entailed catheter dilation and insertion of a single 10-French plastic stent. Over the course of 8 months, the patient underwent repeated ERCPs, during which the stents were upsized from 1 stent to 2 then 3 side-by-side 10-French stents. Despite long-term plastic stenting, the stricture remained uncorrected (Figure 1).

Figure 1. ERCP images showing distal bile duct stricture (arrow) and proximal debris after removal of occluded plastic stents.

After careful consideration and discussion with the patient, the decision was made to proceed with the placement of a covered metal stent, with the expectation that a metal stent would provide durable patency, reduce the need for frequent ERCP stent replacement, and allow for easy stent removal when replacement was eventually necessary. A fully covered metal stent (Viabil, Conmed) measuring 10 mm × 6 cm was deployed across the stricture (Figure 2).

Figure 2. Post-ERCP radiograph showing metal stent (Viabil, Conmed) in place, permitting complete emptying of the bile duct.

After placement, the patient had a symptom-free period of 7 months before the cholangitis returned. An ERCP evaluation confirmed that the stent was occluded by sludge and debris (Figure 3). The covered metal stent was easily removed by a snare that was used to grasp the distal end of the stent and withdraw it from the bile duct (Figure 4). After stent removal, cholangiography demonstrated the presence of a persistent distal biliary stricture (Figure 5), and the decision was made to position the same type of metal stent (Figure 6). The patient has remained asymptomatic for the past 6 months.

Figure 3. ERCP image showing metal stent occluded by debris.

Figure 4. ERCP image showing the removal of the metal stent by means of snare traction.

Figure 5. ERCP image showing persistence of the distal bile duct stricture.

Figure 6. ERCP image showing placement of a new metal stent (Viabil, Conmed).

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