Introduction and Case PresentationIntroduction
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).
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).
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.
Medscape Gastroenterology © 2009
Cite this: Patrick S. Yachimski, David L. Carr-Locke. Covered Metal Stents Straight-Arm Benign Biliary Stricture - Medscape - Aug 10, 2009.