Percutaneous placement of H-configured triple biliary and enteral stents through a single access: A solution for complex bilio-enteric obstruction

Abstract

Introduction

Malignancies of pancreato-biliary system frequently cause biliary tract obstructions and surgical resection is known to be the only potentially curative therapy.1 Approximately 15%–20% of these neoplasms undergo surgical treatment and the rest malignant obstructions caused by unresectable tumors are managed with biliary stent insertions.2,3 Even after curative surgery, majority of patients eventually need biliary stent insertion due to the high recurrence rate of the cancer.4 The postoperative anatomic alterations complicate conventional endoscopic approach3 and thus percutaneous drainage is initially considered as a palliative therapy for such cases, along with more complex or invasive procedures such as combined stent insertion or bypass creations.5–8 Moreover, a percutaneous drainage allows a wider range of stent choice and stent configurations than an endoscopic approach does, being more preferable in such complicated obstructions. Adding a minimally invasive palliation solution, this paper introduces a single-access percutaneous ‘H-configured’ bilio-enteric stenting, opening up the bilateral hepatic ducts, extrahepatic bile duct and small bowel at once in an endoscopic retrograde cholangiopancreatography inaccessible patient.

Case Report

A 75-year-old male with history of pancreatic adenocarcinoma and previous Whipple’s operation came to hospital with a newly developed jaundice, 13 months after the surgery. A preliminary percutaneous transhepatic biliary drainage (PTBD) with brush biopsy confirmed recurrent metastatic pancreatic adenocarcinoma. The computed tomography scan showed the advanced tumor invading the hilum and extending to the right hepatic biliary duct. The cholangiogram confirmed a high grade stenosis at the level of common hepatic duct with no antegrade flow of contrast into the small bowel. On the cholangiography after cannulation of the common hepatic duct, a complete occlusion of small bowel loop at the hepaticojejunostomy anastomosis was identified (Fig. 1). Via the existing PTBD tract, a 10 F braided vascular sheath (Cook Medical, Bloomington, IN, USA) was placed in the right main hepatic duct. With a combination of a 0.035 inch Glidewire (Terumo Medical Corp., Tokyo, Japan) and a 5 F angio-catheter, the tumor occlusion was cannulated. An Amplatz Super Stiff PTFE Coated Guidewire (Boston Scientific Corp., Washington, DC, USA) was then exchanged and advanced into the afferent limb of the small bowel, forming a loop and then extending into the efferent limb of the small bowel (Fig. 2). The second Amplatz wire was then placed in the efferent loop directly (Fig. 3). Next, the third Amplatz wire was placed from the right hepatic duct into the left intrahepatic duct (Fig. 4).

Subsequently, a 22-mm diameter/60-mm length bare metal WallFlex stent (Boston Scientific Corp.) was placed over the looped wire in the small bowel covering the malignant anastomotic stenosis. This stent was dilated using a 12-mm diameter/40-mm length Atlas balloon (Bard PV, Tempe, AZ, USA). Next, a 10-mm diameter/40-mm length Protégé self-expanding bare metal stent (Covidien, Plymouth, MN, USA) was placed horizontally from the right to the left bile duct and postdilated using a 8-mm diameter/20-mm length Dorado balloon (Bard PV). Next, catheter access was obtained from the right hepatic duct, passing through a central mesh of the right-to-left horizontal intrahepatic biliary stent at the hilar level. A 0.035” glidewire (Terumo Medical Corp.) was cannulated to the efferent enteric limb. A 10-mm diameter/80-mm length Protégé bare metallic stent (ev3 Endovascular Inc., Plymouth, MN, USA) was then placed from the right bile duct to the efferent enteric limb through the central mesh of the previously placed horizontal stent and dilated using a 10-mm diameter/20-mm length Dorado balloon (BARD Peripheral Vascular Inc., Tempe, AZ, USA) (Fig. 5). After the stents were placed, a safety catheter, a 10 Fr UreSil biliary drainage catheter (UreSil, Skokie, IL, USA), was placed from the right ducts and into the efferent limb. It was placed to bag drainage. Except transient bacteremia symptoms which were managed with fluid therapy and antibiotics, the patient presented no other minor or major complications. The safety catheter was removed 2 weeks later after a follow-up cholangiogram which demonstrated successful drainage of the affected areas with appropriate contrast flow into the efferent limb (Fig. 6). Cholangitic symptoms also improved with normalization of total bilirubin and alkaline phosphatase.

Ten months later, the patient was admitted for recurrence of cholangitic symptoms. PTBD presented advanced ingrowth and overgrowth of the metastatic tumor with occlusion of a right posterior hepatic duct. Successful placement of additional stents and radiofrequency ablation for tumor control were done. Follow-up was lost 3 months after the additional stent placement.

Discussion

Advanced pancreatic adenocarcinoma is one of the major causes of malignant biliary tract obstruction because of its high predisposition for local or metastatic invasion.9 In addition, pancreatic head carcinoma is the most common cause of malignant gastric outlet obstruction, approximately 20% of pancreatic head cancer developing the enteric obstruction.10,11 Despite the technical advances, endoscopic technical challenge remains in proximal common bile duct or hilar obstructions. Consequently, the presence of both hilar and enteric obstructions require percutaneous drainage or more complicated methods, such as rendezvous procedures or endoscopic ultrasonography-guided choledochoduodenostomy.4,5,8,12

The patient we reported in this article had Whipple’s surgery and Roux-en-Y gastrojejunostomy, which caused anatomic alteration preventing endoscopic access. A successful single-access stenting of the whole biliary tree was achieved by T-configured dual biliary stent placement developed by Kim et al.12 The intestinal drainage was accomplished with the looped-wire guided jejunal stent placement. This combination of T-configured stents and a small bowel stent, resulting in “H-configuration”, enabled a full bilio-enteric drainage for the patient. The loop formation of the second Amplatz wire was necessary to make the bowel stent cover anastomotic tumor stricture. This approach has advantages over simply placing a longer biliary stent into the efferent limb for following reasons. First, the afferent loop can be drained. Second, the tumor was so tight that there was a concern for incomplete expansion of the vertical biliary stent even with balloon dilation. Third, the large sized jejunal stent could delay early tumor ingrowth into the biliary stent resulting into a long-term patency. With average patency of self-expandable metal stents ranging from 6 to 10 months,13 this ‘H-configured’ triple stents remained patent for adequate time of 10 months without obstructive symptoms or complications. This result is more significant considering that median patency of stents inserted in cancer recurrence at hepaticojejunostomy site was reported to be 5 months.3

Although covered stents are reported to be preferable in preventing stent occlusions in recurrent malignant biliary obstructions,14 several factors were considered in choosing bare metal stents instead of covered ones in this case. First, an insertion of covered stent in the intrahepatic duct bears a risk of sectoral duct obstruction, especially in trifurcation hilar anatomy. Second, covering the stent from the intrahepatic duct to bowel can block the left hepatic duct and afferent loop of bowel. Third, a covered bowel will require an increased diameter of the biliary tract to accommodate the large sized delivery sheath for the stent. It will also mandate the parallel placement and extension of a biliary stent. Overall, covered or partially covered stents could be used under certain conditions but the possibilities of duct blockage and complex techniques required made bare stents more preferable in this case. Recognizing that these stents stayed patent 10 months, which are similar or longer than median stent patency in malignant biliary obstructions,3,14 the choice of bare metal stents in this procedure can be considered effective.

In conclusion, percutaneous single-access ‘H-configured’ triple stent placement is a new feasible and effective interventional option for palliation of complicated malignant bilio-enteric obstructions, especially for patients with challenging endoscopic access.

Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

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