ercp cbd stenting

December 15, 2021 By admin Off

Management of large common bile duct (CBD) calculi is controversial. Endoscopic treatment is fraught with difficulty, particularly when stones are over one centimetre in diameter and the patient’s coagulation is deranged. Between 1988 and 1993, 56 patients have been managed by endoscopic retrograde cholangiopancreatography (ERCP) and stent placement as the initial treatment for large CBD calculi. Complete follow up has been possible in 50 cases (89.3%). The median age was 73.5 years (range 29-92) and primary presenting symptoms were jaundice (n = 39), cholangitis (n = 6) or abdominal pain (n = 5). Median bilirubin was 99 mumol/L (range 7-926) and 60% of the patients had deranged clotting with a median thrombotest of 61%. Stones ranged in size from 0.9 to 4.5 cm (median 1.6 cm). Treatment was with a 7F ‘pigtail’ stent in 39 cases and a 10F straight stent in 11 patients. Morbidity occurred in 12% of cases with two deaths (4%). Stents remained in place for a median of 1 month (range 0.2-59). Definitive treatment of CBD stones, once the jaundice and sepsis had settled, involved surgery in 24 patients and repeat ERCP with sphincterotomy +/- mechanical lithotripsy in 17 cases. Nine patients remain alive and well with their stents still in place. Initial management of large CBD calculi by ERCP and stent placement carries a low morbidity and mortality and is a useful adjunct in the management of a difficult clinical problem.

Bilirubin is a substance found in bile, and jaundice develops when there’s a build-up of bilirubin in the blood. Levels of bilirubin are measured with blood tests called liver function tests. The level of bilirubin in your blood will affect how soon you may be able to start treatment such as chemotherapy or radiotherapy. Your hospital should give you blood test forms or a letter to take to your GP to have the blood tests after one week, two weeks and so on.

You can also order a physical copy of this fact sheet.

Some people may not be able to have a stent put in with an ERCP. Instead, the stent is passed through the tummy wall and liver, and into the bile duct, using a thin needle. This is called a Percutaneous Transhepatic Cholangiogram (PTC) . A PTC is often used if the blockage is high up in the bile duct, near the liver.

The PTC needle is guided into the bile duct using x-ray pictures on a computer screen. Dye is injected into the needle so that the blockage shows up on the screen. A wire is put into the needle and used to guide the stent into position. An x-ray will then be taken of your bile duct to make sure that the stent is in the right place.

It is normally easy to know if the stent is working. Any symptoms of jaundice usually improve in the first couple of days. It may take around two to three weeks for your jaundice to go completely and for you to feel better. Until the jaundice is completely gone you may still feel tired and not have much appetite.

Will I feel better?

You will have a sedative to make you sleepy. You will also have injections of a local anaesthetic into your tummy area or lower chest. This will make it numb, so that you can’t feel anything.

Before the ERCP, tell your medical team about any medicines that you are taking, especially medicine to thin your blood (such as warfarin or clopidogrel) or for diabetes (such as metformin or insulin). Your medical team will tell you how to take these medicines before the ERCP.

To read more about stents for a blocked bile duct, download our fact sheet, Stents to treat jaundice caused by a blocked bile duct .

A stent for a blocked bile duct is usually put in using a procedure called an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) . An ERCP uses a tube with a camera on the end which is passed down your throat.

The ERCP usually takes 30-40 minutes.

After an ERCP you may have a blood test to check that the ERCP has not caused any problems such as inflammation of the pancreas. You will be told when you can drink and eat again (normally after four to six hours). You will be told who to contact if you have any problems after the ERCP.

You will have a sedative before the stent is put in. This will make you sleepy and relaxed, but won’t send you to sleep.

You may be able to go home on the same day or the next day. If you are going home on the same day, you will need someone to collect you from the hospital and stay with you overnight. This is because the sedative can stay in your body for up to 24 hours. Don’t drive, use machinery or sign any legal documents for 24 hours.

You may be given antibiotics before and after an ERCP or PTC to prevent an infection of the bile duct (cholangitis).

We also have information about stents for a blocked duodenum. To download this fact sheet, see Stents for a blocked duodenum .

Read our fact sheets about stents.

The flexible tube with a camera and light on the end (an endoscope) is put into your mouth and passed down your throat into your stomach. The camera shows the inside of your body on a screen. The stent is put inside the bile duct using a small wire. When the stent is in the right place the wire is removed. The stent should unblock the bile duct, which should then drain normally.

If you have a PTC you will usually need to stay in hospital for a few days afterwards. There may be a drain left in the bile duct for a few days to help the bile to flow freely. This will be removed before you leave hospital.

You will be asked not to eat or drink for at least six hours before the ERCP – although you may be able to have small sips of water up to two hours before. This is to make sure that your stomach and duodenum are empty.

If you have any questions or worries about having a stent put into your bile duct, speak to your doctor or nurse.

Having a stent put in with an ERCP.

We have seen that patients who have GOO from duodenal, ampullary or pancreatic malignancy frequently develop biliary obstruction which may require either surgical or endoscopic intervention[1]. Usually we can divide patients into any one of the following three categories depending on the chronological order of the obstruction, i.e ., biliary obstruction before the duodenal obstruction, concurrent biliary and duodenal obstruction or biliary obstruction after duodenal obstruction. In most cases duodenal obstruction happens later during the disease course[4,6,7]. Further classification can be done based on anatomic location of the duodenal obstruction in relation to the papilla. GOO type I has duodenal obstruction before the papilla, type II involves the papilla and type III is post papilla. GOO-II is the most difficult to manage via endoscopic stenting whereas GOO-III is the easiest to manage[4,6,7].

During hospitalization in October 2017, esophagogastroduodenoscopy (EGD) showed retained fluid in the gastric body. There was a malignant appearing, intrinsic moderate stenosis in the second part of the duodenum suggesting type II GOO. The biopsy showed active duodenitis with gastric metaplasia and inflammatory exudates consistent with an ulcer. This area was traversed and stented with a 22 mm × 12 cm WallFlex stent using fluoroscopic guidance (Figure ​ (Figure2). 2 ). Three days later the patient underwent repeat EGD for acute, new onset jaundice and failure to respond to medical treatment. Endoscopic evaluation showed a patent WallFlex SEMS without any migration. Endoscopic retrograde cholangiopancreatography (ERCP) with fluoroscopy was simultaneously performed and confirmed the previously placed duodenal and biliary stents. The scope was passed through the duodenal stent with precision fluoroscopic guidance and the bile duct containing the previously placed CBD stent (10 mm × 6 cm BMS) was deeply cannulated with the short-nosed traction auto-tome and guidewire. Contrast was injected and ductal flow of contrast was adequate. Contrast extended to the main bile duct; however, the lower third of the main bile duct, the middle third of the main bile duct and CBD was completely obstructed by what appeared to be a mass with tumor ingrowth (the same mass that had eroded and obstructed the duodenum previously). A 0.035-inch × 260 cm straight guidewire (Hydra Jag wire) was passed into the biliary tree. Dilatation of the duodenal stent side was accomplished with a Hurricane 10 mm × 4 cm balloon dilator and was successful. One 10 mm × 4 cm covered metal stent (CMS) was placed 3 cm into the previous 10 mm × 6 cm BMS within the CBD. Bile and clear fluid flowed through the stent and the stent was in proper position (Figure ​ (Figure3). 3 ). The patient’s total bilirubin dropped from 5.7 to 3.5 the next day. Four days later, his total bilirubin was 1.5, his acute symptoms had resolved and he was discharged from the hospital.

Another way to relieve CBD obstruction is endoscopic ultrasound-guided biliary drainage (EUS-BD). This is a relatively new technique in which a fistula is made between the biliary duct and intestine[12]. This method has been shown to be equivalent to percutaneous biliary drainage (PTBD) and is used as a salvage procedure after ERCP has failed and can be utilized in patients with or without duodenal stenosis[13,14]. A study done by Dhir et al[14] in patients that failed one or more ERCP attempts revealed that the short-term outcome of EUS-BD were comparable to that of ERCP. Similarly, another study done by Moon et al showed that EUS-BD is a therapeutic option when ERCP approach through the lumen of the duodenal SEMS fails. EUS-BD could be performed through the duodenum or through an existing mesh of a duodenal stent[3].

Initial endoscopic retrograde cholangiopancreatography findings. A: Area of the papilla visualized in the 2 nd part of the duodenum; B: CBD malignant stricture visualized in the distal CBD with aid of fluoroscopy during ERCP; C: Cannulating the CBD; D: BMS interested into the CBD visualized protruding from the papilla in the 2 nd portion of the duodenum. CBD: Common bile duct; ERCP: Endoscopic retrograde cholangiopancreatography; BMS: Bare metal stent.

A 78-year-old man presented with complaints of abdominal pain, nausea and emesis. CT imaging showed findings consistent with GOO. A year prior in July 2016 he had presented to our facility with obstructive jaundice secondary to a pancreatic head mass (3 mm × 2 mm) with sonographic evidence suggesting both superior mesenteric artery and portal vein invasion. He underwent endoscopic retrograde cholangiopancreatography (ERCP) and successful dilatation of the CBD with the placement of a 10 mm × 6 cm BMS approximately 5 cm into the CBD (Figure ​ (Figure1). 1 ). Biopsy of the mass confirmed adenocarcinoma.

DISCUSSION.

Before the advancement of endoscopic intervention, biliary bypass surgery was the treatment of choice[8]. With recent advancements in the endoscopic field (such as placement of biliary and duodenal SEMS), safer and more cost-effective ways have emerged to help improve the quality of life of patients who are otherwise not surgical candidates[9].

Relevant patient information: BMI 26.6, non-smoker. History: Coronary heart disease and percutaneous coronary intervention, cerebrovascular accident, atrial fibrillation, pulmonary embolism, nonresectable pancreatic adenocarcinoma, hypothyroidism, depression and hypertension.

While recently published literature has addressed initial stent placed into the CBD through a duodenal prosthesis for biliary obstruction, this is the first known case of inserting a second stent into the previous CBD stent through the duodenal prosthesis. In the future, endoscopists can consider this technique to stent an already existing CBD stent for alleviating malignant biliary obstruction in patients who are otherwise not candidates for surgical intervention. Researchers and clinicians should continue to investigate this modality and future utilization will allow us to identify any new findings or complications associated with this unique technique.

There have been previous studies showing plastic biliary stents that were combined with biliary and duodenal metal stenting[15,16], but to our knowledge, the above studies did not include patients with duodenal SEMS and CBD BMS who required further biliary stenting. Additionally, there are no published guidelines to follow in these scenarios. Our patient had an existing duodenal prosthesis along with a CBD BMS and was still experiencing biliary obstructive symptoms. The placement of the duodenal stent did not affect the patency of the existing CBD BMS. Considering ERCP as the first line therapy, we deployed a CMS on top of the BMS. This technique worked for our patient as a successful palliative and quality of life measure and was without any complications. By the time of hospital discharge, he had clinically improved and his total bilirubin continued to normalize.

Core tip: Patients with gastric outlet obstruction from duodenal, ampullary or pancreatic malignancy frequently develop biliary obstruction. These patients usually undergo prophylactic biliary stent placement as the likelihood of developing biliary stricture or obstruction is very high. Here, we present a case of a patient who already had a duodenal and biliary stent which required placement of a covered metal stent into the existing common bile duct prosthesis to relieve his biliary obstructive symptoms.

For patients suffering from both biliary and duodenal obstruction, endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the treatment of choice. ERCP through an already existing duodenal prosthesis is an uncommon procedure and furthermore no studies have reported installing a covered metal stent onto an already existing bare metal stent in the common bile duct (CBD). We describe a rare case of a stent-in-stent dilatation of the CBD through an already existing self-expanding metal stent in the second part of duodenum for the patient presenting with jaundice in setting of biliary and duodenal obstruction from pancreatic adenocarcinoma. The biliary obstruction was relieved with a decrease in bilirubin levels post-stenting.

Esophagogastroduodenoscopy findings 15 mo after initial endoscopic retrograde cholangiopancreatography. A: Duodenal mass visualized encroaching in the lumen of 2 nd portion of duodenum; B: SEMS placed over the area of the encroaching mass in the 2 nd portion of the duodenum. SEMS: Self expanding metal stent.

Typically, patients who present with malignant GOO typically undergo prophylactic biliary stent placement as the likelihood of developing biliary stricture or obstruction is very high; moreover, data in the past has shown that an estimated 60% of patients receiving duodenal stents also end up with biliary stents[2]. For patients who do not undergo biliary stenting (usually placed during the placement of an enteral stent), the gastroenterologist will have to uniquely perform the ERCP through an already existing duodenal stent. Our patient case fell under an even rarer clinical scenario in which not only did the patient have a duodenal stent, but he also had CBD prosthesis. To our knowledge this is the first case of true stent-in-stent placement of a BMS into the CBD through an already existing duodenal and CBD stent.

Endoscopic retrograde cholangiopancreatography to place a subsequent 2 nd common bile duct stent through an existent duodenal stent. A: CBD BMS and duodenal prosthesis (SEMS) visualized on the 2 nd ERCP before inserting the CMS into the CDB; B: Endoscopic visualization of the papilla site filled with debris and tumor invasion; C: CMS deployed on the existing BMS in the CBD through the SEMS in the duodenum; D: Endoscopic visualization of the CBD stent protruding through the papilla in the 2 nd portion of duodenum after the completion of the 2 nd ERCP. CBD: Common bile duct; BMS: Bare metal stent; SEMS: Self expanding metal stent; CMS: Covered metal stent; ERCP: Endoscopic retrograde cholangiopancreatography.

INTRODUCTION.

Studies in the past have explored risk factors and success rates of ERCP biliary metallic stenting in patients with an already existing SEMS due to duodenal obstruction. A study done by Yao et al[10] showed that for malignant duodenal stricture with SEMS, ERCP with biliary metallic stenting was safe and effective. The study showed that 60 mm duodenal stent had ERCP success rate of 88% as compared to longer 80-90 mm stents that had a success rate of 18.2%. Furthermore, type 1 (GOO above the ampulla) and 2 (GOO at the level of ampulla) GOO with stricture length greater than 3.5 cm had lower ERCP success rates than strictures with a length less than 3.5 cm. GOO type 3 (GOO distal to the ampulla) had 100% ERCP success rate. To summarize, a stricture length of > 3.5 cm and duodenal stent length of 80-90 mm were independent risk factors for the failure of ERCP in patients with prior SEMS in the duodenum[10].

A study done by Hamada et al[11] evaluated time to recurrent biliary obstruction (TBRO) in patients who underwent endoscopic biliary drainage combined with a duodenal stent. The median TBRO was 450 d but no information about subsequent intervention was mentioned[11]. Another study done by Moon et al[5] on 8 patients with duodenal and biliary obstruction showed that biliary stenting following a duodenal SEMS is highly successful and feasible but no data was mentioned for patients having persistent biliary obstruction after the abovementioned procedure.

Malignant gastric outlet obstructions (GOOs) often present with associated malignant biliary stenosis either on initial presentation or later in the clinical course[1]. Most patients get biliary stenting before having duodenal stents placed as it is difficult to access the papilla through the self-expanding metal stents (SEMS) in the duodenum[2-4] even though recent studies have shown that biliary stenting is feasible with high success rate through the duodenal stent[3,5]. We describe even a rarer case in which the patient already had a bare metal stent (BMS) in the common bile duct (CBD) and SEMS in the duodenum who needed further biliary stenting.

The treatment of initial malignant biliary stenosis resulting in GOO- II that is alleviated with a duodenal SEMS is the most common scenario of biliary and duodenal obstruction intervention. It is easier to stent the duodenal obstruction after stenting the biliary obstruction but not vice versa[7]; however, Moon et al[3,5] have shown great success in biliary stenting through duodenal stents. In our case, even though the patient had an existent biliary stent, accessing the CBD was difficult due to tumor invasion and bloody debris (Figure ​ (Figure3B). 3B ). There was zero visualization of the papilla making fluoroscopy the only way to visualize and cannulate the CBD as compared to the naïve papilla (Figure ​ (Figure1A) 1A ) that is seen during the initial CBD stent placement.

The patient with a bare metal stent (BMS) in the common bile duct (CBD) and self-expanding metal stent (SEMS) in the duodenum presented with worsening jaundice symptoms.

ARTICLE HIGHLIGHTS.