De novo stent-stone complex after long-term biliary stent placement: pathogenesis, diagnosis, and endotherapy

CT imaging features of bile duct stent complications

Biliary stents have been widely used to treat both malignant and benign biliary obstruction. Biliary stenting serves as a temporary measure to maintain ductal patency and promote bile drainage. Biliary decompression can help relieve clinical symptoms of pain, obstructive jaundice, pruritis, fat malabsorption, and failure to thrive and prevent disease progression, such as secondary biliary cirrhosis and end-stage liver failure. Endoscopic placement of biliary endoprosthesis is a minimally invasive procedure well tolerated by most patients but is not without problems. Multiple early and late complications have been reported in the literature and Computed Tomography (CT) is the most used modality to assess normal positions and evaluate patients suspected of stent complications. The aim of this article is to provide a review various of biliary stent related complications, as seen on CT. Current literature on risk factors, diagnosis and management is also discussed.

Risk Factors for Recurrence of Cholangitis After Pancreaticoduodenectomy and Comparison of Stents in Hepaticojejunostomy

BACKGROUND

Postoperative cholangitis is a common complication of pancreaticoduodenectomy. Frequent cholangitis impairs patients' quality of life after pancreaticoduodenectomy. However, the risk factors for recurrence of cholangitis remain unclear. Hence, this retrospective study aimed to identify risk factors for recurrence of cholangitis after pancreaticoduodenectomy.

METHODS

The medical records of patients who underwent pancreaticoduodenectomy between 2015 and 2019 in our institution were retrospectively reviewed. At least two episodes of cholangitis a year after pancreaticoduodenectomy were defined as 'recurrence of cholangitis' in the present study. Univariate and multivariate analyses were performed.

RESULTS

The recurrence of cholangitis occurred in 40 of 207 patients (19.3%). Multivariate analysis revealed that internal stent (external, RR: 2.16, P = 0.026; none, RR: 4.76, P = 0.011), firm pancreas (RR: 2.61, P = 0.021), constipation (RR: 3.49, P = 0.008), and postoperative total bilirubin>1.7 mg/dL (RR: 2.94, P = 0.006) were risk factors of recurrence of cholangitis. Among patients with internal stents (n = 54), those with remnant stents beyond 5 months had more frequent recurrence of cholangitis (≥5 months, 75%; <5 months, 30%).

CONCLUSIONS

Internal stents, firm pancreas, constipation, and postoperative high bilirubin levels are risk factors for cholangitis recurrence after pancreaticoduodenectomy. In addition, the long-term implantation of internal stents may trigger cholangitis recurrence.

Successful electronic hydraulic lithotripsy for a stent-stone complex causing gastric output obstruction formed by an anti-migration system of a self-expandable metallic stent

Okuaki and colleagues present a case video of a stent-stone complex formed by the anti-migration system of a self-expandable metallic stent used in endoscopic ultrasound-guided biliary drainage. As the stone caused gastric outlet obstruction, they successfully crushed it using a balloon catheter and electronic hydraulic lithotripsy with a two-channel scope.

A case in which the tip of a plastic stent placed to prevent recurrence of walled‐off necrosis penetrated the bile duct and formed a stent–stone complex

A woman in her 60s underwent endoscopic sphincterotomy for choledocholithiasis. Unfortunately, post‐endoscopic retrograde cholangiopancreatography pancreatitis occurred. In addition, huge walled‐off necrosis (WON) appeared as a late complication. For the infected WON, endoscopic ultrasound‐guided fistuloplasty and endoscopic necrosectomy were performed, and a double pigtail plastic stent (PS) (7Fr, 7 cm) was placed to prevent a recurrence. Plain computed tomography conducted two years later showed that the stent implanted for WON had deviated. The distal end of the stent was found to have migrated into the bile duct. In addition, common bile duct stones with stents as nuclei were observed. Upon performing endoscopic retrograde cholangiography, it was revealed that the stent tip perforated the distal bile duct just above the papilla. After removal of the stent using grasping forceps, we made an incision between the duodenal – bile duct fistula and bile duct orifice using a sphincterotome. Then, the stone was removed by a balloon catheter. Although such late adverse events are rare occurrences, placement of long‐term PS after treatment of WON should be followed up regularly with imaging examination, and if there is no recurrence for several months, removal of the PS at that point may be considered.

Request for biliary drainage for IgG4-SC could be waived before steroid administration?

BACKGROUND

In IgG4-related sclerosing cholangitis (IgG4-SC), the necessity of biliary drainage (BD) is unclear. In this study, we aimed to retrospectively investigate the improvement of liver damage and jaundice in cases of IgG4-SC with and without BD, before starting steroids.

METHODS

A total of 52 patients with IgG4-SC were investigated in the study. The study endpoints were the normalization rate of alkaline phosphatase (ALP)/total bilirubin (T-Bil) after 8 weeks of steroids, with and without BD.

RESULTS

Propensity score matching was performed based on ALP and T-Bil, and 28 patients were included. There were 14 patients each in the BD and non-BD groups. Before initiation of steroids, the mean ALP in the BD group and the non-BD group was 378/461 (P = .541); the mean T-Bil was 2.5/1.8 (P = .401). Eight weeks after initiation of steroids, ALP improvement rate in the BD group/non-BD group was 69.2%/61.5% (P = 1.000), and T-Bil improvement rate was 100%/100% (P = Ns).

CONCLUSIONS

Steroids for IgG4-SC could prove effective in improving liver damage and jaundice, regardless of the presence or absence of BD. BD for IgG4-SC aimed to improve jaundice may not be necessary.

Long-term outcomes and risk factors of recurrent biliary obstruction after permanent endoscopic biliary stenting for choledocholithiasis in high-risk patients

OBJECTIVE

To elucidate the long-term outcomes of permanent endoscopic biliary stenting (EBS) and risk factors for recurrent biliary obstruction (RBO) in high-risk or elderly patients with common bile duct (CBD) stones.

METHODS

The electronic database of Hakodate Municipal Hospital was searched to identify elderly or high-risk patients with CBD stones who had undergone permanent EBS using a plastic stent without stone removal and were followed up between April 2011 and May 2019, with no further intervention until symptoms occurred.

RESULTS

We analyzed a total of 47 patients, of whom 19 (40.4%) were men, with a median age of 86 years (interquartile range 80-90 years). RBO and death without biliary disease occurred in 14 (29.8%) and 19 (40.4%) patients, respectively. The cumulative RBO rates at 20, 40, and 60 months were 22.1%, 31.8%, and 35.5%, respectively. The median time to RBO was 13.0 and 38.0 months in the group with CBD stone  ≥15 mm and 11-14 mm in diameter, respectively. The cumulative RBO incidence rate in the group with CBD stone ≤10 mm in diameter did not reach 50%. The cumulative RBO incidence rates were significantly different among the three groups based on the CBD stone diameter (competing risk analysis, P < 0.01). Multivariate analysis showed that an increase in CBD stone diameter predicted the increased risk of RBO (hazard ratio 1.26, P = 0.01).

CONCLUSIONS

Permanent EBS is a feasible option for high-risk patients with small CBD stones.

Successful Endoscopic Removal of a Biliary Stent with Stent-Stone Complex after Long-Term Migration

A 49-year-old man was referred to our hospital for an abnormality of the hepatobiliary enzyme. The patient was diagnosed with primary sclerosing cholangitis 9 years ago, and he had a biliary stent with a string placed as an inside stent. We attempted to remove the stent 6 months later, but the string was cut off, so the stent could not be removed. Removal was attempted again, but the patient cancelled the outpatient appointments. During the examination performed at the present visit, we discovered that the biliary stent had migrated into the bile duct, and a stone had formed around the stent. We attempted to remove the stent-stone complex by endoscopic retrograde cholangiopancreatography, but it was difficult; thus, we decided to implant a new biliary stent and remove the other stent later. When we performed endoscopic retrograde cholangiopancreatography again 2 days later, the bile duct axis was linearized thanks to the additional stent, enabling us to grab the migrated stent with stent-stone complex using grasping forceps and to successfully pull it out. By implanting an additional plastic stent temporarily, we were able to straighten the biliary axis and endoscopically remove the biliary stent that migrated and caused the development of stent-stone complex in a 2-staged approach.

Iatrogenic bile duct Injury with a retained T-tube in common bile duct for 10 years: A case report

RATIONALE

Bile duct injury (BDI), a major complication of cholecystectomy, usually needs hepaticojejunostomy or primary repair over T-tube in severe cases. There were few cases about retained fragments of T-tube. Whereas, intact T-tube retained in common bile duct (CBD) for years after BDI was very rare.

PATIENT CONCERNS

A 55-year-old female complaining of a retained T-tube in the right upper quadrant for 10 years with bilious exudation for 3 months.

DIAGNOSIS

Based on the medical history of reoperation after the initial laparoscopic cholecystectomy (LC), the retained T-tube, the bilious exudation, and the feature of image modalities, she was diagnosed with retained biliary T-tube, biliary leak, hepatolithiasis, and BDI.

INTERVENTIONS

After nonsurgical management at local hospitals, the patient had her indwelling T-tube removal during laparotomy in our center finally. During this procedure, bile duct exploration, hilar bile ducts reconstruction, and primary Roux-en-Y hepaticojejunostomy were performed.

OUTCOMES

Unfortunately, bile leakage occurred postoperatively. After drainage of the peritoneal bilious fluid, the patient recovered gradually without further complication.

LESSONS

T-tube in CBD could act as nidus for stone formation after long-time placement. As a result of gradual stone formation on T-tube, severe hepatic ducts dilatation may occur without the presence of jaundice. Timely follow-up and proper surgical intervention should be suggested for patients with T-tube placement or iatrogenic BDI to avoid further impacts.

Clinical characteristics and risk factors for stent-stone complex formation following biliary plastic stent placement in patients with common bile duct stones

BACKGROUND

Stent-stone complex (SSC) formation is one of the complications of endoscopic biliary stent placement. This study aimed to clarify the clinical characteristics and risk factors for SSC formation following plastic stent (PS) placement in patients with common bile duct (CBD) stones.

METHODS

We retrospectively reviewed the charts of 78 patients with CBD stones who had undergone 107 biliary stent placements as palliative treatment. Demographic, historical, and stent-related data were collected and analyzed.

RESULTS

At PS removal, SSC formations were observed in 18% of the 107 cases (SSC group) studied and not in the remaining 82% (non-SSC group). The duration of PS placement was significantly longer in the SSC group. The increase in CBD diameter during the stenting period as well as the incidence of cholangitis at PS removal was significantly greater in the SSC group. Multivariate analysis identified long-term (≥301 days) PS placement and the increase in CBD diameter during the stenting period as independent factors for SSC formation.

CONCLUSIONS

Long-term PS placement induces a risk of SSC formation in patients with CBD stones. The increase in diameter of CBD during the period of PS placement is a predictive factor for SSC formation in this situation.

Endoscopic management of acute cholangitis as a result of common bile duct stones

Acute cholangitis is infectious disease of the biliary system and potentially can cause significant morbidity and mortality. With advances in intensive care, antibiotic therapy advances and endoscopic and other modalities of biliary drainage, mortality rates have significantly come down of late. Although most cases respond to antibiotics alone, definitive therapy is required later in most of the patients. Increased biliary pressure leads to biliovenous reflux of bacteria and purulent bile into the circulation leading to systemic inflammation and sepsis with subsequent organ dysfunction. Biliary decompression increases antibiotic penetration in bile. Therefore, patients with high-risk factors and organ dysfunction require early and urgent biliary drainage, respectively, as they are unlikely to respond with antibiotics alone. Biliary decompression is best achieved by endoscopic retrograde cholangiopancreatography (ERCP) compared to percutaneous and surgical decompression. ERCP can be technically difficult and sometimes unsuccessful especially in patients with altered anatomy and upper gastrointestinal obstruction. Earlier percutaneous transhepatic biliary drainage (PTBD) and surgery were the only viable options in those patients. PTBD requires a dilated biliary system, is more invasive and cannot achieve ductal clearance in cholangitis as a result of choledocholithiasis, whereas surgery is associated with high morbidity and mortality. Advances in therapeutic endoscopy such as balloon enteroscopy-guided biliary drainage or endoscopic ultrasound guided-biliary drainage have added new dimensions to endoscopic management of acute cholangitis as a result of choledocholithiasis obviating the need for more invasive procedures.

De novo Choledocholithiasis in Retained Common Bile Duct Stent

De novo choledocholithiasis means formation of stone in the common bile duct (CBD). It can present as biliary colic, jaundice, cholangitis, pancreatitis or it may be asymptomatic. There are various indications for biliary stenting like CBD stone, CBD stricture, biliary leak, peri ampullary carcinoma, CBD malignancy, etc. Foreign bodies like silk sutures, endo-clips, fish bone, retained T- tubes, plastic or metallic stents, etc. lead to biliary stasis leading to eventual stone formation. Here, we discuss a case of choledocholithiasis post-cholecystectomy with CBD stenting done 15 years back which had migrated and acted as a nidus for stone formation in the CBD and hepatic duct.

Complete transection of the main bile duct: minimally invasive treatment with an endoscopic-radiologic rendezvous

BACKGROUND

Complete transection of the common bile duct (CBD) is a dramatic and often extremely difficult-to-repair event after surgery. Abdominal biliary fluid collection or jaundice is the initial symptom, and ERCP is the determinant for diagnosis.

OBJECTIVE

To evaluate the safety and efficacy of a combined endoscopic-radiologic technique for the reconstruction of the CBD.

DESIGN

Single-center retrospective study.

SETTING

Tertiary-care center for biliary surgery.

PATIENTS

This study involved 22 patients with complete transection of the CBD after cholecystectomy.

INTERVENTION

A guidewire is passed in the subhepatic space through the endoscopic approach. A snare loop is advanced from the percutaneous entry site to catch the free end of the wire and then pulled outside the body: a percutaneous biliary-duodenal (PTBD) drainage is put in place. After a new contralateral PTBD, 4 plastic stents are inserted. The stents are removed endoscopically after 8 to 12 months.

MAIN OUTCOME MEASUREMENTS

Success of the rendezvous maneuver, patient recovery, and patient mortality.

RESULTS

After a mean follow-up period of 4 years, 16 patients are asymptomatic. Two patients are still under treatment, and 4 patients underwent surgery, as was the surgeon's choice.

LIMITATIONS

Single-center, retrospective study with a small population.

CONCLUSION

Interruption of the biliary tree does not represent an indication for an often-difficult surgical treatment, because the CBD is often thin in the presence of biliary peritonitis. However, the condition can be treated with a rendezvous technique. Surgery can be performed in elective conditions or completely avoided when conservative therapy is selected.

Removal of a large stone growing around and encasing a plastic biliary stent: respect the ductal axis

Plastic biliary stents are commonly used during Endoscopic Retrograde Cholangio-Pancreatography (ERCP). The main indication for biliary stenting is benign or malignant obstruction. Plastic stents, among others, can be used as an escape route in patients with large common bile duct stones, or in cases of acute cholangitis with or without sphincterotomy to provide drainage until definitive treatment. Stent occlusion is the main disadvantage, limiting their patency to around 3 months, after which replacement is recommended. We present a case of a large, close to 2cm, stone developing around and encasing the proximal end of a plastic biliary stent. The stent/stone complex was successfully removed en bloc. The stent was placed in the common bile duct without sphincterotomy, and remained in situ for 2 years. The presented case highlights the importance of definitive treatment for common bile duct stones, the need to respect the ductal axis especially when dealing with large stones and the significance of biliary sphincterotomy during endoscopic interventions in the bile duct.

Safety and utility of ERCP during pregnancy

BACKGROUND

ERCP is an important diagnostic and therapeutic tool in patients with biliary and pancreatic disease. Its utility and safety during pregnancy is largely unknown because it is not often required and because its use has been only infrequently reported in the published literature.

OBJECTIVE

Our purpose was to report the clinical experience with ERCP during pregnancy.

DESIGN

Retrospective review, single academic center.

PATIENTS

All (consecutive) pregnant women who underwent ERCP at Parkland Memorial Hospital from 2000 to 2006.

MAIN OUTCOME MEASUREMENTS

History, clinical data, hospital course, procedure-related complication rates and outcomes, and delivery and fetal outcomes were abstracted from medical records.

RESULTS

During the study period, 68 ERCPs were performed on 65 pregnant women. The calculated ERCP rate was 1 per 1415 births. The common indications for ERCP in pregnancy were recurrent biliary colic, abnormal liver function tests, and dilated bile duct on US. ERCP was technically successful in all patients. The median fluoroscopy time was 1.45 minutes (range 0-7.2 minutes). There was no perforation, sedation-related adverse event, postsphincterotomy bleeding, cholangitis, or procedure-related maternal or fetal deaths. Post-ERCP pancreatitis was diagnosed in 11 patients (16%). None of these 11 patients had local or systemic complications. Fifty-nine patients had complete follow-up. Endoscopic therapy at the time of ERCP was undertaken in all patients. Furthermore, 9 patients (32.1%) underwent cholecystectomy in the first and second trimesters for either acute cholecystitis (6) or symptomatic gallstones (3). Term pregnancy was achieved in 53 patients (89.8%). Patients having ERCP in the first trimester had the lowest percentage of term pregnancy (73.3%) and the highest risk of preterm delivery (20.0%) and low-birth-weight newborns (21.4%). None of the 59 patients with long-term follow-up had spontaneous fetal loss, perinatal death, stillbirth, or fetal malformation.

LIMITATION

Retrospective review.

CONCLUSIONS

ERCP can be performed safely during pregnancy. Further, ERCP performed in pregnancy leads to specific therapy in essentially all patients. However, ERCP may be associated with a higher rate of post-ERCP pancreatitis than in the general population.

Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis

Gallstone disease is encountered commonly in clinical practice. The diagnosis of biliary stones has become less problematic with current, less-invasive imaging methods. The relatively invasive endoscopic techniques should be reserved for therapy and not used for diagnosis. Acute cholangitis and gallstone pancreatitis are two major complications that require prompt recognition and timely intervention to limit morbidity and prevent mortality or recurrence. Appropriate noninvasive diagnostic studies, adequate monitoring/supportive care, and proper patient selection for invasive therapeutic procedures are elements of good clinical practice.