Endoscopic biliary recanalization by using a needle catheter in patients with complete ligation or stricture of the bile duct: safety and feasibility of a novel technique (with videos)

Abstract

Benign bile duct strictures involving the extrahepatic biliary tree can pose a therapeutic challenge. Occurrence of such strictures is well-recognized in patients after liver transplantation at the site of duct-to-duct anastomoses, in cases of ischemic injury to the bile duct, and after inadvertent ligation or injury to the bile duct during cholecystectomy. 1 Parmeggiani D. Cimmino G. Cerbone D. et al. Biliary tract injuries during laparoscopic cholecystectomy: three case reports and literature review. G Chir. 2010; 31: 16-19 PubMed Google Scholar , 2 Safdar K. Atiq M. Stewart C. et al. Biliary tract complications after liver transplantation. Expert Rev Gastroenterol Hepatol. 2009; 3: 183-195 Crossref PubMed Scopus (14) Google Scholar Although conventional treatment includes surgical hepaticojejunostomy or, in the past, percutaneous dilation and stenting, there is increasing evidence for and acceptance of treatment of such strictures via ERCP. 3 Vitale G.C. Tran T.C. Davis B.R. et al. Endoscopic management of postcholecystectomy bile duct strictures. J Am Coll Surg. 2008; 206 (discussion 24-5): 918-923 Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar At ERCP, a guidewire is passed through the stricture into the intrahepatic ducts. The stricture is subsequently treated with placement of multiple plastic stents (7F, 8.5F, or 10F), with increasing data indicating that the best long-term outcomes are achieved by multiple, large-bore stents left in for a long duration (1 year). 4 Costamagna G. Pandolfi M. Mutignani M. et al. Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc. 2001; 54: 162-168 Abstract Full Text Full Text PDF PubMed Scopus (357) Google Scholar The stents usually are placed after dilation of the stricture, but in some cases dilation may not be necessary. There have been case reports describing placement of fully or partially covered metal stents for such strictures. 5 Tee H.P. James M.W. Kaffes A.J. Placement of removable metal biliary stent in post-orthotopic liver transplantation anastomotic stricture. World J Gastroenterol. 2010; 16: 3597-3600 Crossref PubMed Scopus (35) Google Scholar To be feasible, however, endoscopic therapy requires traversing the stricture with a guidewire. In some patients with very high-grade strictures or complete ligation of the bile duct, a guidewire cannot be passed through the stenosis, and no contrast material can be forced upstream. Such patients generally have been precluded from endoscopic or percutaneous therapy and have been treated with surgical intervention involving a Roux-en-Y hepaticojejunostomy. As an alternative to endoscopic recanalization, percutaneous access to the upstream duct and a subsequent attempt at ERCP rendezvous for recanalization has been reported. 6 Dowsett J.F. Vaira D. Hatfield A.R. et al. Endoscopic biliary therapy using the combined percutaneous and endoscopic technique. Gastroenterology. 1989; 96: 1180-1186 Abstract PubMed Google Scholar However, there are no prior case series of endoscopic recanalization of a completely disconnected or ligated bile duct stricture. Previously we reported a case using this technique and placement of plastic stents. 7 Artifon E. Lopes T. da Silveira E. et al. Endoscopic recanalization following accidental ligation of the common hepatic duct A new technique. Rev Gastroenterol Mex. 2010; 75: 191-194 PubMed Google Scholar In this prospective series we describe safety and feasibility of this novel technique for recanalization and subsequent endoscopic therapy of completely occluded or ligated bile duct strictures by placement of a partially covered, self-expandable metallic stent (SEMS).