Endoscopic Management of Biliary Stent Occlusion With Bipolar Electrocautery

Abstract

Persistent biliary obstruction due to stent occlusion is a major cause of morbidity and mortality in patients with malignant obstruction of the bile duct. The standard of care for endoscopic management of these occlusions involves mechanical cleaning with a balloon or additional stent insertion. We present the case of a patient with biliary metal stent occlusion that was successfully treated with the aid of endoscopic bipolar electrocautery. A 73-year-old man with history of metastatic gastrinoma complicated by malignant biliary obstruction presented to the hospital with sepsis and was admitted to the MICU. During his workup, he was found to have rising total bilirubin levels, despite previously having four stent-in-stents placed to maintain patency of the CBD. Imaging was concerning for worsening CBD and intrahepatic biliary duct dilation. During ERCP, the stents were found to be occluded by sludge and debris. After attempted manual debridement with endoscopic forceps, a catheter could not be advanced through the stent occlusion. A bipolar electrocautery probe was then used to tunnel through the occlusion using soft coagulation. After tunneling, a balloon was passed through the inner stent for manual debridement. Occlusion cholangiogram after cleaning demonstrated patency of the duct with good drainage. Self-expanding metal stent placement is the standard therapy for endoscopic treatment of malignant biliary obstruction. Unfortunately, ensuring patency of these stents is difficult. Simple stent occlusions can be treated with a stent-in-stent approach or with mechanical cleaning with a balloon catheter. However, problems can arise that make this approach technically infeasible. With significant tumor ingrowth into the lumen of the stent, or with densely packed debris, a guidewire cannot be passed through the stent. Several studies have highlighted the use of radiofrequency ablation to tunnel through the occlusion. An alternative that has not been studied is the use of bipolar electrocautery to deliver thermal energy directly within the occluded stent. Our case demonstrated that an electrocautery probe can be used in a controlled manner to debride biliary duct occlusions, after which a balloon can be passed for more thorough cleaning. The wide availability of the gold probe catheter, ease of use, and minimal cost, make this a compelling alternative to radiofrequency ablation. Further study is warranted to assess the efficacy and safety of this approach.1414_A.tif Figure 1: Fully occluded uncovered SEMS seen protruding from the ampulla of Vater1414_B.tif Figure 2: Gold Probe catheter was used to burrow through the debris within the stent1414_C.tif Figure 3: After debridement, bile was visualized flowing freely through the stent