Intraductal Fenestration of Biliary Metal Stents Using Argon Plasma to Facilitate Bilateral Hilar Stenting

Abstract

Background: When placed across the biliary confluence, uncovered self-expanding metal stents (SEMS) may impede access to the contralateral intrahepatic ducts. In particular it is difficult to place additional plastic or metal stents across multiple adjacent cells of a hilar SEMS. Argon plasma has been used to trim biliary SEMS. However, the use of argon plasma for intraductal fenestration of biliary metal stents has not been described. Case report: A 38-year-old man with hilar cholanogiocarcinoma presented with cholangitis and right lobe liver abscesses. He had been previously treated with placement of multiple closed-cell, uncovered SEMS extending from duodenum to left hepatic duct. A percutaneous transhepatic catheter was placed into an abscess cavity, which communicated with right hepatic ducts. Subsequently a percutaneous transhepatic guidewire was advanced through the hilar SEMS interstices and into the duodenum. During ERCP a temporary plastic stent was placed into the left main duct for venting of argon gas. The percutaneous guidewire was then grasped with a snare and brought out via the mouth. Choledochoscopy was then performed using a pediatric gastroscope which was advanced over the guidewire into the existing SEMS up to the level of the hilum. Metal struts of the embedded SEMS were seen crisscrossing over the right duct orifice. The visible SEMS wires were fenestrated using a pediatric argon plasma coagulation probe at power of 80 W and flow 0.3 L/min, and further unwoven with a pediatric biopsy forceps. Argon gas vented from the percutaneous biliary sheath as well as the left hepatic duct stent. Subsequently plastic stents were placed via a duodenoscope into 4 separate right intrahepatic ducts, each of which was accessed across adjacent interstices of the SEMS. The patient had rapid clinical improvement and a follow-up computed tomography at 4 weeks showed resolution of liver abscesses. Conclusion: Fenestration of hilar biliary SEMS using argon plasma under direct endoscopic visualization can facilitate bilateral hilar stent placement in patients with complex malignant obstruction of the central intrahepatic ducts. Argon plasma has been used to trim biliary and rectal SEMS. The use of argon plasma for endoscopic fenestration of duodenal stents to facilitate ERCP has also been reported. Our case extends the application of this technique by describing intraductal fenestration of an indwelling biliary SEMS to accomplish bilateral hilar stenting.