Mind the gap! Extraluminal percutaneous-endoscopic rendezvous with a self-expanding metal stent for restoring continuity in major bile duct injury: A case series

Jessica Lindemann,Christo Kloppers,Sean Burmeister,Marc Bernon,Eduard Jonas

doi:10.1016/j.ijscr.2019.06.059

Abstract

IntroductionTreatment of major iatrogenic and non-iatrogenic bile duct injury (BDI) often requires delayed surgery with interim external biliary drainage. Percutaneous transhepatic cholangiography (PTC) with biliary catheter placement and endoscopic retrograde cholangiography (ERC) with stent placement have been used to bridge defects. In some patients, bridging the defect cannot be achieved through ERC or PTC alone. Materials and methodsTwo patients with major BDIs, one iatrogenic and one non-iatrogenic underwent an extraluminal PTC/ERC rendezvous with placement of a fully covered self-expandable metal stent (SEMS) for the acute management of BDI with substantial loss of bile duct length. ResultsIn both patients the intraperitoneal PTC/ERC rendezvous with SEMS placement was successful with no complications after 12 and 18 months follow-up, respectively. DiscussionThis study is the first to report a standardized approach to the acute management of iatrogenic and non-iatrogenic major BDIs using extraluminal intraperitoneal PTC/ERC rendezvous with placement of a fully covered SEMS. The described technique may serve as a “bridge to surgery” strategy for patients where definitive management of BDIs are deferred. However, long-term data of the success of this technique, specifically the use of a SEMS to bridge the defect, are lacking and further investigation is required to determine its role as a definitive treatment of BDIs with substance loss. ConclusionPTC/ERC rendezvous with restoration of biliary continuity and internalization of bile flow is particularly useful for patients who have previously failed ERC and/or PTC alone, and in whom immediate surgical repair is not an option.

Highlights

Treatment of major iatrogenic and non-iatrogenic bile duct injury (BDI) often requires delayed surgery with interim external biliary drainage
The initial management of the BDI is similar to iatrogenic BDI with external drainage of bile and definitive repair at a later stage
We describe an extraluminal Percutaneous transhepatic cholangiography (PTC)/endoscopic retrograde cholangiography (ERC) rendezvous technique with placement of a fully covered self-expandable metal stent (SEMS) for the acute management BDIs with substantial substance loss

Summary

Introduction

Treatment of major iatrogenic and non-iatrogenic bile duct injury (BDI) often requires delayed surgery with interim external biliary drainage. MATERIALS AND METHODS: Two patients with major BDIs, one iatrogenic and one non-iatrogenic underwent an extraluminal PTC/ERC rendezvous with placement of a fully covered self-expandable metal stent (SEMS) for the acute management of BDI with substantial loss of bile duct length. In patients with iatrogenic BDI, reconstruction may be deferred for uncontrolled sepsis and to optimize the patient’s condition [4] In this interval, the biliary fistula is controlled with percutaneous drains resulting in external loss of bile production, and possible fluid and electrolyte imbalances [5]. In a substantial percentage of these patients, initial surgery will be according to damage control principles In this setting, the initial management of the BDI is similar to iatrogenic BDI with external drainage of bile and definitive repair at a later stage

Methods

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Conclusion