The Magic of Covered Self Expanding Metallic Stents: A Novel Therapeutic Approach for Bile Leaks

Abstract

Introduction Bile leak is not an uncommon complication following hepatobiliary surgery. Leaks are treated with endoscopic sphincterotomy with or without stenting. Plastic stents have been used traditionally for this indication; however, CSEMS (covered self-expanding metallic stent) is a novel therapeutic approach. Case Presentation A 61-year-old gentleman with history of significant ethyl alcohol abuse, was brought to Orange Park Medical Center Emergency with complaints of right upper quadrant abdominal pain for 1 week along with fever and vomiting. Right upper quadrant was tender on palpation. There was no hepatosplenomegaly. White blood cell count was 18.6/L, bilirubin was 1.3 mg/dl. Computed tomography (CT) scan and ultrasound of gallbladder showed findings consistent with acute cholecystitis. Gallbladder was found to be gangrenous during laparoscopic cholecystectomy. Open cholecystectomy was performed. No bile leak was noted at the time of closure. Next day patient was found to have 100 ml of bile in Jackson-Pratt drain. Endoscopic retrograde cholangiopancreatography (ERCP) was done. A single filling defect was noted in the distal common bile duct suggestive of a stone with extravasation of the contrast material into the gallbladder fossa suggesting bile leak. A 1 cm biliary sphincterotomy was performed. A 10-French 7 cm long plastic biliary stent was placed across the area of leak. Patient had persistent bile leak. Repeat ERCP revealed bile leak from cystic duct remnant. A 10 cm plastic stent was placed. Patient had persistent bilious output after 2nd ERCP. Third ERCP was executed and a CSEMS was placed with proximal end above the cystic duct origin and the distal part into the duodenum. Drainage decreased markedly after that. Metallic stent was later removed without complication. Discussion Bile leak can be a challenging clinical entity. Endoscopic sphincterotomy with or without stenting reduces intraductal pressure and diverts the flow form the leaking site. Plastic stents are mostly used, however, CSEMS may provide better therapeutic alternative. The large diameter of these stents allows an effective drainage away from the leakage site. Furthermore, placing the stent across the injured site may help to seal it. So far, only plastic stents could be removed safely endoscopically if necessary. The disadvantage of plastic stents, however, is the small internal diameter which predisposes to occlusion by biliary sludge. CSEMS can help overcome this.1443_A.tif Figure 1: bile leak observed1443_B.tif Figure 2: Covered self expanding metallic stent