Endoscopic Biliary Stent Placement Research Articles

Endoscopic ultrasound-guided placement of biliary lumen-apposing metal stent through a duodenal stent.

Endoscopic ultrasound-guided placement of biliary lumen-apposing metal stent through a duodenal stent.

Robotic Pancreaticoduodenectomy After Unsuspected Double Perforation (Bile Duct And Portal Vein) During Endoscopic Biliary Stent Placement

Presenter: Fabio Makdissi MD | Hospital Nove de Julho Background: Endoscopic placement of biliary stent (ERCP) is a common procedure used in malignant jaundice patients. However, sometimes the cannulation of the bile duct fails, and an alternative is to perform a choledochoduodenal fistula (infundibulotomy) to access the biliary tract and place a biliary stent. We present a robotic pancreaticoduodenectomy performed after a complicated ERCP that required emergency laparotomy for drainage. The initial diagnosis was duodenal perforation. During the definitive operation, an unsuspected double perforation (bile duct and portal vein) was found and successfully treated. Methods: A 57-year-old woman presented with progressive jaundice. ERCP disclosed a 2-cm tumor in the ampulla but cannulation of the biliary duct through the papilla failed. A choledochoduodenal fistula (infundibulotomy) was performed. A plastic endoprosthesis was inserted. Immediate after this procedure, patient developed diffuse peritonitis, leading to emergency laparotomy. Duodenal perforation was suspected but perforation site was not identified. Drain was placed. Drainage ceased after 3 weeks, drain was removed, and patient was transferred to our care. Multidisciplinary team decided for upfront pancreaticoduodenectomy. Robotic approach was proposed, and consent was obtained. Da Vinci Xi robotic system was used. Operation begins with division of adhesions from previous operation. The Kocher maneuver is performed and the ligament of Treitz is mobilized. The proximal jejunum is passed behind the mesenteric vessels and divided with stapler. The duodenum is divided with stapler 2 centimeters below the pylorus. The gastroduodenal artery is dissected, ligated and divided between hemolocks. The common bile duct is divided with robotic scissors; however, the biliary stent is not found in the common bile duct. We suspected that it has migrated distally. Pancreas is divided with harmonic shears until identification of the pancreatic duct which is divided with scissors. Pancreatic head and uncinate process are carefully dissected from the portal vein and from the superior mesenteric artery. When the surgical specimen was only attached by a large branch from portal vein, this branch was dissected for hemolock insertion. However, hemolock insertion failed due to tissue resistance. We then realize that the missing biliary stent was, in fact, inside this portal branch and extended into the main portal vein. This branch is encircled and opened with identification of the biliary stent. Portal vein branch was clamped for safe removal of the biliary stent with minimum loss of blood. Reconstruction of the alimentary tract was then performed as usual. Surgical specimen is removed through extension of auxiliary port incision. Abdominal cavity is drained, and procedure is completed. Results: Total operative time was 6 hours and 38 minutes. Estimated blood loss was 320 mL, with no need of transfusion. Recovery was uneventful and patient was discharged on the 7th postoperative day. Pathology confirmed ampulla of Vater adenocarcinoma T2N0M0. Patient is well with no signs of disease, 4 months after operation. Conclusion: Robotic pancreaticoduodenectomy is safe and feasible even after ERCP complications that required laparotomy. Absence of endoprosthesis in the common bile duct may arise suspicion of wrongful insertion towards adjacent organs and must be dealt with caution.

Percutaneous transhepatic approach to endoscopic placement of a 10F plastic biliary stent: step-by-step description of a novel technique.

Percutaneous transhepatic approach to endoscopic placement of a 10F plastic biliary stent: step-by-step description of a novel technique.

3040 An Uncommon Presentation of Post-Cholecystectomy Bile Leak in the Setting of Existing CBD Stent Successfully Managed With Metallic Stent Placement

INTRODUCTION: About 1% of patients undergoing cholecystectomy develop bile leaks. Bile leaks from cystic duct stump or from a duct of Luschka are the most common sites. Endoscopic biliary sphincterotomy and stent placement remains cornerstone in management of most post-operative bile leaks. We present an unusual case of post cholecystectomy bile leak from cystic duct stump in the presence of existing common bile duct stent. CASE DESCRIPTION/METHODS: A 48-year-old lady presented with 4 days history of worsening abdominal pain after cholecystectomy. She was admitted one week ago for acute exacerbation of chronic pancreatitis and underwent repeat ERCP. A plastic biliary and pancreatic stent was placed. She complained of RUQ pain and underwent HIDA scan which showed delayed gall bladder emptying suspicious for chronic cholecystitis. Given history of recurrent acute pancreatitis and chronic cholecystitis, cholecystectomy was recommended. Patient underwent laparoscopic cholecystectomy one week before this presentation. Abdominal exam on admission showed severe diffuse abdominal tenderness. X ray abdomen in ER showed non obstructive bowel pattern and possible ileus but no perforation. Labs showed WBC 13,000, TB 1.0, AST 11, ALT 20, ALP 186 and lactate 1.0. Given significant abdominal tenderness a CT abdomen and pelvis was done which showed moderate to large subcapsular and intraperitoneal fluid and 2 cm caudal migration of CBD stent with slight prominence of the adjacent common bile duct. HIDA scan showed collection of radionuclide activity along the inferior margin of the liver, increasing overtime, consistent with bile leak. A CT guided percutaneous drain was placed. Patient underwent ERCP 2 days after presentation. Cystic duct stump bile leak was seen which was treated with placement of 8 mm × 60 mm self-expandable fully covered metallic biliary stent (FCSEMS). Distal common bile duct stricture was again seen, measured 2.5 cm in length. Patient underwent repeat ERCP one month later with showed healed site of cystic duct stump leak. DISCUSSION: Presence of CBD stent does not preclude diagnosis of post cholecystectomy bile leak. In our case, CBD stricture, multiple previous endoscopic interventions and stent migration were reasons for failure to eliminate the transpapillary pressure gradient, thereby permitting preferential extravasation at the site of the leak. Further research is needed to establish role of FCSEMS in management of complicated biliary leaks especially in setting of CBD stricture.

Risk factors for distal migration of biliary plastic stents and related duodenal injury

BackgroundThe risk factors of duodenal injury from distal migrated biliary plastic stents remain uncertain. The aim of this study was to determine the risk factors of distal migration and its related duodenal injury in patients who underwent placement of a single biliary plastic stent for biliary strictures.MethodsWe retrospectively reviewed all patients with biliary strictures who underwent endoscopic placement of a single biliary plastic stent from January 2006 to October 2017.ResultsTwo hundred forty-eight patients with 402 endoscopic retrograde cholangiopancreatography procedures were included. The incidence of distal migration was 6.2%. The frequency of duodenal injury was 2.2% in all cases and 36% in cases with distal migration. Benign biliary strictures (BBS), length of the stent above the proximal end of the stricture (> 2 cm), and duration of stent retention (< 3 months) were independently associated with distal migration (p = 0.018, p = 0.009, and p = 0.016, respectively). Duodenal injury occurred more commonly in cases with larger angle (≥ 30°) between the distal end of the stent and the centerline of the patient’s body (p = 0.018) or in cases with stent retention < 3 months (p = 0.031).ConclusionsThe risk factors of distal migration are BBS and the length of the stent above the proximal end of the stricture. The risk factor of duodenal injury due to distal migration is large angle (≥ 30°) between the distal end of the stent and the centerline of the patient’s body. Distal migration and related duodenal injury are more likely to present during the early period after biliary stenting.

Risk Factors for the Development of Stent-Associated Cholangitis Following Endoscopic Biliary Stent Placement.

To elucidate the overall risk and risk factors for developing cholangitis following biliary stent placement by endoscopic retrograde cholangiopancreatography (ERCP) and to determine the clinical outcomes of these individuals. We performed a retrospective review of 796 patients who had undergone 1127 ERCPs with biliary stent placement between 2007 and 2015 at a single tertiary care center. There were 91 episodes of stent-associated cholangitis (SAC) during the study period. Data obtained through the medical records included ERCP indication, patient factors (biliary anatomy, demographics, and comorbidities), stent characteristics (material, length, and design), change in serum bilirubin, stent indwelling time, rates and etiologies of bacteremia, and the mortality rate. Those with SAC were more likely to have an anatomic biliary stricture (13.1% vs. 2.3%, p < .0001), with hilar and multiple strictures having the highest risk (19.1% vs. 11.6%, p = .04). The ERCP indication of malignant biliary obstruction was associated with higher rates of SAC (15.6% vs. 3.4%, p = < .0001). Rates of SAC were higher in those who failed to normalize total bilirubin (16.9% vs. 7.8%, p = .0005), and these episodes occurred earlier compared to those who normalized total bilirubin (median 30.5days vs. 140.5days, p < .0001). Patients at increased risk of SAC include those with an anatomic stricture, malignant biliary obstruction, and those who fail to normalize total bilirubin after biliary stent placement. Future protocols should be designed to reduce the risk of cholangitis in these populations.

Endoscopic side-by-side uncovered self-expandable metal stent placement for malignant hilar biliary obstruction.

Aim:To investigate outcomes of endoscopic bilateral side-by-side placement across the papilla using 10-mm-diameter uncovered self-expandable metal stents for unresectable malignant hilar biliary obstruction.Methods:We retrospectively analyzed 23 patients who underwent endoscopic biliary uncovered self-expandable metal stent placement for unresectable malignant hilar biliary obstruction between January 2015 and September 2016 at our institution. We performed endoscopic side-by-side placement across the papilla using 10-mm-diameter longer-model uncovered self-expandable metal stents. Outcomes included the technical and functional success rates, recurrent biliary obstruction rate, time to recurrent biliary obstruction, reintervention rate, and incidence of adverse events other than recurrent biliary obstruction.Results:Of the 23 patients, 10 with malignant hilar biliary obstruction underwent endoscopic side-by-side uncovered self-expandable metal stent placement across the papilla (median age, 83 years; 6 men). The locations of malignant hilar biliary obstruction were Bismuth types II (n = 3), III (n = 3), and IV (n = 4). The median common bile duct diameter was 8 mm. The technical and functional success rates were 100% and 80%, respectively. Seven patients (70%) developed recurrent biliary obstruction because of stent occlusions, including early hemobilia in two patients and late tumor ingrowth in five patients. The median time to recurrent biliary obstruction was 66 (95% confidence interval: 29–483) days. Six patients (60%) required reintervention, and 1 (10%) underwent transcatheter arterial embolization for right hepatic arterial pseudoaneurysm. Early adverse events other than recurrent biliary obstruction occurred in four patients and late adverse event in one patient.Conclusion:Endoscopic side-by-side placement across the papilla using 10-mm-diameter uncovered self-expandable metal stents was technically feasible for unresectable malignant hilar biliary obstruction; however, it might be better to avoid this method for patients with malignant hilar biliary obstruction because of high recurrent biliary obstruction rate and shorter time to recurrent biliary obstruction.

Bronchobiliary Fistula - A Rare Case of a Patient Presenting With Biliptysis

Bronchobiliary fistula (BBF) is an abnormal communication between the biliary tract and bronchial trees. Patients typically present with pneumonia and biliptysis. We present a case of a patient with an acquired BBF after radiofrequency ablation (RFA) and transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).1398_A.tif Figure 1: Multifocal segmental atelectasis or consolidation in the right lower lobe1398_B.tif Figure 2: Occlusion cholangiogram revealing dilated right hepatic duct with communication with small channels into the right lung.A 72-year-old woman with history of HCC treated with RFA and TACE presented with a four-day history of worsening productive cough of orange and green colored sputum, as well as right hemithorax and right upper quadrant abdominal pain. Physical exam was notable for bilateral rhonchi most prominent over the right hemithorax. Laboratory work-up showed WBC 3.8 TH/UL, platelets 110 TH/UL, normal AST and ALT, ALP 109 IU/L, and total bilirubin 3.8 IU/L. Chest x-ray revealed a consolidation over the right lower lung field. HIDA scan showed a right biliary-pleural lower lobe bronchial fistula with extension of the tracer into the right lung and oropharynx. ERCP with occlusion cholangiogram revealed a dilated right hepatic duct with communication with small channels into the right lung, confirming the presence of a BBF. The patient underwent biliary stenting and her symptoms resolved. BBF is an uncommon entity that requires a high index of suspicion for diagnosis. The most common cause of acquired BBF is hydatid disease. Other causes include trauma, biliary lithiasis, postsurgical states, subdiaphragmatic abscess, cholecystitis/pancreatitis and liver/biliary tree tumor. In rare cases it occurs after RFA and TACE. BBF carries a mortality and morbidity rate of about 12.2% making early detection and treatment imperative. Diagnosis can be made by HIDA scan, percutaneous transhepatic cholangiography, ERCP, CT, or MRCP. Detection of bilirubin in sputum using sputum dipstick can help in its recognition. Management is with endoscopy or surgery. Like in our patient, endoscopic placement of a large biliary plastic stent with drainage can be a means of nonsurgical treatment and achieve success. Few reports demonstrate successful use of endoscopic injection of Histoacryl glue and Lipiodol, as well as cyanoacrylate glue for embolization through bronchoscopy. Surgical interventions are considered when nonsurgical means are unsuccessful. Thoracotomy can prevent further lung damage by preventing further bile leak. Although rarely necessary, surgical intervention is associated with significant morbidity and mortality, and can lead to frequent reoperation.1398_C.tif Figure 3: Biliary, right pleural, and right lower lobe bronchial fistula with extension of tracer into the left lung and the oropharynx.

Clinical characteristics and risk factors for stent-stone complex formation following biliary plastic stent placement in patients with common bile duct stones.

Stent-stone complex (SSC) formation is one of the complications of endoscopic biliary stent placement. This study aimed to clarify the clinical characteristics and risk factors for SSC formation following plastic stent (PS) placement in patients with common bile duct (CBD) stones. We retrospectively reviewed the charts of 78 patients with CBD stones who had undergone 107 biliary stent placements as palliative treatment. Demographic, historical, and stent-related data were collected and analyzed. At PS removal, SSC formations were observed in 18% of the 107 cases (SSC group) studied and not in the remaining 82% (non-SSC group). The duration of PS placement was significantly longer in the SSC group. The increase in CBD diameter during the stenting period as well as the incidence of cholangitis at PS removal was significantly greater in the SSC group. Multivariate analysis identified long-term (≥301 days) PS placement and the increase in CBD diameter during the stenting period as independent factors for SSC formation. Long-term PS placement induces a risk of SSC formation in patients with CBD stones. The increase in diameter of CBD during the period of PS placement is a predictive factor for SSC formation in this situation.

TOKYO criteria: Standardized reporting system for endoscopic biliary stent placement

TOKYO criteria: Standardized reporting system for endoscopic biliary stent placement

Endoscopic biliary stent placement for anastomotic stricture following esophageal atresia repair in infant

Abstract Esophageal atresia is the most common congenital anomaly of the esophagus. Treatment optimally includes primary tension-free anastomosis of the upper and lower aspects of the esophagus. Distance between the upper and lower esophagus predisposes the anastomosis to tension, increasing the risk of anastomotic stricture. Esophageal stricture has historically been managed with repeated endoscopic balloon dilations. Multiple failed attempts at endoscopic balloon dilation requires surgical revision of the anastomosis. Stenting of esophageal stricture has been used in the adult population but has not been described for children. This case report demonstrates the placement of biliary stents in a 2-month-old infant with esophageal stricture following repair of a long gap Type C tracheoesophageal fistula. Successful stenting procedure averted the need for surgical revision.

Large Amoebic Liver Abscess with Persistent Biliary Fistula

ABSTRACT Liver abscess with biliary communication poses management problem if percutaneous drainage is performed. We report a case of large amoebic liver abscess (ALA) with jaundice. Prolonged high‑output bile drainage after percutaneous drainage of ALA showed suspicion of communication of abscess with intrahepatic bile ducts (biliary fistula). The same was managed successfully with endoscopic biliary stent placement with medical management.

Endoscopic biliary stent insertion through specialized duodenal stent for combined malignant biliary and duodenal obstruction facilitated by stent or PTBD guidance

Objectives: Endoscopic stenting for combined malignant biliary and duodenal obstruction is technically demanding. However, this procedure can be facilitated when there is guidance from previously inserted stent or PTBD tube. This study aimed to evaluate the feasibility and clinical success rate of endoscopic placement of biliary self-expandable metal stent (SEMS) through duodenal SEMS in patients with combined biliary and duodenal obstruction due to inoperable or metastatic periampullary malignancy.Materials and methods: A total of 12 patients with combined malignant biliary and duodenal stricture underwent insertion of biliary SEMS through the mesh of specialized duodenal SEMS from July 2012 to October 2016. Technical and clinical success rate, adverse events and survival after completion of SEMS insertion were evaluated.Results: The duodenal strictures were located in the first portion of the duodenum in four patients (Type I), in the second portion in three patients (Type II), and in the third portion in five patients (Type III). Technical success rate of combined metallic stenting was 91.7%. Insertion of biliary SEMS was guided by previously inserted biliary SEMS in nine patients, plastic stent in one patient, and PTBD in two patients. Clinical success rate was 90.9%. There were no early adverse events after the procedure. Mean survival period after combined metallic stenting was 91.9 days (range: 15–245 days).Conclusions: Endoscopic placement of biliary SEMS through duodenal SEMS is feasible with high success rates and relatively easy when there is guidance. This method can be a good alternative for palliation in patients with combined biliary and duodenal obstruction.

Single-step retrieval of a proximally migrated biliary stent.

biliary stent Endoscopic biliary stent placement is a well-established procedure for biliary drainage. However, it has been shown that approximately 5% of plastic stents placed in the biliary tract migrate proximally [1]. The endoscopic retrieval of a proximally migrated biliary stent is technically challenging and occasionally unsuccessful. Several techniques for retrieving proximally migrated plastic stents have been reported [2]. We report here a novel retrieval technique, in which a biliary dilation balloon was used to pull out in one step a trapped plastic stent, previously placed to treat an anastomotic biliary stricture in a patient with a liver transplant. A 0.035-inch guidewire (Acrobat; Cook Ireland Ltd., Limerick, Ireland) was passed through the 10-Fr, 9-cm proximally migrated stent (Cotton-Leung; Cook Ireland Ltd.) (● Fig.1a,b). A dilation balloon with a diameter of 4mm and a length of 4cm (Hurricane RX Biliary Balloon Dilatation Catheter; Boston Scientific, Marlborough, Massachusetts, USA) was coaxially inserted over the guidewire and advanced to the distal portion of the stent (● Fig.1c). It was then inflated to nominal pressure. The inflated balloon was anchored inside the stent, resulting in a firm, retrievable coaxial system. With the elevator of the scope (TJF-Q180V; Olympus Europa, Hamburg, Germany) completely opened, the balloon–stent system was withdrawn through the operative channel (diameter of 4.2mm) (● Fig.1d,e), with the guidewire left in situ for any further applications that might be needed (● Fig.1 f). Inspired by the timeless suggestions advanced by Chaurasia et al. in 1999 [2], we report an improved technique of retrieval with the use of a biliary dilation balloon instead of an extraction balloon. The technique results in the safe, single-step retrieval of a migrated stent from the bile duct directly into the endoscopist’s hand (● Fig.2), avoiding potential damage to the bile duct and the need for withdrawal of the duodenoscope.

Biliary leakage after urgent cholecystectomy: Optimization of endoscopic treatment.

To investigate the results of endoscopic treatment of postoperative biliary leakage occurring after urgent cholecystectomy with a long-term follow-up. This is an observational database study conducted in a tertiary care center. All consecutive patients who underwent endoscopic retrograde cholangiography (ERC) for presumed postoperative biliary leakage after urgent cholecystectomy in the period between April 2008 and April 2013 were considered for this study. Patients with bile duct transection and biliary strictures were excluded. Biliary leakage was suspected in the case of bile appearance from either percutaneous drainage of abdominal collection or abdominal drain placed at the time of cholecystectomy. Procedural and main clinical characteristics of all consecutive patients with postoperative biliary leakage after urgent cholecystectomy, such as indication for cholecystectomy, etiology and type of leakage, ERC findings and post-ERC complications, were collected from our electronic database. All patients in whom the leakage was successfully treated endoscopically were followed-up after they were discharged from the hospital and the main clinical characteristics, laboratory data and common bile duct diameter were electronically recorded. During a five-year period, biliary leakage was recognized in 2.2% of patients who underwent urgent cholecystectomy. The median time from cholecystectomy to ERC was 6 d (interquartile range, 4-11 d). Endoscopic interventions to manage biliary leakage included biliary stent insertion with or without biliary sphincterotomy. In 23 (77%) patients after first endoscopic treatment bile flow through existing surgical drain ceased within 11 d following biliary therapeutic endoscopy (median, 4 d; interquartile range, 2-8 d). In those patients repeat ERC was not performed and the biliary stent was removed on gastroscopy. In seven (23%) patients repeat ERC was done within one to fourth week after their first ERC, depending on the extent of the biliary leakage. In two of those patients common bile duct stone was recognized and removed. Three of those seven patients had more complicated clinical course and they were referred to surgery and were excluded from long-term follow-up. The median interval from endoscopic placement of biliary stent to demonstration of resolution of bile leakage for ERC treated patients was 32 d (interquartile range, 28-43 d). Among the patients included in the follow-up (median 30.5 mo, range 7-59 mo), four patients (14.8%) died of severe underlying comorbid illnesses. Our results demonstrate the great efficiency of the endoscopic therapy in the treatment of the patients with biliary leakage after urgent cholecystectomy.

Development of a novel and simple ex vivo biologic ERCP training model

Training and teaching of ERCP in biologic models has gained importance over the past decade. However, many existing models are expensive, are not widely available, or rely on live animals. We describe a novel and simple ex vivo, biologic model for hands-on teaching. Ex vivo porcine study. Experimental endoscopy unit. Experimental study using a custom-made ex vivo biologic ERCP simulation model. This model contains 2 new key concepts: (1) formation of a duodenal sweep by using the porcine stomach and (2) use of multiple neo-papillae for endoscopic sphincterotomy and biliary stent placement. The papilla was re-created with chicken heart, and the bile ducts were built from chicken trachea. Endoscopic sphincterotomy was performed by using a pull-type sphincterotome. Stenting was performed with Amsterdam-type plastic stents and guidewires. The following definitions were used to evaluate the model: successful implantation of the neo-papilla, stability of the neo-papilla to the neo-duodenum, successful removal of the neo-papilla, and damage to the model. The following endoscopic endpoints were evaluated: successful cannulation, cannulation time, difficulties in positioning the papilla, quality of the biliary sphincterotomy, and prosthesis placement. Procedure-related adverse events such as perforation were also assessed. Ten neo-papillae were consecutively used in 1 duodenalized stomach. The implantation and removal of the neo-papillae were easily and successfully accomplished in all 10 cases without any damage to the duodenalized stomach. The stability of the neo-papilla on the duodenal sweep was excellent in all cases. Cannulation, biliary sphincterotomy, and stent placement could be successfully performed in 100% of cases. There was no damage and were no technical problems with the model. There were no adverse events during endoscopy (ie, perforations, stent misplacement). Pilot study. Although further studies are necessary, this simple, novel ex vivo model appears useful for training in sphincterotomy and bile duct cannulation. Because the neo-papillae are interchangeable, repetitive sphincterotomies and other interventions can be performed using a single porcine model.

Managing malignant biliary obstruction in pancreas cancer: choosing the appropriate strategy.

Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) has shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depends on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, percutaneous or surgical treatments are appropriate. Endoscopic therapy or surgical approach can be used to treat concomitant duodenal and biliary obstruction.

Atypical Cause of Recurrent Cholangitis: Green Leafy Vegetables in the Biliary Tree

Purpose: Acute abdominal pain is a commonly reported symptom with a broad differential diagnosis. We present a challenging case with an interesting cause of cholangitis. A 61-year-old female presented to a gastroenterology clinic for right upper quadrant abdominal pain. Past medical history included a cholecystectomy secondary to symptomatic cholelithiasis 5 years prior. One year after her surgery, she began experiencing recurrent episodes of sharp right upper quadrant abdominal pain lasting 30 minutes at a time, and associated with fevers, nausea, and vomiting. She also endorsed progressive symptoms of early satiety, bloating, and regurgitation. The episodes were relieved by endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and biliary stent placement. However, there had been an increased frequency of these episodes and she underwent 5 ERCPs within the last 4 years. The most recent suggested proximal common bile duct strictures and the biliary stents were removed at the time. On presentation to our clinic, the patient was asymptomatic. A repeat ERCP was done to better understand her anatomy and determine the cause of her recurrent pain; findings demonstrated a widely patent sphincterotomy site. The biliary tree was swept with a 15-mm balloon and produced clear golden bile, followed by a celery-like material and fruit skins (Image 1). No stones or typical biliary sludge were seen and vegetable matter was confirmed by pathology. The patient was advised to eat a low-residue diet and has been free of recurrent exacerbations. Acute cholangitis commonly presents with right upper quadrant abdominal pain, fever, and jaundice. While it is often secondary to biliary obstruction or stasis, this patient presented with recurrent cholangitis due to obstruction by food particles. Repeat sphincterotomies had enlarged the diameter by which food particles can travel retrograde through the biliary tree. This was likely exacerbated by an underlying motility disorder that allowed food to linger in the biliary system.Figure

An Unexpected Encounter at the Hepatic Bifurcation

Clinical Presentation: A 45-year-old African-American female presented with melena and acute anemia 1 week after an endoscopic sphincterotomy and biliary stent placement for bile duct obstruction. An upper GI endoscopy revealed fresh blood and clots in the second portion of the duodenum, likely coming from the major papilla. After epinephrine injection, ERCP with selective biliary cannulation and balloon sweeps yielded fragments of stones, clots, and debris. On cholangiogram, a large filling defect was also at the hepatic bifurcation. The patient was discharged several days later in stable condition. The patient returned 3 months later with nausea, vomiting, and abdominal pain consistent with acute pancreatitis, with lipase >14,000, ALP >600, and normal bilirubin. An abdominal contrast-enhanced CT scan and ultrasound showed a 3 x 3-cm mass in the CBD extending into the left and right hepatic ducts with biliary dilation. The patient responded to conservative therapy but extensive investigation was continued to identify the cause of the biliary lesion. ERCP with cholangioscopy as well as EUS with FNA revealed the lesion to be a biliary intraductal papillary mucinous neoplasm (B-IPMN). Given her age and the possible malignant potential of B-IPMNs, the patient was referred for local resection, which was performed successfully. Discussion: B-IPMNs have been increasingly recognized over the last 10 years. Due to common embryologic origins, it was postulated that B-IPMN may behave similarily to pancreatic IPMNs. Others theorized that they may follow a more benign course similar to biliary papillomas. Analysis of histopathologic subtypes and type-specific mucin expression patterns of B-IPMN seem to indicate a closer link to the main duct pancreatic IPMN lesions, with associated malignant potential favoring primary resection as the preferred modality of treatment. Several recent studies revealed carcinoma association with B-IPMN lesions ranging between 68-83%, with 5 year survival of 38% after resection. Conclusion: Persistent evaluation of an underlying biliary abnormality first noted during ERCP and on repeat imaging tests to help explain the source of GI bleeding and acute pancreatitis led to the diagnosis of a biliary lesion with malignant potential. Biliary IPMN seem to be a unique clinical entity which warrants further evaluation which may lead to better understanding of biliary malignancies.

Endoscopic Stent Placement for Gastric Outlet Obstruction

Gastric outlet obstruction (GOO) is caused by either intrinsic or extrinsic obstruction of the pylorus or duodenum. The technical success rates of duodenal stenting for malignant GOO are > 90%, and 60–80% of patients are able to eat at least soft mechanical diets. Combined endoscopic biliary and duodenal self-expanding metal stent (SEMS) placement is safe and effective for palliation in malignant biliary and duodenal obstruction. This video manuscript describes endoscopic techniques in gastroduodenal stenting, procedure-related complications, and two commonly used duodenal SEMS: Evolution® Duodenal (Cook Medical) and WallFlex® Duodenal (Boston Scientific) stents. This article is part of an expert video encyclopedia.