Benign biliary strictures are traditionally managed by placement of either plastic
stents or, more recently, fully covered self-expandable metal stents (FcSEMs) [1]
[2]. Though effective, plastic stents need replacement every 2 – 3 months, whereas FcSEMs
need removal in 6 – 9 months, both requiring repeat endoscopic retrograde cholangiopancreatography
(ERCP). Surgically altered anatomy makes ERCP challenging, and these patients require
either a percutaneous approach or balloon-assisted endoscopy with specially designed
biliary instruments.
An 80-year-old man presented with cholangitis. He had previously undergone gastrectomy
with Roux-en-Y gastrojejunostomy for gastric cancer. Imaging revealed common bile
duct (CBD) stones and a distal CBD stricture ([Fig. 1]). As conventional ERCP was not possible, he underwent percutaneous transhepatic
biliary drainage, radiological sphincteroplasty, and stone removal. However, he continued
to have recurrent cholangitis when the external drain was clamped, thus requiring
long-term external drainage. Following multidisciplinary team discussion, diagnostic
percutaneous cholangioscopy followed by placement of biodegradable stents was planned.
Fig. 1 Distal common bile duct stricture (arrow).
An initial cholangiogram via the indwelling biliary drain revealed a focal distal
CBD stricture ([Video 1]). The biliary drain was exchanged for an 8-Fr sheath, followed by the insertion
of two 180 cm wires. The cholangioscope was passed over one of the wires to visualize
the stricture, which looked benign. SpyBite (Boston Scientific, Marlborough, Massachusetts,
USA) biopsies were taken. Two 8-Fr biodegradable stents were then placed. The biopsies
did not show any evidence of malignancy and liver biochemistry returned to normal.
Magnetic resonance imaging after 6 months showed resolution of the stricture with
some degraded stent particles. Another scan after 3 months revealed a clear duct ([Fig. 2]).
Video 1 Common bile duct stricture and placement of biodegradable stents.
Fig. 2 Resolved common bile duct stricture (arrow).
Biodegradable stents are a novel alternative to conventional stents in highly selected
cases, and can be placed both endoscopically or percutaneously. They are made of polydioxanone
and have been licensed for use in the esophagus and lower gastrointestinal tract [3]
[4]. They degrade via hydrolysis with variable degradation times: slow (11 weeks), medium
(20 days), and fast (12 days). They have a helicoidal shape to facilitate bile flow
on the outer surface while supporting ductal flow. There have been no significant
complications other than a few reported cases of cholangitis due to degraded stent
particles.
This case demonstrates the importance of considering novel biodegradable stents in
cases of biliary obstruction with altered surgical anatomy. Biodegradable stents offer
the improved patency of metal stents, but obviate the need for repeat, complex interventions
required to remove or exchange them.
Endoscopy_UCTN_Code_TTT_1AR_2AZ
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
