Management of large common bile duct (CBD) calculi is controversial. Endoscopic treatment is fraught with difficulty, particularly when stones are over one centimetre in diameter and the patient’s coagulation is deranged. Between 1988 and 1993, 56 patients have been managed by endoscopic retrograde cholangiopancreatography (ERCP) and stent placement as the initial treatment for large CBD calculi. Complete follow up has been possible in 50 cases (89.3%). The median age was 73.5 years (range 29-92) and primary presenting symptoms were jaundice (n = 39), cholangitis (n = 6) or abdominal pain (n = 5). Median bilirubin was 99 mumol/L (range 7-926) and 60% of the patients had deranged clotting with a median thrombotest of 61%. Stones ranged in size from 0.9 to 4.5 cm (median 1.6 cm). Treatment was with a 7F ‘pigtail’ stent in 39 cases and a 10F straight stent in 11 patients. Morbidity occurred in 12% of cases with two deaths (4%). Stents remained in place for a median of 1 month (range 0.2-59). Definitive treatment of CBD stones, once the jaundice and sepsis had settled, involved surgery in 24 patients and repeat ERCP with sphincterotomy +/- mechanical lithotripsy in 17 cases. Nine patients remain alive and well with their stents still in place. Initial management of large CBD calculi by ERCP and stent placement carries a low morbidity and mortality and is a useful adjunct in the management of a difficult clinical problem.
Studies in the past have explored risk factors and success rates of ERCP biliary metallic stenting in patients with an already existing SEMS due to duodenal obstruction. A study done by Yao et al showed that for malignant duodenal stricture with SEMS, ERCP with biliary metallic stenting was safe and effective. The study showed that 60 mm duodenal stent had ERCP success rate of 88% as compared to longer 80-90 mm stents that had a success rate of 18.2%. Furthermore, type 1 (GOO above the ampulla) and 2 (GOO at the level of ampulla) GOO with stricture length greater than 3.5 cm had lower ERCP success rates than strictures with a length less than 3.5 cm. GOO type 3 (GOO distal to the ampulla) had 100% ERCP success rate. To summarize, a stricture length of > 3.5 cm and duodenal stent length of 80-90 mm were independent risk factors for the failure of ERCP in patients with prior SEMS in the duodenum.
For patients suffering from both biliary and duodenal obstruction, endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the treatment of choice. ERCP through an already existing duodenal prosthesis is an uncommon procedure and furthermore no studies have reported installing a covered metal stent onto an already existing bare metal stent in the common bile duct (CBD). We describe a rare case of a stent-in-stent dilatation of the CBD through an already existing self-expanding metal stent in the second part of duodenum for the patient presenting with jaundice in setting of biliary and duodenal obstruction from pancreatic adenocarcinoma. The biliary obstruction was relieved with a decrease in bilirubin levels post-stenting.
Esophagogastroduodenoscopy findings 15 mo after initial endoscopic retrograde cholangiopancreatography. A: Duodenal mass visualized encroaching in the lumen of 2 nd portion of duodenum; B: SEMS placed over the area of the encroaching mass in the 2 nd portion of the duodenum. SEMS: Self expanding metal stent.
We have seen that patients who have GOO from duodenal, ampullary or pancreatic malignancy frequently develop biliary obstruction which may require either surgical or endoscopic intervention. Usually we can divide patients into any one of the following three categories depending on the chronological order of the obstruction, i.e., biliary obstruction before the duodenal obstruction, concurrent biliary and duodenal obstruction or biliary obstruction after duodenal obstruction. In most cases duodenal obstruction happens later during the disease course[4,6,7]. Further classification can be done based on anatomic location of the duodenal obstruction in relation to the papilla. GOO type I has duodenal obstruction before the papilla, type II involves the papilla and type III is post papilla. GOO-II is the most difficult to manage via endoscopic stenting whereas GOO-III is the easiest to manage[4,6,7].
Initial endoscopic retrograde cholangiopancreatography findings. A: Area of the papilla visualized in the 2 nd part of the duodenum; B: CBD malignant stricture visualized in the distal CBD with aid of fluoroscopy during ERCP; C: Cannulating the CBD; D: BMS interested into the CBD visualized protruding from the papilla in the 2 nd portion of the duodenum. CBD: Common bile duct; ERCP: Endoscopic retrograde cholangiopancreatography; BMS: Bare metal stent.
Another way to relieve CBD obstruction is endoscopic ultrasound-guided biliary drainage (EUS-BD). This is a relatively new technique in which a fistula is made between the biliary duct and intestine. This method has been shown to be equivalent to percutaneous biliary drainage (PTBD) and is used as a salvage procedure after ERCP has failed and can be utilized in patients with or without duodenal stenosis[13,14]. A study done by Dhir et al in patients that failed one or more ERCP attempts revealed that the short-term outcome of EUS-BD were comparable to that of ERCP. Similarly, another study done by Moon et al showed that EUS-BD is a therapeutic option when ERCP approach through the lumen of the duodenal SEMS fails. EUS-BD could be performed through the duodenum or through an existing mesh of a duodenal stent.
Endoscopic retrograde cholangiopancreatography to place a subsequent 2 nd common bile duct stent through an existent duodenal stent. A: CBD BMS and duodenal prosthesis (SEMS) visualized on the 2 nd ERCP before inserting the CMS into the CDB; B: Endoscopic visualization of the papilla site filled with debris and tumor invasion; C: CMS deployed on the existing BMS in the CBD through the SEMS in the duodenum; D: Endoscopic visualization of the CBD stent protruding through the papilla in the 2 nd portion of duodenum after the completion of the 2 nd ERCP. CBD: Common bile duct; BMS: Bare metal stent; SEMS: Self expanding metal stent; CMS: Covered metal stent; ERCP: Endoscopic retrograde cholangiopancreatography.
During hospitalization in October 2017, esophagogastroduodenoscopy (EGD) showed retained fluid in the gastric body. There was a malignant appearing, intrinsic moderate stenosis in the second part of the duodenum suggesting type II GOO. The biopsy showed active duodenitis with gastric metaplasia and inflammatory exudates consistent with an ulcer. This area was traversed and stented with a 22 mm × 12 cm WallFlex stent using fluoroscopic guidance (Figure (Figure2). 2 ). Three days later the patient underwent repeat EGD for acute, new onset jaundice and failure to respond to medical treatment. Endoscopic evaluation showed a patent WallFlex SEMS without any migration. Endoscopic retrograde cholangiopancreatography (ERCP) with fluoroscopy was simultaneously performed and confirmed the previously placed duodenal and biliary stents. The scope was passed through the duodenal stent with precision fluoroscopic guidance and the bile duct containing the previously placed CBD stent (10 mm × 6 cm BMS) was deeply cannulated with the short-nosed traction auto-tome and guidewire. Contrast was injected and ductal flow of contrast was adequate. Contrast extended to the main bile duct; however, the lower third of the main bile duct, the middle third of the main bile duct and CBD was completely obstructed by what appeared to be a mass with tumor ingrowth (the same mass that had eroded and obstructed the duodenum previously). A 0.035-inch × 260 cm straight guidewire (Hydra Jag wire) was passed into the biliary tree. Dilatation of the duodenal stent side was accomplished with a Hurricane 10 mm × 4 cm balloon dilator and was successful. One 10 mm × 4 cm covered metal stent (CMS) was placed 3 cm into the previous 10 mm × 6 cm BMS within the CBD. Bile and clear fluid flowed through the stent and the stent was in proper position (Figure (Figure3). 3 ). The patient’s total bilirubin dropped from 5.7 to 3.5 the next day. Four days later, his total bilirubin was 1.5, his acute symptoms had resolved and he was discharged from the hospital.