Abbreviations:BEBS (balloon expandable biodegradable stent), RHD (right hepatic duct), FCSEMS (fully covered self-expandable metal stent)
A 26-year-old woman had a complicated laparoscopic cholecystectomy 12 months earlier that led to biliary stricture (Fig. 1). She required multiple ERCP sessions with balloon dilation and incremental plastic stents over the past year, without resolution of biliary stricture.
At ERCP (using an EVS JF 180; Olympus, Tokyo, Japan), blocked biliary plastic stents were removed using a snare (Video 1, available online at www.giejournal.org). On cholangiogram, Multiple soft stones seen on cholangiogram were cleared with balloon sweep. The perihilar stricture (involving the common hepatic duct and bifurcation of both the right and left hepatic ducts) was persistent, with an overlying surgical clip (Fig. 2).
A novel biliary balloon expandable biodegradable stent (BEBS) (UNITY-B; AMG International, Winsen, Germany) was considered for the persistent perihilar benign biliary stricture. The BEBS is a radiolucent stent tightly crimped over a deflated balloon (Figs. 3 and 4). This stent is currently not approved by the U.S. Food and Drug Administration.
Two 0.025-inch guidewires (Visiglide, Olympus America, Center Valley, Penn) were passed into the left and right hepatic ducts. After accurate positioning of the stent assembly was confirmed using the radio-opaque markers at both ends, the underlying balloon was inflated with contrast. This was followed by placement of a 10-mm caliber (57-mm-long) BEBS across the approved left hepatic duct stricture after dilation of the balloon. The BEBS is radiolucent except for 2 radio-opaque markers each at both ends (Fig. 5). Another guidewire was negotiated through the mesh of the biodegradable stent using the prior right hepatic duct (RHD) wire for proper direction (Fig. 6). The latter was removed after successful passage of through-the-stent wire. The RHD stricture was dilated with a standard balloon (8 mm, Titan, Cook Medical LLC, Bloomington, Ind, USA). This was followed by similar placement of an 8-mm caliber BEBS (57 mm length) through the mesh of the biodegradable stent placed in the left hepatic duct (in a stent-in-stent “Y shaped” configuration). Accurate positioning of both BEBSs was confirmed on fluoroscopy showing the end markers and aerobilia (Fig. 7). Mild periprocedural pain was managed with analgesics on an outpatient basis. A CT scan performed 24 hours later confirmed that the bilateral stents were open (Fig. 8). The patient was comfortable at 8 weeks after the procedure and has normal biochemistry (Video 1, available online at www.giejournal.org).
Biodegradable stents with different stent designs have been used for various indications (after liver transplant, after Whipple with biliary anastomoses for chronic pancreatitis) to prevent bile leaks or in patients with equivocal common biliary duct clearance.
- Lakhtakia S.
- Yaacob N.
- Jarmin R.
- et al.
339 novel bio-degradable stent in patients with biliary or pancreatic obstruction: a pilot study to assess clinical efficacy and safety [abstract].
Gastrointest Endosc. 2018; 87: AB71-AB72
2Such biliary stents have efficacy for benign biliary strictures.
- Repici A.
- Vleggaar F.P.
- Hassan C.
- et al.
Efficacy and safety of biodegradable stents for refractory benign esophageal strictures: the BEST (Biodegradable Esophageal Stent) study.
Gastrointest Endosc. 2010; 72: 927-934
- Siiki A.
- Rinta-Kiikka I.
- Sand J.
- et al.
A pilot study of endoscopically inserted biodegradable biliary stents in the treatment of benign biliary strictures and cystic duct leaks.
Gastrointest Endosc. 2018; 87: 1132-1137
Benign common biliary duct strictures can be managed efficiently endoscopically by serial placement of multiple plastic stents or a single fully covered self-expandable metal stent (FCSEMS). However, complex benign hilar biliary strictures pose a greater challenge, with options including bilateral multiple plastic stents placed over several ERCP procedures, a combination of plastic on one side and an FCSEMS on the contralateral side, and, rarely, a bilateral FCSEMS.
4The advantage of the BEBS is continuous dilation of the stricture with remodeling of the bile duct around the expanded stent without the need for additional procedure(s) to remove or replace the stent. This case report presents the use of the novel biliary BEBS for postcholecystectomy perihilar benign biliary stricture. An additional interesting aspect is that a BEBS can be placed stent-in-stent (Y-shaped-configuration), which may be useful for biliary drainage in complex benign or indeterminate biliary strictures.
- Devière J.
- Nageshwar Reddy D.
- Püspök A.
- et al.
Successful management of benign biliary strictures with fully covered self-expanding metal stents.
Gastroenterology. 2014; 147: 385-395
Supported by a Robert W. Summers grant from the American Society for Gastrointestinal Endoscopy.
All authors disclosed no financial relationships.
- Video 1
Bilateral balloon expandable biodegradable stent (Y-stent) for postcholecystectomy perihilar biliary stricture.
- 339 novel bio-degradable stent in patients with biliary or pancreatic obstruction: a pilot study to assess clinical efficacy and safety [abstract].Gastrointest Endosc. 2018; 87: AB71-AB72
- Efficacy and safety of biodegradable stents for refractory benign esophageal strictures: the BEST (Biodegradable Esophageal Stent) study.Gastrointest Endosc. 2010; 72: 927-934
- A pilot study of endoscopically inserted biodegradable biliary stents in the treatment of benign biliary strictures and cystic duct leaks.Gastrointest Endosc. 2018; 87: 1132-1137
- Successful management of benign biliary strictures with fully covered self-expanding metal stents.Gastroenterology. 2014; 147: 385-395
Published online: January 07, 2021
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© 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.
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