Late occlusion of the biliary metal stent in a patient with benign biliary stricture

Introduction: Laparoscopic cholecystectomy has some adventages over open surgery, but the incidence of bile duct injury became more frequent. The resulting biliary strictures can be definitely treated by insertion of multiple plastic stents. The metal stents should be avoided in such cases.

Case: A 49 year old women was admitted because of obstructive jaundice. She had been operated on by laparoscopy for biliary stone disease 7 years ago. A bile duct injury occurred which was corrected during consecutive laparotomy. After half a year obstructive jaundice developed again and the patient was treated by percutaneously placed biliary metal stent. For 7.5 years the patient did well, then the jaundice returned. An unsuccessful percutaneous transhepatic drainage was attempted than, the ERCP revealed occlusion of the metal stent complicated with cholangitis. We performed EST and after dilation we placed a nasobiliary catheter over the stent occlusion caused by debris and tissue ingrowth. Next day a gastrointestinal bleeding occurred from the proximal end of the papillotomy. At the urgent ERCP a 10 French biliary stent was inserted into the left hepatic duct. The bleeding stopped and on the third day a second 10 French stent was inserted into the right hepatic duct. The jaundice disappeared and the patient is symptom free for more than 4 months.

Summary: Use of metal stents in benign biliary strictures in patients with long life expectancy has significant disadvantages, although in our case more than 7.5 years passed until the occlusion has appeared. Endoscopic insertion of plastic stents inside the occluded metal one can provide the only solution. Unfortunately this patient needs regular stent exchanges during her whole life, while primary multiple plastic stenting would offer definitive healing presumably.