Persistent Distal CBD Stricture with Marked Dilation of the Upstream Ducts and Friable GI Mucosa
Patient History
A 71-year-old female with a history of Roux-en-Y gastric bypass (RYGB, 1999) and decompensated cirrhosis with ascites, presented with severe obstructive jaundice with CT showing distal common bile duct (CBD) stricture with marked upstream dilation. Single-balloon enteroscopy-assisted ERCP (Figure 1) was performed that confirmed a distal CBD stricture and multiple 7Fr double-pigtail plastic stents were placed (Figure 2). Subsequently, she required a repeat procedure for stent replacement two months later. The patient’s ERCPs have been challenging given long-limb RYGB and friable GI mucosa with touch friability, and easy and excessive bleeding during procedures. Further work-up, including exploratory laparotomy, showed peritoneal metastasis with excisional biopsy of the peritoneal implant confirming metastatic adenocarcinoma.
Procedure
The patient presented for a repeat ERCP. The three previously placed pigtail stents were removed using a snare. Subsequently, the bile duct was cannulated using a guidewire and an extraction balloon catheter.A cholangiogram showed a persistent distal CBD stricture with marked dilation of the upstream ducts (Figure 3). Next, a transpapillary 6mm by 40mm uncovered biliary metal stent (Epic™ Biliary Endoscopic Stent System) was successfully placed through a single-balloon enteroscope over a 0.035in Dreamwire™ High Performance Guidewire (Figure 4,5,6).
Conclusion
This case highlights the utility of a biliary metal stent with a 6Fr delivery system and a 220cm long catheter enabling stent placement through an enteroscope during single-balloon enteroscopy assisted ERCPs for altered anatomy or long-limb ERCP procedures. In the past, these patients have required repeat, technically challenging, and prolonged procedures for plastic stent exchanges because only 7Fr plastic stents could be placed through the enteroscopes. Availability of a 6Fr metal stent does provide a valuable option for such patients with malignant stricture.
Tarun Rustagi, MD Assistant Professor of Medicine Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology University of New Mexico School of Medicine Albuquerque, New Mexico
