Biliary - Luminex Biliary Stent
Comments: This 70 year old woman presents with painless jaundice and pruritis. She was diagnosed with unresectable gallbladder cancer about 4 months prior. MRI shows dilated ducts in R and L lobes, neither of which is atrophic. MRCP shows complex obstruction at takeoff of R anterior and posterior sectoral ducts (segments V-VIII). The left main duct is intact, at least segments II and III, as these rotated views confirm. This is thus a Bismuth III tumor. Our target for selective access and drainage will be the left hepatic duct, staying out of right as this would require multiple stents with possible failure and doubtful additional benefit.
Cannulation requires a fully flexed papillotome (Dome tip DASH, Wilson Cook) due to somewhat compressed duodenum from the tumor. Contrast enters the bile duct and a wire is passed far enough to perform biliary sphincterotomy. Sphincterotomy is done to guarantee future duct access, and also we believe, although there are no data, that it reduces risk of pancreatitis from large transpapillary biliary stents, especially in patients with normal pancreatic ducts.
Now we try to find a path through the tumor. Initially we thought this was gallbladder, and directed a 035 glidewire (Boston Scientific) in a different direction. Although it heads appropriately Northwards, it doesn’t necessarily seem to be in a duct. Minimal contrast injection around the wire reveals that the wire is outside the bile duct lumen.
We turn our attention back the other direction, and flip the glidewire into what seems to clearly be left hepatic duct. Another look at the MRCP confirms we are in the correct direction.
Very importantly, we do not inject contrast until we have advanced our cannula deep into the left duct, so we only fill the intercommunicating branches that a single stent will drain. We stop short of back-filling any right hepatic duct branches.
After exchanging to a more stable standard guidewire, a dilating balloon is used to find and dilate the stricture.
Our first stent is a 8mm x 8 cm long Luminexx open mesh stent (Conmed). We use wide mesh stents in hilar tumors in case we ever need to access through the side of the mesh into undrained ducts. The stent is carefully deployed from above the stricture to out the papilla.
We can see that the stent has expanded nicely at both ends. However we are concerned that the top of the stent is angled into the takeoff of the left hepatic duct, which might pose a future problem if tumor overgrows the top of the stent, or there is reactive hyperplasia.
Therefore we overlap a second identical stent deep into L hepatic duct.
The patient is sent home after a few hours observation and does well.
| Contributed by: |
Martin L. Freeman, M.D. Professor of Medicine Hennepin County Medical Center University of Minnesota |
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Citation: Freeman, ML (Feb 16 2006). Biliary - Luminex Biliary Stent. The DAVE Project. Retrieved Sep, 9, 2010, from http://daveproject.org/viewfilms.cfm?film_id=311 Times viewed since Feb 2006: 5683 |
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