Clinical Radiology(1992) 45, 46 47
Case Report: Broken Intracholedochal Stent R. Z I S S I N , B. N O V I S * a n d Z. R U B I N S T E I N ' ~
Departments of Radiology and *Gastroenterology, Meir Hospital, KJitr Saba, and tThe Chaim Sheba Hospital, Ramat Gan, and Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel Decompression of biliary obstruction by an internal stent is well accepted in patients with malignant strictures. Less frequent is the use of this technique for the management of benign disorders. In the latter situation the biliary stent may be left in place for a very long period. We report a rare complication of a broken intracholedochal stent which had been inserted for a benign post-operative stricture. Zissin, R., Novis, B. & Rubinstein, Z. (1992). Clinical
Radiology 45, 4 6 - 4 7 . C a s e R e p o r t : B r o k e n I n t r a c h o l e d o c h a l S t e n t
P e r c u t a n e o u s t r a n s h e p a t i c i n s e r t i o n o f i n t e r n a l stents for d e c o m p r e s s i o n o f biliary o b s t r u c t i o n has n o w b e c o m e a w i d e l y a c c e p t e d t r e a t m e n t for p a t i e n t s w i t h h e p a t o b i l i a r y d i s o r d e r s ( M u e l l e r et al., 1982). M o r e recently, e n d o s c o p i c i n s e r t i o n o f biliary stents has b e e n p e r f o r m e d (Siegel, 1984). T h e s e n o n - o p e r a t i v e t e c h n i q u e s are m a i n l y used for p a l l i a t i v e d r a i n a g e in m a l i g n a n t c o n d i t i o n s o r for preo p e r a t i v e d e c o m p r e s s i o n . In these s i t u a t i o n s the stent is left in p l a c e for a r e l a t i v e l y s h o r t p e r i o d o f tfme (Siegel, 1984). H o w e v e r , in c e r t a i n b e n i g n c o n d i t i o n s i n s e r t i o n o f a biliary i n t e r n a l p r o s t h e s i s is i n d i c a t e d a n d t h e r e are n o w many patients who depend upon a functioning long-term i n - d w e l l i n g c a t h e t e r ( G a l l a c h e r et al., 1985; J o s e p h et al., 1986). A m o n g the c o m m o n c o m p l i c a t i o n s o f c h r o n i c biliary s t e n t i n g are c a t h e t e r d i s l o d g m e n t , t u b e o b s t r u c t i o n a n d c h o l a n g i t i s (Siegel, 1984). W e r e p o r t the r a r e c o m p l i c a t i o n o f a b r o k e n i n t r a c h o l e d o c h a l stent, w h i c h was i n s e r t e d for a b e n i g n b i l i a r y lesion.
CASE REPORT A 53-year-old man was admitted to hospital with recurrent episodes of ascending cholangitis. His past history included a vagotomy and pyloroplasty performed for a bleeding duodenal ulcer, 5 years previously. Inadvertent surgical injury of the common bile duct (CBD) during the operation was repaired by suture of the common bile duct and temporary insertion of a T-drain. One month later the patient underwent an uneventful elective cholecystectomy. However, several months later he was readmitted to hospital because of acute cholangitis. Endoscopic cannulation of the CBD failed and he was referred for percutaneous transhepatic cholangiography (PTC). The PTC showed a short CBD stricture, which was considered to be post-traumatic and therefore benign. Following balloon dilatation a 14 F internal biliary stent was inserted, with the distal end situated in the duodenum. For 4 years the patient was free of all biliary symptoms and failed to return for examination at the follow-up clinic. In July 1989 he was again admitted to hospital for evaluation of jaundice and fever. A plain abdominal film showed two parallel fragments of the stent in the right upper quadrant. Endoscopic retrograde cholangiopancreatinography (ERCP) demonstrated two broken pieces of stent and numerous stones within the dilatated CBD proximal to a short narrow segment (Fig, 1). A sphincterotomy was performed, followed by removal of both fragments of the stent, as well as the calculi. When seen 6 weeks later at the clinic the patient was asymptomatic and his liver function studies had returned to normal. However, 6 months later he had an episode of fever and Correspondence to: Dr R. Zissin, Department of Radiology, Meir Hospital, 44281 Kfar Saba, Israel.
Fig. 1 ERCP
two pieces of broken stent within a dilatated CBD.
BROKEN INTRACHOLEDOCHAL STENT
Fig. 2 ERCP 15 months later. A short stricture at distal CBD with proximal dilatation. chills. A repeat ERCP showed a short stricture in the distal CBD with sludge proximally. Balloon dilatation was again performed and the sludge was removed. Repeat ERCP 15 months after removal of the stent again demonstrated a stricture of the distal choledochus. On this occasion it was dilatated with a 12 mm balloon, but without total obliteration of the stenotic area (Fig. 2).
DISCUSSION Interventional percutaneous transhepatic procedures for decompression of the biliary tract are now widely performed for the definitive or palliative treatment of cholestatic disorders. O f particular significance is the technique for insertion of endoprosthesis which provides a safe and effective palliation in patients with unresectable malignant disease (Mueller et al., 1982; Siegel, 1984). However, there are benign conditions that can be treated by such non-operative management. Benign post-operative biliary strictures are one of these indications (Gallacher et al., 1985; Mueller et al., 1986; Williams et al., 1987). Post-operative biliary strictures, although uncommon, cause considerable morbidity. In 95% of the cases it is a complication of elective cholecystectomy. Operative repair is associated with a significant recurrence rate with subsequent morbidity and even mortality. Recently it has been replaced by the combined percutaneous technique of balloon dilatation and placing a temporary stent across the stricture in order to allow healing around the endoprosthesis. However, the need for and duration of
47
placing a stent across a stricture after dilatation are still controversial. It is doubtful if there is a correlation between a successful outcome and prolonged stenting. Several authors remove a drainage catheter 24 h after a successful dilatation (Mueller et al., 1986). Others recommend that stenting should be done for a minimum of 6 months before removal and, if required, the stricture should be redilatated and changed at 4-6 month intervals (Gallacher et al., 1985; Williams el al., 1987). Our practice usually follows the latter policy. Unfortunately, in this case the patient failed to attend for periodic follow up as he was completely asymptomatic. This resulted in his endoprosthetic stent being left in place for 4 years until jaundice and fever recurred. Two of the common reported complications of long term percutaneous biliary drainage are cholangitis due to blockage of the endoprosthesis, and dislodgment of the catheter (Mueller et al., 1982, 1986). As far as we know there are no reported cases of a biliary endoprosthetic stent having broken within the CBD. The above case demonstrates this rare complication which may be asymptomatic or can cause symptoms of ascending cholangitis. As the patient was not examined while symptom-free, the exact duration of stent patency, or the time of stent fracture, are not clear. We have subsequently had a second patient, in whom an intracholedochal stent was inserted endoscopically 3 years previously for retained choledochal stones and in whom a broken stent was found and removed at ERCP. Radiographically controlled drainage procedures are likely to become more commonplace, increasing the necessity for follow-up and care of the drainage catheters. Our recommendation in cases of chronic biliary stents is to perform an ultrasound examination and to obtain a plain abdominal film whenever symptoms suggest that stent occlusion has developed, in order to recognize this rare complication. Because of its radio-opacity, a fractured or displaced stent is easily detectable on the plain film, although better demonstration of its relationship to the biliary tree is achieved by ERCP. In cases where a broken catheter is found, speedy and efficient removal of the broken stent, and of the sludge that develops around the fragments, by E R C P using either a Dormia basket or Fogarty balloon catheter following an endoscopic sphincterotomy, is essential. In some cases it may also be necessary to replace the biliary stent. In this case the removal of the broken stent and sludge and balloon dilatation of the stricture were all that was required. REFERENCES Gallacher, DJ. Kadir, S, Kaufman, SL, Mitchell, SE, Kinnison, ML & Chang, R (1985). Nonoperative management of benign postoperative biliary strictures. Radiology, 156, 625 629. Joseph, PK, Bizer, LS, Sprayregen, SS & Gliedman, ML (1986). Percutaneous transhepatic biliary drainage. Results and complications in 8l patients. Journal of the American Medical Association, 255, 2763-2767. Mueller, PR, van Sonnenberg, E & Ferrucci, JT (1982). Percutaneous biliary drainage: technical and catheter related problems in 200 procedures. American Journal of Roentgeno/ogy, 138, 17 23. Mueller, PR, van Sonnenberg, E, Ferruci, ,IT, Weyman, P J, Butch, R J, Malt, RA et aL (1986). Biliary stricture dilatation: multieenter review of clinical management in 73 patients. Radiology, 160, 17 20. Siegel, JH (1984). Interventional endoscopy in diseases of the biliary trcc and pancreas. Mount Sinai Journal of Medicine, 51,535-542. Williams, H J, Bender, CE & May, G R (1987). Benign post-operative biliary strictures: dilation with fluoroscopic guidance. Radiology, 163, 629 634.
Case Report: Broken Intracholedochal Stent R. Z I S S I N , B. N O V I S * a n d Z. R U B I N S T E I N ' ~
Departments of Radiology and *Gastroenterology, Meir Hospital, KJitr Saba, and tThe Chaim Sheba Hospital, Ramat Gan, and Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel Decompression of biliary obstruction by an internal stent is well accepted in patients with malignant strictures. Less frequent is the use of this technique for the management of benign disorders. In the latter situation the biliary stent may be left in place for a very long period. We report a rare complication of a broken intracholedochal stent which had been inserted for a benign post-operative stricture. Zissin, R., Novis, B. & Rubinstein, Z. (1992). Clinical
Radiology 45, 4 6 - 4 7 . C a s e R e p o r t : B r o k e n I n t r a c h o l e d o c h a l S t e n t
P e r c u t a n e o u s t r a n s h e p a t i c i n s e r t i o n o f i n t e r n a l stents for d e c o m p r e s s i o n o f biliary o b s t r u c t i o n has n o w b e c o m e a w i d e l y a c c e p t e d t r e a t m e n t for p a t i e n t s w i t h h e p a t o b i l i a r y d i s o r d e r s ( M u e l l e r et al., 1982). M o r e recently, e n d o s c o p i c i n s e r t i o n o f biliary stents has b e e n p e r f o r m e d (Siegel, 1984). T h e s e n o n - o p e r a t i v e t e c h n i q u e s are m a i n l y used for p a l l i a t i v e d r a i n a g e in m a l i g n a n t c o n d i t i o n s o r for preo p e r a t i v e d e c o m p r e s s i o n . In these s i t u a t i o n s the stent is left in p l a c e for a r e l a t i v e l y s h o r t p e r i o d o f tfme (Siegel, 1984). H o w e v e r , in c e r t a i n b e n i g n c o n d i t i o n s i n s e r t i o n o f a biliary i n t e r n a l p r o s t h e s i s is i n d i c a t e d a n d t h e r e are n o w many patients who depend upon a functioning long-term i n - d w e l l i n g c a t h e t e r ( G a l l a c h e r et al., 1985; J o s e p h et al., 1986). A m o n g the c o m m o n c o m p l i c a t i o n s o f c h r o n i c biliary s t e n t i n g are c a t h e t e r d i s l o d g m e n t , t u b e o b s t r u c t i o n a n d c h o l a n g i t i s (Siegel, 1984). W e r e p o r t the r a r e c o m p l i c a t i o n o f a b r o k e n i n t r a c h o l e d o c h a l stent, w h i c h was i n s e r t e d for a b e n i g n b i l i a r y lesion.
CASE REPORT A 53-year-old man was admitted to hospital with recurrent episodes of ascending cholangitis. His past history included a vagotomy and pyloroplasty performed for a bleeding duodenal ulcer, 5 years previously. Inadvertent surgical injury of the common bile duct (CBD) during the operation was repaired by suture of the common bile duct and temporary insertion of a T-drain. One month later the patient underwent an uneventful elective cholecystectomy. However, several months later he was readmitted to hospital because of acute cholangitis. Endoscopic cannulation of the CBD failed and he was referred for percutaneous transhepatic cholangiography (PTC). The PTC showed a short CBD stricture, which was considered to be post-traumatic and therefore benign. Following balloon dilatation a 14 F internal biliary stent was inserted, with the distal end situated in the duodenum. For 4 years the patient was free of all biliary symptoms and failed to return for examination at the follow-up clinic. In July 1989 he was again admitted to hospital for evaluation of jaundice and fever. A plain abdominal film showed two parallel fragments of the stent in the right upper quadrant. Endoscopic retrograde cholangiopancreatinography (ERCP) demonstrated two broken pieces of stent and numerous stones within the dilatated CBD proximal to a short narrow segment (Fig, 1). A sphincterotomy was performed, followed by removal of both fragments of the stent, as well as the calculi. When seen 6 weeks later at the clinic the patient was asymptomatic and his liver function studies had returned to normal. However, 6 months later he had an episode of fever and Correspondence to: Dr R. Zissin, Department of Radiology, Meir Hospital, 44281 Kfar Saba, Israel.
Fig. 1 ERCP
two pieces of broken stent within a dilatated CBD.
BROKEN INTRACHOLEDOCHAL STENT
Fig. 2 ERCP 15 months later. A short stricture at distal CBD with proximal dilatation. chills. A repeat ERCP showed a short stricture in the distal CBD with sludge proximally. Balloon dilatation was again performed and the sludge was removed. Repeat ERCP 15 months after removal of the stent again demonstrated a stricture of the distal choledochus. On this occasion it was dilatated with a 12 mm balloon, but without total obliteration of the stenotic area (Fig. 2).
DISCUSSION Interventional percutaneous transhepatic procedures for decompression of the biliary tract are now widely performed for the definitive or palliative treatment of cholestatic disorders. O f particular significance is the technique for insertion of endoprosthesis which provides a safe and effective palliation in patients with unresectable malignant disease (Mueller et al., 1982; Siegel, 1984). However, there are benign conditions that can be treated by such non-operative management. Benign post-operative biliary strictures are one of these indications (Gallacher et al., 1985; Mueller et al., 1986; Williams et al., 1987). Post-operative biliary strictures, although uncommon, cause considerable morbidity. In 95% of the cases it is a complication of elective cholecystectomy. Operative repair is associated with a significant recurrence rate with subsequent morbidity and even mortality. Recently it has been replaced by the combined percutaneous technique of balloon dilatation and placing a temporary stent across the stricture in order to allow healing around the endoprosthesis. However, the need for and duration of
47
placing a stent across a stricture after dilatation are still controversial. It is doubtful if there is a correlation between a successful outcome and prolonged stenting. Several authors remove a drainage catheter 24 h after a successful dilatation (Mueller et al., 1986). Others recommend that stenting should be done for a minimum of 6 months before removal and, if required, the stricture should be redilatated and changed at 4-6 month intervals (Gallacher et al., 1985; Williams el al., 1987). Our practice usually follows the latter policy. Unfortunately, in this case the patient failed to attend for periodic follow up as he was completely asymptomatic. This resulted in his endoprosthetic stent being left in place for 4 years until jaundice and fever recurred. Two of the common reported complications of long term percutaneous biliary drainage are cholangitis due to blockage of the endoprosthesis, and dislodgment of the catheter (Mueller et al., 1982, 1986). As far as we know there are no reported cases of a biliary endoprosthetic stent having broken within the CBD. The above case demonstrates this rare complication which may be asymptomatic or can cause symptoms of ascending cholangitis. As the patient was not examined while symptom-free, the exact duration of stent patency, or the time of stent fracture, are not clear. We have subsequently had a second patient, in whom an intracholedochal stent was inserted endoscopically 3 years previously for retained choledochal stones and in whom a broken stent was found and removed at ERCP. Radiographically controlled drainage procedures are likely to become more commonplace, increasing the necessity for follow-up and care of the drainage catheters. Our recommendation in cases of chronic biliary stents is to perform an ultrasound examination and to obtain a plain abdominal film whenever symptoms suggest that stent occlusion has developed, in order to recognize this rare complication. Because of its radio-opacity, a fractured or displaced stent is easily detectable on the plain film, although better demonstration of its relationship to the biliary tree is achieved by ERCP. In cases where a broken catheter is found, speedy and efficient removal of the broken stent, and of the sludge that develops around the fragments, by E R C P using either a Dormia basket or Fogarty balloon catheter following an endoscopic sphincterotomy, is essential. In some cases it may also be necessary to replace the biliary stent. In this case the removal of the broken stent and sludge and balloon dilatation of the stricture were all that was required. REFERENCES Gallacher, DJ. Kadir, S, Kaufman, SL, Mitchell, SE, Kinnison, ML & Chang, R (1985). Nonoperative management of benign postoperative biliary strictures. Radiology, 156, 625 629. Joseph, PK, Bizer, LS, Sprayregen, SS & Gliedman, ML (1986). Percutaneous transhepatic biliary drainage. Results and complications in 8l patients. Journal of the American Medical Association, 255, 2763-2767. Mueller, PR, van Sonnenberg, E & Ferrucci, JT (1982). Percutaneous biliary drainage: technical and catheter related problems in 200 procedures. American Journal of Roentgeno/ogy, 138, 17 23. Mueller, PR, van Sonnenberg, E, Ferruci, ,IT, Weyman, P J, Butch, R J, Malt, RA et aL (1986). Biliary stricture dilatation: multieenter review of clinical management in 73 patients. Radiology, 160, 17 20. Siegel, JH (1984). Interventional endoscopy in diseases of the biliary trcc and pancreas. Mount Sinai Journal of Medicine, 51,535-542. Williams, H J, Bender, CE & May, G R (1987). Benign post-operative biliary strictures: dilation with fluoroscopic guidance. Radiology, 163, 629 634.
