Transhepatic metallic stenting for hepaticojejunostomy stricture following laparoscopic cholecystectomy biliary injury: A case of successful 20 years follow-up.

Laparoscopic cholecystectomy is still associated with a considerable rate of biliary injuries and related strictures. Advances in interventional endoscopy and percutaneous techniques have made stenting a preferred treatment modality for the management of these strictures. We report successful 20 years of follow-up of a case of trans-hepatic metallic stenting (2 Gianturco(®) prostheses, 5 cm long, 2 cm in diameter) done for stenosed hepatico-jejunostomy anastomosis after laparoscopic CBD injury. Percutaneous transhepatic stenting and long-term placement of metallic stents need to be re-evaluated as a minimally invasive definitive treatment option for benign biliary strictures in patients with altered anatomy such as hepatico-jejunostomy or in whom re-operation involves high risk.

INTRODUCTION

Laparoscopic cholecystectomy is associated with biliary injuries in 0.3%-0.7% of cases.[1] Biliary strictures can be managed by balloon dilatation but this technique has a high rate of re-stenosis.[2] Advances in interventional endoscopy and percutaneous techniques have made stenting a preferred treatment modality for the management of these strictures.[3] Plastic and covered metallic stents appear to be superior to uncovered metallic stents as they may prevent luminal tissue overgrowth.[4] There are some studies reporting the results of Percutaneous Interventional Radiologic Treatments (PIRT) for laparoscopy-associated bile duct injuries, but data on the long-term efficacy is scarce.[56] We report a twenty-year follow-up of a patient after transhepatic metallic stenting for stenosed bilio-enteric anastomosis after laparoscopic common bile duct (CBD) injury. Such report may help in re-evaluating the role of stenting for benign strictures.

CASE REPORT

A 51-year-old man underwent a laparoscopic cholecystectomy for cholelithiasis 20 years ago. Post-operatively, re-exploration was done because he developed jaundice and peritonitis and complete trans-section of CBD was evident. A T-tube stented end-to-end choledochal anastomosis was performed. Jaundice regressed, but the patient remained febrile. After 12 days, bleeding was observed in the T-tube and drains with metabolic acidosis, acute renal failure and respiratory distress. After resuscitation, a surgical re-exploration demonstrated a right hepatic artery bleeding with complete dehiscence of the choledochal anastomosis. After hemostasis, the distal end of the CBD was ligated and its proximal portion was drained to the skin over the biliary stent (Cron prostheses). Ten weeks later, a Roux-en-Y hepaticojejunostomy was fashioned. The T-tube inserted at the time of operation was removed after two months. Four months later, the hepaticojejunostomy got stenosed resulting in dilatation of the intrahepatic ducts. The re-operation was considered highly challenging and a percutaneous radiological stenting was planned. Two Gianturco® prostheses, 5 cm long, 2 cm in diameter, were successfully placed using a percutaneous transhepatic route, one after the other, across the stenosis [Figure 1]. The outcome was favourable with gradual normalization of hepatic laboratory values, and normal calibre of intrahepatic ducts. Patient was successfully followed up at regular intervals with laboratory and ultrasound investigations for 5 years and showed no signs of obstructive biliopathy.

Figure 1

Percutaneous transhepatic cholangiography (dye injection in left duct) at the time of stent deployment: Two 5 cm transhepatic Gianturco® prostheses placed through the right ducts across the anastomosis. The lower prosthesis is fully open; the upper, located in normal size duct, is partially open

Now, the patient presented with a right colonic carcinoma. In past 20 years, he had no episode of cholangitis or jaundice. His liver function tests are within normal limits except for mild elevation of GGT. During this visit, CT scan and 3D reconstruction of the liver and biliary tree were done. In VR-Render™, WeBSurg Limited Edition (WLE) - IRCAD Image Viewer Software (http://www.websurg.com/softwares/vr-render/), the images demonstrate that the prostheses are well positioned and no dilatation of intra-hepatic bile ducts [Figure 2]. It also shows aerobilia, predominantly on left side, with no signs of secondary biliary cirrhosis or liver atrophy.

Figure 2

Recent CT scan and 3D reconstruction of the liver and biliary tree in virtual imaging [using VR-Render™, WeBSurg Limited Edition (WLE) - IRCAD Image Viewer Software (http://www.websurg.com/softwares/vr-render/)]. The prostheses (white arrow) are still well positioned. Left and right hepatic ducts are not dilated

DISCUSSION

Surgical hepaticojejunostomies have a stenosis rate of 10%-30%[7] mainly due to the biliary conditions and devascularisation ischemia caused due to right hepatic artery injury, as described in the present case. Operative approaches for repair of biliary injuries are a time-tested management option and achieve good long-term results with minimal morbidity and mortality in most patients.[8] Cholangioplasty or dilatation with SEMS is one of the options to treat and avoid re-stenosis. Two cases with complete membranous occlusion of the bilioenteric anastomosis, successfully treated using percutaneous transhepatic cholangioscopy have been published.[9] Blockage of lumen with tissue overgrowth in uncovered stents is more frequent in benign biliary strictures than in bilio-enteric anastomosis.[7] The efficacy of covered metallic stents has been demonstrated in various studies, even for the long-term treatment.[1011] Some intrahepatic refractory benign strictures have been managed successfully with them.[12] On the other hand, there are recommendations against usefulness of metallic endobiliary stents for benign strictures in patients with more than 2 years of life expectancy.[13] Our 20-year follow-up of hepatico-jejunostomy stenosis, treated with Gianturco® stent is, probably, the longest documented follow-up for a post-laparoscopic cholecystectomy CBD stricture. We do not want to pass on the message that uncovered metallic stents should be considered as a preferred treatment for benign biliary strictures, but this option can definitely be considered for selected patients.

Percutaneous transhepatic stenting and long-term placement of metallic stents need to be re-evaluated as a minimally invasive definitive treatment option for benign biliary strictures in patients with altered anatomy such as hepaticojejunostomy or in whom re-operation invloves high risk.