Figure 1
A 60-year-old female patient with Bismuth type IV cholangiocarcinoma underwent an endoscopic procedure for the implant of a 7 Fr plastic biliary stent. At 10 weeks after the procedure, her jaundice worsened. Computed tomography of the abdomen showed marked dilatation of the intrahepatic biliary tract due to improper positioning of the biliary stent. Percutaneous drainage and bilateral cholangiography (A) showed the failing plastic biliary stent. The stent was dislodged with a diagnostic catheter (B) and a new 6 × 60 mm biliary stent was placed in the right pre-papillary biliary tract (C). It was not possible to resolve the stenosis in the left biliary tract, and unilateral drainage was therefore performed. Her bilirubin levels normalized by day 30.
Figure 2
Patient with pancreatic neoplasia in whom a plastic biliary stent was placed via ERCP and developed an occlusion. A new attempt was made by first moving the old stent upward and then inserting a new one adjacently (A), although it did not result in an improvement in the jaundice or cholangitis. A percutaneous approach was used in order to position the new (distal) plastic biliary stent within the duodenum (B,C) and the old (proximal) stent was removed with a snare (D). A metal biliary stent was then put in place (E,F), resulting in improvement of the clinical and biochemical parameters.
Figure 3
An 80-year-old female patient, with locally advanced adenocarcinoma of the pancreatic head, who presented with cholangitis. She underwent an endoscopic procedure to implant a metal stent (WallFlex; Boston Scientific, Marlborough, MA, USA). At two weeks after the procedure, her jaundice worsened. Computed tomography of the abdomen revealed marked dilatation of the left intrahepatic biliary tract-the consequence of an improperly positioned biliary stent, selective in the right hepatic duct by upward migration, occluding the confluence with the left hepatic duct (A). Another endoscopic procedure was performed to remove or reposition the stent. After its distal end had been captured, it was possible to crack the ring and the coating of the stent without moving it. Cholangiography showed peri-stent contrast retention and positioning of a different metal stent (Viabil; W.L. Gore, Flagstaff, AZ, USA) parallel to the WallFlex stent (B). Postprocedure cholangiography showed satisfactory biliary drainage into the duodenum (C).
Figure 4
A 71-year-old male patient presenting with obstructive jaundice due to neoplasia (A). A coated, covered metal biliary stent was placed via ERCP. However, the stent placement did not result in an improvement in the obstruction. Subsequently, ERCP was again performed in order to place another (fenestrated) stent within the previously positioned stent. Computed tomography showed the original stent positioned in the left biliary tract (atrophied hepatic segment) and increased biliary dilatation in the right hepatic lobe (B). Because of the cholangitis, external percutaneous drainage of the right biliary tract was performed as an emergency procedure. After 60 days, the patient underwent the removal of the external drain and the RUPS-100 kit was used in order to introduce a hydrophilic wire into the original stent (C). Direct percutaneous puncture of the coated biliary stent was performed with the RUPS-100 cutting needle, after which a 5 × 40 mm expanding coronary balloon stent was positioned (D). The procedure resulting in technical success with no complications.
Figure 5
Female patient with locally advanced, inoperable pancreatic cancer. She underwent ERCP for the placement of a metal biliary stent, thereafter evolving to controlled hemorrhagic shock, followed by sepsis. Contrast-enhanced computed tomography of the abdomen and pelvis showed the proximal portion of the stent in the portal vein and its distal portion in the duodenum (A,B). We simultaneously performed procedures for percutaneous drainage of biliary ducts, removal of the porto-duodenal stent by ERCP, and percutaneous portal angioplasty for occlusion of the porto-duodenal fistula (C,D).