Percutaneous biliary stenting

Case contributed by Dr Maciej Mazgaj

Presentation

Jaundice, sonography: biliary tree dilatation. Known non-surgical pancreatic malignancy. Palliative treatment.

Patient Data

Age: 60 years
Gender: Male

Fluoroscopy control of biliary tree puncture and defining common bile duct (CBD) occlusion level.

Fluoroscopy

Step-by-step images of first part of stenting common bile duct (CBD) procedure: from biliary tree puncture to proper catheter placement.

  1. Ultrasound guided puncture of right-lobe intrahepatic biliary tree. Contrast agent filling the biliary tree confirms proper needle placement. Care must be taken as minimal needle movement will result with losing its proper intra-biliary position.
  2. Further biliary contrast filling through soft introduction needle. Needed for most distal ducts visualization.
  3. Guide wire placed in the furthest part of biliary tree - will be used for changing introduction needle for angled catheter. 
  4. Angled catheter mounted in the beginning of stricture. Using this catheter hydrophilic guide wire will be used to traverse the patent part of common bile duct. 

Traversing occluded part of CBD and stent applying.

Fluoroscopy

After approaching the patent CBD part, stenting begins: first traversing occlusion, then measurements and stent opening.

5. Catheter with hydrophilic guide wire (not shown) passed through CBD stricture.
6. Both proximal CBD and duodenum contrast filling in order to stent size determining.
7. Stiff guide wire applied allows proper and reliable stent location.
8. Stent (Wallstent 10 mm diameter, length 70 mm) placing.
10. Stent released. Narrowing in middle part still visible.

Baloon remodeling of CBD stent.

Fluoroscopy

Stent remodeling and patency control.

11. The Series shows continuous increase of stent middle part diameter.
12. Additionally drainage catheter was placed in common hepatic duct. Contrast agent introduced through catheter shows decrease of biliary tree diameter and patency of stent in CBD.

Summary control x ray.

X-ray

Abdominal x ray shows proper stent and drainage pig-tail catheter positions.

Note: This case has been tagged as "legacy" as it no longer meets image preparation and/or other case publication guidelines.

Case Discussion

Percutaneous biliary tree stenting is a procedure proposed to palliative management of jaundice resulting from CBD occlusion not amenable to surgical treatment.

This method is better for patient's quality of life, as does not require external drainage (in this case drainage was used as additional mean to support stent patency).

This method especially appreciated when ERCP is not possible (in this case duodenum was narrowed).

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