August Georg University Augusta, GA, United States
Shreyans Doshi, MD1, Shreyu Umapathy, 1, Haoran Peng, MD, PhD2, Bonnie Clark, 1, Alexis Moore, 1, Ayesha Cheema, MBBS3, Hafiz Muhammad Sharjeel Arshad, MD3, Subbaramia Sridhar, MBBS, MPH, FRCP, FRCPC, FACG4 1August Georg University, Augusta, GA; 2Medical College of Georgia, Augusta, GA; 3Medical College of Georgia, York, PA; 4AUMC, Augusta, GA
Introduction: Self-expandable metal stents (SEMS) are widely used in the management of difficult common bile duct (CBD) stones. Similarly, endoscopic placement of multiple plastic biliary stents & stent within a stent have also been reported for complex choledocholithiasis or benign biliary strictures as a safe alternative to surgery. We report the transpapillary placement of double, side-by side CBD metal stents in a patient with complex bile duct stones.
Case Description/Methods: A 90-year-old Pt. with multiple comorbidities deemed not a candidate for surgery presented with recurrent rt. upper quadrant abdominal pain & fever. A CT scan of the abdomen confirmed acute cholecystitis complicated by contained perforation. She also had multiple CBD stones with the largest stone measuring 22 mm & CBD size 23 mm. She had normal liver tests. She underwent an ERCP with sphincterotomy, & removal of multiple large CBD stones followed by saline irrigation to remove the sludge. Percutaneous cholecystostomy was performed considering her being a poor surgical candidate. Follow up cholecystostomy check after 3 weeks identified multiple large filling defects in CBD & the gallbladder. A repeat ERCP & cholangiograms confirmed persistently dilated CBD to 24 mm & large CBD stones. Multiple attempts to clear the CBD failed even after using a cholangioscopy-guided electrohydraulic lithotripsy with high power & stone extraction basket. The sphincterotomy site was dilated with a TTS balloon to 18 mm followed by sequential placement of two Viabil SEMS (10 mm x 10 cm & 8 mm x 8 cm) into the CBD with an intention of preventing stent migration. To our best knowledge, we present the first case report regarding the safe placement of two side-by-side transpapillary metal stents into the CBD. The patient remained well one week after the procedure with no complications.
Discussion: Transpapillary placement of side-by-side SEMS into the CBD may be safely performed for successful biliary drainage in a select group of patients with complex choledocholithiasis. Twin CBD stents might prevent stent migration.
Figure: Twin Trans- Papillary Metal Stents for Common Bile Duct Obstruction
Disclosures: Shreyans Doshi indicated no relevant financial relationships. Shreyu Umapathy indicated no relevant financial relationships. Haoran Peng indicated no relevant financial relationships. Bonnie Clark indicated no relevant financial relationships. Alexis Moore indicated no relevant financial relationships. Ayesha Cheema indicated no relevant financial relationships. Hafiz Muhammad Sharjeel Arshad indicated no relevant financial relationships. Subbaramia Sridhar indicated no relevant financial relationships.
Shreyans Doshi, MD1, Shreyu Umapathy, 1, Haoran Peng, MD, PhD2, Bonnie Clark, 1, Alexis Moore, 1, Ayesha Cheema, MBBS3, Hafiz Muhammad Sharjeel Arshad, MD3, Subbaramia Sridhar, MBBS, MPH, FRCP, FRCPC, FACG4. P0049 - “Double- Barrel”, “Owl’s Eye” or “Side-by-Side” or What to Call?, Twin Trans-Papillary Metal Stents for Common Bile Duct Obstruction?, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.