Obstructive Jaundice after Bilioenteric Anastomosis: Transhepatic and Direct Percutaneous Enteral Stent Insertion for Afferent Loop Occlusion

Abstract

Recurrent tumour after radical pancreaticoduodenectomy may cause obstruction of the small bowel loop draining the liver. Roux-loop obstruction presents a particular therapeutic challenge, since the postsurgical anatomy usually prevents endoscopic access. Careful multidisciplinary discussion and multimodality preprocedure imaging are essential to accurately demonstrate the cause and anatomical location of the obstruction. Transhepatic or direct percutaneous stent placement should be possible in most cases, thereby avoiding long-term external biliary drainage. Gastropexy T-fasteners will secure the percutaneous access and reduce the risk of bile leakage. The static bile is invariably contaminated by gut bacteria, and systemic sepsis is to be expected. Enteral stents are preferable to biliary stents, and compound covered stents in a sandwich construction are likely to give the best long-term results. Transhepatic and direct percutaneous enteral stent insertion after jejunopexy is illustrated and the literature reviewed. (Gut Liver 2010; 4(Suppl. 1):S89-95)

Percutaneous transhepatic access to allow per-oral enteric stent insertion for malignant duodenal obstruction following failed endoscopic attempt

“…Transhepatic access to facilitate enteric stenting has previously been used to treat malignant af- ferent loop obstruction following pancreaticoduodenectomy as an alternative to surgery. [5][6][7] In these cases there is no endoscopic alternative. These procedures also require the enteric stent to be introduced through the transhepatic tract, therefore necessitating a 11 to 12 French access through the liver.…”

Complex Post-cholecystectomy Biliary Injuries: Management with 10 Years' Experience in a Major Referral Center

“…18,20,36,40,41 All complications were managed conservatively except incisional hernia and postoperative anastomotic stricture, which were treated by other tools. Anastomotic stricture was managed by percutaneous dilation and stenting in 3 of 5 cases as it is very beneficial in such cases as documented by other authors, 47,48 and surgery was repeated in 2 patients.…”

Endoscopic management of combined malignant biliary and gastric outlet obstruction

“…However, external drainage greatly impairs quality of life (QOL) and should be avoided whenever possible. Even enteral stent placement through the PTBD route can be possible in some cases, but is carried out only in limited situations such as afferent limb syndrome in post‐surgical patients …”

“…Even enteral stent placement through the PTBD route can be possible in some cases, but is carried out only in limited situations such as afferent limb syndrome in post-surgical patients. 30 Endoscopic double stenting is probably the treatment of choice in many institutions. The advantage of endoscopic procedures is its lower invasiveness, safety and high technical success rate.…”