Early Biodegradable Stent Placement for Percutaneous Hepaticojejunostomy Stricture Management

Dear Editor,

Percutaneous hepaticojejunostomy (HJ) stricture dilatation is associated with significant patient discomfort.¹ There is also a higher rate of cholangitis and restenosis, with lower patient compliance. Biodegradable biliary stents (BDS) to treat benign biliary strictures is a recent innovation.² BDS comprises polydioxanone material that degrades in 3–6 months via hydrolysis. BDS provides the beneficial effects of stenting without needing subsequent removal.² BDS in HJ stricture management is a promising strategy. However, the previous studies describe different protocols for placing BDS.^{3, 4, 5, 6}

We describe four patients (all females, median age 48.5 years, range: 21–72 years) with HJ strictures who underwent percutaneous placement of BDS between January 2022 and March 2023. The study was approved by the institute's ethics committee, and the need for informed written consent was waived.

All the patients were treated with BDS after discussion with the multidisciplinary team. Preprocedural cross-sectional imaging was reviewed. All patients received pre-procedure intravenous antibiotics as per the institutional protocol. Biliary decompression was achieved by the percutaneous transhepatic (PTBD) insertion of the 8F biliary catheter. Within a week, the catheter was internalized and upsized to 12 F. All the patients underwent BDS placement (Ella-DV biliary stent, ELLA-CS) under conscious sedation and analgesia within ten days of inserting their first PTBD procedure using the technique described previously.³ The BDS was placed by an interventional radiologist with eight years of experience in biliary interventions. No pre- or post-stenting balloon dilatation was performed. The external catheters were removed, and patients were discharged within 24 h of the stent placement.

Technical success was defined as the successful deployment of the stent at the stricture site and the establishment of unobstructed flow across the stricture as documented by the post-procedure cholangiogram (Figure 1, Figure 2). The patients were followed up in the radiology clinic at one month after the BDS placement and three months thereafter with ultrasound and liver function tests (LFT). The clinical success was defined as the symptomatic relief and normalization of LFTs. Table 1 summarizes patient characteristics, pre- and post-procedural LFTs, complications, and follow-up. The median stent insertion time from the first PTBD was eight days (7–10 days). Technical and clinical success was achieved in all patients. Mild haemobilia occurred in one patient and resolved with conservative management within 24 h. The mean follow-up was 7.5 months (6–9 months). All patients had normal LFTs at one month and at the last follow-up (Table 1). None of the patients developed cholangitis during the follow-up period. There was no radiological evidence of recurrence of stricture on follow-up after degradation of the BDS.

Figure 1.

(A) Magnetic resonance cholangiopancreatography image of a 21-year-old female following choledochal cyst excision shows stricture at the HJ site(arrow). (B) Post contrast T1-weighted image showing multiple cholangitic abscesses in the right lobe of liver (arrow). (C) Percutaneous transhepatic cholangiogram via biliary catheter shows opacification of the ductal system and the jejunum across the HJ (arrow); (D) Placement of biodegradable stent (arrow). (E) Free flow of contrast across the stent into the jejunum. (F) Ultrasound image at 1 month shows stent in situ (arrow) with decompressed intrahepatic biliary system.

Figure 2.

(A) Magnetic resonance cholangiopancreatography image of a 54-year-old patient with post cholecystectomy stricture who underwent hepaticojejunostomy (HJ) 1.5 years back shows stricture at HJ site(arrow). (B–D) Percutaneous transhepatic cholangiogram via biliary catheter opacifies biliary ducts and the jejunum across the HJ (arrow, B). Following placement of biodegradable stent (arrow, C), there is free flow of contrast into the jejunum (arrow, D). (E and F) Ultrasound images showing stent in situ (arrow, E) with decompressed intrahepatic biliary system.

Table 1.

Patient Characteristics and Outcomes.

Age (years), gender	Indication of HJ	Presentation	Stent size (mm)	Preprocedural LFT (TB/CB/AST/ALT/ALP)	LFT (TB/CB/AST/ALT/ALP) at last follow-up	Complications	Total follow-up
43, Female	Post cholecystectomy biliary duct injury	Cholangitis	10 × 80	1.45/0.5/149/120/465	0.9/0.3/54/66/176	None	6 months No cholangitis
54, Female	Post cholecystectomy biliary duct injury	Jaundice with pruritis	10 × 60	2.1/0.3/27/27/900	1.1/0.4/31/39/90	None	9 months No cholangitis
21, Female	Type 1C choledochal cyst resection	Cholangitis	10 × 80	0.9/0.7/41/48/671	0.8/0.3/72/36/119	None	9 months No cholangitis
72, Female	Post left hepatectomy	Cholangitis	10 × 80	6.3/3.6/53/77/789	1.01/0.64/47/26/105	Mild Haemobilia	6 months No cholangitis

AST: aspartate transaminase; ALT: alanine transaminase; ALP: alkaline phosphatase; CB: conjugated bilirubin; HJ, hepaticojejunostomy; TB: total bilirubin.

HJ stricture treatment with BDS has been described as a safe and effective technique.³ However, the previous studies report a long interval from initial PTBD to BDS placement.^{3, 4, 5, 6} Also, most patients had multiple interventions before BDS placement. Early BDS placement may reduce patient morbidity and increase compliance. Our small series shows the feasibility, safety, and favourable short-term clinical outcomes. Larger studies with long-term follow-up are needed.

CRediT authorship contribution statement

Pankaj Gupta – Conceptualization, Methodology, Writing - Original Draft, Writing - Review & Editing, Formal analysis.

Dollphy Garg, Vansha Mehta - Writing - Original Draft, Methodology.

Arunanshu Behera, Anupam Kumar Singh, Vikas Gupta, Usha Dutta- Data Curation, Methodology, Writing - Review & Editing.

Conflicts of interest

None.

Funding

None.