Endoscopic multiple metal stenting for the treatment of enteral leaks near the biliary orifice: A novel effective rescue procedure

Abstract

Between April 2013 and October 2015, 6 patients developed periampullary duodenal or jejunal/biliary leaks after major abdominal surgery. In all patients, percutaneous drainage of the collection or re-operation with primary surgical repair was attempted at first but failed. A fully covered enteral metal stent was placed in all patients to seal the leak. Subsequently, we cannulated the common bile duct and, in some cases, and the main pancreatic duct inserting hydrophilic guidewires through the stent after dilating the stent mesh with a dilatation balloon or breaking the meshes with Argon Plasma Beam. Finally, we inserted a fully covered biliary metal stent to drain the bile into the lumen of the enteral stent. In cases of normal proximal upper gastrointestinal anatomy, a pancreatic plastic stent was also inserted. Oral food intake was initiated when the abdominal drain outflow stopped completely. Stent removal was scheduled four to eight weeks later after a CT scan to confirm the complete healing of the fistula and the absence of any perilesional residual fluid collection. The leak resolved in five patients. One patient died two days after the procedure due to severe, pre-existing, sepsis. The stents were removed endoscopically in four weeks in four patients. In one patient we experienced stent migration causing small bowel obstruction. In this case, the stents were removed surgically. Four patients are still alive today. They are still under follow-up and doing well. Bilio-enteral fully covered metal stenting with or without pancreatic stenting was feasible, safe and effective in treating postoperative enteral leaks near the biliopancreatic orifice in our small series. This minimally invasive procedure can be implemented in selected patients as a rescue procedure to repair these challenging leaks.

Keywords: Endoscopic retrograde pancreatic duct, Fully covered metal stent, Duodenal leak, Postoperative complications, Enteral leak, Enteral stent, Biliary stent, Pancreatic stent

Core tip: Despite the small number of patients treated, the results of our experience seem promising. Early total fluid diversion with bilio-enteric fully covered metal stent, and plastic pancreatic stent when necessary, is a feasible, safe, effective and minimally invasive endoscopic procedure for postoperative duodenal leaks/fistulas. It is a reasonable option when primary surgical repair or other surgical treatment has failed. Moreover, our treatment could be offered as a first line treatment in patients with poor clinical status avoiding surgery altogether.