Endoscopic multiple metal stenting for the treatment of enteral leaks near the biliary orifice: A novel effective rescue procedure.
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.
Massimiliano Mutignani, Lorenzo Dioscoridi, Edoardo Forti, Raffaele Manta, Mariano Sica, Alberto Tringali, Francesco Pugliese, Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, 20162 Milano, Italy.
Massimiliano
M
Mutignani
Massimiliano Mutignani, Lorenzo Dioscoridi, Edoardo Forti, Raffaele Manta, Mariano Sica, Alberto Tringali, Francesco Pugliese, Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, 20162 Milano, Italy.
Lorenzo
L
Dioscoridi
Massimiliano Mutignani, Lorenzo Dioscoridi, Edoardo Forti, Raffaele Manta, Mariano Sica, Alberto Tringali, Francesco Pugliese, Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, 20162 Milano, Italy.
Stefanos
S
Dokas
Massimiliano Mutignani, Lorenzo Dioscoridi, Edoardo Forti, Raffaele Manta, Mariano Sica, Alberto Tringali, Francesco Pugliese, Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, 20162 Milano, Italy.
Paolo
P
Aseni
Massimiliano Mutignani, Lorenzo Dioscoridi, Edoardo Forti, Raffaele Manta, Mariano Sica, Alberto Tringali, Francesco Pugliese, Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, 20162 Milano, Italy.
Pietro
P
Carnevali
Massimiliano Mutignani, Lorenzo Dioscoridi, Edoardo Forti, Raffaele Manta, Mariano Sica, Alberto Tringali, Francesco Pugliese, Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, 20162 Milano, Italy.
Edoardo
E
Forti
Massimiliano Mutignani, Lorenzo Dioscoridi, Edoardo Forti, Raffaele Manta, Mariano Sica, Alberto Tringali, Francesco Pugliese, Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, 20162 Milano, Italy.
Raffaele
R
Manta
Massimiliano Mutignani, Lorenzo Dioscoridi, Edoardo Forti, Raffaele Manta, Mariano Sica, Alberto Tringali, Francesco Pugliese, Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, 20162 Milano, Italy.
Mariano
M
Sica
Massimiliano Mutignani, Lorenzo Dioscoridi, Edoardo Forti, Raffaele Manta, Mariano Sica, Alberto Tringali, Francesco Pugliese, Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, 20162 Milano, Italy.
Alberto
A
Tringali
Massimiliano Mutignani, Lorenzo Dioscoridi, Edoardo Forti, Raffaele Manta, Mariano Sica, Alberto Tringali, Francesco Pugliese, Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, 20162 Milano, Italy.
Francesco
F
Pugliese
Biliary stent; Duodenal leak; Endoscopic retrograde pancreatic duct; Enteral leak; Enteral stent; Fully covered metal stent; Pancreatic stent; Postoperative complications