Post written by Sundeep Lakhtakia, MD, DM, and Harsh Vardhan Tevethia, MD, DM, from the Department of Medical Gastroenterology, AIG Hospitals and Asian Institute of Gastroenterology, Hyderabad, Telangana, India.

Following complicated laparoscopic cholecystectomy, a young woman developed a biliary stricture that required several ERCP sessions. She presented with recurrent jaundice. MRCP revealed a perihilar stricture (involving common hepatic duct and bifurcation of both the right and left hepatic ducts) with biliary stent in situ. At ERCP, cholangiogram confirmed perihilar stricture with multiple soft stones that were cleared with balloon sweep. A novel biliary ‘balloon expandable biodegradable stent’ (BEBS) (UNITY-B; AMG International, Winsen, Germany) was considered for bilateral biliary placement. UNITY B is a 57-mm-long biodegradable tubular stent mesh crimped over a collapsed balloon. The dilation of the balloon expands the stent to the desired preset diameter. The expanded stent is finally released in position by deflating the balloon and its gentle removal.

In this patient, 2 guidewires were placed into the left and right hepatic ducts. The first stent was accurately positioned across the LHD stricture confirmed by the radio-opaque markers at both ends. The underlying balloon was inflated with contrast (10 mm diameter). Another guidewire was then negotiated through the mesh of the biodegradable stent to the right hepatic duct (RHD). The RHD stricture was dilated with a standard balloon (8 mm) followed by similar placement of an 8-mm diameter BEBS through the mesh of the first biodegradable stent placed in the LHD (in a stent-in-stent “Y shaped” configuration).

Accurate positioning of both BEBS were confirmed on fluoroscopy that showed the end markers along with pneumobilia. CT imaging a few days later confirmed the bilateral stents opened up. The patient experienced mild periprocedural pain, which was managed with analgesics on an outpatient basis. She continues to do well with normal biochemistries at >12 weeks.

Benign biliary strictures pose a challenge to endoscopists. The current therapeutic options include multiple plastic stents or FCSEMS. The critical advantage that BEBSs provide is continuous dilation of the stricture that allows remodeling of the bile duct around the expanded stent without any further need of endoscopic procedures to remove or replace the stent. So far BEBSs have been used for distal CBD stricture as single stents. The interesting aspect of the current case is the use of BEBSs in complex hilar stricture at hepatic hilum leading to placement of 2 stents as ‘stent-in-stent’ technique (Y-shaped-configuration). Such placements may be considered for biliary drainage in complex benign or indeterminate biliary strictures.

In endoscopic management of benign biliary stricture, availability of BEBSs will add an important alternative to the current use of single/multiple plastic stents or FCSEMS. BEBSs can be a ‘game changer’ in endoscopic management of BBS, as experience accumulates with the wider availability and usage of BEBSs that maintain their lumen patency for a sustained period.

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