Insertion of two overlapping new covered metal stents for closure of a complex biliary leak and description of a safe technique for their removal

ered self-expandable metal stents (FCSEMSs) has been described for the treatment of complex bile leaks after laparoscopic or open cholecystectomy [1,2]. A 72-year-old woman developed a bile leak after an open cholecystectomy (●" Fig. 1). An initial attempt at closure with plastic stents was unsuccessful (●" Fig. 2). Therefore, it was decided to use a 10-mm diameter, 8-cm long FCSEMS (WallFlex; Boston Scientific, Natick, Massachusetts, USA), which was successfully placed (●" Fig. 3), and the bile output into the external drain decreased. Unfortunately, 1week later a large amount of bile reappeared in the external drain. A third endoscopic retrograde cholangiogram (ERC) showed shortening of the stent with the proximal end now below the bile duct defect, and therefore leakage of contrast (●" Fig. 4a); therefore, another 8-cm FCSEMS was placed partly inside the first, completely covering the area of damaged bile duct with complete resolution of the leakage (●" Fig. 4b). A follow-up ERC was performed 6 weeks later, and the stents were removed using the following technique. The mesh of the nearest FCSEMS was grasped with a rattoothed forceps, but the other FCSEMS was sticking within the bile duct. A 10mm diameter through-the-scope CRE balloon dilator (Boston Scientific) was therefore positioned inside the stents and inflated (●" Fig. 5a), after which, the stents were easily pulled out of the bile duct and drawn into the gastric cavity (●" Fig. 5b). The FCSEMSs were grasped with a forceps (●" Fig. 5c) and withdrawn along with the endoscope (●" Fig. 5d). Finally, cholangiography confirmed the resolution of the bile leak (●" Fig. 6). To the best of our knowledge, this case is the first reported use of a fully covered WallFlex stent for closure of a complex biliary leak secondary to open cholecystectomy. In this case, with a large area of damage in the proximal bile duct, we have shown that the placement of two overlapping FCSEMs is an effective method of lining the bile duct lumen and covering the site of leakage. The technique of inflating a balloon inside a stent to assist its removal has been previously used [3], Insertion of two overlapping new covered metal stents for closure of a complex biliary leak and description of a safe technique for their removal