A 60-years-old female was admitted with signs of posthepatic jaundice and coagulopathy: total bilirubin (TB) : 538.7 mumol/L, direct bilirubin (DB) : 412.1 mumol/L. Coagulation test showed fibrinogen level at 110 mg/dl (normal range 180-350 mg/dl), prothrombin Quick value : 46% (normal range 0.85-1.2), international normalized ratio (INR) : 2.4 (normal range 0.85-1.2), indicating high risk of bleeding. A diagnosis of Klatskin tumor of the left hepatic duct (type 3B by Bismuth-Corlette classification) was established based on a contrast-enhanced CT scan and biopsy. The CT scan analyses revealed the tumor to be intimately adherent to the common hepatic artery (highly suspicious for invasion) as well as wrapped around the half of the portal vein. The resection of the liver with major vessels was not performed because such operation is not covered by the Medical Guarantees Package from the National Health Service of Ukraine due to poor financing of healthcare in Ukraine, and the patient was not able to cover such expenses by herself. The malignancy was diagnosed as an unresectable tumor; therefore, a palliative minimally invasive approach was chosen. The study was approved by the local ethical committee at Bogomolets National Medical University. The patient provided written informed consent to participate in the study. All data generated or analyzed during this study are included in this published article.
Initially, we thought that percutaneous transhepatic biliary drainage might be favorable compared to the endoscopic approach. However, the decision was made to performed an endoscopic approach because the patient had a Klatskin tumor with a spread into the left hepatic duct, whereas the right hepatic duct was dilated and free from tumor, indicating a good prognosis for endoscopic management in this particular case. The dilation of the right hepatic duct was due to obstruction at the level of bile duct confluence. Also, a high risk of bleeding was taken into consideration, and a decision was made to perform endoscopic retrograde cholangiopancreatography (ERCP) followed by endoscopic sphincterotomy and endobiliary stenting. Application of self-expanding metal stents (SEMS) is associated with better clinical outcomes and enhanced biliary decompression. As compared to plastic stents, SEMS have a wider diameter, which is resulted in enhanced bile flow after the stent insertion. In such a condition, biliary decompression is rapid, and the risk of liver failure is increased according to Khoronko et al and our clinical observations (unpublished data). Hence, we decided to use a plastic stent in order to achieve gradual decompression because of signs of liver failure due to posthepatic jaundice. The polyvinyl chloride (PVC) stent (10 Fr, 150 mm) was placed into the right hepatic duct (Figure 1) and colorless "white" bile was received. The selective stenting of the right hepatic duct was achieved by maneuvering the flexible part of the endoscope and its elevator as well as using guidewires with J-tip, fixed, and moveable core. Also, a significant decrease in bilirubin levels was achieved. In 2.5 months after the PVC insertion, the patient was diagnosed with posthepatic jaundice and cholangitis: TB : 120.6 mumol/L, DB : 86.3 mumol/L, WBC : 12.7 x 109/L, band neutrophils (BN) : 18%, erythrocyte sedimentation rate (ESR) : 29 mm/hour. Occlusion of the PVC stent was established by MRI, followed by ERCP (Figure 2), and replacement of the stent was performed with a larger diameter (11.5 Fr, 130 mm). The patient was administrated chemotherapy with 3 g of capecitabin (18 courses).
Two months later after the endobiliary restenting procedure, the patient reported fever up to 38 C and dry cough with a sudden onset. According to the patient, she had an active lifestyle, doing regular chores like farming and gardening in the countryside. During the next 7 days after the initial presentation, the dry cough was changed to a wet one with an admixture of bile, indicating biliptysis. The blood test showed WBC : 10.5 x 109/L, ESR : 66 mm/hour, TB : 12 mumol/L. CT scan showed the proximal migration of the endobiliary stent with penetration through the liver, the right dome of the diaphragm, and right lung (Figure 3). The distal part of the stent was at the level of the common hepatic duct (Figure 3C and D). The patient was not able to receive immediate endoscopic management, because such a clinical facility was not available in the area of her residence, and transportation to a tertiary referral center was not possible because of patient's fear to get infected with COVID-19. In such circumstances, conservative therapy was started by administration of Meloxicam 15 mg/day, Amoxicillin 1.5 g/day, Ceftazidim 3 g/day, and Furosemide 40 mg/day. The normalization of body temperature and blood parameters as well as the absence of biliptysis were reported in 2 weeks.
During the follow-up of 9 months, there were detected neither signs of BBF nor posthepatic jaundice. MRI investigation showed signs of fibrotic tissue around the part of the endobiliary stent in the pulmonary parenchyma with a clear demarcation from the normal lung tissue (Figure 4).
As the epidemic situation with COVID-19 became better, the patient arrived at a tertiary center for endoscopic treatment in Kyiv (National Military Medical Clinical Center of Ministry of Defense of Ukraine). To remove the proximally migrated endobiliary stent we visualized its proximal tip by ERCP in the common bile duct at the level of the cystic duct. Then, the tip was captured with 4 wire Dormia basket followed by its removal. The removed stent was replaced with a PVC stent (10 Fr, 150 mm) by ERCP (Figure 5). The surgical team considered possible technical problems and complications associated with fibrosis around the migrated stent, and conversion to open surgery was considered in case of unsuccessful endoscopic management. Complications were not observed at follow-up.