Nonoperative therapy of a complicated biliary stricture

Summary

Three recent reports have described external placement of biliary drains for common bile duct (CBD) strictures in children. We report combining endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), and transductal stenting for the precise diagnosis and management of a complicated CBD stricture. A $5{\raise0.5ex\hbox{$\scriptstyle 1$}\kern-0.1em/\kern-0.15em\lower0.25ex\hbox{$\scriptstyle 2$}}$-year-old boy diagnosed with hepatic rhabdomyosarcoma was treated with induction chemotherapy and extended left hepatic resection. Postoperative neutrophil dysfunction contributed to multiple septic complications requiring three operative procedures for drainage. During these septic episodes cholangitis occurred with a peak serum bilirubin level of 30 mg/dl that finally stabilized at 20 mg/dl. The patient could not be cleared of biliary sepsis. PTC was performed with simultaneous ERCP. A well-defined, discrete CBD stricture was delineated and an external biliary drain was placed. Three weeks later, after the sepsis had cleared and the bilirubin level had markedly decreased, a transhepatic intraductal stent was placed exiting in the duodenum. This was later internalized and remained in place. The patient died 6 months later from a massive pelvic recurrence of his tumor. He suffered no further biliary complications and maintained normal bilirubin levels until his death. We conclude that modalities well-documented in adults for non-operative management of biliary strictures (PTC, ERCP, stents) can be used successfully in the pediatric population in selected cases.