Roux-en-Y jejunal loop obstruction by a giant stent-related stone following liver transplantation

Abstract

This is a 14-year-old girl who had suffered from biliary atresia since birth. A Kasai operation failed, and she gradually progressed into end-stage liver disease, necessitating liver transplantation (LT). At the age of three, she underwent cadaveric LT in the United States, where during her surgery a small plastic catheter was used to stent the roux-en-Y (REY) choledochojejunostomy anastomosis. After her transplant, she was followed up in our institute and was admitted several times with a clinical picture suggestive of recurrent cholangitis. LT, liver transplantation; REY, roux-en-Y; FB, foreign body. Recently, she presented to our emergency room with an attack of severe acute cholangitis. Doppler ultrasound examination confirmed patency of all vessels with minimal biliary dilatation. Percutaneous-transhepatic-cholangiogram was urgently performed and showed a widely patent choledochojejunostomy; however, the REY jejunal loop looked dilated and obstructed with a large, sausage-shaped filling defect that has a central radio-opaque shadow and is obstructing its caudal end nearby the enteroenterostomy (Fig. 1). CT scan of the abdomen was performed, and a large, sausage-shaped foreign body (FB) was noticed within the REY jejunal loop; this FB had a central dense line within, suggestive of dense radio opaque material. There also was distal tapering of the bowel beyond the FB, probably at the junction of REY loop with the small bowel (site of enteroenterostomy). On the other hand, the proximal portion of the REY jejunal loop nearby was noted to be dilated, indicating obstruction of the REY jejunal loop by this FB. The patient was taken to the operating room, and the large FB was felt within the REY jejunal loop, causing partial obstruction of lumen as indicated by the distension of the proximal portion and collapse of the loop beyond the FB. The jejunal loop was opened and a large stone was surgically delivered from within the REY jejunal loop. This stone seemed to obstruct the REY jejunal loop at the site of entero-enteric anastomosis. Examination of the stone showed that it was a 7 × 2.5 × 2.7 cm mixed stone (calcium palmitate 50% and bilirubin 50%) formed around a 5-cm plastic biliary stent (Figs. 2 and 3). Apparently, the small plastic tube that was used to stent the biliary anastomosis during the LT procedure failed to migrate through the distal end of the REY jejunal loop, where it was impacted and acted as a nidus for the formation of this giant mixed stone over a 12-year period following LT. The patient recovered well from the surgery; her liver functions normalized, and up until now the patient did not suffer from any further attacks of cholangitis. Percutaneous-transhepatic-cholangiogram showing a large stone surrounding a radio-opaque plastic biliary stent. The giant stone after removal. Cross section of the stone showing the plastic biliary stent within. This case describes a late life-threatening complication that is related to the use of an internal biliary catheter to stent the REY biliary anastomosis. Many studies have shown a significant number of stent-related morbidities and even mortalities.1 Furthermore, recent studies have shown that the use of stents did not significantly reduce the risk of biliary complications, in addition to adding the extra risk of stent-related complications.2-4 However, and with the introduction of living donor liver transplantation, the need for the use of biliary stents may increase due to the high incidence of biliary complications linked to those procedures.5 Finally, we believe that the use of biliary stents in LT will always remain controversial. The final decision is usually taken by the surgical team based on their judgment during different surgical situations.