The management of surgically placed silastic transhepatic biliary stents

In recent years, the use of surgically placed Silastic transhepatic biliary tubes to stent high biliary structures after hepaticojejunostomy has become common. This technique is often used for benign or malignant strictures occurring in the common hepatic duct or at the hepatic duct bifurcation. More recently, this technique has been used in the surgical management of sclerosing cholangitis. After resection of a benign or malignant stricture involving the hepatic duct bifurcation, transhepatic stents are placed in both the right and left hepatic ducts. This is accomplished by placing an instrument in the right or left hepatic duct at the porta hepatitis and passing it peripherally as far as possible. The instrument is then forced through hepatic parenchyma and out the superior surface of the liver. A biliary stent, 6 mm in outside diameter and 60 cm long, is attached to the instrument and pulled back down through hepatic parenchyma, the intrahepatic biliary tree, and out the porta hepatis. A Roux-en-Y jejunal loop is then brought up, and a hepaticojejunostomy is performed over this stent. The opposite end of the biliary tube is brought out through a stab wound in the anterior abdominal wall and connected to gravity drainage. The biliary stents serve to eliminate the possibility of recurrence of stricture in the biliary tree or at the anastomoses. Initially the tubes used were made of rubber or polyethylene. At our institution Silastic transhepatic biliary tubes (Dow Corning) are used. Silastic is a soft, virtually nonreactive material, thus minimizing the possibility of tissue damage and maximizing patient comfort. The tubes are relatively thick-walled and virtually noncompressible by tumor or stricture. There are several side holes in the distal 24 cm of the tube. The distal end of the tube within the jejunum must be left with an end hole for subsequent management. The tubes are left in place permanently in patients with malignancies and sclerosing cholangitis. The tubes are left in place for 12 months in patients with localized benign structures. The tubes must be flushed twice daily by the patient with sterile physiologic saline solution to reduce the incidence of obstruction by inspissated bile or intestinal contents. They are changed every 3 months as an outpatient procedure. This report details our experience in over 100 patients with the problems that may be encountered with transhepatic stents and their routine management.