Korean J Radiol.  2012 Dec;13(6):795-802. 10.3348/kjr.2012.13.6.795.

Percutaneous Biliary Drainage Using Open Cell Stents for Malignant Biliary Hilar Obstruction

• Ahn SJ
• Bae JI
• Han TS
• Won JH
• Kim JD
• Kwack KS
• Lee JH
• Kim YC

• KMID: 1397511
• DOI: http://doi.org/10.3348/kjr.2012.13.6.795

Abstract

OBJECTIVE
To evaluate the feasibility, safety and the effectiveness of the complex assembly of open cell nitinol stents for biliary hilar malignancy.
MATERIALS AND METHODS
During the 10 month period between January and October 2007, 26 consecutive patients with malignant biliary hilar obstruction underwent percutaneous insertion of open cell design nitinol stents. Four types of stent placement methods were used according to the patients' ductal anatomy of the hilum. We evaluated the technical feasibility of stent placement, complications, patient survival, and the duration of stent patency.
RESULTS
Bilobar biliary stent placement was conducted in 26 patients with malignant biliary obstruction-T (n = 9), Y (n = 7), crisscross (n = 6) and multiple intersecting types (n = 4). Primary technical success was obtained in 24 of 26 (93%) patients. The crushing of the 1st stent during insertion of the 2nd stent occurred in two cases. Major complications occurred in 2 of 26 patients (7.7%). One case of active bleeding from hepatic segmental artery and one case of sepsis after procedure occurred. Clinical success was achieved in 21 of 24 (87.5%) patients, who were followed for a mean of 141.5 days (range 25-354 days). The mean primary stent patency period was 191.8 days and the mean patient survival period was 299 days.
CONCLUSION
Applying an open cell stent in the biliary system is feasible, and can be effective, especially in multiple intersecting stent insertions in the hepatic hilum.

Keyword

Obstructive jaundice; Malignant biliary obstruction; Percutaneous biliary stent

MeSH Terms

Adult
Aged
Aged, 80 and over
*Alloys
Bile Duct Neoplasms/*complications
Cholangiocarcinoma/*complications
Cholestasis, Intrahepatic/etiology/*therapy
Drainage/*instrumentation
Female
Gallbladder Neoplasms/complications
Humans
Male
Middle Aged
*Palliative Care
*Stents

Figure

• 

  Fig. 1 Stent configurations.A. T-configured stent placement. 1st stent (black arrow) was placed connecting right and left lobar ducts, then 2nd stent white arrow connecting transverse stent to CBD was inserted through same access. B. Y-configured stent placement. First stent white arrow was placed from right lobar duct to common bile duct. 2nd stent black arrow was inserted from left lobar duct through first stent to CBD. C. Crisscross-configured stent place placement. First stent black arrow was placed connecting one right anterior sectoral duct and left hepatic duct. Second stent white arrow was inserted from right posterior sectoral duct crossing first stent and into common bile duct. CBD = common bile duct

• 

  Fig. 2 F/67 patient with cholangiocarcinoma.A. Right posterior ducts (RPD; arrow) and left hepatic ducts (LHD; arrowhead) are nearly completely separated by deeply infiltrating lesion in hepatic hilum. Right anterior ducts (RAD) are not visible. B. RAD (black arrow) was visualized by percutaneous cholangiography. RAD are in hepatic dome and acutely angled to be accessed percutaneously, thus left access was made and followed by crossing of guide wire (arrowheads) from RPD to LHD. C. Crisscross configured stent placement connecting LHD-RAD and RPD-CBD was attempted but pathway connecting LHD-RAD could not be found. Thus 1st stent was placed from RPD to LHD (white arrowheads). 2nd stent was placed from RPD to CBD through 1st stent (white arrows). Then we found way (black arrow) to connect LHD and RAD through stent. D. 3rd stent was placed from LHD through stents to RAD. Because RPD anomalously joined CBD, 4th stent was placed from RPD through stent to CBD. Nearly complete internal drainage was obtained with 4 open cell stents.

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  Fig. 3 Stent crushing during T-configured stent placement in patient with cholangiocarcinoma.A. T-configured stent placement was attempted via left. B. Crushing of left limb of first transverse stent (arrow) occurred during insertion of second stent. C. Stent placement was secondarily completed after insertion of additional transverse stent through new right access. Follow-up cholangiographies revealed successful drainage of both hepatic lobes.

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  Fig. 4 Stend patency and patient survival.A. Kaplan-Meier analysis of primary stent patency rate. Mean patency period was 191.8 days (95% CI, 144.2-239.5 days). B. Kaplan-Meier analysis of patient survival rates. Mean patient survival time was 299 days (95% CI, 205.6-392.4 days).

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