Korean J Radiol.  2013 Feb;14(1):97-101. 10.3348/kjr.2013.14.1.97.

A Newly Designed Y-shaped Covered Stent in the Palliative Treatment of Hepatic Hilar Malignant Obstruction: Case Report

• Kang BC
• Lee SY
• Chung HH

• KMID: 1430051
• DOI: http://doi.org/10.3348/kjr.2013.14.1.97

Abstract

We report a case in an inoperable patient with the hilar malignant biliary obstruction treated palliatively by the use of a newly designed Y-shaped covered stent without interfering contra-lateral bile duct. We percutaneously inserted a newly designed Y-shaped covered stent into a biliary tree in an inoperable patient with Bismuth Type II cholangiocarcinoma. We checked tubograms, enhanced CT studies, and blood bilirubin levels before, one week after, and at every three month after the stenting, by observing closely the signs of clinical infection as well. The follow-up period was about 12 months. The placement of the Y-shaped covered stent was successful and resulted in adequate biliary drainage in the immediate post-procedural tubogram and in the follow-up abdominal CT. The serum bilirubin levels did not show elevation after the insertion of the Y-shaped covered stent.

Keyword

Cholangiocarcinoma; Biliary stent; Covered stent; Percutaneous transhepatic biliary drainage; Bismuth type

MeSH Terms

Aged
Bile Duct Neoplasms/pathology/radiography/*therapy
*Bile Ducts, Intrahepatic
Bilirubin/blood
Cholangiocarcinoma/pathology/radiography/*therapy
Cholangiography
Drainage/instrumentation
Female
Humans
*Palliative Care
Prosthesis Design
*Stents
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 New stant and its use for hepatic hilar malignant obstruction treatmeant. A. Newly designed Y-shaped Covered Biliary Stent. Y-configured stent appearance can be achieved by connecting short limb covered stent of main piece and contra-lateral long limb covered stent. Diameter of Y-shaped branched covered stent is 10 mm at main bare trunk (T) and 7 mm at covered limb stents (L). Insertion of Y-shaped covered biliary stent in 72-year old woman with type II cholangiocarcinoma. B-a. Initial cholangiogram showed patient's tumor as Bismuth type II cholangiocarcinoma (Arrows indicates cancerous proximal and distal margins). B-b. For insertion of newly designed Y-shaped covered stent, we made another percutaneous transhepatic biliary drainage (PTBD) tract through left IHD and inserted drainage catheters (arrows) bilaterally. C. After bilateral PTBD, we inserted and located main piece of stent into common bile duct through left PTBD tract, under guidance of 0.035-inch guide wire. Proximal end (thick arrows) of main piece stent (EGIS KEY-MB stent) was located in left intrahepatic bile duct (IHD) beyond boundary of hilar tumor. Short limb covered portion of main piece stent was directed toward left side in common bile duct (Thin arrows indicate lateral markers of short limb covered stent). D. Only short limb covered stent (thin arrows) of main piece was deployed, and long limb covered stent (thick arrows) of main piece (EGIS KEY-MB stent) was not deployed. E. After confirmation of its proximal end located in right IHD beyond boundary of hilar tumor and distal end located within lumen of short limb covered stent, we deployed contra-lateral long limb covered stent (arrows) (EGIS KEY-CL stent) (S&G Bio, Seoul, Korea). F. Post-stenting cholangiography showed good internal drainage into duodenum and bilateral IHD communication, after completely deploying long limb covered stent of main piece. Outer diameter of Y-shaped covered stent introducer is 7 Fr.

Reference

1. Bae JI, Park AW, Choi SJ, Kim HP, Lee SJ, Park YM, et al. Crisscross-configured dual stent placement for trisectoral drainage in patients with advanced biliary hilar malignancies. J Vasc Interv Radiol. 2008. 19:1614–1619.

2. Gwon DI, Ko GY, Yoon HK, Kim YJ, Kim TH, Lee WH, et al. Safety and efficacy of percutaneous Y-configured covered stent placement for malignant hilar biliary obstruction: a prospective, pilot study. J Vasc Interv Radiol. 2012. 23:528–534.

3. Hwang JC, Kim JH, Lim SG, Kim SS, Yoo BM, Cho SW. Y-shaped endoscopic bilateral metal stent placement for malignant hilar biliary obstruction: prospective long-term study. Scand J Gastroenterol. 2011. 46:326–332.

4. Gwon DI, Ko GY, Yoon HK, Kim JH, Lee JM, Ohm JY, et al. Prospective evaluation of a newly designed T-configured stent graft system for palliative treatment of advanced hilar malignant biliary obstructions. J Vasc Interv Radiol. 2010. 21:1410–1418.

5. Kim CW, Park AW, Won JW, Kim S, Lee JW, Lee SH. T-configured dual stent placement in malignant biliary hilar duct obstructions with a newly designed stent. J Vasc Interv Radiol. 2004. 15:713–717.

6. Inal M, Akgül E, Aksungur E, Seydaoğu G. Percutaneous placement of biliary metallic stents in patients with malignant hilar obstruction: unilobar versus bilobar drainage. J Vasc Interv Radiol. 2003. 14:1409–1416.

7. Golfieri R, Giampalma E, Fusco F, Galuppi A, Faccioli L, Galaverni C, et al. Unresectable hilar cholangiocarcinoma: multimodality treatment with percutaneous and intraluminal plus external radiotherapy. J Chemother. 2004. 16:Suppl 5. 55–57.

8. Naitoh I, Ohara H, Nakazawa T, Ando T, Hayashi K, Okumura F, et al. Unilateral versus bilateral endoscopic metal stenting for malignant hilar biliary obstruction. J Gastroenterol Hepatol. 2009. 24:552–557.

9. Tsang TK, Pollack J, Chodash HB. Silicone-covered metal stents: an in vitro evaluation for biofilm formation and patency. Dig Dis Sci. 1999. 44:1780–1785.

10. Mihalache F, Tantau M, Diaconu B, Acalovschi M. Survival and quality of life of cholangiocarcinoma patients: a prospective study over a 4 year period. J Gastrointestin Liver Dis. 2010. 19:285–290.