Clin Endosc.  2011 Dec;44(2):76-86. 10.5946/ce.2011.44.2.76.

Endoscopic Stent Placement in the Palliation of Malignant Biliary Obstruction

• Kim JH

• KMID: 1805253
• DOI: http://doi.org/10.5946/ce.2011.44.2.76

Abstract

Biliary drainage with biliary stent placement is the treatment of choice for palliation in patients with malignant biliary obstruction caused by unresectable neoplasms. In such patients, the endoscopic approach can be initially used with percutaneous radiological intervention. In patients with unresectable malignant distal bile duct obstructions, endoscopic biliary drainage with biliary stent placement has now become the main and least invasive palliative modality, which has been proven to be more effective in >80% of cases with lower morbidity than surgery, and perhaps may provide a survival benefit. In patients with unresectable malignant hilar obstruction, the endoscopic approach for biliary drainage with biliary stent placement has also been considered as the treatment of choice. There is still a lack of clear consensus on the use of covered versus uncovered metal stents in malignant distal bile duct obstructions and plastic versus metal stents and unilateral versus bilateral drainage in malignant hilar obstructions.

Keyword

Biliary stent; Malignant biliary obstruction; Biliary drainage

MeSH Terms

Cholestasis
Consensus
Drainage
Humans
Plastics
Stents
Plastics

Figure

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  Fig. 1 Schema of 'Through-the-mesh' technique for endoscopic bilateral metal stenting using a Y-type biliary Niti-S stent. The joining of the Y-stent with a wider-mesh portion in the center (left) and conventional metal stent (middle) through the wider-mesh portion of the Y-stent produces a Y-shaped arrangement (right).

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  Fig. 2 Endoscopic placement of bilateral metal stenting using a Y-type biliary Niti-S stent in patients with unresectable Bismuth type II malignant hilar obstruction. The first stent, being a Y-stent, was endoscopically placed in the left hepatic duct which is usually more difficult to access first, and balloon dilatation was done to widen the opening of its central portion, thereafter a second stent, being a conventional biliary metal stent, was inserted through the open-mesh wall of the first stent to gain access to the opposite hepatic lobe, resulting in a Y-configuration.

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  Fig. 3 'Through-the-mesh' technique for endoscopic bilateral metal stenting using a biliary M-Hilar stent. The M-Hilar stent has been designed with a differently woven structure in the center (left upper, noted portion), which permits easy passage of the delivery catheter of the second stent, even though it has no wider-mesh portion. The joining of both stents through the central-mesh portion of the M-Hilar stent produces a Y-shaped arrangement.

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  Fig. 4 Endoscopic placement of bilateral metal stenting using a biliary M-Hilar stent in patients with unresectable Bismuth type IIIa malignant hilar obstruction. The first stent, being M-Hilar stent, was endoscopically placed in the left intrahepatic bile duct, and the second stent, being a conventional biliary metal stent, was inserted through the differently woven structure in the center of the first stent to gain access to the right hepatic lobe, resulting in a Y-configuration.

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  Fig. 5 'Through-the-mesh' technique for endoscopic bilateral metal stenting using a biliary K-Hilar stent. The K-Hilar stent is a special stent with a large hole in the center of the stent (middle). When this particular stent is used as the second stent during bilateral stenting, lumens of both stents are absolutely patent without blockage of the wire mesh. The joining of both biliary M-Hilar stent (left) and K-Hilar stent through the central-mesh portion of the M-Hilar stent (left, noted portion) produces a Y-shaped arrangement (right).

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  Fig. 6 Endoscopic placement of bilateral metal stenting using two biliary K-Hilar stents in a patient with unresectable Bismuth type IIIa malignant hilar obstruction. The first K-Hilar stent was endoscopically placed in the left intrahepatic bile duct, and the second K-Hilar stent was inserted through the large hole in the center of the first stent to gain access to the opposite hepatic lobe, resulting in a Y-configuration.

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