Clin Endosc.  2013 May;46(3):260-266. 10.5946/ce.2013.46.3.260.

Technical Tips and Issues of Biliary Stenting, Focusing on Malignant Hilar Obstruction

• Lee TH

• KMID: 2048931
• DOI: http://doi.org/10.5946/ce.2013.46.3.260

Abstract

Although there is no survival advantage, inoperable hilar cholangiocarcinoma managed by palliative drainage may benefit from symptomatic improvement. In general, biliary drainage is divided into endoscopic or percutaneous approaches and surgical drainage. Plastic or metal stent is the most preferred device for palliative drainage in endoscopic approach. Considering cost-effectiveness, use of metallic stent is preferred than plastic stents in patients with more than 3 months of life expectancy with inoperable malignant biliary obstruction. In patients with unresectable malignant hilar obstruction, the endoscopic approach with biliary stent placement by experts has been considered as the treatment of choice. However, the endoscopic management of hilar obstruction is often more challenging and complex than distal malignant biliary obstructions. There is still a lack of clear consensus on the use of plastic versus metal stents and unilateral versus bilateral drainage since the decision should be made under many grounds such as the volume of liver drainage more than 50%, life expectancy, and expertise of the facility.

Keyword

Malignant hilar obstruction; Biliary drainage; Stents

MeSH Terms

Cholangiocarcinoma
Consensus
Drainage
Humans
Imidazoles
Life Expectancy
Liver
Nitro Compounds
Plastics
Stents
Imidazoles
Nitro Compounds
Plastics

Figure

• 

  Fig. 1 Side-by-side deployment of metallic stents (Bonastent; Standard SciTech Inc.); sequential images of bilateral side-by-side stent placement in a patient with hilar cholangiocarcinoma (Bismuth type IIIA). The stricture was first negotiated with a guidewire inserted into the left hepatic duct, and the right hepatic duct was then accessed using the same method. Following the introduction of these two guidewires, the first stent (with a radiopaque X mark) was inserted in the left hepatic duct without removing the preloaded guidewire; the second stent was then deployed in the right hepatic duct using the same method.

• 

  Fig. 2 Stent-in-stent deployment of metallic stents in Bismuth type IV (Bonastent; Standard SciTech Inc.); guidewires were initially introduced into both intrahepatic ducts bilaterally. The first stent with a radiopaque X mark was inserted into the left hepatic duct. After deployment of the first stent, the remaining guidewire was carefully withdrawn using an endoscopic retrograde cholangiopancreatography catheter, without pulling it back completely. The guidewire was then inserted into the right hepatic duct through the central portion of the first stent. Following deployment of the second stent, the bilateral metal stents were in a Y-configuration.

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