Percutaneous Bilateral Metallic Stent Placement Using a Stentin-Stent Deployment Technique in Patients With Malignant Hilar Biliary Obstruction

Percutaneous biliary drainage for obstructive jaundice in patients with inoperable, malignant biliary obstruction

Aim of the study

Most of the malignancies leading to obstructive jaundice are diagnosed too late when they are already advanced and inoperable, with palliation being the only treatment option left. Due to progressing hyperbilirubinaemia with its consequent adverse effects, biliary drainage must be established even in advanced malignancies. This study aims to investigate and analyse factors that affect clinical outcomes of percutaneous trans-hepatic biliary drainage (PTBD) in patients with obstructive jaundice due to advanced inoperable malignancy, and identify potential predictors of patient survival. Study design: Observational retrospective cohort study.

Material and methods

Baseline variables and clinical outcomes were evaluated in 108 consecutive patients treated with PTBD. The study’s primary endpoints were significant bilirubin level decrease and survival rates. Secondary endpoints included periprocedural major and minor complication rates and catheter primary and secondary patency rates.

Results

PTBD was technically successful and bile ducts were successfully drained in all 108 patients. Median serum bilirubin level, which was 282 (171-376) µmol/l before drainage, decreased significantly, to 80 (56-144) µmol/l, 15 days after stent placement (p < 0.001). Patient survival ranged from 3 to 597 days and the overall (median) survival time following PTBD was 168 days (90-302). The 1, 3, 6, 12 and 18-month survival rates were 96.3%, 75.9%, 48.1%, 8.3% and 1.9%, respectively. Multivariate analysis revealed that liver metastases and alkaline phosphatase were significantly associated with mortality. The overall complication rate was 9.3%.

Conclusions

PTBD is a safe and effective method to relieve jaundice caused by advanced inoperable malignant disease. Careful patient selection is necessary when introducing PTBD in order to avoid invasive procedures in patients with a poor prognosis.

Percutaneous Y-shape reconstructive biliary stenting in Klatskin cholangiocarcinoma through a single left-sided entry

Percutaneous Y-shape reconstructive biliary stenting in the Klatskin tumor is typically performed through bilateral biliary access. Single access from a right-side biliary entry is the more commonly used side for biliary access in general. We present a successful Y-shaped biliary stent reconstruction through a single left-side biliary approach. Unilateral single access Y-shaped biliary stenting can be technically challenging; when performed through a left biliary approach, an additional technical challenge may arise due to the unusual combination of Y-shaped biliary stent reconstruction and the single left-side biliary approach. We concluded that percutaneous Y-shaped biliary reconstruction through a left-sided unilateral approach is a technically feasible, less invasive interventional approach in managing Klatskin tumor. SIMILAR CASES PUBLISHED: None.

Percutaneous stent-in-stent placement with large cell-type stents for malignant hilar biliary obstruction

BACKGROUND

To overcome the technical difficulty of bilateral stent-in-stent placement, large cell-type biliary stents have been developed. However, most of the studies using large cell-type stents were conducted with endoscopic method.

PURPOSE

To evaluate the efficacy and safety of percutaneous stent placement with a stent-in-stent method using large cell-type stents in patients with malignant hilar biliary obstruction.

MATERIAL AND METHODS

From December 2015 and October 2018, 51 patients with malignant hilar biliary obstruction were retrospectively studied. All of the patients underwent bilateral (n=46) or unilateral (n=5) stenting in a T, Y, or X configuration with a stent-in-stent method using large cell-type stents. Technical success, complications, successful internal drainage, stent patency, and patient survival were analyzed.

RESULTS

A total of 118 stents were successfully placed in 51 patients (100.0%). Three patients had minor complications with self-limiting hemobilia. Major complications were not observed in any patient. Successful internal drainage was achieved in 45 patients (88.2%). Clinical follow-up information until death or the end of the study was available for 50 of 51 patients. The median patient survival was 285.5 days (95% confidence interval [CI] 197-374). Stent dysfunction occurred in 16 patients (35.6%) due to tumor ingrowth (n=9) or tumor ingrowth combined with biliary sludge (n=7) among the patients who achieved successful internal drainage. Median stent patency was 179 days (95% CI 104-271).

CONCLUSION

Percutaneous stent-in-stent placement with large cell-type stents is technically feasible and safe, and can be an effective technique in patients with malignant hilar biliary obstruction.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Percutaneous Image-Guided Biliary Procedures

Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.

Percutaneous stent placement for malignant hilar biliary obstruction: side-by-side versus stent-in-stent technique

BACKGROUND

Currently, side-by-side (SBS) and stent-in-stent (SIS) are the two main techniques for stent deployment to treat hilar biliary obstructions. Previous studies comparing these two techniques are very limited, and thus, no consensus has been reached on which technique is better. The purpose of this study is to compare the clinical efficacy and safety of SBS and SIS deployment via a percutaneous approach for malignant hilar biliary obstruction.

METHODS

From July 2012 to April 2019, 65 patients with malignant hilar biliary obstruction who underwent bilateral stenting using either the SBS or SIS techniques were included in this study. Among them, 27 patients underwent SIS stent insertion (SIS group), and the remaining 38 patients underwent SBS stent insertion (SBS group). Technical success, improvement of jaundice, complications, duration of stent patency, and overall survival were evaluated.

RESULTS

Technical success was achieved in all patients in the two groups. The serum bilirubin level decreased more rapidly 1 week after the procedures in the SBS group than in the SIS group (P = 0.02). Although the total complication rate did not differ between the two groups, cholangitis was found to be more frequent in the SIS group (P = 0.04). The median stent patency was significantly longer in the SBS group (149 days) than in the SIS group (75 days; P = 0.02). The median overall survival did not significantly differ between the two groups (SBS vs. SIS, 155 days vs. 143 days; P > 0.05).

CONCLUSIONS

Percutaneous transhepatic bilateral stenting using either the SBS or SIS technique is safe and effective in the management of malignant hilar biliary obstruction. However, SBS offers a quicker improvement of jaundice, a lower incidence of cholangitis after the procedure, and a longer stent patency period than SIS.

Embolization for delayed arterial bleeding after percutaneous self-expandable metallic stent placement in patients with malignant biliary obstruction

OBJECTIVES

To retrospectively evaluate the safety and efficacy of transcatheter arterial embolization (TAE) for delayed arterial bleeding secondary to percutaneous self-expandable metallic stent (SEMS) placement in patients with malignant biliary obstruction (MBO).

METHODS

From January 1997 to September 2017, 1858 patients underwent percutaneous SEMS placement for MBO at a single tertiary referral center. Among them, 19 patients (mean age, 70.2 [range, 52-82] years; 13 men) presented with delayed SEMS-associated arterial bleeding and underwent TAE.

RESULTS

The incidence of delayed arterial bleeding was 1.0% (19/1858) after SEMS placement, with a median time interval of 225 days (range, 22-2296). Digital subtraction angiography (DSA) showed pseudoaneurysm alone close to the stent mesh (n = 10), pseudoaneurysm close to the stent mesh with contrast extravasation to the duodenum (n = 3), pseudoaneurysm close to the stent mesh with arteriobiliary fistula (n = 1), in-stent pseudoaneurysm alone (n = 4) and in-stent pseudoaneurysm with arteriobiliary fistula (n = 1). Bleeding was stopped after the embolization in all patients. Overall clinical success rate was 94.7% (18/19). One patient with recurrent bleeding was successfully treated with a second embolization. Overall 30-day mortality rate was 26.3% (5/19). A major procedure-related complication was acute hepatic failure in one hilar bile duct cancer patient (5.3%), which was associated with an obliterated portal vein.

CONCLUSION

TAE is safe and effective for the treatment of delayed arterial bleeding after percutaneous SEMS placement for MBO.

ADVANCES IN KNOWLEDGE

This study demonstrated TAE is safe and effective for arterial bleeding after SEMS placement after MBO through the largest case series so far.

Transjugular insertion of biliary stent in patients with malignant biliary obstruction complicated by ascites with/without coagulopathy: a prospective study of 12 patients

PURPOSE

In patients with malignant biliary obstruction complicated by massive ascites, when endoscopy fails, safe routes for biliary decompression are needed as an alternative to percutaneous approach. We aimed to evaluate the safety and effectiveness of transjugular insertion of biliary stent (TIBS) in patients with malignant biliary obstruction complicated by massive ascites with or without coagulopathy.

METHODS

From March 2012 to December 2017, a total of 12 consecutive patients with malignant biliary obstructions treated with TIBS were enrolled in this study. Five patients had jaundice and cholangitis, while seven had jaundice only. Clinical parameters including technical and clinical success rates and complications following TIBS were evaluated. Overall survival and stent occlusion-free survival were assessed using Kaplan-Meier analysis.

RESULTS

The indications for transjugular approach were massive ascites with (n=2) or without (n=10) coagulopathy. TIBS was technically successful in 11 of 12 patients. Clinical success was defined as successful internal drainage and was achieved in eight patients. The mean serum bilirubin level was initially 13.9±6.3 mg/dL and decreased to 4.9±5.3 mg/dL within 1 month after stent placement (P = 0.037). Two patients had procedure-related complications (hemobilia). During the follow-up period (mean, 30 days; range, 1-146 days), all 12 patients died of disease progression. The median overall survival and stent occlusion-free survival times were 19 days (95% confidence interval [CI], 16-22 days) and 19 days (95% CI, 12-26 days), respectively. There was no stent dysfunction in the eight patients that had successful internal drainage.

CONCLUSION

TIBS appears to be safe, technically feasible, and clinically effective for patients with malignant biliary obstruction complicated by massive ascites with or without coagulopathy.

No evidence of improved efficacy of covered stents over uncovered stents in percutaneous palliation of malignant hilar biliary obstruction: results of a prospective randomized trial

OBJECTIVE

To investigate whether covered stents show a higher efficacy than uncovered stents in percutaneous treatment of malignant hilar biliary obstruction.

METHODS

Patients with obstructive jaundice caused by an unresectable hilar malignancy were included after failed endoscopic intervention in a prospective randomized trial comparing expanded polytetrafluoroethylene and fluorinated ethylene propylene (ePTFE-FEP)-covered nitinol stents with uncovered nitinol stents. Exclusion criteria were as follows: primary tumors existing more than 3 months, a biliodigestive anastomosis, previous stenting, and a Karnofsky score of less than 50. Safety, clinical success, and adjuvant chemotherapy were compared as well as occlusion rate, patency, and survival.

RESULTS

A total of 120 patients were included. One patient was post hoc excluded. Fourteen patients who died within 7 days and one patient without patency data were excluded from patency analysis. Serious adverse events (p = 0.4), 30-day mortality (p = 0.5), and clinical success (p = 0.8) were equivalent for both stent groups. Twenty-one out of 61 (34%) patients in the covered and 24/58 (41%) in the uncovered stent groups received adjuvant chemotherapy (p = 0.5). Occlusion rate was 54% (27/50) in the covered stent group and 57% (31/54) in the uncovered stent group (p = 0.8). Median patency was 229 days (95% CI 113-345) for covered stents and 130 days (95% CI 75-185) for uncovered stents (p = 0.1). Median survival in patients with covered stents was 79 days (95% CI 52-106) and with uncovered stents 92 days (95% CI 60-124) (p = 0.3).

CONCLUSION

In malignant hilar biliary obstruction, there is no evidence that ePTFE-FEP-covered stents are superior to uncovered stents in terms of safety, clinical success, adjuvant chemotherapy, patency, or survival.

KEY POINTS

• Percutaneous palliation of hilar biliary obstruction is feasible with both uncovered and covered stents. • Clinical success in terms of bilirubin decrease and adjuvant chemotherapy is achievable with both stents. • Thirty-day mortality is considerable when stenting is also offered to patients with a low performance status.

Percutaneous Metallic Stent Placement for Palliative Management of Malignant Biliary Hilar Obstruction

Objective

To investigate the outcomes of percutaneous metallic stent placements in patients with malignant biliary hilar obstruction (MBHO).

Materials and Methods

From January 2007 to December 2014, 415 patients (mean age, 65 years; 261 men [62.8%]) with MBHO were retrospectively studied. All the patients underwent unilateral or bilateral stenting in a T, Y, or crisscross configuration utilizing covered or uncovered stents. The clinical outcomes evaluated were technical and clinical success, complications, overall survival rates, and stent occlusion-free survival.

Results

A total of 784 stents were successfully placed in 415 patients. Fifty-five patients had complications. These complications included hemobilia (n = 19), cholangitis (n = 13), cholecystitis (n = 11), bilomas (n = 10), peritonitis (n = 1), and hepatic vein-biliary fistula (n = 1). Clinical success was achieved in 370 patients (89.1%). Ninety-seven patients were lost to follow-up. Stent dysfunction due to tumor ingrowth (n = 107), sludge incrustation (n = 44), and other causes (n = 3) occurred in 154 of 318 patients. The median overall survival and the stent occlusion-free survival were 212 days (95% confidence interval [CI], 186-237 days) and 141 days (95% CI, 126-156 days), respectively. The stent type and its configuration did not affect technical success, complications, successful internal drainage, overall survival, or stent occlusion-free survival.

Conclusion

Percutaneous stent placement may be safe and effective for internal drainage in patients with MBHO. Furthermore, stent type and configuration may not significantly affect clinical outcomes.

Percutaneous biliary approach as a successful rescue procedure after failed endoscopic therapy for drainage in advanced hilar tumors

BACKGROUND AND AIM

Palliative endoscopic or percutaneous biliary drainage is used for unresectable advanced hilar cancer (HC). The best option for drainage in Bismuth type III or IV HC has not been established. The aims of this study are to identify factors predictive of endoscopic stenting failure and evaluate the effectiveness of rescue percutaneous stenting in patients with advanced HC.

METHODS

Data from 110 patients with inoperable advanced HC were retrospectively reviewed. All received bilateral self-expandable metallic stents. Patients were divided into three groups: I, successful initial endoscopic stenting; II, unsuccessful initial endoscopic stenting, followed by percutaneous stenting; and III, initial percutaneous stenting. We analyzed clinical results and radiologic tumor characteristics.

RESULTS

Baseline characteristics and clinical outcomes of all groups were similar, except the hospital stay was longer in group III than group I. Technical success rate was higher in groups II and III (100%) than in group I (72.4%). The functional success rate, stent patency time, patient survival time, and complication rate were similar between groups. Endoscopic stenting failed because of guide-wire passage failure (n = 12) or stent passage failure (n = 7). The only factor significantly associated with endoscopic failure was a smaller left intrahepatic duct-common bile duct angle.

CONCLUSIONS

As clinical outcomes were generally similar between approaches, percutaneous stenting is recommended for patients with Bismuth type III or IV advanced HC. Acute left intrahepatic duct-common bile duct angulation predicts endoscopic stenting failure. If endoscopic stenting fails, immediate conversion to the percutaneous approach is a necessary and effective rescue method.

Percutaneous "Y" biliary stent placement in palliative treatment of type 4 malignant hilar stricture

BACKGROUND

This study evaluated the technical and clinical efficacy of percutaneous bilateral biliary stent-in-stent (SIS) deployment technique with a "Y" configuration using open-cell-design stents in type 4 Klatskin tumor patients.

METHODS

Retrospective evaluation ten patients with type IV Bismuth malignant hilar stricture (MHS) treated with percutaneous bilateral "Y" SIS deployment technique placement followed in our institution between March of 2012 and November of 2014.

RESULTS

Bilateral SIS deployment was technically successful in all patients. One patient (10%) had major complications (episode of cholangitis); one patient (10%) had minor complications, including self-limiting hemobilia. Successful internal drainage was achieved in nine (90%) patients. Stent occlusion by tumor overgrowth and sludge formation occurred in two patient (20%). The median survival and stent patency time were 298 and 315 days respectively.

CONCLUSIONS

Percutaneous bilateral metal stenting using a Y-stent is a valid option for the palliative treatment of type 4 Bismuth MHS, improving quality patient' life.

Drainage-related Complications in Percutaneous Transhepatic Biliary Drainage: An Analysis Over 10 Years

BACKGROUND

Procedure-related complications of percutaneous transhepatic biliary drainage (PTBD) have been well documented in the literature. However, relatively restricted data are available concerning drainage-related complication rates in long-term PTBD therapy. The present retrospective study evaluated the extent and the nature of drainage complications during PTBD therapy and associated risk factors for these complications.

PATIENTS AND METHODS

Between June 1997 and May 2007, a total of 385 patients with PTBD were identified by analyzing the PTBD database and hospital charts, with a total of 2468 percutaneous biliary drainages being identified.

RESULTS

Among the identified patients, 243 (63%) had malignant and 142 (37%) had benign bile duct strictures. At least 1 drainage-related complication was observed in 40% of the patients. With respect to the total number of drains, prosthesis complications occurred in 23%. Occlusion, dislocation, and cholangitis were the most common complications observed during PTBD therapy. Risk factors for cholangitis and occlusion were malignant disease, prior occurrence of complications, and bilateral drainage. Proximal stenosis of the biliary system was close to significant.

CONCLUSIONS

Drainage-related complications are a major problem in PTBD therapy. The risk factors for occlusion and cholangitis discovered in this study can help to refine individual strategies to reduce the rate of these drainage complications.

Percutaneous transhepatic biliary metal stent for malignant hilar obstruction: results and predictive factors for efficacy in 159 patients from a single center

AIM

To investigate and compare the efficacy and safety of percutaneous transhepatic biliary stenting (PTBS) using a one- or two-stage procedure and determine the predictive factors for the efficacious treatment of malignant hilar obstruction (MHO).

METHODS

159 consecutive patients with MHO who underwent PTBS were enrolled between January 2010 and June 2013. Patients were classified into one- or two-stage groups. Independent predictors of therapeutic success were evaluated using a logistic regression model.

RESULTS

108 patients were treated with one-stage PTBS and 51 patients were treated with two-stage PTBS. The stents were technically successful in all patients. Successful drainage was achieved in 114 patients (71.4 %). A total of 42 early major complications were observed. Re-interventions were attempted in 23 patients during follow-up. The cumulative primary patency rates at 3, 6, and 12 months were 88, 71, and 48 %, respectively. Stent placement using a one- or two-stage procedure did not significantly affect therapeutic success, early major complications, median stent patency, or survival. A stent placed across the duodenal papilla was an independent predictor of therapeutic success (odds ratio = 0.262, 95 % confidence interval [0.107-0.642]). Patients with stents across papilla had a lower rate of cholangitis compared with patients who had a stent above papilla (7.1 vs. 20.3 %, respectively, p = 0.03).

CONCLUSIONS

The majority of patients with MHO who underwent one-stage PTBS showed similar efficacy and safety outcomes compared with those who underwent two-stage PTBS. Stent placement across the duodenal papilla was associated with a higher therapeutic success rate.