Patency of side branches after peripheral placement of metallic biliary endoprostheses

Expandable Metallic Endoprostheses for Biliary Obstruction

Expandable metal stents (20 Gianturco Z-stents and 1 Strecker stent deployed through 8.5 F sheaths) were used with initial success for palliating bile duct obstruction in 10 patients, 8 with malignant and 2 with benign strictures. Short-term failure occurred in one patient after 2 weeks, one died of unrelated causes after 10 days, and one remained jaundiced due to fulminant liver metastases. In the remaining 7 patients the obstruction was markedly palliated, with normalization of the serum bilirubin. Four have died without recurrent bile duct obstruction after a mean of 5.9 months, the 2 with benign strictures are well after 4 and 7 months, and one patient is presently palliated with a plastic endoprosthesis following reocclusion after 4 months. Expandable stents were easier to insert than conventional percutaneous endoprostheses of plastic polymers, and had longer patency in several patients, but reocclusion by tumor growth remains a constant threat in malignant disease. Metallic stents may be the therapy of choice in recurrent benign strictures, although the definitive conclusion needs longer observation and larger materials.

Optimum palliation of inoperable hilar cholangiocarcinoma: comparative assessment of the efficacy of plastic and self-expanding metal stents

BACKGROUND

Endoscopic retrograde biliary drainage (ERBD) with plastic or self-expanding metal stents (SEMS) is often performed for palliative care for cholangiocarcinoma.

OBJECTIVE

The objective was to compare the clinical effectiveness, including stent patency, complication rate, and need for salvage percutaneous transhepatic biliary drainage, of SEMS and plastic stents.

METHODS

A total of 100 patients with inoperable cholangiocarcinoma were identified from an endoscopic database from 1/1/01 to 9/30/06 at a tertiary cancer hospital and their clinical history was retrospectively reviewed. All patients were followed to death, re-intervention, or for at least one year. Stent patency and patient survival were estimated by Kaplan-Meier analysis, supplemented by the log-rank test for comparisons between groups.

RESULTS

Forty-eight patients had SEMS placed and 52 patients had plastic stents placed. ERBD was successful in 46 (95.8%) in the SEMS group and 49 (94.2%) in the plastic group (P = 0.67). Median patency times were 1.86 months in the plastic group and 5.56 months in the SEMS group (P < 0.0001). A mean of 1.53 and 4.60 re-interventions were performed in the SEMS and plastic groups, respectively (P < 0.05). Complications occurred in 4/48 (8.3%) in the SEMS group and 4/52 (7.7%) in the plastic group (P = 0.79). Median survival was 9.08 and 8.22 months in the SEMS and plastic stent groups, respectively (P = 0.50).

CONCLUSION

Metallic stent patency was superior to that of plastic stents in all Bismuth-Corlette classifications of hilar cholangiocarcinoma with similar complication rates. SEMS seem to be cost-effective and, when feasible, should be considered as an initial intervention in patients with inoperable hilar cholangiocarcinoma.

Result of endoscopic biliary drainage in hilar cholangiocarcinoma

Patients with hilar obstruction usually require bilateral biliary drainage. The prognosis of patients who fail bilateral biliary drainage after contrast injection into both intrahepatic ducts is poor due to a high infection rate in the undrained segments. The incidence of post-endoscopic retrograde cholangiopancreatography cholangitis in those with successful bilateral biliary drainage was less, but still significant. Incomplete subsegmental intrahepatic duct drainage is suggested to be responsible for post-biliary drainage cholangitis in cases of advanced hilar tumors. This study was undertaken to determine the incidence of post-endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and stent clogging in different types of malignant biliary obstruction after biliary drainage. From our endoscopic retrograde cholangiopancreatography database, there were 63 patients who underwent endoscopic biliary drainage between September 2000 and November 2001, for malignant biliary obstruction. Sixty-one endoscopic retrograde cholangiopancreatographies had biliary drainage performed (2 patients who failed biliary drainage were excluded). We divided our patients into 3 groups: Group 1 = Bismuth I, Group 2 = Bismuth II, and Group 3 = Bismuth III and IV. All but 2 Group 1 patients had successful biliary endoprosthesis (plastic [n = 13], metallic [n = 12], failed [n = 2]) placement into an extrahepatic duct. All patients from Group 2 (n = 10) and 20 patients from Group 3 (n = 26) had successful bilateral biliary drainage. Unilateral biliary drainage was performed in 6 patients from Group 3, each with a plastic endoprosthesis. The incidence of post-biliary drainage cholangitis (new onset of fever >38.5 degrees C with leukocytosis), jaundice resolution (normal bilirubin level), and the duration of endoprosthesis patency were compared among the 3 groups. The incidences of post-endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and the duration of endoprosthesis patency were: Group 1 (4%, 96%, and 87.2 days, respectively), Group 2 (10%, 100%, and 69.1 days, respectively) and Group 3 (57.7%, 73.1%, and 41.3 days, respectively). Of those patients who did not undergo surgery, patients from Group 3 required endoprosthesis exchange sooner than others. The outcome of biliary drainage in patients with advanced hilar tumors (Bismuth III or IV) was poorer than hilar tumor at earlier stages (Bismuth I or II).

Role of radiology in the treatment of malignant hilar biliary strictures 1: Review of the literature

Malignant strictures of the biliary tree are an uncommon cause of obstructive jaundice. There are a number of pathological subtypes, but tumours in this region tend to have similar clinical and diagnostic features and therapeutic and prognostic implications. We review the published literature on this topic discussing diagnostic modalities and treatment options with a focus on radiological intervention. Diagnosis currently is best achieved using a range of procedures. Direct cholangiography remains the gold standard in delineating anatomy, but the invasiveness of this procedure limits its use as a purely diagnostic tool. Magnetic resonance technology, in particular magnetic resonance cholangiopancreatography, has an increasing role as accessibility is improved. Treatment of these tumours is difficult. Surgical resection and palliative biliary enteric bypass are the most common methods used with endoscopic and percutaneous therapies reserved for palliating patients not fit for surgery. There is little firm evidence to suggest that any one palliative modality is superior. Interventional radiology is particularly suitable for palliative management of difficult and expansive lesions as the anatomy can preclude easy access by surgical or endoscopic techniques. Good palliative results with minimal mortality and morbidity can be achieved with percutaneous stenting.

Percutaneous self-expandable uncovered metallic stents in malignant biliary obstruction. Complications, follow-up and reintervention in 154 patients

PURPOSE

Evaluation of technique, complications and the long-term follow-up data of 154 patients with inoperable malignant biliary obstruction who underwent percutaneous placement of metallic stents.

MATERIAL AND METHODS

During a 6-year period, 224 self-expanding metallic stents (150 biliary Wallstents and 74 Memotherm nitinol stents) were inserted in 154 patients with inoperable malignant biliary obstruction. 100 patients had obstructions at the proximal (supracystic) level, and 54 at the distal (infracystic) level. The causes of obstructions were hilar cholangiocarcinoma (n = 64), pancreatic carcinoma (n = 34), gallbladder carcinoma (n = 24), metastatic carcinoma (n = 21), common bile duct carcinoma (n = 8), and hepatocellular carcinoma (n = 3). A complete follow-up was available for all patients.

RESULTS

The 30-day mortality was 9%, with no procedure-related deaths. The clinical success rate within the first 30 days was 88%. The total rate of early, procedure-related complications was 28%, and half of them were due to the percutaneous transhepatic catheter drainage procedure. Recurrent jaundice occurred in 28 (18%) patients and in 23 (82%) of these, reinterventions were made in order to relieve reobstructions. The mean length of survival for the entire patient group was 4 months, while the mean period of patency for all stents was 6 months. We found no statistically significant difference in patient survival or stent patency periods in regard to the level and cause of obstruction.

CONCLUSION

Percutaneous metallic stent placement maintains equal palliation in patients with proximal and distal malignant biliary obstructions caused by any tumor type. Most of the early complications were due to procedures performed before stent insertion and could be decreased by direct stent insertions. The most common late complication, reobstruction, is inevitable but can be easily treated in the majority of patients.

Patency and complications of percutaneously inserted metallic stents in malignant biliary obstruction

PURPOSE

The aim of this study was to analyze the patency of percutaneously inserted metallic stents in malignant biliary obstruction and to evaluate all the complications associated with the stents and the reinterventions needed.

MATERIALS AND METHODS

Thirty-nine patients with 42 malignant strictures were treated percutaneously with 55 metallic self-expandable stents. Forty-eight were Wallstents and seven were Memotherm stents. Twenty-five strictures were hilar, 16 were in the common bile duct, and one was in the hepaticojejunal anastomosis. The patients were followed until death and the mean follow-up was 6.4 months.

RESULTS

Stent insertion was successful in 97% of the patients. Thirty percent had early complications (<30 days), and as many as 66% had late complications, including stent occlusions, which were seen in 10 patients. The patency rates of patients with cholangio-carcinoma were significantly lower than those of the patients with other diagnoses. There was also a tendency toward obstruction with less dilation of the stents, Y, T or tandem-style stent placement, an increasing number of stents, longer strictures, and hilar strictures. Thirty-one percent of the patients alive after the first 30 days had late reinterventions.

CONCLUSIONS

Although metallic stents offer an alternative in the palliation of malignant bile duct obstruction, there seem to be numerous early and late complications.

Interventional radiology and the use of metal stents in nonvascular clinical practice: a systematic overview

PURPOSE

The intent of this systematic overview was to describe the clinical role of metal stents in nonvascular health care interventions and the level of evidence supporting their use.

MATERIALS AND METHODS

Structured searches of Medline were conducted and limited to original peer-reviewed articles published in English.

RESULTS

Clinical practice involving metal stents was reported in more than 109 clinical series involving 4,753 patients. Stents were placed mainly for palliation of malignant biliary, esophageal, and airway obstruction in patients who were untreatable or had surgically unresectable lesions. Assessment of these interventions has so far centered on safety and technical success. Efficacy, quality of life, and costing factors were not routinely reported. Randomized trial evidence was available but limited; six randomized trials involving metal stents have been reported. Three trials involved biliary malignant obstruction, and all three reported metal stent (132 patients) palliation to be superior to plastic stent palliation (136 patients) based on longer patency and lower reintervention costs. Safety and complication differences between stents, however, were inconsistent across trials. In three trials involving esophageal malignant obstruction, metal stent (82 patients) palliation was reported to be superior to plastic stent (41 patients), based on lower complication and reintervention rates, and superior to laser therapy (18 patients), based on better dysphagia relief.

CONCLUSION

Use of metal stents has been reported for obstructed ducts and passageways of most body systems. There is, however, limited controlled trial evidence confirming the advantages of their use over plastic stents or other forms of treatment.

Metallic stents in malignant biliary obstruction

PURPOSE

Retrospective analysis of our results with metallic stent placement for malignant biliary strictures. We sought to determine parameters that influence stent patency.

METHODS

A total of 95 Wallstents were implanted in 65 patients (38 men, 27 women; mean age, 65.1 years) with malignant biliary obstruction. Serum bilirubin levels were assessed in 48 patients; the mean value prior to intervention was 15.0 mg/dl.

RESULTS

In 12 patients (21%) complications occurred as a result of percutaneous transhepatic drainage. Stent implantation was complicated in 13 patients, but was possible in all patients. A significant decrease in bilirubin level was seen in 83.3% of patients following stent implantation. Approximately 30% of patients developed recurrent jaundice after a mean 97.1 days. In 9 patients (15%) the recurrent jaundice was caused by stent occlusion due to tumor growth. The mean follow-up was 141.8 days, the mean survival 118.7 days. Patients with cholangiocarcinomas and gallbladder carcinomas had the best results. Worse results were seen in patients with pancreatic tumors and with lymph node metastases of colon and gastric cancers.

CONCLUSIONS

The main predictive factors for occlusion rate and survival are the type of primary tumor, tumor stage, the decrease in bilirubin level, and the general condition of the patient.

Biliary strictures in hepatic transplantation: treatment with self-expanding Z stents

PURPOSE

To determine the long-term results of Gianturco-Rösch Z (GRZ) stent placement for the treatment of recurrent, benign biliary strictures in liver transplant recipients.

MATERIALS AND METHODS

During a 5-year period, eight orthotopic liver transplant recipients underwent transhepatic placement of GRZ stents to treat 12 recurrent biliary strictures (six anastomotic, six intrahepatic). Prior treatment of 11 strictures with balloon dilation therapy had failed. Patients were followed up for 1-65 months.

RESULTS

Stent placement was successful in all patients. Stent position remained stable in all but one patient. Three patients died (1, 25, and 28 months after stent placement), all with patent stents. Four patients required no further biliary intervention. Two of the other four patients needed intermittent biliary balloon dilation with removal of bile duct debris. The third patient had a stable, nonobstructing stenosis in the stent. The fourth passed his stents and needed no further intervention.

CONCLUSION

GRZ stents are useful in patients who are refractory to repetitive balloon dilation of biliary strictures or who are poor surgical candidates.

Metallic biliary endoprostheses

In patients with obstructive jaundice caused by unresectable malignant tumors, biliary endoprostheses inserted percutaneously or endoscopically can provide excellent palliation. Conventional plastic stents are associated with a relatively high rate of occlusion caused by biliary sludge. Migration is another significant problem. Self-expandable, metallic stents can be inserted percutaneously via a small transhepatic track but expand to achieve a relatively large internal diameter. This minimizes the problem of occlusion due to encrusted bile and reduces the rate of reintervention. Migration rarely occurs. Metallic stents have also been employed in the management of recurrent benign biliary strictures unsuitable for surgery. In those patients in whom the frequency of radiological intervention is unacceptably high, such endoprostheses can provide a means of preventing restenosis.

Complications of percutaneously inserted biliary Wallstents

PURPOSE

Complications were assessed during and after percutaneous Wallstent endoprosthesis insertion in patients with inoperable malignant biliary obstruction.

PATIENTS AND METHODS

Two hundred seven Wallstents were inserted in 176 patients: 74 had hilar strictures and 102 had distal strictures. Median survival after stent placement was 95 days.

RESULTS

Early complications occurred in 12 patients (7%), predominantly cholangitis and reobstruction. Thirty-day mortality was 12%; 2% of deaths (three patients) were procedure related. Late complications, predominantly reobstruction, occurred in 35 patients (20%). Obstruction recurred in 33 patients (19%) after a median period of 135 days; 27 had a hilar stricture. Tumor overgrowth was the major cause of reobstruction (n = 19), especially proximal overgrowth. Tumor ingrowth caused reobstruction in three patients. Other causes were rare. No reobstruction due to sludge occurred. Reintervention was performed in 25 patients. Nineteen of the 25 patients benefited from repeated intervention.

CONCLUSION

The use of the Wallstent is preferable to use of a plastic stent, as the major complication--reobstruction--is not stent related predominantly but is caused by tumor progression.

Percutaneous palliation of malignant obstructive jaundice with the Wallstent endoprosthesis: follow-up and reintervention in patients with hilar and non-hilar obstruction

PURPOSE

The authors analyzed the follow-up data of 58 patients with malignant obstructive jaundice who underwent percutaneous palliative treatment with Wallstents over a 4-year period.

PATIENTS AND METHODS

Thirty-nine patients had obstruction at the hilar level, and 19 patients had common bile duct obstruction without hilar involvement. Stent patency and survival were calculated with the Kaplan-Meier method.

RESULTS

Early complications occurred in 14 patients (24%) and were managed conservatively. There were two procedure-related deaths (3.4%) due to sepsis and pancreatitis, and the overall 30-day mortality was 14%. Forty-eight patients have died, nine patients are surviving (average, 11 months), and one patient was lost to follow-up. Forty-four patients (77%) experienced relief of their initial symptoms, with bilirubin levels returning to normal in 63%. The 12-month patency rate of the endoprostheses was 46% in patients with hilar obstruction and 89% in patients with non-hilar obstruction (P = .029). Late biliary complications were documented in 20 patients (35%). Thirteen patients with hilar obstruction and two patients with common duct obstruction required at least one reintervention; stent patency was restored in all patients but one. The overall 6-month survival rate was 50%, and the 12-month survival rate, 36%; no significant difference was found between patients with hilar and non-hilar obstruction.

CONCLUSION

The long-term patency of the Wallstent endoprosthesis was excellent if common duct obstruction was treated but was significantly lower in the presence of hilar involvement. Use of the Wallstent did not result in a lower complication rate compared with the reported results of plastic endoprostheses. Reinterventions to restore stent patency were successful in almost all cases. The survival of patients with hilar and with non-hilar obstruction was similar.

Bilateral internal biliary drainage of hilar cholangiocarcinoma with modified Gianturco Z stents inserted via a single percutaneous tract

PURPOSE

Modified Gianturco Z stents were used in five patients with hilar cholangiocarcinoma to permit bilobar hepatic drainage via a single percutaneous tract.

PATIENTS AND METHODS

After successful negotiation of strictures from the ipsilateral hepatic duct to the contralateral hepatic duct and the common bile duct, a modified endoprosthesis--made by connecting two double-body Z stents with two stainless steel wires in order to leave a space in between--was implanted in one stricture and a 'space' was located at the hepatic confluence. A second endoprosthesis, a two- to six-body Z stent, was introduced into the second stricture through the 'space' of the initial endoprosthesis and was implanted so that a part of the endoprosthesis should overlap the initial endoprosthesis.

RESULTS

Optimal positioning of the two endoprostheses was successful in all patients.

CONCLUSION

The technique seems simple, safe, and reliable in reconstructing the bilateral hepatic ductal systems via a single percutaneous approach in patients with hilar cholangiocarcinoma.