A Comparison of Right Versus Left Hepatic Duct Endoprosthesis Insertion in Malignant Hilar Biliary Obstruction

Abstract

Endoscopic endoprosthesis insertion plays an increasingly important role in the palliation of jaundice in patients with unresectable malignant hilar biliary obstruction (HBO). Drainage of both obstructed lobes in Types II and III HBO is not necessary to achieve adequate palliation, providing 25% of the liver volume is drained by a single endoprosthesis. The anatomy of the main hepatic ducts suggests some benefit may accrue from preferential drainage of the left hepatic duct. We have reviewed a consecutive series of 151 patients with Type II and III HBO over a 4-year period to compare the outcome of endoprosthesis placement in either the right (RHD) or left (LHD) hepatic duct, to test this hypothesis. No significant difference was found in terms of successful drainage, complications, 30-day mortality, number of endoprosthesis changes and survival between patients with right system drainage compared with those with left sided drainage (chi 2-test and Mann Whitney U test). When dealing with a patient with a Type II or III HBO, we would recommend single endoscopic endoprosthesis insertion into the technically most accessible obstructed system. This would achieve adequate palliation in 84% of the patients.

Newly designed large cell Niti-S stent for malignant hilar biliary obstruction: a pilot study

“…On the other hand, an increased risk of cholangitis has been described if only one side is drained [1, 12,13]. Moreover, bilateral drainage is more physiologic than unilateral drainage [1, 12,14,15]. We perform unilateral SEMS placement in principle, but bilateral SEMS placement is necessary in cases with prolonged jaundice or contralateral cholangitis after unilateral drainage.…”

Palliation of Malignant Obstructive Jaundice

“…Decompression of both left and right hepatic ducts ideally requires the insertion of two stents, although there is evidence that unilateral stent insertion can be attempted, with good palliation [5], particularly if MRCP is utilized to direct stent placement [6]. Despite anatomical considerations suggesting that the left hepatic duct should be preferentially stented, it has been previously shown that drainage of the most technically accessible system will achieve adequate palliation in over 80% of patients [7].…”

Role of Palliative Endoscopic Drainage in Patients with Malignant Biliary Obstruction

“…However, they did translate into significantly more re-interventions (p = 0.05) and longer total hospital stay (p = 0.03), as well as costs among patients treated with plastic compared to metal stents. In a retrospective study by Polydorou et al [31, 52], comprising 151 patients and comparing endoscopic drainage of the right versus the left hepatic lobe, no significant differences were found regarding procedure-related morbidity and survival. Unilateral hepatic drainage at the first attempt has been found to afford good palliation in 80% of patients in another study by Polydorou et al [32], and by Freeman et al [55] who registered no post-procedure cholangitis episodes.…”

“…Such measures will hopefully prevent septic complications from translating into increased mortality and reduced survival [32, 55]. Although based on one RCT only [4], and there are few other data to support this view (table 4), the findings suggest that the ductal system (right or left hepatic duct according to Polydorou et al [31, 52]), easily filled with contrast medium and most easily/immediately accessible by guide wires, should be negotiated and subsequently drained with large-bore plastic or metal stents. This mode of action would also be appropriate with regard to survival and desired improvement in QOL [32].…”