Multiple metallic stents placement for malignant hilar biliary obstruction: Perspective of a radiologist

Abstract

A B S T R A C TIn the palliative setting, the necessity of biliary drainage of both liver lobes for malignant hilar biliary obstruction remains controversial. However, bilateral biliary drainage is a reasonable option to prevent cholangitis of the undrained lobe and to preserve liver function during the course of chemotherapy. Bilateral biliary drainage can be accomplished by the percutaneous or endoscopic placement of multiple self-expandable metallic stents (SEMS). Although SEMS placement via bilateral (multiple) percutaneous routes is technically simple, multiple percutaneous transhepatic biliary drainage (PTBD) may lead to additional morbidity. SEMS placement via a single percutaneous route is a useful method; however, negotiation of a guidewire into the contralateral bile duct is occasionally impossible if the hilar angle between the right hepatic duct and left hepatic duct is acute. Percutaneous dual SEMS placement is generally performed using the stent-in-stent technique (T configuration or Y configuration) or the side-byside technique. In addition, the crisscross technique has been reported as being a useful method for trisegmental drainage. The side-to-end technique is also useful for multiple SEMS placement. In the future, the combination of percutaneous intervention and endoscopic ultrasonography-guided procedures may be effective in the management of malignant hilar biliary obstruction.

Percutaneous biliary intervention: tips and tricks

“…18,19 It is hypothesized that a single stent may suffice in Bismuth type I, II and III strictures, but multi-segmental occlusions, with complex proximal strictures (Bismuth type IV) would require placement of multiple stentsto prevent cholangitis of undrained segments and to achieve adequate relief of cholestasis to initiate chemotherapy. [20][21][22][23] But, in the absence of sufficient prospective data or randomized controlled trials, efficacy of one over the other cannot be established unequivocally for palliative intent.…”

“…Both plastic and metallic stents are available, although the latter are preferably used in patients with malignant biliary obstruction in view of their prolonged patency rates 18 apart from technical advantages like greater flexibility and minimal foreshortening at deployment. 20 Uncovered self-expanding metallic stents have shown good results in palliation of jaundice with reduced need for intervention and delayed stent occlusion. 33 Plastic stents, on the other hand, have limited role in long term palliation of malignant biliary obstruction due to early occlusion.…”