GENERAL SURGERY

Percutaneous transhepatic self-expanding metal stents for palliation of malignant biliary obstruction

A J Lawson^I; S J Beningfield^I; J E J Krige^II; P Rischbieter^III; S Burmeister^IV

^IMB ChB, FFRad (SA); Department of Radiology, Faculty of Health Sciences, University of Cape Town
^IIMB ChB, MSc, FACS, FRCS, FCS (SA); Department of Surgery, Faculty of Health Sciences, University of Cape Town, and Surgical Gastroenterology, Groote Schuur Hospital, Cape Town
^IIIMB ChB; Department of Medicine, Themba Hospital, White River, Mpumalanga
^IVMB ChB, FCS (SA); Department of Surgery, Faculty of Health Sciences, University of Cape Town, and Surgical Gastroenterology, Groote Schuur Hospital, Cape Town

ABSTRACT

BACKGROUND: Malignant biliary obstruction is often inoperable at presentation and has a poor prognosis. Percutaneously placed self-expanding metal stents (SEMS) have been widely used for palliation of malignant biliary obstruction as an alternative to major bypass surgery or when endoscopic drainage is not technically feasible. The success rate, procedural complications and outcomes in patients who underwent placement of SEMS in a tertiary referral centre are presented.
METHODS: All patients who had percutaneous transhepatic cholangiography (PTC) and SEMS for palliation of malignant biliary obstruction between May 2008 and July 2010 at Groote Schuur Hospital, Cape Town, were reviewed. A retrospective chart review was undertaken using multidisciplinary case notes of all patients. The data analysed included demographic information, diagnosis, level of biliary obstruction, number and type of procedures, efficacy and complications of SEMS insertion. Boston Scientific 69 mm by 10 mm Wallstent SEMS were used in all patients.
RESULTS: Fifty patients (28 men, 22 women, mean age 61 years, range 48 - 80 years) underwent percutaneous SEMS placement. Twenty-one patients had biliary obstruction at the level of the hilum involving the hepatic duct bifurcation, 5 in the mid-common bile duct and 24 in the low common bile duct. In 20 patients (40%) SEMS were placed at the time of initial biliary drainage (one-stage procedure), while the remaining 30 patients underwent stent placement within 2 - 23 days of biliary drainage as a two-stage procedure because of difficult access through the lesion during the initial procedure. Five patients (10%) required bilateral SEMS insertion. Stent placement was successful in all patients and biliary obstruction was relieved in all.
The mean serum bilirubin level decreased by a mean of 56% from 294 µmol/l to 129 µmol/l measured 5 days after stent insertion. Mean hospital stay after stent insertion was 4.1 days. The average length of hospital stay for patients who underwent a one-stage procedure was 3.2 days (range 1 - 11 days), and for patients who underwent a two-stage procedure 7.6 days (range 3 - 23 days).
Nine patients (18%) developed a procedure-related complication, which included cholangitis after stent insertion (n=4), cholangitic liver abscesses (n=1), subphrenic liver collection (n=1), bile leakage (n=1) and cholecystitis (n=2). Three patients (6%) developed complications unrelated to SEMS insertion, which included myocardial ischaemia (n=2) and pneumonia (n=1).
Stent occlusion occurred in 4 patients (8%) within a week as result of stent migration (n=3) or presumed biliary sludge (n=1); 2 (4%) stents occluded between 7 days and 1 month. Four patients (8%) died during hospital admission due to pre-existing biliary sepsis (n=3) and pneumonia (n=1). Nine patients developed duodenal obstruction due to disease progression and required endoscopic duodenal stenting. Four patients (8%) survived less than 1 month, 12 (24%) between 1 month and 3 months, 11 (22%) between 3 and 6 months, and 10 (20%) beyond 6 months. Follow-up was not possible for 9 patients (18%) from distant referral sites.
CONCLUSION: These results demonstrate that percutaneously placed SEMS achieved satisfactory palliation with a low complication rate in a high-risk patient group with advanced malignant biliary obstruction.

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REFERENCES

1. Pinol V, Castells A, Bordas JM, et al. Percutaneous self-expanding metal stents versus endoscopic polyethylene endoprostheses for treating malignant biliary obstruction: randomized clinical trial. Radiology 2002;225(1):27-34. [http://dx.doi.org/10.1148/radiol.2243011517]        [ Links ]

2. Maetani I, Tada T, Ukita T, Inoue H, Sakai Y, Nagao J. Comparison of duodenal stent placement with surgical gastrojejunostomy for palliation in patients with duodenal obstructions caused by pancreaticobiliary malignancies. Endoscopy 2004;36(01):73-78.         [ Links ]

3. Kaassis M, Boyer J, Dumas R, et al. Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study. Gastrointest Endoscop 2003;57(2):178-182. [http://dx.doi.org/10.1067/mge.2003.66]        [ Links ]

4. Isayama H, Komatsu, Y, Tsujino T, et al. A prospective randomised study of covered versus uncovered diamond stents for the management of distal malignant biliary obstruction. Gut 2004;53(5):729-734. [http://dx.doi.org/10.1136/gut.2003.018945]        [ Links ]

5. Knyrim K, Wagner H. J, Pausch J, Vakil, N. A prospective, randomized, controlled trial of metal stents for malignant obstruction of the common bile duct. Endoscopy 1993;25(03):207-212. [http://dx.doi.org/10.1055/s-2007-1010294]        [ Links ]

6. Davids PHP, Groen AK, Rauws EAJ, Tytgat GNJ, Huibregtse K. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 1992;340:1488-1492. [http://dx.doi.org/10.1016/0140-6736(92)92752-2]        [ Links ]

7. Khan SA, Thomas HC, Davidson BR, Taylor-Robinson SD. Cholangiocarcinoma. Lancet 2005;366:1303-1314. [http://dx.doi.org/10.1016/S0140-6736(05)67530-7]        [ Links ]

8. Pappas P, Leonardou P, Kurkuni A, Alexopoulos T, Tzortzis G. Percutaneous insertion of metallic endoprostheses in the biliary tree in 66 patients: relief of the obstruction. Abdom Imaging 2003;28(5):678-683. [http://dx.doi.org/10.1007/s00261-003-0004-3]        [ Links ]

9. Park SB, Kim HW, Kang DH, et al. Metallic or plastic stent for bile duct obstruction in ampullary cancer? Dig Dis Sci 2012;57:786-790. [http://dx.doi.org/10.1007/s10620-011-1909-2]        [ Links ]

10. Brountzos E, Ptochis N, Panagiotou I, Malagari K, Tzavara C, Kelekis D. A survival analysis of patients with malignant biliary strictures treated by percutaneous metallic stenting. Cardiovasc Intervent Radiol 2007;30(1):66-73. [http://dx.doi.org/10.1007/s00270-005-0379-3]        [ Links ]

11. Van Delden O, Laméris J. Percutaneous drainage and stenting for palliation of malignant bile duct obstruction. Eur Radiol 2008;18(3):448-456.         [ Links ]

12. Kneuertz PJ, Cunningham SC, Cameron JL, et al. Palliative surgical management of patients with unresectable pancreatic adenocarcinoma: trends and lessons learned from a large, single institution experience. J Gastrointest Surg 2011 15(11):1917-1927. [http://dx.doi.org/10.1007/s11605-011-1665-9 ]        [ Links ]

13. Hosono S, Ohtani H, Arimoto Y, Kanamiya Y. Endoscopic stenting versus surgical gastroenterostomy for palliation of malignant gastroduodenal obstruction: a meta-analysis. J Gastroenterol 2007;42(4):283-290. [http://dx.doi.org/10.1007/s00535-006-2003-y]        [ Links ]

14. Shaw JM, Bornman PC, Krige JE, Stupart DA, Panieri E. Self-expanding metal stents as an alternative to surgical bypass for malignant gastric outlet obstruction. Br J Surg 2010;97(6):872-876. [http://dx.doi.org/10.1002/bjs.6968]        [ Links ]

15. Gomez-Oliva C, Guarner-Argente C, Concepcion M, et al. Partially covered self-expanding metal stent for unresectable malignant extrahepatic biliary obstruction: results of a large prospective series. Surg Endosc 2012;26(1):222-229.         [ Links ]

16. Ahmad N, Ginsberg GG. Expandable metal stents for malignant biliary obstruction. Techniques in Gastrointestinal Endoscopy 2001;3:93-102. [http:// dx.doi.org/10.1053/tgie.2001.22151]        [ Links ]

17. Tsuyuguchi T, Takada T, Miyazaki M, et al. Stenting and interventional radiology for obstructive jaundice in patients with unresectable biliary tract carcinomas. J Hepatobiliary Pancreat Surg 2008;15(1):69-73. [http://dx.doi.org/10.1007/s00534-007-1282-x]        [ Links ]

18. De Palma GD, Masone S, Esposito D, Persico G. Endoscopic or percutaneous approach for advanced biliary stenoses at the hepatic hilum? Gastrointest Endosc 2009;70(2):403-404. [http://dx.doi.org/10.1016/j.gie.2008.12.058]        [ Links ]

19. Lameris JS, Stoker J, Nijs HG, Zonderland HM, Terpstra OT, van Blankenstein M. Malignant biliary obstruction: percutaneous use of self-expandable stents. Radiology 1991;179(3):703-707.         [ Links ]

20. Perdue D, Freeman, ML, DiSario JA, et al. Plastic versus self-expanding metallic stents for malignant hilar biliary obstruction: A prospective multicenter observational cohort study. J Clin Gastroenterol 2008;42(9):1040-1046.         [ Links ]

21. Young-Min HH-SK, Gong-Yong J, Seung-Ok L, Gyung-Ho C. Treatment of malignant biliary obstruction with a PTFE-covered self-expandable nitinol stent. Korean J Radiol 2007;8(5):410-417.         [ Links ]

22. George C, Byass OR, Cast JE. Interventional radiology in the management of malignant biliary obstruction. World Journal of Gastrointestinal Oncology 2010;2(3):146-150. [http://dx.doi.org/10.4251/wjgo.v2.i3.146]        [ Links ]