Biliary Stenting
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Over the past few decades, biliary interventions have evolved a great deal. Opacification of the biliary system was first reported in 1921 with direct puncture of the gallbladder. Subsequent reports described direct percutaneous biliary puncture. The technique was revolutionized in 1960s with the introduction of fine-gauge (22- to 23-gauge) needles.
During the 1970s, percutaneous biliary drainage (PBD) for obstructive jaundice and percutaneous treatment of stone disease was introduced. Percutaneous cholecystostomy was first described in the 1980s. With the advent of metallic and plastic internal stents, further applications in the treatment of biliary diseases were developed. [1]
Current percutaneous biliary interventions include percutaneous transhepatic cholangiography (PTC) and biliary drainage to manage benign [2] and malignant obstruction and percutaneous cholecystostomy. [3] Percutaneous treatment of biliary stone disease, with or without choledochoscopy, is still performed in selected cases. Other applications include cholangioplasty for biliary strictures, biopsy of the biliary duct, and management of complications from laparoscopic cholecystectomy and liver transplantation.
This article outlines the procedure for biliary stenting. For descriptions of other biliary interventions, see Percutaneous Cholecystostomy, Percutaneous Cholangiography, and Percutaneous Biliary Drainage.
The most common indication for biliary stenting is for treatment of obstructive jaundice from either benign or malignant causes. [4, 5] On occasion, stents are placed for management of bile leaks. Stents are made of either plastic or metal, and they are placed to provide internal drainage, eliminating the need for an external catheter.
The major advantage plastic stents have over metallic stents is that they can be removed and replaced if necessary. Metallic stents, on the other hand, are generally permanent, but they have the advantage of a larger lumen and longer patency. This advantage is achieved by a design that enables placement with a relatively small delivery device (7 French) that contains the constrained stent by an outer sheath. Once the stent is positioned, the outer sheath is retracted, allowing the stent to expand.
Self-expanding metallic stents placed in the biliary tree have a luminal diameter of 10 mm, which is significantly larger than plastic stents, which are typically 2-4 mm in luminal diameter. Nevertheless, the patency of metallic stents is only 60-70% at 6 months, and nearly all are occluded by 1 year. Therefore, the use of permanent metallic stents to treat benign biliary obstruction is not recommended.
The choice of plastic or self-expanding metallic stents depends on the etiology of the obstruction. In patients with malignant disease and a life expectancy less than 6-12 months, metallic stents are more cost-effective and are associated with shorter hospital stays and fewer reinterventions. [6] Therefore, the use of metallic stents for biliary obstruction is reserved for patients with inoperable malignant biliary obstruction and a life expectancy less than 6-12 months.
Covered self-expanding metal stents are available that have a thin layer of material such as polytetrafluoroethylene (PTFE) on the exterior, which improves patency by preventing tumor ingrowth. These stents can be repositioned or removed with the use of a snare or forceps.
There are only a few contraindications for percutaneous biliary stenting in appropriately selected patients, and these are primarily related to bleeding. Therefore, any bleeding disorders should be corrected prior to the procedure.
Ascites is a contraindication because it limits tamponade of blood or bile. Therefore, a paracentesis should be performed immediately prior to the procedure.
It is essential that patients are able to hold still and cooperate for the procedure. Most procedures are performed under conscious sedation, but an uncooperative patient may require general anesthesia.
Kaneko T, Sugimori K, Shimizu Y, Miwa H, Kameta E, Koh R, et al. Efficacy of plastic stent placement inside bile ducts for the treatment of unresectable malignant hilar obstruction (with videos). J Hepatobiliary Pancreat Sci. 2014 May. 21 (5):349-55. [Medline].
Kocher M, Cerna M, Havlík R, Kral V, Gryga A, Duda M. Percutaneous treatment of benign bile duct strictures. Eur J Radiol. 2007 May. 62(2):170-4. [Medline].
Link BC, Yekebas EF, Bogoevski D, et al. Percutaneous transhepatic cholangiodrainage as rescue therapy for symptomatic biliary leakage without biliary tract dilation after major surgery. J Gastrointest Surg. 2007 Feb. 11(2):166-70. [Medline].
Almadi MA, Barkun JS, Barkun AN. Stenting in Malignant Biliary Obstruction. Gastrointest Endosc Clin N Am. 2015 Oct. 25 (4):691-711. [Medline].
Mangiavillano B, Pagano N, Baron TH, Luigiano C. Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review. World J Gastroenterol. 2015 Aug 14. 21 (30):9038-54. [Medline]. [Full Text].
Lammer J, Hausegger KA, Flückiger F, et al. Common bile duct obstruction due to malignancy: treatment with plastic versus metal stents. Radiology. 1996 Oct. 201(1):167-72. [Medline].
Lee TH, Kim TH, Moon JH, Lee SH, Choi HJ, Hwangbo Y, et al. Bilateral versus unilateral placement of metal stents for inoperable high-grade malignant hilar biliary strictures: a multicenter, prospective, randomized study (with video). Gastrointest Endosc. 2017 Nov. 86 (5):817-827. [Medline].
[Guideline] Dumonceau JM, Tringali A, Blero D, Devière J, Laugiers R, Heresbach D, et al. Biliary stenting: indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy. 2012 Mar. 44(3):277-98. [Medline].
Gabelmann A, Hamid H, Brambs HJ, Rieber A. Metallic stents in benign biliary strictures: long-term effectiveness and interventional management of stent occlusion. AJR Am J Roentgenol. 2001 Oct. 177(4):813-7. [Medline].
Lopez RR Jr, Cosenza CA, Lois J, et al. Long-term results of metallic stents for benign biliary strictures. Arch Surg. 2001 Jun. 136(6):664-9. [Medline].
Mangiavillano B, Pagano N, Baron TH, Luigiano C. Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review. World J Gastroenterol. 2015 Aug 14. 21 (30):9038-54. [Medline]. [Full Text].
Omodeo M, Malaga I, Manazzoni D, Curvale C, de Maria J, Guidi MA, et al. Insertion of fully covered self-expanding metal stents in benign biliary diseases. Rev Esp Enferm Dig. 2017 Nov 6. 5 (7):332-9. [Medline]. [Full Text].
Navaneethan U, Jayanthi V. Endoscopic management of biliary leaks. The answer for the future. Minerva Gastroenterol Dietol. 2008 Jun. 54(2):141-50. [Medline].
Gupta K, Mallery S, Hunter D, Freeman ML. Endoscopic ultrasound and percutaneous access for endoscopic biliary and pancreatic drainage after initially failed ERCP. Rev Gastroenterol Disord. 2007 Winter. 7(1):22-37. [Medline].
Kwon CI, Ko KH, Hahm KB, Kang DH. Functional Self-Expandable Metal Stents in Biliary Obstruction. Clin Endosc. 2013 Sep. 46(5):515-521. [Medline]. [Full Text].
Kaskarelis IS, Papadaki MG, Papageorgiou GN, Limniati MD, Malliaraki NE, Piperopoulos PN. Long-term follow-up in patients with malignant biliary obstruction after percutaneous placement of uncovered wallstent endoprostheses. Acta Radiol. 1999 Sep. 40(5):528-33. [Medline].
Lee BH, Choe DH, Lee JH, Kim KH, Chin SY. Metallic stents in malignant biliary obstruction: prospective long-term clinical results. AJR Am J Roentgenol. 1997 Mar. 168(3):741-5. [Medline].
Sofi AA, Khan MA, Das A, Sachdev M, Khuder S, Nawras A, et al. Radiofrequency ablation combined with biliary stent placement versus stent placement alone for malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc. 2017 Nov 3. [Medline].
Sampaziotis F, Elias J, Gelson WT, Gimson AE, Griffiths WJ, Woodward J, et al. A retrospective study assessing fully covered metal stents as first-line management for malignant biliary strictures. Eur J Gastroenterol Hepatol. 2015 Nov. 27 (11):1347-53. [Medline].
Sugawara S, Arai Y, Sone M, Katai H. Frequency, Severity, and Risk Factors for Acute Pancreatitis After Percutaneous Transhepatic Biliary Stent Placement Across the Papilla of Vater. Cardiovasc Intervent Radiol. 2017 Dec. 40 (12):1904-1910. [Medline].
Philip L Johnson, MD Chairman, Department of Radiology, Associate Professor of Radiology, University of Kansas School of Medicine; Clinical Service Chief, Department of Radiology, University of Kansas Hospital
Philip L Johnson, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, American Society of Neuroradiology, Association of University Radiologists, Kansas Medical Society, Phi Beta Kappa, Radiological Society of North America, Association of Program Directors in Radiology, Society of Interventional Radiology, American Society of Spine Radiology, Kansas Radiological Society, Mid-America Interventional Radiological Society, American Society of Interventional and Therapeutic Neuroradiology, Association of Program Directors in Interventional Radiology
Disclosure: Nothing to disclose.
Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.
Douglas M Coldwell, MD, PhD Professor of Radiology, Director, Division of Vascular and Interventional Radiology, University of Louisville School of Medicine
Douglas M Coldwell, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Heart Association, SWOG, Special Operations Medical Association, Society of Interventional Radiology, American Physical Society, American College of Radiology, American Roentgen Ray Society
Disclosure: Received consulting fee from Sirtex, Inc. for speaking and teaching; Received honoraria from DFINE, Inc. for consulting.
Kyung J Cho, MD, FACR, FSIR William Martel Emeritus Professor of Radiology (Interventional Radiology), Frankel Cardiovascular Center, University of Michigan Health System
Kyung J Cho, MD, FACR, FSIR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America
Disclosure: Nothing to disclose.
Gary P Siskin, MD Professor and Chairman, Department of Radiology, Albany Medical College
Gary P Siskin, MD is a member of the following medical societies: American College of Radiology, Society of Interventional Radiology, Cardiovascular and Interventional Radiological Society of Europe, Radiological Society of North America
Disclosure: Nothing to disclose.
Medscape Reference thanks Dawn Sears, MD, Associate Professor of Internal Medicine, Division of Gastroenterology and Hepatology, Scott and White Memorial Hospital; and Dan C Cohen, MD, Fellow in Gastroenterology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine, for assistance with the video contribution to this article.
Biliary Stenting
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