Original Articles
Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents,☆☆

Presented orally at the annual meeting of the American Society for Gastrointestinal Endoscopy Digestive Diseases Week, May 19-23, 2002, San Francisco, California (Gastrointest Endosc 2002;55:AB93).
https://doi.org/10.1067/mge.2003.292Get rights and content

Abstract

Background: Endoscopic management of malignant hilar biliary obstruction is controversial with respect to optimal types of stents and extent of drainage. This study evaluated outcomes of selective MRCP and CT-targeted drainage with self-expanding metallic stents. Methods: Consecutive patients undergoing attempted palliative ERCP for malignant hilar biliary obstruction were prospectively followed. Whenever possible, management strategy included evaluation and staging for potential resectability before ERCP, with primary placement of metallic stents at the first ERCP in nonsurgical candidates, and early conversion to a metallic stent when a tumor proved to be unresectable. MRCP and/or CT were used to plan selective guidewire access, opacification, and drainage only of the largest intercommunicating segmental ducts. Unilateral stent placement was intended in all cases except for selected patients with Bismuth II cholangiocarcinoma. Results: Thirty-five patients were included. Bismuth classification was I, 10; II, 6; III, 8; and IV, 11. Tumor origin was bile duct (17), gallbladder (5), and metastatic (13). Metallic stents were placed in 27 patients as the initial stent, and in 8 after plastic stent placement. Initial stents were placed endoscopically in 33 patients and percutaneously in 2 patients in whom lumenal tumor precluded ERCP. Stent placement was unilateral in 31 patients and bilateral in 4 patients. There were no episodes of cholangitis or other complications within 30 days after any procedures. Initial metallic stents were clinically effective in 27 (77%) of the 35 patients. Additional percutaneous drainage in 3 patients who did not respond to initial stent placement did not resolve jaundice. Median patency of first metallic stents was 8.9 months for patients with primary bile duct tumors and 5.4 months for all patients, and was not related to Bismuth classification. No further intervention was needed in 25 (71%) patients. Conclusions: Unilateral metallic stent placement by using MRCP and/or CT to selectively target drainage provides safe and effective palliation in most patients with malignant hilar biliary obstruction. (Gastrointest Endosc 2003;58:41-9.)

Section snippets

Patients and methods

Over a period of 5 years, all patients undergoing ERCP by a single endoscopist (M.L.F.) for attempted palliative therapy of biliary obstruction resulting from malignant hilar lesions were entered into the study, which was approved by the institutional review board of our medical center. Informed consent was obtained from all patients or nearest relative at the time of initial ERCP and before final follow-up. Tumors were considered to be hilar if the stricture was within 1 cm of the hepatic

Results

A total of 37 patients underwent one or more ERCP procedures for malignant hilar biliary obstruction by one endoscopist (M.L.F.) during a 5-year interval. One patient underwent surgical resection and one debulking of the primary tumor, and both were excluded from analysis. The remaining 35 patients (19 men, 16 women; median age 65 years [interquartile range (IQR) 55-74]; range 36-85 years) in whom endoscopic palliation with metallic stents was intended are included in the analysis. Seven were

Discussion

The results of this study suggest that use of MRCP and/or CT to selectively target endoscopic placement of unilateral metallic stents into the largest intercommunicating group of intrahepatic ducts provides effective palliation with minimal risk of complications for most patients with malignant hilar biliary obstruction. In rare cases in which ERCP was impossible, similarly targeted unilateral percutaneous stent placement also provided effective drainage. This selective approach resulted in

References (36)

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Reprint requests: Martin L. Freeman, MD, University of Minnesota, Division of Gastroenterology, Hennepin County Medical Center, 701 Park Ave., Minneapolis, MN 55415.

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0016-5107/2003/$30.00 + 0

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