Jeanne

M. LaBerge,

MD

#{149} Margaret

Doherty,

RN

#{149} Roy

L Gordon,

MD

J.

#{149} Ernest

Ring,

MD

Hilar Malignancy: Treatment with an Expandable Metallic Transhepatic Biliary Stent’ An expandable

transhepatic was used to treat 20 patients with hilar malignancy and isolated right and left intrahepatic ducts. In 12 patients, only one intrahepatic ductal system was drained; in eight patients, both systems were drained. In five patients, both systems were drained through a single transhepatic track by arrangement of two stents in a T configuration. The initial technical success rate in placing the stents and achieving internal drainage was 100%. Complications necessitating further intervention occurred in two of the 20 patients. Short-term clinical follow-up was available for 19 of the 20 patients. Two months after stent Insertion, two patients complained of persistent jaundice, two patients died without jaundice, and 15 patients were free of symptoms of biliary obstruction. A vanety of geometric configurations are possible with this endoprosthesis. The relative merits of these stent arrangements are discussed, and a new technique for placing the stents in a T configuration is described. biliary

Index

metallic

endoprosthesis

terms:

Bile ducts,

dure, 76.1229 #{149} Bile Bile ducts, prostheses, nosis

or

interventional proceducts, neoplasms, 76.3 #{149} 76.1229 #{149} Bile ducts, ste-

obstruction,

Radiology

76.289

1990; 177:793-797

T

different types of expandable metallic stents have recently become available for use in treating patients with biliary strictures. The Wallstent endoprosthesis (Schneider USA, Minneapolis) is constructed with a flexible, tightly woven stainless steel mesh that when fully expanded is 4.2 cm long and 10 mm wide (1). The Gianturco-R#{246}sch Zstent (Cook, Bloomington, md) is a more rigid tubular stent with widely spaced stainless steel struts and is available in 1.5-cm or 3-cm lengths and 8-12-mm diameters (2). The chief advantage of these metallic stents is that they can be introduced through a small transhepatic delivery system (7-10 F), but when fully deployed across a biliary stricture, the stents open up to provide a large luminal diameter (24-30 F). Another potential advantage of metallic endoprostheses is that they can be configured to allow placement in multiple intrahepatic strictures through a single transhepatic track. Coons reported successful stent placement in right-side strictures from a left duct access with Gianturco-R#{246}sch Z-stents (3). The geometric configurations possible for the placement of the Wallstent endoprosthesis for intrahepatic strictures have not been well described. We review here our preliminary experience prosthesis lignancy

with the in patients and isolated

Wallstent endowith hilar maintmahepatic

ducts. MATERIALS

AND

METHODS

Patients Between 1990, I

0628,

From the Department of Radiology, Box University of California, San Francisco,

San Francisco,

CA 94143.

1990; ceived

revision requested July 24; accepted

print

requests

C

RSNA,

to J.M.L. 1990

Received

May 18,

June 26; revision July 25. Address

mere-

September 32 patients with

1989 and malignant

March biliamy

obstruction were treated with an expandable metallic endoprosthesis (Wallstent). In 20 patients, an obstructive lesion of the common hilum,

hepatic

hepatic duct extended into the isolating the right and left intraducts. The causes of the obstruc-

tion in these patients included cholangiocarcinoma (n = 10), gallbladder carcinoma (n 3), and metastatic carcinoma (n 7). Patients ranged in age from 48 to 82 years and included 12 women and eight men. Symptomatic jaundice was the indication

for metallic

stent

placement

in all pa-

tients. Serum bilirubin levels before biliany drainage ranged from 6.1 mg/dL (104 imol/L) to 24.7 mg/dL (422 mol/L). Additionally, eight patients had cholangitis before stent placement. Three patients had undergone prior biliary stent place-

ment

with

a plastic

endoprosthesis.

Technique The

endoprosthesis is comsteel mesh that is elongated and compressed onto a 7-F catheter and then covered with an invaginated plastic membrane. The stent is deployed by rolling the invaginated membrane back, allowing the stent to expand in a distal to proximal direction. After the stent has been deployed across a malignant stricture, it is dilated with an 8-mm balloon to accelerate stent opening and

posed

Wallstent

of a stainless

maximize

bile flow.

The Wallstent

trans-

hepatic biliary endoprosthesis (Schneider USA) is similar to the Wallstent endoprosthesis (Medinvent, Lausanne, Swit-

zerland)

described

by previous

authors

(1,4). The only design difference is that the fully expanded length of the stent used in this study was 4.2 cm, compared with stents of 3 cm or 6 cm used in other series. The Wallstent transhepatic biliary endoprosthesis was used in all patients. The following drainage configurations were used: stent placement in a single duct through a single transhepatic track, stent placement in both right and left ducts through separate transhepatic tracks, and stent placement in both ducts through a single transhepatic track. When a single duct was drained through a single transhepatic track, stan-

damd techniques

were

used

to insert

and

deploy the stent. Our technique differs slightly from those described by other authors (1,4). In brief, our stent placement technique was as follows. A 5-F catheter (Surgimed, Oakland, NJ) was negotiated past the hilar obstruction into the duodenum. An 8-F vascular sheath was ad-

Figure

1.

Percutaneous

drainage

of the left

duct was performed in a 64-year-old woman with hilar obstruction due to cholangiocarcinoma. The following day an expandable metallic stent was placed across the hilar lesion. (a) Plain radiograph shows the appearance of the fully expanded stent. A Malecot catheter (Amplatz Anchor; Medi-tech/Boston Scientific, Watertown, Mass) was positioned in the left duct for temporary drainage. (b) Cholangiogram obtained after stent insertion demonstrates excellent drainage through the stent.

vanced over a heavy-duty exchange wire (Amplatz Extra Stiff; Cook) and positioned so that the tip of the sheath was just

inside

the

ductal

system.

The

stent,

which is loaded onto a 7-F delivery ter, was placed through the sheath, tioned across the obstructing lesion, then

deployed

stent with

was dilated at the level an 8-mm high-pressure

8-F

or

was vide ter

from

10-F

the

external

catheter.

biliary

a.

catheposiand

b.

The

of the lesion balloon. An drain

(Cook)

left in place for several days to protemporary drainage and removed afstent

patency

was

confirmed.

An

ex-

ample of a typical single duct stent is shown in Figure 1. When both right and left biliary systems were drained through separate transhepatic tracks, the stents were deployed simultaneously. The standard

technique

was modified

F transhepatic through

as follows.

sheaths

the

were

bilateral

The 8-

advanced

obstructions

into

the common bile duct and then pulled back simultaneously as the stents were deployed. The stents were aligned to lie side by side in the common bile duct. An example of this parallel configuration is shown in Figure 2. When both right and left systems were drained through the same transhepatic track, the stents were arranged in a T configuration. The initial stent was placed transhepatically

into

the

common

bile

duct, and a second stent (forming the T) was placed transductally from the entry duct across the contralateral duct. The mitial

stent

was

fashion common

from bile

as the

released

in

the

stent).

After

2.

ample

of this

Percutaneous drainage of both right and left ducts was performed in a 75-yearold man with cholangitis and jaundice due to cholangiocarcinoma. (a) Plain radiograph shows the appearance of the bilateral stents. Note that the stents are not fully expanded in the common bile duct. (b) Cholangiogram obtained after stent insertion demonstrates excellent drainage of both systems.

to

placement

figuration In some

of the ipsilateral stent, a torqueable wire (Glidewire; Medi-tech/Boston Scientific) was advanced through the wire mesh of

stents stents. tioned

the

stent

stent

then

into

the

hepatic

manipulated

mesh.

Inflation

both the tralateral

the

contralateral

8-mm

balloon

was

through

the

wire

and

of the

balloon

deployed in a transductal position. Subsequently, a torqueable wire was manipulated through the wire mesh of the transductal stent down into the ipsilateral

biliary

opening ‘SflA

in the

the was

opening

dilated

A

stent

common bile duct. then used to create

tnansductal

stent.

The an

An ex-

T stent

placement

is shown patients,

and

con-

in Figure 3. Gianturco-R#{246}sch

stent

coverage,

difficult,

stent

complished

insertion

as a two-stage

and

tree

was

initially

was

was

tient

did

if the

smoothly,

not

have

initial

The

decompressed

the

a history

drainage stent

was

of cholangitis

procedure placed

at the

drainage

in a one-stage

proce-

nously

tizoximine ics

were

before were

in patients

administered

stent

sodium).

without

cholangitis

antibiotic

dose

(1 g of

Intravenous

continued

with

intrave-

placement after

stent

cholangitis. received before

the

cef-

antibiotplacement

Patients a one-time procedure.

RESULTS

ac-

procedure.

with an external-internal drainage catheter (8-F Cope loop; Cook), and the stent was placed at a second session. If the paand

initial Antibiotics

were used in addition to the WallThe Gianturco stent was posiat the intraductal end of the Wallto increase

of dure.

deployed in the standard fashion described elsewhere (23). When patients had cholangitis or when the initial drainage procedure was particularly

and into balloon

mesh lesion.

and

and the conwas then

stent 8-mm

wire hilar

confluence

into

duct. A high-pressure advanced over the

b.

Figure

standard

the duct of entry into the duct (this will be referred

ipsilateral

a.

went time

Stent placement in a single isolated system from a transhepatic access was attempted in 13 patients (four from the right, nine from the left). Followup cholangiograms at 1-2 days after stent placement showed that the system was adequately decompnessed in

December

1990

b.

d. Figure placed, later,

vanced

3.

A 66-year-old

and the necessitating

over

woman

following right

the wire

and

presented

with

e.

jaundice

due

to bilateral

day an expandable metallic stent was duct drainage. A wire was manipulated

inflated,

dilating

the stent

opening

inserted through

and

tal stent into the left duct-common bile duct stent, and a balloon ductal stent. (d) Cholangiogram obtained after stent placement shows the appearance of the I stent configuration.

obstruction

cholangiocarcinoma.

across the obstruction. the left duct stent

the right

was shows

from

hilar

advanced excellent

(c) A wire wire and of both

all cases. In one case, cholangitis that developed after stent placement necessitated drainage of the contralateral obstructed duct, which was accomplished with the T configuration. Stent placement in both right and left isolated ducts was accomplished

intrahepatic ducts a single transhepatic

by means of two separate transhepatic tracks in two patients. In both cases, the patient had cholangitis and jaundice. Follow-up cholangiography at 1-2 days after stent placement showed that the systems were adequately decompressed. Drainage of both the right and left

In four of the five patients, transductal drainage could be accomplished with two Wallstents. In one case, the distance from the duct entry site to the peripheral aspect of the contralateral duct was not long enough to accommodate a Wallstent. Therefore, a double-barreled Gianturco stent was

Volume

177

Number

#{149}

3

patients.

The

initial

was

stricture. over the drainage

achieved from access in five

transhepatic

(a) A left duct

(b) The patient into the right duct.

ac-

cess was from the left in three patients and from the night in two patients. Two stents were arranged in a T configuration in all five patients.

developed An 8-mm

was manipulated

inflated, right and

drain

was

cholangitis balloon was

through

4 days ad-

the transduc-

dilating the opening left ducts. (e) Plain

of the radiograph

trans-

placed in the transductal position, as shown in Figure 4. The indication for bilateral ductal drainage was cholangitis in three patients. In the other two patients, the indication for drainage was jaundice, but it was thought that the biliary anatomy was easily amenable to transductal drain-

age.

Follow-up

cholangiography

1-2

days after stent placement demonstrated prompt drainage of both lateral and contralateral systems through all of the T-configuned stents. Drainage

of both

right

and

Radiology

left

ipsi-

in795

#{149}

tnahepatic ducts was accomplished with a T-tube track in one patient with gallbladder carcinoma. The combination of a Wallstent plastic endoprosthesis was

achieve

bilateral

Cholangiognaphy ment showed both obstructed Complications

ductal

rr

a to

drainage.

after prompt systems. requiring

intervention

and used

occurred

stent drainage

placeof further

in two

pa-

tients. One patient developed cholangitis of the contralateral duct after stent placement, necessitating an additional drainage procedure. One patient developed brisk biliary tract

bleeding

after

an initial

night

duct

a.

drainage procedure and before stent placement; the bleeding resolved aften selective right hepatic artery embolization. Two other patients had transient hemobilia that did not mequire additional therapy. No specific complications were noted in the patients who had T-configured stents. Short-term (2-month) clinical follow-up was available for 19 of 20 patients. Two patients complained of

persistent

jaundice

teen patients Follow-up

were

and

pnuritus.

Fif-

were asymptomatic. serum bilirubin levels

available

for only

eight

of 20

DISCUSSION palliation obstruction

malignancy

can

due

of patients to hilar

be accomplished

in a

variety of ways (5-8). When the tumom extends into the hilum, isolating the right and left ducts, the treatment options include (a) dnaining only one system through a single transhepatic track, (b) draining both systems through separate transhepatic tracks, or (c) draining both systems through

a single

tnanshepatic

track.

Drainage of a single system will usually provide adequate palliation in patients who have symptomatic jaundice (9,10). When only one systern is to be drained, we prefer the left-side approach. The left duct has fewer branches near the hilum than the might duct and thus has a greaten potential for long-term the malignant tumor the hilum. Occasionally,

slow-growing

tumor

in the left duct and the left duct for an 796

Radiology

#{149}

palliation spreads from when a

has

originated

has obstructed extended period

4.

as

An 80-year-old

man

with

jaundice

right-side biliary drainage and stent placement. stent placement shows obstruction of the left the left duct stricture. Cholangiogram obtained

age of both

is not

adequate

in these

cases, and a right-side drainage is indicated. A single Walistent endoprosthesis can be placed through eithem the rightor left-side appnoach without technical difficulty.

When

patients

cholangitis

have

contralateral

or if jaundice

solve with unilateral age, bilateral drainage

fails

biliary may

to ne-

drainbe neces-

sary. Bilateral drainage is most cornmonly accomplished through separate tnanshepatic punctures. The deployment of stents through separate transhepatic tracks is straightfon-

ward when

and the

was easily accomplished stents wene released

simul-

taneously. Since the distal ends of the stents were aligned in a parallel fashion in the common bile duct,

each

stent

opened

to somewhat

less

than its full diameter. Although adequate drainage was achieved with this arrangement, the fact that the stents opened up to less than the full 10-mm diameter resulted in elongation of the stent in the common bile duct. This fact must be kept in mind

when

the

stents

are positioned.

Decompression of isolated through a single tnanshepatic is preferable to the dual-access proach because it has a lower bidity and is better tolerated tients. A number of techniques been described the contralateral

ipsilatenal

due

to metastatic

colon

(a) Cholangiogram duct. (b) A Gianturco after stent placement

carcinoma

underwent

obtained after right-side stent was inserted across shows excellent drain-

systems.

before invading the right side, the left lobe will develop biliary cimrhosis. Diagnostic percutaneous transhepatic cholangiography will show the typical appearance of biliary cirrhosis in the left ducts. A single left duct

drainage

patients. In seven of eight patients, the serum bilirubin level was less than 2.4 mg/dL (42 pmol/L) (twice the upper limit of normal). In one patient the bilirubin level was 2.8 mgI dL (48 tmol/L), and that patient complained of prunitus and anorexia.

Percutaneous with biliary

b.

Figure

ducts access apmorby pahave

for decompressing biliary tree from

transhepatic

access

(11-

an

14). Internal-external catheters, traditional plastic endoprostheses, and metallic Gianturco stents can all be arranged to accomplish this task. When plastic endoprostheses are used to decompress both ducts from single access, they are usually aligned so that the transductal stent

is parallel

to the

common

bile

a

duct

stent in the arrangement

duct of entry. A similar could be used with the Wallstents; however, the creation of a true T with the techniques we have described seems preferable because it offers a large luminal diameter throughout

the

T system.

Creation of a T with two Wallstents may not be possible in all patients with hilar obstruction. When the distance from the peripheral contralateral duct to the ipsilateral duct entry point is short, a Wallstent may be too long for use in the transductal position. One must remember that the currently available Wallstent is 4.2 cm long when fully expanded to a 10-mm diameter, but when it is opened to less than its maximum diameter, it will be longer than 4.2 cm. When the transductal distance is short, or when the ducts are small, a Gianturco stent can be used to form the T bar in the system. Although our usual approach to the patient with hilar malignancy has been to drain only one system by inserting a stent through the left duct, we now believe that T-configured stents provide an attractive alternative approach when bilateral drainage is indicated. Prompt and effective drainage of both obstructed

systems through

can

be accomplished

a single

transhepatic

December

access 1990

without

a significant

increase

in mom-

bidity or patient discomfort. In addition to anatomic ing, several other technical expandable-stent insertion thy

of comment.

As

we

positiondetails of are wonhave

men-

tioned, one advantage of expandable stents is that a large luminal diameter can be achieved through a small transhepatic track. This allows the establishment of biliary drainage and the placement of a stent in one procedune rather than the two-stage procedune required for most plastic endoprostheses. Despite the small size of the transhepatic track, transient hemobilia may result from either the creation of a transhepatic track or balloon dilation of the obstructing lesion.

We

prudent drain

therefore

believe

to leave in place

a temporary for

stent insertion. giogram shows temporary

guide served

24-48

bleeding

from

after

cholanthe

is removed

wire. The skin entry for several minutes;

it is

biliary

hours

If a follow-up stent patency,

drain

significant

that

over

a

patients with hilar obstructions are comparable with our experience with conventional plastic endoprostheses (15). The short-term clinical improvement seen in 17 of 19 (89%) of our patients is similar to that reported by Gillams et a!, who noted a 90% clinical improvement in patients with biliary obstruction treated with Wallstents. In conclusion, this expandable metallic stent provided effective shortterm,.biliary drainage in 89% of patients with hilar malignancy. We believe that the chief technical advantage of this stent is ease of insertion. Another

tients ability

the

track,

advantage

bilateral

to drain

177

Number

#{149}

3

from

Gillams El-Din

braided 2.

tures. Irving

A.

JS, Wallsten

Self-expandable

endoprosthesis Radiology JD, Adam

stainless

for biliary

4.

Coons biliary 983.

McLean

9.

GK,

Ring

EJ,

Freiman

drainage

transhepatic

endoprosthesis

for

biliary

obstruction.

Radiology

1989;

Mueller E, et a!.

PR, Ferrucci

JT, vanSonnenberg

Obstruction of the left hepatic duct: diagnosis and treatment by selective fine-needle cholangiography and percutaneous biliary drainage. Radiology 1982; 145:297-302.

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Kaufman SL, Kadir S, Mitchell SE, Kinnison ML, Chang R. Left lobe of liver: percutaneous biliary drainage. Radiology

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systems

Lammer

in pa-

obstruction

both

single transhepatic of arrangement configuration.

site is obif there is

the temporary biliary drain is meplaced. The drain is removed after 1-. 2 weeks, when a mature transhepatic track has formed. Data establishing the long-term patency rates of the Wallstent endoprosthesis in our patient population are not yet available. The initial technical success rate and the immediate complication rate for these stents in

potential

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14.

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Percutaneous

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#{149}