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Gut,
1991,32,685-689
Palliation
of
proximal
malignant
biliary
obstruction
by
endoscopic
endoprosthesis
insertion
A A
Polydorou,
S
R
Cairns,
J
F
Dowsett,
R
C
G
Russell
A
R
W
Hatfield,
P
R
Salmon,
P
B
Cotton,
Departments
of
Gastroenterology
and
Surgery,
University
College
and
Middlesex
Hospital
Medical
School,
London
A
A
Polydorou
J
F
Dowsett
A
R
W
Hatfield
P
R
Salmon
R
C
G
Russell
Royal
Sussex
County
Hospital,
Brighton
S
R
Cairns
Division
of
Gastroenterology,
Duke
University
Medical
Centre,
Durham,
North
Carolina,
USA
P
B
Cotton
Correspondence
to:
Dr
Stuart
R
Cairns,
Royal
Sussex
County
Hospital,
Eastern
Road,
Brighton
BN2
5BE.
Accepted
for
publication
16
July
1990
Abstract
For
four
years
up
to
December
1987,
190
patients
(median
age
73
years)
with
proximal
malignant
biliary
obstruction
were
treated
by
endoscopic
endoprosthesis
insertion.
Altogether
101
had
cholangiocarcinoma,
21
gail
bladder
carcinoma,
20
local
spread
of
pancreatic
carcinoma,
and
48
metastatic
malig-
nancy.
Fifty
eight
patients
had
type
I,
54
type
II,
and
78
type
III
proximal
biliary
strictures
(Bismuth
classification).
All
patients
were
either
unfit
or
unsuitable
for
an
attempt
at
curative
surgical
resection.
A
single
endo-
prosthesis
was
placed
initially,
with
a
further
stent
being
placed
only
if
relief
of
cholestasis
was
insufficient
or
sepsis
developed
in
undrained
segments.
The
combined
per-
cutaneous-endoscopic
technique
was
used
to
place
the
endoprosthesis
when
appropriate,
after
failed
endoscopic
endoprosthesis
inser-
tion
or
for
second
endoprosthesis
placement.
Full
follow
up
was
available
in
97%.
Thirteen
patients
were
still
alive
at
the
time
of review
and
all
but
one
had
been
treated
within
the
past
six
months.
Initial
endoprosthesis
insertion
succeeded
technically
at
the
first
attempt
in
127
patients,
at
the
second
in
30,
and
at
a
combined
procedure
in
a
further
13
(cumulative
total
success
rate
89%
-
type
I:
93%;
type
II:
94%;
and
type
HI:
84%).
There
was
adequate
biliary
drainage
after
single
endoprosthesis
insertion
in
152
of
the
170
successful
placements,
giving
an
overall
successful
drainage
rate
of
80%.
Three
patients
had
a
second
stent
placed
by
combined
procedure
because
of
insufficient
drainage,
giving
an
overall
successful
drainage
rate
of
82%
(155
of
190).
The
final
overall
drainage
success
rates
were
type
I:
91%;
type
I:
83%;
and
type
III:
73%.
The
early
complica-
tion
rates
were
type
I:
7%;
type
II:
14%;
and
type
1I:
31%.
The
principal
early
complication
was
clinical
cholangitis,
which
occurred
in
13
patients
(7%)
and
required
second
stent
place-
ment
in
five.
The
30
day
mortality
was
22%
overall
(type
I:
14%;
type
II:
15%;
and
type
III:
32%)
but
the
direct
procedure
related
mortality
was
only
3%.
Median
survival
overall
for
types
I,
II,
and
III
strictures
were
21,
12,
and
10
weeks
respectively
but
survival
was
signifi-
cantly
shorter
for
metastatic
than
primary
malignancy
(p<005).
Endoscopic
insertion
of
a
single
endoprosthesis
will
provide
good
pal-
liation
of
proximal
malignant
biliary
obstruc-
tion
caused
by
unresectable
malignancy
in
80%
of
patients.
Second
stents
should
be
placed
only
if
required.
Extensive
stricturing
because
of
metastatic
disease
carries
a
poor
prognosis
and
careful
patient
selection
for
treatment
is
required.
Although
management
of
distal
malignant
biliary
obstruction
by
endoprosthesis
insertion
is
well
established,'
the
place
of
endoscopic
endo-
prosthesis
insertion
for
proximal
malignant
biliary
obstruction
(Fig
1)
remains
controversial.
Surgery,
involving
hepatic
resection
if
necessary,
offers
the
only
chance
of long
term
cure
but
carries
considerable
procedure
related
morbidity
and
mortality.2
Most
(90%)
patients
are,
how-
ever,
unsuitable
or
unfit
for
attempted
curative
resection.3
Palliative
options
include
surgical
bypass
and
surgical
percutaneous
or
endoscopic
endoprosthesis
insertion.
`
Internal
drainage
should
always
be
preferred
to
external drain-
age.89
Drainage
may,
if
desired,
be
supple-
mented
by
radiotherapy.`'0
1
Attempts
at
palliation,
even
in elderly
patients,
are
usually
worthwhile
because
the
quality
of
life
may
be
improved
considerably
by
the
relief
of
the
pruritus
and
nausea
of
cholestasis.
As
surgical
bypass
procedures,
in
the
best
hands
and
in
the
fittest
patients,
carry
a
33%
operative
mortality2
and
surgical
intubation
carries
a
60
day
post-
operative
morbidity
of
26%
and
a
30%
mortal-
ity,3
a
strong
argument
can
be
made
for
management
by
percutaneous
or
endoscopic
endoprosthesis
insertion.
Large
studies
of
both
techniques
in
single
centres
have
been
few.
A
randomised
trial
from
this
institution,
however,
suggested
a
lower
complication
rate
with
endo-
scopic
than
percutaneous
insertion,
and
the
endoscopic route
is
therefore
the
preferred
pri-
mary
intervention.
2
Moreover,
the
development
of
the
combined
percutaneous-endoscopic
tech-
nique
(CP)
has
provided
an
increased
endoscopic
Type
I
Type
II
r;*.r.1
Type
III
Figure
1:
Diagram
of
types
of
proximal
biliary
obstruction.
685
Polydorou,
Cairns,
Dowsett,
Hatfield,
Salmon,
Cotton,
Russell
success
rate,
while
still
avoiding
large
bore
hepatic
puncture.
3
It
has
become
our
second
line
intervention.
We
report
our
experience
with
endoscopic
endoprosthesis
placement
in
190
patients
with
either
primary
or
secondary
proximal
malignant
biliary
obstruction
at
the
hilum.
In
the
analysis
we
have
attempted
to
address
several
points
of
importance
to
the
clinician.
These
include
the
initial
success
rate,
the
number
of
endo-
prostheses
required
to
provide
adequate
relief
of
cholestasis,
the
relative
merits
of
stent
placement
into
the
left
or
right
lobe,
the
prevalence
of
early
and
late
septic
complications,
the
prevalence
of
late
stent
change
either
because
of
stent
blockage
or
tumour
progression
with
overgrowth,
and
finally
the
value
of
stenting
patients
with
secon-
dary
malignancy.
Methods
Between
October
1983
and
December
1987,
190
consecutive
patients
with
biliary
obstruction
at
the
hilum
because
of
primary
or
secondary
malignancy
were
treated
by
attempted
endo-
scopic
endoprosthesis
insertion.
Details,
includ-
ing
intention
to
treat
and
the
result
of
treatment,
were
prospectively
entered
onto
a
computer
programme
(PEDRO).
There
were
74
men
and
116
women
with
a
median
(range)
age
of
73
(35-
94)
years.
The
mean
(range)
duration
of
jaundice
before
the
first
endoscopy
was
5
(1-14)
weeks
and
the
mean
(range)
serum
bilirubin
was
361
(22-
913)
mmol/l,
normal
<
17.
Other
data
included
a
mean
(range)
serum
alkaline
phosphatase
of
1540
(360-4600)
IU/1,
normal
<280,
mean
(range)
serum
albumin
of
34
(20-43)
g/l,
normal
35-53,
mean
(range)
serum
creatinine
of
106
(82-420)
[imol/l,
normal
50-125,
and
mean
(range)
haemoglobin
of
11.7
(8'0-14-3)
g/dl.
All
patients
were
considered
unsuitable
for
resection
on
the
basis
of
medical
fitness
or
tumour
extent,
or
both,
as
defined
by
ultra-
sound,
computed
tomogram
(tumour
extending
into
both
lobes
or
major
vascular
involvement)
or
cholangiography
(type
II/III
obstruction),
or
both.
The
proximal
obstruction
was
subdivided
according
to
Bismuth's
classification
on
the
basis
of
cholangiographic
or
ultrasound
information
(Fig
1),
or
both,
and
according
to
proved
or
presumed
histology
(Table
I).
It
is
stressed
that
no
attempt
was
made
at
any
stage
to
obtain
a
'complete'
diagnostic
cholangiogram.
Contrast
medium
injection
before
stricture
passage
was
stopped
once
a
duct
deemed
suitable
for
stenting
was
identified
and
was
continued
only
after
TABLE
I
Type
of
stricture
in
study
group
Type
of
biliary
obsruction*
I
II
III
Total
No
(%)
of
patients
58
(31)
54
(28)
78
(41)
190
(M/F)
19/39 23/31
32/46
74/116
Mean
age
(years)
(range)
72
(41-94)
70
(35-91)
71
(42-92)
71
(35-94)
Mean
bilirubin
(,umol/l)
(range)
292
(22-714)
444
(140-913)
343
(31-728)
361(22-913)
Cholangiocarcinoma
25
28
48
101
Pancreatic
carcinoma
12
5
3
20
Metastatic
carcinoma
14
16
18
48
Gall
bladder
carcinoma
7
5
9
21
*Bismuth
classification.
secure
access
to
the desired
segment
was
obtained
with
a
5
FG
catheter.
The
rationale
behind
this
approach
was
to
avoid
contrast
medium
injection
into
segments
that
would
not
be
adequately
drained
by
the
inserted
stent.
One
stent
only
was
placed
in
all
but
two
patients,
in
whom
the
first
segment
stented
was
thought
inadequate
at
the
time
of
initial
stenting.
All
patients
received
parenteral
antibiotics
(usually
mezlocillin
2
g,
eight
hourly,
given
one
hour
before
the
procedure
and
continued
for
at
least
36
hours
after
successful
stent
placement
or
until
successful
drainage
was
achieved).
An
experienced
senior
endoscopist
was
present
during
most
of
the
procedures.
Amsterdam
type
10
FG
polyethylene
endoprostheses
were
routinely
inserted
but
10%
of
patients
had
8
or
11.5
FG
stents
placed
either
initially
or
at
stent
change.
Stents
were
inserted
over
a
guide
wire
and
coaxial
catheter
via
an
Olympus
TJFIO
4.2
mm
channel
endoscope,
using
standard
tech-
niques.'4
Endoscopic
sphincterotomy
was
per-
formed
in
most
patients
both
to
assist
stent
insertion
and
to
facilitate
later
change.
When
a
stent
could
not
be
placed
endoscopically,
the
combined
percutaneous-endoscopic
technique
(CP)
was
used.'5
All
patients
were
carefully
monitored
clinically
after
the
procedures
with
particular
attention
to
fever,
serial
biochemistry,
and
ultrasound
evidence
of
decompression.
Patients
were
withdrawn
from
repeated
attempts
at
palliation
and
designated
'failed
palliation'
if
non-specific
general
deterioration
occurred
or
if,
on
discussion
with
the
patient,
the
risks
of
further
intervention
were
agreed
to
outweigh
the
possible
benefit.
Successful
endoprosthesis
placement
was
defined
as
passage
of
the
prosthesis
across
the
stricture
with
good
radiological
positioning,
immediate
bile
passage
down
the
stent,
and
aerocholia
on
subsequent
plain
x
ray
or
ultra-
sound.6
17
Most
patients
also
had
segment
decompression
assessed
by
ultrasonography,
usually
36-72
hours
after
the
procedure.
Successful
drainage
was
defined
as
loss
of
pruritus,
if
present,
plus
a
fall
in
the
bilirubin
concentration
greater
than
30%
of
the
pretreat-
ment
value
within
30
days
(but
usually
within
10
days).
It
should
be
stressed
that
the
aim
was
reduction
in
bilirubin
to
acceptable
concentra-
tions
(usually
<
100
,umol/l)
where
it
was
likely
to
relieve
symptoms
of
cholestasis
such
as
pruritus
and
nausea.
8
Early
complications
were
defined
as
those
occurring
within
30
days
of
endoprosthesis
placement.
Cholangitis
was
diagnosed
if
a
fever
above
38°C
developed
without
other
cause
and
was
associated
with
rigors
or
persisted
for
longer
than
48
hours
after
the
procedure.
That
is,
postprocedural
fever
on
the
night
of
the
pro-
cedure,
which
is
undoubtedly
caused
by
a
brief
bacteraemia
and
settles
rapidly
either
spon-
taneously
or
because
of
antibiotic
prophylaxis,
was
not
labelled
cholangitis.
Complications
of
percutaneous
biopsies
are
not
included
and
did
not
contribute
to
the
overall
mortality
and
morbidity.
Thirty
day
mortality
was
defined
as
death
within
30
days
of
the
first
attempt
at
endoscopic
endoprosthesis
insertion,
whether
successful
or
686
Palliation
of
proximal
malignant
biliary
obstruction
by
endoscopic
endoprosthesis
insertion
TABLE
II
Results
in
190
patients
with
proximal
biliary
obstruction
treated
by
endoscopic
endoprosthesis
insertion
Type
of
stricture*
lII
III
Total
No
of
patients
1st
attempt
58
54
78
190
Technical
success:
1st
attempt
(S/F)
45/13
(78%)
36/18
(67%)
46/32
(59%)
127/63
(67%)
No
further
attempt
4
2
10 16
2nd
attempt
(S/F)
5/4(9%)
12/1
(22%)
13/5(17%)
30/10
(16%)
Combined
procedure
(S/F)
4/0
(7%)
3/1
(6%)
6/2
(8%)
13/3
(7%)
Total
54
(93%)
51(94%)
65
(84%)
170
(89%)
Successful
drainage:
Single
stent
53
(91%)
44 (81%)
55
(71%)
152
(80%)
Two
stents
-
1
(2%)
2
(3%)
155
(82%)
Early
complications:
Noofpatients
4(7%)
8(15%)
24(31%)
36(19%)
No
of
events
6
(10%)
16
(30%)
28
(36%)
50
(26%)
30
Day
mortality
8
(14%)
8
(15%)
25
(32%)
41(22%)
Survival:
Mean
(wks)
23
22
17
20
Median
(range)
(wks)
21
(2-85)
12
(1-94)
10
(1-115)
12
(1-115)
Stent
change:
No
of
patients
27
(47%)
25
(46%)
28
(36%)
80
(42%)
No
of
events
(S/F)
48/4
36/5
46/11
130/20
*Bismuth
classification.
not.
Procedure
related
mortality
was
defined
as
death
directly
related
to
a
complication
of
endo-
prosthesis
insertion,
including
the
complications
of
papillary
access
(sphincterotomy)
or
hepatic
puncture
(CP).
All
patients
were
carefully
informed
of
the
possible
symptoms
of
endo-
prosthesis
blockage
and
change
was
only
performed
when
clinical
or
ultrasonographic
evidence,
or
both,
of
endoprosthesis
blockage
was
present.
Histological
confirmation
of
malignancy
was
attempted
only
after
biliary
decompression
and
was
obtained
in
108
patients
(57%)
either
by
aspiration
cytology
or
by
Biopty
gun
trucut
biopsy.
This
was
normally
done
at
the
time
of
the
ultrasonographic
decompression
check.
Diagnosis
of
the
histological
origin
of
the
biliary
obstruction
was
surmised
from
available
clinical
and
imaging
data
in
the
remainder
of
cases.
Follow
up
was
obtained
by
examination
of
the
case
notes
and
from
referring
consultants
and
general
practitioners.
Statistical
analysis
was
performed
using
X'
with
Yates's
correction
and
Mann-Whitney
U
test.
Results
ENDOPROSTHESIS
PLACEMENT
AND
FUNCTION
Endoscopic
placement
of
an
endoprosthesis
was
achieved
in
127
patients
at
the
first
attempt,
in
30
at
the
second,
and
in
13
patients
at
CP.
As
shown
TABLE
III
Early
complications
in
190
patients
with
proximal
malignant
biliary
obstruction
treated
by
endoscopic
endoprosthesis
insertion
Type
of
biliary
obstruction*
Complication
I
II
III
Total
Cholangitis
2
3
8
13
Pancreatitis
--
3
3
Retroperitoneal
perforation
2
2
3
7
Gastrointestinal
bleeding
-
2
5
7
Stent
migration
2
4
2
8
Bile
leakage
-
3
5
8
Respiratory
failure
-
1
1
2
Renal
failure
-
1
1
2
*Bismuth
classification.
in
Table
II,
16
patients
had
no
further
attempts
after
a
failed
first
procedure
(type
I:
four;
type
II:
two;
type
III:
10).
Seven
patients
proceeded
to
CP
immediately
after
an
initial
failure
of
endo-
scopic
stent
placement
(type
II:
three;
type
III:
four),
and
all
patients
except
one
who
had
a
type
III
obstruction
proceeded
to
CP
after
a
second
failed
endoscopic
attempt.
The
overall
success
rate
for
stent
placement
was
170
of
190
(89%)
(Table
II).
Of
the
20
patients
with
failed
stent
placement,
two
had
external
drainage
only
after
failed
CP
and
the
remaining
18
patients
had
no
further
intervention.
The
site
of
stent
placement
was
identified
in
116
patients
with
type
II
or
III
strictures.
In
70
patients
the
stent
was
placed
in
the
right
hepatic
duct
and
in
39
the
left
duct.
No
definite
location
was
identified
in
the
remaining
seven
cases.
Successful
drainage
was
obtained
in
80%
of
patients
overall
(type
I:
91%;
type
II:
81%;
type
III:
71%)
(Table
II).
That
is,
inadequate
relief
of
cholestasis
despite
adequate
placement
of
a
single
stent
occurred
overall
in
7%
of
patients
(2%,
13%,
and
13%
for
types
I,
II,
and
III
strictures
respectively).
Failure
of
drainage
was
signifi-
cantly
more
common
after
-technically
successful
endoprosthesis
placement
in
type
III
than
type
I
obstruction
(p<0
01).
A
second
stent
was
placed
by
CP
in
three
patients
(type
II:
one;
type
III:
two)
because
of
failure
of
resolution
of
jaundice
despite
segmental
decompression
by
the
first
stent
-
all
of
which
provided
successful
drainage.
The
success
rate
of
drainage
overall
thus
increased
to
83%
for
type
II
strictures
and
74%
for
type
III
strictures.
EARLY
COMPLICATIONS
Complications
occurring
within
30
days
of
the
procedure
were
present
in
36
patients
(19%)
(Table
III).
Cholangitis
was
the
principal
major
complication
occurring
in
13
(7%),
and
if
not
associated
with
endoprosthesis
insertion
failure,
it
was
presumed
to
be
caused
by
sepsis
in
undrained
segments.
Cholangitis
resolved
on
parenteral
antibiotics
alone
in
five
patients,
with
replacement
of
the
single
stent
in
three,
and
in
five
the
placement
of
an
additional
second
stent
into
the
presumed
undrained
segment
was
per-
formed
(this
was
achieved
endoscopically
in
two
and
via
CP
in
three
patients).
All
CP
were
performed
via
the
ducts
of
the
left
lobe
of
the
liver
and
all
three
patients
had
had
initial
endo-
scopic
endoprosthesis
insertion
into
right
lobe
ducts.
The
prevalence
of
complications
after
stent
placement
in
patients
with
type
II
or
III
obstruc-
tion
was
not
significantly
different
in
patients
with
an
endoprosthesis
placed
in
the
right
ducts
compared
with
those
with
an
endoprosthesis
placed
in
the
left
hepatic
duct
(p>0Q05).
MORTALITY
Follow
up
to
30
days
was
obtained
for
all
patients.
The
30
day
mortality
was
22%
overall
(41
patients)
and
was
14%
for
type
I
obstruction,
15%
for
type
II,
and
32%
for
type
III
(Table
II).
There
was
a
significant
difference
in
30
day
mortality
between
patients
presenting
with
type
I
687
Polydorou,
Cairns,
Dowsett,
Hatfield,
Salmon,
Cotton,
Russell
W
CL
0)
0.
*
Type
I
&-^
Type
11
a
Type
III
Months
0
1
\
t
X-~~~Metastatic
carcinoma
60-
0.
-0
40-
20-
0
036
9
1'2
15
Months
Figure
2:
(A)
Patient
survival
according
to
type
of
stricture
Actuarial
18
month
survival
after
endoscopic
placement
of
endoprosthesis
in
patients
with
unresectable
malignant
liver
hilar
strictures
(n=
172).
P
(50%
survival):
I
v
II=0
288;
v
III=0
006;
II
v
III=0
162.
(B)
Patient
survival
according
to
cause
of
stricture.
Actuarial
survival
of
patien:
with
hilar
stricture
who
were
dead
at
the
time
of
review.
according
to
histological
diagnosis
(n=172).
and
type
III
hilar
stricturing
(p<0Q05)
an
between
patients
with
type
II
and
type
I
strictures
(p<0
05)
(Fig
2).
Death
within
30
days
was
caused
by
a
pr(
cedure
related
complication
in
five
patients
(30/
(bleeding
four,
sepsis
one).
The
remainir
patients
died
from
progressive
malignant
disear
rather
than
a
complication
of
the
procedure.
SURVIVAL
Thirteen
patients
were
alive
at
the
time
of
reviev
All
except
one
had
been
treated
within
tI
previous
six
months.
The
single
long
term
su
vivor
still
alive
was
first
treated
132
weeks
befo:
this
review.
Five
patients
were
lost
to
long
tern
follow
up.
Data
about
patients
who
have
die
(172)
is
provided
in
Table
II.
All
patients
who
di
not
have
biliary
drainage
established
died
withi
six
weeks.
Survival
was
significantly
longer
fi
type
I
than
type
III
obstruction
(p<001)
(Fig
2
Shorter
survival
was
seen
in
patients
wil
obstruction
caused
by
metastatic
disease
or
pai
creatic
carcinoma
than
in
those
with
eith
cholangiocarcinoma
or
gall
bladder
carcinonr
TABLE
IV
Median
and
mean
survival
and
30
day
mortality
according
to
extent
and
cause
o
hilar
stricture.
(Only
patients
with
a
histological
diagnosis
are
included,
n=
108.
)
Mean
(median)
(weeks)
p
30
day
mortality
(%)
C+GB
P+M
C+GB
P+M
I
26
(22)
19
(12)
(0-291)
10
19
II
23
(16)
17
(10)
(0.507)
12
23
III
19
(12)
8
(6)
(0.048)
28
42
C=cholangiocarcinoma;
GB=gall
bladder
cancer;
P=pancreatic
cancer;
M=metastatic
cancer.
(Table
IV;
Fig
2).
Survival
of
patients
with
successfully
drained
type
II
or
III
obstruction
was
not
significantly
longer
in
those
treated
by
insertion
of
a
stent
in
the
left
rather
than
the
right
hepatic
duct
system
(p>005).
LATE
COMPLICATIONS
Eighty
patients
required
between
one
and
six
stent
changes
(one
change:
54
patients;
two
changes:
13
patients;
>two
changes:
13
patients)
(Table
II).
1
Discussion
There
are
numerous
alternative
palliative
treat-
ments
available
for
patients
with
proximal
malig-
_J
nant
biliary
obstruction
for
whom
attempted
curative
surgical
resection
is
not
possible.'920
These
include
surgical
bypass2
4
2'
and
surgical,3
22
percutaneous,
and
endoscopic`
11
20
23
endo-
prosthesis
insertion.
Internal
drainage
is
prefer-
red
to
external
drainage
for
fluid
and
electrolyte,
tumour
seeding,
and
cosmetic/psychological
reasons,
though
it
probably
carries
a
higher
risk
8
of
sepsis.24
Extensive
obstructive
stricturing
is
not,
however,
amenable
to
conventional
surgical
bypass
and
requires
special
surgical
techniques.25
Although
surgical
bypass
offers
the
possibility
of
r
a
single
permanent
definitive
palliative
pro-
I
cedure,
it
carries
a
high
procedural
morbidity
ts
and
mortality,22'
has
only
been
reported
in
the
minority
subgroup
of
fit,
younger
patients,
and
although
generally
technically
straightforward,
it
involves
a
general
anaesthetic
and
tissue
dissec-
id
tion.
Surgical
intubation
has
been
performed
II
when
surgical
bypass
has not
been
possible
and
carries
all
the
disadvantages
of
surgery
and
no
o-
proved
benefit
over
the
non-surgical
alter-
to)
natives.3
For
most
patients,
who
are
either
ig
elderly,
unfit,
or
have
extensive
bilobar
disease,
se
percutaneous
or
endoscopic
endoprosthesis
insertion
are
valid
and
often
the
only
alternatives.
As
a
randomised
study
has
shown
the
complica-
tion
rate to
be
lower
with
the
latter,'2
endoscopic
stent
placement
is
now
our
treatment
of
choice
v.
for
all
patients
not
amenable
to
attempted
resec-
he
tion.
If
this
fails,
the
CP
technique
may
be
used
r-
to
place
the
endoprosthesis,
with
the
advantage
re
over
pure
percutaneous
placement
of
a
smaller
m
bore
liver
puncture
and
presumably
less
bleeding
~d
and
bile
leakage.
3
1'
id
In
this
series
of
190
patients
treated
endo-
in
scopically,
the
only
group
with
potentially
or
resectable
disease
was
those
with
type
I
!).
cholangiocarcinoma
(n=25).
Eighteen
of
these
th
patients
were
over
the
age
of
70
years,
four
had
n-
intrahepatic
metastases,
and
12
had
strong
er
medical
contraindications
to
surgery.
The
rarity
na
of
potentially
resectable
hilar
cancer
is
well
illustrated
by
Bismuth's
series
of
213
patients
f
referred
to
a
specialist
liver
surgical
unit
over
25
years,3
with
only
16
(7
5%)
patients
undergoing
curative
resection.
Overall,
the
results
in
this
series
of
patients
with
proximal
malignant
biliary
obstruction
treated
by
endoscopic
endoprosthesis
insertion
were
similar
to
results
of
previous
series.'820
26
-
Successful
stenting
was
achieved
in
170
(89%)
patients
and
successful
drainage
of
the
biliary
688
Palliation
of
proximal
malignant
biliary
obstruction
by
endoscopic
endoprosthesis
insertion
689
tree
in
155
(82%).
Early
complications
occurred
overall
in
36
patients
(19%),
and
41
(22%)
died
within
30
days.
Cholangitis
was
the
principal
complication
occurring
in
13
patients
(7%).
Patients
with
failed
stent
insertion
or
drainage
in
this
series
were
generally
managed
further
by
conservative
means
only,
although
three
had
external
drainage.
It
is
probable
that
the
tech-
nical
success
rate
of
stent
placement
and
the
drainage
success
rate
could
have
been
increased
if
all
patients
had
had
the
combined
procedure
performed
after
initial
or
second
endoscopic
failure.
However,
continuation
of
palliative
attempts
was
deemed
inappropriate
for
16
patients
because
of
a
very
poor
clinical
state
(Table
II).
There
are
two
prominent
areas
of
difference
between
this
and
previous
series.
Firstly,
the
immediate
periprocedural
cholangitis
rate
was
lower
than
previously
reported.20
26
This
was
probably
the
result
of
our
use
of
prophylactic
antibiotics
combined
with
the
policy
of
attempt-
ing
to
inject
contrast
medium
only
into
the
segment
subsequently
stented.
It
is
our
belief
that
the
filling
of
all
segments
to
obtain
a
complete
'diagnostic'
cholangiogram
should
be
avoided
and
only
sufficient
contrast
should
be
injected
to
obtain
imaging
of
the
duct
to
be
stented.
Applying
this
rule,
only
five
patients
required
placement
of
a
second
endoprosthesis
for
cholangitis.
Secondly,
only
a
single
endo-
prosthesis
was
placed
unless
either
sepsis
developed
in
undrained
segments
or
resolution
of
cholestasis
was
insufficient.
The
former
occurred
in
five
patients
as
described
and
the
latter
in
a
further
three
patients.
That
is,
a
single
endo-
prosthesis
provided
palliation
in
all
but
eight
of
the
patients
successfully
treated.
Most
of
these
second
endoprostheses
were
placed
in
the
left
lobe
using
the
CP
procedure.
Thus,
routine
placement
of
more
than
one
stent
to
achieve
drainage
of
all
obstructed
liver
segments
as
advocated
by
Deviere
et
aPF6
would
seem
unneces-
sary,
and
if
attempted
but
unsuccessful
may
be
the
cause
of
a
raised
prevalence
of
cholangitis.2
Moreover,
the
placement
of
a
nasobiliary
drain
above
the
stent
to
irrigate
the
liver,
as
advocated
by
some
groups,
would
seem
more
likely
to
cause
sepsis
in
undrained
segments
than
prevent
it.26
The
least
intervention
for
the
desired
result
is
always
the
best.
Distant
or
local
metastatic
cancer
causing
proximal
biliary
obstruction
may
be
managed
in
an
identical
manner
to
primary
malignancy,
except
that
resection
is
not
suitable.
The
morbidity
and
mortality
associated
with
endo-
prosthesis
insertion,
however,
is
considerably
higher
for
these
patients
and
the
survival
is
significantly
shorter
(Fig
2;
Table
IV).
This
is
undoubtedly
because
of
the
influence
of
the
underlying
disease,
yet
even
a
short
term
survival
may
be
considerably
improved
in
terms
of
qual-
ity
of
life
by
relief
from
pruritus
or
nausea.
The
poor
prognosis
in
this
group
does,
however,
demand
careful
patient
selection
for
treatment
and
we
would
not
advocate
intervention
on
the
basis
of
serum
biochemistry
alone.
In
conclusion,
most
patients
with
unresectable
malignant
proximal
biliary
obstruction
may
be
treated
successfully
with
an
acceptably
low
com-
plication
rate
by
the
endoscopic
insertion
of
a
single
endoprosthesis.
Both
primary
and
second-
ary
malignancy
may
be
managed
successfully.
The
prevalence
of
cholangitis
is
lower
than
with
more
complex
interventions.
Surgical
interven-
tion
should
probably
be
limited
to
the
minority
of
younger
and
fitter
patients
in
whom
the
tumour
seems
to
be
resectable.
A A
Polydorou
is
supported
by
the
State
Scholarships
Foundation
of
Greece
and
J
F
Dowsett
by
the
Cancer
Research
Campaign.
The
authors
thank
Mr
M
J
McMahon
and
Mr
E
M
Elliot
of
the
Department
of
Surgery,
Leeds
General
Infirmary,
for
their
help
in
preparation
of
this
manuscript.
1
Dowsett
JF,
Polydorou
AA,
Vaira
D,
et
al.
Endoscopic
stenting
for
malignant
biliary
obstruction:
how
good
really?
A
review
of
641
consecutive
patients.
Gut
1988;
29:
1458.
2
Blumgart
LH,
Hadjis
NS,
Benjamin
IS,
Beazley
R.
Surgical
approaches
to
cholangiocarcinoma
at
confluence
of
hepatic
ducts.
Lancet
1984;
i:
66-70.
3
Bismuth
H,
Castaing
D,
Traynor
0.
Resection
or
palliation:
priority
of
surgery
in
the
treatment
of
hilar
cancer.
WorldJ7
Surg
1988;
12:
39-47.
4
Bismuth
H,
Corlette
MB.
Intrahepatic
cholangioenteric
anastomosis
in
carcinoma
of
the
hilus
of
the
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Surg
Gynecol
Obstet
1975;
140:
170-8.
5
Nakayama
T,
Ikeda
A,
Okuda
K.
Percutaneous
transhepatic
drainage
of
the
biliary
tract:
techniques
and
results
in
104
cases.
Gastroenterology
1978;
74:
554-9.
6
Soehendra
N,
Reyders-Frederix
V.
Palliative
bile
duct
drain-
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-
a
new
endoscopic
method
of
introducing
a
trans-
papillary
drain.
Endoscopy
1980;
12:
8-11.
7
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N,
Grimm
H.
Endoscopic
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bile
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cancer.
WorldJ
Surg
1988;
12:
85-90.
8
Burcharth
F,
Jensen
LI,
Olesen
K.
Endoprosthesis
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internal
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of
the
biliary
tract.
Gastroenterology
1979;
77:
133-7.
9
McPherson
GAD,
Benjamin
IS,
Hodgson
HJF,
Bowley
NB,
Allison
DJ,
Blumgart
LH.
Preoperative
percutaneous
trans-
hepatic
biliary
drainage:
the
results
of
a
controlled
trial.
BrJ
Surg
1984;
71:
371-5.
10
Mayer
WC,
Scott
Jones
R.
Internal
radiation
for
bile
duct
cancer.
WorldJr
Surg
1988;
12:
99-104.
11
Levitt
MD,
Laurence
BH,
Cameron
F,
Klemp
PFB.
Trans-
papillary
iridium-192
wire
in
the
treatment
of
malignant
bile
duct
obstruction.
Gut
1988;
29:
149-52.
12
Speer
AG,
Cotton
PB,
Russell
RCG,
et
al.
Randomised
trial
of
endoscopic
versus
percutaneous
stent
insertion
in
malignant
obstructive
jaundice.
Lancet
1987;
ii:
57-62.
13
Dowsett
J,
Vaira
D,
Hatfield
A,
et
al.
Endoscopic
biliary
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using
combined
percutaneous
and
endoscopic
tech-
niques.
Gastroenterology
1989;
96:
1180-6.
14
Cotton
PB.
Endoscopic
method
for
relief
of
malignant
obstruc-
tive
jaundice.
WorldJ
Surg
1984;
8:
854-61.
15
Dowsett
JF,
Vaira
D,
Hatfield
ARW,
et
al.
Endoscopic
biliary
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using
combined
percutaneous
and
endoscopic
tech-
niques.
Gastroenterology
1989;
96:
1180-6.
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Laurence
BH,
Cotton
PB.
Decompression
of
malignant
biliary
obstruction
by
duodenoscopic
intubation
of
bile
ducts.
BMJ
1980;
280: 522-3.
17
Cotton
PB.
Duodenoscopic
placement
of
biliary
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to
relieve
malignant
obstructive
jaundice.
BrJI
Surg
1982;
69:
501-3.
18
Leung
JWC,
Emery
R,
Cotton
PB,
Russell
RCG,
Vallon
AG,
Mason
RR.
Management
of
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obstructive
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The
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BrJr
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