Percutaneous Bilateral Metallic Stent Placement Using a Stentin-Stent Deployment Technique in Patients With Malignant Hilar Biliary Obstruction

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DOI: 10.2214/AJR.12.8780 · Source: PubMed
Abstract
Objective: The purpose of this study is to investigate the technical and clinical efficacy of percutaneous bilateral stent-in-stent deployment using open cell-design stents and to compare the clinical outcomes of bilateral stent placement using T and Y configurations. Materials and methods: From January 2006 to December 2010, 106 patients with malignant hilar biliary obstruction (Bismuth type II or higher) were included in this retrospective study. All patients were treated with percutaneous bilateral stent-in-stent deployment using open cell-design stents (64 in a T configuration and 42 in a Y configuration). Results: Bilateral stent-in-stent deployment was technically successful in all patients. Seven patients (6.6%) had major complications, including one with severe hemobilia, two with acute cholecystitis, and four with cholangitis; seven (6.6%) patients had minor complications, including self-limiting hemobilia. Successful internal drainage was achieved in 94 patients (88.7%). Stent occlusion by tumor ingrowth, with or without overgrowth, occurred in 37 patients (34.9%). The median survival and stent patency times were 192 days (95% CI, 153.6-230.4 days) and 319 days (95% CI, 148.5-489.5 days), respectively. Stent configuration did not significantly affect technical success, complications, successful internal drainage, patient survival, or stent patency. Conclusion: Percutaneous bilateral stent-in-stent placement using open cell-design stents is effective for bilateral drainage in patients with malignant hilar biliary obstruction. In addition, there was no significant difference in technical and clinical outcomes between T and Y stent configurations.
AJR:200, April 2013 909
central portion has been used to facilitate pas-
sage of the second metallic stent during bilat-
eral stenting [14–16], less is known about the
outcomes of this technique when open cell–
design stents are used in patients with malig-
nant hilar biliary obstruction. We therefore
evaluated the technical and clinical efficacy
of the percutaneous bilateral stent-in-stent
deployment technique, using open cell–de-
sign stents, in patients with malignant hilar
biliary obstruction. We also compared the
clinical outcomes of the T and Y configura-
tions for bilateral stent placement.
Materials and Methods
Patient Population
This retrospective study was approved by the in-
stitutional review board of our institution, and writ-
ten informed consent was waived from each pa-
tient. From January 2006 to December 2010, 106
patients with malignant hilar biliary obstruction of
Bismuth type II or higher were included in this
study. Their demographic, clinical, and laboratory
Percutaneous Bilateral Metallic
Stent Placement Using a Stent-
in-Stent Deployment Technique
in Patients With Malignant Hilar
Biliary Obstruction
Dong Il Gwon
1
Gi-Young Ko
Jin Hyoung Kim
Ji Hoon Shin
Kyung-Ah Kim
Hyun-Ki Yoon
Kyu-Bo Sung
Gwon DI, Ko GY, Kim JH, et al.
1
All authors: Department of Radiology and Research
Institute of Radiology, University of Ulsan College of
Medicine, Asan Medical Center, 86 Asanbyeongwon-gil,
Songpa-gu, Seoul 138-736, Korea. Address correspondence
to D. I. Gwon (radgwon@amc.seoul.kr).
Vascular and Interventional Radiology Original Research
AJR 2013; 200:909–914
0361803X/13/2004–909
© American Roentgen Ray Society
B
iliary obstruction due to advanced
hepatic hilar malignancy is diffi-
cult to treat, both surgically and
nonsurgically, using endoscopic
or percutaneous drainage. Because only about
10–20% of patients are eligible for resection of
hepatic hilar malignancies [1, 2], most patients
receive palliative rather than curative treatment.
Percutaneous palliation of advanced he-
patic hilar malignancies can be accomplished
in a variety of ways. Although it is unclear
whether drainage of both liver lobes in pa-
tients with Bismuth type II or higher malig-
nant hilar tumors is necessary, bilateral drain-
age may be a reasonable option to preserve
the functional volume of the liver during the
course of chemotherapy and to prevent pro-
cedure-related cholangitis of a contaminated
undrained lobe [3–9]. Bilateral biliary drain-
age can be accomplished by the percutaneous
or endoscopic placement of multiple stents
[10–19]. Although a percutaneous stent-in-
stent deployment technique with a wide-mesh
Keywords: biliary obstruction, biliary stent, malignancy
DOI:10.2214/AJR.12.8780
Received February 21, 2012; accepted after revision
April20,2012.
OBJECTIVE. The purpose of this study is to investigate the technical and clinical effi-
cacy of percutaneous bilateral stent-in-stent deployment using open cell–design stents and
to compare the clinical outcomes of bilateral stent placement using T and Y congurations.
MATERIALS AND METHODS. From January 2006 to December 2010, 106 patients
with malignant hilar biliary obstruction (Bismuth type II or higher) were included in this ret-
rospective study. All patients were treated with percutaneous bilateral stent-in-stent deploy-
ment using open cell–design stents (64 in a T configuration and 42 in a Y conguration).
RE SU LT S . Bilateral stent-in-stent deployment was technically successful in all patients.
Seven patients (6.6%) had major complications, including one with severe hemobilia, two
with acute cholecystitis, and four with cholangitis; seven (6.6%) patients had minor compli-
cations, including self-limiting hemobilia. Successful internal drainage was achieved in 94
patients (88.7%). Stent occlusion by tumor ingrowth, with or without overgrowth, occurred
in 37 patients (34.9%). The median survival and stent patency times were 192 days (95% CI,
153.6230.4 days) and 319 days (95% CI, 148.5–489.5 days), respectively. Stent conguration
did not significantly affect technical success, complications, successful internal drainage, pa-
tient survival, or stent patency.
CONCLUSION. Percutaneous bilateral stent-in-stent placement using open cell–design
stents is effective for bilateral drainage in patients with malignant hilar biliary obstruction.
In addition, there was no significant difference in technical and clinical outcomes between T
and Y stent configurations.
Gwon et al.
Stent-in-Stent Technique for Malignant Hilar Biliary
Obstruction
Vascular and Interventional Radiology
Original Research
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910 AJR:200, April 2013
Gwon et al.
data were collected from their medical records or
from the electronic patient information database.
Definitive follow-up data were obtained from all
106 patients. Patient characteristics are summarized
in Table 1. A diagnosis of malignant hilar biliary
obstruction was confirmed by examination of path-
ologic specimens obtained from 66 patients (62%),
22 via percutaneous transbiliary biopsy and 44 via
endoscopic brushing cytology and biopsy; the di-
agnosis was presumed in the remaining 44 patients
(38%) on the basis of CT, MRCP, and ERCP find-
ings. Patients were included if they had biliary hi-
lar obstruction caused by a hilar malignancy that
could not be treated surgically, because of unre-
sectability, late-stage tumor, advanced age, or a co-
morbid condition, and if an endoscopic attempt to
drain the obstructed bile ducts was unsuccessful.
Exclusion criteria included abnormal coagulation
status (international normalized ratio 1.5 and
platelet count 50,000/mm
3
) or poor general health
status (Eastern Cooperative Oncology Group per-
formance status grade 3–4; i.e., confined to bed or
chair more than 50% of waking hours and totally
confined to bed or chair).
Technique
Before percutaneous transhepatic biliary drain-
age (PTBD), CT or MRCP was performed to as-
sess the anatomy and plan the most appropriate
approach for intervention. All PTBD procedures
were performed at the peripheral intrahepatic bile
duct under conscious sedation using IV pethidine
hydrochloride (Demerol, Keukdong Pharmaceuti-
cals) and local anesthesia using lidocaine. The in-
trahepatic bile duct was punctured with a 21-gauge
Chiba needle under the guidance of fluoroscopy or
sonography, and an 8.5-French drainage catheter
was inserted to relieve jaundice or cholangitis be-
fore insertion of the stent. Stent insertion was ac-
complished within 2 weeks after PTBD, allowing
cholangitis, if present, to be treated. IV antibiotics
were administered 12 hours before and for at least
48 hours after the procedure.
Commercially available open cell–design stents
(Zilver, Cook Medical; and Sentinol, Boston Sci-
entific) were used as first and second stents in all
patients. The open cell–design stents were made
of laser-cut nitinol, had high flexibility during de-
ployment, and were accompanied by 6-French in-
troducing systems. The fully expanded diameter
of both stent types was 10 mm, and their fully ex-
panded lengths were 6 and 8 cm, respectively. The
type of open cell–design stent used was at the dis-
cretion of each operator.
Stents were deployed in a T configuration (Fig.
1), consisting of bilateral stenting through a sin-
gle percutaneous site (n = 64), or a Y configuration
(Fig. 2), consisting of bilateral stenting through bi-
lateral percutaneous sites (n = 42). We initially at-
tempted to use the T configuration in all patients
because it did not require an additional contralat-
eral puncture. However, when negotiation of a
guidewire into the contralateral duct was not pos-
sible, the Y configuration was used.
After stent placement, one or two 8.5- or 10-French
temporary drainage catheters were inserted just
proximal to the stents. For the next 1–2 days of ex-
ternal drainage, the catheter was frequently irrigat-
ed to remove possible blood clots or sludge. The
temporary drainage catheters were removed after
2–3 days of catheter clamping, without further in-
tervention, if free contrast agent flow through the
stents into the common bile duct and the duode-
num was documented. Information regarding cur-
TABLE 1: Characteristics of
106 Patients
Characteristic Value
Sex (no. of patients)
Male 78
Female 28
Age (y), range (mean ± SD) 3788 (67 ± 11)
Underlying disease
Bile duct carcinoma 61 (57.5)
Gallbladder carcinoma 18 (17)
Intrahepatic cholangiocarcinoma 14 (13.2)
Gastric carcinoma metastasis 11 (10.4)
Hepatocellular carcinoma 2 (1.9)
Bismuth type
II 7 (6.6)
III 35 (33)
IV 64 (60.4)
NoteExcept where noted otherwise, data are no.
(%) of patients.
A
D
Fig. 1—78-year-old man with hilar cholangiocarcinoma (Bismuth type IV).
A, Cholangiogram shows malignant hilar stricture.
B, After deployment of first open cell–design stent (Sentinol, Boston Scientific) from right side into left side,
guidewire was inserted from right side into common bile duct through mesh of first stent.
C, Second stent (Sentinol) was deployed.
D, Cholangiogram after stent insertion shows good bilateral communication via stents and internal drainage.
C
B
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AJR:200, April 2013 911
Stent-in-Stent Technique for Malignant Hilar Biliary Obstruction
rent status or death was obtained for all patients by
telephone or from medical records.
Study Endpoints and Definitions
Major study endpoints were assessments of
technical success, complications, successful inter-
nal drainage, stent patency, and patient survival.
Technical success was defined as stent deployment
in an adequate position across the stricture with
good contrast agent passage through the stents.
Complications were classified as major and minor
according to the guidelines of the Society of In-
terventional Radiology Standards of Practice Com-
mittee [20]. Minor complications were defined as
those requiring no or nominal therapy, including
overnight admission for observation only. Major
complications were defined as those necessitating
major therapy, those necessitating an unplanned
increase in the level of care or prolonged hospital-
ization (> 48 hours), and those resulting in perma-
nent adverse sequelae or death. Successful inter-
nal drainage was defined as successful removal of
temporary drainage catheters and a decrease in se-
rum bilirubin level to less than 75% of the pretreat-
ment level within 1 month after stent placement.
Stent occlusion was defined as biliary obstruction,
confirmed endoscopically or radiologically, serum
bilirubin levels greater than 3 mg/dL, or any con-
dition requiring reintervention to improve biliary
drainage. Tumor ingrowth was defined as tissue
occluding the stent lumen that could not be cleared
by biliary balloon sweeping. Tumor overgrowth
was defined as new strictures at the proximal or
distal end of a stent. Stent patency time was de-
fined as the interval between initial stent placement
and stent occlusion. If there was no evidence of
obstruction during a patient’s lifetime, the patency
period was considered equal to patient overall sur-
vival. Overall survival was defined as the interval
between initial stent placement and patient death.
Statistical Analysis
Statistical analysis was conducted using SPSS
software (version 14.0, SPSS). The Mann-Whitney
U test was used to compare pairs of independent
continuous variables between groups. Fisher ex-
act tests were used to compare categoric variables
between groups, and paired-sample Student t tests
were used to compare pre- and postprocedural se-
rum bilirubin levels. Stent patency and patient sur-
vival rates were calculated using the Kaplan-Meier
method, and the two groups were compared us-
ing the log-rank test. Statistical significance was
reached when p values were less than 0.05.
Results
Bilateral stent deployment was technical-
ly successful in all patients. All 106 patients
received open cell–design stents as first and
second stents, including 112 Sentinol and
100 Zilver stents. The T configuration was
used in 64 patients, and the Y configuration
was used in 42 patients; patient characteris-
tics and outcomes in these two groups are
shown in Table 2.
Procedure-related minor complications oc-
curred in seven patients (6.6%), with self-lim-
iting hemobilia that completely resolved with-
in 3 days without transfusion. There were no
significant between-group differences in com-
plication rates. Major complications occurred
in seven patients (6.6%). One patient had se-
vere hemobilia secondary to a pseudoaneu-
rysm of the left intrahepatic artery and was
treated successfully with selective transarteri-
al embolization. Two patients had acute chole-
cystitis and underwent percutaneous transhe-
patic gallbladder drainage. Three patients had
cholangitis, which was rapidly resolved within
4 days by antibiotic treatment alone.
Follow-up cholangiography 3–5 days after
stent placement showed adequate decompres-
sion of the biliary ducts in all patients. The
temporary drainage catheters were removed
from 101 patients (95.3%) after confirma-
tion of good stent patency; despite good stent
patency, the catheters could not be removed
from the other five patients because of in-
creased serum bilirubin levels caused by rap-
id disease progression. The mean (± SD) se-
rum bilirubin level, which was 13.5 ± 7.6 mg/
dL before drainage, decreased significantly,
to 1.7 ± 1.3 mg/dL, 1 month after stent place-
ment (p < 0.001). Successful internal drainage
A
D
Fig. 248-year-old man with hilar cholangiocarcinoma (Bismuth type III).
A, Cholangiogram shows malignant hilar stricture.
B, After inserting guidewire into common bile duct, first open celldesign stent (Zilver, Cook Medical) was
deployed from right side.
C, Second stent (Sentinol, Boston Scientific) was deployed from left side into common bile duct through mesh
of first stent (Zilver).
D, Cholangiogram after stent insertion shows good bilateral communication via stents and internal drainage.
C
B
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912 AJR:200, April 2013
Gwon et al.
was achieved in 94 of 106 patients (88.7%),
including 57 of the 64 patients (89%) in the
T-congured stent group and 37 of 42 (88%)
in the Y-configured stent group (p > 0.999).
All patients were clinically followed up un-
til death or the cutoff date of April 30, 2011,
with a mean follow-up after stent placement
of 224 days (range, 23562 days). At the time
of this analysis, seven patients remain alive.
Two patients (1.9%) died within 30 days af-
ter placement of a T-configured stent, with
death in both cases caused by rapid progres-
sion of the underlying malignancy and not di-
rectly related to the procedure. Kaplan-Mei-
er analysis showed that median overall patient
survival was 192 days (95% CI, 153.6–230.4
days; Fig. 3A), 184 days in the T-configured
and 203 days in the Y-configured stent group
(p = 0.970; Fig. 3B).
Stent occlusions caused by tumor ingrowth,
with or without tumor overgrowth, occurred
in 37 patients (34.9%): 22 of 64 patients in the
T-configured stent group and 15 of 42 patients
in the Y-configured stent group. Stent occlu-
sions were managed by PTBD in 36 patients
and by endoscopic biliary stent placement in
one patient. Of the 36 patients who underwent
PTBD, bilateral drainage with one drainage
catheter was possible in 20 of 22 patients in
the T-configured stent group and in six of 15
patients in the Y-configured stent group. Ad-
ditional contralateral PTBD was performed in
11 patients because guidewire negotiation into
the contralateral duct was impossible because
of severe tumor ingrowth and extensive tumor
overgrowth. Two patients with stent occlusion
caused by tumor ingrowth underwent percu-
taneous placement of open cell–design stents,
resulting in good internal drainage for 3.5 and
4.5 months, respectively, before these patients
died. In the remaining 34 patients, additional
stent placement was not performed because of
disease progression and poor general health.
Kaplan-Meier analysis showed that the me-
dian stent patency time was 319 days over-
all (95% CI, 148.5489.5 days; Fig. 4A), 319
days in patients who received T-configured
stents, and 497 days in those who received Y-
configured stents (p = 0.927; Fig. 4B).
Discussion
In patients with malignant hilar biliary ob-
struction, it is unclear whether stent placement
should be unilateral or bilateral [3–9]. Unilat-
eral stenting may not completely relieve jaun-
dice [7], may induce acute cholangitis [8], and
may result in shorter stent patency than bilat-
eral stenting [9]. Moreover, bilateral drain-
age has been associated with superior surviv-
al rates, with the worst survival rates reported
for patients with cholangiographic opacifica-
tion of both lobes but drainage of only one
[7]. However, unilateral drainage is associat-
ed with a lower risk of complications [5], and
drainage of only 25% of the liver is associated
with adequate palliation [21]. Therefore, inser-
tion of a single biliary stent into one functional
liver lobe for unilateral drainage may provide
adequate palliation for most patients with ma-
lignant hilar biliary obstruction. In some pa-
tients, however, bilateral biliary stents may be
the best option for palliative drainage of both
liver lobes when both sides are contaminated
or if chemotherapy is scheduled.
Two techniques have been developed for
the percutaneous placement of bilateral me-
tallic stents: side-by-side and stent-in-stent
deployment techniques. The side-by-side de-
ployment technique results in the simultane-
ous insertion of two parallel metallic stents
to drain the bile ducts of both hepatic lobes.
This parallel arrangement, however, may pre-
vent full expansion of metallic stents at and
below the hepatic confluence [14]. Although
adequate drainage may be achieved, expan-
sion of the stents to less than their full diam-
eter may result in partial collapse of one or
both stents. In the stent-in-stent deployment
technique, a second stent is placed through
the mesh of the first stent to enter the com-
mon bile duct. By use of this technique, the
entire length of the stricture can continuously
expand within a single stent caliber, a result
that cannot be achieved using the side-by-side
stent deployment technique. Moreover, over-
lapping of the two stents can effectively pre-
vent displacement of the stents [14, 15]. How-
ever, passing a second metallic stent through
the mesh of the first stent can be technically
difficult if the first stent has a tightly woven
closed-cell design [22].
To overcome the technical difficulties asso-
ciated with the stent-in-stent deployment tech-
nique using closed cell–design stents, in this
study, we adopted open cell–design stents. The
cells of the open cell–design stents we studied
are connected more easily than the tight weav-
ing and interlocking of other closed cell–design
stents. Thus, open cell–design stents can be di-
lated easily by ballooning and remain dilated,
thus permitting easy passage of the second stent
during bilateral stenting and its wide expansion.
We found that technical success rate (100%),
complication rate (13.2%), and successful in-
TABLE 2: Comparison of Characteristics and Outcomes of Groups With
T- and Y-Configured Stents
Characteristic T Configuration Y Configuration p
Sex (no. of patients) 0.075
Male 43 35
Female 21 7
Age (y), mean 66.8 67 0.786
Underlying disease (no. of patients) 0.321
Bile duct carcinoma 30 25
Gallbladder carcinoma 16 7
Intrahepatic cholangiocarcinoma 8 6
Gastric carcinoma metastasis 9 2
Hepatocellular carcinoma 1 2
Bismuth type (no. of patients) 0.057
II 6 1
III 25 10
IV 33 31
Technical success rate (%) 100 100 > 0.999
Complication rate (%) 7.8 14.1 0.338
Successful internal drainage rate (%) 89 88 > 0.999
Stent occlusion rate (%) 34.4 35.7 > 0.999
Stent patency (d), median 319 497 0.927
Patient survival (d), median 184 203 0.970
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AJR:200, April 2013 913
Stent-in-Stent Technique for Malignant Hilar Biliary Obstruction
0
0
20
40
60
80
10 0
100 200 300
Time (d)
Cumulative Survival (%)
400 500 600 0
0
20
40
p = 0.970
Configuration
T
Y
T-censored
Y-censored
60
80
10 0
100 200 300
Time (d)
Cumulative Survival (%)
400 500 600
A
Fig. 3Kaplan-Meier curves for survival rates.
A, Graph shows overall survival rate of study patients.
B, Graph shows no significant difference in patient survival between T and Y configuration groups.
B
0
0
20
40
60
80
10 0
100 200 300
Time (d)
Cumulative Patency Rate (%)
400 500 600
0
0
20
40
p = 0.927
Configuration
T
Y
T-censored
Y-censored
60
80
10 0
100 200 300
Time (d)
Cumulative Patency Rate (%)
400 500 600
A
Fig. 4Kaplan-Meier curves for stent patency.
A, Graph shows overall stent patency rate.
B, Graph shows no significant difference in stent patency between T and Y configuration groups.
B
ternal drainage rate (88.7%) of this study are
in accordance with the results of other stud-
ies involving percutaneous bilateral metallic
stent placement in patients with advanced hi-
lar malignancies (i.e., technical success rates,
93–100%; overall complication rates, 17–33%;
successful drainage rates, 89–92%) [3, 11, 12].
The median patient survival time we observed,
192 days, was similar to the 176–247 days re-
ported previously [3, 15–19]. The median stent
patency time we observed, 319 days, was much
longer than that reported in patients who un-
derwent percutaneous bilateral stent-in-stent
placement using a T configuration (median,
170 days) [15] and an X configuration (median,
187 days) [16], although the reason for this dis-
crepancy remains unclear.
We also found no significant differenc-
es in rates of technical success (p > 0.999),
complications (p = 0.338), and successful
internal drainage (p > 0.999) or in stent pa-
tency (p = 0.927) and patient survival (p =
0.970) between the T- and Y-configured stent
groups. For achievement of bilateral drain-
age in patients with stent occlusion, reinter-
vention was more easily performed in pa-
tients in whom stents had been inserted in a
T rather than in a Y configuration. Two of 22
patients with T-configured stents and nine of
15 patients with Y-configured stents required
additional contralateral PTBD. Although we
did not observe complications related to ad-
ditional contralateral PTBD in the Y-config-
ured stent group, T-configured stent-in-stent
deployment for bilateral drainage may be
preferable in patients with malignant hilar
biliary obstruction unless technical difficul-
ties necessitate Y-configured stent-in-stent
deployment. However, because differences
among the two types of stents used may have
influenced stent patency, further prospective
randomized comparisons are necessary.
In conclusion, percutaneous bilateral stent-
in-stent placement using open cell–design
stents is a feasible and effective method of
achieving bilateral drainage in patients with
malignant hilar biliary obstruction. Moreover,
although there was no significant difference in
technical and clinical outcomes between T and
Y configurations, T-configured stent-in-stent
deployment for bilateral drainage may be pref-
erable in patients with malignant hilar biliary
obstruction unless technical difficulties neces-
sitate Y-configured stent-in-stent deployment.
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  • [Show abstract] [Hide abstract] ABSTRACT: The concept of percutaneous management of malignant biliary obstruction has not significantly changed in the last two decades and is based on the successful drainage of bile toward the duodenum, which normalizes liver function and prevents the development of cholangitis and sepsis. However, patient survival has changed slightly in the last two decades due to the advance of the diagnostic methods, chemo-radiotherapy protocols, and minimally invasive local control of the disease. Bare metal stents have not improved; however, newly developed covered biliary stents have been designed, and there is now evidence supporting their use in the clinical practice. However, other novel devices that may potentially offer benefit to patients with malignant biliary obstruction have been developed, such as drug-eluting biliary stents and intraductal ablation devices, and first feasibility trials have been published that offer encouraging results. These new technological developments, in combination with increased patient survival, bring new exciting data in this constantly developing area. The purpose of this review article is to investigate the latest published evidence on percutaneous minimal invasive palliation of malignant biliary disease and to delineate current trends.
    Article · Jul 2013
  • [Show abstract] [Hide abstract] ABSTRACT: Aim: To investigate and compare the efficacy and safety of percutaneous transhepatic biliary stenting (PTBS) using a one- or two-stage procedure and determine the predictive factors for the efficacious treatment of malignant hilar obstruction (MHO). Methods: 159 consecutive patients with MHO who underwent PTBS were enrolled between January 2010 and June 2013. Patients were classified into one- or two-stage groups. Independent predictors of therapeutic success were evaluated using a logistic regression model. Results: 108 patients were treated with one-stage PTBS and 51 patients were treated with two-stage PTBS. The stents were technically successful in all patients. Successful drainage was achieved in 114 patients (71.4 %). A total of 42 early major complications were observed. Re-interventions were attempted in 23 patients during follow-up. The cumulative primary patency rates at 3, 6, and 12 months were 88, 71, and 48 %, respectively. Stent placement using a one- or two-stage procedure did not significantly affect therapeutic success, early major complications, median stent patency, or survival. A stent placed across the duodenal papilla was an independent predictor of therapeutic success (odds ratio = 0.262, 95 % confidence interval [0.107-0.642]). Patients with stents across papilla had a lower rate of cholangitis compared with patients who had a stent above papilla (7.1 vs. 20.3 %, respectively, p = 0.03). Conclusions: The majority of patients with MHO who underwent one-stage PTBS showed similar efficacy and safety outcomes compared with those who underwent two-stage PTBS. Stent placement across the duodenal papilla was associated with a higher therapeutic success rate.
    Full-text · Article · Oct 2014
  • [Show abstract] [Hide abstract] ABSTRACT: Procedure-related complications of percutaneous transhepatic biliary drainage (PTBD) have been well documented in the literature. However, relatively restricted data are available concerning drainage-related complication rates in long-term PTBD therapy. The present retrospective study evaluated the extent and the nature of drainage complications during PTBD therapy and associated risk factors for these complications. Between June 1997 and May 2007, a total of 385 patients with PTBD were identified by analyzing the PTBD database and hospital charts, with a total of 2468 percutaneous biliary drainages being identified. Among the identified patients, 243 (63%) had malignant and 142 (37%) had benign bile duct strictures. At least 1 drainage-related complication was observed in 40% of the patients. With respect to the total number of drains, prosthesis complications occurred in 23%. Occlusion, dislocation, and cholangitis were the most common complications observed during PTBD therapy. Risk factors for cholangitis and occlusion were malignant disease, prior occurrence of complications, and bilateral drainage. Proximal stenosis of the biliary system was close to significant. Drainage-related complications are a major problem in PTBD therapy. The risk factors for occlusion and cholangitis discovered in this study can help to refine individual strategies to reduce the rate of these drainage complications.
    Article · Dec 2014
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