Controversial issues of biliary stenting in patients with proximal biliary obstruction

The management of biliary decompression in malignant hilar carcinoma remains controversial. This review shows the most relevant aspects of endoprosthetics for proximal biliary obstruction, including necessity of stenting and morphological verification before radical surgery, selection of approach to drain etc. The main contradictions and ways to solve them are presented in this article, based on evidence researches, international and expert consensus conferences.

Percutaneous Biliary External–Internal Drainage for Malignant Obstruction of Self-Expanding Uncovered Metal Stents Placed for Hilar Carcinoma: Retrospective Analysis of Long-Term Outcome in 160 Patients

Aims and Objectives We evaluated the safety and effectiveness of reestablishing adequate bile flow in patients with malignant obstruction of multilobar self-expanding uncovered metal stents (SEUMSs) inserted for palliative treatment of malignant hilar stenosis, an otherwise fatal setting. From September 1991 to January 2019, 160 patients (100 men and 60 women; median: 69 [range: 37–87] years) with malignant obstruction of multilobar SEUMSs were treated by percutaneous transhepatic external–internal biliary drainage. All patients were followed in their respective oncology services where they were treated (or not) according to local protocols adapted to their disease and overall general status. Result External–internal biliary drainage was successful in all 160 patients. All patients were discharged within 5 days. Both immediate (4 patients; 2.5%) and late complications (29 patients; 18%) were managed successfully with minimal morbidity and no mortality. After reestablishment of adequate bile flow, the median survival was 191 days (range: 2–5,668 days). Forty-one (25.6%) patients survived for more than 12 months, and 10 (6.2%) survived for more than 3 years. Conclusion In our series, external–internal biliary drainage was safe and effective; it was life-saving and afforded acceptable quality of survival for patients who otherwise would have been left untreated with short-term fatality.

Y-Shaped Bilateral Self-Expandable Metallic Stent Placement for Malignant Hilar Biliary Obstruction: Data from a Referral Center for Palliative Care

Background and Aim. Malignant hilar strictures are a clinical challenge because of the current therapeutic approach and the poor prognosis. In recent years, self-expandable metallic stents have proven more effective than plastic stents for palliation of malignant hilar strictures, with the bilateral stent-in-stent technique registering a high success rate. We report our experience with Y-shaped endoscopic self-expandable metallic stents placement for treatment of advanced malignant hilar strictures.Methods. From April 2009 to August 2012, we prospectively collected data on patients treated with Y-shaped SEMS placement for advanced malignant hilar carcinoma. Data on technical success, clinical success, and complications were collected.Results. Twenty patients (9 males) were treated (mean age 64.2 ± 15.3 years). The grade of malignant hilar strictures according to the Bismuth classification was II in 5 patients (25%), IIIa in 1 (5%), and IV in 14 (70%). The mean bilirubin level was 14.7 ± 4.9 mg/dL. Technical success was achieved in all patients, with a significant reduction in bilirubin levels (2.9 ± 1.7 mg/dL). One patient experienced cholangitis as early complication, while in 2 patients stent ingrowth was observed. No stents migration was recorded. There was no procedure-related mortality. At the end of the follow-up (7.1 ± 3.1 months), 13 of the 20 patients (65%) had died.Conclusions. Our experience confirms endoscopic bilateral self-expandable metallic stents placement with stent-in-stent technique (Y-shaped configuration) as a feasible, effective, and safe procedure for palliation of unresectable malignant hilar strictures.