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ABDOMINAL IMAGING Table of Contents   
Year : 2004  |  Volume : 14  |  Issue : 1  |  Page : 45-51
Hilar cholangiocarcinoma : Results of percutaneous stenting with self-expandable metal stents


Dept. of Radiology, Gastroenterology, Amrita Institute of Medical Sciences, Amrita Lane, Elamakkara, Cochin-682026, Kerala, India

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   Abstract 

Objectives- The determine the success rate of deployment and long term patency of Gianturco Rosch metal stents in inoperable hilar cholangiocarcinomas and to evaluate the effectiveness of partial drainage in the palliation of jaundice in these patients. Materials and Methods : Over a period of two years, nine patients of inoperable hilar cholangiocarcinomas were referred for percutaneous biliary drainage and stent placement. All patients were put on internal external catheter drainage as aa first step prior to stenting. One patient, who had severe pre-existing cholangitis, died a few days after catheter drainage. Of the remaining eight patients, seven had only partial drainage of the liver. The segments or lobe with atrophy, portal vein occlusion or tumour infiltration were excluded. The eight patients received a total of 14 Gianturco Rosch Z-stents. There were no major procedure related complications and no evidence of cholangitis up to 30 days after discharge. Bilirubin levels in all patients dropped sharply following the stenting. On follow up, 2 patients had stent occlusions at 2 months, one patient at 6.5 months. One patient had a 11-month survival without stent occlusion. Cholangitis episodes on follow up were found to be uncommon and mild when present. Endoscopic insertion of a plastic stent through the metal stent was done in 3 patients with stent occlusion. Conclusions: Percutaneous deployment of Gianturco Rosch metal stents is safe, has a high success rate and provides adequate palliation even when few segments of the liver are not drained. Due to the relatively long survival of these patients, reinterventions may be required frequently.

Keywords: Cholangiocarcinoma, Bile ducts, Interventional procedures, Stents

How to cite this article:
Moorthy S, Prabhu N K, Sreekumar K P, Pillai A K, Nair P V. Hilar cholangiocarcinoma : Results of percutaneous stenting with self-expandable metal stents. Indian J Radiol Imaging 2004;14:45-51

How to cite this URL:
Moorthy S, Prabhu N K, Sreekumar K P, Pillai A K, Nair P V. Hilar cholangiocarcinoma : Results of percutaneous stenting with self-expandable metal stents. Indian J Radiol Imaging [serial online] 2004 [cited 2019 Sep 21];14:45-51. Available from: http://www.ijri.org/text.asp?2004/14/1/45/28554

   Introduction Top


Cholangiocarcinoma is the most common primary malignancy of the bile duct, about 50% arising in the confluence of the right and left hepatic ducts [1]. The role of imaging in these cases is to establish a diagnosis, assess the lesion for respectability and plan percutaneous intervention if unresectable. Inoperable biliary obstructions at the hilum are best dealt with by percutaneous radiological intervention as this method is safer and has a higher success rate than the endoscopic method [2]. We present our two-year experience of percutaneous management of nine patients with hilar cholangiocarcinoma using metallic self-expandable Gianturco Rosch Z-stents.


   Materials and methods Top


Over a period of 2 years (August 1999-October 2001) nine patients with hilar cholangiocarcinoma were managed with percutaneous biliary drainage and stenting to palliate jaundice. There were 6 males and 3 females with age ranging from 46 to 73 years. Patients were referred for radiological intervention if they were inoperable or had co-morbid conditions precluding curative surgery. All patients had USG and spiral CT for diagnosis and staging [Figure - 1]. Five patients also had MRCP before procedure to evaluate segmental duct involvement and length of stricture [Figure - 2]. All patients had isolation of the right (segments 5, 6, 7, 8) and left (segments 2, 3, 4) systems. Involvement of the secondary confluence isolating right anterior (segments 5 and 8) and right posterior (segments 6 and 7) was present in five patients.

Pre-procedure evaluation included a complete hemogram, direct and indirect bilirubin, serum alkaline phosphatase, SGOT, SGPT, albumin/globulin, PTT and INR. Patients were hydrated with 150ml/hr dextrose normal saline starting 8 hours before procedure. Broad spectrum antibiotics- Inj ciprofloxacin 200mg and metronidazole 500mg or Inj cephaperazone 1g iv was started on the morning of the procedure and continued for 72 hours. Inj pethidine 50mg and phenergan 25mg im was administered for sedation one hour before procedure in all patients.

Eight patients had drainage of only selected segments of the liver [Table - 1]. Decision not to drain segments was taken on the basis of atrophy, involvement of portal supply and/or infiltration of tumour into that segment. After an initial percutaneous transhepatic cholangiogram using 22G Chiba needle, the system targeted for drainage was repunctured with an Accustick II introducer set (Boston Scientific, MA) and a.038` Teflon wire was placed into the system. Using a 65 cm 5F Cobra catheter and a.038` Terumo wire, the obstruction was crossed and an 8.5F internal-external biliary drainage catheter was placed [Figure - 3]. In one patient, an external drainage catheter was placed following an unsuccessful initial attempt to cross the lesion. A 2nd attempt at crossing the lesion was successful two days later. Drainage of other systems was attempted in the same sitting in some patients while in others; procedure time and patient condition mandated multiple sittings. Following successful placement of internal-external drainage catheters across the obstruction, the patients were kept on external drainage for 2 to 5 days before stenting. One patient who had severe pre-existing cholangitis and septicemia developed renal failure and died 3 days after catheter drainage. Eight patients received self-expandable metallic stents [Figure - 4],[Figure - 5]. The Gianturco Rosch Z-stents (Cook, Bloomington) used in this study require a 12F introducer system and the two-step approach was required to minimize bleeding and patient discomfort. Seven patients received thirteen 8mm stents of appropriate length. In patients in whom the secondary confluence was free of tumour, a single stent was sufficient to drain both the right anterior and posterior systems. In one patient a single 12mm stent was used to drain the left lobe.


   Results Top


There was a 100 % technical success rate in crossing the obstruction. Fourteen biliary systems were targeted for drainage in eight patients. Stents were successfully delivered in all systems. The number of sittings of intervention required to achieve stenting varied from two in four patients to five in one patient. In patients managed in a single admission (7/8) the number of days of hospital stay ranged from 13 to 27 days (mean 19 days). One patient who was discharged on internal-external drainage prior to stenting developed cholangitis, which required intravenous antibiotics for control. Stenting could be performed only in a subsequent admission after bile cultures were reported negative. There was no evidence of cholangitis up to 30 days post-procedure in other patients (n=7) who were managed in a single admission. All stented patients (n=8) showed rapid lowering of bilirubin values [Figure - 6]. On the first follow up visit 3 weeks after discharge, all patients were free of pruritus. Minor procedure related complications, seen in 4 patients did not impact response to drainage or final outcome. Two patients developed small right-sided pleural effusions, which were drained under US guidance. One patient had a sub capsular bilioma requiring drainage and one patient had to have 24 hour ICU admission for severe abdominal pain after stenting.

In the four patients who developed stent occlusion on follow up the median patency was 6.5 months. Prior to actual stent occlusion, only two patients had signs of mild cholangitis, which were managed by oral antibiotics alone. One patient (Patient 3) developed occlusion of one of the stents at 6.5 months and was managed by endoscopic insertion of a 7F plastic stent through the occluded stent [Figure - 7]. He continues to be on follow up 12 months after the initial procedure. Two other patients who developed stent occlusions at two months were also managed by endoscopic stenting.


   Discussion Top


Cholangiocarcinoma is an adenocarcinoma having three distinct subtypes: sclerosing, nodular and papillary. The sclerosing subtype constitutes a majority of all cases presenting as a tight stricture at the hilum [3]. A definite mass may not be identifiable on imaging raising the possibility of a benign stricture. However, the serum bilirubin in cholangiocarcinoma patients tends to be higher than seen in benign strictures. A focal stenotic lesion in the absence of previous biliary tract surgery combined with the appropriate clinical presentation is sufficient for a diagnosis of cholangiocarcinoma [4]. Resection with partial hepatectomy with restoration of biliary enteric continuity is the only effective therapy. Majority is not suitable for resection due to tumour involvement of secondary biliary radicles, portal vein encasement, too little residual liver tissue or co-morbid condition [5]. The indications for palliation are intractable pruritus, cholangitis and for intraluminal radiotherapy.

Hilar cholangiocarcinomas typically produce isolation of the right anterior, right posterior and the left systems. MR cholangiopancreatography maps out patency of the primary and secondary confluence, length of the stricture, anatomic variation of the biliary ducts and lobar atrophy. This information can be used to limit the drainage procedure and avoid contrast injection into atrophied or infiltrated segments, thereby reducing procedure time and morbidity [6]. Percutaneous approach has the advantage of being able to specifically target and simultaneously deliver stents into multiple systems. ERCP and endoscopic endoprosthesis insertion have a limited value in the management of patients with hilar cholangiocarcinomas. Liu, Lo et al in their series of 55 patients managed by endoscopy, reported an overall satisfactory drainage in only 41%, a periprocedure complication rate of 25% and a 30-day mortality of 18% [7]. In our series, technical success rate of stenting was 100% with no significant periprocedure morbidity.

The results of our study lead us to infer that the percutaneous approach is clearly superior to endoscopic intervention in the palliative management of hilar cholangiocarcinomas. Self-expandable metal stents have been shown to have longer patency rates than plastic stents [8]. Majority of bile duct tumours is relatively slow growing and the consequent longer life expectancy makes metal stents ideal [3],[4]. The median stent patency of 6.5 months observed in our series co-relates very well with the reported 6-month median patency of metallic stents in the hilum [9]. Becker et al have shown that the one-year patency rate of stents in the hilum is only 46% compared to 89% in the distal CBD [10].

Self-expandable metal stents allow a larger diameter to be achieved in situ - up to 12mm (36F) - through a relatively small transhepatic access [11]. The Z-stents require a 12F access while the Wallstents can be delivered using a 7F system, which enables the stenting process to be completed in a single step. This can significantly reduce hospital stay and, consequently, the cost of the procedure. Compared to the Wallstent, the Z-stent is more radio-opaque and has no foreshortening on release allowing very accurate positioning. The Z-stent is, however, more rigid in structure and, hence, may be difficult to maneuver across tight curves [12]. Compared to the fine meshwork of the Wallstent, the relatively large gaps between the metal struts of the Z-stent could allow early tumour ingrowth. However, a large series from South Korea using modifies Z-stents has documented tumour overgrowth as a much more frequent cause for stent occlusion than ingrowth [13]. It follows that the proximal and distal ends of the stent should ideally lie well clear of the malignant stricture.

Early reports of percutaneous stenting had advocated drainage of all obstructed systems and claimed better outcomes with an aggressive approach combining stenting and radiotherapy [14]. A growing body of evidence is now pointing to a more conservative and targeted approach [4],[9], [10]. Seven out of eight stented patients in the present series had undrained segments of the liver. Palliation was achieved in all patients with no serious episode of cholangitis on follow up till the stents occluded. Our results lead us to conclude that a conservative approach achieves good palliation with, presumably, reduction in expense and periprocedure morbidity. Due to the relatively long

life expectancy of even inoperable cholangiocarcinomas, reinterventions may be required for stent occlusion. We have found that endoscopy is technically easy in these patients since the indwelling stent `guides` the guide-wire into the obstructed segments. An inexpensive plastic stent can then be placed through the metal stent. It must be emphasized that a close multispeciality team approach and a treatment strategy that aims at adequate palliation through minimum intervention is essential in the management of patients with hilar cholangiocarcinoma.


   Acknowledgement Top


We are deeply indebted to the Mata Amritanandamayi Math for arranging the donation of the Gianturco stents used in our study. We would also like to thank our colleagues in the departments of Surgical and Medical Gastroenterology for their support.

 
   References Top

1.MacCarty RL, Diseases of the bile ducts In: Taveras JM, Ferucci JT, eds. Radiology. Diagnosis, imaging, intervention. Vol 4. Philadelphia JB Lippincott, 1994; 1-16   Back to cited text no. 1    
2.Mclean GK, Burke PR. Role of endoprosthesis in the management of malignant biliary obstruction. Radiology 1989; 170:961-967   Back to cited text no. 2    
3.Altenmeir WA, Gall EA, Culbertson WR, Inge WW. Sclerosing carcinoma of the intrahepatic (hilar) bile ducts. Surgery 1966; 60:191-200   Back to cited text no. 3    
4.Jarnagin WR, Saldinger PF, Blumgart LH. Cancer of the bile ducts: The hepatic ducts and common bile ducts. In: Blumgart LH, Fong Y, eds. Surgery of the liver and biliary tract, 3rd ed. Philadelphia: WB Saunders, 2001:1017-1058   Back to cited text no. 4    
5.Burke EC. Hilar cholangiocarcinoma: patterns of spread, the importance of hepatic resection for curative and a presurgical clinical staging system. Annals of Surgery 1998; 228:385-394   Back to cited text no. 5    
6.Lopera JE, Soto AJ, Munera F Malignant hilar and perihilar biliary obstruction: Use of MR cholangiography to define the extent of biliary ductal involvement and plan percutaneous interventions. Radiology 2001; 220:90-96   Back to cited text no. 6    
7.Liu MB, Lo C, Lai CS et al Endoscopic retrograde cholangiopancreatography and endoscopic endoprosthesis insertion in patients with Klatskin tumors. Arch Surg.1998; 133:293-296   Back to cited text no. 7    
8.David PHP, Groen AK, Rauws EAJ et al Randomized trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 1992; 340:1488-1492   Back to cited text no. 8    
9.Glattli A, Stain SC, Baer HU, Schweizer W, Tsiller J and Blumgart LH 1993. Unresectable malignant biliary obstruction: Treatment by self-expandable biliary endoprosthesis. Hepatobiliary Surgery 1994; 6:175-184   Back to cited text no. 9    
10.Becker CD, Glattli Axial, Maibach R et al Percutaneous palliation of malignant obstructive jaundice with the Wallstent endoprosthesis: Follow up and reintervention in patients with hilar and nonhilar obstruction. JVIR 1993; 4:597-604   Back to cited text no. 10    
11.Lameris JS, Stoker J, Nijs HGT et al Malignant biliary obstruction: Percutaneous use of self-expandable stents Radiology 1991; 179:703-707   Back to cited text no. 11    
12.Douglas A, Howell MD, Steven F et al Endoscopically placed Gianturco endoprosthesis in the treatment of malignant and benign biliary obstruction Gastrointest Endosc Clin N Am 2000; 9:479-490   Back to cited text no. 12    
13.Lee BH, Do YS, Lee JH et al : Metallic stents in malignant biliary obstruction: Prospective long-term clinical results. AJR Am Roentgenol. 1997; 168:741-745   Back to cited text no. 13    
14.Coons H: Metallic stents for the treatment of biliary obstruction: A report of 100 cases. Cardiovasc Intervent Radiol 1992; 15:367-374   Back to cited text no. 14    

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Correspondence Address:
S Moorthy
Dept. of Radiology, Gastroenterology, Amrita Institute of Medical Sciences, Amrita Lane, Elamakkara, Cochin-682026, Kerala
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]

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