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Biliary Stenting

  • Author: Philip L Johnson, MD; Chief Editor: Kyung J Cho, MD, FACR, FSIR  more...
 
Updated: Nov 18, 2015
 

Background

Over the past few decades, biliary interventions have evolved a great deal. Opacification of the biliary system was first reported in 1921 with direct puncture of the gallbladder. Subsequent reports described direct percutaneous biliary puncture. The technique was revolutionized in 1960s with the introduction of fine-gauge (22- to 23-gauge) needles.

During the 1970s, percutaneous biliary drainage (PBD) for obstructive jaundice and percutaneous treatment of stone disease was introduced. Percutaneous cholecystostomy was first described in the 1980s. With the advent of metallic and plastic internal stents, further applications in the treatment of biliary diseases were developed.[1]

Current percutaneous biliary interventions include percutaneous transhepatic cholangiography (PTC) and biliary drainage to manage benign[2] and malignant obstruction and percutaneous cholecystostomy.[3] Percutaneous treatment of biliary stone disease with or without choledochoscopy is still performed in selected cases. Other applications include cholangioplasty for biliary strictures, biopsy of the biliary duct, and management of complications from laparoscopic cholecystectomy and liver transplantation.

This article outlines the procedure for biliary stenting. For descriptions of other biliary interventions, see Percutaneous Cholecystostomy, Percutaneous Cholangiography, and Percutaneous Biliary Drainage.

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Indications

The most common indication for biliary stenting is for treatment of obstructive jaundice from either benign or malignant causes.[4, 5] On occasion, stents are placed for management of bile leaks. Stents are made of either plastic or metal, and they are placed to provide internal drainage, eliminating the need for an external catheter.

Recurrent jaundice or cholangitis due to obstruction of the stents is the major limitation of biliary stents. The main cause of obstruction is biliary sludge and tissue hyperplasia in the lumen of the stent, which necessitates removal and replacement every 2-3 months, and sometimes more frequently. In the case of malignant disease, tumor overgrowth can be an additional cause of obstruction.

The major advantage plastic stents have over metallic stents is that they can be removed and replaced if necessary. Metallic stents, on the other hand, are generally permanent, but they have the advantage of a larger lumen and longer patency. This advantage is achieved by a design that enables placement with a relatively small delivery device (7 French) that contains the constrained stent by an outer sheath. Once the stent is positioned, the outer sheath is retracted, allowing the stent to expand.

Self-expanding metallic stents placed in the biliary tree have a luminal diameter of 10 mm, which is significantly larger than plastic stents, which are typically 2-4 mm in luminal diameter. Nevertheless, the patency of metallic stents is only 60-70% at 6 months, and nearly all are occluded by 1 year. Therefore, the use of permanent metallic stents to treat benign biliary obstruction is not recommended.

The choice of plastic or self-expanding metallic stents depends on the etiology of the obstruction. In patients with malignant disease and a life expectancy less than 6-12 months, metallic stents are more cost-effective and are associated with shorter hospital stays and fewer reinterventions.[6] Therefore, the use of metallic stents for biliary obstruction is reserved for patients with inoperable malignant biliary obstruction and a life expectancy less than 6-12 months.

Covered self-expanding metal stents are available that have a thin layer of material such as polytetrafluoroethylene (PTFE) on the exterior, which improves patency by preventing tumor ingrowth. These stents can be repositioned or removed with the use of a snare or forceps.

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Contraindications

There are only a few contraindications for percutaneous biliary stenting in appropriately selected patients, and these are primarily related to bleeding. Therefore, any bleeding disorders should be corrected prior to the procedure.

Ascites is a contraindication because it limits tamponade of blood or bile. Therefore, a paracentesis should be performed immediately prior to the procedure.

It is essential that patients are able to hold still and cooperate for the procedure. Most procedures are performed under conscious sedation, but an uncooperative patient may require general anesthesia.

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Contributor Information and Disclosures
Author

Philip L Johnson, MD Chairman, Department of Radiology, Associate Professor of Radiology, University of Kansas School of Medicine; Clinical Service Chief, Department of Radiology, University of Kansas Hospital

Philip L Johnson, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, American Society of Neuroradiology, Association of University Radiologists, Kansas Medical Society, Phi Beta Kappa, Radiological Society of North America, Association of Program Directors in Radiology, Society of Interventional Radiology, American Society of Spine Radiology, Kansas Radiological Society, Mid-America Interventional Radiological Society, American Society of Interventional and Therapeutic Neuroradiology, Association of Program Directors in Interventional Radiology

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Douglas M Coldwell, MD, PhD Professor of Radiology, Director, Division of Vascular and Interventional Radiology, University of Louisville School of Medicine

Douglas M Coldwell, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Heart Association, SWOG, Special Operations Medical Association, Society of Interventional Radiology, American Physical Society, American College of Radiology, American Roentgen Ray Society

Disclosure: Received consulting fee from Sirtex, Inc. for speaking and teaching; Received honoraria from DFINE, Inc. for consulting.

Chief Editor

Kyung J Cho, MD, FACR, FSIR William Martel Professor of Radiology, Interventional Radiology, University of Michigan Health System, Frankel Cardiovascular Center

Kyung J Cho, MD, FACR, FSIR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Additional Contributors

Gary P Siskin, MD Professor and Chairman, Department of Radiology, Albany Medical College

Gary P Siskin, MD is a member of the following medical societies: American College of Radiology, Society of Interventional Radiology, Cardiovascular and Interventional Radiological Society of Europe, Radiological Society of North America

Disclosure: Nothing to disclose.

Acknowledgements

Medscape Reference thanks Dawn Sears, MD, Associate Professor of Internal Medicine, Division of Gastroenterology and Hepatology, Scott and White Memorial Hospital; and Dan C Cohen, MD, Fellow in Gastroenterology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine, for assistance with the video contribution to this article.

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Self-expanding stent placed in the common bile duct (CBD) in a patient with an unresectable pancreatic tumor.
This video, captured via endoscopic retrograde cholangiopancreatography, shows the placement of a biliary stent into the common bile duct. Video courtesy of Dawn Sears, MD, and Dan C. Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via endoscopic retrograde cholangiopancreatography, shows the brushing of a common bile duct stricture using a biliary brush. This is done to collect cells that can then be analyzed to rule out malignancy. Video courtesy of Dawn Sears, MD, and Dan C. Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via endoscopic retrograde cholangiopancreatography, shows the insertion of a biliary stent into the common bile duct. Video courtesy of Dawn Sears, MD, and Dan C. Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via endoscopic retrograde cholangiopancreatography, shows the advancement of a biliary cannulation catheter over a guidewire into the common bile duct. Video courtesy of Dawn Sears, MD, and Dan C. Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via endoscopic retrograde cholangiopancreatography, shows the advancement of a biliary stent into the common bile duct. Video courtesy of Dawn Sears, MD, and Dan C. Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via endoscopic retrograde cholangiopancreatography, shows successful insertion, advancement, and deployment of a biliary stent into the common bile duct. Bile is seeing draining from the stent into the duodenum. Video courtesy of Dawn Sears, MD, and Dan C. Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
 
 
 
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