Biliary Stenting 

  • Author: Atif Rana, MBBS; Chief Editor: Kyung J Cho, MD, FACR   more...
 
Updated: Oct 13, 2011
 

Overview

Percutaneous biliary interventions

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.

Current percutaneous biliary interventions include percutaneous transhepatic cholangiography (PTC) and biliary drainage to manage benign[1] and malignant obstruction and percutaneous cholecystostomy.[2] 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 eMedicine articles Percutaneous Cholecystostomy, Percutaneous Cholangiography, and Percutaneous Biliary Drainage.

Stents

Internal biliary stents are either plastic or metallic, and various types of each kind are available. Internal biliary stents have several advantages. An external tube can be uncomfortable and have a psychological disadvantage (especially in cases of malignant obstruction). An internal stent prevents the problems related to external catheters, for example, pericatheter leakage of bile and the need for daily flushing. The disadvantages include having to perform endoscopic retrograde cholangiopancreatography (ERCP; see videos below) or new PTC procedures to obtain access in case of stent obstruction.

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.

Better patency rates are reported with metallic than with plastic stents in cases malignant obstruction, though no effect on survival is noted. Plastic internal stents are cheapest but reportedly prone to migration. Various types of plastic stents in use include the Carey-Coons stent (Percuflex; Meditech/Boston Scientific) and silicone stents (Malecot; Cook, Inc).

Metallic stents are generally not used in the treatment of benign disease because studies have shown poor long-term patency rates. Gabelman et al reported a patency rate of only 25% at 36 months when metallic stents were used to treat benign obstruction.[3] In another study, Lopez et al found that two thirds of patients had poor clinical results and that one half of these required major surgical intervention.[4] The Gianturco-Rosch Z stent (Cook, Inc), a metallic stent, has been used in benign strictures, but it should not be used for primary treatment. Limited applications may include the treatment of patients who are poor surgical candidates or of those in whom surgical treatment fails. Most postoperative strictures are treated surgically, though endoscopic and (less commonly) percutaneous placement of nonmetallic stents has increasingly been used in the past few years.[5, 6]

In cases of malignant obstruction, stents are placed as a palliative measure only if the tumor is unresectable (see the image below). Various stents are approved for use in the biliary system, including self-expanding and balloon-mounted stents. Various self-expanding stents include the Wallstent (Boston Scientific; Natick, Mass), Luminex stent (Bard; Tempe, Ariz), and Smartstent (Cordis Endovascular; Miami, Fla). Kaskarelis et al reported a 98% technical success rate in the treatment of malignant biliary obstruction with metallic stents.[7] They reported an 18% stent occlusion rate at a mean interval of 288 days. Lee et al showed a 50-week patency rate of 53%.[8]

Self-expanding stent placed in the common bile ducSelf-expanding stent placed in the common bile duct (CBD) in a patient with an unresectable pancreatic tumor.

Causes of stent obstruction include tumor ingrowth through the stent, proximal or distal tumor overgrowth, and biliary sludge. Covered stents are now being investigated to overcome the problem of tumor ingrowth. Two recent studies of stents covered with polytetrafluoroethylene–fluorinated ethylene propylene (ePTFE-FEP) stents showed 12-month patency rates of more than 75%.

Next

Technique

  • The stent is usually placed at an interval of a few days after percutaneous biliary drainage (PBD), though in cases of uncomplicated percutaneous transhepatic cholangiography (PTC), the stent procedure can be accomplished at the same time.
  • An introducer sheath is passed into the biliary system over a stiff wire.
  • The stent delivery system is then advanced over the wire and the stent is deployed.
  • Balloon dilation is occasionally needed to achieve adequate expansion.
  • In cases of hilar malignancy that causes obstruction of both hepatic ducts, bilateral stents may be needed.
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Contributor Information and Disclosures
Author

Atif Rana, MBBS  Assistant Professor, Department of Radiology, Shifa College of Medicine, Islamabad, Pakistan

Atif Rana, MBBS is a member of the following medical societies: Radiological Society of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

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, Cardiovascular and Interventional Radiological Society of Europe, Radiological Society of North America, and Society of Interventional Radiology

Disclosure: Nothing to disclose.

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 College of Radiology, American Heart Association, American Physical Society, American Roentgen Ray Society, Society of Cardiovascular and Interventional Radiology, Southwest Oncology Group, and Special Operations Medical Association

Disclosure: Sirtex, Inc. Consulting fee Speaking and teaching

Robert M Krasny, MD  Resolution Imaging Medical Corporation

Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America

Disclosure: Nothing to disclose.

Chief Editor

Kyung J Cho, MD, FACR  William Martel Professor of Radiology, Interventional Radiology Fellowship Director, University of Michigan Health System

Kyung J Cho, MD, FACR 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, and Radiological Society of North America

Disclosure: Nothing to disclose.

Additional Contributors

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.

References

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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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