- Author: Philip L Johnson, MD; Chief Editor: Kyung J Cho, MD, FACR, FSIR more...
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 and malignant obstruction and percutaneous cholecystostomy. 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.
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. 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.
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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