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.
Endoscopic ultrasonography (EUS)-guided biliary interventions are the subject of increasing interest (eg, in patients with unresectable distal biliary malignant obstruction who failed endoscopic retrograde cholangiography [ERCP]). [4]
The Cardiovascular and Interventional Radiological Society of Europe (CIRSE) has published standards of practice for biliary stenting. [5]
This article outlines the procedure for biliary stenting. For descriptions of other biliary interventions, see Percutaneous Cholecystostomy, Percutaneous Cholangiography, and Percutaneous Biliary Drainage.
Indications
The most common indication for biliary stenting is for treatment of obstructive jaundice from either benign or malignant causes. [6, 7] 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.
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 stent constrained 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, whereas plastic stents typically have a luminal diameter of only 2-4 mm. 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 of less than 6-12 months, metallic stents are more cost-effective and are associated with shorter hospital stays and fewer reinterventions. [8] Therefore, the use of metallic stents for biliary obstruction is reserved for patients who have inoperable malignant biliary obstruction and whose life expectancy is shorter 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.
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 be able to hold still and cooperate for the procedure. Most procedures are performed under conscious sedation, but an uncooperative patient may require general anesthesia.
Outcomes
In a prospective study by Lakhtakia et al, 118 patients with chronic pancreatitis (CP) and a benign biliary stricture (BBS) were treated with temporary placement of a single fully covered self-expanding metal stent (FCSEMS) with scheduled removal at 10-12 months and followed for 5 years. [9] The probability of remaining stent-free at a median of 58 months was 61.6%; in the 94 patients whose BBSs resolved at the end of FCSEMS indwell, the probability of remaining stent-free 5 years later was 77.4%. Serious stent-related adverse events occurred in 22.9% of patients; all resolved with medical therapy or repeated endoscopy. Severe CP and longer stricture length were predictors of stricture recurrence.
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Self-expanding stent placed in the common bile duct (CBD) in a patient with an unresectable pancreatic tumor.
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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.
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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.
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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.
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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.
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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.
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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.
