Biliary Stenting Technique

Updated: Nov 27, 2017
  • Author: Philip L Johnson, MD; Chief Editor: Kyung J Cho, MD, FACR, FSIR  more...
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Technique

Placement of Plastic and Metallic Biliary Stents

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. [7] (See the videos below.)

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.

Plastic vs metallic stents

Internal biliary stents are either plastic or metallic, and various types of each kind are available.

Internal biliary stents have several advantages. [8]  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 (eg, pericatheter leakage of bile and the need for daily flushing). Disadvantages include having to perform endoscopic retrograde cholangiopancreatography (ERCP; see the videos above) or new PTC procedures to obtain access in case of stent obstruction.

Better patency rates are reported with metallic than with plastic stents in cases of 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, Marlborough, MA) and silicone stents (Malecot; Cook Medical, Bloomington, IN).

Metallic stents have not been commonly used in the treatment of benign disease, because studies showed 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. [9] 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. [10]  However, there is increasing interest in using covered metallic stents in the setting of benign disease. [11, 12]

The Gianturco-Rosch Z stent (Cook Medical, Bloomington, IN), a metallic stent, has been used in benign strictures but has not been generally recommended 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. [13, 14]

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. Self-expanding stents include the Wallstent (Boston Scientific, Natick, MA), the Luminex stent (Bard, Tempe, AZ), and the Smartstent (Cordis Endovascular, Miami, FL). [15]

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

Kaskarelis et al reported a 98% technical success rate in the treatment of malignant biliary obstruction with metallic stents [16] ; the stent occlusion rate was 18% at a mean interval of 288 days. Lee et al showed a 50-week patency rate of 53%. [17]

There are some data from observational studies to suggest that the use of radiofrequency ablation (RFA) as an adjunct to biliary stenting is safe and may be associated with improved stent patency; it may also be associated with improved survival in these patients. [18]

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Complications

Recurrent jaundice or cholangitis due to obstruction of the stents is the major limitation of biliary stenting. 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 ingrowth through the stent and proximal and distal tumor overgrowth can also cause obstruction.

Covered stents are being investigated to overcome the problem of tumor ingrowth. Two studies of stents covered with expanded polytetrafluoroethylene–fluorinated ethylene propylene (ePTFE-FEP) reported 12-month patency rates higher than 75%.

In a multicenter retrospective study of 315 consecutive patients with distal malignant biliary strictures who underwent ERCP and placement of (a) a fully covered self-expanding metal stent, (b) an uncovered self-expanding metal stent, or (c) a plastic stent as first-line treatment, Sampaziotis et al found that the fully covered metal stents remained patent longer and caused fewer complications than either of the other types, though they were also associated with a higher rate of pancreatitis than the uncovered metal stents were. [19]

Sugawara et al reported a 24.2% rate of acute pancreatitis necessitating pharmacologic treatment in patients who underwent percutaneous placement of metallic biliary stents across the papilla of Vater for malignant biliary stricture. [20]

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