Unresectable Malignant Biliary Obstruction: Treatment by Self‐Expandable Biliary Endoprostheses

Abstract

The primary goal in the treatment of malignant obstruction is the relief of jaundice. Although operative biliary bypass is a reliable method of palliation, nonoperative palliation may be desirable in selected patients.We report our experience with forty-eight self expandable metallic biliary endoprostheses (Wallstent) percutaneously placed in 35 patients with irresectable malignant biliary obstruction. In twelve patients more than one stent was necessary to bridge the entire length of the biliary stenosis. The obstruction was due to primary tumors in 14 and to lymph node metastases in 12. In nine patients transanastomotic stents were placed after previous bilioenteric anastomosis because of malignant obstruction.Complications occurred in 11 patients (31.4%), and five patients died within 30 days of stent placement (14.3%). The mean stent patency to date of patients discharged is 6.1 months, and the mean survival 7.2 months. Follow up data is available for 29 patients, and excellent palliation was achieved for more than 75% of the survival time in 22 (76%). Seven patients have had documented stent occlusion requiring further intervention (24%).In this selected group of patients, the results of percutaneous self-expandable stents are encouraging. However, our data does not support the initial reports of self-expandable endoprostheses that suggest an improved result compared to conventional plastic stents. A randomized study using either expandable stents as compared to operative biliary enteric bypass is necessary.

A Continuing Role for Surgical Bypass in the Palliative Treatment of Pancreatic Carcinoma

“…In assessing the various types of palliation for malignant jaundice, the initial risk of operation and the need to keep the patient in hospital for 2 weeks must be balanced against the security of accurate diagnosis and staging plus the absence of any stent with its potential to block [2, 8]. The median survival of an endoscopic stent has been reported as 4–9 months for polyethylene and metal stents [9].…”

“…Endoscopic intubation of the biliary stricture is preferred for patients with advanced cancer or serious intercurrent disease. Self-expandable metal stents may remain patent for their remaining life-span, though tumour ingrowth or overgrowth will eventually cause recurrent jaundice [2]. Surgical bypass could, therefore, retain a role in younger or fitter patients with a better life expectancy, provided that its initial risk does not greatly exceed that of non-operative stenting [3, 4, 5].…”

Multidisciplinary Approach to Palliation of Obstructive Jaundice Caused by a Central Hepatocellular Carcinoma

“…Either surgical [2, 3]or endoscopical [5]or percutaneous [4]drainage can be achieved in most cases with malignant biliary obstruction. If the tumour proves to be unresectable at the time of laparatomy, we prefer a surgical drainage by a segmental bilioenteric anastomosis to a Roux-en-Y loop, preferably to the segment III (‘round ligament approach’) [2, 38].…”

“…Obstructive jaundice due to mechanical tumour obstruction of the biliary tree, however, is only rarely caused by HCC. As for other hilar obstructions, there exist various possibilities for treatment: surgical excision in curative or palliative attempt, a variety of surgical biliodigestive bypass procedures [2, 3], interventional radiological [4]and endoscopical [5]insertion of an endoluminal prosthesis in order to bypass the obstruction, percutaneous injection of ethanol to reduce the size of the tumour [6, 7]and transcatheter arterial embolization (TAE) with different agents including radionuclide embolization with yttrium-90 [8, 9, 10]. …”

Pancreatic cancer

“…[47][48][49][50] Although nonoperative palliation is associated with decreased procedure-related morbidity and mortality and a shorter initial hospitalization, its principle limitation is the tendency of the stent to occlude from biliary sludge and debris. Stent occlusion may occur in 35 percent of patients, and rehospitalization for treatment of cholangitis secondary to stent occlusion impacts on the quality of life and may outweigh the morbidity of operative palliation.…”