cbd stent radiology

Cbd stent radiology

Stents can occasionally block due to either biliary sludge or tumor recurrence resulting in the reappearance of jaundice. Recurrent tumor growth can be either through the stent struts or overgrowth of the proximal or distal ends (Figure ​ (Figure6A). 6A ). US and CT will aid in diagnosing and planning further intervention in these patients. Endoscopic intervention can serve as a complementary procedure where a plastic stent is inserted into the blocked primary stent. However, if this is not possible, then PBDS will be needed where a similar size or smaller metal stent is coaxially inserted into the blocked one with or without balloon dilatation (Figure ​ (Figure6B 6B ).

PBDS offers a safe and effective method in providing palliative treatment for patients with malignant biliary obstruction. Discussion and consensus at multidisciplinary meetings will dictate the best treatment option for such patients. Percutaneous biliary intervention has an important role in the management of patients with malignant biliary obstruction with a view to improving their quality of life, irrespective of their suitability for surgical intervention.

Malignant biliary obstruction is commonly due to pancreatic carcinoma, cholangiocarcinoma and hepatic or nodal metastatic disease. Other causes include gall bladder carcinoma, hepatocellular carcinoma, lymphoma and advanced gastric or duodenal cancer. In these patients with obstructive jaundice, treatment by percutaneous biliary drainage and/or stenting plays an important role in their overall management. Drainage or stenting in patients with malignant biliary obstruction can relieve the symptoms and signs of obstructive jaundice. This optimizes the patient’s condition for surgical resection or for receiving palliative chemotherapy or radiotherapy, bringing about an improvement in their quality of life, even if only for a matter of weeks or months. This article reviews our local practice in the care of these patients with an overview of percutaneous biliary drainage and stenting (PBDS) in malignant biliary obstruction.

RE-INTERVENTION

Following biopsy the obstructing lesion is crossed using a combination of a biliary manipulation catheter and hydrophilic guide wire (Terumo, Tokyo, Japan). These are then exchanged for a stiff guide wire and the stent delivery system respectively. Ten millimeter diameter Wallstent (Boston Scientific, Galway, Ireland) or Nitinella (Ella CS, Hradec Kralove, Czech Republic) uncovered metal stents are used and in most cases the distal end of the stent is placed across the ampulla. This ensures maximum biliary drainage and reduces the risk of post-procedure cholangitis. Multiple stent placements may be required depending on the location of the stricture or strictures (Figure ​ (Figure4A 4A and B). Hilar strictures often require stent placement via the right and left hepatic ductal systems. Occasionally, a Flexima biliary catheter system (Boston Scientific, Natick, USA) is placed. This internal-external drainage catheter (IEDC) acts as a bridge between early intervention and definitive surgical management by maintaining homeostasis, as the bile flow into the bowel resumes. Another indication for an IEDC is in cases of cholangiocarcinoma where intraluminal brachytherapy is being considered (Figure ​ (Figure5). 5 ). A 192-iridium wire with appropriate measurements is placed into the lumen of the drainage catheter for 2 d and the lesion is subsequently stented. This results in improvement in local disease control and increases long-term stent patency. Antibiotics are prescribed for 48 h for those patients who undergo biliary stenting and all have a post-procedure care plan inserted into the case notes. The index team on the wards usually looks after post-procedure pain relief.

PBDS is a recognized and established method of palliation in patients with malignant biliary obstruction. In most patients, the malignant biliary obstruction is due to pancreatic adenocarcinoma or cholangiocarcinoma. Treatment options for achieving biliary drainage include percutaneous, endoscopic, and surgical biliary interventions, with each method having its own advantages and disadvantages. In many hospitals, endoscopic placement of a biliary stent is the preferred method but this depends on local practice and availability of endoscopic interventional expertise. Type of biliary stricture, MDT discussion outcome, and patient choice will all contribute towards the final treatment plan. Whatever method of intervention is chosen, the main aim is to provide palliation by relieving the pain and symptoms related to jaundice, including preventing and/or treating deranged liver function and cholangitis secondary to biliary obstruction.

CONCLUSION

In our experience, most complications can be treated conservatively although the more serious ones may need further radiological or surgical intervention. Procedure related mortality is low although 30-day mortality is significant, usually due to the underlying disease process. In our review[1] of 90 stent deployments in 76 patients (male: female = 40: 36; age range = 43 to 94 years) with malignant biliary strictures, there were certain predictors of likely poor outcome following biliary stenting. The causes of malignant biliary obstruction were: pancreatic carcinoma (55.3%); cholangiocarcinoma (11.8%); ampullary carcinoma (6.6%); metastatic carcinoma (18.4%); and other causes (7.9%). The strictures were located at the hilum in 13.1%, mid CBD in 26.3%, distal CBD in 59.2%, and anastomosis in 1.3%. In most cases the stents were placed across the ampulla. Technical success was obtained in all cases. Mean primary stent patency rate was 471 d with a mean patient survival of 160 d (5-656 d). Thirty days mortality was 14/76 (18%) with a complication rate of 9/76 (11.8%). Our results are comparable with those in the literature[2,3]. Patients were divided into 2 groups: those who died within 30 d of stenting and those who survived beyond this. The mean bilirubin, mean albumin, mean creatinine, and presence of metastatic disease were analyzed in these 2 groups. The results (Table ​ (Table1) 1 ) show that independent poor predictors of early mortality were dictated by high serum bilirubin, high serum creatinine, and low serum albumin. However, in our experience, the presence of metastatic disease was not a statistically significant predictor of early mortality.

Factors affecting outcome following stenting

Cbd stent radiology

Stenting may be preceded or followed by biliary dilatation, which involves dilating a segment of bile duct with a balloon to open up the stricture.

(A plastic biliary stent)

What are the indications for percutaneous biliary drainage +/- stenting?

Biliary drainage may also be necessary if a hole develops in the bile duct, resulting in leakage of bile into the abdominal cavity. This leak may cause severe pain and infection. Biliary drainage stops the leak and helps the hole in the bile duct to heal.

Biliary drainage relieves obstruction by providing an alternative pathway to exit the liver.

Who will perform the procedure and where will it take place?

The most common indication for biliary drainage is blockage or narrowing (stricture) of the bile ducts. There are several conditions that may cause this including: