Endoscopic stenting for hilar cholangiocarcinoma: efficacy of unilateral and bilateral placement of plastic and metal stents in a retrospective review of 480 patients

Abstract

Background: Endoscopic biliary drainage of hilar cholangiocarcinoma is controversial with respect to the optimal types of stents and the extent of drainage. This study evaluated endoscopic palliation in patients with hilar cholangiocarcinoma using self-expandable metallic stents (SEMS) and plastic stents (PS).We also compared unilateral and bilateral stent placement according to the Bismuth classification.

Methods: Data on 480 patients receiving endoscopic biliary drainage for hilar cholangiocarcinoma between September 1995 and December 2010 were retrospectively reviewed to evaluate the following outcome parameters: technical success (TS), functional success (FS), early and late complications, stent patency and survival. Patients were followed from stent insertion until death or stent occlusion. Patients were divided into 3 groups according to the Bismuth classification (Group 1, type I; Group 2, type II; Group 3, type ≥ III).

Results: The initial stent insertion was successful in 450 (93.8%) patients. TS was achieved in 204 (88.3%) patients treated with PS and in 246 (98.8%) patients palliated with SEMS (p < 0.001). In the intention-to-treat (ITT) analysis, the FS in patients treated with SEMS (97.9%) was significantly higher than in patients treated with PS (84.8%) (p < 0.001). Late complications occurred in 115 (56.4%) patients treated with PS and 60 (24.4%) patients treated with SEMS (p < 0.001). The median duration of stent patency in weeks (w) were as follows: 20 w in patients palliated with PS and 27 w in patients treated with SEMS (p < 0.0001). In Group 2, the median duration of PS patency was 17 w and 18 w for unilateral and bilateral placement, respectively (p = 0.0004); the median duration of SEMS patency was 24 w and 29 w for unilateral and bilateral placement, respectively (p < 0.0001). Multivariate analysis using the Poisson regression showed that SEMS placement (B = 0.48; P < 0.01) and bilateral deployment (B = 0.24; P < 0.01) were the only independent prognostic factors associated with stent patency.

Conclusions: SEMS insertion for the palliation of hilar cholangiocarcinoma offers higher technical and clinical success rates in the ITT analysis as well as lower complication rates and a superior cumulative stent patency when compared with PS placement in all Bismuth classifications. The cumulative patency of bilateral SEMS or PS stents was significantly higher than that of unilateral SEMS or PS stents, with lower occlusion rates in Bismuth II patients.

Figure 1

Bilateral self-expandable metal stents (SEMS) placement using a stent-within-stent technique. (A) After deployment of the first stent across the hilar stricture, the guidewire was inserted, under fluoroscopic guidance, into the contralateral hepatic duct trough the interstices of the initial SEMS. (B) Dilatation of the interstices of the first SEMS with a hydrostatic balloon to facilitate the passage of a second SEMS into the contralateral hepatic duct. (C) Bilateral SEMS placement obtaining a Y-shaped configuration.

Figure 2

Bilateral metal stenting using the novel 6 French delivery system. (A) Side-by-side bilateral hilar predeployment. (B) Bilateral hilar postdeployment to form a Y-shaped configuration.

Figure 3

Bilateral metal stenting using side-by-side deployment.

Figure 4

Kaplan-Meier analysis showing that cumulative stent patency was significantly longer in patients treated with self-expandable metal stents (SEMS) than in patients palliated with plastic stents (PS) (p < 0.0001).

Figure 5

Cumulative Stent Patency curves by Kaplan-Meier analysis in patients treated using unilateral (Uni) and bilateral (Bil) plastic stents (PS) and self-expandable metal stents (SEMS). Uni PS versus Bil PS (p = 0.0004). Uni versus Bil SEMS (p < 0.0001).