Endoscopic Drainage of >50% of Liver in Malignant Hilar Biliary Obstruction Using Metallic or Fenestrated Plastic Stents

Abstract

Objectives: Endoscopic drainage of complex hilar tumors has generally resulted in poor outcomes. Drainage of >50% of liver volume has been proposed as optimal, but not evaluated using long multifenestrated plastic stents (MFPS) or self-expanding metal stents (SEMS). We evaluated outcomes of endoscopic drainage of malignant hilar strictures using optimal strategy and stents, and determined factors associated with stent patency, survival, and complications.

Methods: Cross-sectional study was conducted at an academic center over 5 years. MFPS (10 French or 8.5 French) or open-cell SEMS were used for palliation of unresectable malignant hilar strictures, with imaging-targeted drainage of as many sectors as needed to drain >50% of viable liver volume. Risk factors were evaluated using regression analysis. The cumulative risk was assessed using Kaplan-Meier analysis.

Results: 77 patients with malignant hilar biliary strictures (median Bismuth IV) underwent targeted stenting (41 MFPS and 36 SEMS). Comparing MFPS vs. SEMS, technical success (95.1 vs. 97.2%, P=0.64), clinical success (75.6 vs. 83.3%, P=0.40), frequency of multiple stents (23/41 vs. 25/36, P=0.19), survival and adverse events were similar, but stent patency was significantly shorter (P<0.0001). Factors associated with survival were Karnofsky score and serum bilirubin level at presentation. Outcomes were independent of Bismuth class with acceptable results in Bismuth III and IV.

Conclusions: Endoscopic biliary drainage with MFPS or open-cell SEMS targeting >50% of viable liver resulted in effective palliation in patients with complex malignant hilar biliary strictures. Patency was shorter in the MFPS group, but similar survival and complications were found when comparing MFPS and SEMS group.

Figure 1

(a–d) MFPS 10 French 20 cm (upper, a), MFPS 8.5 French 20 cm (middle, b). MFPS is pliable (lower, left, and right, c, d) and is suitable for stenting of sectoral biliary ducts. (e, f) A tight hilar stenosis and severe upstream dilatation from metastatic rectal carcinoma to the hepatic hilum (e). This was treated with three 8.5 French 16 cm MFPS to all sectoral ducts (left, right anterior and right posterior) (f).

Figure 2

(a) Open-cell laser cut metallic stents used for hilar tumor drainage showing large interstices allowing Y stent placement. (b) Y configuration of standard open-cell laser cut metallic stent. (c, d) Complex Bismuth IV tumor (c) treated with three 10 mm laser cut stents in “Y” configuration to drain all three sectoral (left, right anterior, and right posterior) ducts (d).

Figure 3

(a) Survival of patients with malignant hilar obstruction treated with multifenestrated plastic stents (MFPS) (n=41) and self-expanding metal stents (SEMS) (n=36), P=0.88 by Kaplan–Meier analysis. (b, c) Survival of patients with malignant hilar obstruction treated with MFPS (n=41) and SEMS (n=36), stratified by nature of malignant hilar obstruction (P=0.95 for cholangiocarcinoma subgroup, and P=0.26 for distant metastasis subgroup). (d) Stent patency in patients with malignant hilar obstruction treated with MFPS (n=41) and SEMS (n=36), P<0.0001 by Kaplan–Meier analysis.