Percutaneous Biliary Metallic Stent Insertion in Patients with Malignant Duodenobiliary Obstruction: Outcomes and Factors Influencing Biliary Stent Patency

Abstract

Objective: To investigate the technical and clinical efficacy of the percutaneous insertion of a biliary metallic stent, and to identify the factors associated with biliary stent dysfunction in patients with malignant duodenobiliary obstruction.

Materials and methods: The medical records of 70 patients (39 men and 31 women; mean age, 63 years; range, 38-90 years) who were treated for malignant duodenobiliary obstruction at our institution between April 2007 and December 2018, were retrospectively reviewed. Variables found significant by univariate log-rank analysis (p < 0.2) were considered as suitable candidates for a multiple Cox's proportional hazard model.

Results: The biliary stents were successfully placed in all 70 study patients. Biliary stent insertion with subsequent duodenal stent insertion was performed in 33 patients and duodenal stent insertion with subsequent biliary stent insertion was performed in the other 37 study subjects. The median patient survival and stent patency time were 107 days (95% confidence interval [CI], 78-135 days) and 270 days (95% CI, 95-444 days), respectively. Biliary stent dysfunction was observed in 24 (34.3%) cases. Multiple Cox's proportional hazard analysis revealed that the location of the distal biliary stent was the only independent factor affecting biliary stent patency (hazard ratio, 3.771; 95% CI, 1.157-12.283). The median biliary stent patency was significantly longer in patients in whom the distal end of the biliary stent was beyond the distal end of the duodenal stent (median, 327 days; 95% CI, 249-450 days), rather than within the duodenal stent (median, 170 days; 95% CI, 115-225 days).

Conclusion: The percutaneous insertion of the biliary metallic stent appears to be a technically feasible, safe, and effective method of treating malignant duodenobiliary obstruction. In addition, a biliary stent system with a distal end located beyond the distal end of the duodenal stent will contribute towards longer stent patency in these patients.

Keywords: Bile duct; Biliary; Duodenum; Obstruction; Stens.

Fig. 1. Flow chart of BS insertion in patients with malignant duodenobiliary obstruction.

BS = biliary stent, DS = duodenal stent

Fig. 2. 61-year-old man with advanced gastric cancer.

Type II duodenal obstruction in this patient had been treated with duodenal uncovered stent 4 months previously. A. Cholangiogram via right PTBD showing malignant distal common bile duct obstruction (arrowhead). Guide wire was successfully inserted into distal duodenum though mesh of duodenal uncovered stent (white arrows). B. Cholangiogram obtained after placement of long type GD stent (TaeWoong Medical; 10 mm × 23 cm, white arrows) showing good stent position and expansion, as well as good passage of contrast medium to jejunum via stent. Distal end of biliary stent was notably located in proximal jejunum. C. Six weeks after biliary stent (white arrows) placement, another duodenal stent (black arrows) was deployed beside biliary stent due to duodenal stent dysfunction. D. Contrast-enhanced coronal CT image obtained 3 months after insertion of additional duodenal stent showing good expansion of biliary stent (white arrows) and pneumobilia in non-dilated left intrahepatic bile duct (white arrowhead), indicating patent biliary stent. There was no clinical evidence of biliary stent dysfunction up to time of patient's death from disease progression at 167 days after its placement. PTBD = percutaneous transhepatic biliary drainage

Fig. 3. 31-year-old man with pancreatic cancer. Biliary obstruction in this patient had been treated with covered biliary stent 2 weeks previously.

A. Fluoroscopic image showing type II duodenal stricture (white arrows). Contrast media had refluxed into previously inserted biliary stent. B. Placement of an uncovered duodenal stent (20 mm × 10 cm). Overlap of distal ends of duodenal stent (black arrow) and biliary stent (white arrow) is evident. C. Cholangiogram via right PTBD at one week after duodenal stent placement indicating stasis of contrast medium in common bile duct (arrowhead), suggesting biliary stent malfunction due to extrinsic compression by subsequently inserted duodenal stent. D. Additional long type GD stent (10 mm × 23 cm, white arrows) was deployed through lumen of previous biliary stent into proximal jejunum. Cholangiogram showing good stent position and expansion, as well as good passage of contrast medium to jejunum via subsequent stent.

Fig. 4. Kaplan-Meier curve showing survival outcomes.

Cross hatches indicate censored events.

Fig. 5. Kaplan-Meier curve showing biliary stent patency rate.

Cross hatches indicate censored events.

Fig. 6. Kaplan-Meier curve showing biliary stent patency rate in accordance with location of its distal end.

Patency was found to be significantly improved if biliary stent distal end was located beyond that of duodenal stent rather than within duodenal stent (p = 0.028). Cross hatches indicate censored events.

Fig. 7. Kaplan-Meier curve showing biliary stent patency rate according to location of its distal end in patients who underwent subsequent biliary stent insertion after duodenal stent insertion.

Patency was found to be significantly improved if biliary stent distal end was placed beyond that of duodenal stent rather than within duodenal stent (p = 0.003). Cross hatches indicate censored events.