Malignant biliary obstruction. An unusual case of re-stenting.

Clinical History

Patient presenting with obstructive jaundice.

Imaging Findings

The patient presented with abnormal liver function tests. Initial ultrasound and CT scans were normal. A liver biopsy showed fatty change only. As the liver functions deteriorated further, ultrasound was repeated and showed early intrahepatic biliary dilatation (Fig.1).

Endoscopic retrograde cholangio-pancreatography (ERCP) showed a hilar stricture suggestive of cholangiocarcinoma, and a 10F-15cm stent was placed across the left side. After ERCP the patient developed pancreatitis and then septicaemia and the biliary ducts continued to be dilated. An external drain was inserted after PTC (Fig. 2).

After recovery from sepsis, the bile ducts were drained internally. Two stents were inserted in a "T" manner, one across the right and left main hepatic ducts and one into the common hepatic/bile duct. Initially the drains worked, but then the liver function deteriorated again. ERCP was repeated, which showed occlusion of the stent(s). An attempt to deploy a second stent endoscopically failed as a guide wire could not be passed upwards (fig. 4).

The patient was referred for an external drain and internal stenting. This was performed via a standard right midaxillary approach. A peripheral right sub-segmental duct was entered. Obstruction was at the level of the distal right hepatic duct (Fig. 5a). There was no communication with the left hepatic duct. A guide wire was manipulated through the interstices of the horizontal stent (1st stent) into the vertical (CBD) stent (fig. 5b). This was dilated and then a new stent (9cm-10mm Walstent, Schneider) was deployed across and into the vertical stent (Fig.5d)(2nd stent). Additional balloon dilatation was performed to create a satisfactory new lumen (Fig 5e). An external drain (6F) was retained, which was removed later after demonstration of satisfactory internal drainage (fig 6a and b). The liver function improved following this procedure.

Discussion

Malignancies of the pancreas, gallbladder, or bile ducts are the most common cause of biliary obstruction. Surgery is the standard treatment, but unfortunately only 20% are operable. Patients with malignancies of the biliary tree have a poor prognosis. Obstruction to bile flow can lead to severe symptoms and ultimately to liver failure. Stent placement is associated with lower procedure-related mortality, complications and shorter hospital stay when compared with surgical procedures. Long-term results with respect to gastric outlet obstruction and hospital readmission rates may favour surgical procedures.

Molnar and Stockum described percutaneous transhepatic biliary drainage in 1974. An internal drain was reported in 1978 by Pereiras et al. Since then various tubes and stents have been tried and described by researchers. Expandable metallic stents with larger inner lumina prolong the duration of patency compared with plastic stents. Incrustation of bile and ingrowth/overgrowth of tumour is responsible for stent occlusion. Self-expanding metal stents avoid permanent external drains and reduce complications and tube-related problems.

Patients with tumours at the hilum are best managed by percutaneous biliary drainage, as this method allows selection of appropriate part of the biliary tree, and has a higher success rate. Stents have been deployed in a 'T' or 'Y'configuration.

Differential Diagnosis List

Final Diagnosis

Hilar cholangiocarcinoma treated by biliary stenting

URL:	https://eurorad.org/case/1900
DOI:	10.1594/EURORAD/CASE.1900
ISSN:	1563-4086