Silicone biliary stents

Large silicone stents (9-28 French) were placed in the biliary tree of 173 patients over a 3-year period. Their use markedly reduced the incidence of catheter occlusion and sepsis. Only three cases of cholangitis and one case each of excessive bleeding and pleural effusion occurred. No skin irritation or pancreatitis occurred. The large bore of the catheter and the use of biocompatible material improved the safety and efficacy of biliary drainage.     

Malignant biliary obstruction: percutaneous use of self-expandable stents

A total of 83 self-expandable metallic stents were placed percutaneously in 69 patients for palliation of malignant biliary obstruction. Stent diameter was 1 cm; length, 3.5-10.5 cm. Of the 41 patients with common bile duct obstruction, 27 died 0.2-12 months (median, 3.2 months) after stent insertion. Two patients developed recurrent jaundice and cholangitis after 6 and 12 months, respectively. One patient underwent reintervention. Fourteen patients were alive without jaundice 1-8 months (median, 6.3 months) after stent placement. Of the 28 patients with hilar lesions, 13 died 0.7-7.6 months (median, 4.3 months) after stent placement. Fifteen were alive 1-15.5 months (median, 8.1 months) afterward. Recurrent jaundice and cholangitis were seen in eight of the 28 patients (28%) after 1-6 months (median, 3.6 months). The cause of malfunction of the stent(s) was tumor ingrowth in one patient, tumor overgrowth at the proximal end in five patients, and overgrowth at the distal end in two patients. Reintervention was performed in five patients (18%). Stent-related complications were seen in four patients.     

Treatment of malignant biliary obstruction by percutaneous transhepatic insertion of expandable metallic stents

A group of 55 patients with jaundice secondary to malignant biliary obstruction were treated with percutaneous transhepatic insertion of self-expandable metal stents (Wallstents). Obstruction was caused by pancreatic carcinoma in 22 patients, cholangiocarcinoma in 21 patients, and other malignancies in 12 patients. A total of 16 patients were treated for hilar obstruction, 35 patients for obstruction of the bile duct below the hilum, and 4 patients for obstruction in a bilioenteric anastomosis. Stent insertion was performed as a two-step procedure in 37 patients, but as a one-step procedure in 18 patients. Adequate bile drainage was achieved in all patients. Procedure-related complications occured in 9 % of cases. After 24 months of observation time 46 patients had died (mean survival 4.6 months). The 30-day mortality rate was 5.5 %. A total of 14 patients (25.5 %) developed recurrent jaundice after an average of 5.3 (0–13) months. Percutaneous insertion of Wallstents ensures good palliation, is relatively safe, and may be performed as a one-step procedure. Correspondence to: P. Hannesson     

Metallic stents in malignant biliary obstruction

Purpose Retrospective analysis of our results with metallic stent placement for malignant biliary strictures. We sought to determine parameters that influence stent patency. Methods A total of 95 Wallstents were implanted in 65 patients (38 men, 27 women; mean age, 65.1 years) with malignant biliary obstruction. Serum bilirubin levels were assessed in 48 patients; the mean value prior to intervention was 15.0 mg/dl. Results In 12 patients (21%) complications occurred as a result of percutaneous transhepatic drainage. Stent implantation was complicated in 13 patients, but was possible in all patients. A significant decrease in bilirubin level was seen in 83.3% of patients following stent implantation. Approximately 30% of patients developed recurrent jaundice after a mean 97.1 days. In 9 patients (15%) the recurrent jaundice was caused by stent occlusion due to tumor growth. The mean follow-up was 141.8 days, the mean survival 118.7 days. Patients with cholangiocarcinomas and gallbladder carcinomas had the best results. Worse results were seen in patients with pancreatic tumors and with lymph node metastases of colon and gastric cancers. Conclusions The main predictive factors for occlusion rate and survival are the type of primary tumor, tumor stage, the decrease in bilirubin level, and the general condition of the patient.     

金属内支架治疗恶性梗阻性黄疸的临床研究：附33例分析

目的：总结胆管金属内支架放置术的临床经验和疗效分析。材料与方法：恶性梗阻性黄疸患者３３例，男２３例，女１０例。胆管癌１６例，胰头癌２例，原发性肝癌２例，肝转移瘤３例，肝门淋巴结转移瘤压迫胆管１０例。本组共采用金属内支架行内引流３３例，共使用６种３８枚金属内支架。１２例支架放置术后加局部放射治疗和化学治疗（简称放、化疗）。结果：３３例采用经皮经肝穿刺置入胆管支架均获得成功，其中２９例一次性植入支架，４例先行胆汁引流术（ＰＴＢＤ）后再放置金属内支架；９例因胆管梗阻复杂，金属支架置入后仍保留引流导管，其中３例在置管１５～２００天后拔除引流管。２８例（８４．８５％）黄疸消退满意。本组中位生存期７个月，支架植入后加局部放、化疗组中位生存期１０个月。结论：胆管内金属支架治疗恶性梗阻性黄疸，可用于不能手术治疗的高位胆管梗阻，支架植入后加局部放、化疗可望提高远期疗效。     

Malignant biliary obstruction: complications of percutaneous biliary drainage

The medical records of 161 patients who underwent percutaneous biliary drainage (PBD) for malignant biliary obstruction were reviewed with attention to the complications resulting from this mode of drainage. Observed was a higher incidence of complications--particularly of cholangitis--than that generally reported in the literature. Although PBD is an effective method of biliary drainage, it carries a high risk of cholangitis in patients with cancer, who frequently receive myelosuppressive agents that predispose them to infections.     

经皮肝穿刺胆管-胃引流治疗梗阻性黄疸动物实验

目的 探讨经皮肝穿刺胆管-胃引流(PTCGD)治疗顽固性胆道梗阻黄疸的可行性、安全性和有效性.方法 健康杂种家猪20只,行胆总管结扎,建立梗阻性黄疸动物模型.动物于术后14 d随机分成两组:①PTCGD组(A组,n=10):行PTCGD,置入内引流管.②对照组(B组,n=10):在胆总管结扎后不予治疗.两组在不同时间段内观察血清总胆红素(TBIL)、直接胆红素(DBIL)、丙氨酸转氨酶(ALT),白蛋白(ALB)变化,比较2组间及内引流前后差异,观察肝脏病理学和影像学改变.结果 A组技术成功率为100%,行PTCGD后肝内胆管扩张明显减轻,肝功能显著改善,病理表现显示肝组织明显修复好转.B组动物分别死于胆总管结扎术后23～32 d,TBIL、DBIL、ALT在胆总管结扎后持续升高,并且随梗阻时间延长逐步加重,胆管造影显示肝内外胆管重度扩张,病理显示肝小叶出现大片状坏死,小叶间胆管胆汁淤滞,扩张明显,肝细胞崩解.结论 PTCGD是梗阻性黄疸动物模型,特别是常规介入放射学技术不能成功的顽固性胆道梗阻又一较为安全、有效、微创的治疗方法.     

Metallic stents for treatment of benign biliary obstruction: a long-term study comparing different stents

PURPOSE: To investigate the role of metallic stents in the treatment of benign biliary strictures and analyze the differences in primary patency associated with the various types of stents deployed. MATERIALS AND METHODS: Between 1990 and 1997, 21 patients with benign obstructive jaundice were treated with transhepatic placement of metallic stents (11 Wallstents in 10 patients, nine Palmaz stents in seven patients, and four tantalum Strecker stents in four patients). Nineteen patients presented with strictures not responding to balloon angioplasty (postsurgical, n = 13; cholangitis, n = 5; unknown, n = 1). Estimates for cumulative patency, patency rate in the different stent groups, and survival were calculated with use of life-table analysis; the log-rank test was used to compare the different stent groups. The prognostic relevance of the selected variables-stent type, stent length, etiology, and location-were modeled with respect to patency according to Weibull distribution. RESULTS: The median follow-up time was 80.5 months (range, 2-116 months). The median survival time was 91 months. One patient was lost to follow-up after 3 months. Repeat intervention for recurrent obstructive jaundice was necessary in 11 patients (55%), and the median patency rate was 26 months (range, 2-96 months). The Palmaz stent was the most effective in achieving long-term patency, with a median patency duration of 36 months (range, 22-96 months), versus 9 months (range, 3-67 months) for the Wallstent and 6 months (range, 2-15 months) for the tantalum Strecker stent. The cumulative patency rate with the Palmaz stent was significantly higher than for the tantalum Strecker stent (log-rank test, P = .017) and nonsignificantly higher compared with the Wallstent (log-rank test, P = .07). Multivariate analysis showed that the type of stent (Wald test, P = .003) and stent length (Wald test, P < .0001) influenced the patency rate. CONCLUSIONS: These results suggest that the type of stent and the stent length have a significant influence on the patency rate. In this series, the Palmaz stent was most effective in achieving long-term patency in benign biliary strictures.     

经皮胆管内支架放置术并发症及发生意外情况的处理方法

目的 回顾性分析经皮肝胆管引流术和置入金属内支架过程中的17例产生并发症或发生意外情况的处理方法。方法 对64例恶性胆管梗阻的患者行经皮经肝引流和置入金属内支架术，17例发生并发症和遇到意外情况。分别为：心率减慢，血压下降5例；支架脱落在十二指肠1例；微导丝断裂2例；胆管穿孔2例；支架位置不佳3例；肝肾功能衰竭导致出血2例；交换导丝折断1例；球囊破裂导致支架移位1例。结果 5例出现心率减慢，血压下降者，对症给予药物治疗或停止操作；1例支架脱落在十二指肠（1枚）后，自动排出体外；2例穿刺胆管时微导丝断裂在肝实质内，无症状直至病故；2例胆管穿孔，采用保守治疗均无临床症状；3例支架释放后位置不佳，再置入短支架；2例肝肾衰竭患者愈后差。1例交换导丝折断在十二指肠内，经胃镜取出。1例球囊破裂导致支架移位，再置入1术支架。结论 年老体弱和高位胆管梗阻的患者，采用经皮胆管内支架放置术是安全有效的方法，但有一定难度，易出现并发症，应慎重。     

Malignant biliary obstruction: treatment with self-expandable metallic stents

In a 3-year period, 57 self-expandable metallic biliary stents (Wallstent) were successfully placed in 49 patients with malignant biliary obstruction. Thirty-three of our patients have died. In this group follow-up was 1–12 months with a mean of 4.5 months and stent patency was 1–12 months with a mean of 4.3 months. Sixteen patients are still alive. In this group, follow-up was 2–26 months with a mean of 8.4 months and stent patency was 1–18 months with a mean of 6.8 months. In 4 patients a secondary stent was used due to malpositioning during deployment. In 1 patient bilateral drainage was achieved with two stents. Four patients required 5 reinterventions due to reocclusion, with a reocclusion rate of 9.4 %; 3 of them were treated with secondary metallic stents, 1 with a conventional stent and the remaining 1 with balloon dilatation. Thirty-day mortality rate was 8.1 % and procedure-related mortality was 2 %. Major and minor complication rates were 10 % and 22 %, respectively. Self-expandable metallic stents provide good palliation in patients with malignant biliary obstruction. Correspondence to: M. N. Özmen     

经皮肝穿刺胆道引流术及胆管内支架植入术在恶性梗阻性黄疸治疗中的应用

目的 评价经皮肝穿刺胆道引流(FTBD)及胆管内支架植入术(PTIBS)治疗恶性梗阻性黄疸的疗效.方法 对56例恶性梗阻性黄疸患者采取PTBD或PTIBS,所有患者均经B超、CT或MRI明确诊断,并确定梗阻部位,其中高位梗阻19例,低位梗阻37例.梗阻原因包括肝癌14例,胆管癌11例,胆囊癌5例,胃癌伴淋巴结转移14例,壶腹部占位1例,胰头癌11例.术中根据造影结果选择合适方案.结果 所有56例均成功完成手术.其中行PTBD 11例,PTIBS 40例,PTBD并PTIBS 5例.TBIL由术前(295.65 ±152.86)μmol/L降至术后(151.05 ± 107.36)μmol/L(P<0.01).术后感染对黄疸消退有影响(P<0.01).梗阻部位与黄疸消退情况比较差异无统计学意义(P=0.063).结论 经皮肝穿刺胆道引流及支架植入术治疗恶性梗阻性黄疸安全有效,可明显减轻黄疸,改善患者生活质量,延长生存期.     

射频消融导管联合支架介入治疗恶性梗阻性黄疸的临床研究

目的探讨经皮肝穿刺胆道腔内射频消融（RFA）联合支架介入治疗恶性梗阻性黄疸的效果及安全性。 方法纳入无法行手术切除的恶性梗阻性黄疸患者共13例,均接受经皮肝穿刺胆道腔内RFA联合支架植入术,观察手术并发症、黄疸缓解情况并密切随访术后1、3、6个月的支架畅通情况及生存时间。 结果所有患者均成功接受手术治疗,术后无胆道穿孔、胆漏、胆汁性腹膜炎等严重并发症发生,术后1周,患者血清总胆红素水平较术前显著降低[（95.4±83.0）μmol/L vs. （196.4±148.4）μmol/L, t=5.156,P<0.01],黄疸缓解率为61.5%。随访术后1个月、3个月支架通畅率均为100%,6个月支架通畅率为80%（8/10）。1个月存活率为100%（13/13）,3个月存活率为92%（12/13）,6个月存活率为77%（10/13）,其中2例分别于65 d、132 d后死于晚期肿瘤严重消耗,1例97 d后死于弥散性血管内凝血。2例患者在术后4~5个月内黄疸复发,再次行RFA并重新放入金属支架。 结论联合支架植入治疗在短期内能有效且安全地延长恶性梗阻性黄疸患者胆道支架通畅时间及无症状生存时间,其远期疗效尚需进一步探讨。     

The use of SMARTeR stents in patients with biliary obstruction

AIM: The purpose of the study was to evaluate the percutaneous use of the new nitinol SMARTeR stents in patients with biliary obstruction. MATERIALS AND METHODS: Four stents were placed in three patients percutaneously under ultrasound and fluoroscopic guidance. RESULTS: The deployment of the stents was successful in all three patients. All stents maintained their patency and position after short-term follow-up. CONCLUSION: The nitinol SMARTeR stent is useful in the management of patients with biliary obstruction although accurate placement across the ampulla was found to be technically more difficult than with the Wallstent. Larger, long-term follow-up studies are required to evaluate the long-term patency of these new devices.     

A simplified percutaneous hepatogastric drainage technique for malignant biliary obstruction

We describe a technique to bypass a malignant biliary obstruction by creating a direct connection between the left biliary tree and the stomach. First, adherence between the left liver parenchyma and the stomach is achieved by a Cope anchor system. Then, the left biliary tree and stomach are connected by Colapinto needle puncture of the stomach from a left biliary duct with the needle inserted through a 9 Fr transhepatic sheath. Over a stiff guidewire, a Ring drainage catheter is placed. Later, the Ring catheter is replaced by a metallic stent. Four patients with malignant biliary obstruction underwent this procedure. The mean survival time was 77 days with maximum follow-up of 171 days. Neither obstruction nor dislocation of the metallic stents occurred.Presented at the 18th CIRSE Meeting, Budapest 1993     

Metallic stents for the treatment of biliary obstruction: A report of 100 cases

The results of the first 100 patients to receive Gianturco-Rösch “Z” stents is presented along with recommendations for their use. The patient population was comprised of 57 men and 43 women, age range 17–85 years (mean 65 years). Fifty-four of the patients had benign obstruction and 46 had malignant obstruction. Of the benign lesions, 11 had sclerosing cholangitis and the remainder had postoperative strictures. Thirty-one of the malignant obstructions were secondary to cholangiocarcinoma with the majority of the others secondary to metastases from various sources. All but one had multiple systems involved. Patients with benign postoperative strictures were all initially treated with balloon angioplasty; if this failed, stents were inserted. In patients who had stents in place for greater than 1 year, the occlusion rate was 13%. The overall occlusion rate in the 43 patients was 7%. Patients with sclerosing cholangitis did less well. In those with sclerosing cholangitis secondary to intraarterial chemotherapy, the occlusion rate was 77%, and we no longer use the metallic “Z” stent in these patients. The stent was not used for malignant common duct obstruction. All patients had hilar involvement. In the patients with malignant obstruction, 17% reobstructed prior to their death. The patients with cholangiocarcinoma did well with a mean survival time of 14 months and a re-obstruction rate of 16%. All late obstructions were secondary to tumor over-growth either proximal or distal to the stents. We conclude that the “Z” stent is an effective form of treatment in patients with benign postoperative strictures and those with malignant obstruction involving the hilum. We do not recommend it as a replacement for conventional stents, but rather as an additional device that allows treatment of some of the more difficult causes of obstruction.     

Indwelling ureteral stents: percutaneous management of complications

Complications of indwelling ureteral stents were managed percutaneously in 13 patients. These complications consisted of three fractured, three heavily encrusted, and seven migrated stents. While most ureteral stent malfunctions are routinely managed with retrograde techniques, the percutaneous approach allows effective clinical management in selected cases in which extensive renal stone material or brittle intrarenal stent fragments are present or when previous surgery or ureteral strictures do not permit a retrograde approach. Fluoroscopically guided removal of migrated stents and percutaneous endoscopic techniques, for complex cases such as those requiring stone removal, were successful and without complications.     

Intra-biliary contrast-enhanced ultrasound for evaluating biliary obstruction during percutaneous transhepatic biliary drainage: A preliminary study

Objectives

The aimed of this study was to investigate the value of intra-biliary contrast-enhanced ultrasound (IB-CEUS) for evaluating biliary obstruction during percutaneous transhepatic biliary drainage (PTBD).

Materials and methods

80 patients with obstructive jaundice who underwent IB-CEUS during PTBD were enrolled. The diluted ultrasound contrast agent was injected via the drainage catheter to perform IB-CEUS. Both conventional ultrasound and IB-CEUS were used to detect the tips of the drainage catheters and to compare the detection rates of the tips. The obstructive level and degree of biliary tract were evaluated by IB-CEUS. Fluoroscopic cholangiography (FC) and computer tomography cholangiography (CTC) were taken as standard reference for comparison.

Results

Conventional ultrasound displayed only 43 tips (43/80, 53.8%) of the drainage catheters within the bile ducts while IB-CEUS identified all 80 tips (80/80, 100%) of the drainage catheters including 4 of them out of the bile duct (P < 0.001). IB-CEUS made correct diagnosis in 44 patients with intrahepatic and 36 patients with extrahepatic biliary obstructions. IB-CEUS accurately demonstrated complete obstruction in 56 patients and incomplete obstruction in 21 patients. There were 3 patients with incomplete obstruction misdiagnosed to be complete obstruction by IB-CEUS. The diagnostic accuracy of biliary obstruction degree was 96.3% (77/80).

Conclusion

IB-CEUS could improve the visualization of the drainage catheters and evaluate the biliary obstructive level and degree during PTBD. IB-CEUS may be the potential substitute to FC in the PTBD procedure.     

Polyorethaoe-covered nitinol strecker stents as primary palliative treatment of malignant biliary obstruction

Purpose: To evaluate the clinical efficacy of the polyurethane-covered Nitinol Strecker stent in the treatment of patients with malignant biliary obstruction. Methods: Twenty-three covered stents produced by us were placed in 18 patients with malignant biliary obstruction. Jaundice was caused by cholangiocarcinoma (n = 5), pancreatic cancer (n = 6), gallbladder cancer (n = 4), metastatic lymph nodes (n = 2), and tumor of the papilla (n = 1). Results: The mean patency period of the stents was 37.5 weeks (5–106 weeks). Recurrent obstructive jaundice occurred in two patients (11%). Adequate biliary drainage over 50 weeks or until death was achieved in 17 of 18 patients (94.4%). Late cholangitis was observed in two patients whose stents bridged the ampulla of Vater. Other late severe complications were not encountered. Conclusion: Although more study is necessary, our results suggest the clinical efficacy of our covered Nitinol Strecker stent in the management of obstructive jaundice caused by malignant diseases.