Korean J Radiol.  2000 Jun;1(2):65-72. 10.3348/kjr.2000.1.2.65.

Percutaneous Placement of Self-expandable Metallic Biliary Stents in Malignant Extrahepatic Strictures: Indications of Transpapillary and Suprapapillary Methods

• Lee DH
• Yu JS
• Hwang JC
• Kim KH

• KMID: 966475
• DOI: http://doi.org/10.3348/kjr.2000.1.2.65

Abstract

OBJECTIVE
To compare the efficacy of suprapapillary and transpapillary meth-ods of transhepatic biliary metallic stent placement in malignant biliary strictures and to specify the indications of each method applied. MATERIALS AND METHODS: Stents were placed in 59 patients. Strictures were cat-egorized as type A (within 3 cm of the ampulla, n = 27), type B (over 3 cm from ampulla, n = 7), type C (within 3 cm of the bending portion, n = 9), or type D (over 3 cm above the bending portion, n=16). The stenting method was suprapapillary in 34 cases and transpapillary in 25. The rates of initial and long-term patency and of early recurrence were compared. RESULTS: Initial patency rates for the suprapapillary and transpapillary methods were 1/7 (14.3%) and 20/20 (100%) respectively for type A (p < 0.0001), 4/5 (80.0%) and 2/2 for type B, 3/7 (42.9%) and 2/2 for type C, and 15/16 (93.8%) and 0/0 for type D. Early recurrence rates were 7/30 (23.3%) using the suprapap-illary method and 4/29 (13.8%) using the transpapillary method (p = 0.51). The long-term patency rate did not differ significantly according to either type (p =0.37) or method (p = 0.62). CONCLUSION: For good initial patency, the transpapillary method is recommended for strictures of the distal extrahepatic duct near the ampulla and just above the bending portion. Long-term patency is not influenced by the stenting method employed.

Keyword

Bile ducts, stenosis or obstruction; Bile ducts, interventional procedure; Bile ducts, stents and prostheses

MeSH Terms

Bile Duct Neoplasms/complications
Bile Duct Obstruction, Extrahepatic/etiology/*therapy
Cholangiography
Comparative Study
Digestive System Neoplasms/complications
Female
Human
Male
Middle Age
Palliative Care/*methods
*Radiology, Interventional
Retrospective Studies
*Stents
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 Anatomically, the extrahepatic duct is not straight for its entire course. Varying degrees of angulation between the proximal and distal axes of the extrahepatic duct can be noted.

• 

  Fig. 2 Cholangiographic categorization of extrahepatic duct strictures according to location of distal margin of stricture within the bile duct and relationship with the angulation of the extrahepatic duct. (A) a stricture located within 3 cm of the ampulla (type A); (B) a stricture located more than 3 cm above the ampulla and at or below the bending portion (Type B); (C) a stricture located above the bending portion but within 3 cm of the bending portion (type C); (D) a stricture located over 3 cm from the bending portion (type D)

• 

  Fig. 3 A 65-year-old man with pancreatic head cancer.A. Because it was located within 3 cm of the ampulla of Vater, the stricture was categorized as type A.B. Using the transpapillary method of stent placement, the stricture was successfully palliated.

• 

  Fig. 4 A 52-year-old man with pancreatic head cancer.A. Because it was located within 3 cm of the ampulla of Vater, the stricture was categorized as type A. The passage of contrast medium injected via a catheter below the main stricture was good, and we therefore initially neglected a focal narrowing (open arrow) near the ampulla of Vater.B. The passage of contrast medium was poor after the suprapapillary method of stent placement was applied. The stricture was dilated using an angioplasty balloon catheter.

• 

  Fig. 5 A 62-year-old man presented with obstructed jaundice due to metastatic lymphadenopathy arising from advanced gastric cancer.A. Because it was located over 3 cm from the ampulla of Vater at the level of the bending portion of the extrahepatic duct, the stricture was categorized as type B.B. By means of the suprapapillary placement method, the stricture was successfully palliated.

• 

  Fig. 6 A 56-year-old man with common hepatic duct cancer.A. Because it was located not more than 3 cm above the bending portion of the extrahepatic duct, the stricture was categorized as type C. Note the bending portion below the stricture (arrow).B. The stricture was palliated by means of the suprapapillary placement method. A cholangiogram obtained the following day demonstrated, however, that the angulation below the stricture was aggravated by the stretching effect of the stent. Note the presence of a significantly dilated intrahepatic duct, indicating poor passage of contrast medium through the extrahepatic duct.

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