The Management of High-Grade Hilar Strictures by Endoscopic Insertion of Self-Expanding Metal Endoprostheses

Abstract

Background and Study Aims: Treatment options for unresectable hepatic hilar strictures include percutaneous or endoscopic stent insertion, using either standard Teflon or self-expanding metal endoprostheses. The use of Teflon stents is complicated by stent migration and high occlusion rates. Published series of endoscopically placed metal stents have not concentrated on their use in the treatment of high-grade hilar strictures (Bismuth grades II and III). We therefore undertook a prospective and open pilot study to evaluate the efficacy of endoscopically placed metal endoprostheses in the palliation of jaundice due to high-grade hilar strictures.

Patients and Methods: Self-expanding metal stents were placed endoscopically in 17 patients (nine women, eight men; median age 64 years, range 33-77). Of the 17 malignancies 11 patients (65 %) had a diagnosis of cholangiocarcinoma, and 12 (71 %) had Bismuth grade III strictures.

Results: The stents were inserted successfully in all 17 patients. Adequate drainage, as demonstrated by a significant reduction in bilirubin, was achieved in 15 (88 %); the two patients in whom drainage failed had extensive intrahepatic disease. Early complications (cholangitis) developed in one patient (6 %), and there were seven late complications (41 %) in five patients (four occluded stents and three cases of duodenal compression). The stent patency appeared to be prolonged (median stent patency 12 months, range 1.5-24 months, in patients surviving five months or more). The median survival was ten months (range 1-48 months) after stent insertion. All of the patients died during follow-up.

Conclusions: These results suggest that endoscopically placed metal stents offer effective palliation for high-grade hilar malignancies, although controlled trials comparing the use of metal and Teflon endoprostheses in this patient group are required.