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Semin intervent Radiol 2016; 33(04): 259-267
DOI: 10.1055/s-0036-1592330
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Management of Malignant Biliary Obstruction

Jonathan M. Lorenz
1   Department of Radiology, The University of Chicago, Chicago, Illinois
› Author Affiliations
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Publication Date:
31 October 2016 (online)

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Abstract

The diagnosis of malignant biliary obstruction combines the use of clinical evaluation, diagnostic imaging, tissue sampling, and minimally invasive options with the initial goal of identifying candidates for curative resection. The most common causes of obstruction are pancreatic adenocarcinoma and cholangiocarcinoma, and most cases are too advanced for surgical options. Interventional radiologists and gastroenterologists offer palliative options for biliary drainage such as plastic stents and catheters, bare metal stents, and covered stents. This article provides an updated review of options and outcomes for the management of malignant biliary obstruction.

Keywords

biliary obstruction - cancer - percutaneous drainage - interventional radiology
 

  • References

  • 1 Leng JJ, Zhang N, Dong JH. Percutaneous transhepatic and endoscopic biliary drainage for malignant biliary tract obstruction: a meta-analysis. World J Surg Oncol 2014; 12 (1) 272
    CrossrefPubMedGoogle Scholar
  • 2 Corvera CU, Blumgart LH, Akhurst T , et al. 18F-fluorodeoxyglucose positron emission tomography influences management decisions in patients with biliary cancer. J Am Coll Surg 2008; 206 (1) 57-65
    CrossrefPubMedGoogle Scholar
  • 3 Suthar M, Purohit S, Bhargav V, Goyal P. Role of MRCP in differentiation of benign and malignant causes of biliary obstruction. J Clin Diagn Res 2015; 9 (11) TC08-TC12
    PubMedGoogle Scholar
  • 4 Xu MM, Sethi A. Diagnosing biliary malignancy. Gastrointest Endosc Clin N Am 2015; 25 (4) 677-690
    CrossrefPubMedGoogle Scholar
  • 5 Canto MI, Hruban RH, Fishman EK , et al; American Cancer of the Pancreas Screening (CAPS) Consortium. Frequent detection of pancreatic lesions in asymptomatic high-risk individuals. Gastroenterology 2012; 142 (4) 796-804 , quiz e14–e15
    CrossrefPubMedGoogle Scholar
  • 6 Burnett AS, Calvert TJ, Chokshi RJ. Sensitivity of endoscopic retrograde cholangiopancreatography standard cytology: 10-y review of the literature. J Surg Res 2013; 184 (1) 304-311
    CrossrefPubMedGoogle Scholar
  • 7 Kim EH, Kim HJ, Oh HC , et al. The usefulness of percutaneous transhepatic cholangioscopy for identifying malignancies in distal common [corrected] bile duct strictures. J Korean Med Sci 2008; 23 (4) 579-585
    CrossrefPubMedGoogle Scholar
  • 8 Kim JY, Kim MH, Lee TY , et al. Clinical role of 18F-FDG PET-CT in suspected and potentially operable cholangiocarcinoma: a prospective study compared with conventional imaging. Am J Gastroenterol 2008; 103 (5) 1145-1151
    CrossrefPubMedGoogle Scholar
  • 9 Di Sena V, Thuler FP, Macedo EP, Paulo GA, Della Libera E, Ferrari AP. Obstructive jaundice secondary to bile duct involvement with Hodgkin's disease: a case report. Sao Paulo Med J 2005; 123 (1) 30-32
    CrossrefPubMedGoogle Scholar
  • 10 Kosuge T, Yamamoto J, Shimada K, Yamasaki S, Makuuchi M. Improved surgical results for hilar cholangiocarcinoma with procedures including major hepatic resection. Ann Surg 1999; 230 (5) 663-671
    CrossrefPubMedGoogle Scholar
  • 11 Nimura Y, Kamiya J, Kondo S , et al. Aggressive preoperative management and extended surgery for hilar cholangiocarcinoma: Nagoya experience. J Hepatobiliary Pancreat Surg 2000; 7 (2) 155-162
    CrossrefPubMedGoogle Scholar
  • 12 Sugiura Y, Nakamura S, Iida S , et al. Extensive resection of the bile ducts combined with liver resection for cancer of the main hepatic duct junction: a cooperative study of the Keio Bile Duct Cancer Study Group. Surgery 1994; 115 (4) 445-451
    PubMedGoogle Scholar
  • 13 Burke DR, Lewis CA, Cardella JF , et al; Society of Interventional Radiology Standards of Practice Committee. Quality improvement guidelines for percutaneous transhepatic cholangiography and biliary drainage. J Vasc Interv Radiol 2003; 14 (9 Pt 2, Suppl): S243-S246
    PubMedGoogle Scholar
  • 14 Abdullah SA, Gupta T, Jaafar KA, Chung YF, Ooi LL, Mesenas SJ. Ampullary carcinoma: effect of preoperative biliary drainage on surgical outcome. World J Gastroenterol 2009; 15 (23) 2908-2912
    CrossrefPubMedGoogle Scholar
  • 15 Kloek JJ, van der Gaag NA, Aziz Y , et al. Endoscopic and percutaneous preoperative biliary drainage in patients with suspected hilar cholangiocarcinoma. J Gastrointest Surg 2010; 14 (1) 119-125
    CrossrefPubMedGoogle Scholar
  • 16 Lygidakis NJ, van der Heyde MN, Lubbers MJ. Evaluation of preoperative biliary drainage in the surgical management of pancreatic head carcinoma. Acta Chir Scand 1987; 153 (11–12) 665-668
    PubMedGoogle Scholar
  • 17 Marcus SG, Dobryansky M, Shamamian P , et al. Endoscopic biliary drainage before pancreaticoduodenectomy for periampullary malignancies. J Clin Gastroenterol 1998; 26 (2) 125-129
    CrossrefPubMedGoogle Scholar
  • 18 Sewnath ME, Birjmohun RS, Rauws EA, Huibregtse K, Obertop H, Gouma DJ. The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy. J Am Coll Surg 2001; 192 (6) 726-734
    CrossrefPubMedGoogle Scholar
  • 19 Hatfield AR, Tobias R, Terblanche J , et al. Preoperative external biliary drainage in obstructive jaundice. A prospective controlled clinical trial. Lancet 1982; 2 (8304) 896-899
    PubMedGoogle Scholar
  • 20 Povoski SP, Karpeh Jr MS, Conlon KC, Blumgart LH, Brennan MF. Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg 1999; 230 (2) 131-142
    CrossrefPubMedGoogle Scholar
  • 21 Hochwald SN, Burke EC, Jarnagin WR, Fong Y, Blumgart LH. Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma. Arch Surg 1999; 134 (3) 261-266
    CrossrefPubMedGoogle Scholar
  • 22 Ferrero A, Lo Tesoriere R, Viganò L, Caggiano L, Sgotto E, Capussotti L. Preoperative biliary drainage increases infectious complications after hepatectomy for proximal bile duct tumor obstruction. World J Surg 2009; 33 (2) 318-325
    CrossrefPubMedGoogle Scholar
  • 23 Lee SH, Park JK, Yoon WJ , et al. Optimal biliary drainage for inoperable Klatskin's tumor based on Bismuth type. World J Gastroenterol 2007; 13 (29) 3948-3955
    CrossrefPubMedGoogle Scholar
  • 24 Bories E, Pesenti C, Caillol F, Lopes C, Giovannini M. Transgastric endoscopic ultrasonography-guided biliary drainage: results of a pilot study. Endoscopy 2007; 39 (4) 287-291
    Google Scholar
  • 25 Horaguchi J, Fujita N, Noda Y , et al. Endosonography-guided biliary drainage in cases with difficult transpapillary endoscopic biliary drainage. Dig Endosc 2009; 21 (4) 239-244
    Google Scholar
  • 26 Park DH, Koo JE, Oh J , et al. EUS-guided biliary drainage with one-step placement of a fully covered metal stent for malignant biliary obstruction: a prospective feasibility study. Am J Gastroenterol 2009; 104 (9) 2168-2174
    CrossrefPubMedGoogle Scholar
  • 27 Wang AY, Strand DS, Shami VM. Prevention of post-ERCP pancreatitis: medications and techniques. Clin Gastroenterol Hepatol 2016; ; pii:S1542-3565(16)30215-4. doi: 10.1016/j.cgh.2016.05.026. [Epub ahead of print]
    PubMedGoogle Scholar
  • 28 Patel IJ, Davidson JC, Nikolic B , et al; Standards of Practice Committee, with Cardiovascular and Interventional Radiological Society of Europe (CIRSE) Endorsement. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol 2012; 23 (6) 727-736
    CrossrefPubMedGoogle Scholar
  • 29 Wayne III PH, Whelan Jr JG. Susceptibility testing of biliary bacteria obtained before bile duct manipulation. AJR Am J Roentgenol 1983; 140 (6) 1185-1188
    CrossrefPubMedGoogle Scholar
  • 30 Spies JB, Rosen RJ, Lebowitz AS. Antibiotic prophylaxis in vascular and interventional radiology: a rational approach. Radiology 1988; 166 (2) 381-387
    CrossrefPubMedGoogle Scholar
  • 31 Speer AG, Cotton PB, Russell RC , et al. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987; 2 (8550) 57-62
    CrossrefPubMedGoogle Scholar
  • 32 Becker CD, Glättli A, Maibach R, Baer HU. Percutaneous palliation of malignant obstructive jaundice with the Wallstent endoprosthesis: follow-up and reintervention in patients with hilar and non-hilar obstruction. J Vasc Interv Radiol 1993; 4 (5) 597-604
    CrossrefPubMedGoogle Scholar
  • 33 Rossi P, Bezzi M, Rossi M , et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients. J Vasc Interv Radiol 1994; 5 (2) 279-285
    CrossrefPubMedGoogle Scholar
  • 34 Berkman WA, Bishop AF, Palagallo GL, Cashman MD. Transhepatic balloon dilation of the distal common bile duct and ampulla of Vater for removal of calculi. Radiology 1988; 167 (2) 453-455
    CrossrefPubMedGoogle Scholar
  • 35 Fidelman N, Bloom AI, Kerlan Jr RK , et al. Hepatic arterial injuries after percutaneous biliary interventions in the era of laparoscopic surgery and liver transplantation: experience with 930 patients. Radiology 2008; 247 (3) 880-886
    CrossrefPubMedGoogle Scholar
  • 36 Mueller PR, vanSonnenberg E, Ferrucci Jr JT , et al. Biliary stricture dilatation: multicenter review of clinical management in 73 patients. Radiology 1986; 160 (1) 17-22
    CrossrefPubMedGoogle Scholar
  • 37 Carrasco CH, Zornoza J, Bechtel WJ. Malignant biliary obstruction: complications of percutaneous biliary drainage. Radiology 1984; 152 (2) 343-346
    CrossrefPubMedGoogle Scholar
  • 38 Chapman WC, Sharp KW, Weaver F, Sawyers JL. Tumor seeding from percutaneous biliary catheters. Ann Surg 1989; 209 (6) 708-713 , discussion 713–715
    CrossrefPubMedGoogle Scholar
  • 39 Audisio RA, Morosi C, Bozzetti F , et al. The outcome of cholangitis after percutaneous biliary drainage in neoplastic jaundice. HPB Surg 1993; 6 (4) 287-293
    CrossrefPubMedGoogle Scholar
  • 40 Libby ED, Leung JW. Prevention of biliary stent clogging: a clinical review. Am J Gastroenterol 1996; 91 (7) 1301-1308
    PubMedGoogle Scholar
  • 41 Lorenz JM, Zangan SM, Leef JA, Van Ha TG. Iatrogenic portobiliary fistula treated by stent-graft placement. Cardiovasc Intervent Radiol 2010; 33 (2) 421-424
    CrossrefPubMedGoogle Scholar
  • 42 Amikura K, Kobari M, Matsuno S. The time of occurrence of liver metastasis in carcinoma of the pancreas. Int J Pancreatol 1995; 17 (2) 139-146
    PubMedGoogle Scholar
  • 43 Kayahara M, Nagakawa T, Ueno K, Ohta T, Takeda T, Miyazaki I. An evaluation of radical resection for pancreatic cancer based on the mode of recurrence as determined by autopsy and diagnostic imaging. Cancer 1993; 72 (7) 2118-2123
    CrossrefPubMedGoogle Scholar
  • 44 Yeoh KG, Zimmerman MJ, Cunningham JT, Cotton PB. Comparative costs of metal versus plastic biliary stent strategies for malignant obstructive jaundice by decision analysis. Gastrointest Endosc 1999; 49 (4, Pt 1): 466-471
    CrossrefPubMedGoogle Scholar
  • 45 Wagner HJ, Knyrim K, Vakil N, Klose KJ. Plastic endoprostheses versus metal stents in the palliative treatment of malignant hilar biliary obstruction. A prospective and randomized trial. Endoscopy 1993; 25 (3) 213-218
    Article in Thieme ConnectPubMedGoogle Scholar
  • 46 Salomonowitz EK, Adam A, Antonucci F, Stuckmann G, Zollikofer CL. Malignant biliary obstruction: treatment with self-expandable stainless steel endoprosthesis. Cardiovasc Intervent Radiol 1992; 15 (6) 351-355
    CrossrefPubMedGoogle Scholar
  • 47 Rossi P, Bezzi M, Salvatori FM, Panzetti C, Rossi M, Pavia G. Clinical experience with covered wallstents for biliary malignancies: 23-month follow-Up. Cardiovasc Intervent Radiol 1997; 20 (6) 441-447
    CrossrefPubMedGoogle Scholar
  • 48 Freeman ML, Overby C. Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents. Gastrointest Endosc 2003; 58 (1) 41-49
    CrossrefPubMedGoogle Scholar
  • 49 Son RC, Gwon DI, Ko HK, Kim JW, Ko GY. Percutaneous unilateral biliary metallic stent placement in patients with malignant obstruction of the biliary hila and contralateral portal vein steno-occlusion. Korean J Radiol 2015; 16 (3) 586-592
    CrossrefPubMedGoogle Scholar
  • 50 Gwon DI, Ko GY, Yoon HK , et al. Safety and efficacy of percutaneous Y-configured covered stent placement for malignant hilar biliary obstruction: a prospective, pilot study. J Vasc Interv Radiol 2012; 23 (4) 528-534
    CrossrefPubMedGoogle Scholar
  • 51 Jo JH, Park BH. Suprapapillary versus transpapillary stent placement for malignant biliary obstruction: which is better?. J Vasc Interv Radiol 2015; 26 (4) 573-582
    CrossrefPubMedGoogle Scholar
  • 52 Bakhru M, Ho HC, Gohil V , et al. Fully-covered, self-expandable metal stents (CSEMS) in malignant distal biliary strictures: mid-term evaluation. J Gastroenterol Hepatol 2011; 26 (6) 1022-1027
    CrossrefPubMedGoogle Scholar
  • 53 Hausegger KA, Thurnher S, Bodendörfer G , et al. Treatment of malignant biliary obstruction with polyurethane-covered Wallstents. AJR Am J Roentgenol 1998; 170 (2) 403-408
    CrossrefPubMedGoogle Scholar
  • 54 Fanelli F, Orgera G, Bezzi M, Rossi P, Allegritti M, Passariello R. Management of malignant biliary obstruction: technical and clinical results using an expanded polytetrafluoroethylene fluorinated ethylene propylene (ePTFE/FEP)-covered metallic stent after 6-year experience. Eur Radiol 2008; 18 (5) 911-919
    CrossrefPubMedGoogle Scholar
  • 55 Han YM, Kwak HS, Jin GY, Lee SO, Chung GH. Treatment of malignant biliary obstruction with a PTFE-covered self-expandable nitinol stent. Korean J Radiol 2007; 8 (5) 410-417
    CrossrefPubMedGoogle Scholar
  • 56 Hatzidakis A, Krokidis M, Kalbakis K, Romanos J, Petrakis I, Gourtsoyiannis N. ePTFE/FEP-covered metallic stents for palliation of malignant biliary disease: can tumor ingrowth be prevented?. Cardiovasc Intervent Radiol 2007; 30 (5) 950-958
    CrossrefPubMedGoogle Scholar
  • 57 Schoder M, Rossi P, Uflacker R , et al. Malignant biliary obstruction: treatment with ePTFE-FEP- covered endoprostheses initial technical and clinical experiences in a multicenter trial. Radiology 2002; 225 (1) 35-42
    CrossrefPubMedGoogle Scholar
  • 58 Krokidis M, Fanelli F, Orgera G , et al. Percutaneous palliation of pancreatic head cancer: randomized comparison of ePTFE/FEP-covered versus uncovered nitinol biliary stents. Cardiovasc Intervent Radiol 2011; 34 (2) 352-361
    CrossrefPubMedGoogle Scholar
  • 59 Kullman E, Frozanpor F, Söderlund C , et al. Covered versus uncovered self-expandable nitinol stents in the palliative treatment of malignant distal biliary obstruction: results from a randomized, multicenter study. Gastrointest Endosc 2010; 72 (5) 915-923
    CrossrefPubMedGoogle Scholar
  • 60 Suk KT, Kim JW, Kim HS , et al. Human application of a metallic stent covered with a paclitaxel-incorporated membrane for malignant biliary obstruction: multicenter pilot study. Gastrointest Endosc 2007; 66 (4) 798-803
    CrossrefPubMedGoogle Scholar
  • 61 Alis H, Sengoz C, Gonenc M, Kalayci MU, Kocatas A. Endobiliary radiofrequency ablation for malignant biliary obstruction. Hepatobiliary Pancreat Dis Int 2013; 12 (4) 423-427
    CrossrefPubMedGoogle Scholar
  • 62 Dolak W, Schreiber F, Schwaighofer H , et al; Austrian Biliary RFA Study Group. Endoscopic radiofrequency ablation for malignant biliary obstruction: a nationwide retrospective study of 84 consecutive applications. Surg Endosc 2014; 28 (3) 854-860
    CrossrefPubMedGoogle Scholar
  • 63 Lee MJ, Dawson SL, Mueller PR , et al. Failed metallic biliary stents: causes and management of delayed complications. Clin Radiol 1994; 49 (12) 857-862
    CrossrefPubMedGoogle Scholar
  • 64 Lee TH, Park SH, Kim SP , et al. Chemical ablation of the gallbladder using alcohol in cholecystitis after palliative biliary stenting. World J Gastroenterol 2009; 15 (16) 2041-2043
    CrossrefPubMedGoogle Scholar