COMBINED ENDOSCOPIC AND PERCUTANEOUS SELF EXPANDABLE METAL STENT PLACEMENT FOR MALIGNANT HILAR STENOSIS OF THE BILIARY TREE

Patients with malignant hilar biliary strictures, not suitable candidates for surgery are referred for palliative treatment. Following generally accepted guidelines they are managed by placement of uncovered self expandable metal stents (SEMS) for biliary decompression and palliative chemotherapy. Hilar strictures are technically challenging even for experienced endoscopists. In specific cases severity of the stenosis makes it difficult to canulate the affected branch and achieve adequate biliary drainage.

We present two cases of combined endoscopic and percutaneous SEMS insertion in the left and right hepatic ducts. Percutaneous approach was used due to failed endoscopic canulation of the right hepatic duct.

Patients were assessed on MDT meeting as not suitable candidates for surgery with malignant Bismuth type II stenosis. Consecutively endoscopic retrograde cholangiopancreatography (ERCP) with uncovered SEMS placement for drainage of left and right hepaitc ducts was attempted in both cases. One of the cases was with altered anatomy (previously done BII resection), which did not reflected on procedure outcome. After endoscopic canulation of left hepatic duct and multiple failed attempts to canulate right hepatic duct a decision for percutaneous transhepatic cholangiography (PTC) was made. Under ultrasound (US) and x-ray guidance we performed PTC of the right hepatic duct and were able to traverse the stenosis with a guide wire. Consecutively we placed two 80/10 mm uncovered SEMS one retrogradely in the left hepatic duct and one percutaneus in the right hepatic duct. Both patients were discharged from the hospital two days after the intervention without complications.

Percutaneous SEMS placement is feasible in experienced high volume centers doing PTC on regular basis. Intuitively, this is an appealing concept for treating hilar strictures after failed endoscopic canulation and warrants further research.