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Abstract
Purpose
To evaluate implanting techniques of T-configured dual stents in malignant hilar obstruction and investigate the clinical factors related to stent obstruction.
Materials and Methods
The study included 28 patients undergoing T-configured dual stent implantation to palliate malignant biliary hilar obstruction. The unilobar approach was first attempted in the procedure, which progressed to bilobar approach when it was found that the unilobar approach was not feasible. If the stent was again obstructed, clinical palliation was attempted using stent re-insertion or PTBD. Clinical factors associated with T-configured dual stenting were examined in the patients with stent re-obstruction, which was followed by a correlation between these clinical factors and stent obstruction.
Results
Eleven of 13 patients were successfully treated by the unilobar approach. The two unsuccessful cases sustained angulation of the central large mesh stent. For the bilobar approach, 14 of 15 patients were successfully treated. For the one unsuccessful patient, the stent failed to pass through the central large mesh. Stent obstruction was revealed in 13 patients during the follow-up period. Balloon-assisted stent re-canalization was successfully performed in 5 patients. The analysis suggests that no definite correlation was found between stent obstruction and the clinical factors associated with dual stent placement. Conversely, bile containing sludge or debris was significantly correlated to early stent obstruction.
Conclusion
Technical adoption considering the bile duct anatomy and obstruction pattern is important for T-configured dual stent implantation. The prudent evaluation of bile juice characters and cholangiographic findings is required for the appropriate clinical application of the T-configured dual stenting.
Figures and Tables
Fig. 2
Conventional technique of T-configured dual stent implantation (A) The large central mesh stent (*) is placed transversely, followed by insertion of an ordinary stent through large central mesh (white arrow). (B) The T-configured appearance of the deployed stents is demonstrated.
Fig. 3
Technical failure due to stent angulation at central large mesh portion (A) A 5F angled tip catheter passing from the right to the left hepatic duct reveals the angle between bilateral primary hepatic ducts is less than 90 degree. (B) T-configured dual stent implantation is achieved using conventional unilobar approaching technique, but angulating collapse of stent occurs subsequently at central large mesh portion.
Fig. 4
T-configured dual stent implantation through bilobar approach in 70-year-old male patient with Klatskin tumor (A) Guidewires are passing to distal CBD through pre-existing PTBD in both hepatic lobes, and then a large central mesh stent is deployed vertically instead of transverse placement in conventional technique. Two guidewires reveal the angle formed by bilateral primary hepatic ducts is quite narrow. (B) An ordinary stent is implanted through the large central mesh, forming Y configuration.
Fig. 5
Ballooning and additional stent insertion to reopen occluded T-configured dual stents (A) A mesh of the ordinary vertical stent is dilated with a balloon. (B) A new large central mesh stent is inserted through the dilated mesh, making its large central mesh overlapped with that of the previously inserted large mesh stent. (C) A new vertical stent is inserted through the newly deployed large central mesh stent, to be placed in the previously inserted vertical stent.
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