Percutaneous biliary approach as a successful rescue procedure after failed endoscopic therapy for drainage in advanced hilar tumors.
OBJECTIVE
Palliative endoscopic or percutaneous biliary drainage is used for unresectable advanced hilar cancer (HC). The best option for drainage in Bismuth type III or IV HC has not been established. The aims of this study are to identify factors predictive of endoscopic stenting failure and evaluate the effectiveness of rescue percutaneous stenting in patients with advanced HC.


METHODS
Data from 110 patients with inoperable advanced HC were retrospectively reviewed. All received bilateral self-expandable metallic stents. Patients were divided into three groups: I, successful initial endoscopic stenting; II, unsuccessful initial endoscopic stenting, followed by percutaneous stenting; and III, initial percutaneous stenting. We analyzed clinical results and radiologic tumor characteristics.


RESULTS
Baseline characteristics and clinical outcomes of all groups were similar, except the hospital stay was longer in group III than group I. Technical success rate was higher in groups II and III (100%) than in group I (72.4%). The functional success rate, stent patency time, patient survival time, and complication rate were similar between groups. Endoscopic stenting failed because of guide-wire passage failure (n = 12) or stent passage failure (n = 7). The only factor significantly associated with endoscopic failure was a smaller left intrahepatic duct-common bile duct angle.


CONCLUSIONS
As clinical outcomes were generally similar between approaches, percutaneous stenting is recommended for patients with Bismuth type III or IV advanced HC. Acute left intrahepatic duct-common bile duct angulation predicts endoscopic stenting failure. If endoscopic stenting fails, immediate conversion to the percutaneous approach is a necessary and effective rescue method.
Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea.|Department of Medicine, Yonsei University Graduate School, Seoul, South Korea.
Sung Ill
SI
Jang
Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
Jin-Hyeok
JH
Hwang
Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
Kwang-Hun
KH
Lee
Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
Jeong-Sik
JS
Yu
Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
Hee Wook
HW
Kim
Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
Chang Jin
CJ
Yoon
Department of Internal Medicine, Keimyung University School of Medicine, Daegu, South Korea.
Yoon Suk
YS
Lee
Department of Internal Medicine, Daejun Eulji University Hospital, Daejeon, South Korea.
Kyu Hyun
KH
Paik
Departments of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea.
Sang Hyub
SH
Lee
Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
Dong Ki
DK
Lee
D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000628:therapy*; D001653:Bile Ducts, Intrahepatic; D004322:Drainage / Q000379:methods*; D004724:Endoscopy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods*; D012189:Retrospective Studies; D015607:Stents; D017211:Treatment Failure; D016896:Treatment Outcome
biliary drainage; endoscopic stenting; hilar tumor; percutaneous stenting; self-expandable metal stent