Y-Shaped Endoscopic Bilateral Stenting with New Wider-Mesh Biliary Stent in Malignant Hilar Obstruction: Long-Term Results

Abstract

Background: Endoscopic bilateral stenting using dual conventional self-expanding metal stents in malignant hilar obstruction is technically difficult despite best efforts to do so, because the second stent isn’t as easily inserted once the first stent is deployed within the bile duct lumen. Methods: We prospectively studied the effectiveness of a newly designed self-expanding nitinol biliary stent(Y-stent, Taewoong Inc., Seoul, Korea) with wider-mesh in the central portion and smaller-mesh in both end portions to facilitate passage of the second stent during endoscopic bilateral stenting for the palliation of unresectable malignant hilar obstruction with Bismuth type II or higher. Y-stent being the first stent, was endoscopically placed in either the left or right hepatic duct whichever more difficult to access first, and then the second stent with conventional biliary stent was advanced over a guidewire from the inside of the Y-stent through the central wider-mesh portion into the contralateral hepatic duct, and released in a Y-shaped arrangement. Results: Endoscopic placement of the Y-stent was attempted in 12 consecutive patients, including 6 in Bismuth type II, 5 in type IIIa, and 1 in type IIIb. The technical success of bilateral biliary stenting was achieved in 83.3%(10/12) without immediate serious complications. Two stents were inserted in 7 patients including 5 in type II and 2 in type IIIa, whereas 3 stents were inserted in 3 patients including 2 in type IIIa and 1 in type IV. Successful drainage was achieved in all of the patients. Four patients were still living, after the mean follow-up period of 125.0 days, and the remaining 6 patients died with a mean survival time of 156.6 days. Recurrent obstructive jaundice was noted in 3 patients during the follow-up period. Conclusion: Endoscopic placement of bilateral metal stents with the new wider-mesh biliary stent and conventional biliary stent in a Y-shaped arrangement appears to be an easy, safe and effective procedure for palliative drainage of both liver lobes in malignant hilar obstruction. Background: Endoscopic bilateral stenting using dual conventional self-expanding metal stents in malignant hilar obstruction is technically difficult despite best efforts to do so, because the second stent isn’t as easily inserted once the first stent is deployed within the bile duct lumen. Methods: We prospectively studied the effectiveness of a newly designed self-expanding nitinol biliary stent(Y-stent, Taewoong Inc., Seoul, Korea) with wider-mesh in the central portion and smaller-mesh in both end portions to facilitate passage of the second stent during endoscopic bilateral stenting for the palliation of unresectable malignant hilar obstruction with Bismuth type II or higher. Y-stent being the first stent, was endoscopically placed in either the left or right hepatic duct whichever more difficult to access first, and then the second stent with conventional biliary stent was advanced over a guidewire from the inside of the Y-stent through the central wider-mesh portion into the contralateral hepatic duct, and released in a Y-shaped arrangement. Results: Endoscopic placement of the Y-stent was attempted in 12 consecutive patients, including 6 in Bismuth type II, 5 in type IIIa, and 1 in type IIIb. The technical success of bilateral biliary stenting was achieved in 83.3%(10/12) without immediate serious complications. Two stents were inserted in 7 patients including 5 in type II and 2 in type IIIa, whereas 3 stents were inserted in 3 patients including 2 in type IIIa and 1 in type IV. Successful drainage was achieved in all of the patients. Four patients were still living, after the mean follow-up period of 125.0 days, and the remaining 6 patients died with a mean survival time of 156.6 days. Recurrent obstructive jaundice was noted in 3 patients during the follow-up period. Conclusion: Endoscopic placement of bilateral metal stents with the new wider-mesh biliary stent and conventional biliary stent in a Y-shaped arrangement appears to be an easy, safe and effective procedure for palliative drainage of both liver lobes in malignant hilar obstruction.