Biliary Metallic Stent Placement

Background and indications

Percutaneous transhepatic metallic biliary stent placement is a palliative treatment for unresectable malignant biliary obstructions. The self-expanding metallic stent restores internal bile flow, eliminating the need for external drainage. Indications include: unresectable cholangiocarcinoma (Klatskin tumor, distal cholangiocarcinoma), biliary compression from pancreatic cancer, and lymph node metastases compressing bile ducts.

Pre-procedure assessment

Assessment includes pre-existing percutaneous biliary access (drain in place for ≥ 1-2 weeks), recent MRI/CT (obstruction mapping, stent length and positioning planning), hepatic panel, and tumor board confirmation of unresectable status.

Procedure

Under sedation, through existing percutaneous biliary access, cholangiography maps the stricture. A self-expanding metallic stent (8-10 mm diameter, covered or uncovered) is deployed across the stricture under fluoroscopic guidance. For hilar tumors (Bismuth III-IV), multiple stents may be placed in Y or T configuration. The external drain is usually maintained 24-48h then removed after stent patency verification. The procedure takes 30-60 minutes.

Results and scientific evidence

Technical success rate is 95-98%. Metallic stents offer 6-12 month median patency (vs 3-4 months for plastic stents). Bilirubin decreases by 50% within 3-5 days. Tumor restenosis (ingrowth or overgrowth) occurs in 20-30% of cases and can be treated with a second stent. Covered stents reduce ingrowth but increase migration risk and secondary duct obstruction.

Risks and complications

Cholangitis (5-10%), pancreatitis (2-3% if distal choledochal stent), hemorrhage (2-3%), stent migration (< 2%, mainly covered stents). 30-day mortality is 2-5%, related to underlying pathology.

Recovery

2-3 day hospitalization. Regular clinical and biological follow-up. If jaundice recurs, a new stent can be placed (stent-in-stent).

Practical information

The procedure is performed as an inpatient. It is performed by an interventional radiologist, in coordination with the gastroenterologist and oncologist.