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Percutaneous transhepatic placement of metallic stents in the treatment of complicated intrahepatic biliary stricture with hepatolithiasis: a preliminary report
THE AMERICAN JOURNAL OF GASTROENTEROLOGY © 1999 by Am. Coll. of Gastroenterology Published by Elsevier Science Inc.
Vol. 94, No. 12, 1999 ISSN 0002-9270/99/$20.00 PII S0002-9270(99)00674-7
Percutaneous Transhepatic Placement of Metallic Stents in the Treatment of Complicated Intrahepatic Biliary Stricture With Hepatolithiasis: A Preliminary Report Kuo-Shyang Jeng, M.D., F.A.C.S., I-Shyan Sheen, M.D., Fi-Sh Yang, M.D., Sho-Jen Cheng, M.D., and Ikuho Ohta, M.D. Departments of Surgery and Radiology, Mackay Memorial Hospital, China Medical College Liver Unit, Chang-Gung Memorial Hospital, and Chang-Gung Medical College, Taipei, Taiwan, Republic of China
OBJECTIVE: We aimed to study the effect of the metallic modified Gianturco-Rosch Z-stent in the management of refractory intrahepatic long-segment biliary strictures with hepatolithiasis. METHODS: Six symptomatic patients with hepatolithiasis and coexisting intrahepatic long-segment biliary strictures, who failed to respond to the silastic external-internal biliary stenting, were selected. The metallic modified GianturcoRosch Z-stent was placed via percutaneous transhepatic cholangiography at the strictured site. Patients were followed regularly to evaluate for recurrence of cholangitis, stones, or strictures. RESULTS: No complications were observed during the procedures. No recurrent strictures or formed calculi were found in these six patients during follow-up periods of 29 to 64 months. However, cholangitis and intrahepatic biliary muddy sludge occurred at 7 and 30 months in two patients after the placement of the metallic Z-stent. Percutaneous transhepatic cholangioscopy was used to clear sludge completely. CONCLUSIONS: Our experience suggests that the metallic stent is a well-tolerated and promising alternative in the management of refractory intrahepatic long-segment biliary strictures with hepatolithiasis. Though biliary sludge may develop, it can be detected and cleared early. Repeated surgery can thus be avoided. (Am J Gastroenterol 1999;94: 3507–3512. © 1999 by Am. Coll. of Gastroenterology)
INTRODUCTION Oriental cholangiohepatitis, characterized by soft, pigmented stones in the dilated intrahepatic or common bile duct, is very prevalent in Southeast Asia. Intrahepatic bile ductal stenosis, resulting from healing of transmural ductal inflammation, is frequently associated with intrahepatic biliary calculi. These often produce acute cholangitis, sepsis, liver abscess, or even secondary biliary cirrhosis. Surgery
and fiberoptic cholangioscopic lithotomy are the mainstay of management (1–16). However, intrahepatic biliary calculi coexisting with intrahepatic biliary strictures is a challenging therapeutic problem for surgeons because extraction of stones behind the strictured duct completely through choledochotomy by fiberoptic cholangioscopy usually fails. The strictured duct may include right or left main hepatic duct, and secondary or smaller intrahepatic ducts. Strictures limit the eradication of stones and increase stone recurrence. To clear the stones and prevent their recurrence, we need to treat not only the stones but also the biliary strictures. In general, when the strictures and stones are confined to the left lobe, a left lateral segmentectomy or left lobectomy can solve the problems of stones and strictures. For right-sided strictures, right lobectomy is not recommended for fear of hepatic failure. Patients with repeated cholangitis frequently develop atrophic changes in the liver in varying degree. The contralateral side of the liver (the part without calculi) does not always have compensatory hypertrophy. Sometimes repeated cholangitis and long-term stricture result in secondary biliary cirrhosis (6). All of these conditions pose a risk of liver decompensation when right lobectomy is performed. Intrahepatic balloon dilation therapy through a postoperative T-tube tract or a percutaneous transhepatic biliary drainage (PTBD) tract instead of resection is the preferred strategy (8, 12–16). Coexistence of cholangiocarcinoma with intrahepatic biliary calculi disease is a well-known risk. Careful evaluation of the cholangiogram, either endoscopic retrograde cholangiogram (ERC) or percutaneous transhepatic cholangiogram (PTC), before treatment, and direct vision of the intrahepatic bile duct by intraoperative and postoperative fiberoptic cholangioscopy may make correct diagnosis of coexistent cholangiocarcinoma in most instances. However, in some patients, it is very difficult to diagnose the coexisting cholangiocarcinoma even with the addition of biopsy or brushing cytology. Long-segment biliary strictures (⬎1.5 cm in length) and those with sharp ductal angulations are the most difficult to
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treat (8, 12–16). We have reported that the use of biliary stenting, using a silastic external-internal biliary stent catheter for at least 6 months after clearance of stones and dilation of the stricture, decreases the incidence of recurrent cholangitis and stones (13). However, even after 6 months’ stenting, the stricture in some patients does not improve. These patients then require redilation and restenting. Unfortunately, a patient’s compliance with repeated, long-term external-internal stenting is usually poor. In addition, the results may be disappointing and the disease may continue to progress. Expandable metallic stents have been accepted as a valuable mode of treatment for stenosis of the peripheral vascular system (17, 18). The development of the metallic stent has greatly expanded the treatment of various other kinds of strictures, such as gastrointestinal (GI), tracheobronchial, and urogenital strictures. The constant outward radial force exerted by the expandable metallic stent and the firm anchorage afforded by the filaments result in a large internal lumen and effectively prevent both stricture recurrence and stent migration. This device has been introduced to treat biliary strictures, both malignant (19 –21)and benign (22– 27). However, experience with metal mesh stenting for intrahepatic biliary strictures with hepatolithiasis is very limited (26, 27). Therefore, we evaluated the modified Gianturco-Rosch expandable metallic Z-stent as an internal stent in the treatment of hepatolithiasis with intrahepatic long-segment biliary strictures that were refractory to conventional treatment. In this preliminary report, we present our experiences and demonstrate the potential applications of the Z-stent in six symptomatic cases who had recurrent hepatolithiasis and complicated intrahepatic biliary strictures. They had received surgery, percutaneous dilation of the stricture, transhepatic percutaneous cholangioscopic lithotomy, and external-internal biliary stenting, but the biliary stricture failed to resolve.
CASE PRESENTATIONS Case 1 A 50-yr-old man who underwent a cholecystectomy 10 yr previously suffered from intermittent right upper quadrant abdominal pain for 2 months. Stones in the dilated common bile duct and right main hepatic ducts were found by abdominal ultrasonography. In addition, a long-segment stricture in the proximal right hepatic ducts was demonstrated by ERC. Twenty days after admission, laparotomy and a choledochotomy to remove stones from the common bile duct and right hepatic ducts were performed. Mild hepatomegaly with micronodular liver cirrhosis, severe adhesions, and fibrotic stenosis over the right hepatic duct were noted. Three days after operation, fever up to 38.0°C developed. A persistent stricture of the right main hepatic duct was noted and PTBD was initiated. Four sessions of balloon dilation of the stricture using a 10- to 16-Fr catheter were undertaken
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over the next 2 wk. Then a 16-Fr silastic tube (Create Medic, Yokohama, Japan) as an external-internal stent was inserted through the PTBD tract into the stenotic intrahepatic bile duct and the patient was discharged. Although the duct was stented for a total of 20 months, the dilation observed on follow-up cholangiography was still not satisfactory. Under fluoroscopic guidance, a Gianturco-Rosch expandable metallic Z-stent through the PTBD tract was carefully positioned in the stenotic duct. The patient was discharged without a drainage catheter. On outpatient follow-up, we evaluated him for clinical symptoms and signs of cholangitis and also checked the location of the stent by plain abdominal X-ray every 3 months. Follow-up abdominal ultrasonography was performed every 4 months to disclose any dilation of the intrahepatic ducts or stone recurrence. Liver biochemistry was checked once every 4 months. He has been regularly followed-up for 64 months and remains asymptomatic. Case 2 A 60-yr-old woman presented with intermittent severe right upper abdominal pain, fever, and chills for 2 months. Transabdominal ultrasound revealed stones in a dilated common bile duct and in the right intrahepatic ducts. An endoscopic retrograde cholangiopancreatography (ERCP) failed. Twenty days after admission, choledochotomy was performed to remove the biliary calculi. The patient refused resection of left lateral segment of the liver. Four sessions of fiberoptic choledochoscopy with stone removal at 3-day intervals were undertaken 2 wk postoperatively. A follow-up cholangiogram showed complete eradication of the stone and a persistent stenosis of the left main hepatic duct near the orifice of the bifurcation. Under fluoroscopic guidance, a 14-Fr catheter was placed within the stenotic lumen of the left hepatic bile duct through the T-tube tract. The catheter was upsized to 16-Fr 1 wk later. A long-segment stricture persisted despite 6 months’ conventional externalinternal stenting. Therefore, we placed a Z-stent, 0.8 cm in diameter and 3 cm in length, in the strictured bile duct (Fig. 1A). The plain film of abdomen confirmed the presence of the stent in approximately the desired position, and the exact position was subsequently confirmed by fiberoptic cholangioscopy (Fig. 1B). Case 3 A 35-yr-old man presented with the acute onset of intense right upper abdominal pain, a spiking fever, chills, and jaundice of 1 wk’s duration. Physical examination revealed an icteric, cachectic man with a blood pressure of 80/50 mm/Hg, pulse rate of 120/min, and a rigid, moderately tender right upper abdomen. Abdominal ultrasonography and ERC demonstrated multiple stones in the common bile duct and intrahepatic ducts bilaterally. During laparotomy, we found a perforation at the common hepatic duct and multiple stones with pus in the common bile duct. Severe adhesion and abscess at the left subhepatic area were also
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Figure 1. (A) Cholangiogram shows a Z-stent (black arrowheads) placed via the PTBD tract into the long-segment biliary stricture of the left main hepatic duct in a 60-yr-old woman. (B) Cholangioscopic evaluation of the location of the Z-stent. The wire skirts can be clearly seen at the stenotic site.
noted. The bile culture grew Klebsiella pneumoniae and E. coli. Cholecystectomy with extended intrahepatic choledocholithotomy was performed and a 16-Fr T-tube left in place. The stones were completely cleared after four sessions of postoperative fiberoptic cholangioscopy. Follow-up cholangiography showed a long-segment stricture at the right main hepatic duct. A silastic external-internal tube was placed in the long-segment stricture after balloon dilation via a PTBD tract. The stenting lasted for 17 months but the follow-up cholangiogram still showed unsatisfactory dilation of the stricture. We then placed a Gianturco-Rosch Z-stent percutaneously via the PTBD tract. He remained asymptomatic for 30 months after stenting, when cholangitis recurred. The patient was readmitted and underwent urgent PTBD. PTC and percutaneous transhepatic fiberoptic cholangioscopy (PTFC) disclosed soft sludge surrounding the wire skirts of the stent. The soft, muddy sludge was completely removed by a basket catheter during two sessions of PTFC. We removed the PTBD tube 2 months later, leaving the metallic stent in place. He was symptom free for a further 22 months (52 months after internal stent placement). We also placed Z-stents in the right intrahepatic ducts in three other female patients (aged 30, 54, and 57 yr old) with refractory stricture, for 48, 30, and 29 months, respectively (Fig. 2A, B, C). Sludge developed and was removed by PTFC at month 22 in the last patient.
DISCUSSION In the last 10 yr, we have managed more than 400 patients with hepatolithiasis. An intrahepatic biliary stricture may
not only limit the clearance of stones but also contribute to the recurrence of stones and cholangitis. To prevent progression of the stricture of the resultant recurrent cholangitis and biliary calculi, as well as secondary biliary cirrhosis and cholangiocarcinoma, aggressive treatment is mandatory. Treatment of intrahepatic ductal stricture is not easy. Some authors have suggested surgical repair or ductoplasty for strictured ducts. However, these procedures are technically difficult, carry a high morbidity, and often yield disappointing results. In our experience, one to several sessions of balloon dilation may improve the intrahepatic biliary stricture (12). For more difficult strictures, subsequent biliary stenting (13) is necessary. During stenting, patients suffer from long-term discomfort and complications, such as bile leaks, cholangitis, hemobilia, intrahepatic liver abscess, clogging, or migration of the stent. The stent has to be removed after a period (usually 6 months) and the stricture usually recurs. In one reported study (13), 21% of such strictures recurred within 4 yr. The use of metallic stents may solve the problems associated with these complicated strictures. The design of metallic stents has several advantages over that of conventional stents. Its skirts fix the ductal wall firmly and can remain in place indefinitely. The constant outward expanding force of the metallic mesh against the ductal wall maintains a large lumen and minimizes restricture in refractory strictures associated with hepatolithiasis. The low mass and small surface area of the metallic stents theoretically decreases the likelihood of bacterial adherence and other secondary depositions on its wall, thus reducing the risk of stent occlusion, cholangitis, and sepsis. Expandable metallic stents have been used with success
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Figure 2. (A) Severe stricture (white arrowhead) of right hepatic duct in a 30 yr-old woman. (B) Unsatisfactory result (black arrowheads) after external-internal stenting. (C) Plain abdominal radiogram demonstrated a Z-stent in her long-segment stricture.
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in malignant (19 –21) and benign biliary strictures (22–25). The majority are in the extrahepatic bile duct. Published reports of the intrahepatic use of this stent for hepatolithiasis and biliary stricture remain limited. Gunther et al. used this stent in one patient having a biliary stricture and hepatolithiasis, with good effect (26). Complications of metallic stents, such as pleurisy, peritonitis, hepatic artery aneurysm, intrahepatic artery bleeding, right subphrenic abscess, or sepsis, have been reported (18, 23, 24). No procedurerelated complications occurred in our patients and none was reported in two prior studies (26, 27). Patients welcome the absence of an external device. Stent placement in all six of our patients was satisfactory with no dislodgment, migration, occlusion, or duct restricturing over a median follow-up of 43 months. In the literature, occlusion of the stent lumen and nonremovability of the stents are the two main concerns for its use in benign disease. The long-term effect of metallic stents on the biliary wall is still unclear. The longest follow-up in our patients was only 64 months. We observed relatively mild reactive inflammatory changes in the wall of the bile ducts on fiberoptic cholangioscopy, as has been reported by Carrasco et al. (28), suggesting that those metal stents can be used safely. The long patency is an advantage of the metallic stent. Metallic stents may remain patent longer than polyethylene ones (21). A 10% clogging rate was reported when metal stents were used for benign strictures (22, 24). Furthermore, Yoon et al. reported a primary patency rate of 92% and 62% at 1 and 3 yr when metallic stents were used for intrahepatic duct strictures associated with hepatolithiasis (27). Epithelial hyperplasia around the stent and formation of sludge or stones were the causes of stent malfunction. Two of our six patients developed cholangitis associated with partial stent occlusion by sludge deposited on the wire skirts of the Z-stent. We cleared it completely and easily with normal saline irrigation and a basket catheter under direct vision with a fiberoptic cholangioscope inserted via the PTBD tract. Yoon et al. had the same experience. Though the primary patency rate of metallic stents in intrahepatic biliary stricture is not excellent, they can remain patent after percutaneous interventions. The sludge may be an immature or early form of recurrent stone. In our cases, sludge was not diagnosed on follow-up abdominal ultrasound examination. Only PTC performed after patients developed signs and symptoms of cholangitis detected this sludge. We diagnosed and cleared it early, before it developed into stones. Detection of sludge as early as possible is an important concern. It is almost impossible at surgery to clear biliary calculi behind a severely strictured duct unless segmental or lobar resection is performed. However, hepatic resection of the right lobe of the liver in benign diseases is not recommended. In addition, troublesome adhesions from previous operations and poor acceptance of repeated surgery by patients are problematic to surgeons. Therefore, we tried using metal stenting. Firm anchorage of the stent to the ductal
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wall, together with the epithelialization over the filament, makes removal of stents difficult except by resection. Because of concern regarding their permanence and tendency to occlude, we only placed metal stents when patients had already undergone multiple surgeries and had failed conventional (plastic) stenting. With regard to younger patients, more experience and observation will be needed to determine whether using metallic stents or conservative treatment will be more beneficial. From our preliminary experience, metallic stent placement seems to be an effective and well-tolerated treatment for complicated refractory hepatic ductal strictures with hepatolithiasis, avoiding repeated surgery. Careful patient selection, further investigation, and longer follow-up are needed. Reprint requests and correspondence: Kuo-Shyang Jeng, M.D., F.A.C.S., Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Chung-Shan North Road, Taipei, Taiwan, R.O.C. Received July 23, 1998; accepted Aug. 17, 1999.
REFERENCES 1. Lim JH. Oriental cholangiohepatitis: Pathological, clinical, and radiological features. Am J Roentgenol 1991;157:1– 8. 2. Sperlong RM, Koch J, Sandhu JS, et al. Recurrent pyogenic cholangitis in Asian immigrants to the United States: Natural history and role of therapeutic ERC. Dig Dis Sci 1997;42: 865–71. 3. Fan ST, Lai CS, Mok PT, et al. Acute cholangitis secondary to hepatolithiasis. Arch Surg 1991;126:1027–31. 4. Nakayama F, Soloway RD, Nakama T, et al. Hepatolithiasis in East Asia: A retrospective study. Dig Dis Sci 1986;31:21– 6. 5. Nakayama F. Intrahepatic calculi: A special problem in East Asia. World J Surg 1982;6:802– 4. 6. Jeng KS, Shih SC, Chiang HJ, et al. Secondary biliary cirrhosis. A limiting factor in the treatment of hepatolithiasis. Arch Surg 1989;124:1301–5. 7. Fan ST, Wong J. Complications of hepatolithiasis. J Gastroenterol Hepatol 1992;7:324 –7. 8. Jeng KS, Ohta I, Yang FS, et al. Coexisting sharp ductal angulation with intrahepatic biliary strictures in right hepatolithiasis. Arch Surg 1994;129:1097–103. 9. Mercadier M, Fingerhut A. Strictures of the intrahepatic bile duct. World J Surg 1984;8:15–21. 10. Fan ST, Choi TK, Lo CM, et al. Treatment of hepatolithiasis: Improvement of result by a systemic approach. Surgery 1991; 109:474 – 80. 11. Matsumoto Y, Fujii H, Yoshioka M, et al. Biliary strictures as a cause of primary intrahepatic bile duct stones. World J Surg 1986;10:867–75. 12. Jeng KS, Yang FS, Ohta I, et al. Dilation of intrahepatic biliary strictures in patients with hepatolithiasis. World J Surg 1990; 14:587–93. 13. Jeng KS, Yang FS, Chiang HJ, et al. Bile duct stents in the management of hepatolithiasis with long-segment intrahepatic biliary strictures. Br J Surg 1992;79:663– 6. 14. Jeng KS, Chiang HJ, Shih SC. Limitations of percutaneous transhepatic cholangioscopy in the removal of complicated biliary calculi. World J Surg 1989;13:603–10. 15. Jeng KS. Treatment of hepatolithiasis with intrahepatic biliary stricture. Hepato- gastroenterology 1997;44:342–51.
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16. Jeng KS, Ohta I, Yang FS. Reappraisal of the systematic management of complicated hepatolithiasis with bilateral intrahepatic biliary strictures. Arch Surg 1996;131:141–7. 17. Rosch J, Bedell JE, Putnam J, et al. Gianturco expandable wire stents in the treatment of superior vena cava syndrome recurring after maximum-tolerance radiation. Cancer 1987;60: 1234 – 46. 18. Charnsangavej C, Carrasco CH, Wallace S, et al. Stenosis of the vena cava:preliminary assessment of treatment with expandable metallic stents. Radiology 1986;161:295– 8. 19. Cremer M, Deviere J, Sugai B, et al. Expandable biliary metal stents for malignancies: Endoscopic insertion and diathermic cleaning for tumor ingrowth. Gastrointest Endosc 1990;36: 451–7. 20. Gordon RL, Ring EJ, LaBerge JM, et al. Malignant biliary obstruction: Treatment with expandable metallic stents—follow-up of 50 consecutive patients. Radiology 1992;182:697– 701. 21. Vitale GC, Larson GM, George M, et al. Management of malignant biliary stricture with self-expanding metallic stent. Surg Endosc 1996;10:970 –3. 22. Schmets L, Delhaye M, Azar C, et al. Postradiotherapy benign
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23. 24. 25. 26.
27.
28.
biliary stricture: Successful treatment by self-expandable metallic stent. Gastrointest Endosc 1996;43:149 –52. Smits ME, Rauws EAJ, van Gilik TM, et al. Long- term results of endoscopic stenting and surgical drainage for biliary stricture due to chronic pancreatitis. Br J Surg 1996;83:764 – 8. Deviere J, Cremer M, Baize M, et al. Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents. Gut 1994;35:122– 6. Maccioni F, Rossi M, Salvatori FM, et al. Metallic stents in benign biliary strictures: Three-year follow-up. Cardiovasc Intervent Radiol 1992;15:360 – 6. Gunther RW, Vorwerk D, Thon HJ, et al. Balloon dilation and insertion of a self- expandable flexible metallic stent in a benign stricture of the left hepatic duct: Case report. Cardiovasc Intervent Radiol 1989;12:69 –71. Yoon HK, Sung KB, Song HY, et al. Benign biliary strictures associated with recurrent pyogenic cholangitis: Treatment with expandable metallic stents. Am J Roentgenol 1997;169: 1523–7. Carrasco CH, Wallace S, Charnsangavej C, et al. Expandable biliary endoprosthesis: An experimental study. Am J Roentgenol 1985;145:1279 – 81.
Vol. 94, No. 12, 1999 ISSN 0002-9270/99/$20.00 PII S0002-9270(99)00674-7
Percutaneous Transhepatic Placement of Metallic Stents in the Treatment of Complicated Intrahepatic Biliary Stricture With Hepatolithiasis: A Preliminary Report Kuo-Shyang Jeng, M.D., F.A.C.S., I-Shyan Sheen, M.D., Fi-Sh Yang, M.D., Sho-Jen Cheng, M.D., and Ikuho Ohta, M.D. Departments of Surgery and Radiology, Mackay Memorial Hospital, China Medical College Liver Unit, Chang-Gung Memorial Hospital, and Chang-Gung Medical College, Taipei, Taiwan, Republic of China
OBJECTIVE: We aimed to study the effect of the metallic modified Gianturco-Rosch Z-stent in the management of refractory intrahepatic long-segment biliary strictures with hepatolithiasis. METHODS: Six symptomatic patients with hepatolithiasis and coexisting intrahepatic long-segment biliary strictures, who failed to respond to the silastic external-internal biliary stenting, were selected. The metallic modified GianturcoRosch Z-stent was placed via percutaneous transhepatic cholangiography at the strictured site. Patients were followed regularly to evaluate for recurrence of cholangitis, stones, or strictures. RESULTS: No complications were observed during the procedures. No recurrent strictures or formed calculi were found in these six patients during follow-up periods of 29 to 64 months. However, cholangitis and intrahepatic biliary muddy sludge occurred at 7 and 30 months in two patients after the placement of the metallic Z-stent. Percutaneous transhepatic cholangioscopy was used to clear sludge completely. CONCLUSIONS: Our experience suggests that the metallic stent is a well-tolerated and promising alternative in the management of refractory intrahepatic long-segment biliary strictures with hepatolithiasis. Though biliary sludge may develop, it can be detected and cleared early. Repeated surgery can thus be avoided. (Am J Gastroenterol 1999;94: 3507–3512. © 1999 by Am. Coll. of Gastroenterology)
INTRODUCTION Oriental cholangiohepatitis, characterized by soft, pigmented stones in the dilated intrahepatic or common bile duct, is very prevalent in Southeast Asia. Intrahepatic bile ductal stenosis, resulting from healing of transmural ductal inflammation, is frequently associated with intrahepatic biliary calculi. These often produce acute cholangitis, sepsis, liver abscess, or even secondary biliary cirrhosis. Surgery
and fiberoptic cholangioscopic lithotomy are the mainstay of management (1–16). However, intrahepatic biliary calculi coexisting with intrahepatic biliary strictures is a challenging therapeutic problem for surgeons because extraction of stones behind the strictured duct completely through choledochotomy by fiberoptic cholangioscopy usually fails. The strictured duct may include right or left main hepatic duct, and secondary or smaller intrahepatic ducts. Strictures limit the eradication of stones and increase stone recurrence. To clear the stones and prevent their recurrence, we need to treat not only the stones but also the biliary strictures. In general, when the strictures and stones are confined to the left lobe, a left lateral segmentectomy or left lobectomy can solve the problems of stones and strictures. For right-sided strictures, right lobectomy is not recommended for fear of hepatic failure. Patients with repeated cholangitis frequently develop atrophic changes in the liver in varying degree. The contralateral side of the liver (the part without calculi) does not always have compensatory hypertrophy. Sometimes repeated cholangitis and long-term stricture result in secondary biliary cirrhosis (6). All of these conditions pose a risk of liver decompensation when right lobectomy is performed. Intrahepatic balloon dilation therapy through a postoperative T-tube tract or a percutaneous transhepatic biliary drainage (PTBD) tract instead of resection is the preferred strategy (8, 12–16). Coexistence of cholangiocarcinoma with intrahepatic biliary calculi disease is a well-known risk. Careful evaluation of the cholangiogram, either endoscopic retrograde cholangiogram (ERC) or percutaneous transhepatic cholangiogram (PTC), before treatment, and direct vision of the intrahepatic bile duct by intraoperative and postoperative fiberoptic cholangioscopy may make correct diagnosis of coexistent cholangiocarcinoma in most instances. However, in some patients, it is very difficult to diagnose the coexisting cholangiocarcinoma even with the addition of biopsy or brushing cytology. Long-segment biliary strictures (⬎1.5 cm in length) and those with sharp ductal angulations are the most difficult to
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treat (8, 12–16). We have reported that the use of biliary stenting, using a silastic external-internal biliary stent catheter for at least 6 months after clearance of stones and dilation of the stricture, decreases the incidence of recurrent cholangitis and stones (13). However, even after 6 months’ stenting, the stricture in some patients does not improve. These patients then require redilation and restenting. Unfortunately, a patient’s compliance with repeated, long-term external-internal stenting is usually poor. In addition, the results may be disappointing and the disease may continue to progress. Expandable metallic stents have been accepted as a valuable mode of treatment for stenosis of the peripheral vascular system (17, 18). The development of the metallic stent has greatly expanded the treatment of various other kinds of strictures, such as gastrointestinal (GI), tracheobronchial, and urogenital strictures. The constant outward radial force exerted by the expandable metallic stent and the firm anchorage afforded by the filaments result in a large internal lumen and effectively prevent both stricture recurrence and stent migration. This device has been introduced to treat biliary strictures, both malignant (19 –21)and benign (22– 27). However, experience with metal mesh stenting for intrahepatic biliary strictures with hepatolithiasis is very limited (26, 27). Therefore, we evaluated the modified Gianturco-Rosch expandable metallic Z-stent as an internal stent in the treatment of hepatolithiasis with intrahepatic long-segment biliary strictures that were refractory to conventional treatment. In this preliminary report, we present our experiences and demonstrate the potential applications of the Z-stent in six symptomatic cases who had recurrent hepatolithiasis and complicated intrahepatic biliary strictures. They had received surgery, percutaneous dilation of the stricture, transhepatic percutaneous cholangioscopic lithotomy, and external-internal biliary stenting, but the biliary stricture failed to resolve.
CASE PRESENTATIONS Case 1 A 50-yr-old man who underwent a cholecystectomy 10 yr previously suffered from intermittent right upper quadrant abdominal pain for 2 months. Stones in the dilated common bile duct and right main hepatic ducts were found by abdominal ultrasonography. In addition, a long-segment stricture in the proximal right hepatic ducts was demonstrated by ERC. Twenty days after admission, laparotomy and a choledochotomy to remove stones from the common bile duct and right hepatic ducts were performed. Mild hepatomegaly with micronodular liver cirrhosis, severe adhesions, and fibrotic stenosis over the right hepatic duct were noted. Three days after operation, fever up to 38.0°C developed. A persistent stricture of the right main hepatic duct was noted and PTBD was initiated. Four sessions of balloon dilation of the stricture using a 10- to 16-Fr catheter were undertaken
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over the next 2 wk. Then a 16-Fr silastic tube (Create Medic, Yokohama, Japan) as an external-internal stent was inserted through the PTBD tract into the stenotic intrahepatic bile duct and the patient was discharged. Although the duct was stented for a total of 20 months, the dilation observed on follow-up cholangiography was still not satisfactory. Under fluoroscopic guidance, a Gianturco-Rosch expandable metallic Z-stent through the PTBD tract was carefully positioned in the stenotic duct. The patient was discharged without a drainage catheter. On outpatient follow-up, we evaluated him for clinical symptoms and signs of cholangitis and also checked the location of the stent by plain abdominal X-ray every 3 months. Follow-up abdominal ultrasonography was performed every 4 months to disclose any dilation of the intrahepatic ducts or stone recurrence. Liver biochemistry was checked once every 4 months. He has been regularly followed-up for 64 months and remains asymptomatic. Case 2 A 60-yr-old woman presented with intermittent severe right upper abdominal pain, fever, and chills for 2 months. Transabdominal ultrasound revealed stones in a dilated common bile duct and in the right intrahepatic ducts. An endoscopic retrograde cholangiopancreatography (ERCP) failed. Twenty days after admission, choledochotomy was performed to remove the biliary calculi. The patient refused resection of left lateral segment of the liver. Four sessions of fiberoptic choledochoscopy with stone removal at 3-day intervals were undertaken 2 wk postoperatively. A follow-up cholangiogram showed complete eradication of the stone and a persistent stenosis of the left main hepatic duct near the orifice of the bifurcation. Under fluoroscopic guidance, a 14-Fr catheter was placed within the stenotic lumen of the left hepatic bile duct through the T-tube tract. The catheter was upsized to 16-Fr 1 wk later. A long-segment stricture persisted despite 6 months’ conventional externalinternal stenting. Therefore, we placed a Z-stent, 0.8 cm in diameter and 3 cm in length, in the strictured bile duct (Fig. 1A). The plain film of abdomen confirmed the presence of the stent in approximately the desired position, and the exact position was subsequently confirmed by fiberoptic cholangioscopy (Fig. 1B). Case 3 A 35-yr-old man presented with the acute onset of intense right upper abdominal pain, a spiking fever, chills, and jaundice of 1 wk’s duration. Physical examination revealed an icteric, cachectic man with a blood pressure of 80/50 mm/Hg, pulse rate of 120/min, and a rigid, moderately tender right upper abdomen. Abdominal ultrasonography and ERC demonstrated multiple stones in the common bile duct and intrahepatic ducts bilaterally. During laparotomy, we found a perforation at the common hepatic duct and multiple stones with pus in the common bile duct. Severe adhesion and abscess at the left subhepatic area were also
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Figure 1. (A) Cholangiogram shows a Z-stent (black arrowheads) placed via the PTBD tract into the long-segment biliary stricture of the left main hepatic duct in a 60-yr-old woman. (B) Cholangioscopic evaluation of the location of the Z-stent. The wire skirts can be clearly seen at the stenotic site.
noted. The bile culture grew Klebsiella pneumoniae and E. coli. Cholecystectomy with extended intrahepatic choledocholithotomy was performed and a 16-Fr T-tube left in place. The stones were completely cleared after four sessions of postoperative fiberoptic cholangioscopy. Follow-up cholangiography showed a long-segment stricture at the right main hepatic duct. A silastic external-internal tube was placed in the long-segment stricture after balloon dilation via a PTBD tract. The stenting lasted for 17 months but the follow-up cholangiogram still showed unsatisfactory dilation of the stricture. We then placed a Gianturco-Rosch Z-stent percutaneously via the PTBD tract. He remained asymptomatic for 30 months after stenting, when cholangitis recurred. The patient was readmitted and underwent urgent PTBD. PTC and percutaneous transhepatic fiberoptic cholangioscopy (PTFC) disclosed soft sludge surrounding the wire skirts of the stent. The soft, muddy sludge was completely removed by a basket catheter during two sessions of PTFC. We removed the PTBD tube 2 months later, leaving the metallic stent in place. He was symptom free for a further 22 months (52 months after internal stent placement). We also placed Z-stents in the right intrahepatic ducts in three other female patients (aged 30, 54, and 57 yr old) with refractory stricture, for 48, 30, and 29 months, respectively (Fig. 2A, B, C). Sludge developed and was removed by PTFC at month 22 in the last patient.
DISCUSSION In the last 10 yr, we have managed more than 400 patients with hepatolithiasis. An intrahepatic biliary stricture may
not only limit the clearance of stones but also contribute to the recurrence of stones and cholangitis. To prevent progression of the stricture of the resultant recurrent cholangitis and biliary calculi, as well as secondary biliary cirrhosis and cholangiocarcinoma, aggressive treatment is mandatory. Treatment of intrahepatic ductal stricture is not easy. Some authors have suggested surgical repair or ductoplasty for strictured ducts. However, these procedures are technically difficult, carry a high morbidity, and often yield disappointing results. In our experience, one to several sessions of balloon dilation may improve the intrahepatic biliary stricture (12). For more difficult strictures, subsequent biliary stenting (13) is necessary. During stenting, patients suffer from long-term discomfort and complications, such as bile leaks, cholangitis, hemobilia, intrahepatic liver abscess, clogging, or migration of the stent. The stent has to be removed after a period (usually 6 months) and the stricture usually recurs. In one reported study (13), 21% of such strictures recurred within 4 yr. The use of metallic stents may solve the problems associated with these complicated strictures. The design of metallic stents has several advantages over that of conventional stents. Its skirts fix the ductal wall firmly and can remain in place indefinitely. The constant outward expanding force of the metallic mesh against the ductal wall maintains a large lumen and minimizes restricture in refractory strictures associated with hepatolithiasis. The low mass and small surface area of the metallic stents theoretically decreases the likelihood of bacterial adherence and other secondary depositions on its wall, thus reducing the risk of stent occlusion, cholangitis, and sepsis. Expandable metallic stents have been used with success
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Figure 2. (A) Severe stricture (white arrowhead) of right hepatic duct in a 30 yr-old woman. (B) Unsatisfactory result (black arrowheads) after external-internal stenting. (C) Plain abdominal radiogram demonstrated a Z-stent in her long-segment stricture.
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in malignant (19 –21) and benign biliary strictures (22–25). The majority are in the extrahepatic bile duct. Published reports of the intrahepatic use of this stent for hepatolithiasis and biliary stricture remain limited. Gunther et al. used this stent in one patient having a biliary stricture and hepatolithiasis, with good effect (26). Complications of metallic stents, such as pleurisy, peritonitis, hepatic artery aneurysm, intrahepatic artery bleeding, right subphrenic abscess, or sepsis, have been reported (18, 23, 24). No procedurerelated complications occurred in our patients and none was reported in two prior studies (26, 27). Patients welcome the absence of an external device. Stent placement in all six of our patients was satisfactory with no dislodgment, migration, occlusion, or duct restricturing over a median follow-up of 43 months. In the literature, occlusion of the stent lumen and nonremovability of the stents are the two main concerns for its use in benign disease. The long-term effect of metallic stents on the biliary wall is still unclear. The longest follow-up in our patients was only 64 months. We observed relatively mild reactive inflammatory changes in the wall of the bile ducts on fiberoptic cholangioscopy, as has been reported by Carrasco et al. (28), suggesting that those metal stents can be used safely. The long patency is an advantage of the metallic stent. Metallic stents may remain patent longer than polyethylene ones (21). A 10% clogging rate was reported when metal stents were used for benign strictures (22, 24). Furthermore, Yoon et al. reported a primary patency rate of 92% and 62% at 1 and 3 yr when metallic stents were used for intrahepatic duct strictures associated with hepatolithiasis (27). Epithelial hyperplasia around the stent and formation of sludge or stones were the causes of stent malfunction. Two of our six patients developed cholangitis associated with partial stent occlusion by sludge deposited on the wire skirts of the Z-stent. We cleared it completely and easily with normal saline irrigation and a basket catheter under direct vision with a fiberoptic cholangioscope inserted via the PTBD tract. Yoon et al. had the same experience. Though the primary patency rate of metallic stents in intrahepatic biliary stricture is not excellent, they can remain patent after percutaneous interventions. The sludge may be an immature or early form of recurrent stone. In our cases, sludge was not diagnosed on follow-up abdominal ultrasound examination. Only PTC performed after patients developed signs and symptoms of cholangitis detected this sludge. We diagnosed and cleared it early, before it developed into stones. Detection of sludge as early as possible is an important concern. It is almost impossible at surgery to clear biliary calculi behind a severely strictured duct unless segmental or lobar resection is performed. However, hepatic resection of the right lobe of the liver in benign diseases is not recommended. In addition, troublesome adhesions from previous operations and poor acceptance of repeated surgery by patients are problematic to surgeons. Therefore, we tried using metal stenting. Firm anchorage of the stent to the ductal
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wall, together with the epithelialization over the filament, makes removal of stents difficult except by resection. Because of concern regarding their permanence and tendency to occlude, we only placed metal stents when patients had already undergone multiple surgeries and had failed conventional (plastic) stenting. With regard to younger patients, more experience and observation will be needed to determine whether using metallic stents or conservative treatment will be more beneficial. From our preliminary experience, metallic stent placement seems to be an effective and well-tolerated treatment for complicated refractory hepatic ductal strictures with hepatolithiasis, avoiding repeated surgery. Careful patient selection, further investigation, and longer follow-up are needed. Reprint requests and correspondence: Kuo-Shyang Jeng, M.D., F.A.C.S., Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Chung-Shan North Road, Taipei, Taiwan, R.O.C. Received July 23, 1998; accepted Aug. 17, 1999.
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