PERCUTANEOUS MANAGEMENT OF HILAR BILIARY MALIGNANCIES WITH METALLIC ENDOPROSTHESES - RESULTS, TECHNICAL PROBLEMS, AND CAUSES OF FAILURE

Malignant obstruction at the biliary hilum is a challenging problem fo r percutaneous management because of the anatomy of the biliary hilum, which facilitates spread of tumor into multiple biliary radicles. Met allic self-expanding stents were used in 22 patients with hilar malign ancies. Sixteen patients had focal common hepatic duct strictures, and six had multisegmental disease. Stents were placed in the biliary sys tem with a single transhepatic approach in 16 patients with common hep atic duct strictures; stent placement in the right and left biliary du cts was performed with a bilateral transhepatic approach in five patie nts and with a single transhepatic approach in one patient. Metal sten t occlusion occurred in six patients (27%) at a mean of 2.5 months aft er initial insertion. Stent occlusion was due to inspissated debris in two of these patients and to tumor overgrowth in four. The key to suc cessful long-term treatment is to ''overstent'' to ensure adequate pur chase above hilar tumors and insertion in a balanced position. Thus, t he prevalence of tumor overgrowth is decreased.