Magnetic resonance cholangiopancreatography-guided unilateral endoscopic stent placement for Klatskin tumors

Background: Advanced and incurable Klatskin tumors of Bismuth-type III and IV cause obstructive jaundice. Palliation of patients with Klatskin tumors is usually carried out by bilateral endoscopic stent placement. Endoscopic retrograde cholangiography (ERC) in such patients is associated with a comp aratively high morbidity and mortality mainly due to postprocedure bacteria l cholangitis. To reduce ERC-related complications the outcome of replacing ERC with magnetic resonance cholangiopancreatography (MRCP) was investigat ed. Subsequently, unilateral contrast injection and stent placement were pe rformed, thus avoiding bilateral contrast injection and stent insertion. Methods: Patients thought to have a Klatskin tumor underwent clinical evalu ation, laboratory, and noninvasive imaging studies before ERC. Patients wer e enrolled in this feasibility study if investigators agreed with the clini cal diagnosis of an advanced and incurable Klatskin tumor. MRCP images were used to determine the predominate ductal drainage for the liver segments t hus directing stent placement. Based on these findings, unilateral ERC and subsequent unilateral stent placement were performed. Antibiotics were not given before ERC. Amsterdam-type stents (10F) were placed and replaced rout inely at 2 months. In cases of earlier occlusion, the stents were replaced immediately. Results: Thirty-five patients underwent MRCP, ERC, and unilateral stent dep loyment. Two further patients enrolled after MRCP were withdrawn because ER C could not be carried out. In 35 patients with unilateral stents bilirubin levels decreased (18.9 +/- 6.3 mg/dL to 3.2 +/- 2.3 mg/dL) and jaundice re solved in 86%. After first stent deployment, post-ERC bacterial cholangitis occurred in 6% (2 of 35) of patients. Conclusions: This new method of MRCP-guided endoscopic unilateral stent pla cement could reduce ERC-related complications caused by initial stent deplo yment. The results of this study justify a randomized prospective comparati ve trial.