Before attempting biliary drainage,
liver volume,
atrophied segments,
and ductal anatomy need to be assessed with noninvasive imaging.
Percutaneous multiple stent placement can be carried out via a single route,
often limited by anatomical factors or via different routes,
which may lead to additional morbidity.
Moreover,
excessive multi-stenting,
particularly in the atrophic area,
should be avoided to reduce the risk of cholangitis.
There are different techniques for multiple stent placement: the side-by-side,
stent-in-stent (T or Y configuration,
criss-cross) or side-to-end:
In the side-by-side technique,
the stents are placed in the common bile duct (CBD) in a parallel manner (Fig. 1 and Fig. 2 ).
This technique implies different percutaneous routes and,
in some cases,
this parallel placement may preclude the complete expansion of the stents.
The stent-in-stent technique consists in the insertion of the second stent through the mesh of the first one.
It permits the dilation of the stricture within a single stent caliber.
However,
passing a stent delivery system through the mesh of the first stent can be technically difficult.
- T configuration: The transverse stent connects both lobar ducts and the second stent is inserted through its mesh to the CBD.
(Figure 3)
- Y configuration: Each stent connects one lobar duct with the CBD.
(Figure 4)
- Criss-cross configuration: one stent connects one right segment duct with the left lobe duct,
and the second stent connects another segmental duct with the CBD,
crossing the first stent.
In the side-to-end technique,
the second stent is placed overlapping with the proximal edge of the first stent.
Major complications of biliary stenting include bleeding,
infection,
and stent obstruction.
Bleeding,
infection (such as cholangitis,
cholecystitis,
peritonitis,
and pleuritis) and pancreatitis are usually early complications related to the initial percutaneous biliary drainage.
Later complications include infections (cholangitis,
cholecystitis) and stent occlusion,
which may lead to a reintervention.
( Fig. 6 and Fig. 7 )
We make a retrospective review of the multiple SEMS placement carried out at a tertiary center from January of 2017 until September of 2018,
in a total of 17 patients with a technical success of 100%.
We found cholangiocarcinoma as the most frequent malignancy (76.5%),
followed by gallbladder cancer (11.7%) and metastases (11.7%).
The mean age at diagnosis was 70 years old.
The principal indication was obstructive jaundice (88.2%) and in 100% of patients the bilirubin levels descended in more than 50% at day 30 after the intervention.
Later infection (cholangitis and cholecystitis) was the most frequent complication (52.9 %),
followed by stent occlusion (0.17%).
Five patients (29.4%) presented early complications such as cholangitis (2/5),
pancreatitis (1/5),
mild bleeding (1/5) and portal vein thrombosis (1/5).
The mean survival rate was 4.8 months after the procedure.