Journal of Gastrointestinal Surgery

, Volume 15, Issue 3, pp 489–495

Radical Surgery in the Presence of Biliary Metallic Stents: Revising the Palliative Scenario

  • Dimitrios Lytras
  • Steven W. M. Olde Damink
  • Zahir Amin
  • Charles J. Imber
  • Massimo Malagó
Original Article



The application of endobiliary self-expandable metallic stents (SEMS) is considered the palliative treatment of choice in patients with biliary obstruction in the setting of inoperable malignancies. In the presence of SEMS, however, radical surgery is the only curative option when the resectability status is revised in case of malignancies or for overcoming complications arising from their application in benign conditions that masquerade as inoperable tumours. The aim of our study was to report our surgical experience with patients who underwent an operation due to revision of the initial palliative approach, whilst they had already been treated with biliary SEMS exceeding the hilar bifurcation.


Three patients with hilar cholangiocarcinoma that was considered inoperable and one patient with IgG4 autoimmune cholangio-pancreatopathy mimicking pancreatic cancer underwent radical resections in the presence of biliary SEMS.


After a detailed preoperative workup, two right trisectionectomies, one left extended hepatectomy and a radical extrahepatic biliary resection were performed. All cases demanded resection and reconstruction of the portal vein. R0 resection was achieved in all the malignant cases. Two patients required multiple biliodigestive anastomoses entailing three and seven bile ducts respectively. There was one perioperative death due to postoperative portal vein and hepatic artery thrombosis, whilst two patients developed grade III complications. At follow-up, one patient died at 13 months due to disease recurrence, whilst the remaining two are free of disease or symptoms at 21 and 12 months, respectively.


Revising the initial palliative approach and operating in the setting of biliary metallic stents is extremely demanding and carries significant mortality and morbidity. Radical resection is the only option for offering cure in such complex cases, and this should only be attempted in advanced hepatopancreaticobiliary centres with active involvement in liver transplantation.


Self-expanding metallic stents Cholangiocarcinoma Bile duct Hilar tumours Hepatic confluence 


  1. 1.
    Costamagna G, Pandolfi M.Endoscopic stenting for biliary and pancreatic malignancies. J Clin Gastroenterol 2004;38:59–67PubMedCrossRefGoogle Scholar
  2. 2.
    Perdue DG, Freeman ML, DiSario JA, Nelson DB, Fennerty MB, Lee JG, Overby CS, Ryan ME, Bochna GS, Snady HW, Moore JP.Plastic versus self-expanding metallic stents for malignant hilar biliary obstruction: a prospective multicenter observational cohort study. J Clin Gastroenterol 2008;42:1040–1046PubMedCrossRefGoogle Scholar
  3. 3.
    Siriwardana HP, Siriwardena AK.Systematic appraisal of the role of metallic endobiliary stents in the treatment of benign bile duct stricture. Ann Surg 2005;242:10–19PubMedCrossRefGoogle Scholar
  4. 4.
    Huibregtse K, Carr-Locke DL, Cremer M, Domschke W, Fockens P, Foerster E, Hagenmuller F, Hatfield AR, Lefebvre JF, Liquory CL, et al.Biliary stent occlusion--a problem solved with self-expanding metal stents? European Wallstent Study Group. Endoscopy 1992;24:391–394PubMedCrossRefGoogle Scholar
  5. 5.
    Gerhards MF, Vos P, van Gulik TM, Rauws EA, Bosma A, Gouma DJ.Incidence of benign lesions in patients resected for suspicious hilar obstruction. Br J Surg 2001;88:48–51PubMedCrossRefGoogle Scholar
  6. 6.
    Strasberg SM.Terminology of liver anatomy and liver resections: coming to grips with hepatic Babel. J Am Coll Surg 1997;184:413–434PubMedGoogle Scholar
  7. 7.
    Dindo D, Demartines N, Clavien PA.Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–213PubMedCrossRefGoogle Scholar
  8. 8.
    Vibert E, Farges O, Regimbeau JM, Belghiti J.Benign hilar biliary strictures stented with metallic stents can be resected by using an oncologic approach. Surgery 2005;137:506–510PubMedCrossRefGoogle Scholar
  9. 9.
    Cheng JL, Bruno MJ, Bergman JJ, Rauws EA, Tytgat GN, Huibregtse K.Endoscopic palliation of patients with biliary obstruction caused by nonresectable hilar cholangiocarcinoma: efficacy of self-expandable metallic Wallstents. Gastrointest Endosc 2002;56:33–39PubMedCrossRefGoogle Scholar
  10. 10.
    Ayaru L, Kurzawinski TR, Shankar A, Webster GJ, Hatfield AR, Pereira SP.Complications and diagnostic difficulties arising from biliary self-expanding metal stent insertion before definitive histological diagnosis. J Gastroenterol Hepatol 2008;23:315–320PubMedCrossRefGoogle Scholar
  11. 11.
    Mullen JT, Lee JH, Gomez HF, Ross WA, Fukami N, Wolff RA, Abdalla EK, Vauthey JN, Lee JE, Pisters PW, Evans DB.Pancreaticoduodenectomy after placement of endobiliary metal stents. J Gastrointest Surg 2005;9:1094–1104; discussion 1104–1105PubMedCrossRefGoogle Scholar
  12. 12.
    Seyama Y, Kubota K, Sano K, Noie T, Takayama T, Kosuge T, Makuuchi M.Long-term outcome of extended hemihepatectomy for hilar bile duct cancer with no mortality and high survival rate. Ann Surg 2003;238:73–83PubMedCrossRefGoogle Scholar
  13. 13.
    Belghiti J, Ogata S.Preoperative optimization of the liver for resection in patients with hilar cholangiocarcinoma. HPB (Oxford) 2005;7:252–253Google Scholar
  14. 14.
    Miyazaki M, Kato A, Ito H, Kimura F, Shimizu H, Ohtsuka M, Yoshidome H, Yoshitomi H, Furukawa K, Nozawa S.Combined vascular resection in operative resection for hilar cholangiocarcinoma: does it work or not? Surgery 2007;141:581–588PubMedCrossRefGoogle Scholar
  15. 15.
    Dimick JB, Cowan JA, Jr., Knol JA, Upchurch GR, Jr.Hepatic resection in the United States: indications, outcomes, and hospital procedural volumes from a nationally representative database. Arch Surg 2003;138:185–191PubMedCrossRefGoogle Scholar
  16. 16.
    Nathan H, Cameron JL, Choti MA, Schulick RD, Pawlik TM.The volume-outcomes effect in hepato-pancreato-biliary surgery: hospital versus surgeon contributions and specificity of the relationship. J Am Coll Surg 2009;208:528–538PubMedCrossRefGoogle Scholar
  17. 17.
    Joseph B, Morton JM, Hernandez-Boussard T, Rubinfeld I, Faraj C, Velanovich V.Relationship between hospital volume, system clinical resources, and mortality in pancreatic resection. J Am Coll Surg 2009;208:520–527PubMedCrossRefGoogle Scholar
  18. 18.
    Nguyen GC, Thuluvath NP, Segev DL, Thuluvath PJ.Volumes of liver transplant and partial hepatectomy procedures are independently associated with lower postoperative mortality following resection for hepatocellular carcinoma. Liver Transpl 2009;15:776–781PubMedCrossRefGoogle Scholar
  19. 19.
    Lee SG, Song GW, Hwang S, Ha TY, Moon DB, Jung DH, Kim KH, Ahn CS, Kim MH, Lee SK, Sung KB, Ko GY: Surgical treatment of hilar cholangiocarcinoma in the new era: the Asan experience. J Hepatobiliary Pancreat Surg 2010; 17:476–489CrossRefGoogle Scholar
  20. 20.
    Witzigmann H, Berr F, Ringel U, Caca K, Uhlmann D, Schoppmeyer K, Tannapfel A, Wittekind C, Mossner J, Hauss J, Wiedmann M.Surgical and palliative management and outcome in 184 patients with hilar cholangiocarcinoma: palliative photodynamic therapy plus stenting is comparable to r1/r2 resection. Ann Surg 2006;244:230–239PubMedCrossRefGoogle Scholar
  21. 21.
    Valle J, Wasan H, Palmer DH, Cunningham D, Anthoney A, Maraveyas A, Madhusudan S, Iveson T, Hughes S, Pereira SP, Roughton M, Bridgewater J: Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Engl J Med 2010; 362:1273–1281.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2011

Authors and Affiliations

  • Dimitrios Lytras
    • 1
  • Steven W. M. Olde Damink
    • 1
  • Zahir Amin
    • 2
  • Charles J. Imber
    • 1
  • Massimo Malagó
    • 1
  1. 1.Department of SurgeryUniversity College of London Hospitals NHS Foundation TrustLondonUK
  2. 2.Department of RadiologyUniversity College of London Hospitals NHS Foundation TrustLondonUK

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