1. Inje University Busan Paik Hospital, KOREA Malignant Hilar Obstructions Causes & Classification Cholangiocarcinoma GB carcinoma Metastases - stomach - pancreas - large bowel * HCC Lee H Y et al. Radiology 2006;239:113-121 Schematic drawing of Bismuth classification of biliary obstruction

2. Inje University Busan Paik Hospital, KOREA Majority of patients in advanced disease - Poor candidates for curative surgery Current Treatment Options in Gastroenterology 2000, 3:113 Malignant Hilar Obstructions Introduction: treatment protocol

3. Inje University Busan Paik Hospital, KOREA Principles of bile drainage - Drain as much of the functioning liver as possible - Choose less invasive method - Do not fill CM in the undrained ducts, but inevitable in many cases Malignant Hilar Obstructions Introduction: catheter drainage

4. Inje University Busan Paik Hospital, KOREA Advantage Good quality of life “ Life without jaundice and tube “ Disadvantage Reintervention for occlusion Stent patency: 6~12 Mo - The standards of practice committee of the SCVIR agreed on a 6-month median period of patency of palliative stents for malignant disease. Malignant Hilar Obstructions Palliation with stent

5. Inje University Busan Paik Hospital, KOREA Palliation in patients with malignant biliary hilar obstruction : complete or incomplete biliary drainage ? Stent placement in patients with malignant biliary hilar obstruction: unilobar drainage or bilobar drainage ? - Endoscopists: Unilobar drainage with a single stent - Interventional radiologists: Bilobar drainage with dual stents Complete drainage Multiple PTBDs : Higher risk of complication Incomplete drainage Undrained ducts: Higher risk of cholangitis Inadequate palliation Malignant Hilar obstructions Introduction: complete vs. incomplete palliation

6. Inje University Busan Paik Hospital, KOREA Causes of Hilar Obstruction Number of the Patients (N=267) Cholangiocarcinoma182 Gallbaldder Carcinoma52 Metastases32 *HCC1 Malignant Hilar obstructions Dual Stenting: Materials

7. Inje University Busan Paik Hospital, KOREA Bismuth ClassifictionNumber of the Patients (N=276) Type I5 Type II41 Type III125 Type IV96 Malignant Hilar obstructions Dual Stenting: Materials

8. Inje University Busan Paik Hospital, KOREA Causes of Hilar Obstruction Bismuth Classification Type IType IIType III Type IV Cholangiocarcinoma (N: 182) 22683 71 Gallbladder carcinoma (N: 52) 2727 16 Metastasis (N: 32) 1814 9 *HCC(N: 1)1 Malignant Hilar obstructions Dual Stenting: Materials

9. Inje University Busan Paik Hospital, KOREA One lobe stenting T-configured stenting Classic Y-configured stenting (Two parallel stents in EHD) Y-configured stenting (Stents through meshwork) Crisscross- configured stenting Malignant Hilar Obstructions Dual Stenting: multiple configurations

10. Inje University Busan Paik Hospital, KOREA Malignant Hilar Obstructions Dual Stenting: Original Kim-stent T-configured Crisscross-configured

11. Inje University Busan Paik Hospital, KOREA RPSD RASD LHD CHD RT LT CHD RT LT CHD Classic Y-configured T-configured Crisscross Malignant Hilar Obstructions Dual stenting Bilateral PTCUnilateral PTC Bilateral PTC RASD : Right Anterior Sectoral Duct RPSE : Right Posterior Sectoral Duct

12. Inje University Busan Paik Hospital, KOREA RT LT CHD Through bilateral tracks 1 st : RHD-to-CD 2 nd : LHD-to-CD - Simple steps - Easy to overcome acute hilar angle Disadvantages - Higher M&M - Overstretching of CD Malignant Hilar Obstructions Dual stenting : Classic Y- configured

13. Inje University Busan Paik Hospital, KOREA Classic Y-configured

14. Inje University Busan Paik Hospital, KOREA Through one track 1 st : RHD-to-LHD 2 nd : RHD-to-CD - Lower M&M - No overstretching of CD Disadvantages - Complex steps - Difficulty to overcome the acute hilar angle 57 pts from 2001-2002 - Mean patency duration ; 170.3 days RT LT CHD CW Kim, et al. 2004 JVIR 2004;15:713-717 Malignant Hilar Obstructions Dual stenting : T- configured

15. Inje University Busan Paik Hospital, KOREA

16. Drainage of most sectoral ducts Two PTBD Complex steps RT LT CHD Vol. distributionVol. distribution Total liver100 Right lobe65 ± 7 Left lobe33 ± 7 Abdalla et al. Surgery 2004 Undrained ducts ! RPSD RASD LHD CHD Malignant Hilar Obstructions Dual stenting : Crisscross RASD : Right Anterior Sectoral Duct RPSE : Right Posterior Sectoral Duct LHD : Left Hepatic Duct CHD : Common Hepatic Duct

17. Inje University Busan Paik Hospital, KOREA RASD RPSD RASD RPSD [Type 1] T: RASD-to-LHD V: RPSD-to-CHD [Type 2] T: RPSD-to-LHD V: RASD-to-CHD Malignant Hilar Obstructions Dual stenting : Crisscross RASD : Right Anterior Sectoral Duct RPSE : Right Posterior Sectoral Duct LHD : Left Hepatic Duct CHD : Common Hepatic Duct

18. Inje University Busan Paik Hospital, KOREA M/77 Cholangiocarcinoma Duration of primary patency: 11 months

19. Inje University Busan Paik Hospital, KOREA 73/M Cholangiocarcinoma Duration of primary patency: 6 months

20. Inje University Busan Paik Hospital, KOREA Median : 199 days Kaplan-Meier analysis (95% CI, 81-317) days Stent Patency (crisscross) Inje University Busan Paik Hospital, KOREA Cholangiocarcinoma (n=16) GB cancer (n=9) Pancreatic cancer (n=1) Bismuth type IIIa (n=23) Bismuth type IV (n=3) JI Bae, et al. 2004 RSNA Scientific Presentation During 33 months (Jan. 2002 ~ Sep. 2004) ; Mean follow-up period - 184 days (7 ~ 468 days) 26 patients ( M:F = 19:7, mean age= 66 ) Advanced hilar invasion Malignant Hilar Obstructions Result of Crisscross stenting

21. Inje University Busan Paik Hospital, KOREA Malignant Hilar Obstructions Dual stenting : Modified Y-stenting (Unilolar Y)

22. Inje University Busan Paik Hospital, KOREA Malignant Hilar Obstructions Drawback of Classic Y-configured dual stents - overexpansion of the common bile duct

23. Inje University Busan Paik Hospital, KOREA Malignant Hilar Obstructions Drawback of T-configured dual stents - weak expansile power & vulnerable to tumor ingrowth at large central meshes

24. Inje University Busan Paik Hospital, KOREA Stent expansion % = B/A x100% Results Technical success: - Stent placement: 100% - Stent expansion: 74 ± 13% (51-92) Complications: - Transient fever & cholangitis : 6/17 (35%) Malignant Hilar Obstructions Dual stenting : Open cell type stents A B GY Ko, et al. 2007 Society of Korean Interventional Radiology Scientific Presentation

25. Inje University Busan Paik Hospital, KOREA M/74, Inoperable Klatskin tumor Zilver stent, 10mm x 2 ea 6mo F/U GY Ko, et al. 2007 Society of Korean Interventional Radiology Scientific Presentation

26. Inje University Busan Paik Hospital, KOREA SWS LWS Malignant Hilar Obstructions Dual stenting : Bonastent K-Hilar

27. Inje University Busan Paik Hospital, KOREA Bismuth Classification Primary Patency, days (mean±SD) Survival time, Days (mean±SD) Type I(n:5)182.0256.0 Type II(n:41)189.31246.17 Type III(n:125)216.13279.28 Type IV(n:96)185.78217.50 Malignant Hilar Obstructions Dual Stenting: Clinical Result

28. Inje University Busan Paik Hospital, KOREA Tumor TypesPrimary Patency, days (mean±SD) Survival time, days (mean±SD) Cholangiocarcinoma (n:182) 242.54296.96 Gallbladder Carcinoma(n: 52) 100.98153.30 Metastases(n:32)103.40134.65 HCC(n:1)820.0836.0 Malignant Hilar Obstructions Dual Stenting: Clinical Result

29. Inje University Busan Paik Hospital, KOREA Intracavitary Radiation Therapy(ICRT) Primary Patency, days (mean±SD) Survival time, days (mean±SD) Without ICRT(N: 230) 195.53246.88 With ICRT (N: 37) 231.13280.56 Malignant Hilar Obstructions Dual Stenting: Clinical Result

30. Inje University Busan Paik Hospital, KOREA Configurations of Stents Primary Patency, days (mean±SD) Survival time, days (mean±SD) Y(n:44)167.15194.29 T(n:117)239.56296.12 Crisscross(n:75)176.04215.08 Y-Modified(n:14)187.85243.64 *Complex (n:17)135.70260.35 Malignant Hilar Obstructions Dual Stenting: Clinical Result *Complex : more than 3 stents

31. Inje University Busan Paik Hospital, KOREA Configurations of Stents Reduction of TB after procedure(mg/dL) Y(n:44)1.27 T(n:117)2.67 Crisscross(n:75)1.88 Y-Modified (n:14)1.20 *Complex (n:17)1.84 Malignant Hilar Obstructions Dual Stenting: Clinical Result *Complex : more than 3 stents

32. Inje University Busan Paik Hospital, KOREA Statiscal analysis was performed with use of the Statistical Package f or Social Sciences (version13.0; SPSS, Chicago, IL). Primary stent patency and patient survival were analyzed for Bismuth classification, tumor type, stent configuration, stent combination and ICRT with use of the ANOVA test and Kruscal- Wallis test. Bonferroni correction was used for multiple comparisions. The level of statistical significance was set at p ≤ 0.05. Statistically significant differences were not observed in the stent patency or the survival in relation to dual-stenting configuration, Bismuth classification, combination of stents, intracavitary radiotherapy, except for tumor type. Malignant Hilar Obstructions Dual Stenting: Clinical Result

33. Inje University Busan Paik Hospital, KOREA 1.Multidisplinary approach : Surgeon / Endoscopist / Radiologist / Oncologist 2. Role of percutaneous radiological intervention : Thorough evaluation & planning  Effective palliation !!! Malignant Hilar Obstructions Catheter vs. Stent Plastic vs. Metallic Single vs. Dual stenting vs. Complex Y-configured Y-modified T-configured Crisscross