Biliary Stenting - Bile Duct Stent Placement

Bile that cannot drain turns the skin yellow within days and poisons the blood within weeks. A stent the width of a drinking straw reopens the duct in under an hour.

The tube goes in through an endoscope passed by the mouth, with no incision, and the jaundice, the itching and the dark urine begin to clear within days. Which tube, by which route and whether to place one at all before an operation have each been settled by randomized trials, and the answers surprise many patients. Across 20 trials and 1,713 patients, metal stents stayed open four and a half months longer than plastic ones. Send us your scan reports and blood tests, and a gastroenterologist will tell you which stent and which route fit your case.

Which route reaches the duct?

1. Endoscopic, by ERCP. An endoscope passed by the mouth to the duodenum, where the bile duct opens. A wire is threaded up the duct, the opening is sometimes cut a little wider, and the stent is pushed over the wire across the blockage. No incision, sedation, home the same day in most cases. The first choice for blockages in the lower duct.
2. Percutaneous, through the skin. A needle through the right side of the chest wall into a bile duct inside the liver, under ultrasound and X-ray, then a wire and a stent. Used when the endoscope cannot reach the duct opening, after some operations, and for blockages high in the liver. Some patients keep a drain through the skin for a few days. In a meta-analysis of nine studies of hilar tumors, the percutaneous route succeeded in draining the liver two and a half times more often than the endoscopic one, with the same complication rate.
3. Endoscopic ultrasound-guided. When ERCP fails, an ultrasound endoscope in the stomach or duodenum finds the dilated duct through the wall and a stent is placed directly between the two. A newer route, used in units with the expertise, that avoids an external drain.

Plastic or metal, covered or bare?

What the trials show

Two large meta-analyses settled the plastic-or-metal question for cancer that cannot be removed. One pooled 20 randomized trials with 1,713 patients and found metal stents stayed open 4.45 months longer, with fewer late complications, half the rate of sepsis or cholangitis, a tenth of the rate of blockage by sludge and fewer repeat procedures. Overall survival did not differ. The other pooled 19 studies with 1,989 patients and found cholangitis in 8 percent of patients with metal stents against 21 percent with plastic, and treatment failure in 7 against 13 percent.

Hilar tumors got their own answer.

That second review looked at them, where the duct splits into left and right, and found that stenting both sides gave no fewer blockages than stenting one. The European guideline that followed recommends a metal stent for palliative drainage of a blocked lower duct, a bare metal stent for hilar tumors, and, when the cause of the blockage has not been confirmed, no bare metal stent at all, since a permanent stent placed for what turns out to be a benign narrowing is a mistake that cannot be undone.

Before an operation, or instead of one?

How do I prepare, and what does the day involve?

Fasting is the only preparation you do yourself, and the team does the rest.

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The procedure

For an endoscopic stent you lie on your front or your left side, asleep under sedation. The endoscope passes to the duodenum, and the physician finds the small opening where the bile duct and pancreatic duct empty. A fine catheter is passed into the bile duct and contrast is injected under X-ray to show the blockage, its length and its position. A guidewire is advanced through it, a cut is made at the opening if the stent is large, a balloon stretches the blockage where it is tight, and the stent is pushed over the wire until it bridges the narrowing with a margin at each end. Bile flows at once. The physician sees it. The X-ray images show the stent in position, and you wake in recovery an hour later with a sore throat and a little bloating. Percutaneous placement follows the same logic from the other direction, through a needle in the side of the chest, and ends with a small drain through the skin that is capped once the stent is seen to work and removed a few days later.

The risks

• Pancreatitis after ERCP. Inflammation of the pancreas from handling its duct opening, in a few percent of patients, with pain and a night or more in hospital. A suppository given at the end of the procedure and a temporary pancreatic stent in high-risk patients lower the rate.
• Cholangitis. Infection when drainage is incomplete, above all in hilar tumors where a duct that received contrast was not drained. Antibiotics and a further drainage procedure.
• Bleeding. From the cut at the duct opening, more with blood thinners, and controlled through the endoscope in nearly every case.
• Perforation. Rare, from the wire or the cut, treated with antibiotics and sometimes surgery.
• Stent problems later. Blockage by sludge or tumor growth, and migration of a covered stent. Both mean a repeat procedure to exchange or clear it, and return of jaundice or fever is the sign.
• Percutaneous route. Bleeding into the liver or the bile, bile leak into the abdomen, and pain at the entry site through the chest wall.

Cholangitis occurred in 8 percent of patients with metal stents and 21 percent with plastic stents, and metal stents needed fewer reinterventions.

Meta-analysis of 19 studies, Gastrointestinal Endoscopy, 2015

1. Fever or shaking chills at any time after the stent, which means infection or blockage and needs a hospital the same day.
2. Return of yellow eyes, dark urine or pale stools weeks or months later, which means the stent has blocked or moved.
3. Severe abdominal pain in the first day, which points to pancreatitis or perforation.
4. Black stools or vomiting blood.
5. Breathlessness or chest pain after a percutaneous procedure.

ESGE recommends against routine preoperative biliary drainage in patients with malignant extrahepatic biliary obstruction.

European Society of Gastrointestinal Endoscopy guideline, Endoscopy, 2018

Three nights for an endoscopic stent. The consultation, the blood tests and any imaging fall on the first day, the procedure on the second, and a check of the bilirubin and a review on the third, after which you can fly. A percutaneous stent needs five to six nights, because the external drain is capped and removed over the following days and a chest X-ray is taken before the flight. Pancreatitis or cholangitis, when they occur, add a few nights.

Many patients arrive with a diagnosis still open.

In many patients a blocked duct is the first sign of a cancer nobody has named, and the stent is placed during the same visit in which the tumor is staged and sampled, by CT, by endoscopic ultrasound with a needle, or by brushings taken from the duct itself during the ERCP. That visit takes a week to ten days, and it ends with a tumor board and a plan, which for some patients means an operation here, for some chemotherapy at home around a stent that will last, and for a few the news that the narrowing was benign and the stents will come out in a year.

The stent sets the price.

It matters more than the procedure does. A metal stent costs several times a plastic one, and a covered metal stent costs more again, so a quote should name the stent. An anesthesiologist for deep sedation, a sphincterotomy, a balloon to stretch the narrowing, a temporary pancreatic stent, brushings for cytology and any biopsy through the scope are each charged. The percutaneous route adds the interventional radiology suite, the drain and one to two nights, and imaging before the procedure and the blood tests afterward sit on their own lines. A later exchange costs what the first did. The patient's own condition moves the total, since cholangitis means antibiotics and admission, and a very high bilirubin means a night of observation.

Packages published by hospitals in Istanbul for ERCP quote a base procedure and add sphincterotomy and stent placement as separate items, with the stent itself sometimes doubling the figure, and they include one to two nights and transfers. Ask which stent the figure includes.

Your own figure follows the free review of your scans and blood tests.

One coordinator from the international patients team is assigned from your first message and stays with you until you fly. The team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and arranges interpreting in other languages on request. An interpreter attends the consultation, consent and the results conversation. An invitation letter naming the hospital and the treating physician goes out ten days before travel, faster for a jaundiced patient on request. The international patients office arranges the airport transfer, the hotel for you and a companion, and the rides to the hospital, and a companion is needed on the day of the procedure. Rooms for patients admitted overnight have a companion bed. Halal, vegetarian and diabetic meals come from the hospital kitchen, and a low-fat diet is prepared for the days after drainage. A prayer room is on site, and a request for a female doctor is passed to the department and met wherever the rota allows. Gastroenterology, interventional radiology, surgery and oncology share one site, so the stent, the biopsy, the tumor board and the operation, where there is one, happen without a change of hospital.

Three facts travel with you.

Back home, the coordinator stays reachable on the same WhatsApp number. Your discharge letter names the stent, its size and the date it was placed, and any doctor who treats you later will need them, because a plastic stent must be exchanged within three to four months and a metal one must be recognized on any future scan or operation. Fever or a return of jaundice means a local hospital the same day, with that letter in your hand.

Biliary stenting FAQ