Overcoming tight perihilar malignant biliary obstructions during percutaneous biliary intervention in Nigerian patients: case reports

Abstract

Background
A major challenge of either endoscopic or percutaneous approach to placing palliative biliary stents is the difficulty in traversing tight perihilar malignant obstructions. This can be overcome with a rendezvous approach (combined endoscopic retrograde cholangiopancreatography (ERCP)/percutaneous approach) or may require initial placement of an external drain and reattempting later. Interventional radiology for biliary obstruction is still in infant days in our locality. Herein, we describe two cases of perihilar malignant biliary obstruction (MBO) managed at a private facility in Lagos, Nigeria, in which we had to come up with a creative approach to crossing these tight junctions in the absence of ERCP facilities. This was done by securing percutaneous retrograde access into the common bile duct and combining it with the initially unsuccessful anterograde approach. In both cases, this combined percutaneous anterograde/retrograde approach resulted in successful traversal of the malignant obstruction and placement of internal biliary stents.

Case presentation
We present the case of two elderly patients with tight malignant biliary obstruction (MBO), one from a suspected cholangiocarcinoma and the other from hepatic metastatic colorectal carcinoma. Both patients had successful traversal of the obstruction via a combined percutaneous anterograde/retrograde approach and biliary stenting.

Conclusions
Our case reports demonstrate an unusual approach that should assist interventional radiologists in resource-limited setting who seek for a viable option to those presently available for traversing perihilar MBOs in the percutaneous placement of internal stents.

Full text

Ninalowoetal. Egypt J Radiol Nucl Med (2024) 55:81
https://doi.org/10.1186/s43055-024-01253-8
CASE REPORT
Overcoming tight perihilar malignant biliary
obstructions duringpercutaneous biliary
intervention inNigerian patients: case reports
Hammed A. Ninalowo1, Peter T. Adenigba1* and Aderemi O. Oluyemi2
Abstract
Background A major challenge of either endoscopic or percutaneous approach to placing palliative biliary stents
is the difficulty in traversing tight perihilar malignant obstructions. This can be overcome with a rendezvous approach
(combined endoscopic retrograde cholangiopancreatography (ERCP)/percutaneous approach) or may require initial
placement of an external drain and reattempting later. Interventional radiology for biliary obstruction is still in infant
days in our locality. Herein, we describe two cases of perihilar malignant biliary obstruction (MBO) managed at a pri-
vate facility in Lagos, Nigeria, in which we had to come up with a creative approach to crossing these tight junctions
in the absence of ERCP facilities. This was done by securing percutaneous retrograde access into the common bile
duct and combining it with the initially unsuccessful anterograde approach. In both cases, this combined percutane-
ous anterograde/retrograde approach resulted in successful traversal of the malignant obstruction and placement
of internal biliary stents.
Case presentation We present the case of two elderly patients with tight malignant biliary obstruction (MBO), one
from a suspected cholangiocarcinoma and the other from hepatic metastatic colorectal carcinoma. Both patients had
successful traversal of the obstruction via a combined percutaneous anterograde/retrograde approach and biliary
stenting.
Conclusions Our case reports demonstrate an unusual approach that should assist interventional radiologists
in resource-limited setting who seek for a viable option to those presently available for traversing perihilar MBOs
in the percutaneous placement of internal stents.
Keywords Malignant biliary obstruction, Percutaneous biliary stents, ERCP, Case report, Nigeria
Background
Malignant biliary obstruction (MBO) most commonly
results from pancreatic adenocarcinoma and cholan-
giocarcinoma (CCAs) [1]. According to their anatomical
location, CCAs are classified as intrahepatic, perihilar
and distal CCA [2]. As less than a third of patients present
with surgically resectable tumors, palliative stenting
remains the most viable management option for many
cases [3, 4]. Endoscopic intervention via endoscopic ret-
rograde cholangiopancreatography (ERCP) is said to be
the mainstay for palliation of these MBO patients. How-
ever, a percutaneous approach is preferred in individuals
with advanced perihilar MBO because of superior tech-
nical success rates for biliary drainage, and comparable
adverse events and 30-day mortality rates with ERCP [5].
A major challenge of either endoscopic or percutane-
ous approach is the difficulty in traversing tight perihi-
lar obstructions caused by perihilar MBOs. is can be
overcome with a rendezvous approach (combined ERCP/
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Egyptian Journal of Radiology
and Nuclear Medicine
*Correspondence:
Peter T. Adenigba
adenigbataiwo@gmail.com
1 IRDOC Interventional Radiology Consulting Limited, Euracare
Multispecialty Hospital, Victoria Island, Lagos State, Nigeria
2 ReMay Consultancy and Medical Services, Ikeja, Lagos State, Nigeria

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Ninalowoetal. Egypt J Radiol Nucl Med (2024) 55:81
percutaneous approach) or may require initial placement
of an external drain and reattempt at a later date (usually
after 1 week or later) [6, 7]. Only recently have the exper-
tise and technical support for regular performance of
both endoscopic and percutaneous biliary interventions
become available in Nigeria [8–10].
Attempts at carrying out percutaneous interventions
for perihilar MBOs in our locality have been met with
similar obstacles as described above. In this report, we
describe two such cases managed at a private facility in
Lagos, Nigeria, in which a born-of-necessity percutane-
ous retrograde access into the common bile duct (CBD)
was used to cross tight perihilar MBOs caused by CCA
and metastatic colorectal carcinoma, in combination
with the conventional anterograde approach (born-
of-necessity as there was no capacity for ERCP within
reach). In both cases, this combined percutaneous anter-
ograde/retrograde approach resulted in successful tra-
versal of the obstruction and placement of internal biliary
stents.
Case presentation
Case 1
A 65-year-old man with no significant past medi-
cal history presented with jaundice of approximately
2-month duration with associated abdominal disten-
tion and weight loss. He was worked up with contrast-
enhanced abdominal computed tomography (CT) scan
which showed evidence of obstruction of the biliary
ducts just below the level of the hilum with concern for
CCA. Large-volume ascites were also detected. Notably,
ERCP is certainly preferred to percutaneous approach in
patients with ascites; however, it was not readily available.
After informed consent was obtained, he was pre-
pared for and had abdominal paracentesis with drain-
age of approximately 5 L of bilious appearing ascites
following the placement of 8-Fr drain (Cook Medical,
Bloomington, USA). Next, local anesthesia was given,
and under real-time ultrasound guidance, a 21-G
AccuStick™ needle (Boston Scientific Corp, Massa-
chusetts, USA) was advanced toward a peripheral bile
duct in the left hepatic lobe. Contrast was gently hand-
injected to opacify the dilated left-sided biliary ducts.
Following the advancement of an 0.018-inch Nitrex™
guidewire (Medtronic, Heerlen, The Netherlands), an
AccuStick™ set was advanced. An 0.035-inch Amplatz
Super Stiff™ wire (Boston Scientific Corp) was then
advanced into the central biliary duct. The AccuS-
tick™ set was exchanged for a 6-Fr sheath (Terumo,
Elkton, USA). Despite multiple attempts, the obstruc-
tion in the perihilar region could not be crossed from
the anterograde approach. Typically, in such cases,
our protocol is to place an external drain and return 2
weeks later to reattempt traversal of the obstruction;
however, the presence of ascites would have presented
certain challenges with pericatheter drainage around
an external drain (which is a well-known problem of
biliary drainage in the presence of peritoneal fluid).
At this time, careful real-time ultrasound of the right
upper quadrant was performed and the distal CBD was
identified. A 22-G needle (Cook Medical) was used to
access the distal CBD from a percutaneous approach,
and contrast was injected (Fig. 1). Following confirma-
tion of the needle location, an 0.018-inch Nitrex™ wire
was advanced from the retrograde approach and used
to cross the obstruction and subsequently gain access
into the intrahepatic biliary tree. Following successful
advancement of this wire, a snare system (Merit Medical)
was placed through the 6-Fr sheath from the anterograde
approach and the 0.018-inch wire was successfully cap-
tured (Fig.2) creating through and through access. e
0.018-inch wire was clamped outside of the body, and a
4-Fr Kumpe catheter (Cook Medical) was advanced over
the captured wire and through the region of obstruction.
A tandem 0.018-inch wire was then advanced alongside
into the duodenum (Fig.3). e stiff 0.035-inch wire was
advanced (Fig.4), brush biopsy sample was obtained, and
subsequently, an 8 mm × 40 mm Protégé self-expanding
biliary stent (Medtronic, Plymouth, USA) was deployed
across the obstruction. Due to unsatisfactory flow, a
second 8 mm × 27 mm express balloon-expandable bil-
iary stent (Boston Scientific Corp) was deployed in the
Fig. 1 Intra-procedure fluoroscopic images showing anterograde
cholangiogram with pigtail catheter (yellow arrow) in the central
biliary tree from a left hepatic approach (green arrow). A 22-G needle
(blue arrow) was used to target the distal common bile duct (red
arrow), with opacification and contrast egress into the duodenum
(purple arrow)

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Ninalowoetal. Egypt J Radiol Nucl Med (2024) 55:81
proximal portion. Contrast was injected to confirm posi-
tion, and this time, the flow was as expected (Fig. 5).
Gelfoam® (Pfizer Inc.) was injected through the tract to
achieve hemostasis, and the anterograde tract and sheath
were removed.
e 8-Fr ascites drain was left in overnight and
removed the next day. Follow-up at 2 weeks and 3 months
Fig. 2 Fluoroscopic image showing 22-G needle in the common
bile duct (Blue arrow), 0.018-inch wire (yellow arrow) inserted
through 22-G needle and advanced through the obstruction.
0.018-inch wire captured by a snare (green arrow)
from the anterograde approach, and opacified distal common bile
duct (red arrow)
Fig. 3 Fluoroscopic image showing a clamp (yellow arrow)
holding a retrogradely inserted wire outside the skin. A 4-Fr
catheter (green arrow) was inserted over the captured wire (blue
arrow), and a tandem 0.018-inch wire (red arrow) was inserted
through the same 4-Fr catheter to gain distal access
Fig. 4 Fluoroscopic image after successful crossing, showing
a 0.035-inch wire traversing the region of obstruction (green arrow)
and spanning the central biliary tree (yellow arrow) to the distal
common bile duct (red arrow)
Fig. 5 Completion cholangiogram showing a metallic stent (red
arrow) bridging the proximal central ducts (blue arrow) to the distal
common bile duct (yellow arrow)

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Ninalowoetal. Egypt J Radiol Nucl Med (2024) 55:81
post-procedure showed that the patient made significant
clinical improvement evidenced by complete resolu-
tion of ascites and improved liver function. At 6 months,
however, he re-presented with recurrence of jaundice and
passage of dark urine and admitted significant anorexia
with weight loss. Abdominal CT images revealed exten-
sive soft tissue tumor surrounding the stent in the region
of the hepatic hilum with soft tissue encasement around
the portal vein. Massive dilatation of the intrahepatic bile
duct and small ascites were also noted. He underwent
percutaneous transhepatic restenting and was discharged
in stable condition.
Case 2
A 75-year-old man with history of colorectal cancer with
metastasis to the liver presented with mild jaundice and
hyperbilirubinemia. He was evaluated for possibility of
biliary stenting to achieve decrease in bilirubin, which
may in turn lead to the commencement of chemotherapy.
Contrast-enhanced abdominal CT revealed evidence of
hepatic metastasis with hypo-enhancing masses within
segments 4B and 6. ere was diffuse intrahepatic biliary
ductal dilatation with transition point in the hilar region
due to extrinsic compression from multiple metastatic
lesions.
He initially had a right external biliary drain placed fol-
lowing an unsuccessful attempt at traversing the tight
obstruction via the standard anterograde approach. Two
weeks later, he returned for repeat attempt to cross the
obstruction and place an internal stent; however, all
efforts to cross the hilar obstruction, including attempts
made from a new left hepatic biliary access, again failed.
Attention was then shifted to the CBD. Under ultrasound
guidance, the mid-segment of the CBD was punctured
from a percutaneous approach using a 21 G Chiba biopsy
needle (Cook Medical), and contrast was slowly hand-
injected to opacify the non-dilated distal two-thirds of
the CBD across the sphincter of Oddi into the duode-
num. An 0.018-inch Nitrex™ wire was advanced, and
the needle was exchanged for the stiffened dilator from
a 4-Fr micro-puncture co-axial introducer (Merit Medi-
cal, Utah, USA), with which the obstruction in the CBD
was eventually crossed. Subsequently a 6-Fr 6–10 mm
snare system (Merit Medical) was advanced through the
left biliary access to snare the 0.018-inch wire, and the
front end was brought out through the sheath, creating
through and through access. Next, an angled catheter was
advanced over the 0.018-inch wire across the obstruction
into the CBD. e 0.018-inch wire was exchanged for a
glide wire, and the catheter was advanced further past
the sphincter of Oddi into the duodenum. A stiff 0.035-
inch wire was advanced, and the catheter was removed.
Finally, an 8 mm × 27 mm self-expandable biliary stent
was deployed extending from the left hepatic duct to the
CBD. Contrast was injected to confirm position, and flow
was satisfactory. Gelfoam® was injected into the left tract
to achieve hemostasis, and the sheath was removed. e
existing right external biliary drain was replaced with a
new 8-Fr external biliary drain (Cook Medical) and ini-
tially connected to a gravity drainage bag. e drain was
later capped and subsequently removed. Following drain
removal, the patient had persistent leakage of bile from
the previous site of the right-sided drain. Access was
gained through the prior stent, and an internal–external
drain was placed. e drain was injected with contrast,
which flowed promptly into the CBD. However, this
patient’s performance status continued to worsen over
the next month, and he eventually passed on 4 weeks
after stent placement.
Discussion
Generally, distal extrahepatic obstruction is best
approached with ERCP, while the proximal perihilar
obstruction is preferably managed percutaneously, as
stenting of biliary hilar obstruction is considered a com-
plex endoscopic procedure [5]. It is being advocated that
the technically feasible route that gives the best clinical
outcome should be adopted. erefore, the experience
of the experts or centers performing the procedure can
inform the choice of either ERCP or percutaneous tran-
shepatic biliary drainage. However, for patients with
markedly elevated bilirubin, cholangitis, extensive steno-
sis, failed ERCP, or altered biliary anatomy from surgery,
percutaneous approach is the proposed route [11].
In a resource-limited country like Nigeria, where exper-
tise for either method only became available recently at a
few centers, the experience of the operator becomes even
more significant in deciding the modality of treatment
[8–10]. Percutaneous biliary drainage with metallic stent
placement has been carried out successfully on patients
with MBO affecting different anatomical levels, at a pri-
vate center in Lagos, Nigeria, by an interventional radi-
ologist [9]. Most importantly, we have shown that we can
mimic the results of ERCP in most patients without the
need for external drainage, as we have achieved primary
biliary stenting in > 90% of our patients [9]. Some of these
procedures are not without challenges, such as inability
to traverse tight biliary obstructions, thus necessitating
placement of external biliary drain and later reattempt-
ing to internalize the stent. Internalizing a stent in the
setting of palliation for MBO is preferred to placing an
external drain, which is inconvenient and impairs quality
of life, in addition to leading to loss of bile salts and dehy-
dration [4, 11]. e inflammation in the biliary system
is much less when the system is allowed to decompress
through external drainage over a period of time, with

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Ninalowoetal. Egypt J Radiol Nucl Med (2024) 55:81
success rates of crossing previously difficult lesions > 70%
on reattempt. Placement of external drain or reattempt of
the procedures also confers unnecessary financial burden
on patients who often pay out of pocket for treatment in
Nigeria.
e two cases described above detailed an ingenious
technique adopted in overcoming these challenges. is
method entails gaining access percutaneously into the
CBD, distal to the obstruction, getting a wire across into
the proximal duct, and snaring the wire. It is very prac-
ticable; however, it does require mastery of ultrasound
anatomy to both gain access into a decompressed CBD
and avoid traversal of important structures in this region,
such as the hepatic or gastroduodenal arteries. To our
knowledge, this is the first report of such biliary inter-
vention. Similar combined retrograde and anterograde
approach has been adopted with success in recanaliza-
tion of chronic vascular occlusion of the lower extrem-
ity vessels [12]. We therefore solicit that interventional
radiologists, especially in low-resource countries with
limited access to ERCP, consider an attempt at this tech-
nique prior to relegating patients to long-term external
drainage.
Conclusions
e percutaneous combined anterograde–retrograde
technique described in this report is worth exploring in
patients who have perihilar MBO that is difficult to trav-
erse or who are being managed in centers where ERCP
is not readily available. Compared to long-term external
biliary drainage, this unusual approach is less expensive
and more convenient for the patient and appears to be
equally effective.
Abbreviations
CBD Common bile duct
CCA Cholangiocarcinoma
CT Computed tomography
ERCP Endoscopic retrograde cholangiopancreatography
MBO Malignant biliary obstruction
Acknowledgements
Not applicable.
Author contributions
HN conceived and designed the study. PA is a major contributor to all parts
of the paper. HN and AO contributed to the writing process and provided
critical feedback, playing a key role in enhancing the report’s overall quality.
All authors contributed to the writing and review of the manuscript and
approved of the final version for submission.
Funding
No funding was obtained for this study.
Availability of data and materials
Not applicable.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Consent to publish was obtained from the patient or legal representative
wherever applicable.
Competing interests
The authors declare no competing interests.
Received: 29 October 2023 Accepted: 6 April 2024
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