Magnetic resonance cholangiopancreatography-guided unilateral endoscopic stent placement for Klatskin tumors

Background: Advanced and incurable Klatskin tumors of Bismuth-type III and IV cause obstructive jaundice. Palliation of patients with Klatskin tumors is usually carried out by bilateral endoscopic stent placement. Endoscopic retrograde cholangiography (ERC) in such patients is associated with a comparatively high morbidity and mortality mainly due to postprocedure bacterial cholangitis. To reduce ERC-related complications the outcome of replacing ERC with magnetic resonance cholangiopancreatography (MRCP) was investigated. Subsequently, unilateral contrast injection and stent placement were performed, thus avoiding bilateral contrast injection and stent insertion. Methods: Patients thought to have a Klatskin tumor underwent clinical evaluation, laboratory, and noninvasive imaging studies before ERC. Patients were enrolled in this feasibility study if investigators agreed with the clinical diagnosis of an advanced and incurable Klatskin tumor. MRCP images were used to determine the predominate ductal drainage for the liver segments thus directing stent placement. Based on these findings, unilateral ERC and subsequent unilateral stent placement were performed. Antibiotics were not given before ERC. Amsterdam-type stents (10F) were placed and replaced routinely at 2 months. In cases of earlier occlusion, the stents were replaced immediately. Results: Thirty-five patients underwent MRCP, ERC, and unilateral stent deployment. Two further patients enrolled after MRCP were withdrawn because ERC could not be carried out. In 35 patients with unilateral stents bilirubin levels decreased (18.9 +/- 6.3 mg/dL to 3.2 +/- 2.3 mg/dL) and jaundice resolved in 86%. After first stent deployment, post-ERC bacterial cholangitis occurred in 6% (2 of 35) of patients. Conclusions: This new method of MRCP-guided endoscopic unilateral stent placement could reduce ERC-related complications caused by initial stent deployment. The results of this study justify a randomized prospective comparative trial.