Percutaneous management of malignant biliary disease: factors influencing the ability to overcome the stricture.

PURPOSE To determine the factors affecting the ability to cross malignant biliary obstructions in percutaneous transhepatic interventions. MATERIALS AND METHODS In this study, 256 patients with 310 obstructive malignant biliary lesions from May 2006 to January 2009 were analyzed retrospectively. All of the patients had undergone percutaneous transhepatic cholangiography and intervention. Obstructions crossed in two or fewer sessions were classified as technically easy obstructions, whereas obstructions that required more than two sessions for crossing were classified as technically difficult obstructions. Possible factors thought to affect the ability of malignant biliary obstructions to be crossed were compared according to the obstruction type (technically easy or difficult obstructions). RESULTS Of the 310 malignant biliary obstructions studied, 79% (246) were technically easy to cross, and 21% (64) were technically difficult to cross. Lesions located between the hilum and the cystic duct and beak-shaped malignant biliary lesions were easily crossed, but suprahilar localized lesions and flat or ovoid-shaped lesions were difficult to cross. The histological nature of the malignant biliary obstruction, the direct-to-total bilirubin ratio, the entry segment for the intervention, the largest bile duct diameter proximal to the obstruction, and the length of the obstruction were not found to influence the ability of the stricture to be overcome. CONCLUSION In patients with malignant biliary obstructions, the factors that can negatively affect obstruction crossing are lesions with suprahilar localization and flat or ovoid-shaped lesions. We also conclude that after five ineffective attempts have been made to pass the stricture, treatment of malignant biliary obstruction should proceed to external biliary drainage.