Outcomes of iodine-125 seed strips combined with double self-expandable metallic stent for Bismuth type III and IV malignant biliary obstruction

Figure 1 Gallbladder cancer invading the hepatic hilar in a 60-year-old female patient. A: Abdominal contrast-enhanced computed tomography indicates gallbladder cancer invading the junction area of the left and right lobes of the liver, with intrahepatic bile duct dilation; B: Cholangiography shows hilar biliary obstruction, Bismuth type IV. Two biliary drainage tubes were inserted, with the tips of the drainage tubes located in the right anterior lobe bile duct and the left intrahepatic bile duct, respectively; C: Intraductal biopsy revealed adenocarcinoma; D: Double self-expandable metallic stent (SEMS) implantation (type X). The right anterior bile duct is connected to the common bile duct [8 mm × 80 mm, 16 iodine-125 (¹²⁵I) seeds]. Subsequently, 4-mm and 6-mm balloons were used to dilate the severe stenosis segment (from the right posterior bile duct to the left bile duct). Implantation of an 8-mm × 60-mm SEMS was performed (from the right posterior bile duct to the left bile duct). Failure to implant ¹²⁵I seed strips occurred due to severe tortuosity of the bile duct; E and F: Posterior-anterior/right anterior oblique 30-degree cholangiography indicates significant tortuosity from the right posterior bile duct to the left bile duct.

Figure 2 Liver metastasis and postoperative gastric cancer in a 61-years old male patient. A: Abdominal contrast-enhanced computed tomography indicates an extensive malignant tumor in the hepatic left lobe, enlargement of the gallbladder, dilation of intrahepatic bile duct branches, abdominal and retroperitoneal lymph nodes metastasis, and ascites; B: Cholangiography shows hilar biliary obstruction, Bismuth type IV. Intraductal biopsy revealed adenocarcinoma; C: Double wires and double 6 French guiding tubes were selected for the common bile duct and the left intrahepatic bile duct, respectively; D: Double iodine-125 (¹²⁵I) seed strip combined with double self-expandable metallic stent implantation (type T). The right bile duct is connected to the common bile duct (8 mm × 80 mm, 16 ¹²⁵I seeds); the right bile duct is connected to the left bile duct (8 mm × 60 mm, 14 ¹²⁵I seeds).

Figure 3 Hilar cholangiocarcinoma in a 49-year-old female patient. A: Abdominal contrast-enhanced computed tomography shows hilar cholangiocarcinoma with intrahepatic metastasis, intrahepatic bile duct dilation, and multiple hilar region lymph node metastases; B: Cholangiography shows hilar biliary obstruction, Bismuth type IV. Intraductal biopsy reveals poorly differentiated adenocarcinoma; C: Double guiding tubes were selected from the left and right intrahepatic bile ducts to the duodenum; D: Double iodine-125 (¹²⁵I) seed strip combined with double self-expandable metallic stent implantation (type Y). The right bile duct is connected to the common bile duct (8 mm × 80 mm, 20 ¹²⁵I seeds) and the left bile duct is connected to the common bile duct (8 mm × 80 mm, 20 ¹²⁵I seeds); E: One month postoperatively, cholangiography showed that the left biliary stent was patent, and the left drainage tube was removed; F: Two months postoperatively, cholangiography showed that the right biliary stent was patent and the right drainage tube was removed.

Figure 4  The overall survival was 189. 00 ± 47.27 days (95%CI: 96.35-281.66), and the stent fluency time was 154.00 ± 12.19 days (95%CI: 130.11-177.89).