Why is it better to have CT before a stent is placed?

A stent and the inflammation around it distort the picture, making it harder to assess the size of the tumor and its relation to the vessels. Whether the tumor can be removed depends on this, so good-quality scans before drainage are very valuable.

How does a plastic stent differ from a metal one?

A metal stent is wider and stays open longer, so it is more often chosen when the tumor cannot be removed or when chemotherapy is planned before surgery. A plastic stent is cheaper but blocks sooner and needs routine replacement.

Jaundice returned after stenting. What should I do?

See a doctor without delay, especially if you have fever or chills: most likely the stent has become blocked or displaced. It is replaced or cleared, and antibiotics are given if there are signs of cholangitis.

Can chemotherapy be started while jaundiced?

Usually bile drainage is restored first and bilirubin is allowed to fall: many drugs are cleared by the liver, and giving them with high bilirubin is dangerous. When exactly treatment can start is decided by the medical oncologist.

Malignant obstructive jaundice: stent, drain or surgery

Q: Is a stent always needed before surgery?

No. For cancer of the pancreatic head, if surgery can be performed soon, routine preoperative drainage is not recommended. It is done for cholangitis, marked jaundice with itching, when surgery is delayed or when chemotherapy is planned before it. For perihilar tumors, drainage is usually needed before a major resection.

Obstructive jaundice occurs when a tumor blocks the bile ducts and bile cannot reach the bowel. It is not a separate disease but a consequence of a tumor of the pancreas, bile ducts or gallbladder, or of metastases. Restoring bile drainage is often the first stage of treatment: it relieves itching, treats cholangitis if it has developed, makes chemotherapy safe, and helps some patients prepare for surgery. But rushing to place a stent before a full work-up can complicate further treatment, so the order of steps matters.

Kateryna Valikhnovska, MD, surgical oncologist, during a laparoscopic operation — The laparoscopic stage of an operation: the lights in the operating room are dimmed because the surgeon works from the camera image on the monitor.

Why a tumor causes jaundice

Bile is produced in the liver and drains through the ducts into the duodenum. If there is an obstruction along this path, bile accumulates, the ducts dilate and bilirubin enters the blood. The most common tumor causes are:

cancer of the head of the pancreas, compressing the lower end of the common bile duct;
cholangiocarcinoma, especially a perihilar tumor or a tumor of the common bile duct;
cancer of the ampulla of Vater, where the duct enters the bowel;
gallbladder cancer that has grown into the ducts;
metastases compressing the ducts at the liver hilum, in the lymph nodes or in the liver itself.

Everything that follows depends on the level of the obstruction: a low one, near the bowel, is usually relieved endoscopically, while a high one, at the liver hilum, is more difficult and is often drained through the skin.

Are there symptoms

Typical signs are yellowing of the skin and the whites of the eyes, dark urine, pale stools and itchy skin, which sometimes appears before the jaundice itself. With tumors, jaundice often develops gradually and painlessly, unlike stones, which usually cause attacks of pain.

Fever with chills in a patient with jaundice may mean cholangitis, an infection of the bile ducts. This is an emergency: antibiotics and urgent restoration of bile drainage are needed, so with these symptoms you should go to hospital at once rather than wait for a scheduled consultation.

Examinations needed

Ultrasound is the first step: dilated ducts confirm that the jaundice is obstructive and not related to disease of the liver itself.
Pancreatic-protocol contrast-enhanced CT and/or MRI with MR cholangiography determine the cause, the level of obstruction and whether the tumor can be removed. They should ideally be done before a stent is placed: a stent distorts the picture and makes it harder to assess tumor spread.
Endoscopic ultrasound shows tumors of the pancreatic head and the ampulla in detail and allows a biopsy to be taken.
Blood biochemistry: bilirubin, liver enzymes and clotting parameters, which are disturbed in prolonged jaundice.
Tumor marker CA 19-9, informative after the jaundice has subsided, because bile stasis itself raises it.

When radical surgery is possible

If the tumor can be removed, surgery is the main treatment and restoring bile drainage is preparation for it. Whether a drain is needed before surgery is decided individually. For cancer of the pancreatic head, if surgery can be performed soon, routine preoperative drainage is not recommended: it adds a risk of complications. A drain is needed for cholangitis, marked jaundice with itching, when surgery has to be delayed, or when chemotherapy is planned before it.

For perihilar tumors, drainage is usually needed before a major resection, and it is the part of the liver that will remain after surgery that is drained. That is why the decision on where to place the drain is best made together with the surgeon who will operate.

If the tumor cannot be removed

The aim is then to restore bile drainage reliably, so that the patient can receive chemotherapy and live as long as possible without jaundice and itching. Once unresectability has been confirmed by a surgeon, a metal stent is usually placed for this: it stays open longer than a plastic one and needs replacement less often. This is especially important during chemotherapy, because many drugs can only be given when bilirubin is normal or close to normal.

If the tumor also narrows the duodenum, its patency is restored with a stent or a gastrojejunal bypass. The final plan is determined by the MDT.

How bile drainage is restored

Drainage is restored in three main ways. Endoscopically (ERCP): a stent is passed through the mouth and duodenum into the duct; this is the main method for a low obstruction. Through the skin under ultrasound and X-ray guidance: a drain is placed directly into the liver ducts, more often for high obstructions or when endoscopic access is not possible. Under endoscopic ultrasound guidance: in experienced centers, when standard ERCP has failed. These procedures are performed by endoscopists and interventional radiologists; we organize this stage and, together with them, determine which approach and which stent are suitable with the future operation in mind.

The radical operation depends on the cause: for cancer of the pancreatic head, distal bile duct or ampulla, a pancreatoduodenectomy; for a perihilar tumor, removal of the ducts with part of the liver; for gallbladder cancer that has caused jaundice, if surgery is possible at all, a more extensive liver resection with removal of the bile ducts and lymph nodes; jaundice in gallbladder cancer more often indicates an advanced tumor. A surgical bypass between the duct and the bowel is rarely performed today: when a stent cannot be placed, or when the tumor turns out to be unresectable during surgery.

A stent is not treatment of the tumor but preparation for it. That is why I ask, whenever possible, that the scans be shown to the surgeon before drainage: this makes it easier to choose the right approach and not complicate the future operation.

Kateryna Valikhnovska, MD, surgical oncologist

Recovery after drainage or surgery

After endoscopic stenting most patients recover quickly; jaundice and itching subside gradually, over days and weeks. After percutaneous drainage an external tube remains for some time; it is cared for at home according to instructions and is often later replaced with an internal stent.

After radical surgery, care follows the enhanced recovery after surgery (ERAS) protocol: early mobilization, early feeding, controlled pain relief.

Follow-up

A stent can become blocked over time. Returning jaundice or itching, darkening of the urine or fever are signs that require seeing a doctor at once: a blocked stent is replaced or cleared. Plastic stents are routinely exchanged after a few months; metal stents last longer.

During chemotherapy, bilirubin and liver tests are monitored regularly. After radical surgery, follow-up is determined by the tumor type.

What to bring to the consultation

CT or MRI discs and reports, especially those done before a stent or drain was placed;
reports of ERCP, drainage, endoscopic ultrasound;
blood biochemistry with bilirubin and liver enzymes, the latest and earlier results;
tumor marker CA 19-9;
cytology or histology reports, if a biopsy was taken;
hospital discharge summaries.

If some materials are missing, that is no reason to postpone the consultation: some examinations can be done on site.

The consultation is free of charge. How it goes and how long it takes is described on the page “Oncologist Consultation”.