Covered metallic stent for ischemic hilar biliary stricture

Compared with surgery, endoscopic treatment is safe and highly effective for a postoperative hilar benign bile duct stricture (BDS). However, the long-term outcome of conventional placement of a single biliary stent for hilar benign BDS is generally poor. Although the placement of multiple biliary stents is preferred, multiple stenting in a BDS is difficult. Alternatively, single or multiple stent placement above the papilla ('inside stent') or fully-covered self-expandable metallic stents (SEMS) are feasible approaches for benign BDS. Nevertheless, controversy remains regarding whether and how to perform endoscopic biliary drainage for a hilar benign BDS. In patients with hilar benign BDS, endoscopic biliary drainage can be performed by placing conventional plastic stents across the papilla, plastic stents above the papilla or fully-covered SEMS. Individualized treatment should be considered. We report the placement of a fully-covered SEMS for a hilar benign biliary stricture after extended left hepatectomy.     

Bilateral Metal Stents for Hilar Biliary Obstruction Using a 6Fr Delivery System: Outcomes Following Bilateral and Side-by-Side Stent Deployment

Background and Study Aim

Controversy exists on optimal endoscopic management for palliation of malignant hilar obstruction, with advocates for metal “side-by-side” (SBS) and “stent-in-stent” (SIS) techniques. We sought to evaluate the technical feasibility, efficacy, and outcomes of bilateral biliary self-expanding metal stents (SEMS) for treatment of malignant hilar obstruction using a stent with a 6Fr delivery system.

Patients and Methods

This was a single-center, retrospective review of all patients who underwent bilateral placement of Zilver^® biliary SEMS for malignant hilar obstruction from January 2010 to August 2012. Patients underwent endoscopic retrograde cholangiopancreatography with placement of stents using either the SIS or SBS stent techniques.

Results

Twenty-four patients (19 men, mean age 63 years) underwent bilateral stenting for malignant hilar obstruction during the study period. Seventeen and seven patients underwent the SBS and SIS technique, respectively. Cholangiocarcinoma (n = 14) was the most common cause of hilar obstruction. Initial technical success was achieved in 24/24 (100 %) of patients; however, 12 (50 %) patients required re-intervention during the study period (median 98 days). Comparison of the SBS and SIS groups revealed no statistical difference with respect to need for re-intervention (P = 0.31), successful re-intervention (P = 0.60), or procedural length (P = 0.89).

Conclusions

Use of bilateral Zilver^® SEMS in either the SBS or SIS configuration is safe, technically feasible, and effective for drainage of malignant hilar obstruction; however, duration of stent patency and procedure-free survival remain variable.     

Endoscopic bilateral stent-in-stent placement for malignant hilar obstruction using a large cell type stent

BACKGROUND: Bilateral stent-in-stent(SIS) self-expandable metal stent placement is technically challenging for palliation of unresectable malignant hilar obstruction. In the SIS technique, the uniform large cell type biliary stent facilitates contralateral stent deployment through the mesh of the first metallic stent. This study aimed to assess the technical success and clinical effectiveness of this technique with a uniform large cell type biliary stent.METHODS: Thirty-one patients who underwent bilateral SIS placement using a large cell type stent were reviewed retrospectively. All patients showed malignant hilar obstruction(Bismuth types Ⅱ,Ⅲ,Ⅳ) with different etiologies.RESULTS: Sixteen(51.6%) patients were male. The mean age of the patients was 67.0±14.0 years. Most patients were diagnosed as having hilar cholangiocarcinoma(58.1%) and gallbladder cancer(29.0%). Technical success rate was 83.9%.Success was achieved more frequently in patients without masses obstructing the biliary confluence(MOC) than those with MOC(95.2% vs 60.0%, P=0.03). Functional success rate was 77.4%. Complications occurred in 29.0% of the patients. These tended to occur more frequently in patients with MOC(50.0% vs 19.0%, P=0.11). Median time to recurrent biliary obstruction was 188 days and median survival was 175 days.CONCLUSIONS: The large cell type stent can be used efficiently for bilateral SIS placement in malignant hilar obstruction. However, the risk of technical failure increases in patients with MOC, and caution is needed to prevent complications for these patients.     

Use of a temporary plastic stent to facilitate the placement of multiple self-expanding metal stents in malignant biliary hilar strictures

BACKGROUND: Although endoscopic palliation of malignant biliary hilar obstruction is preferable to surgery or percutaneous drainage, it remains technically challenging. This is especially true when multiple self-expanding metal stents (SEMS) are placed, because difficulty is commonly encountered in passing the second SEMS at the level of the previously deployed initial stent. We have devised a method of deploying multiple metal stents by using a temporary plastic stent, which makes deployment of the second stent much easier. METHODS: After guidewire placement, a plastic stent is deployed in a subhilar position. The initial SEMS is deployed, with the plastic stent maintaining a passage for the second SEMS. After the second SEMS is deployed, the plastic stent is retrieved. OBSERVATIONS: This technique has been used successfully in 7/8 patients, all of whom presented with symptomatic jaundice secondary to malignant hilar obstruction of various etiologies (cholangiocarcinoma, n=4; metastatic disease, n=3; and hepatocellular carcinoma, n=1). Drainage was successful in all cases, with significant improvement in symptoms and cholestasis. CONCLUSIONS: This simple technique lessens the technical difficulty of placing bilateral hilar SEMS.     

Removal of an embedded "covered" biliary stent by the "stent-in-stent" technique

A 46-year-old man was admitted with obstructive jaundice and cross-sectional imaging with computed tomography suggested distal biliary obstruction.A distal common bile duct stricture was found at endoscopic retrograde cholangiopancreatography(ERCP)and cytology was benign.A 6 cm fully covered self-expanding metal stent(SEMS)was inserted across the stricture to optimize biliary drainage.However,the SEMS could not be removed at repeat ERCP a few months later.A further fully covered SEMS was inserted within the existing stent to enable extraction and both stents were retrieved successfully a few weeks later.Fully covered biliary(SEMS)are used to treat benign biliary strictures.This is the first reported case of inability to remove a fully-covered biliary SEMS.Possible reasons for this include tissue hyperplasia and consequent overgrowth into the stent proximally,or chemical or mechanical damage to the polymer covering of the stent.Application of the stent-in-stent technique allowed successful retrieval of the initial stent.     

Self‐expanding plastic stent to palliate symptomatic tissue in/overgrowth after self‐expanding metal stent placement for esophageal cancer

Self‐expanding metal stents (SEMS) are used to treat obstructive malignancies of the esophagus or esophagogastric junction; however, a potential complication is recurrent dysphagia because of tissue in/overgrowth. The placement of a second SEMS is one strategy to re‐establish patency of the esophageal lumen. We evaluated the safety and efficacy of an alternative and likely less costly approach: placing a self‐expanding plastic stent (SEPS) to manage relapsing dysphagia in patients previously treated with a partially covered SEMS. From December 2007 to January 2009, 13 patients previously treated with a SEMS for malignant dysphagia underwent treatment by inserting a SEPS to palliate relapsing dysphagia, as a result of tissue in/overgrowth. Stenosis was located in the upper esophagus in one patient, in the middle in four patients, and in the lower esophagus in eight patients. Clinical evaluation was performed at the time of stent placement, after 1 week, and then, monthly until death. The SEPS was successfully placed in a single treatment session for all patients. No preliminary dilation was required, and no further treatment was necessary for any patient. Before stenting, the median dysphagia score was 4 (range 3–4), and 1 week later the score was 0 for all patients. The resolution of dysphagia persisted until patient death (from tumor progression). The mean survival after the SEPS insertion was 4 months (range 3–8). This case series supports the use of a SEPS to palliate dysphagia from tissue in/overgrowth of a SEMS. Future clinical trials with larger patient samples are warranted.     

Treating bilio-duodenal obstruction: Combining new endoscopic technique with 6 Fr stent introducer

Periampullary cancer may cause not only biliary but also duodenal obstructions. In patients with concomitant duodenal obstructions, endoscopic biliary stenting remains technically difficult and may often require percutaneous transhepatic biliary drainage. We describe a method of metal stent placement via a thin forwardviewing endoscope in patients with simultaneous biliary and duodenal obstruction. In two consecutive patients with biliary and duodenal obstruction due to pancreatic cancer, a new biliary meta...     

Endoscopic biliary stent insertion through specialized duodenal stent for combined malignant biliary and duodenal obstruction facilitated by stent or PTBD guidance

Objectives: Endoscopic stenting for combined malignant biliary and duodenal obstruction is technically demanding. However, this procedure can be facilitated when there is guidance from previously inserted stent or PTBD tube. This study aimed to evaluate the feasibility and clinical success rate of endoscopic placement of biliary self-expandable metal stent (SEMS) through duodenal SEMS in patients with combined biliary and duodenal obstruction due to inoperable or metastatic periampullary malignancy.

Materials and methods: A total of 12 patients with combined malignant biliary and duodenal stricture underwent insertion of biliary SEMS through the mesh of specialized duodenal SEMS from July 2012 to October 2016. Technical and clinical success rate, adverse events and survival after completion of SEMS insertion were evaluated.

Results: The duodenal strictures were located in the first portion of the duodenum in four patients (Type I), in the second portion in three patients (Type II), and in the third portion in five patients (Type III). Technical success rate of combined metallic stenting was 91.7%. Insertion of biliary SEMS was guided by previously inserted biliary SEMS in nine patients, plastic stent in one patient, and PTBD in two patients. Clinical success rate was 90.9%. There were no early adverse events after the procedure. Mean survival period after combined metallic stenting was 91.9 days (range: 15–245 days).

Conclusions: Endoscopic placement of biliary SEMS through duodenal SEMS is feasible with high success rates and relatively easy when there is guidance. This method can be a good alternative for palliation in patients with combined biliary and duodenal obstruction.     

Combination of endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography‐guided biliary drainage in malignant hilar biliary obstruction

Adequate biliary drainage (BD), defined as more than 50% of liver volume drained, is an ideal BD method in patients with advanced and unresectable malignant hilar biliary obstruction (MHBO). Endoscopic retrograde cholangiopancreatography (ERCP) with multi‐segmental BD is technically challenging. ERCP with percutaneous biliary drainage (PTBD) or PTBD alone has cumbersome maintenance of PTBD line and external bag. The utility of EUS‐guided BD (EUS‐BD) has risen significantly over last 5 years mostly in the clinical setting of distal bile duct obstruction. Information on EUS‐BD for malignant hilar biliary obstruction (MHBO) is thus far limited to only two small studies. This review suggests a new concept of a combination of ERCP and EUS‐BD (CERES) for BD in MHBO as a primary BD method whereby ERCP with a single self‐expandable metal stent (SEMS) is placed into either the right or the left intrahepatic bile duct (IHD). If SEMS is placed in the right biliary system, EUS‐guided hepaticogastrostomy (EUS‐HGS) can subsequently be carried out. However, if the stent is placed into the left biliary system, EUS‐guided hepaticoduodenostomy (EUS‐HDS) is done. For MHBO with non‐functioning right lobe of the liver, EUS‐HGS is carried out after failed ERCP, or primary HGS can be carried out in the left lobe of liver. For MHBO with non‐functioning left lobe of the liver, EUS‐HDS is carried out after failed transpapillary stenting of the right lobe by ERCP. Based on our experience, CERES is promising as it can fulfil gaps of both PTBD and ERCP by allowing internal drainage that can circumvent the inconvenience associated with PTBD and offer higher technical success rate compared to ERCP with bilateral SEMS placement.     

Metallic stent deployment in endosonography‐guided biliary drainage: Long‐term follow‐up results in patients with bilio‐enteric anastomosis

Background and Aim: Although reports on endosonography‐guided biliary drainage (ESBD) have been increasing, only a few reports on deployment of a self‐expandable metal stents (SEMS) have been reported. The aim of the present study was to evaluate the safety and efficacy of SEMS deployment in ESBD. Methods: Of 42 patients who underwent ESBD during the period from January 2007 to August 2011, 21 patients with unresectable malignant biliary obstruction in whom SEMS deployment had been attempted were included. In the first session, a plastic stent or SEMS was placed in a bilio‐enteric anastomosis (BEA) method. SEMS was deployed with the one‐step technique or with replacement of a plastic stent with a SEMS in the second session. The technical success, early and late complications, and stent patency of SEMS were evaluated. Results: One‐step SEMS deployment was attempted in seven patients, and SEMS was deployed with stent exchange in 14. SEMS deployment was successful in all patients without any complications. Finally, SEMS was placed in a BEA method in 16 patients (extrahepatic bile duct, 13; intrahepatic bile duct, three), and with antegrade deployment in five. Late complications occurred in three patients who underwent deployment of SEMS in a BEA method (stent obstruction in two and reflux cholangitis in one). The mean stent patency period was 433 days. Conclusions: As SEMS deployment in ESBD is safe and provides long stent patency, a SEMS seems to be the stent of choice in ESBD for patients with unresectable malignant biliary obstruction in whom long survival is expected.     

内镜下同期放置双侧金属胆道支架的方法探讨

目的 探讨经内镜同期置入双侧可膨式金属胆道支架的方法。方法9例Ⅱ～Ⅳ型肝门部胆管恶性梗阻患者,平均血胆红素（162．8±193．8）μmol／L,内镜下插入双导丝分别留置在左、右侧胆管内,在充分扩张狭窄段后,逐一插入金属支架至双侧肝管予以释放。观察操作的便利性、成功率、控制黄疸有效性、早期并发症和近期的临床疗效。结果全组均一次成功置入双侧支架,分别采用“Y”型支架置入法2例、塑料支架过渡法1例和并行支架法6例,平均耗时（38．1±14．8）min,以并行法置入且留置支架末端在乳头外的方法最为便捷。9例患者术后除1例外其他黄疸均迅速消退,3周内均退至正常,无明显并发症发生。结论同期置人双侧金属支架是安全可行的,可迅速有效地控制肝门部肿瘤所致的黄疸和胆道感染;采用特殊设计的金属支架并行置入,并将支架末端留置在乳头外,是较为简便效佳的方法。     

New guide wire technique for stent placement through an occluded self-expandable metal stent: The hairpin technique

BACKGROUND AND AIMS: Self-expandable metal stents (SEMS) for malignant biliary strictures sometimes occlude, requiring the insertion of another stent. When a guide wire is advanced conventionally through the proximal portion of an occluded SEMS, the guide wire sometimes penetrates the stent mesh. The present study reports a new guide wire insertion technique that prevents this problem from occurring. METHODS: In this new method of advancing a guide wire, the tip is not straight but bent into a curve. Because the advancing end of the guidewire is rounded like a hairpin, it cannot penetrate the stent mesh. Before cannulation, the flexible tip of the guide wire is extended out of the tip of the cannula in the descending duodenum and then cannulation is carried out as the flexible tip makes a hairpin curve. The guide wire with a maintained hairpin curve is advanced through the proximal end of the SEMS. The hairpin curve pops open and the guide wire straightens out when the guide wire has passed through the SEMS. After that, a second stent can be inserted over the guide wire. This technique has been utilized 14 times for occluded SEMS in 10 patients between June 2001 and September 2003. RESULTS: In all patients the technique served to ensure access to the biliary tree and successful placement of a second stent. CONCLUSIONS: This new hairpin guide wire technique was effective in preventing the guide wire from penetrating the stent mesh and, therefore contributed to successful stent placement within occluded SEMS.     

Temporary use of an accuflex stent for unextractable common bile duct stones

Endoscopic management has become the main therapeutic approach for the extraction of common bile duct (CBD) stones, and successful removal can be achieved in 80-90% patients using conventional balloon and basket techniques. However, if it is difficult to completely fragment a stone, or to clear the CBD, which may occur for a variety of reasons, the therapeutic problem will remain. When bile duct stones can not be removed, a viable management option is to place a biliary stent to ensure drainage. However, recent studies of long-term biliary stenting, with a plastic stent, showed a relatively high rate of morbidity and mortality. We report an alternative, unique treatment for unextractable common bile duct stones, using the temporal placement of an expandable metallic stent (EMS) to facilitate passage of fragments through the papilla.     

Development of Severe Acute Pancreatitis Following Uncovered Metallic Stent Placement: A Rare Case Report

Self-expandable metallic stents (SEMSs) are widely used for malignant biliary stricture (MBS). Acute pancreatitis is an early complication following SEMS placement. In the present case, the patient developed severe acute pancreatitis after SEMS placement for MBS because of metastatic lymph nodes. Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy and an endoscopic nasobiliary drainage tube placement were performed. After seven days, an uncovered SEMS was placed; however, severe acute pancreatitis occurred, and the SEMS was drawn out emergently. In SEMS placement for patients with MBS caused by non-pancreatic cancer, SEMS should be selected carefully while considering each patient''s case.     

Revision of bilateral self-expandable metallic stents placed using the stent-in-stent technique for malignant hilar biliary obstruction

Background

Endoscopic biliary decompression using bilateral self-expandable metallic stent (SEMS) placed using the stent-in-stent (SIS) technique is considered favorable for unresectable malignant hilar biliary obstruction (MHBO). However, occlusion of the bilateral SIS placement is frequent and revision can be challenging. This study was performed to investigate the efficacy, the long-term patency and the appropriate approach for revision of occluded bilateral SIS placement in unresectable MHBO.

Hilar Malignant Biliary Obstruction Treated with Four Metallic Stents Involving a New Slim Device

Endoscopic hilar multiple stenting is challenging. A 68-year-old patient had self-expandable metallic stents (SEMSs) inserted for unresectable hilar malignant biliary obstruction. After the SEMSs were inserted into the left hepatic duct and bile duct branch of segment (B) 6, a new SEMS with a wide mesh and slim delivery system was inserted into the right anterior hepatic duct. However, liver abscess and dilated B7 were observed on computed tomography; therefore, an additional new SEMS was quickly and easily inserted into B7. After the placement of these four SEMSs, the liver abscess improved. The new SEMS was effective for hilar multiple biliary drainage.     

Metal stents: a bridge to surgery in hilar cholangiocarcinoma

BackgroundObstructive jaundice in patients with hilar cholangiocarcinoma is a known risk factor for hepatic failure after liver resection. Plastic stents are most widely used for preoperative drainage. However, plastic stents are known to have limited patency time and therefore, in palliative settings, the self‐expanding metal stent (SEMS) is used. This type of stent has been shown to be superior because it allows for rapid biliary decompression and a reduced complication rate after insertion. This study explores the use of the SEMS for biliary decompression in patients with operable hilar cholangiocarcinoma.MethodsA retrospective evaluation of a prospectively maintained database at a tertiary hepatobiliary referral centre was carried out. All patients with resectable cholangiocarcinoma were recorded.ResultsOf 260 patients referred to this unit with cholangiocarcinoma between January 2008 and April 2012, 50 patients presented with operable cholangiocarcinoma and 27 of these had obstructive jaundice requiring stenting. Ten patients were initially treated with SEMSs; no stent failure occurred in these patients. Seventeen patients initially received plastic stents, seven of which failed in the interval between stent placement and laparotomy. These stents were replaced by SEMSs in four patients and by plastic stents in three patients. Median time to laparotomy was 45 days and 68 days in patients with SEMSs and plastic stents, respectively.ConclusionsSelf‐expanding metal stents provide adequate and rapid biliary drainage in patients with obstruction caused by hilar cholangiocarcinoma. No re‐interventions were required. This probably reflects the relatively short interval between stent placement and laparotomy.     

Endoscopic retrograde cholangiopancreatography drainage for palliation of malignant hilar biliary obstruction — stent-in-stent or side-by-side? A systematic review and meta-analysis

BACKGROUNDBiliary drainage, either by the stent-in-stent (SIS) or side-by-side (SBS) technique, is often required when treating a malignant hilar biliary obstruction (MHBO). Both methods differ from each other and have distinct advantages.AIMTo compare both techniques regarding their efficacy and safety in achieving drainage of MHBO.METHODSA comprehensive search of multiple electronic databases (MEDLINE, Embase, LILACS, BIREME, Cochrane) was conducted and grey literature from their inception until December 2020 with no restrictions regarding the year of publication or language, since there was at least an abstract in English. The included studies compared SIS and SBS techniques through endoscopic retrograde cholangiopancreatography. Outcomes analyzed included technical and clinical success, early and late adverse events (AEs), stent patency, reintervention, and procedure-related mortality.RESULTSFour cohort studies and one randomized controlled trial evaluating a total of 250 patients (127 in the SIS group and 123 in the SBS group) were included in this study. There were no statistically significant differences between the two groups concerning the evaluated outcomes, except for stent patency, which was higher in the SIS compared with the SBS technique [mean difference (d) = 33.31; 95% confidence interval: 9.73 to 56.90, I² = 45%, P = 0.006].CONCLUSIONThe SIS method showed superior stent patency when compared to SBS for achieving bilateral drainage in MHBO. Both techniques are equivalent in terms of technical success, clinical success, rates of both early and late AEs, reintervention, and procedure-related mortality.     

Metallic stents are more efficacious than plastic stents in unresectable malignant hilar biliary strictures: a randomized controlled trial

Background

Endoscopic biliary stenting is a well-established palliative treatment for unresectable malignant biliary strictures, for which plastic tube stents (PSs) and self-expandable metallic stents (SEMSs) are most commonly used. The efficacy of these stents has been extensively described in distal biliary strictures, but not in hilar biliary strictures. The present study aimed to compare the efficacy of PSs and SEMSs for unresectable malignant hilar biliary strictures.

Methods

From June 2004 to November 2008, 60 patients were enrolled and prospectively randomized into the PS or SEMS group.

Results

The 6-month patency rate was significantly higher in the SEMS group than in the PS group (81 vs. 20%; p = 0.0012). Kaplan–Meier analysis showed significantly longer patency in the SEMS group than in the PS group (p = 0.0002); the 50% patency period was 359 days in the SEMS group and 112 days in the PS group. There was no significant difference in the overall survival period between the PS and SEMS groups (p = 0.2834). The mean number of reinterventions for stent failures was significantly lower in the SEMS group (0.63 times/patient) than in the PS group (1.80 times/patient) (p = 0.0008). The overall total cost for the treatment was significantly lower in the SEMS group than in the PS group (p = 0.0222).

Conclusions

SEMSs were associated with a longer patency than PSs in patients with unresectable hilar biliary stricture. SEMSs were also more advantageous in reducing the number of reintervention sessions and the overall treatment cost.     

Unilateral versus bilateral endoscopic metal stenting for malignant hilar biliary obstruction

Background and Aim: The extent of liver drainage for palliative treatment of malignant hilar biliary obstruction is controversial. The aim of this study was to compare endoscopic unilateral versus bilateral drainage in patients with malignant hilar biliary obstruction using a self‐expanding metal stent (SEMS). Methods: We carried out a retrospective review of 46 consecutive patients with malignant hilar biliary obstruction who were treated by endoscopic biliary drainage using SEMS between 1997 and 2005. Unilateral metal stenting (group A) was performed in 17 patients between 1997 and 2000, and bilateral metal stenting (group B) was performed in 29 patients between 2001 and 2005. The successful stent insertion, successful drainage, early complications, late complications, stent patency, and survival rate for groups A and B were evaluated and compared retrospectively. Results: There were no significant differences between the two groups in successful stent insertion (100% vs 90%, group A vs B, respectively), successful drainage (100% vs 96%), early complications (0% vs 10%), or late complications (65% vs 54%). Cumulative stent patency was significantly better in group B than in group A (P = 0.009). In cases of cholangiocarcinoma, cumulative stent patency was significantly better in group B than in group A (P = 0.009), whereas there were no inter‐group differences for gallbladder carcinoma. Cumulative survival did not differ significantly between the groups. Conclusions: Endoscopic bilateral drainage using SEMS for malignant hilar biliary obstruction is more effective than unilateral drainage in terms of cumulative stent patency, especially in cases of cholangiocarcinoma.