全覆膜金属支架与塑料支架在不可切除的远端胆道 恶性梗阻中的应用对比研究

目的探讨经内镜逆行胆胰管造影术（endoscopic retrograde cholangiopancreatography,ERCP）下胆道全覆膜金属支架及塑料支架置入治疗远端胆道恶性梗阻性黄疸的有效性及安全性。方法回顾性分析并总结2012年11月—2018年12月收治的52例接受ERCP下全覆膜金属支架（WallFlex）置入和40例胆道塑料支架置入治疗不可切除的恶性梗阻性黄疸患者的操作成功率、临床成功率、通畅时间、堵塞率、再干预次数、总费用等临床资料。结果ERCP 操作成功率两组均为100.0%（92/92）,金属支架组和塑料支架组临床成功率分别为94.2%（49/52）和75.0%（30/40）（χ2 =6.89,P<0.01）。两组生存时间比较,差异无统计学意义（6.5个月比7.2个月, χ2=0.25,P>0.05）。金属支架组中位通畅时间较塑料支架组明显延长（182.0 d 比 84.0 d,P<0.01）。两组胰腺炎（χ2 =0.2,P>0.05）及胆管炎发生率(χ2 =0.2,P>0.05）比较差异无统计学意义。金属支架组发生堵塞的概率要明显少于塑料支架组 [7.8%（4/51）比 25.0%（10/40）, χ2 =5.25,P<0.05],在再次干预次数方面,金属支架组要明显少于塑料支架组（0.06 次比 0.38次,t=2.91,P<0.01）。塑料支架组和金属支架组在总费用上比较差异无统计学意义（42 956.1元比 44 851.5元,t=1.84,P=0.07）。结论ERCP下全覆膜金属支架置入对于不可切除的远端胆道恶性梗阻患者是一种安全、有效、经济的治疗方法,在通畅时间及再次干预次数等方面要明显优于塑料支架。     

Fully covered metal biliary stents: A review of the literature

Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.     

Evaluation of fully covered self-expanding metal stents in benign biliary strictures and bile leaks

AIM: To investigate the use of fully covered metal stents in benign biliary strictures (BBS) and bile leaks.METHODS: We studied 17 patients, at Harbor-UCLA Medical center (Los Angeles), with BBS (n = 12) and bile leaks (n = 5) from July 2007 to February 2012 that had received placement of fully covered self-expanding metal stents (FCSEMs). Fourteen patients had endoscopic placement of VIABIL^® (Conmed, Utica, New York, United States) stents and three had Wallflex^® (Boston Scientific, Mass) stents. FCSEMS were 8 mm or 10 mm in diameter and 4 cm to 10 cm in length. Patients were followed at regular intervals to evaluate for symptoms and liver function tests. FCSEMS were removed after 4 or more weeks. Resolution of BBS and leak was documented cholangiographically following stent removal. Stent patency can be defined as adequate bile and contrast flow from the stent and into the ampulla during endoscopic retrograde cholangiopancreatography (ERCP) without clinical signs and/or symptoms of biliary obstruction. Criterion for bile leak resolution at ERCP is defined as absence of contrast extravasation from the common bile duct, cystic duct remanent, or gall bladder fossa. Rate of complications such as migration, and in-stent occlusion were recorded. Failure of endoscopic therapy was defined as persistent biliary stenosis or continuous biliary leakage after 12 mo of stent placement.RESULTS: All 17 patients underwent successful FCSEMS placement and removal. Etiologies of BBS included: cholecystectomies (n = 8), cholelithiasis (n = 2), hepatic artery compression (n = 1), pancreatitis (n = 2), and Whipple procedure (n = 1). All bile leaks occurred following cholecystectomy. The anatomic location of BBS varied: distal common bile duct (n = 7), common hepatic duct (n = 1), hepaticojejunal anastomosis (n = 2), right intrahepatic duct (n = 1), and choledochoduodenal anastomatic junction (n = 1). All bile leaks were found to be at the cystic duct. Twelve of 17 patients had failed prior stent placement or exchange. Resolution of the biliary strictures and bile leaks was achieved in 16 of 17 patients (94%). The overall median stent time was 63 d (range 27-251 d). The median stent time for the BBS group and bile leak group was 62 ± 58 d (range 27-199 d) and 92 ± 81 d (range 48-251 d), respectively. All 17 patients underwent successful FCSEMS removal. Long term follow-up was obtained for a median of 575 d (range 28-1435 d). Complications occurred in 5 of 17 patients (29%) and included: migration (n = 2), stent clogging (n = 1), cholangitis (n = 1), and sepsis with hepatic abscess (n = 1).CONCLUSION: Placement of fully covered self-expanding metal stents may be used in the management of benign biliary strictures and bile leaks with a low rate of complications.     

Fully versus partially covered self‐expandable metal stents in benign esophageal strictures

Self‐expandable plastic stents are currently recommended for refractory benign esophageal strictures but they show disappointing results in terms of migration and long‐term efficacy. We report here our experience in the management of benign esophageal strictures with partially covered (PCSEMS) and fully covered self‐expandable metal stents (FCSEMS). We performed a retrospective analysis of self‐expandable metal stent (SEMS) placements for benign esophageal strictures from 1998 to 2011 in Rouen University Hospital. Twenty‐two patients (15 men, 7 women) attempted 40 esophageal SEMS placements (17 PCSEMS, 23 FCSEMS) during this period. All technical complications were migrations. Migration was noted after 3/17 PCSEMS (17.6%) and 4/23 FCSEMS placement (17.4%, P = ns). Clinical complications occurred after 6/17 PCSEMS and 2/23 FCSEMS placements (35.3% vs. 8.7%, P = 0.053). PCSEMS caused two major complications (fistulae) whereas FCSEMS did not cause any major complication (11.7% vs. 0%). Mean dysphagia score was significantly lower after SEMS placement (1.68 vs. 3.08, P < 0.001) with similar results for PCSEMS and FCSEMS. Stent placement resulted in long‐term clinical success for 23.5% of PCSEMS and 34.7% of FCSEMS (P = 0.0505). FCSEMS provide satisfying clinical success rate with an acceptable complication rate and they could constitute a relevant therapeutic option in the management of benign esophageal strictures.     

Fully covered self-expandable metallic stents for malignant airway disorders

Background

Airway stenting is an established procedure for treating airway stenosis and fistulas. The AERO stent (Merit Medical Systems, South Jordan, UT, USA), a relatively new, fully covered, self-expandable metallic stent, was approved in Japan in 2014. This study evaluated the efficacy and safety of this stent for malignant airway disorders.

Use of fully covered self-expanding metal stents in benign biliary diseases

Biliary fully covered self-expanding metal stents (FCSEMS) are now being used to treat several benign biliary conditions. Advantages include small predeployment and large postexpansion diameters in addition to an easy insertion technique. Lack of imbedding of the metal into the bile duct wall enables removability. In benign biliary strictures that usually require multiple procedures, despite the substantially higher cost of FCSEMS compared with plastic stents, the use of FCSEMS is offset by the reduced number of endoscopic retrograde cholangiopancreatography interventions required to achieve stricture resolution. In the same way, FCSEMS have also been employed to treat complex bile leaks, perforation and bleeding after endoscopic biliary sphincterotomy and as an aid to maintain permanent drainage tracts obtained by means of Endoscopic Ultrasound-guided biliary drainage. Good success rates have been achieved in all these conditions with an acceptable number of complications. FCSEMS were successfully removed in all patients. Comparative studies of FCSEMS and plastic stents are needed to demonstrate effi cacy and cost-effectiveness     

Evaluation of anti-migration properties of biliary covered self-expandable metal stents

AIM: To assess anti-migration potential of six biliary covered self-expandable metal stents(C-SEMSs) by using a newly designed phantom model. METHODS: In the phantom model, the stent was placed in differently sized holes in a silicone wall and retracted with a retraction robot. Resistance force to migration(RFM) was measured by a force gauge on the stent end. Radial force(RF) was measured with a RF measurement machine. Measured flare structure variables were the outer diameter, height, and taper angle of the flare(ODF, HF, and TAF, respectively). Correlations between RFM and RF or flare variables were analyzed using a linear correlated model.RESULTS: Out of the six stents, five stents were braided, the other was laser-cut. The RF and RFM of each stent were expressed as the average of five replicate measurements. For all six stents, RFM and RF decreased as the hole diameter increased. For all six stents, RFM and RF correlated strongly when the stent had not fully expanded. This correlation was not observed in the five braided stents excluding the laser cut stent. For all six stents, there was a strong correlation between RFM and TAF when the stent fully expanded. For the five braided stents, RFM after full stent expansion correlated strongly with all three stent flare structure variables(ODF, HF, and TAF). The laser-cut C-SEMS had higher RFMs than the braided C-SEMSs regardless of expansion state.CONCLUSION: RF was an important anti-migration property when the C-SEMS did not fully expand. Once fully expanded, stent flare structure variables plays an important role in anti-migration.     

Placement of a fully covered self-expandable metal stent in a young patient with chronic pancreatitis

Plastic stent insertion is a treatment option for pancreatic duct stricture with chronic pancreatitis. However, recurrent stricture is a limitation after removing the plastic stent. Self-expandable metal stents have long diameters and patency. A metal stent has become an established management option for pancreatic duct stricture caused by malignancy but its use in benign stricture is still controversial. We introduce a young patient who had chronic pancreatitis and underwent several plastic stent insertions due to recurrent pancreatic duct stricture. His symptoms improved after using a fully covered self-expandable metal covered stent and there was no recurrence found at follow-up at the outpatient department.     

Retrospective comparison of different percutaneous approaches to manage occluded primary uncovered self-expandable metal stents in patients with unresectable malignant hilar biliary obstruction

Abstract

Purpose: To compare different percutaneous approaches to manage occluded primary uncovered self-expandable metal stents (SEMS) in patients with unresectable malignant hilar biliary obstruction (MHBO).

Materials and Methods: A retrospective study was performed in patients with MHBO who underwent percutaneous management of occluded primary uncovered SEMS between January 2014 and January 2018. Patients were assigned into three groups based on the types of secondary stents, which included SEMS, internal-external drainage (IED), and external drainage (ED). Clinical success, requirement for reintervention, survival times, complications, and cost were evaluated.

Results: A total of 58 patients were identified, with 21, 9, and 28 patients received SEMS, IED, and ED treatments, respectively. The overall clinical success rate was 67.2% (39/58), with no significant difference among three groups (p?=?.489). The median time to reintervention was 82, 57, and 61?days for the SEMS, IED, and ED groups, respectively (p?=?.045 for SEMS vs. IED; p?=?.011 for SEMS vs. ED). There was no significant difference in the median survival times among three groups (p?=?.308). Seven patients (12.7%) experienced minor complications including self-limiting haemobilia (n?=?3) and catheter-related pain (n?=?4). Fourteen patients (24.1%) had major complications, including early cholangitis (n?=?8), pancreatitis (n?=?3), stent dislodgement (n?=?2), and bile leakage (n?=?1). There was no statistical difference in the mean cost of the management of occluded primary SEMS between the three groups (p?=?.162).

Conclusion: Uncovered SEMS could provide a longer duration to reintervention compared to the catheter drainages to manage occluded primary SEMS in patients with unresectable MHBO.