Application of rectal stents for palliation of obstructing rectosigmoid cancer

Background: The rationale of palliative endoscopic treatment is to avoid a colostomy in patients with advanced disease and limited life expectancy. This study was conducted to evaluate the role of endoscopic stent implantation for palliation of obstructing rectal cancer. Methods: Overall, 19 patients (aged 47–87 years) with nonresectable or metastatic rectal cancer were treated by stent insertion after laser recanalization or dilation. Three types of stents, i.e., plastic tubes (n= 8), self-expanding mesh stents (n= 6), and endocoil stents (n= 5), were used to maintain luminal patency. Results: Endoscopic stent implantation was successfully performed in all 19 patients. Long-term luminal patency and satisfactory bowel function were achieved in 16 of 19 patients (84%). After a median follow-up of 6 months, eight of the patients have died and eight are still alive without evidence of recurrent obstruction. Dislocation of the endoprosthesis occurred in two of eight plastic tubes and one of five mesh stents. Recurrent obstruction due to tumor ingrowth was only observed in patients treated with self-expanding mesh stents (n= 2). In spite of reinsertion and laser therapy a colostomy was required in three of 19 patients. There was no evidence of treatment failure in five patients who received endocoil stents. None of the patients experienced serious complications related to the endoscopic procedure. Conclusions: Endoscopic stent implantation seems to be a safe and efficient palliative approach to selected patients with obstructing rectal cancer. Currently, self-expanding coil stents are superior to other devices because of lower risk of dislocation and tumor ingrowth. Received: 10 May 1996/Accepted: 11 November 1996     

Adjuvant therapies using biliary stenting for malignant biliary obstruction

The aim of this study was to analyze the patency of expandable metallic stents in malignant biliary obstruction and to evaluate the efficacy of adjuvant therapy accompanied by biliary stenting. We analyzed 29 patients in whom bile duct stenting was performed for malignant biliary obstruction. Their types of disease were: hilar ductal carcinoma (n = 8), gallbladder carcinoma (n = 11), and pancreatic carcinoma (n = 10). Initially, 46 expandable metallic stents were placed in 29 patients. In 23 of the 29 patients, adjuvant therapy was administered. Seventeen patients underwent radiotherapy, and 16 patients received various systemic chemotherapies. In principle, hyperthermia was performed twice a week, simultaneously with radiotherapy. Patient survival and the probability of stent patency were calculated using actuarial life table analysis. There was no significant difference in stent patency among the patients according to type of disease. Hyperthermia did not influence the stent patency rate. The median stent patency time was significantly greater in the chemo-radiation group than in the no-adjuvant therapy group: 182 days versus 68 days, respectively (P = 0.017). Moreover, a significant increase was seen in the median survival time in the chemo-radiation group: 261 days versus 109 days (P = 0.0337). Complications occurred in 9 patients (31.0%). Stent occlusion occurred in 6 patients (20.7%), with all of these patients managed successfully using a transhepatically placed new expandable metallic stent, employing the stent-in-stent method. Stent migration occurred in 2 patients after radiotherapy. Adjuvant therapies such as radiotherapy and systemic chemotherapy, in combination with stent insertion, resulted in an increase in the patency period of expandable metallic stents and in increased patient survival time. Received: August 18, 2000 / Accepted: December 1, 2000     

Metallstents in der Gastroenterologie

Self-expanding metal stents have, when introduced in their constrained form through gastrointestinal and biliary strictures, a relatively small diameter. Once placed through the stricture and released, however, they expand to a much larger internal diameter, thus giving rise to sufficient palliative reopening of these strictures. Since metal stents are usually not removable, their primary use has been in malignant stenoses. Benign strictures should be treated with metal stents only in exceptional situations. For palliation of dysphagia in esophagocardial malignancies, metal stents have been shown to be associated with significantly fewer initial complications on placement than plastic tubes. The long-term fate of both stent types seems to be similar. In the palliation of malignant jaundice, metal stents were demonstrated to have a significantly longer patency rate, resulting in a favourable cost-benefit ratio despite the high price of metal stents. Continued developments are necessary to further reduce long-term complications and effectiveness.     

Tannenbaum and metal stents in the palliative treatment of malignant distal bile duct obstruction: a comparative study of patency and cost effectiveness

Background Stent clogging is the major limitation of palliative treatment for malignant biliary obstruction. Metal stents have much better patency than plastic stents, but are more expensive. Preliminary data suggest that the recently designed plastic (Tannenbaum) stent has better duration of patency than the polyethylene stent. This study aimed to compare the efficacy and cost effectiveness between the Tannenbaum stent without side holes and the uncovered metal stent for patients with malignant distal common bile duct obstruction. Methods In this study, 47 patients (median age, 73 years, range, 56–86 years) with inoperable malignant distal common bile duct strictures were prospectively randomized to receive either a Tannenbaum stent (n = 24) or an uncovered self-expandable metal stent (n = 23). The patients were clinically evaluated, and biochemical tests were analyzed if necessary until their death or surgery for gastric outlet obstruction. Cumulative first stent patency and patient survival were compared between the two groups. Cost-effectiveness analysis also was performed for the two study groups. Results The two groups were comparable in terms of age, gender, and diagnosis. The median first stent patency was longer in the metal group than in the Tannenbaum stent group (255 vs 123.5 days; p = 0.002). There was no significant difference in survival between the two groups. The total cost associated with the Tannenbaum stents was lower than for the metal stents (17,700 vs 30,100 euros; p = 0.001), especially for patients with liver metastases (3,000 vs 6,900 euros; p < 0.001). Conclusions Metal stent placement is an effective treatment for inoperable malignant distal common bile duct obstruction, but Tannenbaum stent placement is a cost-saving strategy, as compared with metal stent placement, especially for patients with liver metastases and expected short survival time.     

Systematic appraisal of the role of metallic endobiliary stents in the treatment of benign bile duct stricture

OBJECTIVE: To carry out a systematic appraisal of the current status of the use of metallic endobiliary stents in the treatment of benign biliary strictures. METHODS: A computerized search of the MEDLINE and EMBASE databases identified 37 studies providing detailed clinical course data on outcome of metallic endobiliary stent placement in 400 patients. Pooled data were examined for etiology of stricture, indications for stent placement, procedure-related complications, and outcome with reference to stent patency. RESULTS: The median (range) number of patients per report was 8 (2-54) with a median recruitment period of 44 (9-126) months. The most frequent indications were postoperative biliary strictures in 123 (31%), stenosed biliary-enteric anastomoses in 79 (20%), and biliary strictures following liver transplantation in 88 (22%). During a median follow up of 31 (1-111) months, 139 (35%) stents occluded, and there are little patency data beyond 2 years after deployment, with 99 (25%) known to be patent at 3 years from stent placement. CONCLUSIONS: These pooled data on 400 patients constitute the largest collective report to date on the use of metallic endobiliary stents for benign biliary strictures. The results show a critical lack of data on long-term patency such that at the present time, metallic endobiliary stents should not be used for benign stricture in those patients with a predicted life expectancy greater than 2 years.     

Endoscopic treatment of distal bile duct stricture from chronic pancreatitis

Background: Endoscopic placement of biliary stents is an effective initial treatment for jaundice and cholangitis caused by common bile duct (CBD) strictures secondary to chronic pancreatitis; however, the role of endoscopic treatment for long-term management of these strictures is less clear. In 1992, we designed a protocol of balloon dilatation and stenting for ≥12 months. This study evaluates endoscopic therapy as a definitive long-term treatment for these strictures. We have treated 25 patients with this protocol. Methods: All patients had an endoscopic sphincterotomy, balloon dilatation of the stricture, and then placement of a polyethylene stent (7–11.5 F). Stents were exchanged at 3–4-month intervals to avoid the complications of clogging and cholangitis. We were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the stent. Results: The length of the CBD strictures ranged from 8 to 40 mm. Within days of stenting, all patients achieved relief of jaundice and cholestasis. Complications consisted of six episodes of cholangitis and nine episodes of pancreatitis. There were no deaths. Twenty of the 25 patients are now stent-free after an average stenting period of 13 months (range, 3–28). To date, there has been no recurrence of stricture, for a mean of 32 months. Three patients still have stents in place, and two patients required operation—one for persistent stricture and recurrent cholangitis after 8 months of stenting, and one for a mass in the head of the pancreas that was thought to be cancer. Conclusions: Our results indicate that these strictures will respond and dilate after a course of stenting in 80% of patients, with an acceptable morbidity. Although these are medium-term results at 32 months, we would expect most recurrences within the 1st year following stent removal. In some cases, stenting is necessary for >12 months. Thus, the data suggest that endoscopic stenting provides definitive treatment in most patients with CBD stricture due to chronic pancreatitis and may be considered a viable alternative to standard surgical bypass. Received: 18 May 1999/Accepted: 24 September 1999     

Laparoscopic gastrojejunostomy and endoscopic biliary stent placement for palliation of incurable gastric outlet obstruction with cholestasis

Background: For patients with incurable malignant gastric outlet obstruction and cholestasis, laparoscopic gastrojejunostomy combined with endoscopic biliary stent placement seems to offer a minimally invasive palliation. Methods: We retrospectively analyzed the data of 16 patients submitted to laparoscopic gastrojejunostomy. Laparoscopic gastroenterostomy was performed as an antecolic, side-to-side gastrojejunostomy with enteroenterostomy. In 12 patients cholestasis was relieved preoperatively by stent placement via endoscopy (n= 6, 37.5%), percutaneous access (n= 5, 31%) or bilioenteric anastomosis (n= 1, 6.25%). One patient needed a percutaneous Yamakawa prosthesis postoperatively. Results: Mean operative time was 126 min. There were no intraoperative complications. In one patient conversion to open surgery became necessary because of extensive adhesions. The only postoperative complication was bleeding from a trocar site requiring reintervention; there was no mortality. Median postoperative hospital stay was 7 days. Delayed gastric emptying was observed in 3 (18.7%) patients. Median survival was 87 days after the operation. All patients died from their primary disease but could maintain oral intake during the remaining survival time. Conclusions: We conclude that laparoscopic gastrojejunostomy and endoscopic or percutaneous biliary stenting provide a good functional result while impairing the quality of life only to a minimal extent. Received: 7 May 1996/Accepted: 12 December 1996     

Video-assisted interventional bronchoscopy

Background: Major airway obstruction due to benign or malignant etiology is not uncommon and is always distressing. Intraluminal stenting has been shown to be a safe and effective approach for symptomatic relief in selected patients based on the European and North American experience. Methods: We reviewed our experience in Hong Kong on airway stenting over a 19-month period. Results: From February 1994 to August 1995, 33 silicone stents (Dumon stent, Cometh, Marseille, France) were placed in 23 patients (20 males, three females with mean age 61.4 years, range from 26 to 81). Eighteen stents were placed in the trachea, nine in the left main stem, five in the right main stem, and one Y-stent over the carina. Twelve patients had esophageal carcinoma involving the airway, seven had bronchial carcinoma, one had metastatic carcinoma, and three had benign strictures (of which two were due to tuberculosis). There was no procedural related mortality. Stent migration occurred in four patients (17%) and required stent change. Symptoms were improved in all patients as documented by the visual analogue scale. Conclusion: Our experience represents the ``stentable' diseases seen in Hong Kong, where carcinoma of the esophagus (and tuberculosis) remains prevalent. We conclude that intraluminal stenting remains a safe and effective approach in selected patients with critical airway stenosis. Complications, however, do exist and should be realized by the operator, the patients, and their families. Received: 4 September 1996/Accepted: 3 August 1996     

Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases

Background Self-expanding metal stents (SEMS) are an established treatment for palliation of malignant colorectal strictures and as a bridge to surgery for acute malignant colonic obstruction. Patients with benign colonic strictures may benefit from stent placement, but little data exist for this indication. Methods All cases of colonic stent placement identified from a prospectively collected gastrointestinal database from April 1999 to August 2006 were reviewed. During the study period, 23 patients with benign obstructive disease underwent endoscopic SEMS placement. The etiologies of the stricture were diverticular/inflammatory (n = 16), postsurgical anastomotic (n = 3), radiation-induced (n = 3), and Crohn’s (n = 1) disease. All strictures were located in the left colon. Five patients had an associated colonic fistula. Uncovered Enteral Wallstents or Ultraflex Precision Colonic stents (Boston Scientific) were endoscopically placed in all but one patient. Results Stent placement was technically successful for all 23 patients, and obstruction was relieved for 22 patients (95%). Major complications occurred in 38% of the patients including migration (n = 2), reobstruction (n = 4), and perforation (n = 2). Of these major complications, 87% occurred after 7 days. Four patients did not undergo an operation. Of the 19 patients who underwent planned surgical resection, 16 were successfully decompressed and converted from an emergent operation to an elective one with a median time to surgical resection of 12 days (range, 2 days to 18 months). Surgery was delayed more than 30 days after stent placement for six of these patients. Of the 19 patients who underwent a colectomy, 8 (42%) did not need a stoma after stent insertion. Conclusions SEMS can effectively decompress high-grade, benign colonic obstruction, thereby allowing elective surgery. The use of SEMS can offer medium-term symptom relief for benign colorectal strictures, but this approach is associated with a high rate of delayed complications. Thus, if elective surgery is planned, data from this small study suggest that it should be performed within 7 days of stent placement. Podium presentation at the annual meeting of the Society of American Gastrointestinal and Esophageal Surgeons (SAGES), 18–22 April 2007 at Las Vegas, NV, USA     

SELF-EXPANDABLE METAL STENTS FOR MALIGNANT DYSPHAGIA

Background : The use of self-expandable metal stents in relieving dysphagia for patients with incurable malignant oesophageal strictures was retrospectively evaluated. Methods : Between September 1993 and August 1996, 66 male and 16 female patients with a median age of 72 years received self-expandable metal stents for malignant dysphagia. Six patients had concurrent tracheo-oesophageal fistulas. All patients were stented under sedation and stent insertion was performed under fluoroscopic guidance. Results : Stent placement was successful in 80 patients (98%). There were seven early complications (inaccurate positioning (n = 3), migration (n = 1), incomplete expansion (n = 1), intractable pain (n = 1), and perforation (n = 1)). Two complications were lethal and three were treated endoscopically. Mean dysphagia grade improved from 3.2 ± 0.7 to 1.8 ± 0.9 (P < 0.05) after implantation. All tracheo-esophageal fistulas were successfully occluded. Upon a median follow-up of 8 weeks (range: 2–20 weeks), 30 complications developed in 21 patients (tumour overgrowth (n = 15), food bolus obstruction (n = 7), tumour ingrowth (n = 2), buckling of stent (n = 2), tracheo-esophageal fistula (n = 2), bleeding (n = 1), and gastric wall herniation through metal coils (n = 1)). Median survival was 13 weeks (range: 1–82 weeks). Conclusion : Self-expandable metal stents provide useful palliation in patients with incurable malignant dysphagia.     

Comparison of bile duct pressures following sphincterotomy and endobiliary stenting in a canine model

Background: Cystic duct (CD) leaks following laparoscopic cholecystectomy may be diagnosed and managed with ERCP. Treatment options include endoscopic sphincterotomy (ES) and/or endobiliary stenting (Stent). This study was undertaken to determine if ES or Stent is more effective in lowering bile duct pressures by disrupting the pressure gradient created by the sphincter of Oddi and therefore more beneficial in the management of CD. Methods: Mongrel dogs underwent midline laparotomy and antegrade cannulation of the common bile duct (CBD) with an umbilical artery catheter. Baseline CBD pressures were measured following duodenotomy; 5 Fr and 7 Fr stents measuring 2.5 cm, 4.5 cm, and 7 cm were inserted retrograde into the CBD. CBD pressure was measured after each stent insertion. A 1-cm sphincterotomy was the performed using a double channel papillotome. Results: Insertion of both 5 Fr and 7 Fr stents significantly lowered CBD pressure as compared to sphincterotomy alone, p < 0.05. There was no significant difference in the reduction in CBD pressure following the insertion of either the 5 Fr or 7 Fr stents of varying lengths. Sphincterotomy alone did not significantly decrease CBD pressure as compared to baseline pressure. The insertion of a stent following sphincterotomy also caused a significant decrease in CBD pressure as compared to sphincterotomy alone, p= 0.034. Conclusion: Stent placement or ES with Stent placement significantly reduced CBD pressure as compared to ES alone. Stent diameter and length were not significant variables in this study. These results support the use of Stent or ES with Stent rather than ES alone in the management of CD leaks. Received: 5 March 1996/Accepted: 23 July 1996     

Long-term results of metallic stents for benign biliary strictures

BACKGROUND: Historically, surgical correction has been the treatment of choice for benign biliary strictures (BBS). Self-expandable metallic stents (MSs) have been useful for inoperable malignant biliary strictures; however, their use for BBS is controversial and their natural history unknown. HYPOTHESIS: To test our hypothesis that MSs provide only short-term benefit, we examined the long-term outcome of MSs for the treatment of BBS. Our goal was to develop a rational approach for treating BBS. DATA EXTRACTION: Between July 1990 and December 1995, 15 patients had MSs placed for BBS and have been followed up for a mean of 86.3 months (range, 55-120 months). The mean age of the patients was 66.6 years and 12 were women. Stents were placed for surgical injury in 5 patients and underlying disease in 10 patients (lithiasis, 7; pancreatitis, 2; and primary sclerosing cholangitis, 1). One or more MSs (Gianturco-Rosch "Z" for 4 patients and Wallstents for 11 patients) were placed by percutaneous, endoscopic, or combined approaches. We considered patients to have a good clinical outcome if the stent remained patent, they required 2 or fewer invasive interventions, and they had no biliary dilation on subsequent imaging. DATA SYNTHESIS: Metallic stents were successfully placed in all 15 patients, and the mean patency rate was 30.6 months (range, 7-120 months). Five patients (33%) had a good clinical result with stent patency from 55 to 120 months. Ten patients (67%) required more than 2 radiologic and/or endoscopic procedures for recurrent cholangitis and/or obstruction (range, 7-120 months). Five of the 10 patients developed complete stent obstruction at 8, 9, 10, 15, and 120 months and underwent surgical removal of the stent and bilioenteric anastomosis. Four of these 5 patients had strictures from surgical injuries. The patient who had surgical removal 10 years after MS placement developed cholangiocarcinoma. CONCLUSIONS: Surgical repair remains the treatment of choice for BBS. Metallic stents should only be considered for poor surgical candidates, intrahepatic biliary strictures, or failed attempts at surgical repair. Most patients with MSs will develop recurrent cholangitis or stent obstruction and require intervention. Chronic inflammation and obstruction may predispose the patient to cholangiocarcinoma.     

EXPANDABLE METALLIC BILIARY STENTS

Eighteen expandable metallic biliary stents were inserted in patients with malignant (16 patients) or benign (two patients) biliary strictures. Four were the Gianturco-Rosch biliary Z-stents and the remaining 14 were the Wallstent. The stents were delivered through either the endoscopic transpapillary (10 patients), percutaneous transhepatic (five patients) or combined percutaneous-endoscopic (three patients) route. No failure in implantation was encountered. Bile drainage was successful in all patients. Stent occlusions were observed in four patients with hilar obstruction due to tumour overgrowth above the stents at 30–67 days (mean 47.75 days) after insertion. The occlusions were drained percutaneously (two patients) or endoscopically (two patients). Migration of stent did not occur. After a median follow-up period of 170.5 days (range 57–731 days), 11 patients were still alive and free of jaundice. The median patency period of the stents for common bile duct and hilar obstruction was 288.5 days (range 117–731 days) and 61.5 days (range 30–188 days), respectively. The overall median patency period was 165 days. It is concluded that expandable metallic biliary stent is a useful adjunct to the treatment of malignant biliary obstructions with a better result in distal obstruction.     

Percutaneous transhepatic insertion of self-expanding short metal stents for biliary obstruction before resection of pancreatic or duodenal malignancy proves to be safe and effective

Background  

The British Society of Gastroenterology guidelines for the management of malignant obstructive jaundice state: “If a stent is placed prior to surgery, this should be of the plastic type and it should be placed endoscopically. Self-expanding metal stents should not be inserted in patients who are likely to proceed to resection.” In 2003, a small series of complications after endoscopic intervention caused a change in the authors’ practice. Currently, all patients requiring relief of biliary obstruction before surgical resection undergo attempted insertion of a short metal biliary stent.     

Complication of benign tracheobronchial strictures by self-expanding metal stents

OBJECTIVES: Self-expanding metal stents are used to palliate benign strictures. We examined the complications of this approach. METHODS: Between 1997 and 2002, we observed recurrent airway obstruction and extension of benign inflammatory strictures after the placement of tracheobronchial Microvasive Ultraflex stents and Wallstents (Boston Scientific Corp, Natick, Mass), in 10 patients with postintubation strictures and 5 with other indications; all but 1 patient were referred to us. Patients with tracheal (9), subglottic (1), combined tracheal and subglottic (3), and bronchial (2) strictures had been treated with covered and uncovered Wallstents (6) and Microvasive Ultraflex stents (9). RESULTS: After stent insertion, stricture and granulations within previously normal airway were seen in all patients. New subglottic strictures resulting from the stent caused hoarseness in 4 patients. A bronchoesophageal fistula was found in 1 patient at presentation and a tracheoesophageal fistula in another during extraction of a Wallstent. Primary surgical reconstruction, judged to have been feasible before wire stent insertion in 10 patients, was possible after stenting in only 7 and failed in 2. Palliative tubes were placed in 60% (9/15). Self-expanding metal stents may lengthen luminal damage, incite subglottic strictures, and cause esophagorespiratory fistula in inflammatory airway strictures. The injury is severe, occurs after a short duration of stenting, and precludes definitive surgical treatment or requires more extensive tracheal resection. CONCLUSION: The current generation of self-expanding metal stents should be avoided in benign strictures of trachea and bronchi.     

Ureteral Obstruction: Is the Full Metallic Double-Pigtail Stent the Way to Go?

Background

The Resonance metallic ureteral stent (Cook Medical, Bloomington, Indiana, USA) has been introduced for the management of extrinsic-etiology ureteral obstruction for time periods up to 12 mo.

Objective

The current study aims to determine short- and medium-term effectiveness of the Resonance stent in malignant and benign ureteral obstruction.

Design, setting, and participants

In total, 50 patients with extrinsic malignant obstruction (n = 25), benign ureteral obstruction (n = 18), and previously obstructed mesh metal stents (n = 7) were prospectively evaluated.

Intervention

All patients were treated by Resonance stent insertion. Twenty stents were inserted in antegrade fashion, and the remaining stents were inserted in a retrograde approach. No patient dropped out of the study. The follow-up evaluation included biochemical and imaging modalities.

Measurements

We evaluated the technical success rate, stricture patency rate, complications, and the presence and type of encrustation.

Results and limitations

The technical success rate of transversal and stenting of the strictures was 100%. In 19 patients, balloon dilatation was performed prior to stenting. The mean follow-up period was 8.5 mo. The stricture patency rate in patients with extrinsic malignant ureteral obstruction was 100% and in patients with benign ureteral obstruction 44%. Failure of Resonance stents in all cases of obstructed metal stents was observed shortly after the procedure (2–12 d). In nine cases, stent exchange was demanding. Encrustation was present in 12 out of 54 stents.

Conclusions

The Resonance stent provides safe and sufficient management of malignant extrinsic ureteral obstruction. Resonance stent use in benign disease needs further evaluation, considering the untoward results of the present study.     

Palliation of malignant rectal obstruction with self-expanding metal stents

BACKGROUND: Surgical management of patients with metastatic or recurrent rectal cancer remains controversial. Self-expanding metal stents are increasingly used for palliative treatment of advanced tumors, although long-term results are not yet available. METHODS: Between 1996 and 2003, 521 patients underwent surgery for rectal neoplasms. In the same time period, self-expanding metal stents were used for palliation of 34 patients with malignant rectal obstruction and incurable disease. The outcome of the patients was analyzed retrospectively. RESULTS: Rectal stents were successfully placed in 33 of 34 patients (97%) without major complications. Early failure occurred in 7 patients (21%) because of stent migration, pain, or incontinence. Long-term success with a mean patency of 5.3 months was observed in 26 patients (79%), but restenting was required in 2 patients. Despite the initial success of stenting, a colostomy was created in 2 other patients after 3.4 months and 9.2 months because of incontinence and rectovesical fistula. Overall, 6 of 33 patients (18%) underwent palliative surgery because of early complications (n = 4) or long-term failure of stent treatment (n = 2). CONCLUSIONS: Self-expanding metal stents are useful to avoid a colostomy in selected patients with incurable rectal cancer and limited life expectancy. Nonetheless, a considerable number (18%) of patients will require surgical palliation because of failure of stent treatment.     

Newly designed large cell Niti-S stent for malignant hilar biliary obstruction: a pilot study

Background

Whether uni- or bilateral drainage should be performed for malignant hilar biliary obstruction remains a matter of debate. Moreover, endoscopic placement of bilateral metallic stents has been considered difficult and complicated. Although the Y-stent with a central wide-open mesh facilitates bilateral stent placement, it has limitations. This study evaluated the feasibility and efficacy of the Niti-S large cell D-type biliary stent (LCD) with a uniform large cell for both uni- and bilateral drainage of malignant hilar biliary obstruction.

Methods

From April 2008 to March 2009, a total of 12 consecutive patients with unresectable malignant hilar biliary obstruction of Bismuth type 2 or greater underwent placement of LCD. Before LCD placement, all the patients underwent endoscopic unilateral biliary drainage using a plastic stent or a nasobiliary drainage tube. If jaundice improved after the procedure, the plastic stent or nasobiliary drainage tube was replaced with the unilateral LCD. If jaundice did not resolve or contralateral cholangitis occurred, bilateral LCD placement was performed.

Results

Seven patients had unilateral and five patients had bilateral LCD placement. Technical success was achieved for all 12 patients. An early complication occurred for one patient (8%), and stent occlusion occurred for six patients (50%) because of tumor ingrowth (n?=?4) or sludge (n?=?2). These patients were managed by insertion of plastic stents (n?=?4) or percutaneous transhepatic biliary drainage (n?=?2). The median stent patency period was 202?days.

Conclusions

The newly designed endoscopic metallic stent may be feasible and effective for malignant hilar biliary obstruction, and endoscopic reintervention is relatively simple.     

Application of resonance metallic stents for ureteral obstruction

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To determine the effectiveness of the Resonance ureteral stent and clarify the risk factors that lead to stent failure. In the present study, we review our clinical experiences using Resonance stent in treating malignant and benign ureteral obstruction.

PATIENTS AND METHODS

• ? Nineteen patients with extrinsic malignant ureteral obstruction (n= 15) and benign stricture (n= 4) were retrospectively evaluated.
• ? All patients had received Resonance stent insertion through antegrade or cystoscopic retrograde approaches. The pre‐insertion and follow‐up interventions included image studies and biochemical tests. The insertion success rate, obstruction patency rate and complications were reviewed.
• ? For categorical variables, the chi‐square test and Fisher’s exact test were carried out to determine associations between variables.

RESULTS

• ? The technical success rate of stent insertion was 84.6%. The mean follow‐up was 5 months (range 1–10.5 months).
• ? Five stents failed to alleviate the obstruction, and the patency rate was 77.3% (17/22).
• ? Patients who had had previous radiation therapy had a lower ureter patency rate in comparison with non‐radiation patients (50% vs 92.3% respectively, P= 0.039).
• ? The 6‐ and 9‐month patency rates were 81.0% with 11 stents and 27.0% with 3 stents, respectively.

CONCLUSIONS

• ? The results of the present study demonstrated that malignant or benign ureteral obstruction could be treated safely and sufficiently with the Resonance metallic stent.
• ? Careful patient selection is critical to achieve successful results.
• ? For malignant ureteral obstruction, previous radiation therapy is a risk factor for stent failure.

     

Are expandable metallic stents better than conventional methods for treating difficult intrahepatic biliary strictures with recurrent hepatolithiasis?

BACKGROUND: Conventional methods for treating patients with recurrent hepatolithiasis associated with complicated intrahepatic biliary strictures include balloon dilatation of the intrahepatic biliary strictures, lithotripsy, and the clearance of difficult stones as completely as possible, with the placement of an external-internal stent for at least 6 months. After these modalities are used, symptomatic refractory strictures remain. Recently we used internal Gianturco-Rosch metallic Z stents to treat patients who had refractory strictures. OBJECTIVE: To compare therapeutic results and complications of an internal expandable metallic Z stent with those of repeated external-internal stent placement. STUDY DESIGN: Case-control study. SETTING: A referral center. PATIENTS: From January 1992 to December 1996, 18 patients with recurrent hepatolithiasis and complicated intrahepatic biliary strictures underwent percutaneous dilatation of stricture and transhepatic percutaneous cholangioscopic lithotomy for recurrent stones. After their stones were completely cleared, their biliary strictures failed to dilate satisfactorily. The patients were randomly enrolled into 2 groups: group A (7 patients), who received an expandable metallic Z stent, and group B (11 patients), who had repeated placement of external-internal stents. INTERVENTIONS: Percutaneous stricture dilatation, electrohydraulic lithotripsy, balloon dilatation, percutaneous transhepatic cholangioscopic lithotomy, and biliary stenting by a Silastic external-internal catheter or a modified Gianturco-Rosch expandable metallic Z stent (for an internal stent). MAIN OUTCOME MEASURES: The number of procedures, days in hospital, procedure-related complications, incidents of stone recurrence and recurrence of cholangitis, readmissions to the hospital, treatment sessions required, and mortality rate. Patients' limitations in ordinary activities were also compared. RESULTS: The follow-up period ranged from 28 to 60 (40.7+/-12.7 [mean +/- SD]) months in group A and from 28 to 49 (36.0+/-7.2) months in group B. Fewer group A patients (3 [43%]) than group B patients (8 [73%]) tended to have recurrent cholangitis and to require readmission to the hospital, but this was not statistically significant (P = .33). When their cumulative probability of a first episode of cholangitis during follow-up was compared, however, it was significantly lower in patients treated with a metallic stent (P = .04). Compared with group B patients, group A patients had less frequent recurrence of stones (0% vs 64%; P = .01), fewer procedures for the clearance of biliary stones or sludge (1.7+/-2.2 vs 6.4+/-4.3; P = .03), and shorter hospital stays (8.0+/-11.5 days vs 17.0+/-12.0 days; P = .07). No patients in group A experienced limitation in ordinary activities, whereas 7 patients in group B did (P<.02). CONCLUSIONS: Compared with the repeated placement of external-internal stents, the use of a metallic internal stent effectively decreases stone recurrence, simplifies further procedures, and is more convenient. Its use is suggested as an alternative choice in the treatment of recurrent hepatolithiasis with refractory intrahepatic biliary strictures.