Comparison of endoscopic stenting for malignant biliary obstruction: A single-center study

AIM: To evaluate the efficacy and safety of single-step endoscopic placement of self-expandable metallic stents(SEMS) for treatment of obstructive jaundice.METHODS: A retrospective study was performed among 90 patients who underwent transpapillary biliary metallic stent placement for malignant biliary obstruction(MBO) between April 2005 and October 2012. The diagnosis of primary disease and MBO was based on abdominal ultrasound, computed tomography, magnetic resonance imaging, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography with brush cytology, biopsy, and/or a combination of these modalities. The type of SEMS(covered or non-covered, 8 mm or 10 mm in diameter) was determined by the endoscopist. Ninety patients were divided into two groups: group 1(49 patients) who underwent a singlestep SEMS placement and group 2(41 patients) who underwent a two-step SEMS placement. The technical success rate, complication rate, stent patency, and patient survival rate were compared between the groups. In addition, to identify the clinical prognostic factors associated with patient survival, the following variables were evaluated in Cox-regression analysis: gender, age, etiology of MBO(pancreatic cancer or nonpancreatic cancer), clinical stage(Ⅳb; with distant metastases or Ⅳa ; without distant metastases), chemotherapy(with or without), patency of the stent, and the use of single-step or two-step SEMS. RESULTS: Immediate technical success was achieved in 93.9%(46/49) in group 1 and in 95.1%(39/41) in group 2, with no significant difference(P = 1.0). Similarly, there was no difference in the complication rates between the groups(group 1, 4.1% and group 2, 4.9%; P = 0.62). Stent failure was observed in 10 cases in group 1(20.4%) and in 16 cases in group 2(39.0%). The patency of stent and patient survival revealed no difference between the two groups with Kaplan-Meier analysis, with a mean patency of 111 ± 17 d in group 1 and 137 ± 19 d in group 2(P = 0.91), and a mean survival of 178 ± 35 d in group 1 and 222 ± 23 d in group 2(P = 0.57). On the contrary, the number of days of hospitalization associated with first-time SEMS placement in group 1 was shorter when compared with that number in group 2(28 vs 39 d; P 0.05). Multivariate analysis revealed that a clinical stage of Ⅳa (P = 0.0055), chemotherapy(P = 0.0048), and no patency of the stent(P = 0.011) were independent prognostic factors associated with patient survival.CONCLUSION: Our results showed that single-step endoscopic metal stent placement was safe and effective for treating obstructive jaundice secondary to various inoperable malignancies.     

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.     

三种方式同期放置双侧金属支架治疗肝门胆管恶性梗阻的比较研究

目的:探讨内镜下3种方式同期平行放置双侧金属支架治疗无法手术切除肝门胆管恶性梗阻的疗效。方法:回顾性分析2012年1月—2019年2月期间上海东方肝胆外科医院采用内镜下同期平行放置双侧金属支架治疗无法手术切除肝门胆管恶性梗阻(Bismuth Ⅱ～Ⅳ型)的118例患者资料。按照支架放置方式分为3组：双侧支架均跨越十二指肠...     

Endoscopic stenting for palliation of malignant biliary obstruction

Since the late 1970s, endoscopic biliary stenting has become a standard palliative treatment for obstructive jaundice due to malignancies of the pancreas and the hepatobiliary system. Despite the high initial success rate in achieving biliary drainage, endoscopic stenting therapy has been limited by the clogging of biliary stents, usually after four to five months, due to formation of adherent bacterial biofilm and accumulation of biliary sludge. Various methods for the prevention of bacterial adhesion and prolongation of stent patency have been investigated, including prophylactic antimicrobial agents and bile salts, new stent materials, and new stent designs. Recently, the introduction of self-expandable metal stents has significantly improved the duration of stent patency but the cost is considerably higher. Each method has its own merits as well as specific problems. This article reviews the pathogenesis of biofilm formation on the biliary stents and the latest status of research in avoiding stent occlusion.     

Endoscopic stenting for inoperable malignant biliary obstruction: A systematic review and meta-analysis

AIM: To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction.METHODS: A systematic review of randomized clinical trials(RCT) was conducted, with the last update on March 2015, using EMBASE, CINAHL(EBSCO), MEDLINE, LILACS/CENTRAL(BVS), SCOPUS, CAPES(Brazil), and gray literature. Information of the selected studies was extracted in sight of six outcomes: primarily regarding dysfunction, complication and reintervention rates; and secondarily costs, survival, and patency time. The data about characteristics of trial participants, inclusion and exclusion criteria and types of stents were also extracted. The bias was mainly assessed through the JADAD scale. This meta-analysis was registered in the PROSPERO database by the number CRD42014015078. The analysis of the absolute risk of the outcomes was performed using the software Rev Man, by computing risk differences(RD) of dichotomous variables and mean differences(MD) of continuous variables. Data on RD and MD for each primary outcome were calculated using the MantelHaenszel test and inconsistency was qualified and reported in χ2 and the Higgins method(I2). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. Student's t-test was used for the comparison of weighted arithmetic means regarding secondary outcomes.RESULTS: Initial searching identified 3660 studies; 3539 were excluded through title, repetition, and/or abstract, while 121 studies were fully assessed and were excluded mainly because they did not compare self-expanding metal stents(SEMS) and plastic stents(PS), leading to thirteen RCT selected, with 13 articles and 1133 subjects meta-analyzed. The mean age was 69.5 years old, that were affected mostly by bile duct(proximal) and pancreatic tumors(distal). The preferred SEMS diameter used was the 10 mm(30 Fr) and the preferred PS diameter used was 10 Fr. In the metaanalysis, SEMS had lower overall stent dysfunction compared to PS(21.6% vs 46.8%, P 0.00001) and fewer re-interventions(21.6% vs 56.6%, P 0.00001), with no difference in complications(13.7% vs 15.9%, P = 0.16). In the secondary analysis, the mean survival rate was higher in the SEMS group(182 d vs 150 d, P 0.0001), with a higher patency period(250 d vs 124 d, P 0.0001) and a lower cost per patient(4193.98 vs 4728.65 Euros, P 0.0985).CONCLUSION: SEMS are associated with lower stent dysfunction, lower re-intervention rates, better survival, and higher patency time. Complications and costs showed no difference.     

Percutaneous needle decompression in treatment of malignant small bowel obstruction

AIM:To investigate the efficacy and safety of percutaneous needle decompression in the treatment ofmalignant small bowel obstruction(MSBO).METHODS:A prospective analysis of the clinical data of 52 MSBO patients undergoing percutaneous needle decompression was performed.RESULTS:Percutaneous needle decompression was successful in all 52 patients.Statistically significant differences were observed in symptoms such as vomiting,abdominal distension and abdominal pain before and after treatment(81.6%vs 26.5%,100%vs 8.2%,and 85.7%vs 46.9%,respectively;all P<0.05).The overall significantly improved rate was 19.2%(11/52)and the response rate was 94.2%(49/52)using decompression combined with nasal tube placement,local arterial infusion of chemotherapy and nutritional support.During the one-month follow-up period,puncture-related complications were acceptable.CONCLUSION:Percutaneous needle intestinal decompression is a safe and effective palliative treatment for MSBO.     

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.     

Biliary stenting for hilar malignant biliary obstruction

Although endoscopic intervention is the mainstay for palliation of malignant biliary obstruction, a percutaneous approach has been preferred, particularly in patients with advanced high-grade hilar malignant biliary obstruction, because of the technical difficulty and risk of complications. However, recently, primary endoscopic palliation using plastic or metal stents has had higher technical and clinical success with fewer adverse events than the percutaneous approach. Endoscopic interventions are being done more and more frequently because of advances in metal stents, accessories, and techniques. However, several concerns, such as optimal stent type, number, and deployment method, remain to be resolved. Therefore, we reviewed the literature in order to identify the optimal biliary stenting strategy for patients with hilar malignant biliary obstruction, focusing on stent type (plastic vs metal), number (unilateral [single] vs bilateral [multiple]), and deployment method (stent-in-stent vs stent-by-stent).     

Biliary stenting with or without sphincterotomy for malignant biliary obstruction: A meta-analysis

AIM: To investigate the benefits of endoscopic sphincterotomy (EST) before stent placement by meta-analysis of randomized controlled trials (RCTs).METHODS: PubMed, EMBASE, Cochrane Library, and Science Citation Index databases up to March 2014 were searched. The primary outcome was incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and successful stent insertion rate. The secondary outcomes were the incidence of post-ERCP bleeding, stent migration and occlusion. The free software Review Manager was used to perform the meta-analysis.RESULTS: Three studies (n = 338 patients, 170 in the EST group and 168 in the non-EST group) were included. All three studies described a comparison of baseline patient characteristics and showed that there were no statistically significant differences between the two groups. Three RCTs, including 338 patients, were included in this meta-analysis. Most of the analyzed outcomes were similar between the groups. Although EST reduced the incidence of PEP, it also led to a higher incidence of post-ERCP bleeding (OR = 0.34, 95%CI: 0.12-0.93, P = 0.04; OR = 9.70, 95%CI: 1.21-77.75, P = 0.03, respectively).CONCLUSION: EST before stent placement may be useful in reducing the incidence of PEP. However, EST-related complications, such as bleeding and perforation, may offset this effect.     

内镜下双侧金属支架与单侧金属支架治疗不能手术切除肝门胆管恶性梗阻的比较：一项大型回顾性研究

目的:比较内镜下双侧金属支架和单侧金属支架治疗不能手术切除肝门胆管恶性梗阻的疗效优劣。方法:回顾性纳入2012年1月—2018年12月在上海东方肝胆外科医院内镜中心采用内镜下金属支架治疗的300例肝门胆管恶性狭窄(BismuthⅡ～Ⅳ型)患者资料,通过倾向性评分匹配法,94例双侧金属支架患者(双侧金属支架组)和94例单...     

恶性胆管梗阻内支架置入后再梗阻的研究现状

通过内镜置入胆道内支架引流是目前治疗恶性胆管梗阻的首选措施,然而内支架再梗阻却是当前困扰临床的主要问题.近年来,国内外在探讨支架阻塞的机制,通过多种方法防治以延长引流时间等方面进行了广泛而深入的研究,此文就此作一综述.     

经ERCP置入胆道金属支架与PTCD治疗老年肝外胆道恶性梗阻患者临床疗效比较*

目的 观察比较经内镜逆行胰胆管造影（ERCP）放置胆道金属支架与经皮肝穿刺胆管引流术（PTCD）治疗老年肝外胆道恶性梗阻患者的临床效果。方法 2014年10月~2017年10月我院收治的60例老年肝外胆道恶性梗阻患者,30接受PTCD治疗（对照组）,另30例接受经ERCP胆道金属支架置入治疗（观察组）。随访1年。结果 术后,观察组支架通畅时间为（225.4±52.6） d,显著长于对照组【（156.7±44.2） d,P<0.05】,住院时间为（12.3±2.4）d,显著短于对照组【（19.9±4.1） d,P<0.05】;观察组血清总胆红素为（110.2±60.1） μmol/L,显著低于对照组【（149.8±64.5） μmol/L,P<0.05】,碱性磷酸酶为（216.8±127.6）IU/L,显著低于对照组【（312.9±149.5） IU/L,P<0.05】,谷氨酰转肽酶为（196.5±100.5） IU/L,显著低于对照组【（269.8±121.3） IU/L,P<0.05】;观察组并发症发生率为10.0%,显著低于对照组的33.3%（P<0.05）;1 a生存率为30.0%,显著高于对照组的10.0%（x²=3.922,P=0.045）。结论 老年肝外胆道恶性梗阻患者接受经ERCP胆道金属支架置入治疗能短期降低黄疸,改善患者的肝功能指标,延长生存期。     

Complications and survival in patients undergoing colonic stenting for malignant obstruction

AIM:To investigate whether predicting patients that might be at a higher risk for complications might serve to improve the selection of patients undergoing colonic stenting.METHODS:A retrospective review of consecutive patients who underwent an attempted self-expandable metal stent(SEMS)insertion for malignant colonic obstruction between November 2006 and March 2013.All patients were either referred for preoperative colonic decompression with the intent of a single surgical procedure,or for palliation of the malignant colorectal obstruction for unresectable cancer.Fisher’s test orχ2test was performed on categorical variables,and the t test for continuous variables.Univariable and multivariable logistic regression were used to examine the association between independent variables and the presence of complications from SEMS insertion.RESULTS:SEMS insertion was attempted in 73 patients.Males comprised 55.71%and the mean age was 67.41±12.41 years.Of these,65.15%underwent subsequent surgery,while 34.85%received SEMS as palliation for advanced disease.Extracolonic tumors were only4.76%.The majority of patients had stageⅣdisease(63.83%),while the remainder had stageⅢ(36.17%).SEMS were successfully inserted in 93.85%(95%CI:87.85%-99.85%).Perforations occurred in 4.10%,SEMS migration in 8.21%,and stent re-occlusion from ingrowth occurred in 2.74%of patients.The mean duration of follow up for the patients was 13.52±17.48 mo(range 0-73 mo).None of the variables:age,sex,time between the onset of symptoms to SEMS insertion,time between SEMS insertion and surgery,length of the stenosis,location of the stenosis,albumin level,or receiving neoadjuvant chemotherapy,could predict the development of complications from either SEMS insertion nor prolonged survival.CONCLUSION:None of the variables could predict the development of complications or survival.Further studies are required to identify patients who would benefit the most from SEMS.     

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.

胆管恶性梗阻的内镜治疗

目的研究经内镜下塑料支架和金属支架对胆管恶性梗阻的治疗效果。方法将我院2010年1月至2012年6月经ERCP确诊为胆管恶性梗阻的120例患者,分成金属支架引流术组（EMBE）（n=62）和塑料支架引流术组（ERBD）（n=58）,监测两组患者血清总胆红素、谷丙转氨酶、碱性磷酸酶、谷氨酰胺转肽酶、血清TNF-α等的变化,并统计分析两组患者并发症的发生率以及死亡率。结果两组插管成功率及并发症发生率为均无明显差异（P〉0.05）,无死亡病例。治疗1周后复查两组患者的肝功能各项指标,结果较治疗前有统计学差异（P〈0.05）。两组成功随访89例,随访率为74.16%（89/120）,12例ERBD患者发生支架阻塞,占30.77%（12/39）,该组中位生存期为5个月。6例EMBE患者发生支架阻塞,占12%（6/50）,该组中位生存期为9.3个月,两组比较P均〈0.05。结论从随访看,支架阻塞发生率和中位生存期EMBE组均优于ERBD组,但两组均能有效的建立胆管内引流,改善患者的肝功能,具有创伤小、痛苦少、恢复快、无体外留管、符合生理过程等优点。     

Current status of endoscopic biliary drainage for unresectable malignant hilar biliary strictures

The management of jaundice and cholangitis is important for improving the prognosis and quality of life of patients with unresectable malignant hilar biliary strictures (UMHBS). In addition, effective chemotherapy, such as a combination of gemcitabine and cisplatin, requires the successful control of jaundice and cholangitis. However, endoscopic drainage for UMHBS is technical demanding, and continuing controversies exist in the selection of the most appropriate devices and techniques for stent deployment. Although metallic stents (MS) are superior to the usual plastic stents in terms of patency, an extensive comparison between MS and “inside stents”, which are deployed above the sphincter of Oddi, is necessary. Which techniques are preferred remains as yet unresolved: for instance, whether to use a unilateral or bilateral drainage, or a stent-in-stent or side-by-side method for the deployment of bilateral MS, although a new cell design and thin delivery system for MS allowed us to accomplish successful deployments of bilateral MS. The development of techniques and devices for re-intervention after stent occlusion is also imperative. Further critical investigations of more effective devices and techniques, and increased randomized controlled trials are warranted to resolve these important issues.     

Effectiveness of combined biliary and duodenal stenting in patients with malignant biliary and duodenal obstruction

Abstract

Introduction. Concomitant biliary and duodenal obstructions are not uncommon complications in patients with gastroduodenal or pancreatobiliary malignancies. Alleviation of obstruction is very important for the palliation of inoperable patients. We studied the clinical outcomes of combined biliary and duodenal stenting. Methods. Between January 2003 and January 2010, the records of 24 patients who underwent biliary and duodenal stent placement due to inoperable malignant biliary and duodenal obstruction were reviewed retrospectively. Results. Of the 24 patients, a duodenal stent was placed after biliary stenting in 23 patients and a biliary stent was placed after duodenal stenting in one patient. Biliary stents were placed endoscopically (33 cases) or percutaneously (14 cases). Duodenal stents were placed endoscopically by fluoroscopic guidance in all patients. Oral feeding was possible at a mean of 2.7 ± 1.2 days (range, 1–6 days) after duodenal stenting. Acute pancreatitis and acute cholangitis developed in three patients and one patient, respectively, as early complications after biliary stenting. Biliary stent occlusion was developed in 12 patients and was treated successfully by stent reinsertion. As complications of duodenal stent, one case of stent migration and five cases of stent occlusion developed. Median survival after initial bilioduodenal stenting was 195.5 days (range, 21–725 days). Stent patency was well maintained in 83.3% of patients after combined stent placements while patients were alive. Conclusion. Combined biliary and duodenal stenting seems to be safe and effective in palliation of inoperable malignant biliary and duodenal obstruction.     

内镜下平行法双金属支架引流治疗晚期肝门部胆管恶性梗阻价值探讨

目的 探讨经内镜平行法双金属支架引流治疗晚期肝门部胆管恶性梗阻的安全性和疗效.方法 2011年1月至2012年9月对11例晚期肝门部胆管恶性梗阻的病人采用内镜平行法双金属支架引流治疗,观察疗效及安全性.结果 10例成功置入左右双金属支架,全组无研究并发症及死亡病例.9例引流有效.发生2例轻微内镜相关并发症.10例双支架治疗病人中4例死亡,死亡时均无腹痛、黄疸、发热等支架阻塞迹象,生存128 ～ 185 d,失访1例,其余5例病人均在随访中.结论 内镜平行法双金属支架引流治疗晚期肝门部胆管恶性梗阻是安全可行的.