Technical Feasibility and Revision Efficacy of the Sequential Deployment of Endoscopic Bilateral Side-by-Side Metal Stents for Malignant Hilar Biliary Strictures: A Multicenter Prospective Study

Background

Theoretically, the side-by-side bilateral placement of metal stents may be technically easier than stent-in-stent bilateral placement in stent revision. However, side-by-side placement can be technically challenging, as the deployment of the first stent can preclude the passage of the second stent.

Aim

We explored the technical feasibility and revision efficacy of endoscopic bilateral side-by-side stent placement for malignant hilar biliary strictures.

Methods

Forty-four patients with Bismuth type II or higher malignant hilar biliary strictures were enrolled in seven academic tertiary referral centers. Endoscopic placement of side-by-side bilateral metal stents with 7F thin delivery shaft was performed. The outcome measurements were the technical and functional success, adverse events, endoscopic revision success rate, and stent patency.

Results

Overall, the technical and functional success rates were 91 % (40/44), and 98 % (39/40), respectively. Two of the failed patients were converted successfully with subsequent contralateral stent-in-stent placement, and the other patients underwent percutaneous intervention. Early stent-related adverse events occurred in 10 %. The endoscopic revision rate due to stent malfunction during follow-up (median: 180 days) was 45 % (18/40; tumor ingrowth in 4 and in-stent sludge impaction/stone formation in 14 patients). The endoscopic revision success rate was 92 % (12/13). Five patients with comorbidity underwent initial percutaneous intervention. The median survival and stent patency periods were 180 and 157 days, respectively.

Conclusions

The sequential placement of a metal stent with a 7F thin delivery shaft in bilateral side-by-side procedures may be feasible and effective for malignant hilar biliary strictures and for endoscopic stent revision.     

The Dramatic Haemostatic Effect of Covered Self-expandable Metallic Stents for Duodenal and Biliary Bleeding

Bilio-duodenal bleeding, such as post-endoscopic sphincterotomy (EST) bleeding, common bile duct (CBD) bleeding after endoscopic retrograde cholangiopancreatography (ERCP), and duodenal bleeding due to malignant tumour invasion, can sometimes become severe. Six cases of refractory bilio-duodenal bleeding were stanched via covered self-expandable metallic stent (CSEMS) insertion, even though three of the patients had a history of gastrectomy. The dumbbell-shaped CSEMS was useful for managing post-EST bleeding. Additional duodenal CSEMS insertion was useful for the patient who had previously undergone uncovered SEMS insertion, and no migration of the CSEMS was observed. CSEMS insertion was useful for treating refractory bilio-duodenal haemorrhaging.     

金属支架置入治疗胆道恶性梗阻性疾病的临床应用与价值

目的探讨金属胆道支架引流术对恶性胆道梗阻的引流效果。方法对33例经ERCP诊断的恶性胆道梗阻患者行经内镜金属胆道支架置入术。结果33例恶性胆道梗阻患者,支架置入成功率为100%,引流有效率为93.93%,支架置入术后1周时STB,γ-GT、AKP平均下降率分别为69.3%、37.9%和37.3%。3、6、9个月有效引流比率分别为90.32%、61.29和35.48%。支架平均通畅时间为7.8±3.7月,平均生存时间8.5±4.3月。结论内窥镜金属支架是治疗胆道恶性梗阻安全有效的姑息治疗方法,可以有效地解除梗阻、消退黄疸、恢复肝功能,起到与外科手术相媲美的治疗效果。     

Management of Occluded Metal Stents in Malignant Biliary Obstruction: Similar Outcomes with Second Metal Stents Compared to Plastic Stents

Background

Covered or uncovered self expandable metallic stents (SEMS) placed in patients with malignant biliary obstruction can occlude in 19–40?%, but optimal management is unclear.

Aim

We sought to summarize current evidence regarding management of occluded SEMS in patients with malignant biliary obstruction.

Methods

Two investigators independently searched Pubmed, Embase, and Web of Science using pre-defined search criteria, and reviewed bibliographies of included studies. Data were independently abstracted by two investigators, and analyzed using RevMan. We compared strategies of second SEMS versus plastic stents with respect to the following outcomes: rate of second stent re-occlusion, duration of second stent patency, and survival.

Results

Ten retrospective studies met inclusion criteria for the systematic review. Management options described were placement of an uncovered SEMS (n?=?125), covered SEMS (n?=?106), plastic stent (n?=?135), percutaneous biliary drain (n?=?7), mechanical cleaning (n?=?18), or microwave coagulation (n?=?7). Relative risk of re-occlusion was not significantly different in patients with second SEMS compared to plastic stents (RR 1.24, 95?% CI 0.92, 1.67, I²?=?0, p 0.16). Duration of second stent patency was not significantly different between patients who received second SEMS versus plastic stents (weighted mean difference 0.46, 95?% CI ?0.30, 1.23, I²?=?83?%). Survival was not significantly different among patients who received plastic stents versus SEMS (weighted mean difference ?1.13, 95?% CI ?2.33, 0.07, I² 86?%, p = 0.07).

Conclusions

Among patients with malignant biliary obstruction and occluded SEMS, available evidence suggests a strategy of placing a plastic stent may be as effective as second SEMS. Limitations of these findings were that all studies were retrospective and heterogeneity between studies was detected for two of the outcomes.     

胆肠联合支架置入姑息性治疗恶性胃出口梗阻合并胆总管梗阻22例分析

背景：予恶性胃出口梗阻合并胆总管梗阻者联合置入肠道和胆道支架是首选的姑息性治疗方法之一。目的：观察胆肠联合支架置入治疗恶性胃出口梗阻合并胆总管梗阻的临床疗效。方法：在内镜和X线造影下予22例恶性胃出口梗阻合并胆总管梗阻者放置经内镜活检孔肠道支架,以及从经皮经肝胆管引流（PTCD）途径放置胆道支架,胆道支架穿过肠道支架网孔,远端位于肠道支架内。结果：22例均成功置入肠道支架（24枚）和胆道支架（22枚）。术后造影示肠道和胆道均通畅,无严重并发症发生,平均生存期为124d。结论：胆肠联合支架置入姑息性治疗恶性胃出口梗阻合并胆总管梗阻安全有效,近期疗效较满意。     

The Comparison of Endoscopic Biliary Drainage in Malignant Hilar Obstruction by Cholangiocarcinoma: Bilateral Metal Stents versus Multiple Plastic Stents

Background/AimsFor the management of hilar malignant biliary obstruction (HMBO), endoscopic biliary drainage (EBD) is preferred over percutaneous transhepatic biliary drainage (PTBD) because of its convenience. However, there is no established guideline for malignant hilar obstruction that requires multiple stenting. In this study, we compared the efficacy of bilateral metal stents (BMS) versus multiple plastic stents (MPS).MethodsIn this retrospective study, we analyzed 102 patients who underwent EBD with either BMS or MPS due to HMBO caused by hilar cholangiocarcinoma between 1996 and 2018 at Samsung Medical Center. We compared the successful drainage rates, cholangitis events, overall complications, mortality, and conversion rates to PTBD between the two groups.ResultsThe successful drainage rates in the BMS group and the MPS group were 71.4% (25/35) and 65.6% (44/67), respectively, with no significant difference. The MPS group had a higher cholangitis risk (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.21 to 3.58) and higher 6-month mortality (HR, 2.91; 95% CI, 1.26 to 6.71) than the BMS group. There were no significant differences in overall complications or the conversion rate to PTBD between the groups.ConclusionsIn patients with malignant HMBO, the BMS group showed better outcomes in terms of the cholangitis rate and 6-month mortality than the MPS group. Therefore, if possible, bilateral metal stenting is recommended for HMBO caused by hilar cholangiocarcinoma.     

内镜下金属支架引流术治疗肝门部胆管癌和肝外恶性胆道梗阻临床观察

临床上恶性胆道梗阻性疾病预后较差。对于不能手术切除者,通常选择内镜下置人胆道支架以解除梗阻,然而该技术对进展期肝门部肿瘤的疗效报道不一。目的：探讨内镜下金属支架引流术对肝门部胆管癌和肝外恶性胆道梗阻的疗效和并发症发生情况。方法：纳入上海交通大学附属第一人民医院2006年6月～2009年6月收治的82例接受ERCP下置入自膨式金属胆道支架引流治疗的恶性胆道狭窄患者,根据病变部位分为肝门部胆管癌组和肝外恶性胆道梗阻组,对其ERCP参数和术后6个月随访记录进行回顾性分析,并分析随访期间急性胆管炎发生的危险因素。结果：两组支架置入成功率均为100％。与肝外恶性胆道梗阻组相比,肝门部胆管癌组术后1周总胆红素降低显效率较低,术后6个月内急性胆管炎发生率增高,初次发生时间提前,支架再狭窄率增高（P=0．000）。ERCP术中括约肌切开为随访期间发生急性胆管炎的危险因素（P=0．004,OR：8．196）。结论：内镜下金属支架引流术对肝门部胆管癌的疗效不及肝外恶性胆道梗阻,且更易早期发生急性胆管炎和支架再狭窄,术中括约肌切开可增加术后急性胆管炎的发生风险。     

Palliation for Advanced Malignant Colorectal Obstruction by Self-Expanding Metallic Stents: Prospective Evaluation of Outcomes

PURPOSE: This study was designed to evaluate the outcomes of self-expanding metallic stents as a palliative treatment for malignant obstruction of the colon and rectum. METHODS: The insertion of self-expanding metallic stents was attempted for palliation in 52 patients (33 males; mean age, 66.5 ± 16.4 years) with colorectal obstruction caused by advanced malignancies. The stents were inserted under endoscopic and fluoroscopic guidance. The data on the success of the procedure, the complications, and the outcomes of the patients were collected prospectively. RESULTS: Thirty patients had locally advanced or disseminated primary colorectal cancers, and 22 had recurrent cancer of colorectal or other primaries. Successful insertion of the stent was achieved in 50 patients. The median survival of the patients was 88 (range, 3-450) days. Complications occurred in 13 patients (25 percent). These included perforation of the colon (n = 1), migration or dislodgement of the stents (n = 8), severe tenesmus (n = 1), colovesical fistula (n = 1), and tumor ingrowth (n = 2). Insertion of a second stent was required in eight patients. Subsequent operations were performed in nine patients, and stoma creation was required in seven patients. CONCLUSIONS: Self-expanding metallic stents are highly effective in relieving malignant colorectal obstruction. The complication rate is acceptable and palliation can be achieved in the majority of the patients without a stoma.Presented at the Tripartite Colorectal Meeting, Melbourne, Australia, October 27 to 30, 2002     

Ultrasound-Guided Endoscopic Biliary Drainage: A Useful Drainage Method for Biliary Decompression in Patients with Biliary Obstructions

Background

Endoscopic retrograde cholangiopancreatography with fluoroscopy guidance is a well-established technique for providing biliary drainage in patients with biliary obstructions. However, fluoroscopic facilities may not always be available and fluoroscopy carries a risk of radiation exposure.

Aim

We retrospectively compared the procedure success rate and efficacy of ultrasound-guided endoscopic biliary drainage (UG-EBD) and fluoroscopy-guided endoscopic biliary drainage (FG-EBD) in patients with biliary obstructions.

Methods

Patients who had received either UG-EBD or FG-EBD were included in the study. Main outcome measurements included the procedure success rate, procedure time, and clinical response.

Results

A total of 125 patients who had undergone UG-EBD (n = 63) and FG-EBD (n = 62) were identified. The total procedure success rate was 93.7 % in the UG-EBD group and 96.8 % in the FG-EBD group without statistical difference. Also, no significant difference was found in the procedure success rate of lower or upper/middle obstructions of the common bile duct (CBD) between the 2 groups. The mean procedure time was not different between the 2 groups [UG-EBD group 24.54 (9.52) min vs. FG-EBD group 21.74 (8.77) min, p = 0.09]. There were no differences in the normalization of clinical and laboratory parameters and immediate complication between the 2 groups.

Conclusions

Endoscopic biliary drainage (EBD) under US-guidance and under fluoroscopy guidance is equally effective and safe for patients with lower or upper/middle obstructions of the CBD. The UG-EBD technique is especially suitable for special patients, such as critically ill patients, pregnant woman, etc.     

Endoscopic Palliation and Survival in Malignant Biliary Obstruction

Malignant biliary obstruction is a common problem that is regarded as having a poor prognosis and is usually managed with palliation. Our aim was to investigate the survival of 182 consecutive subjects with malignant biliary obstruction where management was palliative within endoscopically placed biliary stent. We undertook a retrospective longitudinal study with date of death or confirmed survival of at least 23 months, as the primary end point. Diagnosis and blood indices from the 24 hr prior to first ERCP were obtained from hospital records. Of the 182 eligible subjects follow-up of date of death or confirmed survival of at least 23 months was obtained in 181 (99.5%). Of these 181 patients, 37 (20.4%) survived for more than one year. Histological confirmation was obtained in 47 of 182 subjects (25.8%). Increased age at first ERCP predicted increased survival (P < 0.05). In conclusion, in patients with malignant biliary obstruction, where management was endoscopic and palliative, 20.4% survived for more than one year with increased age at diagnosis being the only significant predictive marker.     

Combined Use of Uncovered Duodenal and Covered Biliary Metallic Stent for Carcinoma of the Papilla of Vater

We have reported successful implantation of self‐expandable metallic stents for palliative treatment in a case of an 87‐year‐old female patient with carcinoma of the papilla of Vater. She suffered from both duodenal and biliary stenoses, but refused surgical treatment. For the duodenal stenting, a self‐expandable knitted nitinol metallic stent, for esophageal use, was inserted endoscopically. For the biliary stenting, a self‐expandable metallic stent, partially polyurethane‐covered on the proximal part to prevent tumor ingrowth and overgrowth, was inserted via the percutaneous transhepatic biliary drainage route. No major complications occured during these procedures. After the two stents were inserted in an end‐to‐side fashion, she was able to eat a normal diet adequately and suffered from no abdominal symptoms and jaundice during the follow‐up period of 13 months. These stenting procedures might be less invasive and more useful than surgical treatment and provide long patency of biliary stenting and a good quality of life.     

Biliary Stenting in Patients with Malignant Biliary Obstruction: Comparison of Double Layer, Plastic and Metal Stents

Background and Aim

The double layer stent (DLS) has a unique design and has been used for palliation of malignant biliary obstruction, but literature on this stent is limited. Our aim was to compare plastic (PS), DLS and metal stents (MS) in terms of complication rates, time to occlusion, and patency rate in patients with malignant biliary obstruction (MBO).

Methods

A retrospective review of stents placed for MBO at our institution in the period between January 2009 and April 2011 was conducted. A total of 114 stents were identified, of which 44 were MS (39 %), 37 DLS (32 %), and 33 PS (29 %). A stent was considered occluded when an unplanned stent removal or intervention occurred due to clinical suspicion of biliary obstruction.

Results

Stents remained patent for 95 days (range 7–359 days) in the DLS group and 59 days (range 7–228 days) in the PS group (P = 0.014) and 128.7 days (range 4–602 days) in the metal stent group. Twenty-seven percent (n = 9) of PS occluded after a mean of 60 days while 16 % (n = 7) of MS occluded after a mean of 87 days and 5 % (n = 2) of DLS occluded after a mean of 85 days (DLS vs. PS P = 0.012, DLS vs. MS P = 0.13, MS vs. PS P = 0.22).

Conclusions

DLS are superior to PS in patients with MBO and appear to be comparable to MS. MS had a longer patency rate but were comparable to DLS in early and late complications. We speculate that the less expensive DLS may be a cost effective alternative in the palliation of MBO.     

Endoscopic Biliary Drainage for Malignant Obstructive Jaundice: Clinical Analysis and Assessment of Biliary Decompression

Abstract: The efficiency of non-operative methods of biliary decompression was evaluated in 74 patients with malignant obstructive jaundice. Endoscopic biliary drainage (EBD) was performed in 54 patients and included nasobiliary drainage (NBD) in 18 patients, duodenobiliary drainage with a endoprosthetic tube measuring 7. 2 Fr in diameter (7.2DB) in 22 patients and duodenobiliary drainage with a endoprosthetic tube measuring 10 Fr in diameter (10DB) in 14 patients. 20 patients had percutaneous transhepatic biliary drainage (PTBD). A “Jaundice Reduction Index” was calculated for each group using the regression coefficient analysis of the fall in serum bilirubin levels measured at 1 week intervals. Values of 0.23, 0.30, 0.62 and 0.65 were obtained for the 10DB, 7.2DB, NBD and PTBD groups respectively. Our results indicate a statistically significant superiority in the efficiency of biliary decompression in the 10DB and 7.2DB patients when compared with the NBD and PTBD patients. The difference between the 10DB and the 7.2DB groups was not statistically significant. Moreover, endoprosthesis using a stent tube, measuring 7.2 Fr in diameter, provided sufficient biliary decompression on initial drainage. A stent tube with a larger diameter is preferable for endoprosthesis, but our results suggest that the use of stent tube with a bigger internal diameter is not necessary for the increased efficiency of biliary decompression.