Partial stent-in-stent placement of biliary metallic stents using a short double-balloon enteroscopy

Endoscopic intervention is less invasive than percutaneous or surgical approaches and should be considered the primary drainage procedure in most cases with obstructive jaundice. Recently, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) using double-balloon enteroscopy (DBE) has been shown to be feasible and effective, even in patients with surgically altered anatomies. On the other hand, endoscopic partial stent-in-stent (PSIS) placement of self-expandable metallic stents (SEMSs) for malignant hilar biliary obstruction in conventional ERCP has also been shown to be feasible, safe and effective. We performed PSIS placement of SEMSs for malignant hilar biliary obstruction due to liver metastasis using a short DBE in a patient with Roux-en-Y anastomosis and achieved technical and clinical success. This procedure can result in quick relief from obstructive jaundice in a single session and with short-term hospitalization, even in patients with surgically altered anatomies.     

Outcome of self-expandable metallic stents in low-grade versus advanced hilar obstruction

Background: Self‐expandable metallic stents (SEMS) are known to provide a longer patency time than plastic stents for malignant biliary obstructions including hilar obstruction. However, studies that focus on the efficacy of SEMS in low‐grade and advanced hilar obstructions are still scanty. Methods: Ninety four patients with malignant hilar obstructions were enrolled (six were later excluded). Patients were divided into two groups according to their Bismuth levels. Group A were patients with Bismuth I (n = 53). Group B were patients with Bismuth II, III and IV (n = 35). Technical success, complications, jaundice resolution, stent patency time, and patients’ survival were analyzed. Results: Our intention‐to‐treat analysis showed that group A had a significant lower rate of post‐endoscopic retrograde cholangiopancreatography (ERCP) cholangitis than group B; 16.1% versus 44.7%, (P < 0.01). Four patients from group B still had persistent jaundice. Our per protocol analysis demonstrated that median stent patency time in groups A and B were not statistically different (74 vs 60 days). Median survival time in groups A and B were also not statistically different (90 vs 75 days). In both groups, those without liver metastasis had significantly better patency and survival time than those with liver metastasis (P = 0.010 and 0.027, respectively). Conclusions: In patients with hilar obstruction, liver metastasis is one of the main factors that determine survival of the patient. Patency times of SEMS in both low‐grade and advanced obstructions are comparable. However, in the advanced group, there is a significant risk of post‐ERCP cholangitis.     

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).     

Endoscopic removal and trimming of distal self-expandable metallic biliary stents

AIM:To evaluate the efficacy and safety of endoscopic removal and trimming of self-expandable metallic stents(SEMS).METHODS:All SEMS had been placed for distal biliary strictures.Twenty-seven endoscopic procedures were performed in 19 patients in whom SEMS(one uncovered and 18 covered) removal had been attempted,and 8 patients in whom stent trimming using argon plasma coagulation(APC) had been attempted at Tokyo Medical University Hospital.The APC settings were:voltage 60-80 W and gas flow at 1.5 L/min.RESU...     

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...     

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.     

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.     

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.     

Evaluation of new plastic stents for malignant biliary obstruction

Background: A new plastic stent was designed for endoscopic biliary stenting to achieve a long and effective drainage period. Method: The Double layer stent is composed of Teflon as the inner layer and nylon as the outer layer divided with metallic mesh. This structure gives the stent several side‐flaps without side‐holes. Double layer stents were applied in 24 patients with inoperable malignant biliary obstruction. Results: The Double layer stents were successfully placed in all cases, and the effective drainage rate of these stents was 96%. The mean patency period evaluated by the Kaplan–Meier method without ineffective cases was 207 days, which was longer than the ordinary plastic stent of the same diameter. Concerning the complications related to inserting, we experienced dislocation was experienced in three patients. Conclusions: The authors regard this new device as an useful stent, which users can expect long patency period, easy exchange management, and reduced cost for the patients with inoperable obstruction in the biliary tract.     

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.     

Self-expandable metallic stents for palliation of patients with malignant gastric outlet obstruction caused by stomach cancer

AIM: To ascertain clinical outcome and complications of self-expandable metal stents for endoscopic palliation of patients with malignant obstruction of the gastrointestinal (GI) tract. METHODS: A retrospective review was performed throughout August 2000 to June 2005 of 53 patients with gastric outlet obstruction caused by stomach cancer. All patients had symptomatic obstruction including nausea, vomiting, and decreased oral intake. All received self-expandable metallic stents. RESULTS: Stent implantation was successful in all 53 (100%) patients. Relief of obstructive symptoms was achieved in 43 (81.1%) patients. No immediate stent-related complications were noted. Seventeen patients had recurrent obstruction (tumor ingrowth in 14 patients, tumor overgrowth in 1 patient, and partial distal stent migration in 2 patients). The mean survival was 145 d. Median stent patency time was 187 d. CONCLUSION: Endoscopic placement of self-expandable metallic stents is a safe and effective treatment for the palliation of patients with inoperable malignant gastric outlet obstruction caused by stomach cancer.     

Treatment of malignant gastric outlet obstruction with endoscopically placed self-expandable metal stents

Malignant gastroduodenal obstruction can occur in up to 20% of patients with primary pancreatic, gastric or duodenal carcinomas. Presenting symptoms include nausea, vomiting, abdominal distention, pain and decreased oral intake which can lead to dehydration, malnutrition, and poor quality of life. Endoscopic stent placement has become the primary therapeutic modality because it is safe, minimally invasive, and a cost-effective option for palliation. Stents can be successfully deployed in the majority of patients. Stent placement appears to lead to a shorter time to symptomatic improvement, shorter time to resumption of an oral diet, and shorter hospital stays as compared with surgical options. Recurrence of the obstructive symptoms resulting from stent occlusion, due to tumor ingrowth or overgrowth, can be successfully treated with repeat endoscopic stent placement in the majority of the cases. Both endoscopic stenting and surgical bypass are considered palliative treatments and, to date, no improvement in survival with either modality has been demonstrated. A tailored therapeutic approach, taking into consideration patient preferences and involving a multidisciplinary team including the therapeutic endoscopist, surgeon, medical oncologist, radiation therapist, and interventional radiologist, should be considered in all cases.