Contrast-free unilateral endoscopic palliation in malignant hilar biliary obstruction: new method

BACKGROUND: Bilateral endoscopic drainage is difficult in malignant hilar biliary obstruction. Recently, unilateral drainage in malignant hilar biliary obstruction has been shown to be equally effective. However, contrast injection leads to cholangitis. There have been no reported studies on contrast-free metal stenting in malignant hilar biliary obstruction. The present study was undertaken to evaluate the results of contrast-free unilateral metal stenting in type II malignant hilar biliary obstruction. METHODS: We prospectively studied the results of unilateral metal stenting in type II malignant hilar biliary obstruction without contrast injection in 18 patients. RESULTS: A successful endoscopic drainage was achieved in 100% (18/18) of patients with hilar strictures. Cholangitis and 30-day mortality occurred in none. CONCLUSIONS: Unilateral endoscopic metal stenting without contrast in type II malignant hilar biliary obstruction is a safe and effective method of palliation.     

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.     

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).     

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.     

Tips and troubleshooting for transpapillary metal stenting for distal malignant biliary obstruction

Endoscopic placement of a self‐expandable metal stent (SEMS) has become a mainstream treatment to relieve non‐resectable distal malignant biliary obstructions—its longer patency and cost‐effectiveness were demonstrated in comparison with plastic biliary stents in several randomized controlled trials. Despite advances in ERCP devices and SEMSs themselves to enable safe and effective biliary drainage via a SEMS, several significant aspects of the endoscopic placement of SEMS must be considered; otherwise, SEMS‐related complications and early SEMS dysfunction may occur. Also, SEMS dysfunction, including occlusion and migration, occurs at a certain frequency in the long term, and appropriate reintervention is necessary to preserve the quality of life of the patient. Here, we present tips for endoscopic transpapillary SEMS placement for distal malignant biliary obstruction and reintervention for SEMS dysfunction.     

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.     

Drug-eluting stent in malignant biliary obstruction

Introduction

In unresectable malignant bile duct obstruction, endoscopic stent insertion is the treatment of choice. However, the current stent allows only mechanical palliation of the obstruction, and has no anti-tumor effect. Currently, in the vascular field, the drug-eluting stent (DES) is very highly favored.

Material and methods

The requirements for a DES in a non-vascular tract, such as the bile duct, are far different from those of a DES to be used in the vascular tract. The non-vascular DES must suppress tumor proliferation as well as mucosal hyperplasia. For example, the non-vascular stent might be covered with a membrane that gradually releases a chemo-agent. We do not have much experience with DES in the bile duct. Nonetheless, we are continuously testing many anti-tumor agents in animal and human studies.

Conclusion

We expect and hope DES will work effectively for tumor cells in diverse ways and, more importantly, will prolong stent patency and the patients’ survival periods. But considerable investigation and a clinical study of DES will be required to achieve these goals.     

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.     

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.

Endoscopic biliary stent insertion through specialized duodenal stent for combined malignant biliary and duodenal obstruction facilitated by stent or PTBD guidance

Objectives: Endoscopic stenting for combined malignant biliary and duodenal obstruction is technically demanding. However, this procedure can be facilitated when there is guidance from previously inserted stent or PTBD tube. This study aimed to evaluate the feasibility and clinical success rate of endoscopic placement of biliary self-expandable metal stent (SEMS) through duodenal SEMS in patients with combined biliary and duodenal obstruction due to inoperable or metastatic periampullary malignancy.

Materials and methods: A total of 12 patients with combined malignant biliary and duodenal stricture underwent insertion of biliary SEMS through the mesh of specialized duodenal SEMS from July 2012 to October 2016. Technical and clinical success rate, adverse events and survival after completion of SEMS insertion were evaluated.

Results: The duodenal strictures were located in the first portion of the duodenum in four patients (Type I), in the second portion in three patients (Type II), and in the third portion in five patients (Type III). Technical success rate of combined metallic stenting was 91.7%. Insertion of biliary SEMS was guided by previously inserted biliary SEMS in nine patients, plastic stent in one patient, and PTBD in two patients. Clinical success rate was 90.9%. There were no early adverse events after the procedure. Mean survival period after combined metallic stenting was 91.9 days (range: 15–245 days).

Conclusions: Endoscopic placement of biliary SEMS through duodenal SEMS is feasible with high success rates and relatively easy when there is guidance. This method can be a good alternative for palliation in patients with combined biliary and duodenal obstruction.     

Endoscopic management of combined malignant biliary and gastric outlet obstruction

Patients with periampullary cancer or gastric cancer often develop malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), and combined MBO and GOO is not rare in these patients. Combined MBO and GOO is classified by its location and sequence, and treatment strategy can be affected by this classification. Historically, palliative surgery, hepaticojejunostomy and gastrojejunostomy were carried out, but the current standard treatment is combined transpapillary stent and duodenal stent placement. Although a high technical success rate is reported, the procedure can be technically difficult and duodenobiliary reflux with subsequent cholangitis is common after double stenting. Recent development of endoscopic ultrasound (EUS)‐guided procedures enables the management of MBO as well as GOO under EUS guidance. EUS‐guided biliary drainage is now increasingly reported as an alternative to percutaneous transhepatic biliary drainage in failed endoscopic retrograde cholangiopancreatography (ERCP), and GOO is one of the major reasons for failed ERCP. In addition to EUS‐guided biliary drainage, the feasibility of EUS‐guided double‐balloon‐occluded gastrojejunostomy bypass for MBO was recently reported, and EUS‐guided double stenting can potentially become the treatment of choice in the future. However, as each procedure has its advantages and disadvantages, treatment strategy should be selected based on the type of obstruction and the prognosis and performance status of the patient.