Clinical evaluation of double stenting for duodenal and biliary obstructions caused by pancreatic head carcinoma using covered self‐expandable metallic stents

Five patients with non‐resectable pancreatic head carcinoma complicated by duodenal and biliary obstructions were successfully treated by double stenting with covered self‐expandable metallic stents (EMS). Diamond (Boston Scientific, Natick City, MA, USA) stents covered with a polyurethane membrane were used to treat biliary obstructions, whereas covered Ultraflex (Boston Scientific) stents for esophageal stenting were used to treat duodenal obstructions. That is, Diamond stents were initially placed in the biliary tract percutaneously in one patient and endoscopically in the remaining four patients. Subsequently, covered Ultraflex stents were placed in the duodenum. Double stenting with EMS was successfully performed in all five patients without inducing early technical complications. All patients were able to take a liquid diet orally at a mean 1.6 days after the double stenting procedure and were able to eat solid foods thereafter. Sludge‐induced biliary obstructions were detected in two patients 3 and 6 months after the placement of EMS. However, recurrent biliary obstruction was not noted in the remaining three patients. The EMS left in the duodenum were not obstructed during the observation period. The survival period of the patients ranged from 86 to 363 days (mean 172 days). There have not been any reports evaluating the usefulness of double stenting using covered EMS for duodenal and biliary obstructions. Because favorable results were obtained by double stenting in our patients, stenting for duodenal and biliary obstructions caused by non‐resectable pancreatic head carcinoma may become a useful treatment modality substituting for bypass surgery.     

COVERED METALLIC STENTS FOR MANAGEMENT OF DISTAL MALIGNANT BILIARY OBSTRUCTION

Covered metallic stent (covered MS) is useful to improve quality‐of‐life in patients with unresectable malignant distal biliary obstruction. We have managed 129 patients with three types of covered MS; polyurethane‐covered Wallstent (hand‐craft), polyurethane‐covered Diamond stent (hand‐craft), and silicone‐covered Wallstent (commercially available). They were compared with 115 cases treated with uncovered metallic stent (uncovered MS). There was no significant difference in survival between the two groups. The cumulative stent patency was significantly higher in the covered MS group than uncovered MS group (P = 0.0027). Stent occlusion occurred in 17 patients (13%) in the covered MS group, and in 48 patients (42%) in the uncovered MS group (P < 0.0001). Complications of covered MS were 8 (6%) in acute cholecystitis, 10 (8%) in acute pancreatitis, and 10 (8%) in migration. We evaluated the risk factors for these complications of covered MS.     

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.     

Analysis of longterm survivors with expandable metallic stent inserted for malignant biliary stenosis

Background/Purpose. Some patients with unresectable malignant biliary stenosis can survive for more than 1 year after the insertion of self-expandable metallic stents (SEMS). The aim of this study was to analyze the background of the longterm survivors.Methods. In our study, 111 patients with inserted SEMS were divided into two groups: patients who died within 1 year and patients still alive for more than 1 year. The parameters analyzed were survival rate, survival period, patent period of the inserted SEMS, adjuvant therapy, and complications.Results. The number of those who survived for more than 1 year totaled 24 (21.6%). Their diagnoses were bile duct carcinoma (15/31; 48.4%) and pancreas carcinoma (9/28; 32.9%). There were no survivors with other diseases. The survival period and stent-patent period of the patients with bile duct carcinoma (429.2 days and 589.7 days, respectively) and pancreas carcinoma (270.1 days and 336.4 days, respectively) were significantly longer than those of the patients with other diseases. The specific complication of the longterm survivors was duodenal obstruction.Conclusions. Many patients with bile duct carcinoma and pancreas carcinoma survived for more than 1 year and adjuvant therapy should be performed to improve the survival of those patients.     

Development of Severe Acute Pancreatitis Following Uncovered Metallic Stent Placement: A Rare Case Report

Self-expandable metallic stents (SEMSs) are widely used for malignant biliary stricture (MBS). Acute pancreatitis is an early complication following SEMS placement. In the present case, the patient developed severe acute pancreatitis after SEMS placement for MBS because of metastatic lymph nodes. Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy and an endoscopic nasobiliary drainage tube placement were performed. After seven days, an uncovered SEMS was placed; however, severe acute pancreatitis occurred, and the SEMS was drawn out emergently. In SEMS placement for patients with MBS caused by non-pancreatic cancer, SEMS should be selected carefully while considering each patient''s case.     

Endoscopic Placement of Metallic Stent for Colonic Stricture Resulting from Carcinoma Located at the Splenic Flexure

A 67‐year‐old woman was admitted to Ikuwakai Memorial Hospital with sub‐ileus symptoms. Radiographic and endoscopic examination revealed that the patient had a colonic cancer approximately 15 cm in length from the descending colon to the distal transverse colon with severe stricture. The histopathological finding was mucinous adenocarcinoma. Abdominal computed tomography showed multiple liver metastases and intraperitoneal lymph‐node swelling. A per‐rectal decompression tube was inserted temporarily, and surgical colostomy was initially proposed. However, the patient rejected surgery, and stent therapy was considered as an alternative therapy. An ultraflex esophageal expandable metallic stent was installed. At day 4, tumor projection through the expandable metal‐stent mesh was observed and additional balloon dilatation was carried out under colonoscopic assistance. At day 7, ileus symptoms disappeared and the patient had been able to maintain oral feeding for 3 months until she died as a result of cachexia by systemic metastasis of colonic cancer.     

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.     

CLINICAL EVALUATION OF METALLIC STENTING FOR MALIGNANT DUODENAL OBSTRUCTION USING COVERED SELF‐EXPANDABLE METALLIC STENT

Covered self‐expandable metallic stent (SEMS) prevents tumor ingrowth and hyperplasia, and allows long‐term patency. However, covered SEMS has rarely been used for malignant duodenal obstruction. In the present study, we applied a covered SEMS for malignant duodenal obstruction, aiming at prevention of tumor ingrowth and hyperplasia and long‐term patency, and performed clinical evaluation. The original disease was pancreas cancer in 23 patients, gallbladder cancer in two, bile duct cancer in two, Vater's papilla cancer in one, duodenal cancer in two, and metastatic tumor (uterine cancer) in one. Treatment of duodenal obstruction using a covered SEMS was successful in 30 of the 31 patients. The patients were able to ingest orally within a mean of 2 days, and 90% of the patients (27/30) were able to eat solid diets later. None of the patients reported a symptom due to obstruction of the SEMS until death. The mean duration of patency of the duodenal covered SEMS was 175 days (SD: ± 114 days). We concluded that palliative thrapy using a covered SEMS for malignant duodenal obstruction obtained good patency and it was useful thrapy.     

A Case of CholangioDuodenal Fistula Formation After Metallic Stenting for Malignant Biliary Stricture

A 68-year-old man presented with melena in June 1993, and was diagnosed as having adenocarcinoma of the rectum with liver metastasis. He underwent anterior resection of the rectum and was given weekly chemotherapy. In October 1993, he developed jaundice due to severe stricture of the middle to lower common bile duct caused by metastatic spread to the lymph nodes around the pancreatic head. A 10mm wide, 51mm long Wallstent^TM (Schneider) was inserted into the lower end of the bile duct through the papilla, resulting in rapid normalization of the serum bilirubin level. Three months later, the Wallstent eroded through the duodenal wall, causing massive fatal hemorrhage. We, therefore, emphasize the necessity of being alert to the potential for such complications in cases involving placement of a self-expanding metallic stent for malignant biliary stricture.     

Fully-covered, self-expandable metal stents (CSEMS) in malignant distal biliary strictures: mid-term evaluation

Background and Aims: Limited data exist regarding fully‐covered, self‐expandable metal stents (CSEMS) with anchoring fins for the management of malignant distal biliary strictures. The aim of this study is to evaluate their safety and patency. Methods: Over a period of 2 years, 70 patients (45 males, 66 ± 13 years) underwent endoscopic retrograde cholangiopancreatography (ERCP) with placement of a 10‐mm (67 patients) or 8‐mm diameter (3 patients) CSEMS for the palliation of distal malignant biliary obstruction (pancreatic [53] or other [17]). Data were collected prospectively for survival and stent patency; complications were evaluated retrospectively. Results: After CSEMS placement, 17 patients proceeded to surgery, and 53 patients were deemed unresectable. Mean survival for non‐surgical candidates was 180 days (range: 15–1091), and 170 days (range: 9–589) for patients who underwent surgical management. CSEMS were left in place and remained patent for a mean of 163 days (range: 15–1091) in non‐surgical candidates, and a mean of 55 days (range: 5–126) in surgical candidates. Complications during placement included wire perforations (4) and proximal deployment requiring repositioning (4), one of which was complicated by a bile leak. Post‐procedure complications were observed in 24 cases (34%) and included post‐ERCP pancreatitis (8, with 2 of them severe), post‐procedure pain (5, with 3 requiring admission), cholecystitis (3), stent occlusion (3), cholangitis (2), proximal migration (1), post‐sphincterotomy bleeding (1), and sepsis leading to death (1). Conclusion: CSEMS appear to provide acceptable short‐term patency rates; however, their limited long‐term patency and high complication rate might limit their widespread use. Further long‐term prospective data are required to confirm this observation.     

Fracture of a Self-expandable Metallic Stent Inserted for Malignant Gastric Outlet Obstruction

Duodenal stenting has gradually been established as the first-line treatment for malignant gastric outlet obstruction (GOO). We encountered a case of duodenal stent fracture in a 76-year-old woman with gastric cancer and GOO. She underwent self-expandable metallic stent (SEMS) placement. The SEMS was found to be fractured 4 weeks after its placement. We removed the broken part of the stent and placed a second SEMS. SEMS fracture is a rare and - to the best of our knowledge - unreported complication; hence, clinicians and their patients should be aware of this possibility.     

Unique usage of a partially covered metal stent for drainage of a pancreatic pseudocyst via endosonography-guided transcystgastrostomy

Pancreatic pseudocysts are frequent complications of pancreatitis episodes. The current therapeutic modalities for drainage of pancreatic pseudocysts include surgical, percutaneous, and endoscopic drainage modalities. Endosonography-assisted endoscopic drainage of these pseudocysts with the placement of multiple plastic or fully covered self-expanding biliary metal stents is becoming more commonly carried out. The present case report discusses the unique and successful drainage of a pancreatic pseudocyst with the placement of a partially covered self-expanding metal stent.