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Machado LC, Martins BC, de Lima MS, Geiger S, Lenz L, de Paulo GA, Safatle-Ribeiro A, Ribeiro U, Maluf-Filho F. Results of Endoscopic Treatment of Recurrent Malignant Biliary Obstruction in Patients with Self-Expanding Metal Stents. Dig Dis Sci 2025; 70:1223-1232. [PMID: 39885050 DOI: 10.1007/s10620-025-08853-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Accepted: 01/06/2025] [Indexed: 02/01/2025]
Abstract
BACKGROUND AND AIM Endoscopic biliary drainage with placement of a self-expanding metal stent (SEMS) is the preferred palliative treatment of malignant biliary obstruction. Recent advances in the treatment have prolonged survival, thus, increasing the chance of recurrent biliary obstruction (RBO) after SEMS placement. The aim of this study was to compare different endoscopic approaches in patients with a SEMS and RBO, regarding clinical success and time to RBO. METHODS This retrospective study included all patients with a SEMS placed because of malignant biliary strictures who underwent endoscopic retrograde cholangiopancreatography between January 2011 and December 2018. We evaluated the results of different endoscopic interventions to RBO, including insertion of a new SEMS, stent cleaning, and insertion of a plastic stent (PS). RESULTS From January 2011 to December 2018, 70 (22.4%) patients developed RBO requiring endoscopic reintervention (n = 105 sessions). From the 105 ERCPs, technical success, clinical success, and adverse events rates were 91,4%, 71,8%, and 7,8%, respectively. Younger age (OR = 1.11 95%CI: 1.03-1.19) and the finding of a patent SEMS (OR = 0.17 95%CI: 0.04-0.08) were predictors of clinical failure (P = 0.006 and P = 0.024, respectively). The mean patency time (in days) after endoscopic reintervention was greater for SEMSs than for PSs (417.2 [95% CI: 250.0-584.4] vs 175.2 [95% CI: 124.0-226.5], P = 0.002). CONCLUSIONS Correct identification and treatment of the causal factor of RBO typically lead to technical and clinical success. Placement of a second SEMS provides longer patency compared to a plastic stent if ingrowth (overgrowth) occurs.
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Affiliation(s)
- Lara Coutinho Machado
- Cancer Institute of the University of São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil.
| | - Bruno Costa Martins
- Cancer Institute of the University of São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
| | - Marcelo Simas de Lima
- Cancer Institute of the University of São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
| | - Sebastian Geiger
- Cancer Institute of the University of São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
| | - Luciano Lenz
- Cancer Institute of the University of São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
| | - Gustavo Andrade de Paulo
- Cancer Institute of the University of São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
| | - Adriana Safatle-Ribeiro
- Cancer Institute of the University of São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
| | - Ulysses Ribeiro
- Cancer Institute of the University of São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
| | - Fauze Maluf-Filho
- Cancer Institute of the University of São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
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Tejedor-Tejada J, Alvarez-Alvarez A, Olmos JM, González-Bernal AC, Jimenez-Jurado A, Robles-Gaitero S, Perez-Pariente JM. Secondary uncovered versus fully-covered metal stents for the management of occluded stent in unresectable distal malignant biliary obstruction. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:502218. [PMID: 38857753 DOI: 10.1016/j.gastrohep.2024.502218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Self-expandable metallic stents (SEMS) have been widely placed for unresectable distal malignant biliary obstruction (UDMBO). However, the dysfunction rate is 19-40% and its treatment is controversial. We aimed asses the efficacy and safety of a secondary biliary stents (uncovered (UC) versus fully-covered (FC) stent) for the management of occluded SEMS. PATIENTS AND METHODS Between 2015 and June 2023, 41 patients with UDMBO underwent secondary biliary stent placement as "stent-in-stent" (20 FCSEMS and 21 UCSEMS). The primary outcomes were technical and clinical success of SEMS placement. Secondary outcomes included adverse events (AEs), patency and survival. Patients were prospectively followed until death or loss of follow-up. RESULTS Technical (100% vs 85.5%) and clinical (100% vs 95.2%) success rates were similar in FCSEMS and UCSEMS groups. The median follow-up period was 510 days (range 290-630). The median duration of stent patency of FCSEMS (220 days, IQR 137.5-442.5) was longer than UCSEMS (150 days, IQR 110-362.5) (P=0.395), although stent dysfunction within 6 months was not different between groups. Multivariate analysis indicated that sex (HR=0.909, 0.852-0.970), antitumor treatment (HR=0.248, 0.032-0.441), stent patency (HR=0.992, 0.986-0.998) and clinical success (HR=0.133, 0.026-0.690) were significant factors for overall survival. There were no remarkable differences in AEs. CONCLUSIONS The placement of additional biliary stent using the stent-in-stent method is an effective and safe rescue treatment for patients with UDMBO and occluded stent. In addition, the use of FCSEMS compared UCSEMS has unclear benefits regarding stent patency and overall survival.
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Affiliation(s)
- Javier Tejedor-Tejada
- Department of Gastroenterology, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain.
| | | | - Jose Manuel Olmos
- Department of Gastroenterology, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
| | | | - Andrea Jimenez-Jurado
- Department of Gastroenterology, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
| | - Samuel Robles-Gaitero
- Department of Gastroenterology, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
| | - Jose M Perez-Pariente
- Department of Gastroenterology, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
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Park N, Jung MK, Kim EJ, Paik WH, Cho JH. In-stent radiofrequency ablation with uncovered metal stent placement for tumor ingrowth/overgrowth causing self-expandable metal stent occlusion in distal malignant biliary obstruction: multicenter propensity score-matched study. Gastrointest Endosc 2023; 97:694-703.e2. [PMID: 36460085 DOI: 10.1016/j.gie.2022.11.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/29/2022] [Accepted: 11/18/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND AND AIMS In patients with unresectable malignant biliary obstruction (MBO), endoscopic drainage with a self-expandable metal stent (SEMS) is a well-established treatment, but stent patency is limited. This study aimed to evaluate the efficacy of in-stent radiofrequency ablation (IS-RFA) followed by uncovered SEMS placement for the management of occluded SEMSs. METHODS From 2016 to 2020, 48 patients with recurrent biliary obstruction due to tumor ingrowth or overgrowth after SEMS placement for pancreatobiliary cancer in 3 tertiary hospitals were analyzed. For distal MBO, patients in the RFA group were treated with IS-RFA and uncovered SEMS placement, and those in the control group were treated with uncovered SEMS placement alone. Patients in both groups were matched on the basis of propensity scores in a 1:1 ratio. RESULTS The median time to recurrent biliary obstruction (TRBO) was 117 days in the RFA group and 82.5 days in the control group (P = .029). No significant differences in median overall survival were detected between the 2 groups (170 days vs 72 days; P = .902). No significant adverse events were reported after the second SEMS placement in either group, but 2 cases of mild cholangitis were reported in the control group. Ablation was interrupted in 5 patients (35.7%) of the RFA group owing to in-stent contact, but sufficient ablative energy was delivered in the majority of the patients (92.9%) after IS-RFA was repeated in the same session. CONCLUSIONS IS-RFA followed by an uncovered SEMS is safe and feasible and may improve TRBO as a stent revision for occluded SEMSs in pancreatobiliary cancer.
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Affiliation(s)
- Namyoung Park
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea; Department of Gastroenterology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Min Kyu Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Eui Joo Kim
- Division of Gastroenterology, Department of Internal Medicine, Gil Medical Center, College of Medicine Gachon University, Incheon, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Jae Hee Cho
- Department of Internal Medicine, Institute of Gastroenterology, Gangnam Severance Hospital, Yonsei University College of Medicine, Korea.
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Kovács N, Pécsi D, Sipos Z, Farkas N, Földi M, Hegyi P, Bajor J, Erőss B, Márta K, Mikó A, Rakonczay Z, Sarlós P, Ábrahám S, Vincze Á. Suprapapillary Biliary Stents Have Longer Patency Times than Transpapillary Stents-A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:898. [PMID: 36769545 PMCID: PMC9917857 DOI: 10.3390/jcm12030898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic biliary stent placement is a minimally invasive intervention for patients with biliary strictures. Stent patency and function time are crucial factors. Suprapapillary versus transpapillary stent positioning may contribute to stent function time, so a meta-analysis was performed in this comparison. METHODS A comprehensive literature search was conducted in the CENTRAL, Embase, and MEDLINE databases to find data on suprapapillary stent placement compared to the transpapillary method via endoscopic retrograde cholangiopancreatography in cases of biliary stenosis of any etiology and any stent type until December 2020. We carried out a meta-analysis focusing on the following outcomes: stent patency, stent migration, rate of cholangitis and pancreatitis, and other reported complications. RESULTS Three prospective and ten retrospective studies involving 1028 patients were included. Suprapapillary stent placement appeared to be superior to transpapillary stent positioning in patency (weighted mean difference = 50.23 days, 95% CI: 8.56, 91.98; p = 0.0.018). In a subgroup analysis of malignant indications, suprapapillary positioning showed a lower rate of cholangitis (OR: 0.34, 95% CI: 0.13, 0.93; p = 0.036). Another subgroup analysis investigating metal stents in a suprapapillary position resulted in a lower rate of pancreatitis (OR: 0.16, 95% CI: 0.03, 0.95; p = 0.043) compared to transpapillary stent placement. There was no difference in stent migration rates between the two groups (OR: 0.67, 95% CI: 0.17, 2.72; p = 0.577). CONCLUSIONS Based on our results, suprapapillary biliary stenting has longer stent patency. Moreover, the stent migration rate did not differ between the suprapapillary and transpapillary groups.
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Affiliation(s)
- Norbert Kovács
- Doctoral School of Clinical Medicine, University of Szeged, 6720 Szeged, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
| | - Dániel Pécsi
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Zoltán Sipos
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Mária Földi
- Doctoral School of Clinical Medicine, University of Szeged, 6720 Szeged, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
- Heim Pál National Pediatric Institute, 1089 Budapest, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, 1083 Budapest, Hungary
- Translational Pancreatology Research Group, Interdisciplinary Centre of Excellence for Research Development and Innovation University of Szeged, 6725 Szeged, Hungary
| | - Judit Bajor
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, 1083 Budapest, Hungary
| | - Katalin Márta
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, 1083 Budapest, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
- Department of Medical Genetics, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, 6720 Szeged, Hungary
| | - Patrícia Sarlós
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Szabolcs Ábrahám
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Centre, University of Szeged, 6720 Szeged, Hungary
| | - Áron Vincze
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
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Raksasataya A, Ahooja A, Krangbunkrong V, Jareanrat A, Titapun A, Khuntikeo N. Palliative Care in Cholangiocarcinoma. Recent Results Cancer Res 2023; 219:245-267. [PMID: 37660336 DOI: 10.1007/978-3-031-35166-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
This chapter details all aspects of the general principles of palliative care for advanced stage cholangiocarcinoma patients. These include symptoms management, communication guide, advance care planning, and management for bereavement. Surgical and intervention techniques of palliative biliary drainage are described in detail for patients with obstructive jaundice with advanced stage CCA. Additionally, details are provided regarding the establishment of a multidisciplinary palliative care team which is critical to provide the most appropriate multimodal treatment for good quality of life and survival of patients.
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Affiliation(s)
- Attakorn Raksasataya
- Palliative Care Unit, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Anucha Ahooja
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Vivian Krangbunkrong
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Apiwat Jareanrat
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Attapol Titapun
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Narong Khuntikeo
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Okamoto T. Malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer. World J Gastroenterol 2022; 28:985-1008. [PMID: 35431494 PMCID: PMC8968522 DOI: 10.3748/wjg.v28.i10.985] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/03/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Malignant biliary obstruction generally results from primary malignancies of the pancreatic head, bile duct, gallbladder, liver, and ampulla of Vater. Metastatic lesions from other primaries to these organs or nearby lymph nodes are rarer causes of biliary obstruction. The most common primaries include renal cancer, lung cancer, gastric cancer, colorectal cancer, breast cancer, lymphoma, and melanoma. They may be difficult to differentiate from primary hepato-pancreato-biliary cancer based on imaging studies, or even on biopsy. There is also no consensus on the optimal method of treatment, including the feasibility and effectiveness of endoscopic intervention or surgery. A thorough review of the literature on pancreato-biliary metastases and malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer is presented. The diagnostic modality and clinical characteristics may differ significantly depending on the type of primary cancer. Different primaries also cause malignant biliary obstruction in different ways, including direct invasion, pancreatic or biliary metastasis, hilar lymph node metastasis, liver metastasis, and peritoneal carcinomatosis. Metastasectomy may hold promise for some types of pancreato-biliary metastases. This review aims to elucidate the current knowledge in this area, which has received sparse attention in the past. The aging population, advances in diagnostic imaging, and improved treatment options may lead to an increase in these rare occurrences going forward.
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Affiliation(s)
- Takeshi Okamoto
- Department of Gastroenterology, St. Luke’s International Hospital, Chuo-ku 104-8560, Tokyo, Japan
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Takenaka M, Kudo M. Endoscopic Reintervention for Recurrence of Malignant Biliary Obstruction: Developing the Best Strategy. Gut Liver 2022; 16:525-534. [PMID: 35193992 PMCID: PMC9289839 DOI: 10.5009/gnl210228] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/22/2021] [Accepted: 08/24/2021] [Indexed: 11/21/2022] Open
Abstract
Drainage therapy for malignant biliary obstruction (MBO) includes trans-papillary endoscopic retrograde biliary drainage (ERBD), percutaneous transhepatic biliary drainage (PTBD), and trans-gastrointestinal endoscopic ultrasound-guided biliary drainage (EUS-BD). With the development of chemotherapy, many MBO cases end up needing endoscopic reintervention (E-RI) for recurrent biliary obstruction. To achieve a successful E-RI, it is necessary to understand the various findings regarding E-RI in MBO cases reported to date. Therefore, in this review, we focus on E-RI for ERBD of distal MBO, ERBD of hilar MBO, and EUS-BD. To plan an appropriate E-RI strategy for biliary stent occlusion for MBO, the following must be considered on a case-by-case basis: the urgency of the drainage, the cause of the occlusion, the original route of drainage (PTBD/ERBD/EUS-BD), the initial stent used (plastic stent or self-expandable metallic stent), and in the case of self-expandable metallic stents, the type used (fully covered or uncovered). Regardless of the original method of stent placement, if the inflammation caused by obstructive cholangitis is severe and/or the patient is in shock, PTBD should be considered as the first choice. Finally, it is important to keep in mind that in many cases, performing E-RI will be difficult.
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Affiliation(s)
- Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
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Bilal M, Freeman ML. Endoscopic Retrograde Cholangiopancreatography Stenting for Hilar Cholangiocarcinoma. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2022; 24:190-199. [DOI: 10.1016/j.tige.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Kitamura H, Hijioka S, Nagashio Y, Sugawara S, Nara S, Sone M, Esaki M, Arai Y, Okusaka T, Nakajima A. Use of endoscopic ultrasound-guided biliary drainage as a rescue of re-intervention after the placement of multiple metallic stents for malignant hilar biliary obstruction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:404-414. [PMID: 34661973 DOI: 10.1002/jhbp.1059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/01/2021] [Accepted: 09/13/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE Endoscopic transpapillary re-intervention (ETP-RI) after multiple self-expandable metallic stent (SEMS) placement for unresectable malignant hilar biliary obstruction (MHBO) is challenging, but endoscopic ultrasound-guided biliary drainage (EUS-BD) could be an alternative following failed ETP-RI. We investigated appropriate re-intervention (RI) methods in MHBO after multiple SEMS placement and evaluated RI with EUS-BD (EUS-RI) benefits following ETP-RI failure. METHODS Patients requiring RI after multiple SEMS placement for MHBO between October 2017 and April 2021 were enrolled. Patients' characteristics, metallic-stent type, stent-placement configuration, overall survival, stent patency, re-intervention results, and re-intervention technical and clinical success rates were reviewed. RESULTS Forty-nine patients underwent ETP-RI for MHBO. ETP-RI's technical success rate was 69.4%. Of 15 failed ETP-RI cases, all underwent EUS-RI, achieving technical and clinical success rates of 86.7% and 100%, respectively. Time to recurrent biliary obstruction (TRBO) after RI was significantly different between EUS-RI and ETP-RI (212 vs 84 days; P = .01). On multivariate analysis, EUS-RI was the only factor associated with TRBO (odds ratio: 4.48; 95% confidence interval: 1.01-19.91; P = .04). Acute pancreatitis and bile peritonitis were present in 6.1% of ETP-RI and 13.3% of EUS-RI cases, respectively; both improved conservatively. CONCLUSIONS EUS-RI was effective and safe in difficult ETP-RI cases after multiple SEMS placement for MHBO.
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Affiliation(s)
- Hidetoshi Kitamura
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
- Department of Gastroenterology and Hepatology, Yokohama City University Hospital, Yokohama, Japan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Yoshikuni Nagashio
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Shunsuke Sugawara
- Department of Diagnostic Radiology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Satoshi Nara
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Chuo-ku, Japan
| | - Miyuki Sone
- Department of Diagnostic Radiology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Minoru Esaki
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Chuo-ku, Japan
| | - Yasuaki Arai
- Department of Diagnostic Radiology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Hospital, Yokohama, Japan
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Tantau AI, Mandrutiu A, Pop A, Zaharie RD, Crisan D, Preda CM, Tantau M, Mercea V. Extrahepatic cholangiocarcinoma: Current status of endoscopic approach and additional therapies. World J Hepatol 2021; 13:166-186. [PMID: 33708349 PMCID: PMC7934015 DOI: 10.4254/wjh.v13.i2.166] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 12/02/2020] [Accepted: 12/13/2020] [Indexed: 02/06/2023] Open
Abstract
The prognosis of patients with advanced or unresectable extrahepatic cholangiocarcinoma is poor. More than 50% of patients with jaundice are inoperable at the time of first diagnosis. Endoscopic treatment in patients with obstructive jaundice ensures bile duct drainage in preoperative or palliative settings. Relief of symptoms (pain, pruritus, jaundice) and improvement in quality of life are the aims of palliative therapy. Stent implantation by endoscopic retrograde cholangiopancreatography is generally preferred for long-term palliation. There is a vast variety of plastic and metal stents, covered or uncovered. The stent choice depends on the expected length of survival, quality of life, costs and physician expertise. This review will provide the framework for the endoscopic minimally invasive therapy in extrahepatic cholangiocarcinoma. Moreover, additional therapies, such as brachytherapy, photodynamic therapy, radiofrequency ablation, chemotherapy, molecular-targeted therapy and/or immunotherapy by the endoscopic approach, are the nonsurgical methods associated with survival improvement rate and/or local symptom palliation.
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Affiliation(s)
- Alina Ioana Tantau
- Department of Internal Medicine and Gastroenterology, “Iuliu Hatieganu” University of Medicine and Pharmacy, 4 Medical Clinic, Cluj-Napoca 400012, Cluj, Romania
| | - Alina Mandrutiu
- Department of Gastroenterology and Hepatology, Gastroenterology and Hepatology Medical Center, Cluj-Napoca 400132, Cluj, Romania
| | - Anamaria Pop
- Department of Gastroenterology and Hepatology, Gastroenterology and Hepatology Medical Center, Cluj-Napoca 400132, Cluj, Romania
| | - Roxana Delia Zaharie
- Department of Gastroenterology, “Prof. Dr. Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Cluj, Romania
- Department of Gastroenterology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400012, Cluj, Romania.
| | - Dana Crisan
- Internal Medicine Department, Cluj-Napoca Internal Medicine Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 5 Medical Clinic, Cluj-Napoca 400012, Cluj, Romania
| | - Carmen Monica Preda
- Department of Gastroenterology and Hepatology, Clinic Fundeni Institute, “Carol Davila” University of Medicine and Pharmacy, Bucharest 22328, Romania
| | - Marcel Tantau
- Department of Internal Medicine and Gastroenterology, “Prof. Dr. Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Cluj, Romania
- Department of Internal Medicine and Gastroenterology, “Iuliu Hatieganu“ University of Medicine and Pharmacy, Cluj-Napoca 400012, Cluj, Romania
| | - Voicu Mercea
- Department of Internal Medicine and Gastroenterology, “Prof. Dr. Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Cluj, Romania
- Department of Internal Medicine and Gastroenterology, “Iuliu Hatieganu“ University of Medicine and Pharmacy, Cluj-Napoca 400012, Cluj, Romania
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Shin J, Park JS, Jeong S, Lee DH. Comparison of the Clinical Outcomes of Suprapapillary and Transpapillary Stent Insertion in Unresectable Cholangiocarcinoma with Biliary Obstruction. Dig Dis Sci 2020; 65:1231-1238. [PMID: 31584136 DOI: 10.1007/s10620-019-05859-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 09/21/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS To prevent stent migration, transpapillary stent placement has been recommended for the endoscopic treatment of malignant hilar biliary stricture. However, recent studies have suggested that placement above the papilla achieves better results, because it is believed to prevent reflux and prolong stent patency. The aim of this study was to compare the efficacy and safety aspects of transpapillary and suprapapillary stent placement. In addition, the success rates of stent revision were evaluated. MATERIALS AND METHODS The medical records of 73 patients with hilar cholangiocarcinoma who underwent endoscopic metal stent insertion between January 2005 and December 2015 were retrospectively reviewed. Patients were assigned by stent location to a suprapapillary (S group; N = 44) or a transpapillary (T group; N = 29) cohort. Clinical outcomes, stent patency, adverse events, and revision success rates were compared between the two study groups. RESULTS Patency periods were similar in the two groups (S; 140 vs. T; 157 days; P = 0.732). Rates of stent obstruction in the S and T groups were 63.4% and 55.2%, respectively (P = 0.470). An adverse event occurred in 15 (20.5%) of total study subjects, with no significant intergroup difference. The endoscopic revision success rate was significantly higher in the T group (P = 0.01), and the time required for revision tended to be shorter in the T group. CONCLUSIONS The effectiveness and safety of suprapapillary and transpapillary stent insertion were found to be similar, but the success rate of endoscopic revision was significantly higher for the T group. Therefore, we recommend that transpapillary stent placement be considered for patients with hilar cholangiocarcinoma and biliary obstruction.
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Affiliation(s)
- Jongbeom Shin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
| | - Jin-Seok Park
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea.
| | - Seok Jeong
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
| | - Don Haeng Lee
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
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12
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Okuno M, Mukai T, Iwashita T, Ichikawa H, Iwasa Y, Mita N, Yoshida K, Iwata K, Tomita E, Shimizu M. Evaluation of endoscopic reintervention for self-expandable metallic stent obstruction after stent-in-stent placement for malignant hilar biliary obstruction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:211-218. [PMID: 30950234 DOI: 10.1002/jhbp.626] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bilateral self-expandable metallic stent (SEMS) placement is effective for long-term management of unresectable malignant hilar biliary obstruction (UMHBO). However, endoscopic reintervention (ERI) for bilateral SEMSs is not well-studied. This study aimed to evaluate ERI efficacy after stent-in-stent placement. METHODS Data of 31 patients who underwent ERI from May 2000 to July 2018 were analyzed. RESULTS The technical success rate was 80.7% (25/31) and no adverse events occurred. The functional success rate was 100% (25/25). In a multivariate logistic regression analysis, the angle between the bilateral SEMSs (ABBS) >104° (odds ratio 50.49, 95% CI 3.370-2131, P = 0.0039) and overgrowth (odds ratio 25.70, 95% CI 1.121-1234, P = 0.0423) were risk factors for ERI failure. Multiple liver metastases, which sometimes cause overgrowth, were also risk factors. After ERI, some patients underwent additional SEMS (n = 4), plastic stent (n = 14) placement, or internal cleaning of the initial SEMS alone (n = 7). There were no significant intergroup differences in the 50% time to recurrent biliary obstruction. CONCLUSIONS ABBS >104° and overgrowth were risk factors for ERI failure after stent-in-stent placement. In the decision-making process for initial SEMS placement for UMHBO, patient condition should be considered, including the angle between bilateral bile ducts and multiple liver metastases.
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Affiliation(s)
- Mitsuru Okuno
- Department of Gastroenterology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu City, Gifu 500-8513, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu City, Gifu 500-8513, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Hironao Ichikawa
- Department of Gastroenterology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu City, Gifu 500-8513, Japan
| | - Yuhei Iwasa
- Department of Gastroenterology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu City, Gifu 500-8513, Japan
| | - Naoki Mita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Kensaku Yoshida
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Prefecture General Medical Center, Gifu, Japan
| | - Eiichi Tomita
- Department of Gastroenterology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu City, Gifu 500-8513, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
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13
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Jirapinyo P, AlSamman MA, Thompson CC. Impact of infected stent removal on recurrent cholangitis with time-to-event analysis. Surg Endosc 2019; 33:4109-4115. [PMID: 30927127 DOI: 10.1007/s00464-019-06714-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 02/19/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND The optimal approach at treating infected biliary stents at the time of cholangitis remains unknown. This study aims to compare the efficacy of stent exchange versus stent sweeping/stent-in-stent approaches at treating cholangitis. METHODS The study was a retrospective cohort study. Patients with biliary stents and cholangitis were included. Outcomes were rate of recurrent cholangitis and time to recurrent cholangitis in those whose stents were left in place (stent sweeping and stent-in-stent) compared to those whose stents were removed (stent exchange). Primary analysis included patients with metal biliary stents only. Secondary analysis included those with metal and plastic biliary stents. RESULTS A total of 182 patients (age 64 ± 12;89 F) with a metal biliary stent(s) at index cholangitis were included. Of these, 40 (22%) had stents removed, i.e., stent exchange. The remaining 142 (78%) did not have stent removal (97 with stent-in-stent and 45 with stent sweeping). Recurrent cholangitis occurred in 22.5% and 42.3% in the stent removal and non-removal groups, respectively (p = 0.02). Stent removal remained a negative predictor of recurrent cholangitis after controlling for age, sex, history of diabetes, and chemotherapy (OR 0.39, p = 0.03). Median time from index cholangitis to recurrent cholangitis was shorter for patients whose stents were not removed compared to those whose stents were removed (182 vs 450 days, p = 0.011). On Cox regression model, stent removal remained a negative predictor of recurrent cholangitis after controlling for age, sex, history of diabetes, and chemotherapy (HR 0.41, p = 0.01). The findings persisted in the secondary analysis including both metal and plastic biliary stents (303 patients). CONCLUSION Biliary stent removal with stent exchange at the time of cholangitis appears to be more effective at preventing recurrent cholangitis than leaving an infected stent in the biliary system.
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Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
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14
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Nennstiel S, Tschurtschenthaler I, Neu B, Algül H, Bajbouj M, Schmid RM, von Delius S, Weber A. Management of occluded self-expanding biliary metal stents in malignant biliary disease. Hepatobiliary Pancreat Dis Int 2018; 17:49-54. [PMID: 29428104 DOI: 10.1016/j.hbpd.2018.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/02/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Occlusion of self-expanding metal stents (SEMS) in malignant biliary obstruction occurs in up to 40% of patients. This study aimed to compare the different techniques to resolve stent occlusion in our collective of patients. METHODS Patients with malignant biliary obstruction and occlusion of biliary metal stent at a tertiary referral endoscopic center were retrospectively identified between April 1, 1994 and May 31, 2014. The clinical records were further analyzed regarding the characteristics of patients, malignant strictures, SEMS, management strategies, stent patency, subsequent interventions, survival time and case charges. RESULTS A total of 108 patients with biliary metal stent occlusion were identified. Seventy-nine of these patients were eligible for further analysis. Favored management was plastic stent insertion in 73.4% patients. Second SEMS were inserted in 12.7% patients. Percutaneous transhepatic biliary drainage and mechanical cleansing were conducted in a minority of patients. Further analysis showed no statistically significant difference in median overall secondary stent patency (88 vs. 143 days, P = 0.069), median survival time (95 vs. 192 days, P = 0.116), median subsequent intervention rate (53.4% vs. 40.0%, P = 0.501) and median case charge (€5145 vs. €3473, P = 0.803) for the treatment with a second metal stent insertion compared to plastic stent insertion. In patients with survival time of more than three months, significantly more patients treated with plastic stents needed re-interventions than patients treated with second SEMS (93.3% vs. 57.1%, P = 0.037). CONCLUSIONS In malignant biliary strictures, both plastic and metal stent insertions are feasible strategies for the treatment of occluded SEMS. Our data suggest that in palliative biliary stenting, patients especially those with longer expected survival might benefit from second SEMS insertion. Careful patient selection is important to ensure a proper decision for either management strategy.
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Affiliation(s)
- Simon Nennstiel
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Isolde Tschurtschenthaler
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Bruno Neu
- Medizinische Klinik II, Krankenhaus Landshut-Achdorf, Academic Teaching Hospital, Technische Universität München, Achdorferweg 3, Landshut 84036, Germany
| | - Hana Algül
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Monther Bajbouj
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Roland M Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Stefan von Delius
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Andreas Weber
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany.
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15
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Inoue T, Naitoh I, Okumura F, Ozeki T, Anbe K, Iwasaki H, Nishie H, Mizushima T, Sano H, Nakazawa T, Yoneda M, Joh T. Reintervention for stent occlusion after bilateral self-expandable metallic stent placement for malignant hilar biliary obstruction. Dig Endosc 2016; 28:731-737. [PMID: 27088888 DOI: 10.1111/den.12657] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/14/2016] [Accepted: 03/16/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Endoscopic reintervention for stent occlusions following bilateral self-expandable metallic stent (SEMS) placement for malignant hilar biliary obstruction (MHBO) is challenging, and time to recurrent biliary obstruction (RBO) of the revisionary stent remains unclear. We aimed to clarify a suitable reintervention method for stent occlusions following bilateral SEMS placement for MHBO. METHODS Between 2002 and 2014, 52 consecutive patients with MHBO who underwent endoscopic reintervention for stent occlusion after bilateral SEMS placement were enrolled at two university hospitals and one tertiary care referral center. We retrospectively evaluated the technical and functional success rates of the reinterventions, and the time to RBO of the revisionary stents. RESULTS Technical and functional success rates of the reinterventions were 92% (48/52) and 90% (43/48), respectively. Univariate analysis did not determine any significant predictive factors for technical and functional failures. Median time to RBO of the revisionary stents was 68 days. Median time to RBO was significantly longer for revisionary SEMS placement than for plastic stent placement (131 days vs 47 days, respectively; log-rank test, P = 0.005). Revisionary SEMS placement was the only independent factor that was significantly associated with a longer time to RBO of the revisionary stent in the multivariate Cox proportional hazards analysis (hazard ratio 0.37; 95% confidence interval 0.14-0.95; P = 0.039). CONCLUSION Revisionary SEMS placement is a suitable endoscopic reintervention method for stent occlusion following bilateral SEMS placement from the perspective of time to RBO of the revisionary stent.
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Affiliation(s)
- Tadahisa Inoue
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan.,Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Fumihiro Okumura
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takanori Ozeki
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Kaiki Anbe
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Hiroyasu Iwasaki
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Hirotada Nishie
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takashi Mizushima
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Hitoshi Sano
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takahiro Nakazawa
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masashi Yoneda
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Takashi Joh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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16
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Betgeri S, Rajesh S, Arora A, Panda D, Bhadoria AS, Mukund A. Percutaneous endobiliary RFA combined with balloon-sweep for re-opening occluded metallic biliary stents. MINIM INVASIV THER 2016; 26:124-127. [PMID: 27611763 DOI: 10.1080/13645706.2016.1235052] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The aim of this report is to discuss the results of percutaneous endobiliary radiofrequency ablation (RFA) combined with balloon-sweep technique in restoring the patency of occluded self-expandable metallic stents (SEMS) secondary to tumor infiltration. A total of eight patients underwent endobiliary RFA for reopening of occluded SEMS at our institute. After endobiliary RFA, all patients showed restoration of stent patency. After a median follow-up of 6.5 months, four patients had succumbed to the underlying disease at 3, 4, 6, and 7 months. Two of these required reinterventions at 2 and 5 months. One patient died of sepsis and aspiration pneumonia at 3 months. Of the remaining three patients, two required re-intervention after 2 months, while the other remained asymptomatic. The mean duration of stent patency after the first session of RFA was 4 ± 2.1 months, which was comparable to the primary patency of these stents (4.2 months). Our experience suggests that endobiliary RFA with balloon sweep is a safe and useful technique for re-establishing the patency of occluded SEMS.
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Affiliation(s)
- Somsharan Betgeri
- a Department of Interventional Radiology and Imaging , Institute of Liver and Biliary Sciences , New Delhi , India
| | - S Rajesh
- a Department of Interventional Radiology and Imaging , Institute of Liver and Biliary Sciences , New Delhi , India
| | - Ankur Arora
- b Department of Radiology , Institute of Liver and Biliary Sciences , New Delhi , India
| | - Dipanjan Panda
- c Department of Medical Oncology , Institute of Liver and Biliary Sciences , New Delhi , India
| | - Ajeet Singh Bhadoria
- d Department of Epidemiology and Public Health , Institute of Liver and Biliary Sciences , New Delhi , India
| | - Amar Mukund
- a Department of Interventional Radiology and Imaging , Institute of Liver and Biliary Sciences , New Delhi , India
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17
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Inoue T, Okumura F, Naitoh I, Fukusada S, Kachi K, Ozeki T, Anbe K, Iwasaki H, Mizushima T, Kobayashi Y, Ishii N, Ito K, Kondo H, Hayashi K, Yoneda M, Sano H. Feasibility of the placement of a novel 6-mm diameter threaded fully covered self-expandable metal stent for malignant hilar biliary obstructions (with videos). Gastrointest Endosc 2016; 84:352-7. [PMID: 27060713 DOI: 10.1016/j.gie.2016.03.1501] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Uncovered self-expandable metal stents (USEMSs) are used to treat unresectable malignant hilar biliary obstructions (MHBOs). However, ingrowth is not prevented, and reintervention is often troublesome. A novel 6-mm threaded fully covered self-expandable metal stent (T-FCSEMS) is available that may mitigate these issues. We aimed to clarify the safety and efficacy of T-FCSEMS placement for MHBO. METHODS Thirty patients underwent T-FCSEMS placements for MHBOs between 2014 and 2015. T-FCSEMSs were used for initial stenting in 17 patients (initial group) and for reinterventions for USEMS occlusions caused by ingrowth in 13 patients (reintervention group). The technical success rates, times to recurrent biliary obstruction, and the reintervention success rates were evaluated. RESULTS The technical success rates were 94% (16/17) and 92% (12/13) in the initial group and reintervention group, respectively. Intrahepatic bile duct occlusions caused liver abscesses 8 days and 22 days after T-FCSEMS placements in 2 cases (7%) in the initial group, in which T-FCSEMSs were placed across the intrahepatic bile duct bifurcation. The median times to recurrent biliary obstruction were 210 days in the initial group after bilateral placement and 112 days and 152 days in the reintervention group after bilateral and unilateral placements, respectively. During reintervention, T-FCSEMS removal was successful in all patients in whom it was attempted, and the success rate of endoscopic reintervention was 100% in both groups. CONCLUSIONS T-FCSEMS placement is a promising option for both initial stenting and reintervention for MHBO. However, we should consider the possibility of intrahepatic bile duct occlusion.
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Affiliation(s)
- Tadahisa Inoue
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan; Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Fumihiro Okumura
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shigeki Fukusada
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Kenta Kachi
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takanori Ozeki
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Kaiki Anbe
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Hiroyasu Iwasaki
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takashi Mizushima
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Yuji Kobayashi
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Norimitsu Ishii
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kiyoaki Ito
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Hiromu Kondo
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kazuki Hayashi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masashi Yoneda
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Hitoshi Sano
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
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18
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Madhusudhan KS, Gamanagatti S, Srivastava DN, Gupta AK. Radiological interventions in malignant biliary obstruction. World J Radiol 2016; 8:518-29. [PMID: 27247718 PMCID: PMC4882409 DOI: 10.4329/wjr.v8.i5.518] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 01/25/2016] [Accepted: 03/07/2016] [Indexed: 02/06/2023] Open
Abstract
Malignant biliary obstruction is commonly caused by gall bladder carcinoma, cholangiocarcinoma and metastatic nodes. Percutaneous interventions play an important role in managing these patients. Biliary drainage, which forms the major bulk of radiological interventions, can be palliative in inoperable patients or pre-operative to improve liver function prior to surgery. Other interventions include cholecystostomy and radiofrequency ablation. We present here the indications, contraindications, technique and complications of the radiological interventions performed in patients with malignant biliary obstruction.
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19
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Hu Z, Patel N, Butani D. External Biliary Conduit for Occlusion of an Endobiliary Stent in Malignant Biliary Obstruction: A Nonsurgical Solution. J Vasc Interv Radiol 2016; 27:770-3. [PMID: 27106653 DOI: 10.1016/j.jvir.2015.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 12/01/2015] [Accepted: 12/01/2015] [Indexed: 10/21/2022] Open
Affiliation(s)
- Zhongxia Hu
- Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642
| | - Nikhil Patel
- Department of Radiology, Kenmore Mercy Hospital, Buffalo, New York
| | - Devang Butani
- Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642
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20
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Jang SI, Lee DK. Update on Pancreatobiliary Stents: Stent Placement in Advanced Hilar Tumors. Clin Endosc 2015; 48:201-8. [PMID: 26064819 PMCID: PMC4461663 DOI: 10.5946/ce.2015.48.3.201] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/11/2015] [Accepted: 05/11/2015] [Indexed: 12/23/2022] Open
Abstract
Palliative drainage is the main treatment option for inoperable hilar cholangiocarcinoma to improve symptoms, which include cholangitis, pruritus, high-grade jaundice, and abdominal pain. Although there is no consensus on the optimal method for biliary drainage due to the paucity of large-scale randomized control studies, several important aspects of any optimal method have been studied. In this review article, we discuss the liver volume to be drained, stent type, techniques to insert self-expanding metal stents, and approaches for proper and effective biliary drainage based on previous studies and personal experience.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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21
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Kawakami H, Itoi T, Kuwatani M, Kawakubo K, Kubota Y, Sakamoto N. Technical tips and troubleshooting of endoscopic biliary drainage for unresectable malignant hilar biliary obstruction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:E12-E21. [PMID: 25379788 DOI: 10.1002/jhbp.186] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Unresectable malignant hilar biliary obstruction (MHBO) occurs in various diseases, such as cholangiocarcinoma, gallbladder carcinoma, hepatocellular carcinoma, pancreatic cancer, and lymph node metastasis of the hilum of the liver. The majority of patients with advanced MHBO are not candidates for surgical resection because of the tumor location in the hepatic hilum and adjacent areas, advanced tumor stage, or comorbidities. Therefore, these patients often have a poor prognosis in terms of survival and quality of life. Most of these patients will require non-surgical, palliative biliary drainage. To date, various biliary drainage techniques for unresectable MHBO (UMHBO) have been reported. Of these techniques, endoscopic biliary drainage is currently considered to be the most safe and minimally invasive procedure. However, endoscopic biliary drainage for UMHBO is still not standardized regarding the optimal stent, drainage area, stenting method, and reintervention technique. Recently, towards standardization of this technique for UMHBO, clinical research and trials including randomized controlled trials have been performed. In this article, we reviewed the most important issues regarding endoscopic biliary drainage for UMHBO, focusing on prospective studies. We also described in detail the techniques and future perspectives of endoscopic biliary drainage in patients with UMHBO.
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Affiliation(s)
- Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Kita 14, Nishi 5, Kita-ku, Sapporo, 060-8648, Japan.
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Boudjema K, Levi Sandri GB, Boucher E, Rohou T, Rayar M, Sulpice L. An update on liver surgery for cholangiocarcinoma. Updates Surg 2014; 66:93-100. [PMID: 24085384 DOI: 10.1007/s13304-013-0235-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 09/17/2013] [Indexed: 12/25/2022]
Abstract
Cholangiocarcinoma is a malignant neoplasm that originates from biliary epithelial cells. Complete tumor resection remains the most effective treatment of intra-hepatic or perihilar cholangiocarcinomas (PHCs). The objectives of this are to update and discuss methods that are likely to increase the resectability of cholangiocarcinomas, and to define the limits beyond which the risks of the treatments outweigh their benefits. We analyzed intra-hepatic cholangiocarcinomas and PHCs separately to determine the site of origin and the resectability of the tumor. We discussed the site at which to perform hepatic optimization prior to surgery, and whether liver transplantation might affect cholangiocarcinoma treatment.
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Affiliation(s)
- Karim Boudjema
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire de Rennes, Université de Rennes 1, Rennes Cedex, France,
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Kaneko T, Sugimori K, Shimizu Y, Miwa H, Kameta E, Koh R, Numata K, Tanaka K, Maeda S. Efficacy of plastic stent placement inside bile ducts for the treatment of unresectable malignant hilar obstruction (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:349-55. [PMID: 24123806 DOI: 10.1002/jhbp.41] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recent reports have addressed the utility of plastic stent (PS) placement inside bile ducts for treating biliary obstructions. Here, we evaluated the utility and safety of PS placement inside bile ducts for treating unresectable malignant hilar biliary obstruction. METHODS We conducted a retrospective study of 27 patients with unresectable malignant hilar biliary obstruction who underwent intraductal modified PS placement. We modified the PS, by cutting off the distal end to facilitate insertion through the papilla of Vater, and attached a nylon thread to the distal end for removal. We evaluated complications, the time to recurrent biliary obstruction (TRBO), and removability. RESULTS Bilateral stenting was performed in nine of the 27 patients. Mild acute pancreatitis occurred in one patient (4%). Recurrent biliary obstruction (RBO) occurred in 16 patients (59%), with a median TRBO of 190 days (95% confidence interval: 174-205 days). Reintervention was necessary in 13 of the 16 patients (81%) with RBO, and we were able to remove the initial stents in all the patients who required reintervention. CONCLUSIONS A relatively long stent patency period (>6 months) and removability make placement of a modified PS inside bile ducts a viable treatment for unresectable malignant hilar biliary obstruction.
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Affiliation(s)
- Takashi Kaneko
- Gastroenterological Center, Yokohama City University Medical Center, 4-57 Urafune, Minami-ku, Yokohama, 2320024, Japan.
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Kim CG, Choi IJ, Lee JY, Cho SJ, Kim SJ, Kim MJ, Park SR, Park YL. Outcomes of second self-expandable metallic stent insertion for malignant gastric outlet obstruction. Surg Endosc 2013; 28:281-8. [PMID: 24026566 DOI: 10.1007/s00464-013-3185-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 08/06/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Self-expandable metallic stents are used widely to relieve malignant gastric outlet obstruction (GOO). However, restenosis or migration of first stents is a frequent complication. The purpose of this retrospective cohort study was to evaluate the effectiveness of second stents as an approach to manage failure of first stents in patients with malignant GOO. METHODS A total of 222 patients with gastric cancer received first stents due to inoperable GOO at National Cancer Center in Korea between January 2008 and June 2011. Monthly follow-up interviews were performed, and second stents (stent-in-stent or stent-after-migration) were inserted in 59 patients by June 2012. Technical and clinical successes and long-term complications were evaluated. RESULTS The technical and immediate clinical success rates were 98.3 % (58/59) and 91.5 % (54/59), respectively. Patients who received a second stent due to late complications involving the first stent (migration, restenosis, and fracture) showed a higher clinical success rate (95.8 % [46/48]) than patients who received a second stent due to immediate clinical failure of the first stent (72.7 % [8/11], p = 0.04). The immediate clinical success rate of stent-after-migration (100 % [11/11]) was not different from that of stent-in-stent (89.6 % [43/48], p = 1.0). The stent dysfunction rate of stent-after-migration (27.3 % [3/11]) also was similar to that of stent-in-stent (29.2 % [14/48], p = 1.0). The median patencies of stent-in-stent and stent-after-migration were 27.4 and 58.4 weeks, respectively (p = 0.177). There were no significant prognostic factors for patency of second stents. CONCLUSIONS Insertion of a second stent is effective for treating the first-stent failure in gastric cancer patients with GOO, especially if the immediate outcome of the first stent was successful.
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Affiliation(s)
- Chan Gyoo Kim
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, Gyeonggi-do, 410-769, Republic of Korea
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Ito K, Ogawa T, Horaguchi J, Koshita S, Fujita N. Reintervention for occluded biliary metal stent for patients with malignant distal biliary stricture. Dig Endosc 2013; 25 Suppl 2:126-31. [PMID: 23617663 DOI: 10.1111/den.12092] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 02/14/2013] [Indexed: 02/08/2023]
Abstract
A metal stent has a longer stent patency than a plastic stent in patients with unresectable malignant distal biliary stricture. However, treatment for stent dysfunction of a metal stent remains unresolved. A review of reported articles regarding reintervention for metal stent dysfunction showed that causes of stent dysfunction included tumor ingrowth/overgrowth, stone/sludge/food impaction, and stent migration. Cleaning of the stent is associated with an early relapse of stent dysfunction. Additional placement of a covered metal stent is expected to have a longer stent patency than that of other stents such as uncovered metal stents or plastic stents. It is recommended that occluded covered metal stents be removed if possible. Stent trimming with argon plasma coagulation is sometimes useful for the treatment of stent displacement. No strategy for occluded metal stents has been established yet. Further clinical trials regarding proper treatments are necessary.
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Affiliation(s)
- Kei Ito
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan.
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Pfau PR, Pleskow DK, Banerjee S, Barth BA, Bhat YM, Desilets DJ, Gottlieb KT, Maple JT, Siddiqui UD, Tokar JL, Wang A, Song LMWK, Rodriguez SA. Pancreatic and biliary stents. Gastrointest Endosc 2013; 77:319-27. [PMID: 23410693 DOI: 10.1016/j.gie.2012.09.026] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 09/20/2012] [Indexed: 02/08/2023]
Abstract
Biliary and pancreatic stents are used in a variety of benign and malignant conditions including strictures and leaks and in the prevention of post-ERCP pancreatitis.Both plastic and metal stents are safe, effective, and easy to use. SEMSs have traditionally been used for inoperable malignant disease. Covered SEMSs are now being evaluated for use in benign disease. Increasing the duration of patency of both plastic and metal stents remains an important area for future research.
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Inatomi O, Bamba S, Shioya M, Mochizuki Y, Ban H, Tsujikawa T, Saito Y, Andoh A, Fujiyama Y. Threaded biliary inside stents are a safe and effective therapeutic option in cases of malignant hilar obstruction. BMC Gastroenterol 2013; 13:31. [PMID: 23410217 PMCID: PMC3598933 DOI: 10.1186/1471-230x-13-31] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 02/12/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Although endoscopic biliary stents have been accepted as part of palliative therapy for cases of malignant hilar obstruction, the optimal endoscopic management regime remains controversial. In this study, we evaluated the safety and efficacy of placing a threaded stent above the sphincter of Oddi (threaded inside plastic stents, threaded PS) and compared the results with those of other stent types. METHODS Patients with malignant hilar obstruction, including those requiring biliary drainage for stent occlusion, were selected. Patients received either one of the following endoscopic indwelling stents: threaded PS, conventional plastic stents (conventional PS), or metallic stents (MS). Duration of stent patency and the incident of complication were compared in these patients. RESULTS Forty-two patients underwent placement of endoscopic indwelling stents (threaded PS = 12, conventional PS = 17, MS = 13). The median duration of threaded PS patency was significantly longer than that of conventional PS patency (142 vs. 32 days; P = 0.04, logrank test). The median duration of threaded PS and MS patency was not significantly different (142 vs. 150 days, P = 0.83). Stent migration did not occur in any group. Among patients who underwent threaded PS placement as a salvage therapy after MS obstruction due to tumor ingrowth, the median duration of MS patency was significantly shorter than that of threaded PS patency (123 vs. 240 days). CONCLUSIONS Threaded PS are safe and effective in cases of malignant hilar obstruction; moreover, it is a suitable therapeutic option not only for initial drainage but also for salvage therapy.
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Affiliation(s)
- Osamu Inatomi
- Division of Gastroenterology, Shiga University of Medical Science, Seta-Tsukinowa cho, Otsu, Shiga, Japan.
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Park YJ, Kang DH. Endoscopic drainage in patients with inoperable hilar cholangiocarcinoma. Korean J Intern Med 2013; 28:8-18. [PMID: 23345990 PMCID: PMC3543964 DOI: 10.3904/kjim.2013.28.1.8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 08/06/2012] [Indexed: 02/08/2023] Open
Abstract
Hilar cholangiocarcinoma has an extremely poor prognosis and is usually diagnosed at an advanced stage. Palliative management plays an important role in the treatment of patients with inoperable hilar cholangiocarcinoma. Surgical, percutaneous, and endoscopic biliary drainage are three modalities available to resolve obstructive jaundice. Plastic stents were widely used in the past; however, self-expanding metal stents (SEMS) have become popular recently due to their long patency and reduced risk of side branch obstruction, and SEMS are now the accepted treatment of choice for hilar cholangiocarcinoma. Bilateral drainage provides more normal and physiological biliary flow through the biliary ductal system than that of unilateral drainage. Unilateral drainage was preferred until recently because of its technical simplicity. But, with advancements in technology, bilateral drainage now achieves a high success rate and is the preferred treatment modality in many centers. However, the choice of unilateral or bilateral drainage is still controversial, and more studies are needed. This review focuses on the endoscopic method and discusses stent materials and types of procedures for patients with a hilar cholangiocarcinoma.
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Affiliation(s)
- Ye Jin Park
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Dae Hwan Kang
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea
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Bilateral biliary drainage for malignant hilar obstruction using the 'stent-in-stent' method with a Y-stent: efficacy and complications. Eur J Gastroenterol Hepatol 2013; 25:99-106. [PMID: 23022984 DOI: 10.1097/meg.0b013e3283590a2a] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The usefulness of bilateral stent placement for malignant hilar obstruction is still under debate. Nevertheless, many endoscopists advocate the placement of an endoscopic bilateral metal stent using various new devices and techniques. OBJECTIVES We compared the technical and clinical efficacy, and the short-term and long-term complications of the 'stent-in-stent' method using a Y-stent for malignant hilar obstruction between the early and the late period of this study. MATERIALS AND METHODS Ninety-seven patients treated with Y-stent implantation for malignant hilar obstruction were enrolled retrospectively. In 31 patients treated during the early period, bilateral Y-configured metal stents were placed for malignant hilar obstruction using the older designed Y-stent and a closed-cell second stent. The newly designed Y-stent and a slimmer open-cell second stent were introduced in 66 patients treated during the late period. New techniques learned through experience were gradually applied throughout the entire study period. RESULTS The rate of successful placement of bilateral stents was significantly higher in patients treated during the late period than those treated during the early period (58.1 vs. 87%; P=0.001). The functional success rate was 97.3%, with no difference between the early and the late periods. Cholangitis occurred as an early complication more frequently during the early period than during the late period (16.1 vs. 1.5%; P=0.012). Cholecystitis as a late complication occurred in 21 of 76 patients (27.6%). The incidence of late complications was similar between the early and the late periods. CONCLUSION With the development of new devices and increased technical experience, there were better outcomes during the late period compared with the early period. Endoscopic bilateral metal stenting using a Y-stent is an attractive option for the palliative treatment of malignant hilar obstruction.
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Shah T, Desai S, Haque M, Dakik H, Fisher D. Management of occluded metal stents in malignant biliary obstruction: similar outcomes with second metal stents compared to plastic stents. Dig Dis Sci 2012; 57:2765-73. [PMID: 22732833 PMCID: PMC3920578 DOI: 10.1007/s10620-012-2272-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 06/01/2012] [Indexed: 12/26/2022]
Abstract
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, I(2) = 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, I(2) = 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, I(2) 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.
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Affiliation(s)
- Tilak Shah
- Division of Gastroenterology, Duke University Medical Center, Box 3913, Durham, NC 27710, USA.
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Ridtitid W, Rerknimitr R. Management of an occluded biliary metallic stent. World J Gastrointest Endosc 2012; 4:157-61. [PMID: 22624066 PMCID: PMC3355237 DOI: 10.4253/wjge.v4.i5.157] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 11/15/2011] [Accepted: 04/27/2012] [Indexed: 02/05/2023] Open
Abstract
In patients with a malignant biliary obstruction who require biliary drainage, a self-expandable metallic stent (SEMS) provides longer patency duration than a plastic stent (PS). Nevertheless, a stent occlusion by tumor ingrowth, tumor overgrowth and biliary sludge may develop. There are several methods to manage occluded SEMS. Endoscopic management is the preferred treatment, whereas percutaneous intervention is an alternative approach. Endoscopic treatment involves mechanical cleaning with a balloon and a second stent insertion as stent-in-stent with either PS or SEMS. Technical feasibility, patient survival and cost-effectiveness are important factors that determine the method of re-drainage and stent selection.
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Affiliation(s)
- Wiriyaporn Ridtitid
- Wiriyaporn Ridtitid, Rungsun Rerknimitr, Director of Endoscopy Unit, Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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Traitement chirurgical du cholangiocarcinome: jusqu’où faut-il aller ? ONCOLOGIE 2012. [DOI: 10.1007/s10269-012-2129-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Jaganmohan S, Lee JH. Self-expandable metal stents in malignant biliary obstruction. Expert Rev Gastroenterol Hepatol 2012; 6:105-14. [PMID: 22149586 DOI: 10.1586/egh.11.95] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Malignant biliary obstruction can be due to direct tumor infiltration, extrinsic compression, adjacent inflammation, desmoplastic reaction from tumors or, more commonly, a combination of the above factors. Pancreatic cancer is the most common cause of malignant biliary obstruction, and jaundice occurs in 70-90% of the patients during the course of the disease. Compared with the uncovered metal stents, covered metal stents have longer patency and a lower rate of tumor ingrowth, but have a higher rate of stent migration. To combat the occlusion and provide an antitumor effect, drug-eluting stents were developed. A duodenal stricture complicates biliary stent placement in 10-20% of patients with distal biliary obstruction due to pancreatic cancer. When both strictures are considered, a biliary stent can be placed either preceding or following duodenal stent placement. Complications of self-expandable metal stents include stent occlusion, stent migration, cholecystitis and pancreatitis.
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Affiliation(s)
- Sathya Jaganmohan
- Department of Gastroenterology, Hepatology, and Nutrition, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
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Ridtitid W, Rerknimitr R, Janchai A, Kongkam P, Treeprasertsuk S, Kullavanijaya P. Reply to Dr. Viroj Wiwanikit. Surg Endosc 2012; 26:278-279. [PMID: 21691922 DOI: 10.1007/s00464-011-1807-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Itoi T, Isayama H, Sofuni A, Itokawa F, Tamura M, Watanabe Y, Moriyasu F, Kahaleh M, Habib N, Nagao T, Yokoyama T, Kasuya K, Kawakami H. Evaluation of effects of a novel endoscopically applied radiofrequency ablation biliary catheter using an ex-vivo pig liver. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 19:543-7. [DOI: 10.1007/s00534-011-0465-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology; Tokyo Medical University; 6-7-1 Nishishinjuku, Shinjuku-ku Tokyo 160-0023 Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology; Tokyo Medical University; 6-7-1 Nishishinjuku, Shinjuku-ku Tokyo 160-0023 Japan
| | - Fumihide Itokawa
- Department of Gastroenterology and Hepatology; Tokyo Medical University; 6-7-1 Nishishinjuku, Shinjuku-ku Tokyo 160-0023 Japan
| | | | | | - Fuminori Moriyasu
- Department of Gastroenterology and Hepatology; Tokyo Medical University; 6-7-1 Nishishinjuku, Shinjuku-ku Tokyo 160-0023 Japan
| | - Michel Kahaleh
- Department of Gastroenterology; Well Cornell Medical Center; New York NY USA
| | - Nagy Habib
- Department of Surgery and Cancer; Imperial College London; London UK
| | - Toshitaka Nagao
- Department of Pathology; Tokyo Medical University; Tokyo Japan
| | - Tomohisa Yokoyama
- Department of Clinical Oncology; Tokyo Medical University; Tokyo Japan
| | - Kazuhiko Kasuya
- Third Department of Surgery; Tokyo Medical University; Tokyo Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology; Hokkaido University Graduate School of Medicine; Sapporo Japan
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Yoon JY, Jung YS, Hong SP, Kim TI, Kim WH, Cheon JH. Outcomes of secondary stent-in-stent self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc 2011; 74:625-33. [PMID: 21762906 DOI: 10.1016/j.gie.2011.05.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 05/17/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although self-expandable metal stents (SEMSs) are widely used for the treatment of malignant colorectal obstruction, they often become occluded by tumor ingrowth. OBJECTIVES To determine the therapeutic effectiveness of secondary stent-in-stent SEMS insertion for the management of occluded SEMS in patients with malignant colorectal obstruction and to identify predictive factors associated with clinical outcomes in terms of immediate clinical success, stent patency, and complications. DESIGN Retrospective case series. SETTING A tertiary-care academic medical center in South Korea. PATIENTS Between November 2005 and July 2010, among a total of 309 patients who underwent SEMS insertion for unresectable malignant colorectal obstruction at Severance Hospital, 87 underwent secondary SEMS insertion. Of these, 36 patients underwent secondary SEMS placement as stent-in-stent. INTERVENTIONS Placement of secondary colorectal stent-in-stent SEMSs. MAIN OUTCOME MEASUREMENTS Immediate and long-term clinical success and complications. RESULTS Immediate clinical success was achieved in 27 of 36 patients (75%), and the median duration of stent patency was 170 days. Factors associated with immediate clinical success included a long duration between the previous stent and stent-in-stent insertion. Moreover, the absence of carcinomatosis was associated with long-term clinical success. LIMITATIONS This was a retrospective, nonrandomized, single-center study. CONCLUSIONS Secondary stent-in-stent SEMS placement led to good outcomes in patients with malignant colorectal obstruction, despite a slightly lower success rate compared with primary SEMS placement. Patency duration of the primary SEMS and carcinomatosis were important factors predictive of immediate and long-term clinical success of stent-in-stent insertion, respectively.
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Affiliation(s)
- Jin Young Yoon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seodaemugu, Seoul, Korea
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Lee JH. Self-expandable metal stents for malignant distal biliary strictures. Gastrointest Endosc Clin N Am 2011; 21:463-80, viii-ix. [PMID: 21684465 DOI: 10.1016/j.giec.2011.04.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Obstructive jaundice can result from benign or malignant etiologies. The common benign conditions include primary sclerosing cholangitis, chronic pancreatitis, and gallstones. Malignant biliary obstruction can be caused by direct tumor infiltration, extrinsic compression by enlarged lymph nodes or malignant lesions, adjacent inflammation, desmoplastic reaction from a tumor, or a combination of these factors. Malignant diseases causing biliary obstruction include pancreatic cancer, ampullary cancer, cholangiocarcinoma, and metastatic diseases. This article focuses on malignant distal biliary obstruction and its management.
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Affiliation(s)
- Jeffrey H Lee
- Department of Gastroenterology, Hepatology, and Nutrition, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030-4009, USA.
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Wiwanitkit V. Second interventions for occluded metallic stents. Surg Endosc 2011; 25:1689. [DOI: 10.1007/s00464-010-1301-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cho JH, Jeon TJ, Park JY, Kim HM, Kim YJ, Park SW, Chung JB, Song SY, Bang S. Comparison of outcomes among secondary covered metallic, uncovered metallic, and plastic biliary stents in treating occluded primary metallic stents in malignant distal biliary obstruction. Surg Endosc 2010; 25:475-82. [PMID: 20602138 DOI: 10.1007/s00464-010-1196-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 06/14/2010] [Indexed: 12/23/2022]
Abstract
BACKGROUND The self-expandable metallic stent (SEMS) has been widely used for unresectable malignant biliary obstruction but eventually becomes occluded by tumor ingrowth/overgrowth and sludge. Therefore, we aimed to determine the therapeutic effectiveness of secondary stents and to find differences according to various combinations of the first and second stents for the management of occluded SEMSs in patients with malignant distal biliary obstruction. METHODS Between 1999 and November 2008, 77 patients with malignant biliary obstruction underwent secondary biliary stent placement as "stent-in-stent" at three university hospitals in Korea (40 covered, 26 uncovered, and 11 plastic stents). The membrane of the covered SEMS was regarded as the barrier against tumor ingrowth. We categorized the patients into three groups based on whether the covered SEMS was either the first or the second stent: membrane-SEMS (18 covered-covered; 9 covered-uncovered; 22 uncovered-covered SEMS), bare-SEMS (17 uncovered-uncovered SEMS), and plastic stent (3 covered-plastic; 8 uncovered-plastic). RESULTS The median patency of second stents was 138, 109, and 88 days (covered, uncovered, and plastic stents). The second covered SEMSs had a significantly longer patency than plastic stents (p=0.047). In a multivariate analysis including membrane-SEMS, bare-SEMS, and plastic stent groups, the bare-SEMS had a worse cumulative stent patency (HR=2.04, CI=1.08-3.86) and survival time (HR=2.37, CI=1.25-4.49) than the membrane-SEMS. Patients with ampulla of Vater cancer had better stent patency (HR=0.27, CI=0.08-0.98) and survival (HR=0.17, CI=0.04-0.77) than those with other pancreatobiliary malignancies. In addition, antitumor treatment prolonged survival time (HR=0.50, CI=0.26-0.99). CONCLUSIONS The placement of additional biliary stents using the "stent-in-stent" method is an effective treatment for an occluded metallic primary stent. In addition, double biliary SEMS placement using at least one covered SEMS (in the primary and/or secondary procedure) might provide longer cumulative stent patency and survival than using uncovered SEMSs in both procedures.
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Affiliation(s)
- Jae Hee Cho
- Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, and Sanggye Paik Hospital, 250 Seongsanno (134 Sinchon-Dong), Seodaemun-Ku, 120-752, Seoul, South Korea
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