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Lee J, Jeong S, Lee DH, Lim JH, Kobayashi M, Takenaka M, Kwon CI. Endoscopic Stenting of a Fully Covered Self-Expandable Metal Stent with a Hole in Each Cavity in Malignant Hilar Biliary Obstruction: A Preclinical Proof-of-Concept Study and Initial Human Experience. Dig Dis Sci 2025; 70:1215-1222. [PMID: 39856481 DOI: 10.1007/s10620-024-08810-1] [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: 09/16/2024] [Accepted: 12/17/2024] [Indexed: 01/27/2025]
Abstract
BACKGROUND AND AIM Stent placement for biliary drainage in patients with malignant hilar biliary obstruction (MHBO) has been a topic of long-standing debate, and the best approach remains controversial. Therefore, we aimed to evaluate the efficacy, safety, and removability of multi-hole fully covered self-expandable metal stents (MH-FCSEMSs) in a preclinical experiment using swine hilar bile duct obstruction (HBDO) models and to assess the feasibility and safety of stent placement in patients with MHBO. METHODS Three minipigs underwent endoscopic retrograde cholangiopancreatography (ERCP)-guided endobiliary-radio frequency ablation (EB-RFA) to establish Bismuth type II hilar bile duct stenosis models. Four weeks after EB-RFA, 10-mm diameter and 4-cm length MH-FCSEMSs were endoscopically inserted into the left intrahepatic bile duct of the models. Stent patency and migration, as well as adverse events including cholangitis and endoscopic stent removability, were assessed three months after stent placement. Additionally, clinical applications of MH-FCSEMS were performed in two patients with MHBO to determine feasibility, safety, and stent patency. RESULTS MH-FCSEMSs were successfully inserted into the left main intrahepatic bile duct and common hepatic duct of the models under ERCP in all three animals without any technical difficulties. Cholangiograms performed 12 weeks after MH-FCSEMS placement showed no stent migration, and all were successfully removed from the animal models. The functional success rate, defined as a decrease in serum total bilirubin level of more than 50% at 12 weeks after stent placement, was 100%. Moreover, MH-FCSEMSs were successfully inserted in two patients with hilar cholangiocarcinoma. The procedures were technically feasible, and no major periprocedural complications were noted. CONCLUSION The preliminary long-term results of both preclinical and clinical pilot studies suggest that endoscopic biliary drainage using MH-FCSEMS may be a safe and effective treatment option for stenting and stent revision in the management of HBDO. Further studies comparing clinical outcomes to those of MH-FCSEMS without multi-hole in malignant hilar biliary obstruction will be needed to verify the clinical benefits.
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Affiliation(s)
- Jungnam Lee
- Division of Gastroenterology, Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, Republic of Korea
| | - Seok Jeong
- Division of Gastroenterology, Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, Republic of Korea.
| | - Don Haeng Lee
- Division of Gastroenterology, Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, Republic of Korea
- Utah-Inha DDS and Advanced Therapeutics Research Center, Incheon, Republic of Korea
| | - Jung-Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, Republic of Korea
| | - Makoto Kobayashi
- Department of Gastroenterology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Chang-Il Kwon
- Digestive Disease Center, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
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Xing L, Liu YT, Ye X, Wang TT, Wu J, Xia MX, Hu B, Gao DJ. Long slim versus conventional self-expandable metallic stent in bilateral endoscopic side-by-side deployment for unresectable malignant hilar biliary obstruction. Gastrointest Endosc 2025:S0016-5107(25)00073-2. [PMID: 39924062 DOI: 10.1016/j.gie.2025.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2024] [Revised: 12/26/2024] [Accepted: 01/31/2025] [Indexed: 02/11/2025]
Abstract
BACKGROUND AND AIMS The goal of this study was to compare the advantages of long slim metal stents (LSMSs) versus conventional metal stents in bilateral endoscopic side-by-side (SBS) deployment for malignant hilar biliary obstruction (MHBO). METHODS A total of 140 consecutive patients with MHBO treated by endoscopic bilateral SBS deployment at a high-volume tertiary referral center were analyzed retrospectively; this included 50 patients in the LSMS group and the other 90 patients in the conventional SBS group as control. Propensity score matching at a 1:2 ratio was used to reduce selection bias. The primary outcome was stent patency. RESULTS After propensity score matching, no significant difference was observed in stent patency (267 vs 268 days; P = .923) or overall survival (225 vs 211 days; P = .883) between the 2 groups. The technical success rate was 100% in both groups, and the clinical success rate was 91.1% in the LSMS group and 92.9% in the control group (P = .735). Early and late adverse events were similar (24.4% vs 34.3%, P = .423; 42.2% vs 38.6%, P = .697); the procedure time and bilateral metal stenting time in the LSMS group were significantly shorter (41.0 minutes vs 57.5 minutes, P = .000; 19.0 minutes vs 28.5 minutes, P = .000). The success rate of endoscopic bilateral revisionary stent insertion in the LSMS group was also higher (100% vs 33.3%; P = .000). CONCLUSIONS Bilateral LSMS placement is a viable option for patients with MHBO. It includes advantages of less operative difficulty and easier future re-intervention over conventional SBS stenting.
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Affiliation(s)
- Ling Xing
- Department of Gastroenterology, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Yan-Ting Liu
- Department of Endoscopy, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Xin Ye
- Department of Endoscopy, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Tian-Tian Wang
- Department of Gastroenterology, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Jun Wu
- Department of Gastroenterology, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Ming-Xing Xia
- Department of Gastroenterology, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Bing Hu
- Department of Gastroenterology, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Dao-Jian Gao
- Department of Gastroenterology, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China.
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Medas R, Ferreira-Silva J, Girotra M, Barakat M, Tabibian JH, Rodrigues-Pinto E. Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage. J Clin Gastroenterol 2023; 57:553-568. [PMID: 36040964 DOI: 10.1097/mcg.0000000000001760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Joel Ferreira-Silva
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mohit Girotra
- Digestive Health Institute, Swedish Medical Center, Seattle, WA
| | | | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA CA
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
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Yoshinari M, Hijioka S, Nagashio Y, Maruki Y, Ohba A, Kawasaki Y, Takeshita K, Morizane C, Tanaka Y, Okusaka T. Comparison of the hybrid and partial stent-in-stent method for endoscopic three-segment drainage for unresectable malignant hilar biliary obstruction. Endosc Int Open 2023; 11:E276-E283. [PMID: 36968981 PMCID: PMC10036201 DOI: 10.1055/a-2039-3936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 01/16/2023] [Indexed: 03/25/2023] Open
Abstract
Background and study aims
The clinical outcome of the new hybrid drainage method for unresectable malignant hilar biliary obstruction (UMHBO) has not yet been compared with that of the partial stent-in-stent (PSIS) method with three or more stents.
Patients and methods
Patients with UMHBO underwent drainage of three segments using the hybrid or PSIS method. The clinical outcomes of both methods were compared retrospectively.
Results
Overall, 54 patients underwent the hybrid (n = 31) or PSIS (n = 23) method of drainage with three or more stents for UMHBO. There were no significant differences in the technical success rate (hybrid vs. PSIS, 87.1 % vs. 87 %), clinical success rate according to per-protocol analysis (81.5 % vs. 70 %), early adverse events rate (14.8 % vs. 10%), late adverse events rate (7.4 % vs. 0 %), and technical success rate of the endoscopic transpapillary reintervention (90.9 % vs. 100 %). Time to recurrent biliary obstruction (TRBO) of the hybrid and PSIS methods was 178 and 231 days, respectively, with no significant difference (
P
= 0.354).
Conclusions
The choice between the two methods should be made at the physician’s discretion.
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Affiliation(s)
- Motohiro Yoshinari
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Tokyo, Japan
- Kumamoto University, Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto, Japan
| | - Susumu Hijioka
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Tokyo, Japan
| | - Yoshikuni Nagashio
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Tokyo, Japan
| | - Yuta Maruki
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Tokyo, Japan
| | - Akihiro Ohba
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Tokyo, Japan
| | - Yuki Kawasaki
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Tokyo, Japan
| | - Kotaro Takeshita
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Tokyo, Japan
| | - Chigusa Morizane
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Tokyo, Japan
| | - Yasuhito Tanaka
- Kumamoto University, Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto, Japan
| | - Takuji Okusaka
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW To summarize the current status and future perspectives of the endoscopic management of biliary strictures. RECENT FINDINGS In addition to conventional diagnostic modalities, such as cross-sectional imaging and endoscopic ultrasonography (EUS), per-oral cholangioscopy is helpful for indeterminate biliary strictures. It allows direct visualization of the biliary tract and targeted biopsy. For distal malignant biliary obstruction (MBO), a self-expandable metal stent (SEMS) via endoscopic retrograde cholangiopancreatography (ERCP) is a standard of care. EUS-guided biliary drainage (EUS-BD) is an emerging alternative to percutaneous transhepatic biliary drainage in cases with failed ERCP. EUS-BD is also an effective salvage option for perihilar MBO, which can not be managed via ERCP or percutaneous transhepatic biliary drainage. Preoperative drainage is necessary for most jaundiced patients as neoadjuvant chemotherapy is widely administered for resectable and borderline resectable pancreatic cancer, and a SEMS is preferred in this setting, too. For benign biliary strictures, a covered SEMS can improve stricture resolution and reduce the number of endoscopic sessions as compared to plastic stents. SUMMARY ERCP and EUS play a central role in the diagnosis and drainage for both malignant and benign biliary strictures.
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Lee TH, Moon JH, Stuart S. Role of ERCP in Malignant Hilar Biliary Obstruction. Gastrointest Endosc Clin N Am 2022; 32:427-453. [PMID: 35691690 DOI: 10.1016/j.giec.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Malignant hilar biliary obstruction (MHO), an aggressive perihilar biliary obstruction caused by cholangiocarcinoma, gallbladder cancer, or other metastatic malignancies, has a poor prognosis. Surgical resection is the only curative treatment method for biliary malignancies. However, most of the patients with MHO cannot undergo surgeries on presentation because of an advanced inoperable state or a poor performance state due to old age or comorbid diseases. Therefore, palliative biliary drainage is mandatory to improve symptomatic jaundice and quality of life. Among drainage methods, endoscopic biliary drainage is the current standard for the palliation of unresectable advanced MHO. The development of stents and various accessories and advances in endoscopic techniques including endoscopic ultrasonography have facilitated primary endoscopic intervention in difficult high-grade hilar strictures. However, some issues are still under debate, such as palliation methods, appropriate stents, the number of stents, deployment methods, and additional local ablation therapies. Therefore, this review presents currently optimal endoscopic palliation methods for advanced MHO based on the reported literature.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, SoonChunHyang University School of Medicine, Cheonan, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Jong Ho Moon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, SoonChunHyang University School of Medicine, 170 Jomaru-Ro, Bucheon 14584, Republic of Korea.
| | - Sherman Stuart
- Department of Medicine, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indiana University Health-University Hospital, 550 North University Boulevard, Suite 1634, Indianapolis, IN 46202, USA
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Kato H, Matsumoto K, Okada H. Recent advances regarding endoscopic biliary drainage for unresectable malignant hilar biliary obstruction. DEN OPEN 2022; 2:e33. [PMID: 35310763 PMCID: PMC8828235 DOI: 10.1002/deo2.33] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 12/14/2022]
Abstract
Biliary drainage for unresectable malignant hilar biliary obstruction (UMHBO) is still associated with a number of controversies to be resolved. The superiority of bilateral drainage in comparison to unilateral drainage has not been proven obviously yet. However, bilateral drainage is necessary to treat obstructive jaundice in some UMHBO patients, and this may be connected with preservation of the functional liver volume. The partial stent-in-stent (SIS) method and side-by-side (SBS) method developed as bilateral drainage methods. There is no significant difference in the technical or clinical success rates of the SIS and SBS methods. In addition, these methods are comparable in terms of adverse events, patency period, and survival period. On the other hand, reintervention for recurrent biliary obstruction (RBO) after the SBS method seems to be easier in comparison to cases with RBO after the SIS method; however, there is no remarkable difference in the clinical results of these procedures. Endoscopic ultrasound (EUS)-guided biliary drainage also has become an option for patients with UMHBO. Left hepatic drainage using EUS-guided hepaticogastrostomy (EUS-HGS) has become common; however, few studies have reported the results of bridging drainage for the right lobe using the EUS-HGS route or EUS-guided hepaticojejunostomy. A few studies addressed the results of newly designed stents, such as the 6-mm braided metal stent and inside stent. The development of various drainage methods and new devices is necessary for the further advancement of endoscopic biliary drainage for patients with UMHBO, further studies to evaluate those methods and devices are warranted.
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Affiliation(s)
- Hironari Kato
- Department of Gastroenterology and Hepatology Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology and Hepatology Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
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Gao DJ, Xing L, Ye X, Wang TT, Wu J, Xia MX, Hu B. Long Slimmer Metal Stent Is Feasible and Effective for Endoscopic Dual Stent-by-Stent Placement in Malignant Hilar Biliary Stricture. Dig Dis Sci 2022; 67:1073-1082. [PMID: 33675491 DOI: 10.1007/s10620-021-06906-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/19/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Bilateral endoscopic biliary stenting remains technically challenging, which limits its wider clinical application. AIMS We have developed a novel long (10-12 cm) and slimmer (6 mm) self-expanded metal stent. The aim of this study was to evaluate the feasibility, efficacy, and safety of the new metal stent for palliative treatment of malignant hilar biliary strictures (MHBS). METHODS This retrospective study of prospectively collected data included 45 patients with unresectable malignant hilar biliary strictures of Bismuth type II or higher. A pair of long slimmer metal stents were sequentially placed into the intrahepatic duct using the stent-by-stent mode. The success rate and short- and long-term clinical outcomes were observed. RESULTS The technical success rate was 100%, with a mean procedure time of 43.7 ± 11.5 min. The clinical success was achieved in 44 patients (97.8%). Early adverse events included mild acute pancreatitis (n = 2) and cholangitis (n = 3). Later cholangitis occurred in 14 of the 45 patients due to stent occlusions. The median stent patency was 260 days (95% CI 228.3-291.7). Stent malfunctions occurred in 23 of the 45 patients, and 15 of them received bilateral endoscopic plastic stents placements. The technical success for the re-intervention was 100% with the mean procedure time of 24.3 ± 4.5 min. The median overall survival of the whole group was 229 days (95% CI 171.2-286.8). CONCLUSIONS The long slimmer metal stent for bilateral endoscopic stent-by-stent placement proved to be safe, feasible, and effective for MHBS and facilitates endoscopic re-intervention as well.
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Affiliation(s)
- Dao-Jian Gao
- Department of Endoscopy, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, People's Republic of China
| | - Ling Xing
- Department of Endoscopy, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, People's Republic of China
| | - Xin Ye
- Department of Endoscopy, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, People's Republic of China
| | - Tian-Tian Wang
- Department of Endoscopy, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, People's Republic of China
| | - Jun Wu
- Department of Endoscopy, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, People's Republic of China
| | - Ming-Xing Xia
- Department of Endoscopy, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, People's Republic of China
| | - Bing Hu
- Department of Endoscopy, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, People's Republic of China.
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Shim SR, Lee TH, Yang JK, Kim JH, Lee YN, Cha SW, Moon JH, Cho YD, Park SH. Endoscopic Bilateral Stent-in-Stent Versus Stent-by-Stent Deployment in Advanced Malignant Hilar Obstruction: A Meta-Analysis and Systematic Review. Dig Dis Sci 2022; 67:716-728. [PMID: 33625611 DOI: 10.1007/s10620-021-06885-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/29/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM There is no clear data to compare the effectiveness and safety of bilateral stent-in-stent (SIS) or stent-by-stent (SBS) deployment for advanced malignant hilar obstruction (MHO). This meta-analysis was done to investigate clinical outcomes of these deployment methods. METHODS We did a literature search to identify studies that reported the clinical outcomes of bilateral metal stents in patients with advanced MHO. Weighed pooled rates (WPR) along with 95% confidence interval (95% CI) were calculated in order to compare outcomes including technical and clinical success, adverse events, and stent occlusion between the two groups. We conducted a meta-analysis using a random-effects model. RESULTS Five comparative studies with 250 patients, and 20 single-arm studies for the SIS or SBS method were eligible for the meta-analysis and systematic review. The bilateral SIS deployment had a significantly higher technical success rate than did SBS deployment (OR 6.43; 95% CI 1.08-38.09). There was no difference in the clinical success (OR 1.23; 95% CI 0.45-3.38), overall adverse events rates (OR 0.42; 95% CI 0.15-1.18), or overall occlusion rate (OR 1.55; 95% CI 0.89-2.70). As a single-armed group, WPR of technical success of the SIS and SBS groups was 96.4% and 89.6%, respectively. Clinical success was 97.5% and 98.3%. Overall, adverse events were 35.9% and 22.6%. Occlusion rates were 27.7% and 37.7%. CONCLUSIONS Although there was a lack of quality data and heterogeneity, bilateral SIS deployment had a higher technical feasibility than did the SBS method in patients with advanced MHO, without differences in terms of clinical success, adverse events, or occlusion rates.
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Affiliation(s)
- Sung Ryul Shim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Urology, Soonchunhyang University Seoul Hospital, SoonChunHyang University School of Medicine, Seoul, Korea
| | - Tae Hoon Lee
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea.
- Division of Gastroenterology, Department of Internal Medicine, Cheonan Hospital, SoonChunHyang University School of Medicine, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, South Korea.
| | - Jae Kook Yang
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea
| | - Jae Heon Kim
- Department of Urology, Soonchunhyang University Seoul Hospital, SoonChunHyang University School of Medicine, Seoul, Korea
| | - Yun Nah Lee
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Sang-Woo Cha
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Seoul, Korea
| | - Jong Ho Moon
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Young Deok Cho
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Seoul, Korea
| | - Sang-Heum Park
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea
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Lee TH. Treatment of Malignant Hilar Strictures. GASTROINTESTINAL AND PANCREATICO-BILIARY DISEASES: ADVANCED DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2022:1399-1421. [DOI: 10.1007/978-3-030-56993-8_81] [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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Lee TH, Moon JH, Park SH. [A Recent Update on Endoscopic Drainage of Advanced Malignant Hilar Obstruction]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 78:94-104. [PMID: 34446632 DOI: 10.4166/kjg.2021.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/11/2021] [Indexed: 11/03/2022]
Abstract
Malignant hilar obstruction (MHO) is considered an aggressive perihilar obstruction caused by cholangiocarcinoma, gallbladder cancer, or metastatic malignancies and has a poor prognosis. Although surgical resection is the only curative treatment method, the majority of patients with MHO do not undergo surgery due to an advanced inoperable state at presentation. Currently, effective biliary drainage provides the necessary palliation for symptomatic improvement. Among the drainage methods, percutaneous access may be preferred, especially for advanced MHO because of the technical difficulty involved with other techniques. Recently, primary endoscopic palliation using plastic or metal stents has been shown to have higher technical feasibility and clinical success without increasing adverse events even in patients with high-degree MHO. The development of various accessories, endoscopic ultrasonography, and advances in techniques have facilitated primary endoscopic intervention. However, some aspects continue to be debated such as the palliation methods, appropriate stents, the number of stents, the deployment methods, and additional local ablation therapies. Therefore, this review discusses the current optimal endoscopic treatment methods for advanced MHO based on reported literature.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, SoonChunHyang University College of Medicine, Cheonan, Korea
| | - Jong Ho Moon
- Division of Gastroenterology, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, SoonChunHyang University College of Medicine, Bucheon, Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, SoonChunHyang University College of Medicine, Cheonan, Korea
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12
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Lee TH. Proper management of inoperable malignant hilar biliary obstruction: Endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, or percutaneous approach? INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021; 10:120-127. [DOI: 10.18528/ijgii210035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 01/03/2025] Open
Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, Soon Chun Hyang University School of Medicine, Cheonan, Korea
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Kawai J, Ogura T, Takenaka M, Shiomi H, Ueshima K, Ueno S, Okuda A, Matsuno J, Minaga K, Omoto S, Nakai A, Ikegawa T, Hakoda A, Higuchi K. Prospective multicenter evaluation of moving cell metallic stents in endoscopic multiple stent deployment for hepatic hilar obstruction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:1195-1203. [PMID: 34110699 DOI: 10.1002/jhbp.1009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/21/2021] [Accepted: 05/29/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Bilateral stent deployment for malignant biliary obstruction (MHBO) can be achieved using side-by-side (SBS) or stent-in-stent (SIS) procedures. Compared with SBS techniques, the procedural steps of SIS are technically complex due to the necessity of introducing the delivery system into a contralateral biliary tract through the mesh of the SEMS. To overcome this issue, a novel uncovered SEMS, the HILZO Moving Cell Stent (MCS) has been released. The present study examined the technical feasibility of treating MHBO using bilateral deployment of this novel stent without dilating the mesh of the first stent to achieve insertion of the second stent within a single session, using a prospective, multicenter setting. METHOD The primary outcome in the present study was the technical success rate. Technical success was defined as deployment of bilateral MCSs into two or more biliary tracts using SIS without a dilation device in a single-session. RESULTS A total of 27 patients with complications of MHBO were enrolled in this study. Bilateral SIS using two MCS was successfully performed in 23 patients without using dilation devices among 27 patients (initial technical success rate; 85.2%). Median time to recurrent biliary obstruction (TRBO) was 271 days. Stent dysfunction was observed in 12 patients (44.4%), and re-intervention was successfully performed in all patients without one patient who instead received best supportive care. CONCLUSIONS The SIS technique using MCS without dilation of the mesh may be technically feasible and safe. In addition, this may be useful for re-intervention. Further comparative randomized trials are needed.
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Affiliation(s)
- Junichi Kawai
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Takeshi Ogura
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Mamoru Takenaka
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Departments of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Hideyuki Shiomi
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazuya Ueshima
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Saori Ueno
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Atsushi Okuda
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Jun Matsuno
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kousuke Minaga
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Departments of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Shunsuke Omoto
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Departments of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Atsushi Nakai
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Departments of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Takuya Ikegawa
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Akitoshi Hakoda
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kazuhide Higuchi
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, 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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15
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Lee TH, Jang SI, Moon JH, Lee YN, Yang JK, Park JS, Jeong S, Lee DH, Heo NH, Park SH, Lee DK. Endoscopic revision efficacy after clinically successful bilateral metal stenting for advanced malignant hilar obstruction. J Gastroenterol Hepatol 2020; 35:2248-2255. [PMID: 32472962 DOI: 10.1111/jgh.15123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/15/2020] [Accepted: 05/25/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUNDS AND AIM Multiple insertions of self-expandable metal stents (SEMS) for advanced malignant hilar obstruction (MHO) are now considered to be an effective palliative method for adequate drainage of liver volume. However, the efficacy of endoscopic reintervention in technically and clinically successful bilateral SEMS is limited. This study investigated the endoscopic revision efficacy in patients who underwent bilateral SEMS in MHO. METHODS Primary endoscopic revision using plastic or metal stents or an alternative percutaneous approach followed by secondary endoscopic revision was performed in patients who underwent clinically successful deployment of bilateral SEMS. The primary outcome was a technical success. Secondary outcomes were clinical success, adverse events, and patency duration after reintervention. RESULTS A total of 55 patients (83.3%) out of 66 enrolled patients underwent reintervention: primary endoscopic reintervention (n = 47) and secondary endoscopic revision following percutaneous drainage (n = 8). Intended technical success rates of primary and secondary endoscopic reintervention were 93.6% (44/47) and 87.5% (7/8), respectively (P = 0.47). Clinical success rates were 72.3% and 50%, respectively (P = 0.23). Stent malfunction rate after reintervention was 48.9% (23/47) and 37.5% (3/8) (P = 0.70) during follow up, and median cumulative stent patency duration was 119 and 55 days, respectively (log-rank P = 0.68). Stent patent rate after reintervention was not different according to the time interval. In univariate and multivariate analysis for stent patency duration-related factors after reintervention, there were no meaningful factors. CONCLUSION Primary endoscopic reintervention for bilateral SEMS in MHO was feasible technically and clinically. However, there were no statistically meaningful factors for stent patency duration after reintervention.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
| | - Sung Ill Jang
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Ho Moon
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Bucheon, Republic of Korea
| | - Yun Nah Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Bucheon, Republic of Korea
| | - Jae Kook Yang
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
| | - Jin-Seok Park
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Seok Jeong
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Don Haeng Lee
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Nam Hun Heo
- Clinical Trial Center, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
| | - Dong Ki Lee
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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16
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Aghaie Meybodi M, Shakoor D, Nanavati J, Ichkhanian Y, Vosoughi K, Brewer Gutierrez OI, Kalloo AN, Singh V, Kumbhari V, Ngamruengphong S, Khashab MA. Unilateral versus bilateral endoscopic stenting in patients with unresectable malignant hilar obstruction: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E281-E290. [PMID: 32118102 PMCID: PMC7035140 DOI: 10.1055/a-1067-4326] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/16/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Endoscopic stent placement is used for palliative management of unresectable malignant hilar obstruction, which could be achieved by either unilateral or bilateral stent insertion. Materials and methods A literature search was performed to identify studies that reported outcomes of metallic biliary stent placement in patients with malignant hilar obstruction. Weighted pooled rates (WPR) along with 95 % confidence intervals (95 %CI) were calculated to determine and compare outcomes including technical and functional success, early and late adverse events, post procedure cholangitis, and stent occlusion between two groups. Results A total of 21 studies with 1292 patients were included. WPR of technical success was significantly higher in the unilateral group (97 %, 95 %CI: 93 -98 %) vs. bilateral group (89 %, 95 %CI: 84 -92 %) ( P = 0.0.003). WPR for functional success in the unilateral and bilateral groups were 96 % (95 %CI: 91 -98 %) and 94 % (95 %CI: 91 -97 %), respectively ( P = 0.48). The rate of early and late complications was comparable between the two groups. Conclusion In patients with unresectable malignant hilar obstruction, unilateral and bilateral metallic stenting techniques are comparable in terms of efficacy and safety.
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Affiliation(s)
- Mohamad Aghaie Meybodi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Delaram Shakoor
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, Maryland, United States
| | - Julie Nanavati
- Welch Medical Library, Johns Hopkins University, Baltimore, Maryland, United States
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Kia Vosoughi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Olaya I. Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Anthony N. Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Vikesh Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States,Corresponding author Mouen Khashab MD, Associate Professor of Medicine, Director of Therapeutic Endoscopy Division of Gastroenterology and HepatologyJohns Hopkins Medical Institutions1800 Orleans StSheikh Zayad 7E Rm 7125GBaltimore, MD 21224+1-443-287-1960
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Kim Y, Jang SI, Lee DK. SEMS Insertion for Malignant Hilar Stricture: ERCP Versus the Percutaneous Approach. ADVANCED ERCP FOR COMPLICATED AND REFRACTORY BILIARY AND PANCREATIC DISEASES 2020:87-107. [DOI: 10.1007/978-981-13-0608-2_7] [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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18
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Tringali A. Endoscopic Management in Malignant Biliary Strictures: Tips and Tricks. ENDOTHERAPY IN BILIOPANCREATIC DISEASES: ERCP MEETS EUS 2020:431-461. [DOI: 10.1007/978-3-030-42569-2_40] [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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19
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Lee TH, Moon JH, Park SH. Biliary stenting for hilar malignant biliary obstruction. Dig Endosc 2020; 32:275-286. [PMID: 31578770 DOI: 10.1111/den.13549] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/29/2019] [Indexed: 02/08/2023]
Abstract
Although endoscopic intervention is the mainstay for palliation of malignant biliary obstruction, a percutaneous approach has been preferred, particularly in patients with advanced high-grade hilar malignant biliary obstruction, because of the technical difficulty and risk of complications. However, recently, primary endoscopic palliation using plastic or metal stents has had higher technical and clinical success with fewer adverse events than the percutaneous approach. Endoscopic interventions are being done more and more frequently because of advances in metal stents, accessories, and techniques. However, several concerns, such as optimal stent type, number, and deployment method, remain to be resolved. Therefore, we reviewed the literature in order to identify the optimal biliary stenting strategy for patients with hilar malignant biliary obstruction, focusing on stent type (plastic vs metal), number (unilateral [single] vs bilateral [multiple]), and deployment method (stent-in-stent vs stent-by-stent).
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Jong Ho Moon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon Hospital, Bucheon, Korea
| | - Sang-Heum Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan Hospital, Cheonan, Korea
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20
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Ogura T, Takenaka M, Shiomi H, Nishioka N, Ueno S, Miyano A, Kamiyama R, Higuchi K. Single-session multiple stent deployment using moving cell stent without dilating initial stent mesh to treat malignant hilar biliary obstruction (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 27:84-89. [PMID: 31628892 DOI: 10.1002/jhbp.688] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Malignant hilar biliary obstruction (MHBO) can be treated with bilateral self-expandable metal stents (SEMS) deployed using side-by-side (SBS) or stent-in-stent (SIS) techniques. Moving cell stents (MCS) are a novel type of SEMS. The present study evaluated the technical feasibility of treating MHBO using bilateral novel uncovered SEMS to insert an SIS technique without dilating the mesh of a first stent within a single session. METHOD We retrospectively assessed patients who were complicated with obstructive jaundice due to MHBO between August and December 2018. Technical success was defined as the deployment of a bilateral MCS into two or more biliary tracts using SIS technique without a dilation device. RESULTS The present study analyzed data from 23 consecutive patients who were complicated with MHBO. Bilateral SIS technique with MCS was deployed in 22 (95.6%) of the 23 patients without dilating the mesh of the first stent. Multiple guidewire insertion failed in one patient with Bismuth-type IV. The median procedural duration was 33.6 min. Time to recurrent biliary obstruction was 230 days. Severe adverse events were not seen in any patients. CONCLUSION In conclusion, uncovered moving cell SEMS might facilitate bilateral stent deployment using SIS technique.
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Affiliation(s)
- Takeshi Ogura
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Mamoru Takenaka
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Departments of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Hideyuki Shiomi
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Nobu Nishioka
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Saori Ueno
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Akira Miyano
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Rieko Kamiyama
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kazuhide Higuchi
- TSOZ Pancreatobiliary Study Group, Osaka, Japan.,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
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21
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Endoscopic Stenting in Hilar Cholangiocarcinoma: When, How, and How Much to Drain? Gastroenterol Res Pract 2019; 2019:5161350. [PMID: 31781190 PMCID: PMC6874867 DOI: 10.1155/2019/5161350] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/16/2019] [Indexed: 12/27/2022] Open
Abstract
Hilar cholangiocarcinoma (HCCA) involves a complex anatomical region where bile ducts, arteries, and veins create a complex network. HCCA can lead to biliary strictures at the main hepatic confluence, involving the right and left radicles. Endoscopic drainage of jaundiced patients with HCCA is challenging and carries a high risk of infective complications. HCCA needs a careful multidisciplinary evaluation to assess the indication and purposes (preoperative/palliative) of the biliary drainage. Biliary drainage in HCCA needs to be planned by magnetic resonance cholangiography in order to study the biliary anatomy and perform a target drainage of the intrahepatic ducts above the malignant hilar stricture; all the opacified intrahepatic ducts above the hilar stricture must be drained to reduce septic complications. Drainage of >50% of the liver volume is important to obtain bilirubin reduction and less complications, but atrophic liver segments (identified by CT scan) do not require drainage due to the increased risk of cholangitis. When preoperative biliary drainage is planned, plastic stents must be inserted. Self-expandable metal stents are indicated for palliative purposes and should be placed only when a complete liver drainage is possible; only uncovered metal stents are indicated to drain malignant hilar strictures to avoid side-branch occlusion.
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Ogura T, Yamada M, Ueno S, Fukunishi S, Higuchi K. Hybrid placement technique for hepatic hilar obstruction using a new uncovered self-expandable metal stent. Endosc Int Open 2019; 7:E1288-E1292. [PMID: 31579711 PMCID: PMC6773583 DOI: 10.1055/a-0998-7847] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/17/2019] [Indexed: 12/31/2022] Open
Abstract
Background and study aim Recently, a novel technique combining stent-in-stent (SIS) and side-by-side (SBS) technique (hybrid technique) has been reported. This technique may have application for hepatic hilar obstruction (HBO) because it reduces the number of times the stent mesh has to be passed. However, to the best our knowledge, evaluation of its use in that setting has not been reported. Recently, a new uncovered self-expandable metal stent (UCSEMS) has become available in Japan. The diameter of this stent delivery shaft is only 5.4 Fr, and the discrepancy between the guidewire and top of stent delivery system is strongly reduced. We herein report technical tips for hybrid metal stent deployment for high-grade HBO using this novel UCSEMS. Hybrid metal stent deployment using he novel UCSEMS was attempted in seven patients. Technical success was obtained in all patients. Mean procedure time was 33.3 minutes (range, 27 to 43). Clinical success was obtained in six patients. Median stent patency was 109 days (range, 48 - 160 days). In conclusion, the hybrid metal stent placement technique appears to be useful using the new UCSEMS because of its fine-gauge stent delivery system.
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Affiliation(s)
- Takeshi Ogura
- Premier Development Research of Medicine, Osaka Medical College, Osaka, Japan,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan,Corresponding author Takeshi Ogura Premier Development Research of Medicine2nd Department of Internal MedicineOsaka Medical College2-7 Daigakuchou, TakatsukishiOsaka 569-8686Japan+81-726846532
| | - Masanori Yamada
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Saori Ueno
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Shinya Fukunishi
- Premier Development Research of Medicine, Osaka Medical College, Osaka, Japan,2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kazuhide Higuchi
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
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23
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Lee TH, Moon JH, Choi JH, Lee SH, Lee YN, Paik WH, Jang DK, Cho BW, Yang JK, Hwangbo Y, Park SH. Prospective comparison of endoscopic bilateral stent-in-stent versus stent-by-stent deployment for inoperable advanced malignant hilar biliary stricture. Gastrointest Endosc 2019; 90:222-230. [PMID: 30905729 DOI: 10.1016/j.gie.2019.03.011] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Although the efficacy of palliative bilateral biliary drainage using self-expandable metal stents has been demonstrated, it is unclear which bilateral method is optimal for advanced malignant hilar biliary strictures (MHSs). This pilot study compared bilateral stent-in-stent (SIS) with stent-by-stent (SBS) deployment for advanced MHSs. METHODS Patients with inoperable high-grade MHSs were enrolled in this prospective randomized multicenter study. The primary outcome was the rate of adverse events, whereas secondary outcomes were technical and clinical success, reintervention, therapeutic outcomes, stent patency, and survival duration. RESULTS This study randomized 69 of 74 pathologically diagnosed patients to the SIS (n = 34) or SBS (n = 35) groups. The total adverse event rate after stent deployment did not differ between the 2 groups (23.5% in the SIS group vs 28.6% in the SBS group, P = .633). The primary technical success rate was 100% (34/34) and 91.4% (32/35) in the SIS and SBS groups, respectively (P = .081). The clinical success rate was 94.1% (32/34) and 90.6% (29/32), respectively (P = .668). The stent patency rate at 3 months was 85.3% in the SIS group and 65.7% in the SBS group (P = .059). At 6 months, the stent patency rate was 47.1% and 31.4%, respectively (P = .184). The median cumulative stent patency and survival probability did not differ between the 2 groups. CONCLUSIONS Efficacy of bilateral SIS and SBS deployment may be similar in terms of total adverse events, technical and clinical success, stent patency, and survival. The stent patency rates at 3 and 6 months was higher in the SIS group without statistical difference. (Clinical trial registration number: NCT01141088.).
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Affiliation(s)
- Tae Hoon Lee
- Department of Internal Medicine, SoonChunHyang University College of Medicine, Cheonan, Republic of Korea
| | - Jong Ho Moon
- SoonChunHyang University College of Medicine, Bucheon, Republic of Korea
| | - Jun-Ho Choi
- Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Sang Hyub Lee
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yun Nah Lee
- SoonChunHyang University College of Medicine, Bucheon, Republic of Korea
| | - Woo Hyun Paik
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong Kee Jang
- Dongguk University College of Medicine, Ilsan Hospital, Goyang, Republic of Korea
| | - Byeong Wook Cho
- Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Jae Kook Yang
- Department of Internal Medicine, SoonChunHyang University College of Medicine, Cheonan, Republic of Korea
| | - Young Hwangbo
- Department of Preventive Medicine, SoonChunHyang University College of Medicine, Cheonan, Republic of Korea
| | - Sang-Heum Park
- Department of Internal Medicine, SoonChunHyang University College of Medicine, Cheonan, Republic of Korea
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Kitamura K, Yamamiya A, Ishii Y, Mitsui Y, Yoshida H. Endoscopic side-by-side uncovered self-expandable metal stent placement for malignant hilar biliary obstruction. Ther Adv Gastrointest Endosc 2019; 12:2631774519846345. [PMID: 31192317 PMCID: PMC6537491 DOI: 10.1177/2631774519846345] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/04/2019] [Indexed: 02/05/2023] Open
Abstract
AIM To investigate outcomes of endoscopic bilateral side-by-side placement across the papilla using 10-mm-diameter uncovered self-expandable metal stents for unresectable malignant hilar biliary obstruction. METHODS We retrospectively analyzed 23 patients who underwent endoscopic biliary uncovered self-expandable metal stent placement for unresectable malignant hilar biliary obstruction between January 2015 and September 2016 at our institution. We performed endoscopic side-by-side placement across the papilla using 10-mm-diameter longer-model uncovered self-expandable metal stents. Outcomes included the technical and functional success rates, recurrent biliary obstruction rate, time to recurrent biliary obstruction, reintervention rate, and incidence of adverse events other than recurrent biliary obstruction. RESULTS Of the 23 patients, 10 with malignant hilar biliary obstruction underwent endoscopic side-by-side uncovered self-expandable metal stent placement across the papilla (median age, 83 years; 6 men). The locations of malignant hilar biliary obstruction were Bismuth types II (n = 3), III (n = 3), and IV (n = 4). The median common bile duct diameter was 8 mm. The technical and functional success rates were 100% and 80%, respectively. Seven patients (70%) developed recurrent biliary obstruction because of stent occlusions, including early hemobilia in two patients and late tumor ingrowth in five patients. The median time to recurrent biliary obstruction was 66 (95% confidence interval: 29-483) days. Six patients (60%) required reintervention, and 1 (10%) underwent transcatheter arterial embolization for right hepatic arterial pseudoaneurysm. Early adverse events other than recurrent biliary obstruction occurred in four patients and late adverse event in one patient. CONCLUSION Endoscopic side-by-side placement across the papilla using 10-mm-diameter uncovered self-expandable metal stents was technically feasible for unresectable malignant hilar biliary obstruction; however, it might be better to avoid this method for patients with malignant hilar biliary obstruction because of high recurrent biliary obstruction rate and shorter time to recurrent biliary obstruction.
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Affiliation(s)
- Katsuya Kitamura
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Akira Yamamiya
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yu Ishii
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuta Mitsui
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hitoshi Yoshida
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Nakai Y, Kogure H, Isayama H, Koike K. Endoscopic Ultrasound-Guided Biliary Drainage for Unresectable Hilar Malignant Biliary Obstruction. Clin Endosc 2018; 52:220-225. [PMID: 30472818 PMCID: PMC6547346 DOI: 10.5946/ce.2018.094] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 06/27/2018] [Indexed: 12/11/2022] Open
Abstract
Endoscopic transpapillary biliary drainage is the current standard of care for unresectable hilar malignant biliary obstruction (MBO) and bilateral metal stent placement is shown to have longer patency. However, technical and clinical failure is possible and percutaneous transhepatic biliary drainage (PTBD) is sometimes necessary. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is increasingly being reported as an alternative rescue procedure to PTBD. EUS-BD has a potential advantage of not traversing the biliary stricture and internal drainage can be completed in a single session. Some approaches to bilateral biliary drainage for hilar MBO under EUS-guidance include a bridging method, hepaticoduodenostomy, and a combination of EUS-BD and transpapillary biliary drainage. The aim of this review is to summarize data on EUS-BD for hilar MBO and to clarify its advantages over the conventional approaches such as endoscopic transpapillary biliary drainage and PTBD.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
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Okuwaki K, Yamauchi H, Kida M, Imaizumi H, Iwai T, Matsumoto T, Kawaguchi Y, Uehara K, Nakatani S, Koizumi W. Efficacy and Long-Term Outcomes of Side-by-Side Self-Expandable Metal Stent Placement Using a 2-Channel Endoscope for Unresectable Malignant Hilar Biliary Obstruction Occurring After Billroth II Reconstruction (with Video). Dig Dis Sci 2018; 63:1641-1646. [PMID: 29557076 DOI: 10.1007/s10620-018-5013-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/06/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Long-term studies evaluating self-expandable metal stents in patients who have unresectable malignant hilar biliary obstruction (UMHBO) after surgical reconstruction of the intestine remain inadequate. We developed a side-by-side (SBS) technique using a two-channel endoscope to place self-expandable metal stents in patients with UMHBO occurring after Billroth II reconstruction. AIMS We validated the long-term outcomes obtained with this technique. METHODS The study group comprised seven patients with UMHBO in whom we attempted to place metal stents by the SBS technique using a two-channel scope. The procedure was validated retrospectively. RESULTS The technical success rate was 86% and functional success rate was 100%. The median time to recurrent biliary obstruction (RBO) was 222 days (95% CI 4.9-439.1). Besides RBO, there were no other complications. CONCLUSIONS The SBS procedure performed using a two-channel scope is a safe and useful new technique for the treatment of UMHBO occurring after Billroth II reconstruction.
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Affiliation(s)
- Kosuke Okuwaki
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan.
| | - Hiroshi Yamauchi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Hiroshi Imaizumi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Takaaki Matsumoto
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Yusuke Kawaguchi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Kazuho Uehara
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Seigo Nakatani
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Wasaburo Koizumi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
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Costamagna G, Tringali A. Can we insert a covered stent, partially or not, in case of hilar biliary stenosis? Endosc Int Open 2017; 5:E1218-E1219. [PMID: 29202006 PMCID: PMC5699906 DOI: 10.1055/s-0043-120665] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Guido Costamagna
- Digestive Endoscopy, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy,Chair of Digestive Endoscopy, IHU-USIAS, University of Strasbourg, Strasbourg, France,Corresponding author Guido Costamagna, MD, FACG Fondazione Policlinico Gemelli, Catholic UniversityLargo Agostino Gemelli 8Rome 00168Italy+39 06 30157220
| | - Andrea Tringali
- Digestive Endoscopy, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
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Kitamura K, Yamamiya A, Ishii Y, Mitsui Y, Nomoto T, Yoshida H. Side-by-side partially covered self-expandable metal stent placement for malignant hilar biliary obstruction. Endosc Int Open 2017; 5:E1211-E1217. [PMID: 29202005 PMCID: PMC5699902 DOI: 10.1055/s-0043-117955] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/26/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS This study investigated the feasibility of side-by-side (SBS) partially covered self-expandable metal stent (PCSEMS) placement for unresectable malignant hilar biliary obstruction (MHBO). PATIENTS AND METHODS We retrospectively analyzed 33 patients from a single center who underwent endoscopic biliary drainage for unresectable MHBO from July 2013 to June 2015. In all patients with bilateral obstruction during complete bilateral intrahepatic cholangiograms, we performed endoscopic SBS placement of a 6-mm diameter PCSEMS using an 8-French delivery system. All patients underwent endoscopic sphincterotomy. Generally, patients with recurrent biliary obstruction (RBO) after stent placement underwent endoscopic reintervention. Our study outcomes included the technical and functional success rates, RBO rate, time to RBO (TRBO), reintervention rate, and incidence of adverse events. RESULTS Seventeen patients with unresectable MHBO during complete bilateral intrahepatic cholangiograms underwent endoscopic SBS PCSEMS placement (median age, 78 years; men, 9). Lesions were Bismuth types II (n = 10), III (n = 1), and IV (n = 6), including 10 cholangiocarcinomas, 3 gallbladder cancers, and 4 metastatic cancers. In all patients, the PCSEMS was placed across the duodenal papilla. The technical and functional success rates were 100 % and 82 %, respectively. The median procedure time was 43 minutes (interquartile range [IQR]: 36 - 52 minutes). Twelve patients had RBO (71 %), including 9 stent occlusions due to sludge and 3 stent migrations. The median TRBO was 79 days (IQR: 58 - 156 days) during the follow-up period (median 192 days [IQR: 88 - 551 days]). The median TRBO of patients with Bismuth type II lesions was significantly longer than that of patients with Bismuth types III and IV lesions (87 days [IQR: 70 - 244 days] vs. 54 days [IQR: 35 - 100 days]; P = 0.030). Thirteen patients (76 %) required endoscopic reintervention. Endoscopic stent removal was possible in 6 patients without tumor ingrowth into the uncovered distal part of the stent. One late adverse event (≥ 31 days) occurred (cholangitis). CONCLUSIONS Endoscopic SBS placement of a PCSEMS was feasible in patients with unresectable MHBO. Additionally, reinterventional stent removal was possible in the absence of tumor ingrowth.
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Affiliation(s)
- Katsuya Kitamura
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
- Corresponding author Katsuya Kitamura, MD, PhD Division of GastroenterologyDepartment of MedicineShowa University School of Medicine1-5-8, Hatanodai, Shinagawa-kuTokyo, 142-8666Japan+81-3-37847553
| | - Akira Yamamiya
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yu Ishii
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuta Mitsui
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tomohiro Nomoto
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hitoshi Yoshida
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Lee TH, Kim TH, Moon JH, Lee SH, Choi HJ, Hwangbo Y, Hyun JJ, Choi JH, Jeong S, Kim JH, Park DH, Han JH, Park SH. Bilateral versus unilateral placement of metal stents for inoperable high-grade malignant hilar biliary strictures: a multicenter, prospective, randomized study (with video). Gastrointest Endosc 2017; 86:817-827. [PMID: 28479493 DOI: 10.1016/j.gie.2017.04.037] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/22/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The efficacy of palliative biliary drainage by using bilateral or unilateral self-expandable metal stents (SEMSs) for a malignant hilar biliary stricture (MHS) remains controversial. This prospective, randomized, multicenter study investigated whether bilateral drainage by using SEMSs is superior to unilateral drainage in patients with inoperable MHSs. METHODS Patients with inoperable high-grade MHSs who underwent palliative endoscopic insertion of bilateral or unilateral SEMSs were enrolled. The main outcome measurements were the rate of primary reintervention for malfunction after successful placement of SEMSs, stent patency, technical and clinical success rates, adverse events, and survival duration. RESULTS A total of 133 pathology-diagnosed patients were randomized to the bilateral group (n = 67) or the unilateral group (n = 66). The primary technical success rates were 95.5% (64/67) and 100% (66/66) in the bilateral and unilateral groups, respectively (P = .244). The clinical success rates were 95.3% (61/64) and 84.9% (56/66), respectively (P = .047). The primary reintervention rates based on the per-protocol analysis were 42.6% (26/61) in the bilateral group and 60.3% (38/63) in the unilateral group (P = .049). The median cumulative stent patency duration was 252 days in the bilateral group and 139 days in the unilateral group. The risk of stent patency failure was significantly higher in the unilateral group (log-rank test; P < .01). In a multivariate Cox proportional hazard model to assess stent patency, bilateral SEMS placement was a favorable factor (adjusted hazard ratio 0.30, 95% confidence interval, 0.172-0.521; P < .001). Survival probability and late adverse events were not different between the 2 groups. CONCLUSIONS Unilateral and bilateral drainage strategies by using SEMSs had similar technical success rates, but bilateral drainage resulted in fewer reinterventions and more durable stent patency in patients with inoperable high-grade MHSs. (Clinical trial registration number: NCT02166970.).
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Affiliation(s)
- Tae Hoon Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
| | - Tae Hyeon Kim
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Republic of Korea
| | - Jong Ho Moon
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Bucheon, Republic of Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Jong Choi
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Bucheon, Republic of Korea
| | - Young Hwangbo
- Department of Preventive Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
| | - Jong Jin Hyun
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Jun-Ho Choi
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jong Hyeok Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Do Hyun Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Sang-Heum Park
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
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Fukasawa M, Takano S, Shindo H, Takahashi E, Sato T, Enomoto N. Endoscopic biliary stenting for unresectable malignant hilar obstruction. Clin J Gastroenterol 2017; 10:485-490. [PMID: 29052124 DOI: 10.1007/s12328-017-0778-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 09/15/2017] [Indexed: 02/06/2023]
Abstract
Palliative drainage is the primary treatment option for unresectable malignant hilar biliary obstruction (UMHBO) to improve the prognosis and quality of life. Currently, endoscopic biliary drainage is considered as a first-line treatment for UMHBO as well as for distal biliary obstruction. Self-expanding metal stents (SEMSs) are preferred over plastic stents (PSs) in patients with life expectancy of >3 months. However, endoscopic treatment of UMHBO is often more challenging and complex than that of distal biliary obstruction. Although no consensus exists on the optimal method for biliary drainage because of the lack of well-designed, large-scale randomized control trials, several essential aspects of various optimal methods have been studied. Presently, technological developments in this field are under way and newly designed or modified stenting devices for UMHBO are being developed. In this review, we assess the optimal stenting strategy for UMHBO based on the previous literature, focusing on the stent type (PS vs SEMS), the liver volume to be drained, unilateral (single) vs bilateral (multiple) stent deployment, and bilateral stenting method (stent-in-stent vs side-by-side).
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Affiliation(s)
- Mitsuharu Fukasawa
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan.
| | - Shinichi Takano
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Hiroko Shindo
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Ei Takahashi
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Tadashi Sato
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Nobuyuki Enomoto
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
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Inoue T, Ishii N, Kobayashi Y, Kitano R, Sakamoto K, Ohashi T, Nakade Y, Sumida Y, Ito K, Nakao H, Yoneda M. Simultaneous Versus Sequential Side-by-Side Bilateral Metal Stent Placement for Malignant Hilar Biliary Obstructions. Dig Dis Sci 2017; 62:2542-2549. [PMID: 28766242 DOI: 10.1007/s10620-017-4691-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 07/21/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic bilateral self-expandable metallic stent (SEMS) placement for malignant hilar biliary obstructions (MHBOs) is technically demanding, and a second SEMS insertion is particularly challenging. A simultaneous side-by-side (SBS) placement technique using a thinner delivery system may mitigate these issues. AIMS We aimed to examine the feasibility and efficacy of simultaneous SBS SEMS placement for treating MHBOs using a novel SEMS that has a 5.7-Fr ultra-thin delivery system. METHODS Thirty-four patients with MHBOs underwent SBS SEMS placement between 2010 and 2016. We divided the patient cohort into those who underwent sequential (conventional) SBS placement between 2010 and 2014 (sequential group) and those who underwent simultaneous SBS placement between 2015 and 2016 (simultaneous group), and compared the groups with respect to the clinical outcomes. RESULTS The technical success rates were 71% (12/17) and 100% (17/17) in the sequential and simultaneous groups, respectively, a difference that was significant (P = .045). The median procedure time was significantly shorter in the simultaneous group (22 min) than in the sequential group (52 min) (P = .017). There were no significant group differences in the time to recurrent biliary obstruction (sequential group: 113 days; simultaneous group: 140 days) or other adverse event rates (sequential group: 12%; simultaneous group: 12%). CONCLUSIONS Simultaneous SBS placement using the novel 5.7-Fr SEMS delivery system may be more straightforward and have a higher success rate compared to that with sequential SBS placement. This new method may be useful for bilateral stenting to treat MHBOs.
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Affiliation(s)
- Tadahisa Inoue
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan.
| | - Norimitsu Ishii
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Yuji Kobayashi
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Rena Kitano
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Kazumasa Sakamoto
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Tomohiko Ohashi
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Yukiomi Nakade
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Yoshio Sumida
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Kiyoaki Ito
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Haruhisa Nakao
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Masashi Yoneda
- Department of Gastroenterology, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
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Minaga K, Takenaka M, Kitano M, Chiba Y, Imai H, Yamao K, Kamata K, Miyata T, Omoto S, Sakurai T, Watanabe T, Nishida N, Kudo M. Rescue EUS-guided intrahepatic biliary drainage for malignant hilar biliary stricture after failed transpapillary re-intervention. Surg Endosc 2017; 31:4764-4772. [PMID: 28424912 DOI: 10.1007/s00464-017-5553-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 03/28/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment of unresectable malignant hilar biliary stricture (UMHBS) is challenging, especially after failure of repeated transpapillary endoscopic stenting. Endoscopic ultrasonography-guided intrahepatic biliary drainage (EUS-IBD) is a recent technique for intrahepatic biliary decompression, but indications for its use for complex hilar strictures have not been well studied. The aim of this study was to assess the feasibility and safety of EUS-IBD for UMHBS after failed transpapillary re-intervention. METHODS Retrospective analysis of all consecutive patients with UMHBS of Bismuth II grade or higher who, between December 2008 and May 2016, underwent EUS-IBD after failed repeated transpapillary interventions. The technical success, clinical success, and complication rates were evaluated. Factors associated with clinical ineffectiveness of EUS-IBD were explored. RESULTS A total of 30 patients (19 women, median age 66 years [range 52-87]) underwent EUS-IBD for UMHBS during the study period. Hilar biliary stricture morphology was classified as Bismuth II, III, or IV in 5, 13, and 12 patients, respectively. The median number of preceding endoscopic interventions was 4 (range 2-14). EUS-IBD was required because the following procedures failed: duodenal scope insertion (n = 4), accessing the papilla after duodenal stent insertion (n = 5), or achieving desired intrahepatic biliary drainage (n = 21). Technical success with EUS-IBD was achieved in 29 of 30 patients (96.7%) and clinical success was attained in 22 of these 29 (75.9%). Mild peritonitis occurred in three of 30 (10%) and was managed conservatively. Stent dysfunction occurred in 23.3% (7/30). There was no procedure-related mortality. On multivariable analysis, Bismuth IV stricture predicted clinical ineffectiveness (odds ratio = 12.7, 95% CI 1.18-135.4, P = 0.035). CONCLUSIONS EUS-IBD may be a feasible and effective rescue alternative with few major complications after failed transpapillary endoscopic re-intervention in patients with UMHBS, particularly for Bismuth II or III strictures.
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Affiliation(s)
- Kosuke Minaga
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan.
| | - Masayuki Kitano
- Second Department of Internal Medicine, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasutaka Chiba
- Clinical Research Center, Kindai University Hospital, Osaka-Sayama, Japan
| | - Hajime Imai
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Kentaro Yamao
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Ken Kamata
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Takeshi Miyata
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Shunsuke Omoto
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Toshiharu Sakurai
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Tomohiro Watanabe
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
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Ogura T, Onda S, Takagi W, Sano T, Okuda A, Masuda D, Yamamoto K, Miyano A, Kitano M, Takeuchi T, Fukunishi S, Higuchi K. Clinical utility of endoscopic ultrasound-guided biliary drainage as a rescue of re-intervention procedure for high-grade hilar stricture. J Gastroenterol Hepatol 2017; 32:163-168. [PMID: 27161286 DOI: 10.1111/jgh.13437] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Re-intervention after stent placement for malignant hepatic hilum obstruction (HBO) is challenging. endoscopic ultrasound-guided biliary drainage (EUS-BD) has been developed as an alternative method for failed endoscopic retrograde cholangiopancreatography (ERCP). In this retrospective study, the clinical utility of EUS-BD as a rescue drainage technique for HBO patients who failed re-intervention under ERCP guidance was evaluated. METHODS Between April 2012 and August 2015, patients with HBO were enrolled. Patients' characteristics, kinds of metallic stents, configuration of stent placement, overall survival, stent patency, and results of re-intervention were reviewed, along with the re-intervention technical success rate. RESULTS The biliary stricture type was Bismuth type IV in 59% (23/39) and types IIIa and b in 20.5% (8/39) each. Biliary metallic stent placement was bilateral in 38.5% (15/39), and unilateral in 61.5% (24/39). Primary stent dysfunction was observed in 71.8% (28/39) of cases. Planned re-intervention under ERCP guidance was attempted in 26 patients. The technical success rate was 62% (16/26). For the 10 patients who failed re-intervention under ERCP guidance, EUS-BD was planned. The technical success rate was 100% (10/10). The procedure time was 25.8 min. Adverse events were not seen in any patients. Stent patency after re-intervention was not significantly different between ERCP (165 days) guidance and EUS-BD (152 days) guidance (P = 0.463) CONCLUSIONS: In conclusion, EUS-BD as a re-intervention method for metallic stent obstruction was safe and feasible. If ERCP was failed, EUS-BD may be one of option as re-intervention method for high-grade hilar stricture.
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Affiliation(s)
- Takeshi Ogura
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Saori Onda
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Wataru Takagi
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Tatsushi Sano
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Atsushi Okuda
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Daisuke Masuda
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | | | - Akira Miyano
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Masayuki Kitano
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Toshihisa Takeuchi
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Shinya Fukunishi
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kazuhide Higuchi
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
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Yoshida T, Hara K, Imaoka H, Hijioka S, Mizuno N, Ishihara M, Tanaka T, Tajika M, Niwa Y, Yamao K. Benefits of side-by-side deployment of 6-mm covered self-expandable metal stents for hilar malignant biliary obstructions. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:548-55. [PMID: 27345771 DOI: 10.1002/jhbp.372] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 06/24/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The best way to perform endoscopic stenting for hilar malignant biliary obstruction (HMBO) is under discussion. Recently, a 6-mm covered self-expandable metal stent (CSEMS) has become available. In this article, the results of side-by-side (SBS) 6-mm CSEMS deployment for HMBO are reported. METHODS A total of 22 patients, 32 procedures of SBS 6-mm CSEMS [16 fully covered (FCSEMS), 16 partially covered (PCSEMS)] deployment for HMBO, were prospectively enrolled from November 2011 to June 2015 and retrospectively analyzed. Technical and clinical success rates, stent patency period, complications, and re-intervention success rates were analyzed. RESULTS The overall/FCSEMS/PCSEMS technical and clinical success rates were 96.9%/93.8%/100% and 93.5%/100%/87.5%, respectively. The mean stent patency period was 95/113/68 days. Early and late complication rates were 3.1%/0%/6.3% and 6.3%/12.5%/0%, respectively. Stent exchange was attempted in 12 procedures, and the stent exchange success rate was 83.3%/100%/75%. CONCLUSIONS This is the first report of SBS 6-mm CSEMS deployment for HMBO. This procedure has high technical and clinical success rates and the advantages of ease of performance and a high success rate of re-intervention. Outcomes appear better with FCSEMS than with PCSEMS deployment. Since stent patency is still controversial, large-sample studies are needed.
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Affiliation(s)
- Tsukasa Yoshida
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa Ward, Nagoya, Aichi, 464-0021, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa Ward, Nagoya, Aichi, 464-0021, Japan.
| | - Hiroshi Imaoka
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa Ward, Nagoya, Aichi, 464-0021, Japan
| | - Susumu Hijioka
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa Ward, Nagoya, Aichi, 464-0021, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa Ward, Nagoya, Aichi, 464-0021, Japan
| | - Makoto Ishihara
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Tsutomu Tanaka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Yasumasa Niwa
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa Ward, Nagoya, Aichi, 464-0021, Japan
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Hwang S, Ha TY, Song GW, Jung DH. Cluster hepaticojejunostomy with radial spreading anchoring traction technique for secure reconstruction of widely opened hilar bile ducts. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2016; 20:66-70. [PMID: 27212993 PMCID: PMC4874047 DOI: 10.14701/kjhbps.2016.20.2.66] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 04/01/2016] [Accepted: 04/07/2016] [Indexed: 11/17/2022]
Abstract
Secure reconstruction of multiple hepatic ducts that are severely damaged by tumor invasion or iatrogenic injury is a challenge. Failure of percutaneous or endoscopic biliary stenting requires lifelong placement of one or more percutaneous transhepatic biliary drainage (PTBD) tubes. For such difficult situations, we devised a surgical technique termed cluster hepaticojejunostomy (HJ), which can be coupled with palliative bile duct resection. The cluster HJ technique consisted of applying multiple internal biliary stents and a single wide porto-enterostomy to the surrounding connective tissues. The technique is described in detail in the present case report. Performing cluster HJ benefits from three technical tips as follows: making the multiple bile duct openings wide and parallel after sequential side-to-side unification; radially anchoring and traction of the suture materials at the anterior anastomotic suture line; and making multiple segmented continuous sutures at the posterior anastomotic suture line. Thus, cluster HJ with radial spreading anchoring traction technique is a useful surgical method for secure reconstruction of severely damaged hilar bile ducts.
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Affiliation(s)
- Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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36
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Shim CS, Kim JH, Bok GH. Development of Biliary and Enteral Stents by the Korean Gastrointestinal Endoscopists. Clin Endosc 2016; 49:113-23. [PMID: 26956192 PMCID: PMC4821526 DOI: 10.5946/ce.2016.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/16/2016] [Indexed: 11/22/2022] Open
Abstract
Stenting in the gastrointestinal tract is a common procedure used for palliation of obstruction in the enteral and biliary tract. Today, stenting of malignant and benign strictures is performed at almost every major tertiary hospital in Korea. Moreover, Korea has become a major global supplier of cutting edge technology in the field of self-expanding metal stents. However, the history of stenting in Korea is relatively short and was far behind that of other nations such as Japan and Germany. The authors are humbled and gratified to have been able to observe the development and application of these stents in Korea, first hand. In this article, the authors review the overall history of stenting with a specific focus on the development of stenting in Korea. The development of esophageal, gastroduodenal, biliary, and colonic stents in Korea are reviewed in this article from a chronological and historical point of view, and a personal account of some of the significant moments of stent development in Korea are described.
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Affiliation(s)
- Chan Sup Shim
- Digestive Disease Center, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jin Hong Kim
- Department of Gastroenterology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Gene Hyun Bok
- Department of Internal Medicine, Min Hospital, Seoul, Korea
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Abstract
Decompression of the biliary system in patients with malignant biliary obstruction has been widely accepted and implemented as part of the care. Despite a wealth of literature, there remains a significant amount of uncertainty as to which approach would be most appropriate in different clinical settings. This review covers stenting of the biliary system in cases of resectable or palliative malignant biliary obstruction, potential candidates for biliary drainage, technical aspects of the procedure, as well as management of biliary stent dysfunction. Furthermore, periprocedural considerations including proper mapping of the location of obstruction and the use of antibiotics are addressed.
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Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University Medical City, King Saud University, Riyadh 11461, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montréal, Quebec H3G 1A4, Canada
| | - Jeffrey S Barkun
- Division of General Surgery, The McGill University Health Centre, McGill University, 1650 Cedar Avenue, Montréal, Quebec H3G 1A4, Canada
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montréal, Quebec H3G 1A4, Canada; Division of Clinical Epidemiology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montréal, Quebec H3G 1A4, Canada.
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Kato H, Tsutsumi K, Kawamoto H, Okada H. Current status of endoscopic biliary drainage for unresectable malignant hilar biliary strictures. World J Gastrointest Endosc 2015; 7:1032-1038. [PMID: 26322156 PMCID: PMC4549660 DOI: 10.4253/wjge.v7.i11.1032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 07/16/2015] [Accepted: 08/07/2015] [Indexed: 02/05/2023] Open
Abstract
The management of jaundice and cholangitis is important for improving the prognosis and quality of life of patients with unresectable malignant hilar biliary strictures (UMHBS). In addition, effective chemotherapy, such as a combination of gemcitabine and cisplatin, requires the successful control of jaundice and cholangitis. However, endoscopic drainage for UMHBS is technical demanding, and continuing controversies exist in the selection of the most appropriate devices and techniques for stent deployment. Although metallic stents (MS) are superior to the usual plastic stents in terms of patency, an extensive comparison between MS and “inside stents”, which are deployed above the sphincter of Oddi, is necessary. Which techniques are preferred remains as yet unresolved: for instance, whether to use a unilateral or bilateral drainage, or a stent-in-stent or side-by-side method for the deployment of bilateral MS, although a new cell design and thin delivery system for MS allowed us to accomplish successful deployments of bilateral MS. The development of techniques and devices for re-intervention after stent occlusion is also imperative. Further critical investigations of more effective devices and techniques, and increased randomized controlled trials are warranted to resolve these important issues.
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Ha TY, Hwang S, Song GW, Jung DH, Kim MH, Lee SG, Kwon DI, Ko GY. Cluster Hepaticojejunostomy Is a Useful Technique Enabling Secure Reconstruction of Severely Damaged Hilar Bile Ducts. J Gastrointest Surg 2015; 19:1537-41. [PMID: 25956723 DOI: 10.1007/s11605-015-2844-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 04/28/2015] [Indexed: 01/31/2023]
Abstract
Secure reconstruction of multiple hepatic ducts severely damaged by tumor invasion or iatrogenic injury is very difficult. If percutaneous or endoscopic biliary stenting fails, one or more percutaneous transhepatic biliary drainage (PTBD) tubes must be maintained in place for the rest of the patient's life. To cope with such difficult situations, we present a surgical technique termed cluster hepaticojejunostomy (HJ), which can be coupled with palliative bile duct resection. The cluster HJ technique consisted of applying multiple internal biliary stents and a single wide porto-enterostomy to surrounding connective tissues. We present a preliminary study with six patients. Five perihilar cholangiocarcinoma patients undergoing palliative bile duct resection received this procedure. Follow-up PTBD tubogram and hepatobiliary scintigraphy were performed at 1-2 weeks after surgery, after which the PTBD tubes were removed. No patient showed surgical complications, and the 6-month patency rate of clustered HJ was 80%. Another patient with laparoscopic cholecystectomy-associated major bile duct injury showed no biliary complications in the 5-year period following this procedure. Based on the results of this study, the cluster HJ technique may be a useful surgical method enabling the secure reconstruction of severely damaged hilar bile ducts.
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Affiliation(s)
- Tae-Yong Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, South Korea
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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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Moy BT, Birk JW. An Update to Hepatobiliary Stents. J Clin Transl Hepatol 2015; 3:67-77. [PMID: 26357636 PMCID: PMC4542081 DOI: 10.14218/jcth.2015.00040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 01/31/2015] [Accepted: 02/05/2015] [Indexed: 12/14/2022] Open
Abstract
Endoscopic stent placement is a common primary management therapy for benign and malignant biliary strictures. However, continuous use of stents is limited by occlusion and migration. Stent technology has evolved significantly over the past two decades to reduce these problems. The purpose of this article is to review current guidelines in managing malignant and benign biliary obstructions, current endoscopic techniques for stent placement, and emerging stent technology. What began as a simple plastic stent technology has evolved significantly to include uncovered, partially covered, and fully covered self-expanding metal stents (SEMS) as well as magnetic, bioabsorbable, drug-eluting, and antireflux stents.(1).
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Affiliation(s)
| | - John W. Birk
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
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Kawakubo K, Kawakami H, Kuwatani M, Kudo T, Abe Y, Kawahata S, Kubo K, Kubota Y, Sakamoto N. Single-step simultaneous side-by-side placement of a self-expandable metallic stent with a 6-Fr delivery system for unresectable malignant hilar biliary obstruction: a feasibility study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:151-155. [PMID: 25345586 DOI: 10.1002/jhbp.173] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bilateral self-expandable metallic stent (SEMS) placement for the management of unresectable malignant hilar biliary obstruction (UMHBO) is technically challenging to perform using the existing metallic stents with thick delivery systems. The recently developed 6-Fr delivery systems could facilitate a single-step simultaneous side-by-side placement through the accessory channel of the duodenoscope. The aim of this study was to evaluate the feasibility of this procedure. METHODS Between May and September 2013, 13 consecutive patients with UMHBO underwent a single-step simultaneous side-by-side placement of SEMS with the 6-Fr delivery system. The technical success rate, stent patency, and rate of complications were evaluated from the prospectively collected database. RESULTS Technical success was achieved in 11 (84.6%, 95% confidence interval [CI]: 57.8-95.8) patients. The median procedure time was 25 min. Early and late complications were observed in 23% (one segmental cholangitis and two liver abscesses) and 15% (one segmental cholangitis and one cholecystitis) patients, respectively. Median dysfunction free patency was 263 days (95% CI: 37-263). Five patients (38%) experienced stent occlusion that was successfully managed by endoscopic stent placement. CONCLUSIONS A single-step simultaneous side-by-side placement of SEMS with a 6-Fr delivery system was feasible for the management of UMHBO.
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Affiliation(s)
- Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
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Naitoh I, Nakazawa T, Ban T, Okumura F, Hirano A, Takada H, Togawa S, Hayashi K, Miyabe K, Shimizu S, Kondo H, Nishi Y, Yoshida M, Yamashita H, Umemura S, Hori Y, Kato A, Sano H, Joh T. 8-mm versus 10-mm diameter self-expandable metallic stent in bilateral endoscopic stent-in-stent deployment for malignant hilar biliary obstruction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:396-401. [PMID: 25611012 DOI: 10.1002/jhbp.219] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 12/22/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND We aimed to clarify the clinical benefits of using 8-mm versus 10-mm diameter self-expandable metallic stent (SEMS) in bilateral endoscopic stent-in-stent (SIS) deployment for malignant hilar biliary obstruction (MHBO). METHODS A total of 72 consecutive patients with MHBO treated by endoscopic bilateral SIS deployment were enrolled. The 8-mm and 10-mm diameter SEMSs were used in 37 patients (8-mm group) and 35 patients (10-mm group), respectively. We retrospectively compared technical success, functional success, complications, successful re-intervention, time to recurrent biliary obstruction (RBO) and survival time between two groups. RESULTS There were no significant inter-group differences in terms of technical success (8-mm vs. 10-mm group, both 100%), functional success (96% vs. 100%), early (5% vs. 9%) and late (19% vs. 14%) complications other than RBO, and successful endoscopic re-intervention (94% vs. 100%), respectively. Time to RBO (median: 198 days vs. 222 days; log-rank, P = 0.440) and survival time (median: 186 days vs. 235 days; log-rank, P = 0.883) did not differ significantly between the two groups. However, the success rate of endoscopic bilateral revisionary stent insertion for RBO was significantly higher in the 10-mm compared to the 8-mm group (68% vs. 31%; P = 0.044). CONCLUSIONS The 10-mm diameter SEMS is more suitable with regard to endoscopic re-intervention.
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Affiliation(s)
- Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
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Kawakubo K, Kawakami H, Toyokawa Y, Otani K, Kuwatani M, Abe Y, Kawahata S, Kubo K, Kubota Y, Sakamoto N. Risk factors for technical failure of endoscopic double self-expandable metallic stent placement by partial stent-in-stent method. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:79-85. [PMID: 25308061 DOI: 10.1002/jhbp.170] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Endoscopic double self-expandable metallic stent (SEMS) placement by the partial stent-in-stent (PSIS) method has been reported to be useful for the management of unresectable hilar malignant biliary obstruction. However, it is technically challenging, and the optimal SEMS for the procedure remains unknown. The aim of this study was to identify the risk factors for technical failure of endoscopic double SEMS placement for unresectable malignant hilar biliary obstruction (MHBO). METHODS Between December 2009 and May 2013, 50 consecutive patients with MHBO underwent endoscopic double SEMS placement by the PSIS method. We retrospectively evaluated the rate of successful double SEMS placement and identified the risk factors for technical failure. RESULTS The technical success rate for double SEMS placement was 82.0% (95% confidence interval [CI]: 69.2-90.2). On univariate analysis, the rate of technical failure was high in patients with metastatic disease and unilateral placement. Multivariate analysis revealed that metastatic disease was a significant risk factor for technical failure (odds ratio: 9.63, 95% CI: 1.11-105.5). The subgroup analysis after double guidewire insertion showed that the rate of technical success was higher in the laser-cut type SEMS with a large mesh and thick delivery system than in the braided type SEMS with a small mesh and thick delivery system. CONCLUSIONS Metastatic disease was a significant risk factor for technical failure of double SEMS placement for unresectable MHBO. The laser-cut type SEMS with a large mesh and thin delivery system might be preferable for the PSIS procedure.
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Affiliation(s)
- Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
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Lee TH, Park DH. Endoscopic prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastroenterol 2014; 20:16582-16595. [PMID: 25469026 PMCID: PMC4248201 DOI: 10.3748/wjg.v20.i44.16582] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/11/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is not an uncommon adverse event but may be an avoidable complication. Although pancreatitis of severe grade is reported in 0.1%-0.5% of ERCP patients, a serious clinical course may be lethal. For prevention of severe PEP, patient risk stratification, appropriate selection of patients using noninvasive diagnostic imaging methods such as magnetic resonance cholangiopancreatography or endoscopic ultrasonography (EUS), and avoidance of unnecessary invasive procedures, are important measures to be taken before any procedure. Pharmacological prevention is also commonly attempted but is usually ineffective. No ideal agent has not yet been found and the available data conflict. Currently, rectal non-steroidal anti-inflammatory drugs are used to prevent PEP in high-risk patients, but additional studies using larger numbers of subjects are necessary to confirm any prophylactic effect. In this review, we focus on endoscopic procedures seeking to prevent or decrease the severity of PEP. Among various cannulation methods, wire-guided cannulation, precut fistulotomy, and transpancreatic septostomy are reviewed. Prophylactic pancreatic stent placement, which is the best-known prophylactic method, is reviewed with reference to the ideal stent type, adequate duration of stent placement, and stent-related complications. Finally, we comment on other treatment alternatives, and make the point that further advances in EUS-guided techniques may afford useful PEP prophylaxis.
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Lee TH, Moon JH, Park SH. Bilateral metallic stenting in malignant hilar obstruction. Clin Endosc 2014; 47:440-6. [PMID: 25325005 PMCID: PMC4198562 DOI: 10.5946/ce.2014.47.5.440] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 06/04/2014] [Indexed: 02/07/2023] Open
Abstract
Endoscopic palliative biliary drainage is considered as a gold standard treatment in advanced or inoperable hilar cholangiocarcinoma. Also, metal stents are preferred over plastic stents in patients with >3 months life expectancy. However, the endoscopic intervention of advanced hilar obstruction is often more challenging and complex than that of distal malignant biliary obstructions. In this literature review, we describe the issues commonly encountered during endoscopic unilateral (single) versus bilateral (multiple) biliary stenting for malignant hilar obstruction. Also, we provide technical guidance to improve the technical success rates and patient outcomes, focusing on bilateral metallic stenting techniques such as stent-in-stent or side-by-side deployment.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jong Ho Moon
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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Law R, Baron TH. Bilateral metal stents for hilar biliary obstruction using a 6Fr delivery system: outcomes following bilateral and side-by-side stent deployment. Dig Dis Sci 2013; 58:2667-72. [PMID: 23625287 DOI: 10.1007/s10620-013-2671-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 03/27/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND STUDY AIM Controversy exists on optimal endoscopic management for palliation of malignant hilar obstruction, with advocates for metal "side-by-side" (SBS) and "stent-in-stent" (SIS) techniques. We sought to evaluate the technical feasibility, efficacy, and outcomes of bilateral biliary self-expanding metal stents (SEMS) for treatment of malignant hilar obstruction using a stent with a 6Fr delivery system. PATIENTS AND METHODS This was a single-center, retrospective review of all patients who underwent bilateral placement of Zilver® biliary SEMS for malignant hilar obstruction from January 2010 to August 2012. Patients underwent endoscopic retrograde cholangiopancreatography with placement of stents using either the SIS or SBS stent techniques. RESULTS Twenty-four patients (19 men, mean age 63 years) underwent bilateral stenting for malignant hilar obstruction during the study period. Seventeen and seven patients underwent the SBS and SIS technique, respectively. Cholangiocarcinoma (n=14) was the most common cause of hilar obstruction. Initial technical success was achieved in 24/24 (100%) of patients; however, 12 (50%) patients required re-intervention during the study period (median 98 days). Comparison of the SBS and SIS groups revealed no statistical difference with respect to need for re-intervention (P=0.31), successful re-intervention (P=0.60), or procedural length (P=0.89). CONCLUSIONS Use of bilateral Zilver® SEMS in either the SBS or SIS configuration is safe, technically feasible, and effective for drainage of malignant hilar obstruction; however, duration of stent patency and procedure-free survival remain variable.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Lee TH. Technical tips and issues of biliary stenting, focusing on malignant hilar obstruction. Clin Endosc 2013; 46:260-6. [PMID: 23767037 PMCID: PMC3678064 DOI: 10.5946/ce.2013.46.3.260] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 03/25/2013] [Indexed: 12/20/2022] Open
Abstract
Although there is no survival advantage, inoperable hilar cholangiocarcinoma managed by palliative drainage may benefit from symptomatic improvement. In general, biliary drainage is divided into endoscopic or percutaneous approaches and surgical drainage. Plastic or metal stent is the most preferred device for palliative drainage in endoscopic approach. Considering cost-effectiveness, use of metallic stent is preferred than plastic stents in patients with more than 3 months of life expectancy with inoperable malignant biliary obstruction. In patients with unresectable malignant hilar obstruction, the endoscopic approach with biliary stent placement by experts has been considered as the treatment of choice. However, the endoscopic management of hilar obstruction is often more challenging and complex than distal malignant biliary obstructions. There is still a lack of clear consensus on the use of plastic versus metal stents and unilateral versus bilateral drainage since the decision should be made under many grounds such as the volume of liver drainage more than 50%, life expectancy, and expertise of the facility.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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