Biliary stenting is not a prerequisite to endoscopic placement of duodenal covered self-expandable metal stents

Success and safety of endoscopic treatments for concomitant biliary and duodenal malignant stenosis: A review of the literature

Synchronous biliary and duodenal malignant obstruction is a challenging endoscopic scenario in patients affected with ampullary, peri-ampullary, and pancreatic head neoplasia. Surgical bypass is no longer the gold-standard therapy for these patients, as simultaneous endoscopic biliary and duodenal stenting is currently a feasible and widely used technique, with a high technical success in expert hands. In recent years, endoscopic ultrasonography (EUS) has evolved from a diagnostic to a therapeutic procedure, and is now increasingly used to guide biliary drainage, especially in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). The advent of lumen-apposing metal stents (LAMS) has expanded EUS therapeutic options, and changed the management of synchronous bilioduodenal stenosis. The most recent literature regarding endoscopic treatments for synchronous biliary and duodenal malignant stenosis has been reviewed to determine the best endoscopic approach, also considering the advent of an interventional EUS approach using LAMS.

Efficacy of EUS-guided and ERCP-guided biliary drainage for malignant biliary obstruction: prospective randomized controlled study

BACKGROUND AND AIMS

ERCP-guided biliary drainage (ERCP-BD) is a criterion standard treatment for malignant biliary obstruction when curative surgery is not an option. Alternative methods such as percutaneous transhepatic biliary drainage would significantly lower the quality of life. EUS-guided biliary drainage (EUS-BD) has been developed and performed by experienced endoscopists. Therefore, the aims of this study were to evaluate the efficacy and safety of EUS-BD compared with ERCP in malignant biliary obstruction.

METHODS

The prospective randomized controlled study was conducted, and 30 patients were enrolled: 15 for each EUS-BD and ERCP-BD arms. The technical success, procedural time, clinical success, and adverse events were evaluated.

RESULTS

Thirty patients had extrahepatic malignant biliary tract obstruction (19 men, 11 women). Twenty-seven patients had unresectable pancreatic ductal adenocarcinomas, 1 patient had distal common bile duct cancer, and 2 patients had metastatic malignant lymphadenopathy. There were no significant differences both in terms of technical success rate and clinical success rate (100% vs 93% and 93% vs 100% in ERCP-BD vs EUS-BD, respectively; P = 1.00, P = 1.00). Four patients (31%) had tumor ingrowth-caused stent dysfunction in the ERCP-BD group, whereas 2 patients had food impaction and 2 patients had stent migration in the EUS-BD group. No significant procedure-related adverse events occurred in either group.

CONCLUSIONS

This prospective randomized controlled study suggests that EUS-BD has similar safety to ERCP-BD. EUS-BD was not superior to ERCP-BD in terms of relief of malignant biliary obstruction. EUS-BD may have fewer cases of tumor ingrowth but may also have more cases of food impaction or stent migration. (Clinical trial registration number: NCT01421836.).

Covered duodenal self-expandable metal stents prolong biliary stent patency in double stenting: The largest series of bilioduodenal obstruction

BACKGROUND AND AIM

Endoscopic biliary and duodenal stenting (DS; double stenting) is widely accepted as a palliation therapy for malignant bilioduodenal obstruction. The aim of the current study was to investigate the patency and adverse events of duodenal and biliary stents in patients with DS.

METHODS

Patients who underwent DS from April 2004 to March 2017 were analyzed retrospectively with regard to clinical outcomes and predictive factors of recurrent biliary and duodenal obstruction (recurrent biliary obstruction [RBO] and recurrent duodenal obstruction [RDO]).

RESULTS

A total of 109 consecutive patients was enrolled. Technical success of DS was achieved in 108 patients (99.1%). Symptoms due to biliary and duodenal obstruction were improved in 89 patients (81.7%). RBO occurred in 25 patients (22.9%) and RDO in 13 (11.9%). The median times to RBO and RDO from DS were 87 and 76 days, respectively. Placement of a duodenal uncovered self-expandable metal stent (U-SEMS) was significantly associated with RBO in the multivariable analysis (P = 0.007). Time to RBO was significantly longer in the duodenal covered self-expandable metal stent group than in the U-SEMS group (P = 0.003). No predictive factors of RDO were detected, and duodenal stent type was not associated with the time to RDO (P = 0.724).

CONCLUSIONS

Double stenting was safe and effective for malignant bilioduodenal obstruction. Duodenal U-SEMS is a risk factor for RBO. The covered self-expandable metal stent is the preferred type of duodenal SEMS in patients with DS (Clinical trial registration number: UMIN000027606).

Oesophageal stent placement to treat a massive iatrogenic duodenal defect after laparoscopic cholecystectomy

Iatrogenic duodenal injury occurring during laparoscopic cholecystectomy (LC) is managed surgically, though rarely a large, persistent fistula is refractory to surgical interventions. We present the case of a 40-year-old woman transferred to our centre following elective LC for a reported perforated duodenal ulcer. An uncontained leak was found to originate from a 1.5 cm duodenal defect, with no evidence of ulceration. A duodenostomy tube was placed. One month after abdominal closure, the patient continued to have a persistent, large duodenal fistula. A through-the-scope covered oesophageal stent was placed under endoscopic and fluoroscopic guidance. Five weeks later, it was successfully retrieved and no subsequent extravasation of contrast from the duodenum was noted. Unrecognised iatrogenic duodenal injuries sustained during LC can be catastrophic. In cases of massive duodenal defects and high-output biliary fistula uncontrolled after surgical intervention, endoscopic-guided and fluoroscopic-guided placement of a fully covered oesophageal stent may be lifesaving.

Partially-covered stent placement versus surgical gastrojejunostomy for the palliation of malignant gastroduodenal obstruction secondary to pancreatic cancer

PURPOSE

To compare the outcomes of partially covered self-expandable metallic stent (SEMS) placement with surgical gastrojejunostomy (GJ) in patients with gastroduodenal obstruction caused by pancreatic cancer.

METHODS

The medical records of 107 patients with gastroduodenal obstruction caused by pancreatic cancer who underwent fluoroscopic partially covered SEMS placement (n = 75) or surgical GJ (n = 32) at our institution were reviewed.

RESULTS

The technical (100% vs. 100%; P > 0.999) and clinical (98.7% vs. 96.9%; P = 0.511) success rates were similar between the SEMS and GJ group. The mean gastric outlet obstruction scoring system score was higher in the SEMS group at 1 week after treatment (2.3 ± 0.5 vs. 1.2 ± 0.4; P < 0.001) but was similar between the two groups at 1 month (2.7 ± 0.5 vs. 2.8 ± 0.5; P = 0.242). The median hospital stay was shorter in the SEMS group than in the GJ group (7 vs. 14 days; P < 0.001). The overall complication (22.7% vs. 28.1%; P = 0.547) and reintervention (21.3% vs. 25.0%; P = 0.677) rates were similar between the two groups. The median patency (99 vs. 138 days; P = 0.102) and survival (106 vs. 140 days; P = 0.245) were also similar between the two groups.

CONCLUSION

The outcomes of partially covered SEMS placement seem to be more favorable than surgical GJ in patients with gastroduodenal obstruction caused by pancreatic cancer.

Temporary duodenal stenting as a bridge to ERCP for inaccessible papilla due to duodenal obstruction: a retrospective study

BACKGROUND AND STUDY AIMS

Duodenal obstruction may prevent performance of endoscopic retrograde cholangiopancreatography (ERCP). Percutaneous transhepatic biliary drainage (PTBD) or Endoscopic ultrasonograhy-guided biliary access (EUS-BD) are alternative treatments but are associated with a higher morbidity and mortality rate. The aim of the study is to report overall technical success rate and clinical outcome with deployment of temporary fully or partially covered self-expanding duodenal stent (pc/fcSEMS) as a bridge to ERCP in case of inaccessible papilla due to duodenal strictures.

PATIENTS AND METHODS

This retrospective study included 66 consecutive patients presenting with a duodenal stricture impeding the ability to perform an ERCP. Provisional duodenal stenting was performed as a bridge to ERCP. A second endoscopic session was performed to remove the provisional stent and to perform an ERCP. Afterward, a permanent duodenal stent was delivered if necessary.

RESULTS

Sixty-six duodenal stents (17 pcSEMS and 49 fcSEMS) were delivered with a median indwelling time of 3.15 (1 - 7) days. Two migrations occurred in the pcSEMS group, 1 of which required lower endoscopy for retrieval. No other procedure-related complications were observed. At second endoscopy a successful ERCP was performed in 56 patients (85 %); 10 patients (15 %) with endoscopic failure underwent PTBD or EUS-BD. Forty patients needed permanent duodenal stenting.

CONCLUSIONS

Provisional removable covered duodenal stenting as a bridge to ERCP for duodenal obstruction is safe procedure and in most cases allows successful performance of therapeutic ERCP. This technique could be a sound option as a step up approach before referring such cases for more complex techniques such as EUS-BD or PTBD.

Temporary placement of a covered duodenal stent can avoid riskier anterograde biliary drainage when ERCP for obstructive jaundice fails due to duodenal invasion

BACKGROUND

Duodenal stenosis is one of the most common causes of failed ERCP for obstructive jaundice. Alternative approaches include anterograde biliary drainage, with higher morbidity. We report in this study the efficacy and safety of temporary placement of a covered duodenal self-expandable metal stent (cSEMS) in order to access the papilla and achieve secondary retrograde biliary drainage in patients with obstructive jaundice and failed ERCP due to concomitant duodenal stenosis.

METHODS

From June 2006 to March 2014, a total of 26 consecutive patients presenting obstructive jaundice without severe sepsis with failed ERCP due to duodenal invasion were enrolled. A temporary 7-day duodenal cSEMS was placed during the failed ERCP, and a second ERCP was attempted at day 7 after duodenal stent removal.

RESULTS

Duodenal cSEMS placement and retrieval were technically successful in all cases. Access to the papilla at day 7 was possible in 25 cases (96 %, 95 % CI 80-99 %). Secondary successful ERCP was achieved in 19 cases (76 %, 95 % CI 55-91 %, i.e., 73 %, 95 % CI 73-86 %, in an intention-to-treat analysis). Mean bilirubin level was 102 ± 90 µmol/L at baseline rising to 164 ± 121 µmol/L at day 7. There were 6 stent migrations and no adverse events recorded between the two ERCPs.

CONCLUSIONS

When ERCP for obstructive jaundice fails due to duodenal invasion, temporary cSEMS placement offers a safe and effective way to achieve successful secondary ERCP while avoiding riskier endoscopic ultrasound or percutaneous transhepatic anterograde biliary drainage.