Endoscopic bilateral metal stent placement for malignant hilar stenoses: identification of optimal technique

Comparison of the hybrid and partial stent-in-stent method for endoscopic three-segment drainage for unresectable malignant hilar biliary obstruction

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.

Comparison of Bilateral and Trisegment Drainage in Patients with High-Grade Hilar Malignant Biliary Obstruction: A Multicenter Retrospective Study

Background/Aims

Bilateral endoscopic drainage with self-expanding metallic stent (SEMS) can be used to effectively manage hilar malignant biliary obstruction. However, the benefits of using a trisegment drainage method remain unknown.

Methods

This study retrospectively reviewed the data of 125 patients with Bismuth type IIIa or IV unresectable malignant strictures who underwent bilateral endoscopic drainage using SEMSs at four tertiary centers. The patients were divided into the bilateral and trisegment drainage groups for comparison. The primary endpoint was stent patency and the secondary endpoints were technical success, technical and clinical success of reintervention, and overall survival.

Results

The technical success rates of the bilateral and trisegment drainage groups were 95% (34/36) and 90% (80/89) (p=0.41), respectively, with median stent patency durations of 226 and 170 days (p=0.26), respectively. Although the technical success of reintervention was not significantly different between the two groups (p=0.51), the clinical success rate of reintrvention was significantly higher in the trisegment drainage group (73% [11/15] vs 96% [47/49], p=0.009). The median survival times were 324 and 323 days in the bilateral and trisegment drainage groups, respectively (p=0.72). Multivariate Cox hazards model revealed no stent patency-associated factor; however, chemotherapy was associated with longer survival.

Conclusions

Although no significant difference was noted with respect to stent patency, significantly higher clinical success rates were achieved with reintervention using the trisegment drainage method than using the bilateral drainage method alone.

Current endoscopic approaches to biliary strictures

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.

Role of ERCP in Malignant Hilar Biliary Obstruction

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.

Recent advances regarding endoscopic biliary drainage for unresectable malignant hilar biliary obstruction

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.

Endoscopic Bilateral Stent-in-Stent Versus Stent-by-Stent Deployment in Advanced Malignant Hilar Obstruction: A Meta-Analysis and Systematic Review

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.

[A Recent Update on Endoscopic Drainage of Advanced Malignant Hilar Obstruction]

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.

Comparison of endoscopic bilateral metal stent drainage with plastic stents in the palliation of unresectable hilar biliary malignant strictures: Large multicenter study

BACKGROUND

Endoscopic stenting to manage malignant hilar biliary obstruction has no consensus regarding the optimal stenting strategy. In this multicenter study, we compared transpapillary parallel-style bilateral metal stenting with bilateral plastic stenting, and evaluated short- and long-term outcomes.

METHODS

We recruited 262 consecutive patients (Bismuth classification types II-IV) who underwent either bilateral metal or plastic stenting as primary therapy at four tertiary centers. To overcome selection bias, we performed 1:1 propensity score matching. Our primary outcome was overall survival.

RESULTS

After propensity score matching, each group comprised 96 patients, with no significant differences in any baseline characteristics. The median survival was significantly longer in the metal stenting group than in the plastic stenting group (7.2 months [95% CI 6.0-8.5] vs. 4.1 months [95% CI 2.9-5.3]; P = 0.015). The clinical success rates were significantly higher in the metal stenting group than in the plastic stenting group (99.0% vs. 71.9%, respectively; P < 0.001), and lower post-procedure cholangitis incidence (7.3% vs. 26.0%; P < 0.001), longer median symptom-free stent patency (9.2 months [95% CI 7.6-10.6] vs. 4.8 months [95% CI 4.2-5.3]; P < 0.001), and fewer total interventions (1.3 ± 0.6 vs. 2.0 ± 1.4; P < 0.001). In multivariate Cox analysis of the overall survival, metal stenting (HR 0.589, P = 0.002), hilar cholangiocarcinoma (HR 0.419, P = 0.009), and adjuvant treatment (HR 0.596, P = 0.006) were independent predictors of death.

CONCLUSIONS

Endoscopic therapy using bilateral metal stenting is superior to bilateral plastic stenting, with prolonged overall survival, higher clinical success, and longer stent patency in patients with advanced hilar biliary malignancies.

Unilateral versus bilateral endoscopic stenting in patients with unresectable malignant hilar obstruction: a systematic review and meta-analysis

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.

Biliary stenting for hilar malignant biliary obstruction

Although endoscopic intervention is the mainstay for palliation of malignant biliary obstruction, a percutaneous approach has been preferred, particularly in patients with advanced high-grade hilar malignant biliary obstruction, because of the technical difficulty and risk of complications. However, recently, primary endoscopic palliation using plastic or metal stents has had higher technical and clinical success with fewer adverse events than the percutaneous approach. Endoscopic interventions are being done more and more frequently because of advances in metal stents, accessories, and techniques. However, several concerns, such as optimal stent type, number, and deployment method, remain to be resolved. Therefore, we reviewed the literature in order to identify the optimal biliary stenting strategy for patients with hilar malignant biliary obstruction, focusing on stent type (plastic vs metal), number (unilateral [single] vs bilateral [multiple]), and deployment method (stent-in-stent vs stent-by-stent).

Evaluation of endoscopic reintervention for self-expandable metallic stent obstruction after stent-in-stent placement for malignant hilar biliary obstruction

BACKGROUND

Bilateral self-expandable metallic stent (SEMS) placement is effective for long-term management of unresectable malignant hilar biliary obstruction (UMHBO). However, endoscopic reintervention (ERI) for bilateral SEMSs is not well-studied. This study aimed to evaluate ERI efficacy after stent-in-stent placement.

METHODS

Data of 31 patients who underwent ERI from May 2000 to July 2018 were analyzed.

RESULTS

The technical success rate was 80.7% (25/31) and no adverse events occurred. The functional success rate was 100% (25/25). In a multivariate logistic regression analysis, the angle between the bilateral SEMSs (ABBS) >104° (odds ratio 50.49, 95% CI 3.370-2131, P = 0.0039) and overgrowth (odds ratio 25.70, 95% CI 1.121-1234, P = 0.0423) were risk factors for ERI failure. Multiple liver metastases, which sometimes cause overgrowth, were also risk factors. After ERI, some patients underwent additional SEMS (n = 4), plastic stent (n = 14) placement, or internal cleaning of the initial SEMS alone (n = 7). There were no significant intergroup differences in the 50% time to recurrent biliary obstruction.

CONCLUSIONS

ABBS >104° and overgrowth were risk factors for ERI failure after stent-in-stent placement. In the decision-making process for initial SEMS placement for UMHBO, patient condition should be considered, including the angle between bilateral bile ducts and multiple liver metastases.

Endoscopic side-by-side uncovered self-expandable metal stent placement for malignant hilar biliary obstruction

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.

Side-by-side partially covered self-expandable metal stent placement for malignant hilar biliary obstruction

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.

Endoscopic biliary stenting for unresectable malignant hilar obstruction

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).

Rescue EUS-guided intrahepatic biliary drainage for malignant hilar biliary stricture after failed transpapillary re-intervention

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.

Percutaneous biliary approach as a successful rescue procedure after failed endoscopic therapy for drainage in advanced hilar tumors

BACKGROUND AND AIM

Palliative endoscopic or percutaneous biliary drainage is used for unresectable advanced hilar cancer (HC). The best option for drainage in Bismuth type III or IV HC has not been established. The aims of this study are to identify factors predictive of endoscopic stenting failure and evaluate the effectiveness of rescue percutaneous stenting in patients with advanced HC.

METHODS

Data from 110 patients with inoperable advanced HC were retrospectively reviewed. All received bilateral self-expandable metallic stents. Patients were divided into three groups: I, successful initial endoscopic stenting; II, unsuccessful initial endoscopic stenting, followed by percutaneous stenting; and III, initial percutaneous stenting. We analyzed clinical results and radiologic tumor characteristics.

RESULTS

Baseline characteristics and clinical outcomes of all groups were similar, except the hospital stay was longer in group III than group I. Technical success rate was higher in groups II and III (100%) than in group I (72.4%). The functional success rate, stent patency time, patient survival time, and complication rate were similar between groups. Endoscopic stenting failed because of guide-wire passage failure (n = 12) or stent passage failure (n = 7). The only factor significantly associated with endoscopic failure was a smaller left intrahepatic duct-common bile duct angle.

CONCLUSIONS

As clinical outcomes were generally similar between approaches, percutaneous stenting is recommended for patients with Bismuth type III or IV advanced HC. Acute left intrahepatic duct-common bile duct angulation predicts endoscopic stenting failure. If endoscopic stenting fails, immediate conversion to the percutaneous approach is a necessary and effective rescue method.

Clinical utility of endoscopic ultrasound-guided biliary drainage as a rescue of re-intervention procedure for high-grade hilar stricture

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.

Serial insertion of bilateral uncovered metal stents for malignant hilar obstruction using an 8 Fr biliary system: a case series of 17 consecutive patients

Controversy exists over the need for unilateral versus bilateral stent placement in patients with malignant obstruction at the biliary hilum. Placement of bilateral uncovered self-expanding metal stent (UCSEMS) at this location is technically challenging, and generally associated with lower rates of procedural success. Serial insertion of side-by-side UCSEMS may be especially difficult when simultaneous deployment is not possible using larger stent delivery catheters. In this single-center, retrospective case series of all patients who underwent bilateral placement of uncovered Wallflex(TM) biliary stents between July 2008 and July 2014, we evaluate the feasibility, technical success, and safety of patients undergoing serial insertion of bilateral UCSEMS using the 8 Fr Wallflex(TM) biliary system for malignant hilar obstruction. A total of 17 patients were included. Primary cholangiocarcinoma, Bismuth IV, was the most common diagnosis. Mean procedure time was 54.4 minutes. Overall procedural technical success was achieved in 17/17 patients. Stricture dilation was necessary prior to Wallflex(TM) insertion in 8/17 patients (47.1%). Transpapillary extension of two stents was performed in all patients. There were no cases of stent deployment malfunction, or inability to insert or deploy the 2(nd) stent. Nine of 17 patients (52.9%) required inpatient hospitalization following ERCP; the most common indications were abdominal pain and need for IV antibiotics. There was one case of ERCP-related cholangitis otherwise; there were no other major complications. Bilateral, serial insertion of UCSEMS using the 8 Fr Wallflex(TM) biliary system in malignant hilar obstruction is feasible with an excellent technical success profile. Using this device for side-by-side deployment of UCSEMS appears to be safe in the majority of patients.

Small cell- versus large cell-sized metal stent in endoscopic bilateral stent-in-stent placement for malignant hilar biliary obstruction

BACKGROUND AND AIM

Although the large cell-sized biliary stent facilitates contralateral stent deployment through the mesh of the first metallic stent for stent-in-stent (SIS) technique, there are concerns about its vulnerability to tumor ingrowth. The aim of the present study was to compare the clinical outcomes of endoscopic bilateral SIS placement according to the cell size of a self-expandable metallic stent (SEMS).

METHODS

A total of 58 patients were enrolled who underwent endoscopic bilateral SIS placement of SEMS for malignant hilar biliary obstruction as a result of cholangiocarcinoma or gallbladder cancer. Finally, 43 patients who underwent successful stent insertion were included in the analysis and divided into the small cell-sized stent (SCS; n = 21) and the large cell-sized stent (LCS; n = 22) groups. We retrospectively compared comprehensive clinical and laboratory data in both groups.

RESULTS

There were no significant differences between the two groups in successful drainage (SCS vs LCS, 100% vs 100%, respectively), early complications (38.1% vs 18.2%), late complications (14.3% vs 22.7%), stent occlusion (42.9% vs 45.5%), tumor ingrowth (33.3% vs 45.5%) or overgrowth (9.5% vs 0%). Duration of stent patency and overall survival were not significantly different between the two groups (P = 0.086 and P = 0.320, respectively).

CONCLUSIONS

Endoscopic bilateral SIS placement for malignant hilar biliary obstruction shows no differences in stent patency, survival, complications and clinical course according to the cell size of SEMS.

Endoscopic treatment of malignant biliary strictures

Endoscopic stenting is a widely accepted strategy for providing effective drainage in both extrahepatic and intrahepatic malignant strictures. In patients with extrahepatic malignancies, uncovered self-expanding metal stents (SEMS) provide excellent palliation. Hilar malignancies are probably best palliated by placement of uncovered SEMS although some disagreement exists among experts regarding the type and number of stents for optimal palliation. Preoperative biliary drainage (PBD) is commonly performed although a higher risk of complications and the lack of clear benefit raise questions about this practice. Certain groups of patients such as those with markedly elevated bilirubin levels, and in those in whom neoadjuvant therapy is planned, are good candidates for PBD. Considerable controversy exists regarding the optimal method as well as type of stent for PBD in patients with hilar malignancies. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have emerged as potential adjuvant therapies in the management of malignant bile duct strictures but need further long-term evaluation to establish survival benefit. This review focuses on the current status of endoscopic therapies for malignant biliary obstructions.

Topic controversies in the endoscopic management of malignant hilar strictures using metal stent: side-by-side versus stent-in-stent techniques

Endoscopic management of unresectable hilar malignant biliary stricture (MBS) is currently challenging, and the best approach is still controversial. Liver volume is the key to adequate biliary drainage in hilar MBS and multiple stenting is mandatory to drain over 50% of liver volume in most cases. The self-expandable metallic stent (SEMS) has shown superior patency to plastic stents in recent reports. There are two methods of multiple stenting for hilar MBS: stent-in-stent (SIS) and side-by-side (SBS). Advantages of SIS include multiple SEMS placement in one stent caliber at the common bile duct (CBD), which is considered physiologically ideal. The through-the-mesh (TTM) technique with guidewires and the SEMS delivery system can be technically difficult in SIS, although the recent development of dedicated SEMSs having a loose portion facilitating the TTM technique makes SIS technically feasible both at stent deployment and re-interventions. Conversely, the SBS technique, if placed across the papilla, is technically simple at initial placement and re-intervention at stent occlusion. However, SBS has potential disadvantages of overexpansion of the CBD because of parallel placement of multiple SEMS, which can lead to portal vein thrombosis. Given the limited evidence available, a well-designed randomized controlled trial comparing these two techniques is warranted.

Update on Pancreatobiliary Stents: Stent Placement in Advanced Hilar Tumors

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.

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

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.

8-mm versus 10-mm diameter self-expandable metallic stent in bilateral endoscopic stent-in-stent deployment for malignant hilar biliary obstruction

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.

Risk factors for technical failure of endoscopic double self-expandable metallic stent placement by partial stent-in-stent method

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.

Bilateral metallic stenting in malignant hilar obstruction

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.

Y-shaped bilateral self-expandable metallic stent placement for malignant hilar biliary obstruction: data from a referral center for palliative care

Background and Aim. Malignant hilar strictures are a clinical challenge because of the current therapeutic approach and the poor prognosis. In recent years, self-expandable metallic stents have proven more effective than plastic stents for palliation of malignant hilar strictures, with the bilateral stent-in-stent technique registering a high success rate. We report our experience with Y-shaped endoscopic self-expandable metallic stents placement for treatment of advanced malignant hilar strictures. Methods. From April 2009 to August 2012, we prospectively collected data on patients treated with Y-shaped SEMS placement for advanced malignant hilar carcinoma. Data on technical success, clinical success, and complications were collected. Results. Twenty patients (9 males) were treated (mean age 64.2 ± 15.3 years). The grade of malignant hilar strictures according to the Bismuth classification was II in 5 patients (25%), IIIa in 1 (5%), and IV in 14 (70%). The mean bilirubin level was 14.7 ± 4.9 mg/dL. Technical success was achieved in all patients, with a significant reduction in bilirubin levels (2.9 ± 1.7 mg/dL). One patient experienced cholangitis as early complication, while in 2 patients stent ingrowth was observed. No stents migration was recorded. There was no procedure-related mortality. At the end of the follow-up (7.1 ± 3.1 months), 13 of the 20 patients (65%) had died. Conclusions. Our experience confirms endoscopic bilateral self-expandable metallic stents placement with stent-in-stent technique (Y-shaped configuration) as a feasible, effective, and safe procedure for palliation of unresectable malignant hilar strictures.

High single-session success rate of endoscopic bilateral stent-in-stent placement with modified large cell Niti-S stents for malignant hilar biliary obstruction

BACKGROUND

Endoscopic bilateral self-expandable metallic stent (SEMS) placement in a stent-in-stent method for malignant hilar biliary obstruction is technically challenging. Technical difficulties in the initial placement and reinterventions for stent occlusion are disadvantages inherent to this stent-in-stent method. We previously reported the feasibility of Niti-S large cell D-type biliary stents (LCD). This multicenter prospective consecutive study evaluated the efficacy of bilateral SEMS placement using modified LCD with large and uniform cells, a slimmer delivery system and high radial force.

PATIENTS AND METHODS

From July 2010 to June 2011, 26 consecutive patients with unresectable malignant hilar biliary obstruction underwent endoscopic bilateral placement of modified LCD in a stent-in-stent method at three tertiary hospitals. Ten patients had gallbladder cancer, eight had cholangiocarcinoma, four had lymph node metastasis, two had intrahepatic cholangiocarcinoma, and two had liver metastasis.

RESULTS

Single-session and final technical success rate was 96% and 100%, respectively. Functional success rate was 89%. Stent occlusion occurred in 11 patients (42%) because of sludge (n = 7) or tumor ingrowth (n = 4). Endoscopic bilateral reintervention was technically easy and successful: six patients had stent clearance by balloon sweeping and five had plastic stent placement. According to Kaplan-Meier analysis, median survival and stent patency were 220 days and 157 days, respectively.

CONCLUSIONS

Modified LCD achieved a high technical success rate both in the initial stent-in-stent placement and in bilateral reinterventions in patients with malignant hilar biliary obstruction.

Bilateral and unilateral stenting for malignant hilar obstruction: a systematic review and meta-analysis

BACKGROUND

Stents are used for palliating inoperable malignant bile duct hilar obstruction. It is not clear if bilateral stenting provides any advantage over unilateral stenting in these patients. Compare bilateral and unilateral stenting in malignant hilar obstruction.

STUDY SELECTION CRITERIA

Studies using stents for palliation in patients with malignant hilar obstruction were selected.

DATA COLLECTION AND EXTRACTION

Articles were searched in MEDLINE, PubMed, Ovid journals, CINAH, International Pharmaceutical Abstracts, OLDMEDLINE, MEDLINE nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Two reviewers independently searched and extracted data. Any differences were resolved by mutual agreement.

STATISTICAL METHODS

Pooled proportions were calculated using both the Mantel-Haenszel method (fixed effects model) and DerSimonian-Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights. The initial search identified 1,640 reference articles, of which 169 were selected and reviewed. Thirteen studies (n = 340) for bilateral metallic stents, eight studies (n = 575) for unilateral metallic stents, eight studies (n = 367) for bilateral plastic stenting, and seven studies (n = 850) for unilateral plastic stenting which met the inclusion criteria were included in this analysis. Pooled data are shown in Tables 1 and 2. The pooled estimates by the fixed and random effect models were similar. The p for chi-squared heterogeneity for all the pooled accuracy estimates was >0.10. Bilateral metal stenting seems to have lower odds of overall complications when compared to unilateral metallic stenting. Bilateral metal stents seem to have higher odds of lowering bilirubin than unilateral metal stents, but the 30-day mortality was no different. For metal stents, bilateral metal stents are superior in palliating symptoms due to hyperbilirubinemia. Unilateral plastic stenting seems to have similar odds of overall complications, cholangitis, and 30-day mortality when compared to bilateral plastic stenting for malignant hilar strictures. In patients with malignant hilar stricture, unilateral plastic stenting is comparable to bilateral plastic stenting for adverse events.

Bilateral metal stents for hilar biliary obstruction using a 6Fr delivery system: outcomes following bilateral and side-by-side stent deployment

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.

Stage of hilar cholangiocarcinoma predicts recurrence of biliary obstruction in patients with metal stents

BACKGROUND & AIMS

Most patients with hilar cholangiocarcinomas present with unresectable tumors, so only palliative biliary drainage with self-expanding metal stents (SEMS) is possible. Stents eventually cease to function because of tumor overgrowth and/or other causes, so it is important to identify factors that affect stent patency and failure. We examined the patency of endoscopically placed SEMS in patients with hilar cholangiocarcinoma and factors associated with patency.

METHODS

We performed a retrospective study of 120 consecutive patients (mean age, 67 ± 14.6 years; 74 male) who presented with obstructive jaundice from hilar cholangiocarcinoma and underwent bilateral SEMS from September 2006 through April 2012 at 2 US tertiary medical centers. We collected data on patient demographics and survival, success of stent placement and function, and immediate adverse events. The primary outcome was duration of stent patency (time from insertion to failure).

RESULTS

Thirty-eight patients had stage 1 hilar cholangiocarcinomas, 45 had stage 2, 12 had stage 3, and 25 had stage 4. The median length of the hilar stricture was 9 mm (range, 8-50 mm). The stent was successfully passaged across the stricture in all patients and was functional in 115; its median length was 8 mm (range, 8-10 mm), and diameter was 80 mm (range, 60-100 mm). Fourteen patients had immediate adverse events, including perforation (n = 2), bleeding (n = 2), pancreatitis (n = 9), and cholangitis (n = 1). Median survival was 17 weeks (range, 1-211 weeks), and 50 patients had stent occlusion. On Kaplan-Meier analysis, the median time from stent placement to occlusion was 17 weeks (range, 1-104 weeks). More patients with stage 3 or 4 tumors (64%) had SEMS occlusion than patients with stage 1 or 2 tumors (28%) in univariate analysis (P = .017). In multivariate analysis, only cancer stage was independently and significantly associated with patency (P = .006; hazard ratio, 2.77); age, sex, length of stricture, and SEMS diameter and length were not.

CONCLUSIONS

The cumulative patency of bilateral SEMS for hilar cholangiocarcinoma significantly decreases as tumor stage increases. Age, sex, length of stricture, and SEMS diameter and length are not associated with SEMS patency.

Endobiliary radiofrequency ablation for malignant biliary obstruction

BACKGROUND

The cornerstone of palliative treatment for inoperable extrahepatic cholangiocarcinoma is the relief of malignant biliary obstruction. The most commonly applied method is endoscopic stenting. However, the procedure can be complicated with stent obstruction. In this respect, endobiliary radiofrequency ablation may serve as an adjunctive tool for prolonging the stent patency.

METHODS

Patients who underwent endoscopic retrograde cholangiopancreatography for differential diagnosis and/or palliative treatment after the diagnosis of inoperable extrahepatic cholangiocarcinoma between March 2011 and January 2012 were analyzed. Those in whom endobiliary radiofrequency ablation and endoscopic stenting was successfully performed were included in the study. Technical details of the procedure, duration of stent patency, length of hospital stay, short-term morbidity and mortality rate were documented.

RESULTS

Seventeen patients were analyzed, and 10 patients were included in the study. The morbidity and mortality rate within the first 30 days after the procedure was 20% and 0%, respectively. In 2 patients, mild pancreatitis occurred because of the endobiliary procedure. In 1 patient, endobiliary decompression could not be achieved, and therefore, percutaneous transhepatic biliary drainage was carried out. The median duration of stent patency in 9 patients with successful biliary decompression was 9 months (range 6-15).

CONCLUSION

Endobiliary radiofrequency ablation seems to be safe and feasible as a palliative measure and may prolong the stent patency and overall survival in patients with malignant biliary obstruction due to inoperable extrahepatic cholangiocarcinoma.

Technical tips and issues of biliary stenting, focusing on malignant hilar obstruction

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.

Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma

Hilar cholangiocarcinoma (HCCA) is one of the most common types of hepatobiliary cancers reported in the world including Asia-Pacific region. Early HCCA may be completely asymptomatic. When significant hilar obstruction develops, the patient presents with jaundice, pale stools, dark urine, pruritus, abdominal pain, and sometimes fever. Because no single test can establish the definite diagnosis then, a combination of many investigations such as tumor markers, tissue acquisition, computed tomography scan, magnetic resonance imaging/magnetic resonance cholangiopancreatography, endoscopic ultrasonography/intraductal ultrasonography, and advanced cholangioscopy is required. Surgery is the only curative treatment. Unfortunately, the majority of HCCA has a poor prognosis due to their advanced stage on presentation. Although there is no survival advantage, inoperable HCCA managed by palliative drainage may benefit from symptomatic improvement. Currently, there are three techniques of biliary drainage which include endoscopic, percutaneous, and surgical approaches. For nonsurgical approaches, stent is the most preferred device and there are two types of stents i.e. plastic and metal. Type of stent and number of stent for HCCA biliary drainage are subjected to debate because the decision is made under many grounds i.e. volume of liver drainage, life expectancy, expertise of the facility, etc. Recently, radio-frequency ablation and photodynamic therapy are promising techniques that may extend drainage patency. Through a review in the literature and regional data, the Asia-Pacific Working Group for hepatobiliary cancers has developed statements to assist clinicians in diagnosing and managing of HCCA. After voting anonymously using modified Delphi method, all final statements were determined for the level of evidence quality and strength of recommendation.

Threaded biliary inside stents are a safe and effective therapeutic option in cases of malignant hilar obstruction

BACKGROUND

Although endoscopic biliary stents have been accepted as part of palliative therapy for cases of malignant hilar obstruction, the optimal endoscopic management regime remains controversial. In this study, we evaluated the safety and efficacy of placing a threaded stent above the sphincter of Oddi (threaded inside plastic stents, threaded PS) and compared the results with those of other stent types.

METHODS

Patients with malignant hilar obstruction, including those requiring biliary drainage for stent occlusion, were selected. Patients received either one of the following endoscopic indwelling stents: threaded PS, conventional plastic stents (conventional PS), or metallic stents (MS). Duration of stent patency and the incident of complication were compared in these patients.

RESULTS

Forty-two patients underwent placement of endoscopic indwelling stents (threaded PS = 12, conventional PS = 17, MS = 13). The median duration of threaded PS patency was significantly longer than that of conventional PS patency (142 vs. 32 days; P = 0.04, logrank test). The median duration of threaded PS and MS patency was not significantly different (142 vs. 150 days, P = 0.83). Stent migration did not occur in any group. Among patients who underwent threaded PS placement as a salvage therapy after MS obstruction due to tumor ingrowth, the median duration of MS patency was significantly shorter than that of threaded PS patency (123 vs. 240 days).

CONCLUSIONS

Threaded PS are safe and effective in cases of malignant hilar obstruction; moreover, it is a suitable therapeutic option not only for initial drainage but also for salvage therapy.

Technical feasibility and revision efficacy of the sequential deployment of endoscopic bilateral side-by-side metal stents for malignant hilar biliary strictures: a multicenter prospective study

BACKGROUND

Theoretically, the side-by-side bilateral placement of metal stents may be technically easier than stent-in-stent bilateral placement in stent revision. However, side-by-side placement can be technically challenging, as the deployment of the first stent can preclude the passage of the second stent.

AIM

We explored the technical feasibility and revision efficacy of endoscopic bilateral side-by-side stent placement for malignant hilar biliary strictures.

METHODS

Forty-four patients with Bismuth type II or higher malignant hilar biliary strictures were enrolled in seven academic tertiary referral centers. Endoscopic placement of side-by-side bilateral metal stents with 7F thin delivery shaft was performed. The outcome measurements were the technical and functional success, adverse events, endoscopic revision success rate, and stent patency.

RESULTS

Overall, the technical and functional success rates were 91 % (40/44), and 98 % (39/40), respectively. Two of the failed patients were converted successfully with subsequent contralateral stent-in-stent placement, and the other patients underwent percutaneous intervention. Early stent-related adverse events occurred in 10 %. The endoscopic revision rate due to stent malfunction during follow-up (median: 180 days) was 45 % (18/40; tumor ingrowth in 4 and in-stent sludge impaction/stone formation in 14 patients). The endoscopic revision success rate was 92 % (12/13). Five patients with comorbidity underwent initial percutaneous intervention. The median survival and stent patency periods were 180 and 157 days, respectively.

CONCLUSIONS

The sequential placement of a metal stent with a 7F thin delivery shaft in bilateral side-by-side procedures may be feasible and effective for malignant hilar biliary strictures and for endoscopic stent revision.

Endoscopic drainage in patients with inoperable hilar cholangiocarcinoma

Hilar cholangiocarcinoma has an extremely poor prognosis and is usually diagnosed at an advanced stage. Palliative management plays an important role in the treatment of patients with inoperable hilar cholangiocarcinoma. Surgical, percutaneous, and endoscopic biliary drainage are three modalities available to resolve obstructive jaundice. Plastic stents were widely used in the past; however, self-expanding metal stents (SEMS) have become popular recently due to their long patency and reduced risk of side branch obstruction, and SEMS are now the accepted treatment of choice for hilar cholangiocarcinoma. Bilateral drainage provides more normal and physiological biliary flow through the biliary ductal system than that of unilateral drainage. Unilateral drainage was preferred until recently because of its technical simplicity. But, with advancements in technology, bilateral drainage now achieves a high success rate and is the preferred treatment modality in many centers. However, the choice of unilateral or bilateral drainage is still controversial, and more studies are needed. This review focuses on the endoscopic method and discusses stent materials and types of procedures for patients with a hilar cholangiocarcinoma.

Bilateral biliary drainage for malignant hilar obstruction using the 'stent-in-stent' method with a Y-stent: efficacy and complications

BACKGROUND

The usefulness of bilateral stent placement for malignant hilar obstruction is still under debate. Nevertheless, many endoscopists advocate the placement of an endoscopic bilateral metal stent using various new devices and techniques.

OBJECTIVES

We compared the technical and clinical efficacy, and the short-term and long-term complications of the 'stent-in-stent' method using a Y-stent for malignant hilar obstruction between the early and the late period of this study.

MATERIALS AND METHODS

Ninety-seven patients treated with Y-stent implantation for malignant hilar obstruction were enrolled retrospectively. In 31 patients treated during the early period, bilateral Y-configured metal stents were placed for malignant hilar obstruction using the older designed Y-stent and a closed-cell second stent. The newly designed Y-stent and a slimmer open-cell second stent were introduced in 66 patients treated during the late period. New techniques learned through experience were gradually applied throughout the entire study period.

RESULTS

The rate of successful placement of bilateral stents was significantly higher in patients treated during the late period than those treated during the early period (58.1 vs. 87%; P=0.001). The functional success rate was 97.3%, with no difference between the early and the late periods. Cholangitis occurred as an early complication more frequently during the early period than during the late period (16.1 vs. 1.5%; P=0.012). Cholecystitis as a late complication occurred in 21 of 76 patients (27.6%). The incidence of late complications was similar between the early and the late periods.

CONCLUSION

With the development of new devices and increased technical experience, there were better outcomes during the late period compared with the early period. Endoscopic bilateral metal stenting using a Y-stent is an attractive option for the palliative treatment of malignant hilar obstruction.

Side-by-side versus stent-in-stent deployment in bilateral endoscopic metal stenting for malignant hilar biliary obstruction

BACKGROUND

The clinical differences between side-by-side and stent-in-stent deployment using a self-expanding metal stent for hilar malignant obstruction have not been evaluated.

AIMS

The purpose of this study was to compare the clinical features between side-by-side and stent-in-stent deployment.

METHODS

We compared side-by-side and stent-in-stent deployment in 52 consecutive patients with malignant hilar biliary obstruction who underwent endoscopic bilateral drainage using self-expanding metal stent. Side-by-side deployment (SBS group) was performed in 28 patients from 2002 to 2005, and stent-in-stent deployment (SIS group) in 24 patients from 2006 to 2010. Technical success, functional success, complications, stent occlusion and cumulative stent patency in the SBS and SIS groups were evaluated and compared retrospectively.

RESULTS

There were no significant inter-group differences in technical success (SBS vs. SIS, 89 vs. 100 %, respectively), functional success (96 vs. 100 %), early complications (11 vs. 4 %), late complications (32 vs. 8 %) or stent occlusion (20 vs. 42 %). The incidence of complications was significantly higher for SBS than for SIS (44 vs. 13 %; p = 0.016). Cumulative stent patency was significantly better for SBS than for SIS (log-rank, p = 0.047). SBS was not associated with significantly longer cumulative stent patency in univariate Cox proportional hazard analysis (HR 0.35; 95 % CI 0.12-1.03; p = 0.056) and multivariate analysis (HR 0.39; 95 % CI 0.13-1.16; p = 0.090).

CONCLUSIONS

The incidence of complications is higher for side-by-side than stent-in stent deployment in bilateral metal stenting. In terms of cumulative stent patency, side-by-side deployment tends to be more effective than stent-in-stent deployment.

Percutaneous biliary drainage using open cell stents for malignant biliary hilar obstruction

Objective

To evaluate the feasibility, safety and the effectiveness of the complex assembly of open cell nitinol stents for biliary hilar malignancy.

Materials and Methods

During the 10 month period between January and October 2007, 26 consecutive patients with malignant biliary hilar obstruction underwent percutaneous insertion of open cell design nitinol stents. Four types of stent placement methods were used according to the patients' ductal anatomy of the hilum. We evaluated the technical feasibility of stent placement, complications, patient survival, and the duration of stent patency.

Results

Bilobar biliary stent placement was conducted in 26 patients with malignant biliary obstruction-T (n = 9), Y (n = 7), crisscross (n = 6) and multiple intersecting types (n = 4). Primary technical success was obtained in 24 of 26 (93%) patients. The crushing of the 1st stent during insertion of the 2nd stent occurred in two cases. Major complications occurred in 2 of 26 patients (7.7%). One case of active bleeding from hepatic segmental artery and one case of sepsis after procedure occurred. Clinical success was achieved in 21 of 24 (87.5%) patients, who were followed for a mean of 141.5 days (range 25-354 days). The mean primary stent patency period was 191.8 days and the mean patient survival period was 299 days.

Conclusion

Applying an open cell stent in the biliary system is feasible, and can be effective, especially in multiple intersecting stent insertions in the hepatic hilum.

Placement of metallic biliary endoprostheses in complex hilar tumours

PURPOSE

To assess the technical success, clinical success and complications after 1 month of percutaneous biliary drainage with the placement of several metallic endoprostheses in complex hilar liver tumours.

MATERIALS AND METHODS

This is a retrospective study, on a homogenous target population of 68 consecutive patients, who underwent multiple percutaneous biliary drainage for complex hilar tumour (Bismuth type II, III and IV) between August 1998 and August 2010. Patients benefiting from previous endoscopic drainage were excluded from the study. The clinical data, biological data, imaging and interventional radiology procedures were studied.

RESULTS

The rate of success of the technique was 98.5% and the clinical rate of success was 84% after 1 week and 93% after 1 month. The rate of minor and major complications was 25 and 13% respectively.

CONCLUSION

Multiple percutaneous biliary drainage in complex hilar tumour is a safe and effective first intention procedure.

Endoscopic stenting for hilar cholangiocarcinoma: efficacy of unilateral and bilateral placement of plastic and metal stents in a retrospective review of 480 patients

Background

Endoscopic biliary drainage of hilar cholangiocarcinoma is controversial with respect to the optimal types of stents and the extent of drainage. This study evaluated endoscopic palliation in patients with hilar cholangiocarcinoma using self-expandable metallic stents (SEMS) and plastic stents (PS).We also compared unilateral and bilateral stent placement according to the Bismuth classification.

Methods

Data on 480 patients receiving endoscopic biliary drainage for hilar cholangiocarcinoma between September 1995 and December 2010 were retrospectively reviewed to evaluate the following outcome parameters: technical success (TS), functional success (FS), early and late complications, stent patency and survival. Patients were followed from stent insertion until death or stent occlusion. Patients were divided into 3 groups according to the Bismuth classification (Group 1, type I; Group 2, type II; Group 3, type > III).

Results

The initial stent insertion was successful in 450 (93.8%) patients. TS was achieved in 204 (88.3%) patients treated with PS and in 246 (98.8%) patients palliated with SEMS (p < 0.001). In the intention-to-treat (ITT) analysis, the FS in patients treated with SEMS (97.9%) was significantly higher than in patients treated with PS (84.8%) (p < 0.001). Late complications occurred in 115 (56.4%) patients treated with PS and 60 (24.4%) patients treated with SEMS (p < 0.001). The median duration of stent patency in weeks (w) were as follows: 20 w in patients palliated with PS and 27 w in patients treated with SEMS (p < 0.0001). In Group 2, the median duration of PS patency was 17 w and 18 w for unilateral and bilateral placement, respectively (p = 0.0004); the median duration of SEMS patency was 24 w and 29 w for unilateral and bilateral placement, respectively (p < 0.0001). Multivariate analysis using the Poisson regression showed that SEMS placement (B = 0.48; P < 0.01) and bilateral deployment (B = 0.24; P < 0.01) were the only independent prognostic factors associated with stent patency.

Conclusions

SEMS insertion for the palliation of hilar cholangiocarcinoma offers higher technical and clinical success rates in the ITT analysis as well as lower complication rates and a superior cumulative stent patency when compared with PS placement in all Bismuth classifications. The cumulative patency of bilateral SEMS or PS stents was significantly higher than that of unilateral SEMS or PS stents, with lower occlusion rates in Bismuth II patients.

Metal stents for hilar lesions

Strictures at the hilum are caused by varied conditions and don't usually become symptomatic until obstructing the bile ducts, thus posing diagnostic and therapeutic challenges to physicians. ERCP is the method of choice for tissue diagnosis and decompression. MRCP or MRI with dedicated liver protocol provides a unique ability to visualize anatomy and promote procedure planning. In patients with unresectable tumor, endoscopic biliary stenting is a palliative approach. Percutaneous or EUS-guided approach is reserved for endoscopic failure. Various new modalities such as radiotherapy, chemotherapy and Photodynamic therapy have emerged but their superiority needs to be confirmed with Randomized Control studies.

Advancements in biliary stenting

Endoscopic therapy is essential in the management of malignant and benign biliary strictures. With new advancements in biliary stent technology and the many controversies surrounding biliary stenting, managing biliary strictures is not always straightforward. The purpose of this article is to review the major issues surrounding biliary stenting, summarize current treatment strategies, discuss advancements in stent technologies, and describe emerging indications of biliary stents.

Endoscopic management of hilar cholangiocarcinoma

Hilar cholangiocarcinoma has a poor prognosis and surgery remains the only curative option. However, few patients are diagnosed at a curable stage and palliative therapies are, therefore, mandatory. Endoscopy could have a useful role in the work-up of patients with hilar cholangiocarcinoma who are unsuitable for surgery. Endoscopic retrograde cholangiopancreatography provides an opportunity to collect specimens for cytological or histological diagnosis, yet is often nondiagnostic. Other techniques, including fluorescence in situ hybridization, confocal laser endomicroscopy and endoscopic ultrasonography, are now improving the accuracy of tissue diagnosis. This Review presents an overview of the diagnostic and therapeutic role of endoscopic procedures in the management of hilar cholangiocarcinoma. The use of such procedures in guiding the therapeutic management of patients with hilar cholangiocarcinoma is discussed, and the relative success of endoscopic stenting as the main palliative therapy for obstructive jaundice (a common complication of hilar cholangiocarcinoma) is described. The potential role of photodynamic therapy as a palliative treatment for patients with hilar cholangiocarcinoma is also outlined.

Endoscopic stent placement in the palliation of malignant biliary obstruction

Biliary drainage with biliary stent placement is the treatment of choice for palliation in patients with malignant biliary obstruction caused by unresectable neoplasms. In such patients, the endoscopic approach can be initially used with percutaneous radiological intervention. In patients with unresectable malignant distal bile duct obstructions, endoscopic biliary drainage with biliary stent placement has now become the main and least invasive palliative modality, which has been proven to be more effective in >80% of cases with lower morbidity than surgery, and perhaps may provide a survival benefit. In patients with unresectable malignant hilar obstruction, the endoscopic approach for biliary drainage with biliary stent placement has also been considered as the treatment of choice. There is still a lack of clear consensus on the use of covered versus uncovered metal stents in malignant distal bile duct obstructions and plastic versus metal stents and unilateral versus bilateral drainage in malignant hilar obstructions.

Endoscopic bilateral metallic stenting for malignant hilar obstruction using newly designed stents

BACKGROUND/PURPOSE

Whether unilateral or bilateral drainage should be performed for malignant hilar biliary obstruction is controversial. Moreover, endoscopic placement of bilateral metallic stents is difficult and complicated.

METHODS

New metallic stents, such as the Niti-S Y-type stent (Y-stent), BONASTENT M-Hilar, and Niti-S large cell D-type stent (LCD), have recently been developed for bilateral stent-in-stent procedures to facilitate contralateral stent deployment through the interstices of the first metallic stent. We review the features and efficacy of these metallic stents designed for bilateral drainage in patients with hilar biliary obstruction.

RESULTS

The newly designed stents examined exhibited high technical success rates, low stent-related complications, and good stent patency. Endoscopic reinterventions for occluded stents could be performed easily, particularly in patients with bilateral LCD placement.

CONCLUSION

Endoscopic bilateral stenting using newly designed metallic stents is feasible, safe, and effective in patients with unresectable malignant hilar biliary obstruction.