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Carr-Locke DL. ERCP: a very personal history. Clin Liver Dis (Hoboken) 2023; 22:211-218. [PMID: 38143813 PMCID: PMC10745235 DOI: 10.1097/cld.0000000000000028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/23/2023] [Indexed: 12/26/2023] Open
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Unmet needs in the diagnosis and treatment of Romanian patients with bilio-pancreatic tumors: results of a prospective observational multicentric study. ACTA ACUST UNITED AC 2021; 59:286-295. [PMID: 33657285 DOI: 10.2478/rjim-2021-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Indexed: 11/20/2022]
Abstract
Background. Biliopancreatic tumors (BPT) are among the most aggressive solid malignancies, and their incidence is rising. Good patient outcome relies heavily on a multidisciplinary approach to therapy, including timely access to endoscopy, surgery and chemo/radiotherapy. We aimed to evaluate current practices as reflected in the management and outcome of patients diagnosed with BPT in the setting of a low-resource medical system in order to identify areas suitable for improvement. Material and methods. We conducted a prospective observational study of patients with pancreatic cancers and extrahepatic cholangiocarcinomas evaluated in 4 referral centers in Romania. We collected data on the pathology of the tumors, staging at diagnosis, ECOG status, surgical interventions, chemo/radiotherapy and endoscopic drainage where applicable. A telephonic follow-up visit at 3 months after the enrollment visit collected additional data regarding evolution, subsequent treatment, performance status and disease-related events and outcomes. Results and conclusions. One hundred seventy-two patients were included in the study during a one-year period at the four participating centers. 72.1% were diagnosed with pancreatic cancer while 27.9% had extrahepatic cholangiocarcinoma. We identified several unmet needs in the current practices of treatment for these malignancies: a lack of pathological confirmation in 25.6% of the cases, a very low percentage of resectable lesions (only 18% of the patients operated with curative intent), and suboptimal choice of drainage in patients who required palliative drainage at their first endoscopic intervention. Significant effort is required to ensure standard-of-care treatment for patient with BPT in low-resource medical systems, including comprehensive auditing and protocol surveillance.
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Voigtländer T, Schweitzer N, von Hahn T, Manns MP, Vogel A, Kirstein MM. Endoscopic biliary drainage in patients with cholangiocarcinoma - self-expanding metal versus polyethylene stents. Scand J Gastroenterol 2019; 54:640-645. [PMID: 31122083 DOI: 10.1080/00365521.2019.1614661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Endoscopic biliary drainage is the standard of care for patients with cholangiocarcinoma (CCA)-induced, obstructive jaundice. Self-expanding metal stents are supposed to be superior to polyethylene stents in terms of reduction of interventions and costs. So far, there are only few real-life data with respect to stent selection and survival in this patient cohort. Methods: In this study, we retrospectively analyzed patients with CCA treated with endoscopic biliary drainage from 2000 to 2015 at Hannover Medical School, Germany. The aim of this study was to analyze whether metal stenting reduces the frequency of interventions and influences survival in a large, real-life cohort. Results: Overall, 422 patients with CCA were included in this study. Indication for endoscopic biliary drainage was most often obstructive jaundice (n = 397; 94.1%). Among these patients, 20 patients (5%) were initially treated with a metal stent and 38 (9.6%) received a metal stent in the subsequent course. Median number of interventions per month was 2.4-fold reduced following metal stenting. Patients first treated with a metal stent had a more advanced tumor stage and a significantly shorter median overall survival (mOS) compared to patients who received a metal stent subsequently (7.5 months vs. 15.2 months; p=.019). There was no difference in mOS for metal vs. polyethylene stenting following a propensity score match for the confounders curative resection and chemotherapy (13.2 vs. 13.7 months, p=.555). Conclusions: Our data confirm that metal stenting reduces the frequency of interventions, but does not influence OS. Metal stenting should be considered specifically in younger patients who are suitable for chemotherapy.
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Affiliation(s)
- Torsten Voigtländer
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
| | - Nora Schweitzer
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
| | - Thomas von Hahn
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
| | - Michael P Manns
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
| | - Arndt Vogel
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
| | - Martha M Kirstein
- a Department of Gastroenterology, Hepatology and Endocrinology , Hannover Medical School , Hannover , Germany
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Jirapinyo P, AlSamman MA, Thompson CC. Impact of infected stent removal on recurrent cholangitis with time-to-event analysis. Surg Endosc 2019; 33:4109-4115. [PMID: 30927127 DOI: 10.1007/s00464-019-06714-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 02/19/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND The optimal approach at treating infected biliary stents at the time of cholangitis remains unknown. This study aims to compare the efficacy of stent exchange versus stent sweeping/stent-in-stent approaches at treating cholangitis. METHODS The study was a retrospective cohort study. Patients with biliary stents and cholangitis were included. Outcomes were rate of recurrent cholangitis and time to recurrent cholangitis in those whose stents were left in place (stent sweeping and stent-in-stent) compared to those whose stents were removed (stent exchange). Primary analysis included patients with metal biliary stents only. Secondary analysis included those with metal and plastic biliary stents. RESULTS A total of 182 patients (age 64 ± 12;89 F) with a metal biliary stent(s) at index cholangitis were included. Of these, 40 (22%) had stents removed, i.e., stent exchange. The remaining 142 (78%) did not have stent removal (97 with stent-in-stent and 45 with stent sweeping). Recurrent cholangitis occurred in 22.5% and 42.3% in the stent removal and non-removal groups, respectively (p = 0.02). Stent removal remained a negative predictor of recurrent cholangitis after controlling for age, sex, history of diabetes, and chemotherapy (OR 0.39, p = 0.03). Median time from index cholangitis to recurrent cholangitis was shorter for patients whose stents were not removed compared to those whose stents were removed (182 vs 450 days, p = 0.011). On Cox regression model, stent removal remained a negative predictor of recurrent cholangitis after controlling for age, sex, history of diabetes, and chemotherapy (HR 0.41, p = 0.01). The findings persisted in the secondary analysis including both metal and plastic biliary stents (303 patients). CONCLUSION Biliary stent removal with stent exchange at the time of cholangitis appears to be more effective at preventing recurrent cholangitis than leaving an infected stent in the biliary system.
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Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
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Nennstiel S, Tschurtschenthaler I, Neu B, Algül H, Bajbouj M, Schmid RM, von Delius S, Weber A. Management of occluded self-expanding biliary metal stents in malignant biliary disease. Hepatobiliary Pancreat Dis Int 2018; 17:49-54. [PMID: 29428104 DOI: 10.1016/j.hbpd.2018.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/02/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Occlusion of self-expanding metal stents (SEMS) in malignant biliary obstruction occurs in up to 40% of patients. This study aimed to compare the different techniques to resolve stent occlusion in our collective of patients. METHODS Patients with malignant biliary obstruction and occlusion of biliary metal stent at a tertiary referral endoscopic center were retrospectively identified between April 1, 1994 and May 31, 2014. The clinical records were further analyzed regarding the characteristics of patients, malignant strictures, SEMS, management strategies, stent patency, subsequent interventions, survival time and case charges. RESULTS A total of 108 patients with biliary metal stent occlusion were identified. Seventy-nine of these patients were eligible for further analysis. Favored management was plastic stent insertion in 73.4% patients. Second SEMS were inserted in 12.7% patients. Percutaneous transhepatic biliary drainage and mechanical cleansing were conducted in a minority of patients. Further analysis showed no statistically significant difference in median overall secondary stent patency (88 vs. 143 days, P = 0.069), median survival time (95 vs. 192 days, P = 0.116), median subsequent intervention rate (53.4% vs. 40.0%, P = 0.501) and median case charge (€5145 vs. €3473, P = 0.803) for the treatment with a second metal stent insertion compared to plastic stent insertion. In patients with survival time of more than three months, significantly more patients treated with plastic stents needed re-interventions than patients treated with second SEMS (93.3% vs. 57.1%, P = 0.037). CONCLUSIONS In malignant biliary strictures, both plastic and metal stent insertions are feasible strategies for the treatment of occluded SEMS. Our data suggest that in palliative biliary stenting, patients especially those with longer expected survival might benefit from second SEMS insertion. Careful patient selection is important to ensure a proper decision for either management strategy.
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Affiliation(s)
- Simon Nennstiel
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Isolde Tschurtschenthaler
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Bruno Neu
- Medizinische Klinik II, Krankenhaus Landshut-Achdorf, Academic Teaching Hospital, Technische Universität München, Achdorferweg 3, Landshut 84036, Germany
| | - Hana Algül
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Monther Bajbouj
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Roland M Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Stefan von Delius
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany
| | - Andreas Weber
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, Munich 81675, Germany.
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Kim JY, Ko GB, Lee TH, Park SH, Lee YN, Cho YS, Jung Y, Chung IK, Choi HJ, Cha SW, Moon JH, Cho YD, Kim SJ. Partially Covered Metal Stents May Not Prolong Stent Patency Compared to Uncovered Stents in Unresectable Malignant Distal Biliary Obstruction. Gut Liver 2017; 11:440-446. [PMID: 28208003 PMCID: PMC5417788 DOI: 10.5009/gnl16245] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/31/2016] [Accepted: 09/20/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIMS Controversy still exists regarding the benefits of covered self-expandable metal stents (SEMSs) compared to uncovered SEMSs. We aimed to compare the patency and stent-related adverse events of partially covered SEMSs (PC-SEMSs) and uncovered SEMSs in unresectable malignant distal biliary obstruction. METHODS A total of 134 patients who received a PC-SEMS or uncovered SEMS for palliation of unresectable malignant distal biliary obstruction were reviewed retrospectively. The main outcome measures were stent patency, stent-related adverse events, and overall survival. RESULTS The median stent patency was 118 days (range, 3 to 802 days) with PC-SEMSs and 105 days (range, 2 to 485 days) with uncovered SEMSs (p=0.718). The overall endoscopic revision rate due to stent dysfunction was 36.6% (26/71) with PC-SEMSs and 36.5% (23/63) with uncovered SEMSs (p=0.589). Tumor ingrowth was more frequent with uncovered SEMSs (4.2% vs 19.1%, p=0.013), but migration was more frequent with PC-SEMSs (11.2% vs 1.5%, p=0.04). The incidence of stent-related adverse events was 2.8% (2/71) with PC-SEMSs and 9.5% (6/63) with uncovered SEMSs (p=0.224). The median overall survival was 166 days with PC-SEMSs and 168 days with uncovered SEMSs (p=0.189). CONCLUSIONS Compared to uncovered SEMSs, PC-SEMSs did not prolong stent patency in unresectable malignant distal biliary obstruction. Stent migration was more frequent with PC-SEMSs. However, tumor ingrowth was less frequent with PC-SEMSs compared to uncovered SEMSs.
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Affiliation(s)
- Jae Yun Kim
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan,
Korea
| | - Gyu Bong Ko
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan,
Korea
| | - Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan,
Korea
- Correspondence to: Tae Hoon Lee, Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan 31151, Korea, Tel: +82-41-570-3662, Fax: +82-41-574-5762, E-mail:
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan,
Korea
| | - Yun Nah Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon,
Korea
| | - Young Sin Cho
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan,
Korea
| | - Yunho Jung
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan,
Korea
| | - Il-Kwun Chung
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan,
Korea
| | - Hyun Jong Choi
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon,
Korea
| | - Sang-Woo Cha
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul,
Korea
| | - Jong Ho Moon
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon,
Korea
| | - Young Deok Cho
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul,
Korea
| | - Sun-Joo Kim
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan,
Korea
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Weledji EP, Enoworock G, Mokake M, Sinju M. How Grim is Pancreatic Cancer? Oncol Rev 2016; 10:294. [PMID: 27471581 PMCID: PMC4943093 DOI: 10.4081/oncol.2016.294] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/12/2016] [Accepted: 06/29/2016] [Indexed: 12/16/2022] Open
Abstract
Pancreatic ductal carcinoma continues to be the most lethal malignancy with rising incidence. It is the fourth most common cause of cancer death in the western world due to its low treatment success rate. In addition, because of its rapid growth and silent course, diagnosis is often only established in the advanced stages. As one of the most aggressive malignancies, the treatment of this disease is a great challenge to clinicians. This paper reviewed the natural history of pancreatic cancer, the current clinical practice and the future in pancreatic cancer management.
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Affiliation(s)
| | | | - Martin Mokake
- Department of Surgery and Obstetrics and Gynaecology, University of Buea, Cameroon
| | - Motaze Sinju
- Department of Surgery and Obstetrics and Gynaecology, University of Buea, Cameroon
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Walter D, van Boeckel PGA, Groenen MJ, Weusten BLAM, Witteman BJ, Tan G, Brink MA, Nicolai J, Tan AC, Alderliesten J, Venneman NG, Laleman W, Jansen JM, Bodelier A, Wolters FL, van der Waaij LA, Breumelhof R, Peters FTM, Scheffer RCH, Leenders M, Hirdes MMC, Steyerberg EW, Vleggaar FP, Siersema PD. Cost Efficacy of Metal Stents for Palliation of Extrahepatic Bile Duct Obstruction in a Randomized Controlled Trial. Gastroenterology 2015; 149:130-8. [PMID: 25790742 DOI: 10.1053/j.gastro.2015.03.012] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 02/10/2015] [Accepted: 03/09/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Endoscopic stents are placed for palliation of extrahepatic bile duct obstruction. Although self-expandable metal stents (SEMS) remain patent longer than plastic stents, they are more expensive. We aimed to evaluate which type of stent (plastic, uncovered SEMS [uSEMS], or partially covered SEMS [pcSEMS]) is the most effective and we assessed costs. METHODS We performed a multicenter randomized trial in 219 patients at 18 hospitals in The Netherlands from February 2008 through February 2013. Patients were assigned randomly for placement of a plastic stent (n = 73), uSEMS (n = 75), or pcSEMS (n = 71) during endoscopic retrograde cholangiopancreatography. Patients were followed up for up to 1 year. Researchers were not blinded to groups. The main study end points included functional stent time and costs. RESULTS The mean functional stent times were 172 days for plastic stents, 288 days for uSEMS, and 299 days for pcSEMS (P < .005 for uSEMS and pcSEMS vs plastic). The initial placement of plastic stents (€1042 or $1106) cost significantly less than placement of SEMS (€1973 or $2094) (P = .001). However, the total cost per patient at the end of the follow-up period did not differ significantly between plastic stents (€7320 or $7770) and SEMS (€6932 or $7356) (P = .61). Furthermore, in patients with short survival times (≤3 mo) or metastatic disease, the total cost per patient did not differ between plastic stents and SEMS. No differences in costs were found between pcSEMS and uSEMS. CONCLUSIONS Although placement of SEMS (uncovered or partially covered) for palliation of extrahepatic bile duct obstruction initially is more expensive than placement of plastic stents, SEMS have longer functional time. The total costs after 1 year do not differ significantly with stent type. Dutch Clinical Trial Registration no: NTR1361.
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Affiliation(s)
- Daisy Walter
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Petra G A van Boeckel
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcel J Groenen
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Gi Tan
- Department of Gastroenterology and Hepatology, Twente Hospital, Hengelo, The Netherlands
| | - Menno A Brink
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Jan Nicolai
- Department of Gastroenterology and Hepatology, Haga Hospital, Den Haag, The Netherlands
| | - Adriaan C Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Joyce Alderliesten
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Alexander Bodelier
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Frank L Wolters
- Department of Gastroenterology and Hepatology, VieCuri Hospital, Venlo, The Netherlands
| | | | - Ronald Breumelhof
- Department of Gastroenterology and Hepatology, Diakonessen Hospital, Utrecht, The Netherlands
| | - Frank T M Peters
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Robbert C H Scheffer
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Max Leenders
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Meike M C Hirdes
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ewout W Steyerberg
- Department of Decision Analysis, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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Lee JK, Kwack WK, Lee SH, Jung JH, Kwon JH, Han IW, Lee JH. Effect of external beam radiotherapy on patency of uncovered metallic stents in patients with inoperable bile duct cancer. Hepatobiliary Pancreat Dis Int 2014; 13:423-7. [PMID: 25100128 DOI: 10.1016/s1499-3872(14)60282-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although biliary decompression with metallic stenting is the preferred treatment for inoperable bile duct cancer (BDC), maintenance of patency is still unsatisfactory. We tried to assess the effectiveness and safety of external beam radiotherapy (EBRT) for prolonging stent patency in patients having uncovered metallic stents. METHOD We retrospectively reviewed 50 patients who received endoscopic stenting, of whom 18 received EBRT (RT group) and 32 did not (non-RT group). RESULTS No difference was found in baseline characteristics between the two groups. Although stent patency was longer in the RT group than that in the non-RT group (140.7+/-51.3 vs 136.4+/-34.9 days, P=0.94), the difference was not statistically significant. There were a lower rate of stent occlusion (27.8% vs 50.0% of patients, P=0.12) and a longer overall survival (420.1+/-73.2 vs 269.1+/-41.7 days, P=0.11) in the RT group than in the non-RT group, and the difference again was not statistically significant. The development of adverse reactions did not differ (55.6% vs 53.1% of patients, P=0.91). There was no serious adverse reaction in both groups (P=0.99). CONCLUSIONS EBRT did not significantly improve stent patency in patients with inoperable BDC having uncovered metallic stents. However, EBRT was safe. Future trials with refined protocols for better efficacy are expected.
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Affiliation(s)
- Jun Kyu Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul 110-744, Korea.
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Han JZ, Qin MF. Endoscopic metal biliary endoprosthesis combined with endoscopic nasobiliary drainage for palliative treatment of malignant biliary obstruction. Shijie Huaren Xiaohua Zazhi 2013; 21:547-552. [DOI: 10.11569/wcjd.v21.i6.547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the clinical effect of endoscopic metal biliary endoprosthesis (EMBE) combined with endoscopic nasobiliary drainage (ENBD) in the palliative treatment of malignant biliary obstruction.
METHODS: The clinical data for 68 patients with malignant biliary obstruction who underwent endoscopic retrograde cholangiopancreatography (ERCP) for EMBE and ENBD from April 2010 to October 2012 were reviewed and analyzed.
RESULTS: ERCP and biliary stent placement were successful in 64 of 68 cases, and the success rate was 94.12%. Jaundice obviously subsided in 95.31% of patients one week after stent placement. Postoperatively, liver function was improved significantly. There were 5 cases of complications, including hyperamylasemia in 3 cases, acute pancreatitis in 1 case and acute cholangitis in 1 case. Fifty-eight patients were followed postoperatively, and their average survival time was 10 mo ± 2.30 mo (3-26 mo). The half-year, 1-year and 2-year survival rates were 67.24% (39/58), 43.10% (25/58) and 5.17% (3/58), respectively. The average stent patency time was 4 mo ± 2.26 mo (0-9 mo).
CONCLUSION: EMBE combined with ENBD can effectively relieve biliary obstruction and improve liver function in patients with malignant biliary obstruction, and is a safe and effective palliative treatment with less invasiveness and fewer complications.
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Fukami Y, Ebata T, Yokoyama Y, Igami T, Sugawara G, Nagino M. Salvage hepatectomy for perihilar malignancy treated initially with biliary self-expanding metallic stents. Surgery 2012; 153:627-33. [PMID: 23270971 DOI: 10.1016/j.surg.2012.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 11/07/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND A salvage hepatectomy for an "inoperable" advanced perihilar tumor initially treated with a self-expanding metallic stent (SEMS) is challenging, and its safety and survival benefits remain unclear. The aim of this study was to report our experiences with this difficult resection. METHODS This study involved 10 consecutive patients with suspected perihilar cholangiocarcinoma who underwent SEMS placement at a local hospital and were referred to our clinic for possible resection as their last option. Their medical records were analyzed retrospectively. RESULTS Tumor extent was first reevaluated using multidetector-row computed tomography. Of the 10 patients, 4 were diagnosed as inoperable owing to locally advanced tumors (n = 3) or poor physical condition (n = 1). In the remaining 6 patients, after additional biliary drainage, a salvage hepatectomy was performed, including a right hepatectomy with a caudate lobectomy in 5 patients and a central bisectionectomy with a caudate lobectomy in 1. A combined portal vein resection was required in 3 patients, and a combined pancreatoduodenectomy was performed in 2 patients. R0 resection was achieved in 5 patients, and all patients tolerated the resection. Three patients died of recurrence, and the remaining 3 were alive without recurrence at the time of publication, 1 of whom has survived >10 years. CONCLUSION Pre-resection SEMS placement does not preclude a subsequent hepatectomy for patients with advanced perihilar tumors. Salvage hepatectomy, although technically demanding, is feasible and can revise the palliative scenario and benefit selected patients treated initially with an SEMS.
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Affiliation(s)
- Yasuyuki Fukami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Choi JM, Kim JH, Kim SS, Yu JH, Hwang JC, Yoo BM, Park SH, Kim HG, Lee DK, Ko KH, Yoo KS, Park DH. A comparative study on the efficacy of covered metal stent and plastic stent in unresectable malignant biliary obstruction. Clin Endosc 2012; 45:78-83. [PMID: 22741136 PMCID: PMC3363115 DOI: 10.5946/ce.2012.45.1.78] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Revised: 02/18/2012] [Accepted: 02/23/2012] [Indexed: 01/28/2023] Open
Abstract
Background/Aims The placement of self expandable metal stent (SEMS) is one of the palliative therapeutic options for patients with unresectable malignant biliary obstruction. The aim of this study was to compare the effectiveness of a covered SEMS versus the conventional plastic stent. Methods We retrospectively evaluated 44 patients with unresectable malignant biliary obstruction who were treated with a covered SEMS (21 patients) or a plastic stent (10 Fr, 23 patients). We analyzed the technical success rate, functional success rate, early complications, late complications, stent patency and survival rate. Results There was one case in the covered SEMS group that had failed technically, but was corrected successfully using lasso. Functional success rates were 90.5% in the covered SEMS group and 91.3% in the plastic stent group. There was no difference in early complications between the two groups. Median patency of the stent was significantly prolonged in patients who had a covered SEMS (233.6 days) compared with those who had a plastic stent (94.6 days) (p=0.006). During the follow-up period, stent occlusion occurred in 11 patients of the covered SEMS group. Mean survival showed no significant difference between the two groups (covered SEMS group, 236.9 days; plastic stent group, 222.3 days; p=0.182). Conclusions The patency of the covered SEMS was longer than that of the plastic stent and the lasso of the covered SEMS was available for repositioning of the stent.
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Affiliation(s)
- Jae Myoung Choi
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
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Luigiano C, Ferrara F, Cennamo V, Fabbri C, Bassi M, Ghersi S, Consolo P, Morace C, Polifemo AM, Billi P, Ceroni L, Alibrandi A, D'Imperio N. A comparison of uncovered metal stents for the palliation of patients with malignant biliary obstruction: nitinol vs. stainless steel. Dig Liver Dis 2012; 44:128-33. [PMID: 21924691 DOI: 10.1016/j.dld.2011.08.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 08/04/2011] [Accepted: 08/14/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Various types of self-expandable metal stents have been introduced for the palliation of malignant biliary obstruction. AIMS To compare the outcomes of WallFlex™ and Wallstent™ uncovered biliary self-expandable metal stents (SEMSs) for the palliation of patients with malignant biliary obstruction. METHODS Between October 2008 and December 2009, all SEMSs placed for malignant biliary obstruction were WallFlex™: all patients palliated were included in the study. Before October 2008, all the SEMSs placed for malignant biliary obstruction were Wallstent™, and the patients palliated from July 2007 to September 2008 were the comparative group. RESULTS A total of 58 WallFlex™ and 54 Wallstent™ SEMSs were placed, and efficacious biliary decompression was achieved in all patients. Early complications occurred in 5 patients in the WallFlex™ group and in 3 in the Wallstent™ group (p=ns). Late complications occurred in 6 patients in the WallFlex™ group and in 16 in the Wallstent™ group (p<0.01). The overall patency of the self-expandable metal stent in the WallFlex™ and the Wallstent™ groups was similar (227 days vs. 215 days, p=ns). Mean patient survival was 242 days in the WallFlex™ group and 257 days in the Wallstent™ group (p=ns). CONCLUSIONS We found no difference in terms of overall patency between the two types of SEMSs, but there was an increased rate of late adverse events in the Wallstent™ group.
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Affiliation(s)
- Carmelo Luigiano
- Unit of Gastroenterology and Digestive Endoscopy, AUSL Bologna Bellaria-Maggiore Hospital, Bologna, Italy.
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15
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Gerges C, Schumacher B, Terheggen G, Neuhaus H. Expandable metal stents for malignant hilar biliary obstruction. Gastrointest Endosc Clin N Am 2011; 21:481-97, ix. [PMID: 21684466 DOI: 10.1016/j.giec.2011.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Most patients with malignant hilar stenoses are candidates for palliation. For this purpose, biliary drainage plays a major role in improving liver function and managing or avoiding cholangitis. Endoscopic interventions are less invasive than the percutaneous approach and should be considered as the first-line drainage procedures in most cases. Transhepatic interventions should be reserved for endoscopic failures or performed as a complementary approach in a combined procedure. After successful endoscopic access to biliary obstruction, implantation of self-expandable metal stents offers advantages over plastic endoprostheses in terms of stent patency and number of reinterventions.
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Affiliation(s)
- Christian Gerges
- Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Kirchfeldstraße 40, 40217 Duesseldorf, Germany
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Raju RP, Jaganmohan SR, Ross WA, Davila ML, Javle M, Raju GS, Lee JH. Optimum palliation of inoperable hilar cholangiocarcinoma: comparative assessment of the efficacy of plastic and self-expanding metal stents. Dig Dis Sci 2011; 56:1557-64. [PMID: 21222156 DOI: 10.1007/s10620-010-1550-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 12/22/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic retrograde biliary drainage (ERBD) with plastic or self-expanding metal stents (SEMS) is often performed for palliative care for cholangiocarcinoma. OBJECTIVE The objective was to compare the clinical effectiveness, including stent patency, complication rate, and need for salvage percutaneous transhepatic biliary drainage, of SEMS and plastic stents. METHODS A total of 100 patients with inoperable cholangiocarcinoma were identified from an endoscopic database from 1/1/01 to 9/30/06 at a tertiary cancer hospital and their clinical history was retrospectively reviewed. All patients were followed to death, re-intervention, or for at least one year. Stent patency and patient survival were estimated by Kaplan-Meier analysis, supplemented by the log-rank test for comparisons between groups. RESULTS Forty-eight patients had SEMS placed and 52 patients had plastic stents placed. ERBD was successful in 46 (95.8%) in the SEMS group and 49 (94.2%) in the plastic group (P = 0.67). Median patency times were 1.86 months in the plastic group and 5.56 months in the SEMS group (P < 0.0001). A mean of 1.53 and 4.60 re-interventions were performed in the SEMS and plastic groups, respectively (P < 0.05). Complications occurred in 4/48 (8.3%) in the SEMS group and 4/52 (7.7%) in the plastic group (P = 0.79). Median survival was 9.08 and 8.22 months in the SEMS and plastic stent groups, respectively (P = 0.50). CONCLUSION Metallic stent patency was superior to that of plastic stents in all Bismuth-Corlette classifications of hilar cholangiocarcinoma with similar complication rates. SEMS seem to be cost-effective and, when feasible, should be considered as an initial intervention in patients with inoperable hilar cholangiocarcinoma.
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Affiliation(s)
- Ramu P Raju
- Department of Gastroenterology, Hepatology, and Nutrition, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030-4009, USA
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Lytras D, Olde Damink SWM, Amin Z, Imber CJ, Malagó M. Radical surgery in the presence of biliary metallic stents: revising the palliative scenario. J Gastrointest Surg 2011; 15:489-95. [PMID: 21246414 DOI: 10.1007/s11605-010-1389-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 11/12/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND The application of endobiliary self-expandable metallic stents (SEMS) is considered the palliative treatment of choice in patients with biliary obstruction in the setting of inoperable malignancies. In the presence of SEMS, however, radical surgery is the only curative option when the resectability status is revised in case of malignancies or for overcoming complications arising from their application in benign conditions that masquerade as inoperable tumours. The aim of our study was to report our surgical experience with patients who underwent an operation due to revision of the initial palliative approach, whilst they had already been treated with biliary SEMS exceeding the hilar bifurcation. METHODS Three patients with hilar cholangiocarcinoma that was considered inoperable and one patient with IgG4 autoimmune cholangio-pancreatopathy mimicking pancreatic cancer underwent radical resections in the presence of biliary SEMS. RESULTS After a detailed preoperative workup, two right trisectionectomies, one left extended hepatectomy and a radical extrahepatic biliary resection were performed. All cases demanded resection and reconstruction of the portal vein. R0 resection was achieved in all the malignant cases. Two patients required multiple biliodigestive anastomoses entailing three and seven bile ducts respectively. There was one perioperative death due to postoperative portal vein and hepatic artery thrombosis, whilst two patients developed grade III complications. At follow-up, one patient died at 13 months due to disease recurrence, whilst the remaining two are free of disease or symptoms at 21 and 12 months, respectively. CONCLUSIONS Revising the initial palliative approach and operating in the setting of biliary metallic stents is extremely demanding and carries significant mortality and morbidity. Radical resection is the only option for offering cure in such complex cases, and this should only be attempted in advanced hepatopancreaticobiliary centres with active involvement in liver transplantation.
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Affiliation(s)
- Dimitrios Lytras
- Department of Surgery, University College of London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
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Yoon WJ, Ryu JK, Lee JW, Ahn DW, Kim YT, Yoon YB, Woo SM, Lee WJ. Endoscopic management of occluded metal biliary stents: Metal versus 10F plastic stents. World J Gastroenterol 2010; 16:5347-52. [PMID: 21072899 PMCID: PMC2980685 DOI: 10.3748/wjg.v16.i42.5347] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To compare the efficacy of self-expandable metal stents (SEMSs) with 10F plastic stents (PSs) in the endoscopic management of occluded SEMSs.
METHODS: We retrospectively reviewed the medical records of 56 patients who underwent SEMS insertion for palliation of unresectable malignant biliary obstruction between 2000 and 2007 and subsequent endoscopic retrograde biliary drainage (ERBD) with SEMS or PS for initial SEMS occlusion between 2000 and 2008.
RESULTS: Subsequent ERBD with SEMS was performed in 29 patients and with PS in 27. The median time to stent occlusion after subsequent ERBD was 186 d in the SEMS group and 101 d in the PS group (P = 0.118). Overall median stent patency was 79 d for the SEMS group and 66 d for the PS group (P = 0.379). The mean number of additional biliary drainage procedures after subsequent ERBD in patients that died (n = 50) during the study period was 2.54 ± 4.12 for the SEMS group and 1.85 ± 1.95 for the PS group (P = 0.457). The mean total cost of additional biliary drainage procedures after the occlusion of subsequent SEMS or PS was $410.04 ± 692.60 for the SEMS group and $630.16 ± 671.63 for the PS group (P = 0.260). Tumor ingrowth as the cause of initial SEMS occlusion was the only factor associated with a shorter time to subsequent stent occlusion (101 d for patients with tumor ingrowth vs 268 d for patients without tumor ingrowth, P = 0.008).
CONCLUSION: Subsequent ERBD with PSs offered similar patency and number of additional biliary drainage procedures compared to SEMSs in the management of occluded SEMS.
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Yoon WJ, Ryu JK, Yang KY, Paik WH, Lee JK, Woo SM, Park JK, Kim YT, Yoon YB. A comparison of metal and plastic stents for the relief of jaundice in unresectable malignant biliary obstruction in Korea: an emphasis on cost-effectiveness in a country with a low ERCP cost. Gastrointest Endosc 2009; 70:284-9. [PMID: 19539921 DOI: 10.1016/j.gie.2008.12.241] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 12/23/2008] [Indexed: 12/22/2022]
Abstract
BACKGROUND In countries where ERCP costs are low relative to those of metal stents (eg, Korea), initial endoscopic retrograde biliary drainage (ERBD) with a plastic stent is thought to be more economical. OBJECTIVE We conducted this study to compare metal and plastic stent-based ERBD in efficacy, complications, and total cost of biliary drainage. DESIGN Retrospective study. SETTING Tertiary referral center. PATIENTS A total of 112 patients who had not undergone previous biliary drainage procedures and who underwent ERBD for unresectable malignant biliary obstruction. INTERVENTIONS Endoscopic sphincterotomy was performed, and covered or uncovered Wallstents were used in 56 patients and plastic stents in 56 patients. RESULTS Stent occlusion occurred in 31 patients after a mean of 278 days in the metal stent group and in 39 patients after a mean of 133 days in the plastic stent group (P = .0004). The incidence of and length of hospitalization for cholangitis were significantly lower in the metal stent group. There was no difference in the total number of drainage procedures between the 2 groups. There was no statistical difference in the mean cost of the relief of jaundice between the 2 groups ($1488.77 in the metal stent group vs $1319.26 in the plastic stent group, P = .422). LIMITATIONS Nonrandomized, retrospective study. CONCLUSION Even in countries where ERCP costs are lower than those of metal stents, ERBD with metal biliary stents as the first-line treatment may offer better palliation without a significant increased cost in patients with unresectable malignant biliary obstruction.
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Affiliation(s)
- Won Jae Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
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20
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Plastic versus self-expanding metallic stents for malignant hilar biliary obstruction: a prospective multicenter observational cohort study. J Clin Gastroenterol 2008; 42:1040-6. [PMID: 18719507 DOI: 10.1097/mcg.0b013e31815853e0] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are few comparative data as to whether plastic or self-expanding metallic stents are preferable for palliating malignant hilar biliary obstruction. METHODS Thirty-day outcomes of consecutive endoscopic retrograde cholangiopancreatographies performed for malignant hilar obstruction at 6 private and 5 university centers were assessed prospectively. RESULTS Patients receiving plastic (N=28) and metallic stents (N=34) were similar except that metallic stent recipients more often had: Bismuth III or IV tumors (16/34 vs. 5/28 P=0.043), higher Charlson comorbidity scores (P=0.003), metastatic disease (P=0.006), and management at academic centers (P=0.018). The groups had similar rates of bilateral stent placement (4/28 vs. 5/34), and similar frequency of opacified but undrained segmental ducts (7/28 vs. 5/34). Adverse outcomes including cholangitis, stent occlusion, migration, perforation, and/or the need for unplanned endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography occurred in 11/28 (39.3%) patients with plastic versus 4/34 (11.8%) with metal stents (P=0.017). By logistic regression, factors associated with adverse outcomes included plastic stent placement (odds ratio 6.32; 95% confidence interval 1.23, 32.56) and serum bilirubin (1.11/mg/dL above normal: 1.01, 1.22) but not center type or Bismuth class. CONCLUSIONS Metallic stent performance was superior to plastic for hilar tumor palliation with respect to short-term outcomes, independent of disease severity, Bismuth class, or drainage quality.
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Ayaru L, Kurzawinski TR, Shankar A, Webster GJM, Hatfield ARW, Pereira SP. Complications and diagnostic difficulties arising from biliary self-expanding metal stent insertion before definitive histological diagnosis. J Gastroenterol Hepatol 2008; 23:315-20. [PMID: 18289360 DOI: 10.1111/j.1440-1746.2006.04562.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Self-expanding metal bile duct stents provide good palliation for inoperable malignant disease. However, problems may arise if metal stents are inserted before definitive histological diagnosis. The aim of this study was to evaluate the outcome of such patients. METHODS A retrospective case note review was conducted of patients referred to a tertiary pancreaticobiliary center between 1992 and 2004 in whom a metal bile duct stent was inserted for presumed unresectable malignant disease before definitive histological diagnosis. RESULTS There were 21 patients identified. Final diagnoses were: group 1, benign disease (n = 3); group 2, resectable malignancy (n = 2); group 3, unresectable malignancy (n = 12); and group 4, diagnosis remains uncertain (n = 4). During a follow-up of 22, 38 and 111 months, the patients in group 1 had one, eight and five episodes of stent occlusion. In group 2, both patients underwent pancreaticoduodenectomy for ampullary carcinoma, 2 and 6 months after presentation. In group 3, the median time to a confirmed malignant diagnosis was 2 months (range 1-27 months). In group 4, a median of two biopsies (range 1-4) were negative for malignancy, during a median follow up of 13 months (range 3-46). Overall in eight patients, the metal stents caused artifacts on computed tomography and/or were associated with tissue in-growth making the differentiation between benign and malignant disease difficult. CONCLUSION These cases indicate that metal bile duct stent insertion before definitive histological diagnosis can be problematic. A proportion of cases will have benign strictures and in others the confirmation of malignancy may be made more difficult.
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Affiliation(s)
- Lakshmana Ayaru
- Department of Gastroenterology, University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
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22
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KIN H, KUBOTA Y, SUMITOMO Y, KIRIYA K, AGAWA H, SHIMATANI M, SUZUKI N, KOJIMA H, ITO K, KOJIMA K, INOUE K. Endoscopic Bilateral Hepatic Drainage with Self‐Expandable Metallic Stents for Malignant Hilar Stricture. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1999.tb00007.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Hideyuki KIN
- *Deparrment of Gastroenterology, Shizuoka Prefectural General Hospital, Shizuoka, Japan
| | - Yoshitsugu KUBOTA
- **Third Department of Internal Medicine, Kansai Medical University, Osaka, Jupan
| | - Yasuhiko SUMITOMO
- *Deparrment of Gastroenterology, Shizuoka Prefectural General Hospital, Shizuoka, Japan
| | - Keiichi KIRIYA
- *Deparrment of Gastroenterology, Shizuoka Prefectural General Hospital, Shizuoka, Japan
| | - Hiroyuki AGAWA
- *Deparrment of Gastroenterology, Shizuoka Prefectural General Hospital, Shizuoka, Japan
| | - Masaaki SHIMATANI
- *Deparrment of Gastroenterology, Shizuoka Prefectural General Hospital, Shizuoka, Japan
| | - Naoyuki SUZUKI
- *Deparrment of Gastroenterology, Shizuoka Prefectural General Hospital, Shizuoka, Japan
| | - Hiroyoshi KOJIMA
- *Deparrment of Gastroenterology, Shizuoka Prefectural General Hospital, Shizuoka, Japan
| | - Kazuki ITO
- *Deparrment of Gastroenterology, Shizuoka Prefectural General Hospital, Shizuoka, Japan
| | - Koichi KOJIMA
- *Deparrment of Gastroenterology, Shizuoka Prefectural General Hospital, Shizuoka, Japan
| | - Kyoichi INOUE
- **Third Department of Internal Medicine, Kansai Medical University, Osaka, Jupan
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KUBOTA Y, KIN H, TAKAOKA M, INOUE K, MURATA T, TANAKA Y. Endoscopic Intraductal Radiation Therapy for Unresectable Cholangiocarcinoma Using a Remote Afterloading Device. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1996.tb00426.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Yoshitsugu KUBOTA
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Hideyuki KIN
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Makoto TAKAOKA
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Kyoichi INOUE
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Takashi MURATA
- Department of Radiology, Kansai Medical University, Osaka, Japan
| | - Yoshimasa TANAKA
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
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RYOZAWA S, AKIYAMA T, IKEDA M, FURUI T, YABUSHTTA Y, KONDO S, NOGUCHI T, NOJIMA S, OKITA K. A Case of CholangioDuodenal Fistula Formation After Metallic Stenting for Malignant Biliary Stricture. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1995.tb00180.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Shomei RYOZAWA
- *First Department of Internal Medicine, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Tetsiyi AKIYAMA
- *First Department of Internal Medicine, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Miyuki IKEDA
- *First Department of Internal Medicine, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Toshifumi FURUI
- *First Department of Internal Medicine, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Yoshiko YABUSHTTA
- *First Department of Internal Medicine, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Satoshi KONDO
- *First Department of Internal Medicine, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Takayoshi NOGUCHI
- *First Department of Internal Medicine, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Shinji NOJIMA
- **First Department of Surgery, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Kiwamu OKITA
- *First Department of Internal Medicine, Yamaguchi University School of Medicine, Yamaguchi, Japan
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Dua KS, Reddy ND, Rao VG, Banerjee R, Medda B, Lang I. Impact of reducing duodenobiliary reflux on biliary stent patency: an in vitro evaluation and a prospective randomized clinical trial that used a biliary stent with an antireflux valve. Gastrointest Endosc 2007; 65:819-28. [PMID: 17383650 DOI: 10.1016/j.gie.2006.09.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2006] [Accepted: 09/05/2006] [Indexed: 12/27/2022]
Abstract
BACKGROUND The mechanisms leading to occlusion of plastic biliary stents (PBS) are not known. OBJECTIVE To evaluate the impact of reducing duodenobiliary reflux on stent patency rate. DESIGN A newly designed antireflux PBS (AR-PBS) was tested in vitro by using ox bile. A prospective randomized trial in human beings was conducted. SETTING Tertiary medical center. PATIENTS Patients with malignant bile-duct strictures were studied. INTERVENTIONS A PBS or an AR-PBS stent was placed by using standard techniques, and the patients were followed at regular intervals. Patients presenting with stent occlusion underwent re-stent placement with either a PBS or a metal stent. MAIN OUTCOME MEASUREMENTS In vitro: resistance to retrograde flow and comparison of the basal and peak antegrade flow pressures between the 2 stents. In vivo: stent patency rates, complications, and the efficacy of the stents in improving the liver test. RESULTS The AR-PBS stent could withstand a retrograde pressure gradient of >320 mm Hg compared with <1 mm Hg for the PBS. Secondary to the siphon effect of the valve, the antegrade flow resistance offered by the AR-PBS was on the negative side for all flow rates compared with PBS (P < .001). The median patency of the AR-PBS in human studies was 145 days (range, 52-252 days) compared with 101 days (range, 41-210 days) for the PBS (P = .002). Both stents were equally effective in improving the liver test, and complication rates were similar in the 2 groups. LIMITATIONS The occluded stents were not examined microscopically. CONCLUSIONS The antireflux biliary stent remains patent for a longer time and hence duodenobiliary reflux may be contributing to stent occlusion.
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Affiliation(s)
- Kulwinder S Dua
- Pancreatico-biliary Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Kundu R, Pleskow D. Biliary and Pancreatic Stents: Complications and Management. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2007. [DOI: 10.1016/j.tgie.2007.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Yoon WJ, Lee JK, Lee KH, Lee WJ, Ryu JK, Kim YT, Yoon YB. A comparison of covered and uncovered Wallstents for the management of distal malignant biliary obstruction. Gastrointest Endosc 2006; 63:996-1000. [PMID: 16733115 DOI: 10.1016/j.gie.2005.11.054] [Citation(s) in RCA: 176] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2005] [Accepted: 11/08/2005] [Indexed: 02/06/2023]
Abstract
BACKGROUND The efficacy and complications of covered self-expandable metal stents (SEMS) remain controversial. OBJECTIVE We conducted this study to compare the efficacies and complication rates of covered and uncovered SEMS in malignant biliary obstruction. DESIGN Data on patients who underwent endoscopic retrograde biliary drainage with covered or uncovered Wallstents for the palliation of unresectable distal malignant biliary obstruction were collected. Stent patency, complications, and causes of stent occlusion were analyzed. SETTING We collected the data retrospectively. PATIENTS A total of 77 patients received Wallstents for unresectable distal malignant biliary obstruction. INTERVENTIONS Endoscopic sphincterotomy was performed, and a Wallstent was deployed after guidewire passage. Polyurethane-covered Wallstents were used in 36 patients and uncovered Wallstents in 41 patients. RESULTS Stent migration occurred in 3 of the covered Wallstent group and in 1 of the uncovered Wallstent group. Cholecystitis occurred in 1 of the covered Wallstent group but in none of the uncovered Wallstent group. Stent occlusion occurred after a mean of 398 days in the covered group and after 319 days in the uncovered Wallstent group (P > .05). Stent patency rates were 83%, 78%, 67%, and 54% at 100, 200, 300, and 400 days, respectively, in covered group and 83%, 66%, 54%, and 36% in the uncovered group, which was not significantly different. LIMITATIONS This study is not a prospective randomized study and sample size is not large. CONCLUSIONS Covered Wallstents are safe with acceptable complication rates. However, we found no significant difference between the stent patencies of covered and uncovered Wallstents.
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Affiliation(s)
- Won Jae Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, 28 Yeongeon-dong, Jongno-gu, Seoul 110-744, Korea
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Park DH, Kim MH, Choi JS, Lee SS, Seo DW, Kim JH, Han J, Kim JC, Choi EK, Lee SK. Covered versus uncovered wallstent for malignant extrahepatic biliary obstruction: a cohort comparative analysis. Clin Gastroenterol Hepatol 2006; 4:790-6. [PMID: 16716757 DOI: 10.1016/j.cgh.2006.03.032] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We examined the use of both covered and uncovered Wallstents in patients with malignant extrahepatic biliary obstruction to determine whether use of covered Wallstents prolonged stent patency without increasing procedure-related complications. METHODS Commercially available silicone-covered Wallstents were prospectively evaluated in 98 patients who underwent insertion from December 2002-December 2004. Those data were compared with data obtained by retrospectively studying 108 consecutive patients who underwent endoscopic insertion of uncovered Wallstents between January 2000-November 2002, and for whom accurate and complete follow-up details were available. RESULTS The mean stent patency was similar for both groups, 148.9 days (range, 3-667 days) for covered Wallstents and 143.5 days (3-910 days) for uncovered Wallstents (P = .531). The 2 groups also did not significantly differ in terms of cumulative stent patency according to the Kaplan-Meier lifetime table. The incidence of mild pancreatitis was similar in both groups, occurring in 6 patients with covered stents (6/98, 6.1%) and 2 patients with uncovered stents (2/108, 1.9%) (P = .154). Excluding those patients who had previously undergone cholecystectomy, acute cholecystitis occurred in 5 of 88 patients with covered Wallstents (6.1%) and 1 of 100 patients with uncovered stents (1%) (P = .104). Stent migration occurred in 6 patients with covered stents (6.1%) and 0 patients with uncovered stents (P = .011). CONCLUSION Covered Wallstents might not prolong stent patency compared with uncovered Wallstents when used in the management of malignant extrahepatic biliary obstruction.
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Affiliation(s)
- Do Hyun Park
- Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, Cheonan, Korea
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Enns R. Hilar strictures - clear management strategies start to emerge. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2006; 20:325-7. [PMID: 16691297 PMCID: PMC2659889 DOI: 10.1155/2006/348416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Robert Enns
- St. Paul's Hospital, University of British Columbia, Vancouver.
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Lee DK, Kim HS, Kim KS, Lee WJ, Kim HK, Won YH, Byun YR, Kim MY, Baik SK, Kwon SO. The effect on porcine bile duct of a metallic stent covered with a paclitaxel-incorporated membrane. Gastrointest Endosc 2005; 61:296-301. [PMID: 15729251 DOI: 10.1016/s0016-5107(04)02570-2] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biliary metallic stents are covered with a membrane to prevent tumor ingrowth and to prolong patency. The only function of these stents is to promote biliary drainage; they have no antitumor effect. METHODS A metallic stent was developed that is covered with a paclitaxel-incorporated membrane. The metallic stents were coated with one of 3 concentrations of paclitaxel (0, 10, and 20 % wt/v) and polyurethane. A stent with each concentration was surgically inserted in the bile duct of two pigs. Four weeks after insertion, the segment of bile duct containing the stent was examined histologically. To determine the efficacy of the drug release, stents were placed in phosphate buffered saline solution for 6 weeks, and the amount of paclitaxel released was measured by high-performance liquid chromatography. RESULTS The histologic changes in the pig biliary epithelium were acceptable with respect to safety and included inflammatory cell infiltration and fibrous reactions. The changes corresponded to the amount of paclitaxel incorporated within the stent in contact with the bile duct. Epithelial denudation, mucin hypersecretion, and epithelial metaplasia were noted in the bile ducts that were in contact with stents containing 20 % wt/v paclitaxel. Transmural necrosis and perforation were not observed in any animal. In the in vitro experiment, the amounts of paclitaxel released over 1 week and over 6 weeks were similar, regardless of the concentration of paclitaxel incorporated in the stent. The stent with 10% (wt/v) paclitaxel in the covering membrane was found to be better than that with 20 % (wt/v) with respect to histologic changes and the effectiveness of drug release. CONCLUSIONS A paclitaxel-incorporated metallic stent could serve as a basis for the development of a new and safe treatment modality for malignant biliary obstruction. Clinical trials of this stent with other adjuvant therapy are warranted.
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Hii MWJ, Gibson RN. Role of radiology in the treatment of malignant hilar biliary strictures 1: Review of the literature. ACTA ACUST UNITED AC 2004; 48:3-13. [PMID: 15027913 DOI: 10.1111/j.1440-1673.2004.01233.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Malignant strictures of the biliary tree are an uncommon cause of obstructive jaundice. There are a number of pathological subtypes, but tumours in this region tend to have similar clinical and diagnostic features and therapeutic and prognostic implications. We review the published literature on this topic discussing diagnostic modalities and treatment options with a focus on radiological intervention. Diagnosis currently is best achieved using a range of procedures. Direct cholangiography remains the gold standard in delineating anatomy, but the invasiveness of this procedure limits its use as a purely diagnostic tool. Magnetic resonance technology, in particular magnetic resonance cholangiopancreatography, has an increasing role as accessibility is improved. Treatment of these tumours is difficult. Surgical resection and palliative biliary enteric bypass are the most common methods used with endoscopic and percutaneous therapies reserved for palliating patients not fit for surgery. There is little firm evidence to suggest that any one palliative modality is superior. Interventional radiology is particularly suitable for palliative management of difficult and expansive lesions as the anatomy can preclude easy access by surgical or endoscopic techniques. Good palliative results with minimal mortality and morbidity can be achieved with percutaneous stenting.
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Hii MWJ, Gibson RN, Speer AG, Collier NA, Sherson N, Jardine C. Role of radiology in the treatment of malignant hilar biliary strictures 2: 10 years of single-institution experience with percutaneous treatment. ACTA ACUST UNITED AC 2004; 47:393-403. [PMID: 14641192 DOI: 10.1046/j.1440-1673.2003.01209.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We reviewed the results of percutaneous intervention of hilar biliary malignancy over a 10-year period at a single institution: the Royal Melbourne Hospital. Ninety-nine patients (100 treated in total) were included. Information was retrieved by retrospective examination of patient notes and radiology, combined with interviews with family and relevant physicians. Sixty-nine patients were treated with insertion of semipermanent stents, 19 had external drain tubes, and 25 received percutaneous access for Iridium brachytherapy. Adequate drainage was achieved in 87% of the patients stented, and percutaneous access was successful in 96% of patients planned for brachytherapy. Of those patients undergoing endoprosthesis insertion, early complications occurred in 39% and late complications in 23%. Average survival for the entire patient population was 227.3 days, with a median of 167 days. Longer survival times (213 vs 142 days) and lower complication rates (44 vs 64%) are observed with metal stents in comparison with plastic stents. Percutaneous intervention is an important treatment option in hilar biliary malignancy, particularly in patients unfit for surgery. Reasonable survival with good palliation is the most common outcome, and most patients do not require further intervention.
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Affiliation(s)
- Gary C Vitale
- Director of Interventional Endoscopy of the Center for Advanced Surgical Technologies, Norton Hospital Surgical Director, Digestive Disease Center, University of Louisville, Louisville, Kentucky, USA
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Parsons WG, Alasadi R. Malignant biliary obstruction: endoscopic approaches. Cancer Treat Res 2002; 109:157-82. [PMID: 11775435 DOI: 10.1007/978-1-4757-3371-6_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- W G Parsons
- Northwestern University Medical School, Chicago, IL, USA
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Kim HS, Lee DK, Kim HG, Park JJ, Park SH, Kim JH, Yoo BM, Roe IH, Moon YS, Myung SJ. Features of malignant biliary obstruction affecting the patency of metallic stents: a multicenter study. Gastrointest Endosc 2002; 55:359-65. [PMID: 11868009 DOI: 10.1067/mge.2002.121603] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although placement of a metallic stent is an established therapeutic option for the palliation of patients with malignant biliary obstruction, it remains unclear which stricture-related or stent-related factors influence stent patency. METHODS Metallic stents were inserted endoscopically in 68 patients (38 men, 30 women; mean age 70.2 plus minus 8.5 years) with malignant biliary obstruction. Patency rates were prospectively analyzed according to malignant stricture characteristics, including length, morphologic type, and degree of narrowing. Furthermore, patient age, initial serum bilirubin level, length of stent, time to adequate expansion, and the location of the distal end of the stent were evaluated as possible factors affecting the stent patency. Stent patency was assessed by using the survival analysis of the Kaplan-Meier estimation and Cox regression analysis. RESULTS Median overall stent patency was 231 days (range 27-379 days) and the overall rate of stent occlusion 41.2% (28/68). The causes of occlusion were tumor ingrowth in 23 patients (33.8%), distal overgrowth in 3 (4.4%), proximal overgrowth in 1 (1.5%), and encrustation with sludge in 1 patient (1.5%). No significant differences in patency rates according to patient age, initial serum bilirubin level, primary tumor type, length and morphologic type of stricture, and length and location of the distal end of the stent were found. Cox regression analysis demonstrated that the degree of narrowing assessed by cannula or guidewire passage and the time to adequate expansion of the stent were independent factors associated with stent patency. CONCLUSION Early expansion of the stent and easy passage of larger-caliber instruments through the stricture were favorable factors for long-term patency of the Wallstent.
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Affiliation(s)
- Hyun Soo Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, 162 Ilsan-Dong, Wonju, 220-701 Korea
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Law WL, Chu KW, Ho JW, Tung HM, Law SY, Chu KM. Self-expanding metallic stent in the treatment of colonic obstruction caused by advanced malignancies. Dis Colon Rectum 2000; 43:1522-7. [PMID: 11089586 DOI: 10.1007/bf02236731] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The treatment of malignant obstruction of the left colon or rectum usually requires emergency surgery on poor-risk patients, and the creation of a stoma is usually inevitable. With the use of self-expanding metallic stents, the prompt relief of large-bowel obstruction without surgery has become possible. This report describes our results in the use of self-expanding metallic stents in the treatment of left-sided colonic obstruction resulting from advanced malignancies. METHODS From November 1997 to March 1999, insertion of self-expanding metallic stents was attempted in 24 patients with acute left-sided colonic obstruction caused by primary or recurrent malignancies. All the procedures were performed by colorectal surgeons. The guidewire was inserted through the channel of the endoscope, and its position was confirmed with fluoroscopy. Uncovered Wallstent esophageal endoprostheses were used in all except the first case. The insertion and deployment of the stents were under both endoscopic and fluoroscopic guidance. RESULTS There were 24 patients (15 males) with a mean age of 63.6 (range, 36-98) years. Thirteen patients had primary colorectal cancer and 11 had recurrent cancers (colorectal cancer, 5; gastric cancer, 5; other, 1). In the treatment of primary colorectal cancer, seven procedures were palliative, and no subsequent surgery was planned because of extensive liver metastasis or poor medical risk. The other six patients underwent elective resection after mechanical bowel preparation. There was no mortality related to the procedure. Stenting was successful in the relief of obstruction in 23 patients. Perforation of the colon occurred in one patient, and an emergency Hartmann's operation was performed. Migration of the stents occurred in three patients. Only 3 of the 18 patients in the palliation group required the subsequent creation of stomas. CONCLUSION The use of the self-expanding metallic stents can achieve rapid and effective nonsurgical means to relieve left-sided colonic obstruction. It provides good palliation for unresectable advanced tumors that cause colonic obstruction. It may also have a role in the temporary relief of obstruction so that subsequent colonic resection can be performed under elective conditions.
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Affiliation(s)
- W L Law
- Department of Surgery, Queen Mary Hospital, University of Hong Kong Medical Centre, Hong Kong
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Nakamura T, Kitagawa M, Takehira Y, Yamada M, Kawasaki T, Nakamura H. Polyurethane-covered Wallstents to recanalize Wallstents obstructed by tumor ingrowth from malignant common bile duct obstruction. Cardiovasc Intervent Radiol 2000. [PMID: 10795847 DOI: 10.1007/bf03035509] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Four patients with malignant obstruction of the common bile duct had been treated with uncovered Wallstents and suffered from a reobstruction after 2-13 months (mean 5.3 months). Repeat cholangiography revealed severe stenosis of the stent lumen caused by tumor ingrowth through the mesh. A Wallstent with a self-made polyurethane-cover was inserted through the uncovered stent in these patients. The four patients were followed for 3-13 months (mean 6.3 months) until death. There was good drainage with no evidence of recurrent obstruction in all patients. We conclude that a covered Wallstent may extend patency of stented bile ducts, preventing tumor ingrowth in patients with neoplastic obstruction. Further observations are needed.
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Affiliation(s)
- T Nakamura
- Department of Gastroenterology, Hamamatsu Medical Center, Shizuoka, Japan
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Pron G, Common A, Simons M, Ho CS. Interventional radiology and the use of metal stents in nonvascular clinical practice: a systematic overview. J Vasc Interv Radiol 1999; 10:613-28. [PMID: 10357489 DOI: 10.1016/s1051-0443(99)70092-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE The intent of this systematic overview was to describe the clinical role of metal stents in nonvascular health care interventions and the level of evidence supporting their use. MATERIALS AND METHODS Structured searches of Medline were conducted and limited to original peer-reviewed articles published in English. RESULTS Clinical practice involving metal stents was reported in more than 109 clinical series involving 4,753 patients. Stents were placed mainly for palliation of malignant biliary, esophageal, and airway obstruction in patients who were untreatable or had surgically unresectable lesions. Assessment of these interventions has so far centered on safety and technical success. Efficacy, quality of life, and costing factors were not routinely reported. Randomized trial evidence was available but limited; six randomized trials involving metal stents have been reported. Three trials involved biliary malignant obstruction, and all three reported metal stent (132 patients) palliation to be superior to plastic stent palliation (136 patients) based on longer patency and lower reintervention costs. Safety and complication differences between stents, however, were inconsistent across trials. In three trials involving esophageal malignant obstruction, metal stent (82 patients) palliation was reported to be superior to plastic stent (41 patients), based on lower complication and reintervention rates, and superior to laser therapy (18 patients), based on better dysphagia relief. CONCLUSION Use of metal stents has been reported for obstructed ducts and passageways of most body systems. There is, however, limited controlled trial evidence confirming the advantages of their use over plastic stents or other forms of treatment.
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Affiliation(s)
- G Pron
- Department of Medical Imaging, University of Toronto, Ontario
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SWANSTROM LEEL. Endoscopic Surgery for Pancreato-Biliary Cancer. J Laparoendosc Adv Surg Tech A 1998. [DOI: 10.1089/lap.1998.8.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Schirmer B. SSAT/SAGES minimally invasive surgeryAdvanced laparoscopic hepatobiliary surgery. Surg Endosc 1998; 12:361. [PMID: 9543532 DOI: 10.1007/s004649900673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- B Schirmer
- Department of Surgery, University of Virginia Health Science Center, Box 181, Charlottesville, VA 22908, USA
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Prat F, Chapat O, Ducot B, Ponchon T, Pelletier G, Fritsch J, Choury AD, Buffet C. A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct. Gastrointest Endosc 1998; 47:1-7. [PMID: 9468416 DOI: 10.1016/s0016-5107(98)70291-3] [Citation(s) in RCA: 346] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although metallic stents remain patent longer than plastic stents, the optimal palliation of inoperable malignant biliary strictures remains controversial because of the high cost of metallic stents and short patient survival. METHODS A total of 101 patients (mean age 72.5+/-12.9 years) with malignant strictures of the common bile duct were included in this study, after three exclusions for technical failure (n = 3) and one for noncompliance with study design. The etiology of the strictures included pancreatic cancer (65), cholangiocarcinoma (21), ampullary tumor (3), and metastatic lymph nodes (12). Patients were randomized to receive either an 11.5F polyethylene stent to be exchanged in case of dysfunction (group 1, n = 33), an 11.5F stent to be exchanged every 3 months (group 2, n = 34), or a self-expanding metallic Wallstent (group 3, n = 34). RESULTS Endoscopic procedures were successful (including complete relief of jaundice) in 97.1 % of cases. Procedure-related morbidity was 11.9%, and mortality was 2.9%. Bilirubinemia after 48 hours (37.2%+/-21.7% decrease from the preoperative level) did not differ between groups. Patients were followed for a mean of 166 days (median 143, range 0 to 596 days). Overall survivals were not different between groups, but complication-free survival for groups 2 and 3 was longer than that of group 1 (p < 0.05). Cumulated hospital days were 7.4+/-1.5, 10.6+/-1.7, and 5.5+/-1.4 (groups 1, 2, and 3, respectively) (p < 0.05; analysis of variance). Cost analysis showed that metallic stents were advantageous in patients surviving more than 6 months, whereas a plastic stent was advantageous in patients surviving 6 months or less. CONCLUSIONS Metallic stents and plastic stents exchanged every 3 months are valuable alternatives for increasing complication-free survival in patients with malignant strictures of the common bile duct. Metal stents are advantageous in patients with the longest life expectancy.
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Affiliation(s)
- F Prat
- Service des Maladies du Fole et de l'Appareil Digestif, INSERM U292, CHU de Bicêtre, Le Kremlin-Bicêtre, France
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Tesdal IK, Adamus R, Poeckler C, Koepke J, Jaschke W, Georgi M. Therapy for biliary stenoses and occlusions with use of three different metallic stents: single-center experience. J Vasc Interv Radiol 1997; 8:869-79. [PMID: 9314381 DOI: 10.1016/s1051-0443(97)70676-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
PURPOSE The authors report their experience with three different metallic stents for the treatment of biliary obstructions during a 6.5-year period (between February 1989 and June 1995). MATERIALS AND METHODS In an uncontrolled, nonrandomized, and prospective study, 168 patients with obstructive jaundice underwent transhepatic placement of metallic stents. Patients were excluded if they were deemed too ill for intervention or had incorrectable coagulopathy. Those patients undergoing external and/or intraluminal radiation therapy, and patients in whom an internal-external catheter was kept in place after insertion of a stent were not included. Inoperable malignant disease was diagnosed in 157 patients (93.5%). Eleven patients presented with a benign biliary stricture that could not be managed by means of angioplasty. One hundred fifty-five Wallstents were placed in 122 patients, 65 tantalum Strecker stents were placed in 30 patients, and 18 Memotherm stents were placed in 16 patients. The patients were followed until September 1996 or until death. RESULTS Regarding malignant obstruction, the 30-day mortality rate was 10.7% without any procedure-related death, and overall survival rates after 100 and 200 days were 63% and 22%, respectively. Regarding benign stricture, eight of 11 patients were alive after a median follow-up of 50.6 months without any 30-day mortality. Major complications occurred in 16 patients (10.2%) who had malignancy, and in two patients (18.2%) with benign biliary disease. The cumulative patency rate in malignant obstructions was significantly higher for the Wallstent than for the Memotherm stent (P < .05) and nonsignificantly higher for the Wallstent than for the tantalum Strecker stent (P > .05). Reintervention due to recurrent obstructive jaundice was necessary in 28 patients (17.8%) with malignancy, and in six patients (54.5%) with benign stricture. CONCLUSIONS The Wallstent is the most effective in achieving long-term palliation in patients with malignant obstructive jaundice. The treatment of benign biliary strictures with metallic stents is associated with a low long-term patency rate.
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Affiliation(s)
- I K Tesdal
- Institute for Clinical Radiology at the University Hospital of Mannheim, Germany
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Abstract
OBJECTIVE Although surgical biliary bypass for nonresectable periampullary tumors is superior to endoscopic stent placement, the latter has become popular because of the "minimally invasive" approach. Laparoscopic biliary bypass would appear to offer the advantages of both. However, this technique remains technically difficult using existing instrumentation. This study investigates the efficacy of a new endoscopic device designed for rapidly completing a small-diameter intestinal anastomosis under laparoscopic guidance. METHODS Eighteen female pigs (mean weight 35 kg, range 31 to 44) were randomly divided into three groups: animals undergoing handsewn (group H) or instrumental transient endoluminally stented anastomosis (TESA; groups P and D) laparoscopic Roux-en-Y choledochojejunostomy. For TESA two different reabsorbable stents were used, polyglycolic acid (PGA; group P) and polyurethane ester (Degrapol; group D). Blood chemistry, weight gain, and abdominal X-rays were taken weekly to document any possible migration or reabsorption of the radio-opaque stents. After 3 months, necropsy was performed. Patency of the biliary bypass and choledochojejunostomy were examined using fluoroscopy and measured by introducing graduated dilators into the anastomosis. RESULTS Fluoroscopy revealed immediate passage of contrast through the anastomosis in all animals. Weight gain, bilirubin, and alkaline phosphatase were within normal range in all groups. Diameter of the bile duct (group H 10.7 +/- 2.9 mm/group P 9.5 +/- 3.6 mm/group D 11.0 +/- 4.6 mm) and choledochojejunostomy (group H 4.5 +/- 1.1 mm/group P 4.7 +/- 1.8 mm/group D 3.6 +/- 1.9 mm) did not differ. The time required to complete the biliary bypass was significantly decreased when TESA was applied (group H 152 +/- 13 min/group P 86 +/- 14 min, P <0.001/group D 110 +/- 20 min, P <0.002). CONCLUSIONS Applying TESA, laparoscopic choledochojejunostomy can be performed rapidly and safely, revealing good bypass function over a period of 3 months. With regard to treatment for nonresectable periampullary tumors, TESA may offer a new therapeutic approach combining the benefits of minimally invasive endoscopic stent placement with the functional results and lower readmission of conventional Roux-en-Y choledochojejunostomy.
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Affiliation(s)
- O M Schöb
- Department of Surgery, University of Zürich Hospital, Switzerland
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van Dijkum EJN, de Wit LT, van Delden OM, Rauws EA, van Lanschot JJ, Obertop H, Gouma DJ. The efficacy of laparoscopic staging in patients with upper gastrointestinal tumors. Cancer 1997. [DOI: 10.1002/(sici)1097-0142(19970401)79:7<1315::aid-cncr7>3.0.co;2-f] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abstract
PURPOSE Retrospective analysis of our results with metallic stent placement for malignant biliary strictures. We sought to determine parameters that influence stent patency. METHODS A total of 95 Wallstents were implanted in 65 patients (38 men, 27 women; mean age, 65.1 years) with malignant biliary obstruction. Serum bilirubin levels were assessed in 48 patients; the mean value prior to intervention was 15.0 mg/dl. RESULTS In 12 patients (21%) complications occurred as a result of percutaneous transhepatic drainage. Stent implantation was complicated in 13 patients, but was possible in all patients. A significant decrease in bilirubin level was seen in 83.3% of patients following stent implantation. Approximately 30% of patients developed recurrent jaundice after a mean 97.1 days. In 9 patients (15%) the recurrent jaundice was caused by stent occlusion due to tumor growth. The mean follow-up was 141.8 days, the mean survival 118.7 days. Patients with cholangiocarcinomas and gallbladder carcinomas had the best results. Worse results were seen in patients with pancreatic tumors and with lymph node metastases of colon and gastric cancers. CONCLUSIONS The main predictive factors for occlusion rate and survival are the type of primary tumor, tumor stage, the decrease in bilirubin level, and the general condition of the patient.
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Affiliation(s)
- A Rieber
- Department of Diagnostic Radiology, University of Ulm, Germany
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Gaglio PJ, Buniak B, Leevy CB. Primary endoscopic retrograde cholecystoendoprosthesis: a nonsurgical modality for symptomatic cholelithiasis in cirrhotic patients. Gastrointest Endosc 1996; 44:339-42. [PMID: 8885359 DOI: 10.1016/s0016-5107(96)70177-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- P J Gaglio
- New Jersey Medical School Liver Center, Newark 07103, USA
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49
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Affiliation(s)
- D Tarver
- Department of Radiology, North Hampshire Hospital, Basingstoke, Hants, UK
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50
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Abstract
Endoscopic stenting has revolutionized the palliation of malignant biliary obstruction. Individuals with biliary obstruction due to pancreatic malignancy are best managed by a team approach comprising individuals with expertise in oncology, surgery, endoscopy, and radiology. The clinical value of alleviating jaundice and associated symptoms of anorexia, pruritus, and malaise cannot be overestimated. These quality-of-life factors deserve more attention in future studies to define subgroups of patients most likely to derive benefit from the array of treatment options. Further technical improvements are required to solve the most important clinical problem of late stent occlusion. New developments such as expandable metallic stents and refinements in existing equipment and techniques have already resulted in measurable gains and hold great promise for future expansion of their use in malignant gastric outlet obstruction secondary to tumor infiltration of the duodenum. Corresponding advances are being made in the fields of percutaneous transhepatic intervention and hepatobiliary surgery such that further prospective randomized trials are necessary to define optimal therapy.
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Affiliation(s)
- D R Lichtenstein
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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