Endoscopic sphincterotomy before deployment of covered metal stent is associated with greater complication rate: a prospective randomized control trial

Clinical Practice Guidelines for post-ERCP pancreatitis 2023

The Clinical Practice Guidelines for post-ERCP pancreatitis (PEP) 2023 provide updated recommendations for the prevention, diagnosis, and management of PEP. Endoscopic retrograde cholangiopancreatography (ERCP), a valuable procedure for diagnosing and treating pancreatobiliary diseases, can result in PEP as the most common adverse event. Since the first guidelines were published in 2015, advances in techniques and new research findings have necessitated this revision. The guidelines developed using the GRADE methodology target adult patients undergoing ERCP. They offer a comprehensive framework for clinicians to minimize the risk of PEP. For high-risk patients, endoscopic ultrasound before ERCP is recommended to avoid unnecessary procedures. The guidelines also discuss procedural and patient-related risk factors for PEP, highlighting that operator experience does not significantly affect PEP rates if performed under the supervision of skilled endoscopists. The diagnostic criteria include monitoring serum pancreatic enzyme levels postprocedure, and early computed tomography is advised in suspected cases. For treatment, the guidelines recommend following acute pancreatitis protocols. Key preventive measures include the use of temporary pancreatic duct stents and rectal nonsteroidal anti-inflammatory drugs, both of which are supported by strong evidence for reducing the incidence of PEP. Overall, these guidelines aim to enhance clinical outcomes by reducing PEP incidence and improving its management through evidence-based practices.

Biliary stenting with and without endoscopic sphincterotomy in patients with malignant biliary obstruction: meta-analysis of randomized controlled trials

Endoscopic biliary sphincterotomy (EBS) is commonly performed during endoscopic retrograde cholangiopancreatography (ERCP) in patients with malignant biliary obstruction (MBO) before stent placement. Studies comparing adverse events between patients with MBO undergoing ERCP with and without EBS have reported conflicting results. We conducted an updated meta-analysis including randomized controlled trials (RCTs) only to evaluate the safety of EBS in these patients and its efficacy in decreasing the risk of post-ERCP pancreatitis (PEP). We reviewed several databases from inception to 10 January 2024 to identify RCTs that compared adverse events of biliary stenting with and without EBS in the patients with MBO. Our outcomes of interest were PEP, successful stent insertion, and adverse events such as cholangitis, bleeding, perforation, stent migration, and stent occlusion. We calculated pooled risk ratio with 95% confidence intervals (CIs) for all of the outcomes and used a random effect model to analyze the data. We included six RCTs with 1070 patients. There was no significant difference in rate of PEP between groups [risk ratio (95% CI): 0.50 (0.23-1.08)]. We found no significant difference in the rate of successful stent insertion between groups [risk ratio (95% CI): 1.01 (0.99-1.02)]. The rate of post-ERCP bleeding was significantly higher in EBS group [risk ratio (95% CI): 7.43 (2.45-22.53)]. We found no significant difference in rates of cholangitis, perforation, stent migration, and stent occlusion between groups. EBS does not decrease the risk of PEP in patients with MBO and is associated with increased risk of bleeding.

Endoscopic sphincterotomy to prevent post-ERCP pancreatitis after self-expandable metal stent placement for distal malignant biliary obstruction (SPHINX): a multicentre, randomised controlled trial

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) with fully covered self-expandable metal stent (FCSEMS) placement is the preferred approach for biliary drainage in patients with suspected distal malignant biliary obstruction (MBO). However, FCSEMS placement is associated with a high risk of post-ERCP pancreatitis (PEP). Endoscopic sphincterotomy prior to FCSEMS placement may reduce PEP risk.

OBJECTIVE

To compare endoscopic sphincterotomy to no sphincterotomy prior to FCSEMS placement.

DESIGN

This multicentre, randomised, superiority trial was conducted in 17 hospitals and included patients with suspected distal MBO. Patients were randomised during ERCP to receive either endoscopic sphincterotomy (sphincterotomy group) or no sphincterotomy (control group) prior to FCSEMS placement. The primary outcome was PEP within 30 days. Secondary outcomes included procedure-related complications and 30-day mortality. An interim analysis was performed after 50% of patients (n=259) had completed follow-up.

RESULTS

Between May 2016 and June 2023, 297 patients were included in the intention-to-treat analysis, with 156 in the sphincterotomy group and 141 in the control group. After the interim analysis, the study was terminated prematurely due to futility. PEP did not differ between groups, occurring in 26 patients (17%) in the sphincterotomy group compared with 30 patients (21%) in the control group (relative risk 0.78, 95% CI 0.49 to 1.26, p=0.37). There were no significant differences in bleeding, perforation, cholangitis, cholecystitis or 30-day mortality.

CONCLUSION

This trial found that endoscopic sphincterotomy was not superior to no sphincterotomy in reducing PEP in patients with distal MBO. Therefore, there was insufficient evidence to recommend routine endoscopic sphincterotomy prior to FCEMS placement.

TRIAL REGISTRATION NUMBER

NL5130.

The addition of endoscopic sphincterotomy to biliary stent placement and its impact on the risk of adverse events: an updated meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Endoscopic sphincterotomy (ES) is not mandatory before biliary stenting. The impact of ES before biliary stent placement remains uncertain. Previous studies have reported that ES can increase adverse event rates by up to 4.5 times compared with no ES. We aimed to assess the occurrence of post-ERCP adverse events following biliary stent placement with and without ES.

METHODS

PubMed, Embase, and Cochrane databases were systematically searched for randomized controlled trials. The primary outcome was post-ERCP pancreatitis (PEP). Subgroup analyses were performed with patients undergoing biliary drainage due to obstruction, using metal stents, and using plastic stents. Secondary outcomes were postprocedural bleeding, perforation, stent/catheter occlusion, stent/catheter migration, and cholangitis. Heterogeneity was examined with I2 statistics, and a random-effects model was used. Review Manager 5.4 was used for statistical analyses.

RESULTS

Seven RCTs with 1022 patients were included. There was no significant difference between the ES and non-ES groups (odds ratio [OR], .46; 95% CI, .19-1.09; P = .08; I2 = 59%) regarding PEP; however, a significant difference in bleeding rates was found between groups, favoring non-ES (OR, 7.01; 95% CI, 2.24-21.99; P = .0008; I2 = 0%). The analysis of the occurrence of cholangitis (OR, 1.25; 95% CI, .58-2.69; P = .56; I2 = 67%), perforation (OR, 1.95; 95% CI, .07-55.73; P = .70; I2 = 58%), stent/catheter migration (OR, 2.15; 95% CI, .61-7.57; P = 0.23; I2 = 6%), and stent/catheter occlusion (OR, .91; 95% CI, .37-2.25; P = .84; I2 = 0%) did not favor either group.

CONCLUSIONS

Performing ES before biliary drainage does not affect the PEP rate but is associated with an increased postprocedural bleeding rate.

Utility of Covered Self-Expanding Metal Stents for Biliary Drainage during Neoadjuvant Chemotherapy in Patients with Borderline Resectable Pancreatic Cancer

OBJECTIVES

We aimed to compare the utility of covered self-expanding metal stents (CSEMSs) with that of plastic stents (PSs) for biliary drainage during neoadjuvant chemotherapy in patients with borderline resectable pancreatic cancer.

METHODS

Forty patients with borderline resectable pancreatic cancer underwent biliary stenting during neoadjuvant chemotherapy at Hiroshima University Hospital. PSs and CSEMSs were placed in 19 and 21 patients, respectively. Two gemcitabine-based regimens for chemotherapy were used. Treatment outcomes and postoperative complications were compared between both groups.

RESULTS

The incidence of recurrent biliary obstruction was significantly lower in the CSEMS group (0% vs. 47.4%, p < 0.001), and the median time to recurrent biliary obstruction in the PS group was 47 days. There was no difference in the incidence of other complications such as non-occlusive cholangitis, pancreatitis, and cholecystitis between the two groups. Delays in the chemotherapy schedule due to stent-related complications were significantly frequent in the PS group (52.6% vs. 4.8%, p = 0.001). There was no significant difference in the incidence of postoperative complications between the two groups.

CONCLUSIONS

CSEMSs may be the best choice for safely performing neoadjuvant chemotherapy for several months in patients with borderline resectable pancreatic cancer with bile duct stricture.

Interventional gastroenterology in oncology

Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.

Novel anti-reflux biliary metal stent with a distal tapered end for distal malignant biliary obstruction: a feasibility study

Background and study aims  We developed a self-expandable metallic stent (SEMS) with a distal tapered end to reproduce the physiological bile flow with a pressure gradient due to the difference in the diameter. We aimed to evaluate the safety and efficacy of the newly developed distal tapered covered metal stent (TMS) for distal malignant biliary obstruction (DMBO). Patients and methods  This single-center, prospective, single-arm study was conducted in patients with DMBO. The primary endpoint was time to recurrent biliary obstruction (TRBO), and the secondary endpoints were the survival time and incidence of adverse events (AEs). Results  Thirty-five patients (15 men, 20 women; median age, 81 years [range: 53-92]) were enrolled between December 2017 and December 2019. The primary diseases were pancreatic head cancer in 25 cases, bile duct cancer in eight cases, and ampullary cancer in two cases. TMS was successfully placed in all cases. Acute cholecystitis occurred as an early AE (within 30 days) in two cases (5.7 %). The median TRBO was 503 days, median survival time was 239 days. RBO was observed in 10 cases (28.6 %), and the causes were distal migration in six cases, proximal migration in two cases, biliary sludge in one case, and tumor overgrowth in one case. Conclusions  Endoscopic placement of the newly developed TMS in patients with DMBO is technically feasible and safe, and the TRBO was remarkably long. The anti-reflux mechanism based on the difference in diameter may be effective, and a randomized controlled trial with a conventional SEMS is required.

Does endoscopic sphincterotomy contribute to the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis after endoscopic biliary stenting for malignant biliary obstruction? A multicenter prospective cohort study

BACKGROUND

There is no consensus on the necessity of endoscopic sphincterotomy (ES) to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after endoscopic stenting in patients with malignant biliary obstruction. We investigated the incidence of PEP after endoscopic biliary stenting for malignant biliary obstruction with or without ES in a multicenter prospective cohort study.

METHODS

We enrolled 807 patients who underwent endoscopic biliary stenting for malignant biliary obstruction with a native papilla at 36 hospitals between April 2017 and March 2018. The incidence of PEP in patients with or without ES was compared for subgroups based on stent type, placement method, and patient background. Univariate and multivariate analysis was performed to investigate the incidence of PEP in all stenting patients.

RESULTS

Plastic and metal stents (MS) were inserted in 598 and 209 patients, respectively. The incidence of PEP in patients with or without ES was 7.9% and 7.4%, respectively among all stenting patients. The incidences of PEP with or without ES in plastic stent insertion patients, patients with MS insertion, stent insertions across the papilla, stent insertions across the papilla in patients without main pancreatic duct obstruction, and fully covered MS insertions across the papilla were compared. There was no overall significant difference in the incidence of PEP between those with or without ES. Multivariate logistic regression analysis for the incidence of PEP in all stenting patients revealed obstruction of the main pancreatic duct at the pancreatic head and epinephrine spraying on the papilla were significant factors; there was no significant difference in the incidence of PEP between patients with or without ES.

CONCLUSION

Endoscopic sphincterotomy may not contribute to the prevention of PEP after endoscopic biliary stenting for malignant biliary obstruction, even in cases of insertion with a fully covered MS across the papilla.

Risk of Pancreatitis Following Biliary Stenting With/Without Endoscopic Sphincterotomy: A Randomized Controlled Trial

BACKGROUND & AIMS

The efficacy of endoscopic sphincterotomy (ES) before endoscopic transpapillary biliary drainage in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) has not been established. The aim of this study was to evaluate the effect of performing ES before biliary stent/tube placement on the occurrence of PEP.

METHODS

Three hundred seventy patients with biliary stricture requiring endoscopic biliary stenting were enrolled and randomly allocated to the ES group (n = 185) or non-ES group (n = 185). All participants were followed up for 30 days after the procedure. The data and occurrence of adverse events were prospectively collected. The primary outcome measure of this study was the incidence of PEP within 2 days of initial transpapillary biliary drainage. Secondary outcome measures were the incidence of other adverse events related to biliary stent/tube placement.

RESULTS

PEP occurred in 36 patients (20.6%) in the non-ES group and in 7 patients (3.9%) in the ES group (P < .001). The difference in the incidence of PEP between the 2 groups in the per-protocol population was 16.7% (95% confidence interval, 10.1%-23.3%), which was not within the noninferiority margin of 6%. Except for bleeding, the incidences of other adverse events were not significantly different between the groups.

CONCLUSION

ES before endoscopic biliary stenting could have the preventive effect on the occurrence of PEP in patients with biliary stricture. University Hospital Medical Information Network Number, UMIN000025727.University Hospital Medical Information Network Clinical Trial Registry URL: https://www.umin.ac.jp/ctr/index.htm.

Prevention of pancreatitis after stent implantation for distal malignant biliary strictures: systematic review and meta-analysis

INTRODUCTION

Biliary stent placement remains a palliative treatment for patients with unresectable distal malignant biliary strictures (DMBS). The incidence of post-ERCP-pancreatitis (PEP) significantly increases in patients receiving fully covered self-expandable metal stents (FCSEMS) who undergo endoscopic retrograde cholangiopancreatography (ERCP).

AREAS COVERED

This review provides an overview of prevention of PEP after stent implantation for DMBSs. The following operational variables were evaluated: (1) stent type (plastic or metal stent); (2) stent location (above or across the sphincter of Oddi); (3) prophylactic pancreatic duct stent placement; (4) endoscopic sphincterotomy (EST). PubMed, EMBASE, and Cochrane database were searched to identify eligible studies up to October 2021. The odds ratio (OR) with 95% confidence intervals (CI) were pooled using fixed- or random- effects models.

EXPERT OPINION

1. PEP occurs more frequently in DMBS patients with self-expandable metal stents (SEMS) compared to that plastic stent (PS). 2. The PEP incidence is higher in covered stents than that in uncovered self-expandable metal stents (USEMS), but not significantly. 3. PEP incidence increases in patients receiving transpapillary FCSEMS placement, particularly when there is an absence of pancreatic duct dilation, and prophylactic pancreatic stenting is recommended for these patients. 4. Limited studies with small sample indicate that there is no significant difference in PEP incidence between transpapillary and suprapapillary stents placement for DMBS. 5. Limited studies indicate that EST does not significantly affect the incidence of pancreatitis in DMBS patients.

Inutility of endoscopic sphincterotomy to prevent pancreatitis after biliary metal stent placement in the patients without pancreatic duct obstruction

Background: The incidence of post-ERCP pancreatitis (PEP) has been reported to be significantly higher in patients without main pancreatic duct (MPD) obstruction who undergo transpapillary biliary metal stent (MS) placement than in those with ordinary ERCP setting.Objective: To evaluate the benefit of endoscopic sphincterotomy (ES) prior to MS placement in preventing PEP in patients with distal malignant biliary obstruction (MBO) without MPD obstruction.Materials and methods: In total, 160 patients who underwent initial MS placement for MBO were enrolled. Eighty-two patients underwent ES immediately prior to MS placement, whereas 78 underwent MS placement without ES. An inverse probability of treatment weighting method was adopted to adjust the differences of the patients' characteristics. The primary outcome was the incidence of PEP. The secondary outcomes included the incidence of other adverse events (bleeding, cholangitis, perforation and stent dislocation) and time to recurrent biliary obstruction.Results: The incidence of PEP was 26.8% in the ES and 23.1% in the non-ES (unadjusted odds ratio [OR] [95%CI]: 1.22, [0.60-2.51], adjusted OR [95%CI]: 1.23, [0.53-2.81], p = .63). Logistic-regression analysis revealed no factors that could be attributed to the occurrence of PEP. The incidence of other adverse events was not different between the groups. The median time to recurrent biliary obstruction was 131 (2-465) days and 200 (4-864) days in the ES and non-ES, respectively (p = .215).Conclusions: ES prior to MS placement for patients with distal MBO without MPD obstruction does not reduce the incidence of PEP.

Acute pancreatitis after percutaneous insertion of metallic biliary stents in patients with unresectable pancreatic cancer

AIM

To investigate the incidence and clinical characteristics of acute pancreatitis following percutaneous insertion of metallic biliary stents in patients with unresectable pancreatic cancer. The clinical efficacy of metallic stent insertion was also evaluated.

MATERIALS AND METHODS

Data from 143 patients (75 men, 68 women; mean age, 65.8 years; range, 35-88 years) with unresectable pancreatic cancer who underwent percutaneous metallic biliary stent insertion between March 2007 and December 2017 were evaluated retrospectively. The incidence and clinical characteristics of acute pancreatitis were analysed. Stent patency and patient survival rates were calculated by Kaplan-Meier analysis.

RESULTS

Technical success was achieved in all patients. Among 31 patients with serum amylase levels above normal values (30-110 U/l), only nine had symptoms of acute pancreatitis (incidence, 6.4%). No statistically significant risk factors were identified. Pancreatitis was successfully managed with conservative treatment at a mean of 2.9 days (range, 1-4 days). The median stent patency and patient survival times were 117 days (95% confidence interval [CI], 87-148 days) and 150 days (95% CI, 125-174.9 days), respectively.

CONCLUSIONS

Acute pancreatitis was a relatively rare complication after percutaneous insertion of metallic biliary stents in patients with unresectable pancreatic cancer, and no significant risk factors were identified. Therefore, insertion of metallic biliary stents was seen to be a feasible and effective treatment approach in this patient group.

Endoscopic Sphincterotomy before Fully Covered Metal Stent Placement Is Not Required for Distal Malignant Biliary Stricture due to a Pancreatic Head Tumor

Background/Aims

Endoscopic sphincterotomy (EST) is often performed before fully covered self-expandable metal stent (FCSEMS) placement in order to prevent pancreatitis. However, it is not clear whether EST prevents pancreatitis or affects other adverse events (AEs). This study is conducted to evaluate the necessity of EST before FCSEMS placement for distal malignant biliary strictures due to a pancreatic head tumor.

Methods

This study included 68 patients who underwent FCSEMS placement for distal malignant biliary stricture due to a pancreatic head tumor. Treatment outcomes and AEs were retrospectively compared between 32 patients with EST before FCSEMS placement (EST group) and 36 patients without EST (non-EST group).

Results

The success rates of drainage for the EST and non-EST groups were 100% and 97.2%, respectively (P = 0.95). The incidence of pancreatitis in the EST and non-EST groups was 3.1% and 0%, respectively (P = 0.95). The incidence of hyperamylasemia in the EST and non-EST groups was 12.5% and 13.9%, respectively (P = 0.85). The incidence of all AEs in the EST and non-EST groups was 15.6% (pancreatitis: 1, cholecystitis: 2, and stent migration: 2) and 13.9% (cholecystitis: 3, stent migration: 2), respectively (P = 0.89).

Conclusions

EST before FCSEMS placement for distal malignant biliary stricture due to a pancreatic head tumor does not affect the successful drainage and incidence of adverse events. The necessity of EST to prevent pancreatitis before FCSEMS placement was deemed low.

Endoscopic biliary self-expandable metallic stent in malignant biliary obstruction with or without sphincterotomy: systematic review and meta-analysis

Background and aim  To assess the rate of adverse events and the technical success rate of biliary stenting with or without EBS.  Methods  A literature search up to February 2017 was performed. Studies assessing adverse events (AEs) and technical success rates of stenting with or without EBS were considered. Results  Seven studies (870 patients; 12 treatment arms) were included. Early AEs, i. e. those occurring within 30 days, were significantly lower in no-EBS vs. EBS-group (11 % vs . 20.1 %; OR: 0.36, 95 %CI: 0.13 - 1.00). Rates of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis were not significantly different in the two groups (no-EBS vs . EBS: 6.1 % vs 5 %; OR: 1.33, 95 %CI: 0.68 - 2.59). The rate of bleeding was significantly lower in patients without EBS (no-EBS vs EBS: 0 % vs 5 %; OR: 0.12, 95 % CI: 0.03 - 0.45). Rates of cholangitis were significantly lower in patients without EBS (no-EBS vs . EBS: 3.3 % vs. 7.4 %; OR: 0.38, 95 %CI: 0.17 - 0.83). Both late AEs and mortality rates did not significantly differ between no-EBS and EBS patients (19.9 % vs. 18.9 %; OR: 0.93, 95 %CI: 0.56 - 1.53, and 2.5 % vs. 2.9 %; OR: 1.18, 95 %CI: 0.22 - 6.29, respectively). The technical success rate for stent insertion also did not differ (98 % vs. 97.6 %; OR: 1.05, 95 %CI: 0.42 - 2.63). Conclusion  EBS seems to be associated, in the first 30 days after the procedure, with an increased risk of cholangitis and bleeding. No difference was observed in the rate of post-ERCP pancreatitis.

Endoscopic Palliation of Pancreatic Cancer

OPINION STATEMENT

Pancreas cancer is a fourth-leading cause of cancer death in the USA and its incidence is rising as the population is aging. The majority of patients present at an advanced stage due to the silent nature of the disease and treatment have focused more on palliation than curative intent. Gastroenterologists have become integral in the multidisciplinary care of these patients with a focus on providing endoscopic palliation of pancreas cancer. The three most common areas that gastroenterologists palliate endoscopically are biliary obstruction, cancer-related pain, and gastric outlet obstruction. To palliate biliary obstruction, the procedure of choice is to perform endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement. We tend to place covered self-expandable metal stents (SEMS) due to their longer patency and removability unless the patient has resectable disease. Pancreas cancer pain is a result of tumor infiltration of the celiac plexus and can be severe and poorly responsive to narcotics. To improve pain control, neurolysis of the celiac plexus has been performed for decades. Since 1996, neurolysis of the celiac area has been performed endoscopically by Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis. This has proven to be as safe and effective as traditional non-endoscopic methods and has allowed the patients to decrease their narcotic use and improve their pain control. This should be done early on in the course of the disease to have maximal effect. Gastric outlet obstruction (GOO) occurs in approximately 15-20% of patients with pancreas cancer. Endoscopic palliation of GOO can be performed by placing uncovered metal enteral stents across the obstruction. This procedure has proven to be very effective in patients who have a short life expectancy (less than two to 6 months) while surgical bypass should be considered for patients with longer life expectancies because it offers better long-term symptom relief. This chapter will review the current literature, latest advancements, and optimal techniques for endoscopic palliation of pancreatic cancer.

Survey study on the practice patterns in the endoscopic management of malignant distal biliary obstruction

BACKGROUND AND STUDY AIM

 Endoscopic biliary drainage for malignant distal biliary obstruction (MDBO) is a common practice. Controversy persists with regard to its role in resectable MDBO, the optimal technical method and type of stent. The aim of this study was to evaluate practice patterns in the treatment of MDBO among endoscopists with varying levels of experience and practice backgrounds.

METHODS

 Electronic survey distributed to members of the American Society for Gastrointestinal Endoscopy (ASGE). The main outcome measures included practice setting (academic vs. community), volume of endoscopic retrograde cholangiopancreatographies (ERCPs), reasons for endoscopic drainage in MDBO, and technical approach.

RESULTS

 A total of 335 subjects (54 % community-based endoscopists) completed the survey. Most academic physicians (69 %) reported performing ≥ 150 ERCPs annually compared to 18.8 % of community physicians ( P  < 0.001). In aggregate, 13.1 % of respondents performed ERCP in resectable MDBO because of surgeon preference or as the standard of care at their institution. The use of metal vs. plastic stents in MDBO varied based on practice setting. Routine sphincterotomy for MDBO was more common among community (78 %) vs academic endoscopists (61.1 %) ( P  < 0.001). Over half (58 %) of the subjects avoided covering the cystic duct take-off during stenting MDBO if there was a gallbladder in situ.

CONCLUSION

 There is significant variability in practice patterns for the treatment of MDBO. In spite of the recent ASGE guideline recommendations, some patients with resectable MDBO still undergo preoperative ERCP. Current clinical practices are not clearly supported by available data and underscore the need to increase adherence to gastrointestinal societal recommendations and an evidence-based approach to standardized patient care.

The Wire-Grasping Method as a New Technique for Forceps Biopsy of Biliary Strictures: A Prospective Randomized Controlled Study of Effectiveness

Background/Aims

Transpapillary forceps biopsy is an effective diagnostic technique in patients with biliary stricture. This prospective study aimed to determine the usefulness of the wire-grasping method as a new technique for forceps biopsy.

Methods

Consecutive patients with biliary stricture or irregularities of the bile duct wall were randomly allocated to either the direct or wire-grasping method group. In the wire-grasping method, forceps in the duodenum grasps a guide-wire placed into the bile duct beforehand, and then, the forceps are pushed through the papilla without endoscopic sphincterotomy. In the direct method, forceps are directly pushed into the bile duct alongside a guide-wire. The primary endpoint was the success rate of obtaining specimens suitable for adequate pathological examination.

Results

In total, 32 patients were enrolled, and 28 (14 in each group) were eligible for analysis. The success rate was significantly higher using the wire-grasping method than the direct method (100% vs 50%, p=0.016). Sensitivity and accuracy for the diagnosis of cancer were comparable in patients with the successful procurement of biopsy specimens between the two methods (91% vs 83% and 93% vs 86%, respectively).

Conclusions

The wire-grasping method is useful for diagnosing patients with biliary stricture or irregularities of the bile duct wall.

Efficacy and safety of limited endoscopic sphincterotomy before self-expandable metal stent insertion for malignant biliary obstruction

AIM

To evaluate the safety and efficacy of limited endoscopic sphincterotomy (ES) before placement of self-expandable metal stent (SEMS).

METHODS

This was a retrospective analysis of 244 consecutive patients with unresectable malignant biliary obstruction, who underwent placement of SEMSs following limited ES from December 2008 to February 2015. The diagnosis of malignant biliary obstruction and assessment of patient eligibility for the study was established by a combination of clinical findings, laboratory investigations, imaging and pathological results. All patients were monitored in the hospital for at least 24 h following endoscopic retrograde cholangio pancreatography (ERCP). The incidence of immediate or early post-ERCP complications such as post-ERCP pancreatitis (PEP) and bleeding related to limited ES were considered as primary outcomes. Also, characteristics and complications according to the cancer type were classified.

RESULTS

Among the 244 patients included, the underlying diagnosis was cholangiocarcinoma in 118 patients, pancreatic cancer in 79, and non-pancreatic or non-biliary malignancies in the remaining 47 patients. Early post-ERCP complications occurred in 9 patients (3.7%), with PEP in 7 patients (2.9%; mild, 6; moderate, 1) and mild bleeding in 2 patients (0.8%). There was no significant association between the incidence of post-ERCP complications and the type of malignancy (cholangiocarcinoma vs pancreatic cancer vs others, P = 0.696) or the type of SEMS used (uncovered vs covered, P = 1.000). Patients who had more than one SEMS placed at the first instance were at a significantly higher risk of post-ERCP complications (one SEMS vs two SEMS, P = 0.031). No other factors were predictive of post-ERCP complications.

CONCLUSION

Limited ES is feasible and safe, and effectively facilitates the placement of SEMS, without any significant risk of PEP or severe bleeding.

The safety and efficacy of nasobiliary drainage versus biliary stenting in malignant biliary obstruction: A systematic review and meta-analysis

BACKGROUND

Preoperative biliary drainage (PBD) has been widely used to treat patients with malignant biliary obstruction. However, it is still unclear which method of PBD (endoscopic nasobiliary drainage or endoscopic biliary stenting) is more effective. Thus, we carried out a meta-analysis to compare the safety and efficacy of endoscopic nasobiliary drainage (ENBD) and endoscopic biliary stenting (EBS) in malignant biliary obstruction in terms of preoperative and postoperative complications.

METHODS

We conducted a literature search of EMBASE databases, PubMed, and the Cochrane Library to identify relevant available articles that were published in English, and we then compared ENBD and EBS in malignant biliary obstruction patients. The preoperative cholangitis rate, the preoperative pancreatitis rate, the incidence of stent dysfunction, the postoperative pancreatic fistula rate, and morbidity were analyzed. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to express the pooled effect on dichotomous variables, and the pooled analyses were performed using RevMan 5.3.

RESULTS

Seven published studies (n = 925 patients) were included in this meta-analysis. We determined that patients with malignant biliary obstruction who received ENBD had reductions in the preoperative cholangitis rate (OR = 0.35, 95% CI = 0.25-0.51, P < 0.0001), the postoperative pancreatic fistula rate (OR = 0.38, 95% CI = 0.18-0.82, P = 0.01), the incidence of stent dysfunction (OR = 0.39, 95% CI = 0.28-0.56, P < 0.0001), and morbidity (OR = 0.47, 95% CI = 0.27-0.82, P = 0.008) compared with patients who received EBS.

CONCLUSIONS

The current meta-analysis suggests that ENBD is better than EBS for malignant biliary obstruction in terms of the preoperative cholangitis rate, the postoperative pancreatic fistula rate, the incidence of stent dysfunction, and morbidity. However, a limitation is that there are no data from randomized controlled trials.

Does endoscopic sphincterotomy reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis after biliary stenting? A systematic review and meta-analysis

BACKGROUND AND AIM

Endoscopic biliary sphincterotomy (ES) is often carried out prior to placement of a biliary stent apparently to reduce the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, the protective effect of ES prior to biliary stenting is controversial. The objective of this meta-analysis is to compare the risk of PEP and other complications after the placement of biliary stent with or without ES in patients with biliary obstruction and bile leak.

METHODS

We carried out a systematic search in several electronic databases for randomized controlled trials (RCT) and observational studies (OS) comparing the risk of PEP after biliary stenting with or without ES. The Mantel-Haenszel method was used to pool data of adverse outcomes into fixed or random effect model meta-analyses.

RESULTS

Seventeen studies (five RCT and 12 OS) with a total of 2710 patients met the inclusion criteria. No significant difference was observed in the risk of PEP with biliary stenting with and without ES (RD -0.01; 95% confidence interval [CI] -0.03, 0.01). In a subgroup analysis of stenting for biliary obstruction, no difference in the risk of PEP was observed with or without ES. However, ES was associated with lower risk of PEP in patients undergoing biliary stenting for bile leak (RD -0.05; CI -0.10, -0.01).

CONCLUSIONS

ES shows risk reduction in prevention of PEP in patients undergoing endoscopic stenting for bile leak. However, placement of biliary stent without ES is not associated with an increased risk of PEP in patients with distal bile duct obstruction with involvement of pancreatic duct.

A retrospective study assessing fully covered metal stents as first-line management for malignant biliary strictures

OBJECTIVES

Fully covered self-expanding metal stents (FCSEMS) constitute the first type of metal stent that can easily be removed endoscopically and/or intraoperatively, which may be advantageous in the management of distal malignant biliary strictures (DMBS). To assess the efficacy of FCSEMS as first-line treatment for DMBS, we compared patency, survival and complication rates between FCSEMS, uncovered self-expanding metal stents (USEMS) and plastic stents (PS).

METHODS

This was a multicentre retrospective study of 315 consecutive patients with DMBS, who underwent endoscopic retrograde cholangiopancreatography and stenting (FCSEMS, USEMS or PS) at two hospitals between 1 January 2007 and 31 December 2013. Stent patency and patient survival were compared using the Kaplan-Meier method; complication rates were compared using Fisher's exact test; and Cox regression analysis was used to screen for confounding factors.

RESULTS

FCSEMS were associated with prolonged stent patency (median=145 days) compared with USEMS (median=110 days, P<0.003) and PS (median=34 days, P<0.001). Biliary sepsis rates were lower for FCSEMS compared with PS (4.7 vs. 17.8%, P=0.02), whereas pancreatitis rates were higher for FCSEMS compared with USEMS (7.8 vs. 1.0%, P=0.04), but not PS (2.6%, P=NS).

CONCLUSION

The use of FCSEMS as first-line management for DMBS is associated with longer patency and reduced complication rates compared with the use of PS. However, the higher rate of pancreatitis compared with USEMS requires further evaluation in a large randomized controlled trial.

Stenting in Malignant Biliary Obstruction

Decompression of the biliary system in patients with malignant biliary obstruction has been widely accepted and implemented as part of the care. Despite a wealth of literature, there remains a significant amount of uncertainty as to which approach would be most appropriate in different clinical settings. This review covers stenting of the biliary system in cases of resectable or palliative malignant biliary obstruction, potential candidates for biliary drainage, technical aspects of the procedure, as well as management of biliary stent dysfunction. Furthermore, periprocedural considerations including proper mapping of the location of obstruction and the use of antibiotics are addressed.

No benefit of endoscopic sphincterotomy before biliary placement of self-expandable metal stents for unresectable pancreatic cancer

BACKGROUND & AIMS

Endoscopic sphincterotomy (ES) is performed routinely before self-expandable metallic stents (SEMS) are placed in malignant distal biliary strictures to prevent postprocedural pancreatitis. However, it is not clear whether ES actually prevents pancreatitis or affects other adverse events (AEs). We conducted a noninferiority trial to examine the necessity of ES before SEMS placement.

METHODS

Two hundred patients with distal biliary strictures caused by unresectable pancreatic cancer were assigned randomly to groups that received ES or did not receive ES (non-ES) before SEMS placement, at 25 hospitals in Hokkaido, Japan, from August 2010 through November 2012. The primary outcome was early AEs (≤30 d) specifically related to the presence or absence of ES (pancreatitis, bleeding, or perforation). Secondary outcomes measured included the effect of ES omission on time to SEMS dysfunction and patient survival times.

RESULTS

The proportions of patients with early AEs were 9.2% in the non-ES group and 10.4% in the ES group (a difference of 1.2%, noninferior). The median times to SEMS dysfunction was longer than 594 days in the non-ES group and 541 days in the ES group (P = .88). The median overall survival times were 202 in the ES group vs 255 days in the non-ES group; P = .20).

CONCLUSIONS

ES before SEMS does not affect the incidence of AEs, SEMS patency, or patient survival times. Our data provide no evidence for a benefit of ES to patients undergoing SEMS placement for a biliary stricture caused by pancreatic cancer. UMIN clinical trials registry number: 000004044.

An Update to Hepatobiliary Stents

Endoscopic stent placement is a common primary management therapy for benign and malignant biliary strictures. However, continuous use of stents is limited by occlusion and migration. Stent technology has evolved significantly over the past two decades to reduce these problems. The purpose of this article is to review current guidelines in managing malignant and benign biliary obstructions, current endoscopic techniques for stent placement, and emerging stent technology. What began as a simple plastic stent technology has evolved significantly to include uncovered, partially covered, and fully covered self-expanding metal stents (SEMS) as well as magnetic, bioabsorbable, drug-eluting, and antireflux stents.(1).

Biliary stenting with or without sphincterotomy for malignant biliary obstruction: a meta-analysis

AIM

To investigate the benefits of endoscopic sphincterotomy (EST) before stent placement by meta-analysis of randomized controlled trials (RCTs).

METHODS

PubMed, EMBASE, Cochrane Library, and Science Citation Index databases up to March 2014 were searched. The primary outcome was incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and successful stent insertion rate. The secondary outcomes were the incidence of post-ERCP bleeding, stent migration and occlusion. The free software Review Manager was used to perform the meta-analysis.

RESULTS

Three studies (n = 338 patients, 170 in the EST group and 168 in the non-EST group) were included. All three studies described a comparison of baseline patient characteristics and showed that there were no statistically significant differences between the two groups. Three RCTs, including 338 patients, were included in this meta-analysis. Most of the analyzed outcomes were similar between the groups. Although EST reduced the incidence of PEP, it also led to a higher incidence of post-ERCP bleeding (OR = 0.34, 95%CI: 0.12-0.93, P = 0.04; OR = 9.70, 95%CI: 1.21-77.75, P = 0.03, respectively).

CONCLUSION

EST before stent placement may be useful in reducing the incidence of PEP. However, EST-related complications, such as bleeding and perforation, may offset this effect.

Biliary sphincterotomy is not required for bile duct stent placement

BACKGROUND

The aim of the present study was to assess the success and outcome of bile duct stent placement without the use of endoscopic biliary sphincterotomy (EBS).

PATIENTS AND METHODS

Over a period of 10 years and 9 months, all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were prospectively identified. Bile duct stent placement was routinely done without EBS unless additional therapy (stone removal, multiple stenting) was anticipated.

RESULTS

Of 5020 patients who underwent ERCP, bile duct stents were placed in 1668 patients. After excluding those requiring additional endoscopic therapy, 1112 patients (89.5%) had ERCP and stent placement without a sphincterotomy and 130 patients (10.5%) had ERCP and stent placement with asphincterotomy. Deployed endoprostheses were self-expandable metallic stents in 15.7% and plastic in 77.5%. Caliber of plastic stents was 10 Fr in 78.9% and <10 Fr in 21.1%. All stents were successfully placed in these 1112 patients without the need for EBS. Comparing patients undergoing bile duct stenting with and without sphincterotomy, no difference was seen in rates of pancreatitis (1.54% vs 2.07%, P > 0.9999).

CONCLUSION

Single bile duct stents, both plastic and metal, can be deployed without EBS.

Covered metal stenting for malignant lower biliary stricture with pancreatic duct obstruction: is endoscopic sphincterotomy needed?

Aims. To evaluate the need for endoscopic sphincterotomy (EST) before covered self-expandable metal stent (CSEMS) deployment for malignant lower biliary stricture with pancreatic duct obstruction. Methods. This study included 79 patients who underwent CSEMS deployment for unresectable malignant lower biliary stricture with pancreatic duct obstruction. Treatment outcomes and complications were compared between 38 patients with EST before CSEMS deployment (EST group) and 41 without EST (non-EST group). Results. The technical success rates were 100% in both the EST and the non-EST group. The incidence of pancreatitis was 2.6% in the EST, and 2.4% in the non-EST group (P = 0.51). The incidences of overall complications were 18.4% and 14.6%, respectively, (P = 0.65). Within the non-EST groups, the incidence of pancreatitis was 0% in patients with fully covered stent deployment and 3.6% in those with partially covered stent deployment (P = 0.69). In the multivariate analysis, younger age (P = 0.003, OR 12) and nonpancreatic cancer (P = 0.001, OR 24) were significant risk factors for overall complications after CSEMS deployment. EST was not identified as a risk factor. Conclusions. EST did not reduce the incidence of pancreatitis after CSEMS deployment in patients of unresectable distal malignant obstruction with pancreatic duct obstruction.

Endoscopic biliary stenting and pancreatitis

Endoscopic biliary stenting across the duodenal papilla can obstruct the adjacent pancreatic orifice and disturb the flow of pancreatic juice, which may result in pancreatitis. However, the relationship of endoscopic biliary stenting to post-procedure pancreatitis has not been thoroughly examined. Therefore, we have reviewed the published literature on this issue. Although biliary stenting, especially with large-bore and self-expandable metallic stents (SEMSs), has been considered a possible additional risk factor for pancreatitis following biliary stenting, most studies have not provided convincing supporting evidence; this failure may be due to inadequate study design or insufficient numbers of subjects. It also remains unclear whether endoscopic sphincterotomy (EST) performed prior to biliary stenting decreases the incidence of post-stenting pancreatitis; some recent studies have claimed that EST is not necessary before biliary stenting, even with placement of SEMSs. Well-designed studies with a large number of subjects will be needed to clarify these issues.

Otaru consensus on biliary stenting for unresectable distal malignant biliary obstruction

Endoscopic biliary drainage with biliary stent placement is the treatment of choice for palliation in patients with malignant biliary obstruction caused by unresectable neoplasms. Various biliary stent designs have become available, but lack of a clear consensus persists on the use of covered versus uncovered metal stents in malignant distal bile duct obstructions, and plastic versus metal stents. In 2012, the European Society of Gastrointestinal Endoscopy indicated guidelines for biliary stenting. Accordingly, the consensus meeting for biliary stenting was held at the Endoscopic Forum Japan 2012, and four selected statements related to stent placement for distal malignant biliary obstruction were discussed to produce a consensus. Two of four statements (related to the usefulness of self-expandable metallic stents, and reintervention after stenting) were agreed upon by almost all participants. Nevertheless, our opinions were divided on the other two statements (necessity of sphincterotomy for stenting, and covered metal stent versus uncovered metal stent). We herein report the results of the meeting, and present proposed new statements via discussion.

Necessity for endoscopic sphincterotomy for biliary stenting in cases of malignant biliary obstruction

Endoscopic biliary stenting is a useful way to treat distal malignant biliary strictures that are not eligible for surgery. A 10-Fr plastic or metal stent is used for stenting. Typically, endoscopic sphincterotomy (EST) has often been carried out as a way to prevent pancreatitis after stent placement given the ease of stent insertion, but EST has flaws such as bleeding and stent migration.The present study describes the need for EST prior to stent placement.

Endoscopic management of malignant bile duct strictures

Malignant biliary obstruction can arise from intrahepatic, extrahepatic, and hilar locations from either primary or metastatic disease. Biliary-enteric surgical bypass has been surpassed in the last 20 years by endoscopic balloon dilation and stenting. The goal of stenting for biliary decompression is to palliate obstructive symptoms; it has not been shown that survival is affected by stenting alone. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have been evaluated and show promise. Both therapies seem to be safe and effective in the treatment of malignant bile duct strictures but are in need of prospective studies of longer duration.

Endoscopic sphincterotomy associated cholangitis in patients receiving proximal biliary self-expanding metal stents

BACKGROUND

Endoscopic biliary stent placement during the procedure of endoscopic retrograde cholangiopancreatography (ERCP) is preferred to provide biliary drainage for unresectable malignant biliary obstruction. There is considerable controversy over the use of endoscopic sphincterotomy (ES) prior to stent placement. This study aimed to determine whether ES before intraductal self-expanding metal stent (SEMS) placement affects the clinical outcome and complications in patients with proximal malignant obstructive biliary diseases.

METHODS

In a prospective randomized controlled trial, 82 patients with inoperable malignant biliary strictures were randomly assigned to biliary stenting groups with or without ES. Resolution of jaundice and the incidence of complications including acute cholangitis, pancreatitis and stent occlusion within 6 months were evaluated.

RESULTS

SEMSs were successfully deployed in all patients, resulting in clinical and biochemical improvement of obstructive symptoms in both groups. The incidence of cholangitis was higher in the ES group than in the non-ES group (58.5% vs 31.7%, P=0.015). The interval between stent placement and the first acute cholangitis was much shorter in the ES group than in the non-ES group (P=0.024). The use of ES increased the incidence of cholangitis (P=0.004, risk ratio, 8.196). The rate of post-ERCP pancreatitis after stent placement was greater in the non-ES group than in the ES group (31.7% vs 9.8%, P=0.014). No significant differences were found in the rate of restenosis and the mortality rate between the two groups.

CONCLUSIONS

ES prior to intraductal SEMS placement was associated with an increased incidence of acute cholangitis. ES should be carefully evaluated prior to its use in patients with proximal malignant obstructive biliary diseases.

One- and two-step self-expandable metal stent placement for distal malignant biliary obstruction: a propensity analysis

BACKGROUND

Although self-expandable metal stents (SEMS) are widely used for distal malignant biliary obstruction, one-step SEMS (direct placement without a prior plastic stent) and two-step SEMS (placement at second endoscopic retrograde cholangiopancreatography [ERCP] following plastic stent placement) have not been fully compared.

METHODS

In this multicenter retrospective study, patients were included who underwent first-time endoscopic SEMS placement between September 1994 and December 2010. We compared the one-step and two-step strategies using a propensity analysis.

RESULTS

In total, 370 patients were identified and one-step SEMS was performed in 59 patients. After adjustment using propensity scores, the median times to dysfunction were 116 and 219 days, respectively, for one-step and two-step SEMS (P = 0.058). Stent migration was more frequently observed in one-step SEMS as compared with two-step SEMS (25 vs. 11 %, P = 0.031). In one-step SEMS, the number of days of hospitalization associated with first-time SEMS placement was shorter compared with that in two-step SEMS (21 vs. 30 days, P = 0.001), and the total costs of SEMS-related interventions within 6 months were lower (6510 and 8100 USD, P = 0.004). The pathological diagnosis rates for pancreatic and biliary tract cancer at initial ERCP were 52 and 61 %. After failed diagnosis at initial ERCP, pathological diagnosis rates for pancreatic cancer were 32 versus 76 % (P = 0.005) by repeated ERCP versus endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA).

CONCLUSIONS

One-step SEMS was associated with increased stent migration, despite having potential cost-effectiveness. The additional yield of pathological diagnosis at repeated ERCP was low compared with that yielded by EUS-guided FNA.

Risk factors for pancreatitis following transpapillary self-expandable metal stent placement

BACKGROUND

Pancreatitis is one of complications after self-expandable metal stent (SEMS) placement. The purpose of this study was to evaluate risk factors for pancreatitis after endoscopic SEMS placement for malignant biliary obstruction (MBO).

METHODS

We retrospectively reviewed 370 consecutive patients who underwent initial transpapillary SEMS placement for biliary decompression. The characteristics of inserted SEMSs were classified according to axial and radial force.

RESULTS

Pancreatitis following SEMS insertion was observed in 22 patients (6%). All of them were mild according to consensus criteria. Univariate analysis indicated that injections of contrast into the pancreatic duct (frequency of pancreatitis, 10.3%), the placement of an SEMS with high axial force (8.3%), and nonpancreatic cancer (16.1%) significantly contributed to the development of pancreatitis, whereas female gender, a younger age, a covered SEMS, and a SEMS with high radial force or without a biliary sphincterotomy did not. In a multivariate risk model, SEMSs with high axial force (odds ratio [OR], 3.69; p = 0.022) and nonpancreatic cancer (OR, 5.52; p < 0.001) were significant risk factors for pancreatitis.

CONCLUSIONS

SEMSs with high axial force and an etiology of MBO other than pancreatic cancer were strongly associated with a high incidence of pancreatitis following transpapillary SEMS placement in patients with distal MBO.

Self-expandable metal stents in malignant biliary obstruction

Malignant biliary obstruction can be due to direct tumor infiltration, extrinsic compression, adjacent inflammation, desmoplastic reaction from tumors or, more commonly, a combination of the above factors. Pancreatic cancer is the most common cause of malignant biliary obstruction, and jaundice occurs in 70-90% of the patients during the course of the disease. Compared with the uncovered metal stents, covered metal stents have longer patency and a lower rate of tumor ingrowth, but have a higher rate of stent migration. To combat the occlusion and provide an antitumor effect, drug-eluting stents were developed. A duodenal stricture complicates biliary stent placement in 10-20% of patients with distal biliary obstruction due to pancreatic cancer. When both strictures are considered, a biliary stent can be placed either preceding or following duodenal stent placement. Complications of self-expandable metal stents include stent occlusion, stent migration, cholecystitis and pancreatitis.

Endoscopic biliary sphincterotomy is not required for transpapillary SEMS placement for biliary obstruction

BACKGROUND

Endoscopic retrograde cholangiopancreatography with biliary self-expanding metal stent placement is the preferred method of providing biliary drainage for pancreaticobiliary malignancies. Some endoscopists routinely perform biliary sphincterotomy to facilitate biliary stent placement and potentially minimize pancreatitis with transpapillary self-expanding metal stent placement.

AIMS

Our hypothesis was that biliary sphincterotomy has no effect on the success rate of transpapillary self-expanding metal stent placement and increases procedure-related complications.

METHODS

In a retrospective analysis, outcomes of two groups were compared: (1) self-expanding metal stent placement without biliary sphincterotomy, (2) self-expanding metal stent placement with biliary sphincterotomy during the same procedure. Complications and stent patency rates were evaluated.

RESULTS

There were 104 subjects included in the study. Post-sphincterotomy bleeding (p = 0.001) was associated with biliary sphincterotomy performed immediately prior to self-expanding metal stent placement. Importantly, self-expanding metal stent placement without biliary sphincterotomy was always technically successful and self-expanding metal stent placement without biliary sphincterotomy was not associated with pancreatitis.

CONCLUSIONS

Patients who undergo biliary sphincterotomy during transpapillary self-expanding metal stent placement experience more immediate complications than those who do not. Biliary sphincterotomy was not associated with longer stent patency. Self-expanding metal stent placement without a biliary sphincterotomy was not associated with pancreatitis regardless of the type of self-expanding metal stent used (covered or uncovered). Of the patients without a biliary sphincterotomy, 100% had successful stent placement, further arguing against its use in this setting.

New method of covered wallstents for distal malignant biliary obstruction to reduce early stent-related complications based on characteristics

AIM

We previously reported a low occlusion rate with covered Wallstents for malignant biliary obstruction, but stent-related complications other than occlusion posed a problem. A modified covered Wallstent insertion method based on stent characteristics was evaluated to reduce stent-related complications.

METHODS

A total of 138 patients with distal malignant biliary obstruction received covered Wallstent placement. From October 2001 to October 2003, 69 patients received covered Wallstent placement (Group 1). Thereafter, we modified our stent insertion method and 69 patients received stent placement using this modified method from November 2003 to January 2007 (Group 2). The modified insertion method consists of endoscopic sphincterotomy carried out in patients without pancreatic duct invasion and longer stent placement with the center of the stent located in the center of the biliary stricture to prevent pancreatitis, kinking of the bile duct, and stent dislocation. A comparative analysis was carried out using prospectively collected data in these two cohorts.

RESULTS

Tumor ingrowth was not observed, and stent occlusion rate was 18.8% in Group 1 and 23.2% in Group 2. The overall rates of stent-related complications did not differ (39.1% in Group 1 and 30.4% in Group 2), but stent-related complications within 3months decreased from 22 episodes in Group 1 to 13 episodes in Group 2. Median event-free survival was prolonged by modified stent insertion method (125days in Group 1 and 268days in Group 2, P=0.020), although cumulative survival and stent patency were not significantly different.

CONCLUSIONS

Our modified method of covered Wallstent placement showed improved event-free survival.

A randomized trial comparing uncovered and partially covered self-expandable metal stents in the palliation of distal malignant biliary obstruction

BACKGROUND

The most common complication of uncovered biliary self-expandable metal stents (SEMSs) is tumor ingrowth. The addition of an impenetrable covering may prolong stent patency.

OBJECTIVE

To compare stent patency between uncovered and partially covered SEMSs in malignant biliary obstruction.

DESIGN

Multicenter randomized trial.

SETTING

Four teaching hospitals.

PATIENTS

Adults with inoperable distal malignant biliary obstruction.

INTERVENTIONS

Uncovered or partially covered SEMS insertion.

MAIN OUTCOME MEASURES

Time to recurrent biliary obstruction, patient survival, serious adverse events, and mechanism of recurrent biliary obstruction.

RESULTS

From October 2002 to May 2008, 129 patients were randomized. Recurrent biliary obstruction was observed in 11 of 61 uncovered SEMSs (18%) and 20 of 68 partially covered SEMSs (29%). The median times to recurrent biliary obstruction were 711 days and 357 days for the uncovered and partially covered SEMS groups, respectively (P = .530). Median patient survival was 239 days for the uncovered SEMS and 227 days for the partially covered SEMS groups (P = .997). Serious adverse events occurred in 27 (44%) and 42 (62%) patients in the uncovered and partially covered SEMS groups, respectively (P = .046). None of the uncovered and 8 (12%) of the partially covered SEMSs migrated (P = .0061).

LIMITATIONS

Intended sample size was not reached. Allocation to treatment groups was unequal.

CONCLUSIONS

There was no significant difference in time to recurrent biliary obstruction or patient survival between the partially covered and uncovered SEMS groups. Partially covered SEMSs were associated with more serious adverse events, particularly migration.

Risk of post-ERCP pancreatitis with placement of self-expandable metallic stents

BACKGROUND

There are conflicting data on the risk of post-ERCP pancreatitis (PEP) related to self-expandable metallic stents (SEMSs).

OBJECTIVE

To compare rates of PEP in patients who undergo biliary drainage with SEMSs or polyethylene stents (PSs).

DESIGN

Retrospective, cohort study.

SETTING

Tertiary-care medical center.

PATIENTS

This study involved patients undergoing ERCP for malignant biliary obstruction between January 2005 and October 2008.

INTERVENTION

First-time placement of a SEMS or PS for biliary decompression.

MAIN OUTCOME MEASUREMENTS

Early post-ERCP complications, particularly PEP.

RESULTS

We identified 544 eligible patients, 248 SEMSs (102 covered), and 296 PSs. The etiology of malignant biliary obstruction was similar between groups, with 55% from pancreatic cancer. The frequency of PEP was significantly higher in the SEMS group (7.3%) versus the PS group (1.3%) (OR 5.7 [95% CI, 1.9-17.1]). On univariate analysis, patient age of <40 years, a history of PEP, and at least 1 pancreatic duct injection were also significant predictors of PEP, whereas female sex and having pancreatic cancer were not. When significant variables were added to a multiple-predictor regression model, the odds of PEP from SEMS placement increased to 6.8 (95% CI, 2.2, 21.4). However, the frequency of PEP was similar between covered (6.9%) and uncovered (7.5%) SEMSs (OR 0.9 [CI, 0.3-2.4]). Purported SEMS-specific risk factors, including the use of cSEMSs, overlapping SEMSs, or having a biliary sphincterotomy were not found to be significant contributors to the higher risk.

LIMITATIONS

Retrospective design.

CONCLUSION

After we controlled for confounding variables, the frequency of PEP was significantly higher with placement of a SEMS compared with a PS. Rates of PEP were comparable with use of covered and uncovered SEMSs.