Otaru consensus on biliary stenting for unresectable distal malignant biliary obstruction

Results of Endoscopic Treatment of Recurrent Malignant Biliary Obstruction in Patients with Self-Expanding Metal Stents

BACKGROUND AND AIM

Endoscopic biliary drainage with placement of a self-expanding metal stent (SEMS) is the preferred palliative treatment of malignant biliary obstruction. Recent advances in the treatment have prolonged survival, thus, increasing the chance of recurrent biliary obstruction (RBO) after SEMS placement. The aim of this study was to compare different endoscopic approaches in patients with a SEMS and RBO, regarding clinical success and time to RBO.

METHODS

This retrospective study included all patients with a SEMS placed because of malignant biliary strictures who underwent endoscopic retrograde cholangiopancreatography between January 2011 and December 2018. We evaluated the results of different endoscopic interventions to RBO, including insertion of a new SEMS, stent cleaning, and insertion of a plastic stent (PS).

RESULTS

From January 2011 to December 2018, 70 (22.4%) patients developed RBO requiring endoscopic reintervention (n = 105 sessions). From the 105 ERCPs, technical success, clinical success, and adverse events rates were 91,4%, 71,8%, and 7,8%, respectively. Younger age (OR = 1.11 95%CI: 1.03-1.19) and the finding of a patent SEMS (OR = 0.17 95%CI: 0.04-0.08) were predictors of clinical failure (P = 0.006 and P = 0.024, respectively). The mean patency time (in days) after endoscopic reintervention was greater for SEMSs than for PSs (417.2 [95% CI: 250.0-584.4] vs 175.2 [95% CI: 124.0-226.5], P = 0.002).

CONCLUSIONS

Correct identification and treatment of the causal factor of RBO typically lead to technical and clinical success. Placement of a second SEMS provides longer patency compared to a plastic stent if ingrowth (overgrowth) occurs.

The assessment of postoperative cholangitis in malignant biliary obstruction: a real-world study of nasobiliary drainage after endoscopic placement of self-expandable metal stent

Objectives

Endoscopic retrograde cholangiopancreatography(ERCP) with endoscopic metallic biliary endoprosthesis(EMBE) serves as a crucial palliative treatment for advanced malignant biliary obstruction(MBO). While endoscopic nasobiliary drainage(ENBD) effectively reduces post-ERCP cholangitis (PEC) incidence, its impact on PEC in MBO patients is unclear. This study evaluates ENBD's effects on PEC in patients undergoing EMBE and identifies risk factors.

Methods

This retrospective cohort study at the First Hospital of Jilin University involved MBO patients who underwent EMBE from September 2011 to September 2022. Propensity score matching (PSM) was applied to minimize selection bias. Primary and secondary outcomes included the incidence and recovery rate/time of PEC, biliary drainage success, and hospitalization duration. Univariate, multivariate, and Lasso regression analyses identified independent risk factors.

Results

In this study of 1,008 patients, 730 were analyzed after PSM(365 each in the EMBE+ENBD and EMBE groups). No significant differences were observed in PEC incidence(10.7% vs 11.2%, p=0.9057) or recovery rates(48.7% vs 31.7%, p=0.1855). However, PEC recovery time was shorter in the EMBE+ENBD group(4.0 days [3.0, 6.0] vs 5.0 days [4.0, 7.5], p=0.0240), as was hospitalization duration(6.0 days [4.0, 8.0] vs 7.0 days [5.0, 10.0], p=0.0146), and a higher success rate of biliary drainage(54.0% vs 43.3%, p=0.0049). Tumor location(HR 1.10, 95% CI 1.00-1.20) and preoperative total bilirubin(HR 2.13, 95% CI 1.66-2.73) were identified as independent risk factors.

Conclusion

In this large-scale PSM study, ENBD did not reduce PEC incidence but expedited recovery and shortened hospital stays. Patients with hilar MBO of Bismuth III-IV or high preoperative bilirubin were more prone to PEC.

Safety and Efficacy of a Large-Bore Biliary Metallic Stent for Malignant Biliary Obstruction

Self-expandable metallic stents (SEMSs) are typically inserted in patients with unresectable malignant biliary obstruction. However, SEMSs are susceptible to occlusion. To overcome this issue, we developed a large-bore, dumbbell-shaped, fully covered SEMS (FCSEMS-L) and compared its efficacy and safety with those of a conventional FCSEMS (FCSEMS-C) in patients with malignant biliary obstruction. Methods: Patients with unresectable distal malignant biliary obstruction were retrospectively enrolled between January 2011 and February 2021. All patients underwent endoscopic insertion of FCSEMSs. Recurrent biliary obstruction (RBO), patient survival time, complications, and prognosis were analyzed. Results: RBO occurred in 31 patients (35.6%) who received an FCSEMS-L, and in 34 (45.9%) who received an FCSEMS-C. Stent occlusion occurred in 19 patients (21.8%) who received an FCSEMS-L, and in 22 (29.7%) who received an FCSEMS-C. Stent migration occurred in 12 patients (13.8%) with an FCSEMS-L and 12 (16.2%) with an FCSEMS-C. The median time to RBO (TRBO) was 301 days with an FCSEMS-L and 203 days with an FCSEMS-C. The median survival time was 479 days with an FCSEMS-L and 523 days with an FCSEMS-C. The TRBO and patient survival time did not significantly differ between the two groups. Conclusions: There were no significant differences in efficacy and complication rates between the fully covered large bore SEMSs and conventional fully covered SEMSs.

Silver Nanofunctionalized Stent after Radiofrequency Ablation Suppresses Tissue Hyperplasia and Bacterial Growth

Intraductal radiofrequency (RF) ablation combined with placement of a self-expandable metal stent (SEMS) for malignant biliary obstruction has risks such as stent- and heat-induced biliary sludge and restenosis. Here, we investigated the efficacy of a silver nanoparticles (AgNPs)-coated SEMS to inhibit tissue hyperplasia and bacterial growth caused by RF ablation with stent placement in the rabbit bile duct. The release behavior and antibacterial effects of AgNPs-coated SEMSs were evaluated. Then, SEMSs were successfully placed in all rabbits immediately after RF ablation. Ag ions were rapidly released at the beginning and then showed a gradual release behavior. The AgNPs-coated SEMS significantly inhibited bacterial activity compared to the uncoated SEMS (p < 0.05). Cholangiography and histological examination confirmed that the level of tissue hyperplasia was significantly lower in the AgNPs group than in the control group (all p < 0.05). Immunohistochemistry analyses revealed that TUNEL-, HSP 70-, and α-SMA-positive areas were significantly lower in the AgNPs group than in the control group (all p < 0.05). Intraductal RF ablation combined with nanofunctionalized stent placement represents a promising new approach for suppressing thermal damage as well as stent-induced tissue hyperplasia and bacterial growth.

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.

Efficacy and safety of EUS biliary drainage in malignant distal and hilar biliary obstruction: A comprehensive review of literature and algorithm

Malignant biliary obstruction (MBO) encompasses a variety of malignancies arising from the pancreaticobiliary system. This can be divided into malignant hilar biliary obstruction (MHBO) or malignant distal biliary obstruction (MDBO) biliary obstruction to which clinical outcomes and technical considerations of various biliary drainage methods may differ. EUS biliary drainage (EUS-BD) has been increasingly influential in the management of MBO together with other familiar biliary drainage methods such as ERCP and percutaneous transhepatic biliary drainage (PTBD). Conventionally, ERCP has always been the primary choice of endoscopic biliary drainage in both MHBO and MDBO and that PTBD or EUS-BD is used as a salvage method when ERCP fails for which current guidelines recommends PTBD, especially for MHBO. This review was able to show that with today's evidence, EUS-BD is equally efficacious and possesses a better safety profile in the management of MBO and should be on the forefront of endoscopic biliary drainage. Therefore, EUS-BD could be used either as a primary or preferred salvage biliary drainage method in these cases.

Biliary endoscopy in the management of primary sclerosing cholangitis and its complications

Primary sclerosing cholangitis (PSC) is a chronic, idiopathic, cholestatic liver disease characterized by inflammation and fibrosis of the intrahepatic and/or extrahepatic bile ducts. It can affect individuals of all age groups and gender, has no established pharmacotherapy, and is associated with a variety of neoplastic (e.g. cholangiocarcinoma) and non-neoplastic (e.g. dominant strictures) hepatobiliary complications. Given these considerations, endoscopy plays a major role in the care of patients with PSC. In this review, we discuss and provide updates regarding endoscopic considerations in the management of hepatobiliary manifestations and complications of PSC. Where evidence is limited, we suggest pragmatic approaches based on currently available data and expert opinion.

Endoscopic palliation of biliary obstruction

Advanced pancreaticobiliary malignancy tends to be uncurable at presentation and causes significant morbidity for patients. Palliation for malignant biliary obstruction should be minimally invasive, cost-effective, and aim to improve quality of life of patients. Strategies of endoscopic palliation of malignant biliary obstruction can differ based on sites and degree of biliary obstruction with complex decisions of optimal stent type and placement that involve conscientious planning by a multidisciplinary team.

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.

What is the current role of endoscopy in primary sclerosing cholangitis?

Endoscopy has important roles in the management of primary sclerosing cholangitis (PSC), ranging from narrowing down the differential diagnoses, screening for complications, determining prognosis and therapy. While the need for a diagnostic endoscopic retrograde cholangiopancreatography (ERCP) may be obviated by a positive magnetic resonance cholangiopancreatography (MRCP), a negative MRCP does not exclude PSC and may therefore necessitate an ERCP, which is traditionally regarded as the gold standard. In this editorial we have not covered the endoscopic management of inflammatory bowel disease in the context of PSC nor of endoscopic surveillance and treatment of portal hypertension complicating PSC.