Management of occluded biliary Wallstents

Fully covered metal biliary stents: A review of the literature

Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.

Experimental model of occluded biliary metal stent recanalization using irreversible electroporation via a tubular catheter

PURPOSE

To demonstrate the feasibility of irreversible electroporation (IRE) for treating biliary metal stent occlusion in an experimental liver model.

METHODS AND MATERIALS

IRE was performed using an expandable tubular IRE-catheter placed in nitinol stents in the porcine liver. A 3-electrode IRE-catheter was connected to an IRE-generator and one hundred 100μs pulses of constant voltage (300, 650, 1000, and 1300 V) were applied. Stent occlusion was simulated by insertion of liver tissue both ex vivo (n = 94) and in vivo in 3 pigs (n = 14). Three scenarios of the relationship between the stent, electrodes, and inserted tissue (double contact, single contact, and stent mesh contact) were studied. Electric current was measured and resistance and power calculated. Pigs were sacrificed 72 h post-procedure. Harvested samples (14 experimental, 13 controls) underwent histopathological analysis.

RESULTS

IRE application was feasible at 300 and 650 V for the single and double contact setup in both ex vivo and in vivo studies. Significant differences in calculated resistance between double contact and single contact settings were observed (ex-vivo p ˂ 0.0001, in-vivo p = 0.02; Mann-Whitney). A mild temperature increase of the surrounding liver parenchyma was noted with increasing voltage (0.9-5.9 °C for 300-1000 V). The extent of necrotic changes in experimental samples in vivo correlated with the measured electric current (r² = 0.39, p = 0.01). No complications were observed during or after the in-vivo procedure.

CONCLUSION

Endoluminal IRE using an expandable tubular catheter in simulated metal stent occlusion is feasible. The relationship of active catheter electrodes to stent ingrowth tissue can be estimated based on resistance values.

Impact of infected stent removal on recurrent cholangitis with time-to-event analysis

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.

Management of occluded self-expanding biliary metal stents in malignant biliary disease

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.

Reintervention for occluded metal stent in malignant bile duct obstruction: A prospective randomized trial comparing covered and uncovered metal stent

BACKGROUND AND AIM

No prospective data are available on comparing covered and uncovered self-expandable metal stent (SEMS) for reintervention of occluded uncovered metal stents during endoscopic retrograde cholangiopancreatography in patients with malignant distal biliary obstruction.

METHODS

From June 2010 to November 2014, 43 patients with inoperable distal biliary obstruction of a previously placed uncovered SEMS were enrolled from three centers in Korea and randomly assigned to covered (n = 22) or uncovered SEMS group (n = 21). The primary outcome was overall stent patency. Secondary outcome was time-to-stent occlusion, patient survival, cause of stent occlusion, and adverse events.

RESULTS

Overall median patency of secondary stent was 112.0 days. Median stent patency of covered and uncovered SEMS was 112.0 and 181.0 days, respectively, (P = 0.373). There was a tendency towards a longer time-to-stent occlusion in uncovered SEMS group (median: 112.0 vs 181.0 days). However, it did not reach statistical significance (P = 0.214). Most common causes of occlusion were stent clogging (36.4%) and tumor ingrowth (33.3%) in covered and uncovered SEMS groups, respectively. There was no significant difference in median survival between the groups (median: 308 vs 300 days; P = 0.325). Acute cholangitis occurred in four patients (three in covered vs one in uncovered SEMS group, P = 0.607).

CONCLUSIONS

In this exploratory trial, there were no statistically significant differences in stent patency, time-to-stent occlusion, patient survival, and complication rates between covered and uncovered SEMS groups. Larger confirmatory multicenter trial is needed for the clear conclusion (ClinicalTrials.gov: NCT01315522).

Partially covered self-expandable metal stents versus polyethylene stents for malignant biliary obstruction: a cost-effectiveness analysis

BACKGROUND⁄

OBJECTIVE

Partially covered self-expandable metal stents (SEMS) and polyethylene stents (PES) are both commonly used in the palliation of malignant biliary obstruction. Although SEMS are significantly more expensive, they are more efficacious than PES. Accordingly, a cost-effectiveness analysis was performed.

METHODS

A cost-effectiveness analysis compared the approach of initial placement of PES versus SEMS for the study population. Patients with malignant biliary obstruction underwent an endoscopic retrograde cholangiopancreatography to insert the initial stent. If the insertion failed, a percutaneous transhepatic cholangiogram was performed. If stent occlusion occurred, a PES was inserted at repeat endoscopic retrograde cholangiopancreatography, either in an outpatient setting or after admission to hospital if cholangitis was present. A third-party payer perspective was adopted. Effectiveness was expressed as the likelihood of no occlusion over the one-year adopted time horizon. Probabilities were based on a contemporary randomized clinical trial, and costs were issued from national references. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

A PES-first strategy was both more expensive and less efficacious than an SEMS-first approach. The mean per-patient costs were US$6,701 for initial SEMS and US$20,671 for initial PES, which were associated with effectiveness probabilities of 65.6% and 13.9%, respectively. Sensitivity analyses confirmed the robustness of these results.

CONCLUSION

At the time of initial endoscopic drainage for patients with malignant biliary obstruction undergoing palliative stenting, an initial SEMS insertion approach was both more effective and less costly than a PES-first strategy.

Reintervention for occluded biliary metal stent for patients with malignant distal biliary stricture

A metal stent has a longer stent patency than a plastic stent in patients with unresectable malignant distal biliary stricture. However, treatment for stent dysfunction of a metal stent remains unresolved. A review of reported articles regarding reintervention for metal stent dysfunction showed that causes of stent dysfunction included tumor ingrowth/overgrowth, stone/sludge/food impaction, and stent migration. Cleaning of the stent is associated with an early relapse of stent dysfunction. Additional placement of a covered metal stent is expected to have a longer stent patency than that of other stents such as uncovered metal stents or plastic stents. It is recommended that occluded covered metal stents be removed if possible. Stent trimming with argon plasma coagulation is sometimes useful for the treatment of stent displacement. No strategy for occluded metal stents has been established yet. Further clinical trials regarding proper treatments are necessary.

Pancreatic and biliary stents

Biliary and pancreatic stents are used in a variety of benign and malignant conditions including strictures and leaks and in the prevention of post-ERCP pancreatitis.Both plastic and metal stents are safe, effective, and easy to use. SEMSs have traditionally been used for inoperable malignant disease. Covered SEMSs are now being evaluated for use in benign disease. Increasing the duration of patency of both plastic and metal stents remains an important area for future research.

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

BACKGROUND

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Management of occluded metal stents in malignant biliary obstruction: similar outcomes with second metal stents compared to plastic stents

BACKGROUND

Covered or uncovered self expandable metallic stents (SEMS) placed in patients with malignant biliary obstruction can occlude in 19-40 %, but optimal management is unclear.

AIM

We sought to summarize current evidence regarding management of occluded SEMS in patients with malignant biliary obstruction.

METHODS

Two investigators independently searched Pubmed, Embase, and Web of Science using pre-defined search criteria, and reviewed bibliographies of included studies. Data were independently abstracted by two investigators, and analyzed using RevMan. We compared strategies of second SEMS versus plastic stents with respect to the following outcomes: rate of second stent re-occlusion, duration of second stent patency, and survival.

RESULTS

Ten retrospective studies met inclusion criteria for the systematic review. Management options described were placement of an uncovered SEMS (n = 125), covered SEMS (n = 106), plastic stent (n = 135), percutaneous biliary drain (n = 7), mechanical cleaning (n = 18), or microwave coagulation (n = 7). Relative risk of re-occlusion was not significantly different in patients with second SEMS compared to plastic stents (RR 1.24, 95 % CI 0.92, 1.67, I(2) = 0, p 0.16). Duration of second stent patency was not significantly different between patients who received second SEMS versus plastic stents (weighted mean difference 0.46, 95 % CI -0.30, 1.23, I(2) = 83 %). Survival was not significantly different among patients who received plastic stents versus SEMS (weighted mean difference -1.13, 95 % CI -2.33, 0.07, I(2) 86 %, p = 0.07).

CONCLUSIONS

Among patients with malignant biliary obstruction and occluded SEMS, available evidence suggests a strategy of placing a plastic stent may be as effective as second SEMS. Limitations of these findings were that all studies were retrospective and heterogeneity between studies was detected for two of the outcomes.

Management of an occluded biliary metallic stent

In patients with a malignant biliary obstruction who require biliary drainage, a self-expandable metallic stent (SEMS) provides longer patency duration than a plastic stent (PS). Nevertheless, a stent occlusion by tumor ingrowth, tumor overgrowth and biliary sludge may develop. There are several methods to manage occluded SEMS. Endoscopic management is the preferred treatment, whereas percutaneous intervention is an alternative approach. Endoscopic treatment involves mechanical cleaning with a balloon and a second stent insertion as stent-in-stent with either PS or SEMS. Technical feasibility, patient survival and cost-effectiveness are important factors that determine the method of re-drainage and stent selection.

Recent advances of biliary stent management

Recent progress in chemotherapy has prolonged the survival of patients with malignant biliary strictures, leading to increased rates of stent occlusion. Even we employed metallic stents which contributed to higher rates and longer durations of patency, and occlusion of covered metallic stents now occurs in about half of all patients during their survival. We investigated the complication and patency rate for the removal of covered metallic stents, and found that the durations were similar for initial stent placement and re-intervention. In order to preserve patient quality of life, we currently recommend the use of covered metallic stents for patients with malignant biliary obstruction because of their removability and longest patency duration, even though uncovered metallic stents have similar patency durations.

Inoperable pancreatic cancer patients who have prolonged survival exhibit an increased risk of cholangitis

CONTEXT

Endoscopically placed metal stents, which are patent for 4-9 months, have been the favored decompressive strategy for biliary obstruction due to inoperable pancreatic cancer in order to minimize interventions. However, in the past decade chemotherapeutic options have improved survival. This raises the question of whether metal stents will continue to be the optimal method of decompression.

OBJECTIVE

We performed a study to determine the outcome of patients with non-operatively managed pancreatic adenocarcinoma with regards to the development of cholangitis.

DESIGN

We reviewed all ERCP performed for malignant distal biliary obstruction in between December 1999 and December 2005 at University of California, San Francisco (UCSF).

PATIENTS

Only patients who received chemotherapy for pancreatic adenocarcinoma were included. Patients who underwent surgical biliary diversion procedures were excluded. PRIMARY OUTCOME MEASUREMENT: The primary outcome was the development of cholangitis requiring hospitalization.

RESULTS

Among 200 patients with malignant distal biliary obstruction who underwent endoscopic biliary decompression procedures, 54 met study criterion. Metal stents were employed in 90.7% of these cases. The median survival of this population was 12.7 months (range: 2.6-34.6 months). Only 3 of 26 patients (11.5%) surviving one year or less developed cholangitis compared to 13 of 28 (46.5%) who survived more than one year. Thus patients surviving greater than one year had a five fold increase in the odds of developing cholangitis (odds ratio: 4.92; P=0.017).

CONCLUSIONS

This cohort of inoperable pancreatic cancer patients undergoing chemotherapy survived longer than the expected patent period of metal stents employed for biliary decompression. The occurrence of cholangitis requiring hospitalization does increase markedly among long term survivors.

Expandable metal stents for malignant hilar biliary obstruction

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.

Endoscopic stenting for palliation of malignant biliary obstruction

Malignant biliary obstruction results in jaundice, often with symptoms that decrease the quality of life. Biliary stent placement has largely supplanted surgical bypass for palliation of malignant biliary obstruction. Traditional rigid plastic stents are commonly used, inexpensive and easily removed, although with limited duration of stent patency. Self-expandable metal stents (SEMS) attain larger luminal diameters and provide longer patency than traditional rigid plastic stents in patients with distal bile duct obstruction. SEMS are composed of a variety of metals and can be uncoated, partially covered, or fully covered. Data do not support a prolongation of patency with covered SEMS for distal obstruction, although they have the potential for removability. The data to support SEMS for palliation of hilar biliary obstruction are not as convincing and reintervention for stent occlusion can be difficult. In this article, the design and performance of expandable metal stents for treatment of malignant biliary obstruction will be reviewed.

Endoscopic management of occluded biliary uncovered metal stents: A multicenter experience

AIM: To compare diverse endoscopic interventions in the management of occluded uncovered self-expanding metal stents (SEMSs) that had been placed for palliative treatment of unresectable malignant biliary obstruction.

METHODS: A retrospective review was undertaken in 4 tertiary endoscopic centers to determine optimal management of different types of occluded SEMSs. The technical success of performed treatment in occluded SEMSs, the patency of the stent, the need for re-intervention and the financial costs of each treatment were analyzed.

RESULTS: Fifty four patients were included in the analysis; 21 received Hanaro, 19 Wallstent and 14 Flexus. For the relief of obstruction, a plastic stent was inserted in 24 patients, a second SEMS in 25 and mechanical cleaning was performed in 5 patients. The overall median second patency rates between second SEMSs and plastic stents did not differ (133 d for SEMSs vs 106 d for plastic stents; P = 0.856). Similarly, no difference was found between the overall survival of SEMS and plastic stent groups, and no procedure-related complications occurred. Incremental cost analysis showed that successive plastic stenting was a cost-saving strategy at least in Greece.

CONCLUSION: Insertion of uncovered SEMSs or plastic stents is a safe and effective treatment for occluded uncovered SEMSs; insertion of plastic stents appears to be the most cost-effective strategy.

Endoscopic management of occluded metal biliary stents: Metal versus 10F plastic stents

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.

Comparison of outcomes among secondary covered metallic, uncovered metallic, and plastic biliary stents in treating occluded primary metallic stents in malignant distal biliary obstruction

BACKGROUND

The self-expandable metallic stent (SEMS) has been widely used for unresectable malignant biliary obstruction but eventually becomes occluded by tumor ingrowth/overgrowth and sludge. Therefore, we aimed to determine the therapeutic effectiveness of secondary stents and to find differences according to various combinations of the first and second stents for the management of occluded SEMSs in patients with malignant distal biliary obstruction.

METHODS

Between 1999 and November 2008, 77 patients with malignant biliary obstruction underwent secondary biliary stent placement as "stent-in-stent" at three university hospitals in Korea (40 covered, 26 uncovered, and 11 plastic stents). The membrane of the covered SEMS was regarded as the barrier against tumor ingrowth. We categorized the patients into three groups based on whether the covered SEMS was either the first or the second stent: membrane-SEMS (18 covered-covered; 9 covered-uncovered; 22 uncovered-covered SEMS), bare-SEMS (17 uncovered-uncovered SEMS), and plastic stent (3 covered-plastic; 8 uncovered-plastic).

RESULTS

The median patency of second stents was 138, 109, and 88 days (covered, uncovered, and plastic stents). The second covered SEMSs had a significantly longer patency than plastic stents (p=0.047). In a multivariate analysis including membrane-SEMS, bare-SEMS, and plastic stent groups, the bare-SEMS had a worse cumulative stent patency (HR=2.04, CI=1.08-3.86) and survival time (HR=2.37, CI=1.25-4.49) than the membrane-SEMS. Patients with ampulla of Vater cancer had better stent patency (HR=0.27, CI=0.08-0.98) and survival (HR=0.17, CI=0.04-0.77) than those with other pancreatobiliary malignancies. In addition, antitumor treatment prolonged survival time (HR=0.50, CI=0.26-0.99).

CONCLUSIONS

The placement of additional biliary stents using the "stent-in-stent" method is an effective treatment for an occluded metallic primary stent. In addition, double biliary SEMS placement using at least one covered SEMS (in the primary and/or secondary procedure) might provide longer cumulative stent patency and survival than using uncovered SEMSs in both procedures.

Outcome of second interventions for occluded metallic stents in patients with malignant biliary obstruction

BACKGROUND

Although self-expandable metallic stent (SEMS) has a longer patency than plastic stent (PS) for malignant biliary obstruction, stent occlusion can occur and drainage has to be reestablished in a patient with expected long survival. However, the choices are still controversial among restenting with SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). This study was designed to determine the efficacy and outcome of PS, SEMS, and PTBD for patients with occluded SEMS.

METHODS

A total of 154 ERCPs with SEMS insertion were performed at the Endoscopy Unit of Chulalongkorn University. The causes of obstructive jaundice were cholangiocarcinoma (n = 110), pancreatic cancer (n = 41), and metastatic carcinoma (n = 3). Thirty-two patients (20.9%) with occluded SEMS (uncovered SEMS = 22 and covered SEMS = 10) were identified. PS, SEMS, and PTBD were used to reestablish drainage in 11, 14, and 7 patients, respectively. The second stent was inserted as stent-in-stent. Patients with less advanced disease were preferably opted to have a second SEMS.

RESULTS

The median stent patency of second SEMS (100 days) was significantly longer than PS (60 days) and PTBD (75 days; p < 0.05). The median survival time for patients with second SEMS (230 days) was significantly longer than patients with PS (130 days) and PTBD (150 days; p < 0.05). Subgroup analysis in hilar obstructions showed no statistical difference in second stent patency and survival between PS and SEMS. Pain that required oral narcotic developed in 71% (5/7) of PTBD patients.

CONCLUSIONS

In general, a second SEMS insertion in occluded SEMS provides a significant longer patency time than PS and PTBD. However, the benefit of SEMS as a second intervention in hilar obstructed patients is still doubtful.

EUS-guided hepaticogastrostomy with a fully covered metal stent as the biliary diversion technique for an occluded biliary metal stent after a failed ERCP (with videos)

BACKGROUND

Percutaneous transhepatic biliary drainage (PTBD) may be the last resort for an occluded biliary metal stent when the ERCP was unsuccessful.

OBJECTIVE

Because an EUS-guided biliary drainage has been proposed as an effective alternative for PTBD after a failed ERCP, we conducted this study to determine the feasibility and usefulness of an EUS-guided hepaticogastrostomy (EUS-HG) with a fully covered self-expandable metal stent (FCSEMS) for an occluded biliary metal stent after a failed ERCP.

DESIGN

A case study.

SETTING

A tertiary referral center.

PATIENTS AND INTERVENTIONS

Five patients who had an occluded biliary metal stent inserted after a hilar bilateral metal stent or a combined duodenal and biliary metal stent insertion and for whom reinterventional ERCP was unsuccessful underwent an EUS-HG with an FCSEMS for alternative PTBD.

MAIN OUTCOME MEASUREMENTS

Technical and functional success, procedural complications, reinterventional rate after EUS-HG with an FCSEMS, and short-term stent patency.

RESULTS

In all 5 patients, an EUS-HG with an FCSEMS was technically successful. No procedural complications, such as bile peritonitis, cholangitis, and pneumoperitoneum, were observed. Functional success was also 100% (5/5). During the follow-up period (median 152 days, range 64-184 days), no late complications, such as stent migration and occlusion, were observed. Thus, no biliary reintervention was performed during the follow-up period.

LIMITATIONS

A small series of patients without a control group.

CONCLUSIONS

The EUS-HG with an FCSEMS may be feasible, effective, and an alternative PTBD for an occluded biliary metal stent after a failed ERCP.

Covered Wallstents for palliation of malignant biliary obstruction: primary stent placement versus reintervention

BACKGROUND

Covered self-expandable metallic stents (SEMSs) are designed to prevent tumor ingrowth and can be removed if necessary. Only limited comparative data are available on the performance of covered SEMSs after primary placement versus reintervention.

OBJECTIVE

To assess the effectiveness and safety of covered SEMS placement either as primary treatment or reintervention in patients requiring palliation of malignant biliary obstruction.

DESIGN

Retrospective clinical cohort study.

SETTING

Tertiary referral center.

PATIENTS

This study involved 104 patients with unresectable malignant biliary strictures.

INTERVENTION

Covered biliary SEMS placement.

MAIN OUTCOME MEASUREMENTS

Stent patency, technical success, and patient survival.

RESULTS

Covered SEMSs were placed as primary treatment in 48 patients (46%), and reintervention was performed in 56 patients (54%). At 3, 6, and 12 months thereafter, the Kaplan-Meier estimated fractions of all patients with patent stents were 94%, 84%, and 58%, respectively. Covered SEMSs remained patent until the patient's death in 75 of 89 nonsurvivors (84%). Although patency rates 3, 6, and 12 months after primary placement (100%, 93%, and 82%, respectively) were higher than those after reintervention (90%, 78%, and 48%, respectively), the differences were not statistically significant (P = .057). Overall, the most frequent adverse events were cholangitis (7%) and stent migration (4%).

LIMITATIONS

The distribution of stricture locations differed among the groups, and survival data suggested the presence of more extensive disease in the primary treatment group at baseline.

CONCLUSION

The clinical utility and safety of primary covered SEMS placement were confirmed. This study provides the most extensive evidence to date that reintervention with a covered SEMS can provide a useful palliative option.

Percutaneous treatment of malignant jaundice due to extrahepatic cholangiocarcinoma: covered Viabil stent versus uncovered Wallstents. Cardiovasc Intervent Radiol. 2010;33:97-106. [PMID: 19495871 DOI: 10.1007/s00270-009-9604-9]

To compare clinical effectiveness of Viabil-covered stents versus uncovered metallic Wallstents, for palliation of malignant jaundice due to extrahepatic cholangiocarcinoma, 60 patients were enrolled in a prospective and randomized study. In half of the patients a bare Wallstent was used, and in the other half a Viabil biliary stent. Patients were followed up until death. Primary patency, survival, complication rates, and mean cost were calculated in both groups. Stent dysfunction occurred in 9 (30%) patients in the bare stent group after a mean period of 133.1 days and in 4 (13.3%) patients in the covered stent group after a mean of 179.5 days. The incidence of stent dysfunction was significantly lower in the covered stent group (P = 0.046). Tumor ingrowth occurred exclusively in the bare stent group (P = 0.007). Median survival was 180.5 days for the Wallstent and 243.5 days for the Viabil group (P = 0.039). Complications and mean cost were similar in the two groups. Viabil stent-grafts proved to be significantly superior to Wallstents for the palliation of malignant jaundice due to extrahepatic cholangiocarcinoma, with comparable cost and complication rates. Appropriate patient selection should be performed prior to stent placement.

Analysis of endoscopic management of occluded metal biliary stents at a single tertiary care center

BACKGROUND

A significant number of self-expandable metal stents (SEMSs) placed to palliate malignant biliary obstruction will occlude. Few data exist as to what constitutes optimal management.

OBJECTIVE

Our purpose was to review the management and outcomes of patients with biliary SEMS occlusion.

DESIGN AND SETTING

Retrospective chart review at a single tertiary care hospital.

PATIENTS

From January 1999 to October 2005, a total of 90 patients had SEMSs placed for malignant biliary obstruction, and 27 of these occluded.

MAIN OUTCOME MEASUREMENTS

Technical success of treating SEMS occlusion, stent patency and need for reintervention, and incremental cost analysis.

RESULTS

A total of 60 ERCPs were performed to treat SEMS occlusions in 27 patients. The success rate was 95%; however, 52% of patients eventually required more than 1 intervention. Placing a second SEMS through the existing SEMS (n = 14) provided the lowest reocclusion rate (43% vs 55% and 100%), the longest time to reintervention (172 days vs 66 and 43 days, P = .03), and a trend toward longer survival (285 days vs 188 and 194 days) compared with plastic stent and mechanical balloon cleaning, respectively. Incremental cost analysis showed both uncovered SEMSs and plastic stents to be cost effective strategies.

LIMITATIONS

Small number of patients, retrospective study.

CONCLUSIONS

Treatment of biliary SEMS occlusion with SEMS insertion provides for longer patency and survival, decreases the number of subsequent ERCPs by 50% compared with plastic stents, and is cost-effective.

Management of occluded uncovered metallic stents in patients with malignant distal biliary obstructions using covered metallic stents

BACKGROUND

Self-expandable metallic stents (EMSs) have been widely used for the palliative treatment of unresectable malignant biliary obstructions, but EMSs are often occluded owing to tumor ingrowth via the wire mesh. Currently, there is no consensus on the management of occluded EMSs. We evaluated the efficacy of a covered EMS as a second endoprosthesis in patients with an occluded EMS.

METHODS

Forty patients with an occluded uncovered EMS (14 men, 26 women; mean age 72 y, range 41 to 89 y) were studied. The patients suffered from the following: pancreatic cancer in 18, bile duct cancer in 11, gallbladder cancer in 5, lymph node metastasis in 4, and papillary cancer in 2. Of these, 26, 7, and 7 were treated with a covered EMS, an uncovered EMS, and a plastic stent (PS), respectively. The second stent was inserted as a stent-in-stent.

RESULTS

The mean patent period for the covered EMS was 220 days, whereas the mean patent periods for the uncovered EMS and plastic stent were 141 and 58 days, respectively. The cumulative patency of the covered EMS group was significantly higher (P=0.0404) than that of the uncovered EMS group. No significant differences in survival were observed between the covered and uncovered groups. No serious complications occurred.

CONCLUSION

Insertion of a covered EMS is an effective and safe treatment for an occluded uncovered EMS.

Photodynamic therapy of malignant biliary strictures using meso-tetrahydroxyphenylchlorin

OBJECTIVES

The palliation of patients with malignant bile duct obstruction using metal or plastic biliary stents may be limited by stent occlusion. The aim of this study was to determine the safety and efficacy of endoscopically delivered meso-tetrahydroxyphenyl chlorin photodynamic therapy in the treatment of irresectable malignant biliary strictures and recurrent stent occlusion.

METHODS

Thirteen patients with malignant biliary obstruction owing to carcinoma of the biliary tract (n=9), pancreas (n=3) or stomach (n=1), were studied. All had been initially palliated with metal (n=10) or polyethylene (n=3) biliary stents, but presented with recurrent obstructive jaundice because of local tumour progression. Patients received meso-tetrahydroxyphenyl chlorin 0.15 mg/kg intravenously 72 h before endoluminal light activation with an endoscopically placed optical fibre, followed by polyethylene stent insertion.

RESULTS

Before photodynamic therapy, patients had a median of three (range 0-5) stent occlusions in the preceding 11 (2-22) months, with a median patency of plastic stents placed inside metal bile duct stents for recurrent stent occlusion of 3.5 (0.5-13) months. After photodynamic treatment, tumour necrosis and/or metal stent recanalization was seen in all patients, with a median of 0 (0-3) stent occlusions during 7 (1-43) months follow-up. The median patency of plastic stents placed inside metal stents after photodynamic therapy was 5 (1-43) months. The median survival after diagnosis and photodynamic therapy administration was 21 (10-56) and 8 (1-43) months, respectively. Photodynamic therapy was generally well tolerated but two patients developed cholangitis within the first week, complicated in one by a fatal liver abscess and two developed haemobilia within 4 weeks of treatment, one of whom died with a gall bladder empyema.

CONCLUSION

In patients with malignant biliary obstruction, endoscopically delivered meso-tetrahydroxyphenyl chlorin photodynamic therapy causes efficient tumour necrosis and recanalization of blocked metal stents, but there is a significant risk of complications.

Endoscopic removal of malfunctioning biliary self-expandable metallic stents

BACKGROUND

Endoscopic removal of malfunctioning self-expandable metallic biliary stents (SEMS) is difficult and not well described. The aim of this study is to review the indications, the techniques, and the results of SEMS removal in a cohort of patients with malfunctioning stents.

METHODS

All patients who underwent an attempt at endoscopic removal of biliary SEMS over a 5-year period were retrospectively identified. The main indications for SEMS removal were the following: distal migration of the stent or impaction to the duodenum, impaction into the bile-duct wall, tissue ingrowth, and inappropriate length of the stent causing occlusion of intrahepatic ducts. SEMS were removed by using foreign-body forceps or polypectomy snares.

RESULTS

Endoscopic removal of 39 SEMS (13 uncovered and 26 covered) was attempted in 29 patients (17 men; mean age, 66 years). SEMS extraction was attempted after a mean of 7.5 months (8.75 months standard deviation) post-SEMS insertion. Removal was successful in 20 patients (68.9%) and in 29 SEMS (74.3%). Covered SEMS were effectively removed more frequently than uncovered ones: 24 of 26 (92.3%) and 5 of 13 (38.4%), respectively (p < 0.05). No major complications were recorded. Multivariate analysis showed that the time interval between insertion and removal, SEMS length, stent-mesh design (zigzag vs. interlaced), and indication for removal were not predictive of success at stent removal.

CONCLUSIONS

Endoscopic removal of biliary SEMS is feasible and safe in more than 70% of cases. Because only 38% of uncovered SEMS were removable, the presence of a stent covering is the only factor predictive of successful stent extraction. The presence of diffuse and severe ingrowth was the main feature limiting SEMS removal.

Expandable metal biliary stents before pancreaticoduodenectomy for pancreatic cancer: a Monte-Carlo decision analysis

BACKGROUND & AIMS

Endoscopic placement of plastic or self-expandable metal biliary stents (SEMS) relieves obstructive jaundice from pancreatic cancer. Short-length, distally placed SEMS do not preclude subsequent pancreaticoduodenectomy. We sought to determine whether SEMS placement in patients whose surgical status is uncertain is cost-effective for management of obstructive jaundice.

METHODS

A Markov model was constructed to evaluate costs and outcomes associated with endoscopic biliary stenting for obstructive jaundice. Strategies evaluated were: (1) initial plastic stent with plastic stents for subsequent occlusions in nonsurgical candidates after staging (plastic followed-up by [f/u] plastic), (2) initial plastic with subsequent SEMS (plastic f/u metal), (3) initial short-length SEMS with subsequent plastic (metal f/u plastic), and (4) initial short-length SEMS with subsequent expandable metal stent (metal f/u metal). Published stent occlusion rates, ERCP complication rates and outcomes, cholangitis rates and outcomes, pancreatic cancer mortality rates, and Whipple complication rates were used. Costs were based on 2004 Medicare standard allowable charges and were accrued until all patients reached an absorbing health state (death or pancreaticoduodenectomy) or 24 cycles (24 mo) ended.

RESULTS

Average costs per patient from Monte Carlo simulation were: (1) metal f/u metal, $19,935; (2) plastic f/u metal, 20,157 dollars; (3) metal f/u plastic, 20,871 dollars; and (4) plastic f/u plastic, 20,878 dollars. For initial plastic stents to be preferred over short-length metal stents, 70% or more of pancreatic cancers would need to be potentially resectable by pancreaticoduodenectomy.

CONCLUSIONS

In patients undergoing ERCP before definitive cancer staging, short-length SEMS is the preferred initial cost-minimizing strategy.

Endoscopic palliation of pancreaticobiliary malignancies

The palliation of pancreaticobiliary malignancies has changed over the last two decades. With the development of biliary stents, minimally invasive procedures have replaced surgical techniques. Endoscopically placed stents remain the mainstay for the palliative treatment of malignant biliary obstruction from unresectable pancreaticobiliary tumors. Further improvements in stent designs and advances in other endoscopic technologies are expected, and these should expand the role of minimally invasive palliation. This article reviews the current and anticipated roles of endoscopic techniques in the palliation of pancreaticobiliary malignancies.

Endobiliary stents for palliation in patients with malignant obstructive jaundice

BACKGROUND

Endobiliary drainage for malignant obstructive jaundice presents a viable palliative alternative. Its role and efficacy depend on factors related to the stent, procedure, and patient.

GOALS

To review the evidence in the literature in which settings plastic or metal stents are cost-effective, and whether adjuvant measures or patient-related factors affect duration of stent patency.

STUDY

Using databases a literature search was performed for papers published from 1979 to April 2004. All retrieved papers reporting experimental or clinical observations were rated according to strength of evidence, and carefully analyzed.

RESULTS AND CONCLUSIONS

Metal stents (Wallstent) stay patent longer than plastic stents (large-bore polyethylene with side-holes), overall median 250 and 110 days, respectively, and seem cost-effective in patients with longer than about 6 months survival, which cannot be accurately predicted. Antibiotics or choleretic agents do not prolong stent patency in clinical settings. In case of stent occlusion, indicated stent exchanges and insertion of a plastic stent, respectively, seem cost-effective in patients initially treated with plastic and metal stents.

New guide wire technique for stent placement through an occluded self-expandable metal stent: The hairpin technique

BACKGROUND AND AIMS

Self-expandable metal stents (SEMS) for malignant biliary strictures sometimes occlude, requiring the insertion of another stent. When a guide wire is advanced conventionally through the proximal portion of an occluded SEMS, the guide wire sometimes penetrates the stent mesh. The present study reports a new guide wire insertion technique that prevents this problem from occurring.

METHODS

In this new method of advancing a guide wire, the tip is not straight but bent into a curve. Because the advancing end of the guidewire is rounded like a hairpin, it cannot penetrate the stent mesh. Before cannulation, the flexible tip of the guide wire is extended out of the tip of the cannula in the descending duodenum and then cannulation is carried out as the flexible tip makes a hairpin curve. The guide wire with a maintained hairpin curve is advanced through the proximal end of the SEMS. The hairpin curve pops open and the guide wire straightens out when the guide wire has passed through the SEMS. After that, a second stent can be inserted over the guide wire. This technique has been utilized 14 times for occluded SEMS in 10 patients between June 2001 and September 2003.

RESULTS

In all patients the technique served to ensure access to the biliary tree and successful placement of a second stent.

CONCLUSIONS

This new hairpin guide wire technique was effective in preventing the guide wire from penetrating the stent mesh and, therefore contributed to successful stent placement within occluded SEMS.

Management of Biliary Neoplastic Obstruction with Two Different Metallic Stents Implanted in One Session

The efficacy of the "one-step" technique using two different metallic stents (Wallstent and Ultraflex) and associated rate of complications was studied in 87 patients with jaundice secondary to malignant biliary obstruction, with bilirubin level less than 15 mg/dl and Bismuth type 1 or 2 strictures. The study group, composed of 40 men and 47 women with a mean age of 59.4 years (range 37-81 years), was treated with a "one-step" percutaneous transhepatic implantation of self-expanding stents. The cause of the obstruction was pancreatic carcinoma in 38 patients (44%), lymph node metastasis in 20 patients (23%), gallbladder carcinoma in 13 patients (15%), cholangiocarcinoma in 12 patients (14%) and ampullary carcinoma in four patients (5%). A significant reduction in jaundice was obtained in all but one patient, with a drop of total serum bilirubin level from a mean of 13.7 mg/dl to 4.3 mg/dl within the first 4 days. The mean postprocedural hospitalization period was 5.4 days in the Wallstent group and 6.4 days in the Ultraflex group. Mean survival rate was 7.8 months (Wallstent group) and 7.1 months (Ultraflex group). The use of both stents did not reveal any significant difference in parameters tested. The implantation of these self-expandable stents in one session, in selected patients, is clinically effective, devoid of important complications and cost-effective due to the reduction in hospitalization.

Removal of self-expandable metallic Wallstents

BACKGROUND

The self-expandable metallic stent is increasingly being used for management of malignant biliary strictures. In certain clinical situations, it also may be an alternative treatment for benign strictures. The ability to remove a metallic stent would be advantageous to the management of many biliary strictures, regardless of etiology.

METHODS

Stent removal was considered in 18 patients with either covered or uncovered Wallstents placed for biliary obstruction. Indications for placement were the following: unresectable cancer (10), chronic pancreatitis (3), benign biliary stricture (3), impacted stone (1), and papillary adenoma (1).

OBSERVATIONS

Stent removal was successful in 17 patients. Mean follow-up after removal was 9 months. Thirteen removed stents were covered. Indications for removal were the following: occlusion (5), migration (3), facilitation of hemostasis (2), malposition (3), persistent cholestasis (1), stone extraction (1), stricture revision (1), gallbladder fossa abscess (1), and abdominal pain (1). Devices and techniques used for successful removal included a snare, an extraction balloon, and electrocoagulation combined with forceps.

CONCLUSIONS

Removal of uncovered Wallstents is difficult and typically requires a combination of techniques. Removal of covered Wallstents with a snare is relatively simple and safe, and can be followed immediately by corrective therapy. Insertion of a covered Wallstent should be considered as initial therapy when malignant biliary obstruction is suspected but unconfirmed.

[Conservative and interventional endoscopic therapy of biliary tract carcinoma]

Endoscopic therapy is central to the palliative treatment of bile duct carcinoma. In obstructive jaundice, biliary drainage has few complications and relieves symptoms reliably. It can prevent further complications and is indispensable to the treatment of cholangitis. The principal drawback of biliary stents is stent occlusion and cholangitis. Prophylactic antibiotics were not proven to be effective. Technical details concerning material, number and location of stents await further clarification. Photodynamic therapy is an emerging adjunct to palliative therapy of biliary cancer. Preoperative biliary drainage in obstructive jaundice is not warranted as a routine intervention. It may be indicated, though, as preoperative bridging or to allow liver function to recover before major hepatic surgery. Finally, stenting of postoperative bile duct stenosis is gaining increasing acceptance.

Endoscopic management of occluded biliary Wallstents: a cancer center experience

BACKGROUND

Biliary obstruction caused by unresectable malignancy commonly is treated by placement of a biliary self-expandable metallic stent. The endoscopic and percutaneous techniques for self-expandable metallic stent placement are well established and can be performed with a high success rate. Self-expandable metallic stent placement affords palliation of pruritus and enables treatment of advanced cancer with chemotherapeutic agents metabolized by the liver. Unfortunately, these stents tend to occlude with time. Optimal management of an occluded self-expandable metallic stent remains to be determined.

METHODS

A retrospective review was undertaken to determine optimal management of the occluded self-expandable metallic stent. Patients with malignant biliary obstruction who had endoscopic management for occluded Wallstents that had been placed percutaneously and endoscopically were studied. All patients underwent ERCP with one of the following interventions: mechanical cleaning, insertion of a plastic stent within the Wallstent, or insertion of a second Wallstent. The effectiveness of the intervention and duration of stent patency thereafter was studied.

RESULTS

A total of 34 patients with occluded biliary Wallstents underwent the following procedures: mechanical cleaning (6 patients), placement of a second Wallstent (4), or insertion of a plastic stent (24). Mechanical cleaning was effective in only one of 6 patients. For all 4 patients who underwent placement of a second Wallstent, there was resolution of jaundice or cholangitis and no reocclusion. Plastic stent insertion was successful in 22 of 24 patients. Median duration of stent patency after intervention was 192 days (range 81-257 days) after second Wallstent placement, 90 days (11-393 days) after plastic stent insertion, and 21 days (3-263 days) after mechanical cleaning. Duration of stent patency was better when the initial malignant stricture involved the distal vs. the proximal bile duct.

CONCLUSIONS

Occlusion of a biliary Wallstent is best managed by endoscopic insertion of a second Wallstent or a plastic stent. Mechanical cleaning is less effective. The level of the initial biliary obstruction influences stent patency.

An unusual case of haemobilia

Arterio-biliary fistula is an uncommon cause of haemobilia. We describe a case of right hepatic artery pseudo-aneurysm causing arterio-biliary fistula and presenting as severe melaena and cholangitis. Gastroduodenoscopy failed to establish the exact source of bleeding and hepatic artery angiography and selective embolization of the pseudo-aneurysm successfully controlled the bleeding. Pseudo-aneurysm of the hepatic artery is mostly iatrogenic due to biliary intervention, as demonstrated in this case. Difficulty in diagnosis and management is discussed together with a review of the literature.

Potentially fatal haemobilia due to inappropriate use of an expanding biliary stent

AIM: To highlight the fatal complication caused by expanding biliary stents and the importance of avoiding use of expanding stent in potentially curable diseases.

METHODS: Arteriobiliary fistula is an uncommon cause of haemobilia. We describe a case of right hepatic artery pseudoaneurysm causing arteriobiliary fistula and presenting as severe malena and cholangitis, in a patient with a mesh metal biliary stent. The patient had lymphoma causing bile duct obstruction.

RESULTS: Gastroduodenoscopy failed to establish the exact source of bleeding and hepatic artery angiography and selective embolisation of the pseudo aneurysm successfully controlled the bleeding.

CONCLUSION: Bleeding from the pseudo aneurysm of the hepatic artery can be fatal. Mesh metal stents in biliary tree can cause this complication as demonstrated in this case. So mesh metal stent insertion should be avoided in potentially benign or in curable conditions. Difficulty in diagnosis and management is discussed along with the review of the literature.

Biliary and pancreatic stents

Endoscopic retrograde cholangiopancreatography is one of the most challenging and demanding procedures performed in endoscopy units. Many endoscopy staff nurses become overwhelmed by the complexity of patient management and the realm of equipment necessary in providing endoscopic therapy for patients with biliary and pancreatic disease. The case of Ray, a 45-year-old patient, is used in this article to demonstrate the current value of biliary stenting and its potential impact on a patient's life. An understanding of the indications for and uses of stents in the treatment of biliary occlusion and pancreatic disease will provide a foundation for those assisting in endoscopic retrograde cholangiopancreatography.