Endoscopic Biliary Stent Placement Research Articles

A pediatric case of Burkitt’s lymphoma with bile duct obstruction requiring surgical biliary reconstruction

BackgroundBiliary obstruction due to compression by a B-cell solid tumor occurs rarely. A few reports have described biliary reconstruction surgery for obstructive jaundice caused by Burkitt’s lymphoma. However, there are no detailed reports on pediatric cases. We report a pediatric case of obstructive jaundice due to malignant lymphoma treated with biliary reconstruction surgery.Case presentationA 5-year-old girl presented to our hospital with a massive abdominal tumor that caused biliary stricture. Chemotherapy was initiated after an open tumor biopsy. However, endoscopic biliary stent placement was performed owing to elevated bilirubin levels. We treated the patient with chemotherapy for 9 months while endoscopically replacing the biliary stent every few months. She achieved complete tumor remission. However, sclerotic lymph nodes were persistent on the dorsal side of the cholecystic duct junction, and biliary stricture at the same site had changed to stent-dependent biliary obstruction. Therefore, we performed choledochojejunostomy and retrocolic Roux-en-Y reconstruction 15 months after initial admission. There were no postoperative complications or tumor recurrences, and the bilirubin level remained low. Histopathologically, the resected bile duct wall was fibrotic and thick, and the bile duct lumen narrowed.ConclusionsBiliary reconstruction is effective to achieve long-term biliary patency in pediatric patients with stent-dependent biliary obstruction due to malignant lymphoma. However, the decision on when to stop biliary stent replacement and proceed to biliary reconstruction surgery is a matter of debate. Further case studies are required to address this issue.

Clinical study of extrahepatic biliary adenoma.

Biliary adenomas that occur in the extrahepatic biliary tree are rare. It is difficult to distinguish it from cholangiocarcinoma or cholangiolithiasis by various imaging examinations, and it is very easy to be misdiagnosed. To evaluate the cumulative experiences including clinical characteristics and treatments of nine patients diagnosed with extrahepatic biliary adenoma admitted to the First Affiliated Hospital of Xi'an Jiaotong University from 2016 to 2022. A total of nine patients were included in our study. The laboratory examinations, disease diagnosis, therapy and pathological characteristics, and follow-up of every patient were evaluated. Our cohort consisted of six females and three males with an average diagnosis age of 65.1 years (range 46-87). Six extrahepatic biliary adenomas were located in the common bile ducts and three in the hepatic duct. On initial presentation, all of the patients have symptom of biliary origin, including obstructive jaundice (4/9, 44.4%), abdominal pain (6/9, 66.7%), and fever (3/9, 33.3%). Preoperative imaging examination considered bile duct carcinoma in 6 cases and bile duct calculi in 3 cases. All the patients received surgical treatment and were confirmed by pathology as biliary adenoma. The symptoms improved significantly in all 9 patients after surgery. Seven of nine patients recovered well at follow-up without tumor recurrence. One patient died 2 mo after the surgery due to heart failure. One patient developed jaundice again 8 mo after surgery, underwent endoscopic retrograde cholangiopancreatography and biliary stent placement. Benign extrahepatic biliary tumors are rare and difficult to diagnosis preoperatively. Intraoperative choledochoscopy and timely biopsy may offer great advantages.

A239 PATIENT OUTCOMES AFTER ENDOSCOPIC STENT INSERTION FOR MALIGNANT BILIARY OBSTRUCTION: A QUALITY ASSURANCE STUDY

Abstract Background Management of pancreaticobiliary malignancy is complex and multi-disciplinary. Decompression of malignant biliary obstruction (MBO) is preferentially achieved with endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent placement. This may improve the quality of life for patients with unresectable disease and improve outcomes in resectable/borderline-resectable disease. Purpose To assess quality outcomes in patients undergoing biliary stenting for MBO. Method This is a retrospective chart audit of patients referred to the University of Alberta Hospital (UAH) for suspected or confirmed MBO. The primary outcome was clinical success (reduction in bilirubin of >50% at 30 days). Secondary outcomes were technical success, type of stent used, need for re-intervention, adverse events (AEs), time from stent placement to surgery or cancer centre assessment, and survival. Result(s) Between January 2020 and June 2022, 222 patients (102 female, 46%) with a mean age of 70±1 years (range 34-93 years) underwent 290 ERCPs. The cause of MBO was pancreatic cancer in 130 (59%), cholangiocarcinoma in 32 (14%), ampullary cancer in 9 (4%), and others in 51 (23%). Technical success for stent insertion on first ERCP was achieved in 180/222 patients (81%) with only brushings performed in 2. Of the 40 patients (18%) with unsuccessful ERCP, further success was achieved by repeat ERCP (8), percutaneous transhepatic drainage (PTC, 15), PTC with rendezvous ERCP (1), surgical decompression (3), and endoscopic ultrasound-guided biliary drainage (1). No biliary drainage was performed in 12 patients. Overall, ERCP with stent insertion was technically successful in 188/222 patients (85%). A total of 233 biliary stents were inserted (38 plastic, 195 metal). Clinical success was achieved in 20/38 patients (53%) with plastic stents and 151/181 patients (83%) with metal stents (Χ2 17.4 p<0.05). Adverse events were encountered in 33 patients (11%) with stent migration occurring in 8 (3%), cholangitis in 7 (2%), post-ERCP pancreatitis in 7 (2%), post-sphincterotomy bleeding in 4 (1%), and death in 2 (1%). Re-intervention was required in 36 patients (20%) after initial ERCP with successful stent placement. The re-intervention rate was significantly higher with plastic stents (14/27, 52%) than with metal stents (22/153, 14%) after initial ERCP (Χ2 20.1 p<0.001). The overall survival was a mean of 249±16 days (5-967) for patients with plastic stents and 248± 16 days (1-959) for those with metal stents. Survival was significantly worse in patients with unresectable disease vs resectable/borderline-resectable disease (Log rank 38.89, p<0.001), Figure 1. Image Conclusion(s) In MBO, metal stents appear to provide significantly better biliary drainage, with less need for re-intervention, but do not appear to be associated with any survival benefit over plastic stents. We hope that this quality assurance project will help in the development of a regional management pathway for optimizing the care of patients presenting with MBO. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Suprapapillary Biliary Stents Have Longer Patency Times than Transpapillary Stents-A Systematic Review and Meta-Analysis.

Endoscopic biliary stent placement is a minimally invasive intervention for patients with biliary strictures. Stent patency and function time are crucial factors. Suprapapillary versus transpapillary stent positioning may contribute to stent function time, so a meta-analysis was performed in this comparison. A comprehensive literature search was conducted in the CENTRAL, Embase, and MEDLINE databases to find data on suprapapillary stent placement compared to the transpapillary method via endoscopic retrograde cholangiopancreatography in cases of biliary stenosis of any etiology and any stent type until December 2020. We carried out a meta-analysis focusing on the following outcomes: stent patency, stent migration, rate of cholangitis and pancreatitis, and other reported complications. Three prospective and ten retrospective studies involving 1028 patients were included. Suprapapillary stent placement appeared to be superior to transpapillary stent positioning in patency (weighted mean difference = 50.23 days, 95% CI: 8.56, 91.98; p = 0.0.018). In a subgroup analysis of malignant indications, suprapapillary positioning showed a lower rate of cholangitis (OR: 0.34, 95% CI: 0.13, 0.93; p = 0.036). Another subgroup analysis investigating metal stents in a suprapapillary position resulted in a lower rate of pancreatitis (OR: 0.16, 95% CI: 0.03, 0.95; p = 0.043) compared to transpapillary stent placement. There was no difference in stent migration rates between the two groups (OR: 0.67, 95% CI: 0.17, 2.72; p = 0.577). Based on our results, suprapapillary biliary stenting has longer stent patency. Moreover, the stent migration rate did not differ between the suprapapillary and transpapillary groups.

Plastic biliary stent migration as a cause of ascending colon perforation.

A 65-year-old male with pancreatic cancer stage IV and history of endoscopic retrograde cholangiopancreatography (ERCP) and plastic biliary stent placement 43 days earlier, arrived to the emergency department with 8-hour right upper quadrant pain, fever, and shivering. Contrast enhanced computed tomography showed migration of the biliary stent to the ascending colon, with signs of perforation on its antimesenteric edge. A surgical approach by laparotomy was decided. The biliary stent was found perforating the ascending colon and in contact with the abdominal wall. The stent contained the colonic perforation, avoiding leakage. Removal of migrated endoprosthesis and primary closure was made. The patient remained in observation and with IV antibiotics, a new was performed ERCP with placement of an 8 cm by 10 Fr Amsterdam-type plastic stent on the 7th day due to cholangitis, with subsequent complete recovery. Endoscopic placement of stents has become a well-established procedure for biliary disease. Stent migration may be present in up to 6-8% of the cases. In most cases, distal migration has an uncomplicated passage, but it may cause bowel injury in up to 1%. This life-threatening complication requires prompt evaluation and management either by endoscopic or surgical approach.

Iatrogenic Portobiliary Fistula following Endoscopic Biliary Stent Placement: A Case Series and Review of the Literature

Iatrogenic portobiliary fistula is a rare adverse event following endoscopic biliary stent placement. Damage to the portal vein following endoscopic biliary stent placement has previously only been reported as single case reports. Management has ranged from conservative monitoring to surgery. Here, the authors present 4 cases of inadvertent endoscopic placement of a biliary stent into the portal vein. Interventional radiology was called to assist in the management of each of these cases. The experience presented here in conjunction with review of the previously reported cases helps shed light on potential management strategies if this adverse event is encountered in the future.

SpyGlass-Guided Photodynamic Therapy for Unresectable Cholangiocarcinoma: A Case Report and Review of the Literature

Endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent placement are standard palliative care procedures for patients with unresectable cholangiocarcinoma. However, the bile duct mucosa cannot be observed directly during the placement of a light diffuser in photodynamic therapy (PDT) and biopsy. SpyGlass can solve the above two problems. In this paper, we report the case of a patient who presented with obstructive jaundice and underwent endobiliary stenting placement several times. However, cholangiocarcinoma hyperplasia still led to stent blockage. We applied SpyGlass to guide the accurate placement of a light diffuser and evaluated the tumor necrosis after PDT. Results revealed the good application effect of this device.

Delayed Hemobilia Caused by Penetration of Biliary Plastic Stent into Portal Vein

Biliary stent migration is one of the late complications of endoscopic retrograde cholangiopancreatography. Most of the biliary stent migration is asymptomatic and successfully managed by stent removal. A 66-year-old man with unresectable pancreatic cancer, common bile duct obstruction, and duodenal third portion obstruction underwent endoscopic plastic biliary stent placement and duodenal uncovered metallic stent placement in two separate sessions. After 3 weeks from the duodenal stenting, he presented with hematemesis. Urgent esophagogastroduodenoscopy and magnetic resonance imaging showed hemobilia. The patient recovered with conservative managements. Cross-sectional imagings done 2 months later demonstrated the penetration of the biliary stent into portal vein. Here, we present a case of delayed hemobilia caused by penetration of biliary plastic stent into the portal vein.

Increased risk of biliary infection after biliary stent placement in users of proton pump inhibitors.

ObjectivesProton pump inhibitors (PPIs) are widely prescribed medications for gastric acid‐induced diseases. Despite the effectiveness of PPIs, recent evidence suggested an increased risk of various bacterial infections in PPI users. The current study was conducted to evaluate the risk of biliary infection after endoscopic biliary stent placement in regular users of PPIs.MethodsConsecutive patients with a native papilla who underwent endoscopic retrograde cholangiopancreatography and stent placement for biliary stricture between January 2010 and August 2019 were included in this retrospective study. The cumulative incidences of biliary infection were compared between regular and non‐regular PPI users.ResultsDuring the study period, 270 regular PPI users and 146 non‐regular PPI users were included in the analyses. Age, gender, and indication of endoscopic retrograde cholangiopancreatography were not different between the two groups. The incidences of biliary infection were 43% in regular PPI users and 36% in non‐regular PPI users but the time to biliary infection was significantly shorter in regular PPI users than in non‐regular users (28 vs. 87 days, p = 0.01). The cumulative incidence of biliary infection was significantly higher in regular PPI users compared with non‐regular users (p = 0.008). The multivariable Cox regression analysis also showed a significantly higher hazard ratio of biliary infection in regular PPI users (1.62 [95% confidence interval 1.16–2.26; p = 0.005]).ConclusionsRegular PPI use was associated with a higher risk of biliary infection after endoscopic biliary drainage. Inappropriate PPI use should be avoided.

Using air cholangiography to reduce postendoscopic retrograde cholangiopancreatography cholangitis in patients with malignant hilar obstruction.

Cholangitis after endoscopic retrograde cholangiopancreatography (ERCP) is a major problem for patients with hilar biliary obstruction. To date, it remains unclear whether air-contrast cholangiography (ACC) can reduce cholangitis in these patients. For this reason, our study assesses the efficacy of reducing cholangitis through ACC. This paper presents a retrospective study conducted at a tertiary university hospital. We enrolled patients who were diagnosed with hilar structures and underwent ERCP between January 2012 and December 2018. From 2015 onwards, ACC was performed following the successful selective cannulation into the dilated intrahepatic bile duct of these patients. The primary aim was to assess patients with cholangitis in both an ACC group and iodine contrast cholangiography (ICC) group. This study included 80 patients, 35 of whom received ACC and 45 who received ICC. There were no differences between the 2 groups in terms of the number of patients who underwent endoscopic papillotomy, endoscopic nasobiliary drainage, endoscopic biliary stent placement, or other technical procedures or complications. A total of 19 patients (23.8%) presented with fever (cholangitis) after the ERCP procedure (4 ACC, 15 ICC; 11.4% vs. 33.3%, respectively; P=0.03). One patient in the ICC group who obtained a plastic stent for palliative drainage died 2 weeks post-ERCP. Among the other 18 cholangitis patients, 8 (1 ACC, 7 ICC) were treated with additional ERCP or percutaneous transhepatic biliary drainage (PTBD), while the remaining 10 only received antibiotics. One patient in the ICC group who obtained a plastic stent for palliative drainage died 2 weeks post-ERCP. We found that ACC significantly reduced the incidence of cholangitis in patients with hilar obstruction.

Accurate Evaluation of Residual Common Bile Duct Stones by Endoscopic Ultrasound: A Two-Step Check Method for Residual Stone Clearance

Background/Aims: Residual common bile duct (CBD) stones occasionally become symptomatic after stone removal with endoscopic retrograde cholangiopancreatography (ERCP) upon removal of the endoscopic biliary stent (EBS). An accurate evaluation of residual stones before stent removal is necessary. This study evaluated a new two-step check method using endoscopic ultrasound (EUS) for the detection of residual stones after ERCP stone removal. Methods: Fifty-six patients who underwent CBD stone removal and EBS placement were prospectively enrolled. Residual stones were evaluated by the check method. EBS was removed at the time of the check method or at a later time of residual stone removal. The primary outcome was to evaluate the efficacy of this check method. Results: Residual CBD stone/sludge was detected in 20 of 56 patients (35.7%; stones: 28.6%, sludge: 7.1%) by the check method and removed by the ERCP procedure at a later time. After stent and final stone removal, patients were followed for an average of 211 days; cholangitis recurred in only 1.8% of patients. There were no adverse events associated with the check method. Temporary EBS prevented the recurrence of cholangitis by residual stone and caused no adverse events in the pancreatobiliary tract until the two-step check method (median, 113 days; range, 17–232 days). Conclusion: The new check method may be ideal and feasible for EBS removal because recurrences are very rare when a clear CBD has been verified, and an additional ERCP procedure is also possibly avoided.

Advantages of Extrahepatic Glissonean Approach in the Donor Operation in Living Donor Liver Transplantation

Introduction: To eliminate biliary complications in living donor hepatectomy, we introduced the extrahepatic glissonean approach combined with liver hanging maneuver (GA+LHM) since 2017. Method: Surgical procedures are as follows: Prior to liver transection, we encircle the extrahepatic Glissonean pedicle at the graft liver side with a tape. Then, we introduce a hanging tape from the encircled Glissonean pedicle to the groove between middle hepatic vein and right hepatic vein. Liver parenchymal transection is facilitated with the LHM. After the completion of transection, hepatic artery and portal vein of the graft liver are isolated in the hilum. The remaining structure is the hilar plate including the hepatic duct(s). After intraoperative cholangiography, bile duct, hepatic artery, portal vein, and hepatic vein are divided in this order and the graft liver is procured. We analyzed the short-term outcomes of the donor using Clavien–Dindo classification: For bile leakage, the International Study Group of Liver Surgery definition was used. Results: GA+LHM was successfully performed in a total of 44 consecutive living donor hepatectomy (right lobe graft in 28, left lobe graft in 15, and left trisegmental lobe +S1 graft in 1). There were no Grade Ⅲa≦ complications and bile leakage until discharge. Biliary stricture occurred in 1 (2%) patient who was readmitted and required endoscopic biliary stent placement. Conclusions: GA+LHM presumably prevents heat and mechanical injury of the bile ducts of the remnant liver by minimization of hilar dissection, thereby contributes to eliminating bile leakage in living donor hepatectomy.

Concomitant endoscopic biliary, duodenal and colonic stent placement for advanced carcinoma of gall bladder

Concomitant endoscopic biliary, duodenal and colonic stent placement for advanced carcinoma of gall bladder

S1499 Large Pancreatic Cyst in Von Hippel-Lindau (VHL) Syndrome Causing Bile Duct Obstruction

Introduction: Von Hippel-Lindau (VHL) syndrome is a rare autosomal inherited disorder characterized by the development of multiple tumors, the most common of which is renal cell carcinoma, hemangioblastomas, pheochromocytomas, and solid and cystic tumors of the pancreas. Morbidity and mortality in VHL are more commonly related to renal and central nervous system pathologies. Extrahepatic biliary obstruction secondary to pancreatic cysts is rare in patients with VHL. We present a case of extrahepatic biliary obstruction secondary to pancreatic cysts in a patient with a history of VHL syndrome successfully managed endoscopically. Case Description/Methods: 35-year-old woman with history of VHL and course complicated by clear cell renal cell carcinoma status post partial nephrectomy, cervical/medullary/fourth ventricle hemangioblastomas status post resection, and serous cystic pancreatic adenoma status post distal pancreatectomy and splenectomy with subsequent development of insulin-dependent diabetes mellitus type 2, presented with three days of right upper quadrant abdominal pain. MR Cholangiopancreatography revealed the residual pancreas was completely replaced by multiple cystic lesions with a dominant cyst in the head of the pancreas measuring 6.2 cm causing mass effect on the portal vein and mid to distal common bile duct with resultant intrahepatic, extrahepatic biliary ductal dilatation, and gallbladder distension. Using EUS with fine-needle biopsy of the cyst was done. Intraprocedural cholangiogram during ERCP revealed 14mm dilation of proximal extrahepatic biliary duct and non-opacification of the distal extrahepatic bile duct in the region of the pancreatic head, consistent with a stricture. CBD brushings were sent for cytology and a straight plastic biliary stent was successfully deployed across the stricture. After the endoscopic procedure, the patient demonstrated clinical improvement. Discussion: The pancreatic manifestation of VHL can present as a cystic, solid, or combined lesion. The management is complex because of the challenge in the differentiation of benign cystic lesions from malignant lesions. This case highlights the fact that pancreatic involvement leading to acute biliary obstruction, although uncommon, can occur in patients with VHL syndrome. Conservative management with endoscopic biliary stent placement and endoscopic surveillance (for secondary manifestations - portal hypertension) may be helpful in these patients, however eventual surgical management may be needed.Figure 1.: (Top left) Stricture/obstruction in ERCP, (Bottom left) EUS with biopsy, (Right) MRI showing cyst, CBD, and distended gallbladder.

S1998 Two Scopes Are Better Than One: Esophageal Recanalization With the Rendezvous Procedure

Introduction: Esophageal strictures can occur in patients with head & neck cancers treated with radiotherapy. Rate of stricture in these cases is estimated to be between 2-16%. We present a case of severe esophageal stricture treated with combined antegrade-retrograde endoscopic dilation and biliary stent placement. Case Description/Methods: 76-year-old female with squamous cell carcinoma of the hypopharynx, with PEG tube for nutrition, presented with persistent dysphagia following completion of radiotherapy. Barium esophagram showed severe pharyngeal dysphagia with esophageal backflow and aspiration. Laryngoscopy and transnasal esophagoscopy revealed a blind ending pouch in the proximal esophagus. After unsuccessful attempts to pass a guidewire through the stenosis under direct visualization, we were consulted to discuss a combined approach. Rendezvous recanalization with access through both the mouth and gastrostomy site was planned. An endoscope was passed through the mouth to the level of the esophagus, revealing severe stenosis with complete obstruction in the hypopharynx. Under fluoroscopic guidance, we attempted to advance a guidewire through the stenosis, but were unsuccessful. An endoscope was then reintroduced through the mature gastrostomy. The scope was advanced to the esophageal stricture in retrograde. A transnasal esophagoscope was used through the mouth for antegrade access. From the retrograde endoscope, a guidewire was passed through the stenosis and captured through the mouth. Under fluoroscopy, a 6-7-8mm x 5.5cm CRE balloon dilator was passed over guidewire through the mouth, and dilation was performed to 6mm. We decided to use a biliary stent given the location of the stricture in the hypopharynx where placement of a larger esophageal stent is not feasible and would cause severe discomfort given the larger diameter. A 10mm x 60mm WallFlex biliary stent was successfully deployed across the stenosis. After repeat dilation was performed twice more 2 weeks apart, her esophagus remains patent at 18mm. On latest follow-up, she is able to tolerate PO liquids and pureed food. Discussion: High-grade stenosis is difficult to treat, often requiring a multidisciplinary approach. In cases of high-grade esophageal stenosis, an antegrade-retrograde endoscopic approach can be employed to dilate the esophageal segment. Recent meta-analysis shows esophageal recanalization using the rendezvous procedure to have a technical success rate >85%, dysphagia improvement rate >55%, and PEG-tube free rate >40%.Figure 1.: Endoscopic view of esophageal stricture (a), fluoroscopic image of antegrade and retrograde scope with wire passing through the stricture (b), endoscopic view of biliary stent in place (c), fluoroscopic image of biliary stent in place (d). Watch the video at https://bit.ly/3eNvMxi.

Alterations in the management for patients with retroduodenal perforations after transpapillary interventions

Aim. To evaluate treatment results of retroduodenal perforations after transpapillary endoscopic procedures, considering new possibilities of modern minimally invasive interventions.Materials and methods. Perforations were identified in 29(0,5%) cases from 5943 endoscopic retrograde procedures in Moscow City Hospital №31 since 01.01.2010 to 01.01.2021. There were 24(82,8 %) women and 5(17,2%) men in the age from 29 to 89 years (median age – 64.2 ± 14.9 years) Endoscopic papillosphincterotomy was performed n 25 (86.2%) cases (in 5 – incisional), with additional lithoextraction in 12 (46.7%), endoscopic papillectomy – in 4 (10%) cases. Perforations developed in 27 (93,1%) patients with two and more risk factors.Results. Combination of endoscopic and conservative treatment was applied to cure the perforation in 24 cases (82.8%). A fully covered self-expandable metal stent was placed in 16 (66.7%) cases, and clips were applied to stenting in 2(8.3%) cases. Isolated endocliping was performed in 5 (20.8%) patients, and a plastic biliary stent – in 1(4.2%) case. Other 5(17.2%) patients underwent conservative (3) and surgical (2) treatment only. Satisfactory results were achieved in 23(79.3%) cases, when combination of endoscopic and conservative therapy was performed. Mortality was observed in 6(20.7%) cases (isolated conservative therapy (3), surgical treatment (2) and endoscopic placement of a plastic biliary stent (1).Conclusion. Retroduodenal perforations can lead to death in 20.7% cases, according to our data. Timely diagnosis and using a combination of conservative and endoscopic methods as biliary stenting with fully covered self-expandable metal stent and endocliping allowed to achieve recovery in all cases.

Predictors of Jaundice Resolution and Survival After Endoscopic Treatment of Primary Sclerosing Cholangitis.

The benefit of endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of primary sclerosing cholangitis (PSC) remains controversial. To identify predictors of jaundice resolution after ERCP and whether resolution is associated with improved patient outcomes, we conducted a retrospective cohort study of 124 patients with jaundice and PSC. These patients underwent endoscopic biliary balloon dilation and/or stent placement at an American tertiary center, with validation in a separate cohort of 102 patients from European centers. Jaundice resolved after ERCP in 52% of patients. Median follow‐up was 4.8 years. Independent predictors of jaundice resolution included older age (P = 0.048; odds ratio [OR], 1.03 for every 1‐year increase), shorter duration of jaundice (P = 0.059; OR, 0.59 for every 1‐year increase), lower Mayo Risk Score (MRS) (P = 0.025; OR, 0.58 for every 1‐point increase), and extrahepatic location of the most advanced biliary stricture (P = 0.011; OR, 3.13). A logistic regression model predicted jaundice resolution with area under the receiver operator characteristic curve of 0.67 (95% confidence interval, 0.5‐0.79) in the validation set. Independent predictors of death or transplant during follow‐up included higher MRS at the time of ERCP (P < 0.0001; hazard ratio [HR], 2.33 for every 1‐point increase), lower total serum bilirubin before ERCP (P = 0.031; HR, 0.91 for every 1 mg/dL increase), and persistence of jaundice after endoscopic therapy (P = 0.003; HR, 2.30). Conclusion: Resolution of jaundice after endoscopic treatment of biliary strictures is associated with longer transplant‐free survival of patients with PSC. The likelihood of resolution is affected by demographic, hepatic, and biliary variables and can be predicted using noninvasive data. These findings may refine the use of ERCP in patients with jaundice with PSC.

A Prospective Multicenter Study of "Inside Stents" for Biliary Stricture: Multicenter Evolving Inside Stent Registry (MEISteR).

Background: Endoscopic biliary stent placement is the standard of care for biliary strictures, but stents across the papilla are prone to duodenobiliary reflux, which can cause stent occlusion. Preliminary studies of “inside stents” placed above the papilla showed encouraging outcomes, but prospective data with a large cohort were not reported. Methods: This was a prospective multicenter registry of commercially available inside stents for benign and malignant biliary strictures. Primary endpoint was recurrent biliary obstruction (RBO). Secondary endpoints were technical success of stent placement and removal, adverse events, and stricture resolution. Results: A total of 209 inside stents were placed in 132 (51 benign and 81 malignant) cases with biliary strictures in 10 Japanese centers. During the follow-up period of 8.4 months, RBO was observed in 19% of benign strictures. The RBO rate was 49% in malignant strictures, with the median time to RBO of 4.7 months. Technical success rates of stent placement and removal were both 100%. The adverse event rate was 8%. Conclusion: This prospective multicenter study demonstrated that inside stents above the papilla were feasible in malignant and benign biliary strictures, but a randomized controlled trial is warranted to confirm its superiority to conventional stents across the papilla.

Association of long-term endoscopic biliary stent placement with choledocholithiasis: a literature review.

Endoscopic stone removal is currently the first-line procedure for the treatment of common bile duct stones. Advances in equipment and treatment techniques have expanded the scope of application of endoscopic treatment to include stones that have previously been difficult to remove endoscopically, such as stacked stones and large stones. For the treatment of common bile duct stones in elderly patients in particular, long-term placement of a biliary stent is increasingly being selected. Although periodic stent replacement is required, some reports have stated that biliary stenting is useful in terms of treatment-associated invasiveness and the incidence of accidental complications. To date, various opinions have been presented on whether the treatment of bile duct stones should aim for complete removal of stones or adopt the biliary stenting approach. Findings in previous reports suggest that both the approach for complete stone removal and the long-term stenting approach are associated with advantages and disadvantages. In this study, we reviewed previous reports on the significance of placing a stent and implementing careful monitoring rather than stone removal in patients with bile duct stones.

Design and evaluation of a novel anti-reflux biliary stent with cone spiral valve.

Endoscopic placement of biliary stent is a well-established palliative treatment for biliary obstruction. However, duodenobiliary reflux after stent placement has been a common problem which may lead to dreadful complications. This paper designed a novel anti-reflux biliary stent with a cone spiral valve. Fluid-Structure Interaction (FSI) simulations were established to evaluate the efficiency of the anti-reflux stent comparing with a clinically applied standard stent. According to the stress distribution of the valve, the fatigue performance in the stress concentration area was analyzed. The results show that when the antegrade flow through the valve, the cone spiral valve could stretch and open to realize adequate drainage under the normal physiological pressure of biliary tract; When the duodenal reflux through the valve, the valve would be compressed and close with a result of nearly zero at the outlet flow rate. Furthermore, the anti-reflux stent achieved improved radial mechanical performance with 2.7 times higher radial stiffness than standard stent. Finite element analysis (FEA) also indicates that compared with the standard stent, the addition of the anti-reflux valve had little negative effect on flexibility of the stent. Fatigue analysis results showed that the valve was reliable. This research provides the new stent with a cone spiral valve and proves that it is technically feasible and effective for preventing the duodenobiliary reflux while ensuring the antegrade bile flow without compromising the other biomechanical performances.