Hilar Biliary Obstruction Research Articles

Bilateral stenting methods for hilar biliary obstructions

OBJECTIVE:There is no consensus regarding the most appropriate methods (i.e., the side-by-side versus the stent-in-stent technique) for placing bilateral stents for malignant hilar biliary obstructions. We aimed to perform a quantitative review of the published data regarding the clinical efficacy of the side-by-side and stent-in-stent bilateral drainage techniques for hilar biliary obstructions.METHODS:A comprehensive search of several databases was conducted and a fixed-effects or random-effects model was used to pool the data from all of the study end-points.RESULTS:Four clinical trials were identified. A comparison of the side-by-side and stent-in-stent groups revealed no significant differences with respect to the rates of successful placement, successful drainage, early complications, late complications and stent occlusions. There were also no significant inter-group differences in stent patency and patient survival and no publication bias was observed.CONCLUSIONS:The performance of the side-by-side technique appears to be similar to that of the stent-in-stent technique for bilateral drainage in patients with malignant hilar biliary obstructions.

Sa1447 A Comparison of Bilateral Side-by-Side Metal Stents Deployed Above and Across the Sphincter of Oddi in the Management of Malignant Hilar Biliary Obstruction

Sa1447 A Comparison of Bilateral Side-by-Side Metal Stents Deployed Above and Across the Sphincter of Oddi in the Management of Malignant Hilar Biliary Obstruction

Su1624 Biliary Stenting for Benign and Malignant Hilar Biliary Obstruction Using Very Long Multi-Sidehole Soft Plastic Stents: a 5-Year Experience From a Single Center

Table 1. Characteristics and outcomes of FCSEMS in BBS AB344 GASTROINTESTINAL EN Hilar (N[10)

Su1630 Feasibility of Single-Step Simultaneous Side-by-Side Placement Using 6Fr Self-Expandable Metallic Stent

In the management of unresectable malignant hilar biliary obstruction, multiple metallic stent placement was frequently mandatory, but still technically challenging. There were two types of multiple metallic stent placement; side-by-side and stent-in-stent procedure. Recently, metallic stent with 6Fr delivery system was developed and enable us to simultaneous side-by-side placement. In this study, we evaluated the feasibility of single-step simultaneous side-by-side placement for hilar malignant obstruction.

Su1619 Small Cell Versus Large Cell-Sized Stent for Endoscopic Bilateral Stent-in-Stent Placement of Metal Stents in Patients With Malignant Hilar Biliary Obstruction

Su1619 Small Cell Versus Large Cell-Sized Stent for Endoscopic Bilateral Stent-in-Stent Placement of Metal Stents in Patients With Malignant Hilar Biliary Obstruction

Su1625 Y-Shaped Bilateral Self Expandable Metallic Stent Placement (Stent-in-Stent Technique) for Malignant Hilar Biliary Obstruction: Data From a Large Saries of Patients Treated in a Tertiary Referral Center

Su1625 Y-Shaped Bilateral Self Expandable Metallic Stent Placement (Stent-in-Stent Technique) for Malignant Hilar Biliary Obstruction: Data From a Large Saries of Patients Treated in a Tertiary Referral Center

Y-shaped bilateral self-expandable metallic stent placement for malignant hilar biliary obstruction: data from a referral center for palliative care.

Background and Aim. Malignant hilar strictures are a clinical challenge because of the current therapeutic approach and the poor prognosis. In recent years, self-expandable metallic stents have proven more effective than plastic stents for palliation of malignant hilar strictures, with the bilateral stent-in-stent technique registering a high success rate. We report our experience with Y-shaped endoscopic self-expandable metallic stents placement for treatment of advanced malignant hilar strictures. Methods. From April 2009 to August 2012, we prospectively collected data on patients treated with Y-shaped SEMS placement for advanced malignant hilar carcinoma. Data on technical success, clinical success, and complications were collected. Results. Twenty patients (9 males) were treated (mean age 64.2 ± 15.3 years). The grade of malignant hilar strictures according to the Bismuth classification was II in 5 patients (25%), IIIa in 1 (5%), and IV in 14 (70%). The mean bilirubin level was 14.7 ± 4.9 mg/dL. Technical success was achieved in all patients, with a significant reduction in bilirubin levels (2.9 ± 1.7 mg/dL). One patient experienced cholangitis as early complication, while in 2 patients stent ingrowth was observed. No stents migration was recorded. There was no procedure-related mortality. At the end of the follow-up (7.1 ± 3.1 months), 13 of the 20 patients (65%) had died. Conclusions. Our experience confirms endoscopic bilateral self-expandable metallic stents placement with stent-in-stent technique (Y-shaped configuration) as a feasible, effective, and safe procedure for palliation of unresectable malignant hilar strictures.

Simultaneous bilateral biliary metal stents versus plastic stents under endoscope for treatment of malignant hilar biliary obstruction

Objective To compare the safety and efficacy of simultaneous bilateral biliary metal stents with plastic stents under endoscope for treatment of malignant hilar biliary obstruction(MHBO).MethodsFrom May 2007 to December 2011,142 MHBO patients were selected for this study,with 32 receiving bilateral metal stent drainage and 110 receiving bilateral plastic stent drainage.The success rate of endoscopic operations,postoperative jaundice-reducing effect,post-endoscopic retrograde cholangiopancreatography(ERCP) complications,and stent patency period were observed.ResultsThe procedures were successful in all patients in the two groups.The postoperative jaundice-reducing effect rates were 96.9%(31/32) in the metal stent group and 88.2%(97/110) in the plastic stent group(P0.05).Two patients in the metal stent group and six in the plastic stent group had post-ERCP cholangitis,which was relieved by anti-inflammatory intervention,replacement of stents or endoscopic nasobiliary drainage.Two patients in the plastic stent group had stent slip.There were no pancreatitis,gastrointestinal bleeding,perforation or ERCP-related deaths in the two groups.Two patients in the metal stent group and 4 in the plastic stent group died,and the biliary stents were patent until they died.Eight patients in metal stent group and 29 patients in the plastic stent group developed recurrent obstructive jaundice,which were treated by reimplantation or replacement of the plastic stents.The post-ERCP complication rates were similar in the two groups(P0.05).The median patency period of the metal stent was(248.53±138.61) d and that of the plastic stent was(101.76±38.53) d,showing significant difference by Log-rank test(P0.001).ConclusionFor Bismuth Ⅱ-type,bilateral bile duct invaded,or non-resectable MHBO patients,if biliary drainage range permits and the expected survival period 3 months,double metal stent biliary drainage has more advantages.

Efficacy of plastic stent placement inside bile ducts for the treatment of unresectable malignant hilar obstruction (with videos)

Recent reports have addressed the utility of plastic stent (PS) placement inside bile ducts for treating biliary obstructions. Here, we evaluated the utility and safety of PS placement inside bile ducts for treating unresectable malignant hilar biliary obstruction. We conducted a retrospective study of 27 patients with unresectable malignant hilar biliary obstruction who underwent intraductal modified PS placement. We modified the PS, by cutting off the distal end to facilitate insertion through the papilla of Vater, and attached a nylon thread to the distal end for removal. We evaluated complications, the time to recurrent biliary obstruction (TRBO), and removability. Bilateral stenting was performed in nine of the 27 patients. Mild acute pancreatitis occurred in one patient (4%). Recurrent biliary obstruction (RBO) occurred in 16 patients (59%), with a median TRBO of 190 days (95% confidence interval: 174-205 days). Reintervention was necessary in 13 of the 16 patients (81%) with RBO, and we were able to remove the initial stents in all the patients who required reintervention. A relatively long stent patency period (>6 months) and removability make placement of a modified PS inside bile ducts a viable treatment for unresectable malignant hilar biliary obstruction.

Endoscopic stenting for malignant hilar biliary obstruction

Endoscopic biliary drainage is the palliative treatment of choice for malignant biliary hilar obstruction. There are conflicting opinions as to whether stents should be plastic or metal and whether stents should be unilateral or bilateral. To systematically review the literature on optimal endoscopic management of malignant hilar biliary obstruction. A comprehensive search of several databases was carried out. A fixed-effect or a random-effect model was used to pool the data according to the result of a statistical heterogeneity test. Ten trials were enrolled. Compared with plastic stents, the use of metal stents was associated with a significantly higher successful drainage rate [odds ratio (OR) 0.26; 95% confidence interval (CI) 0.16-0.42; I2=40.3%], lower early complication rate (OR 2.92; 95% CI 1.65-5.17; I2=0%), longer stent patency [hazard ratio (HR) 0.43; 95% CI 0.30-0.61; I2=57.6%], and longer patient survival (HR 0.73; 95% CI 0.56-0.96; I2=56.9%). The unilateral biliary drainage group achieved a significantly higher successful stent insertion rate compared with the bilateral drainage group (OR 3.44; 95% CI 1.91-6.19; I2=0%), whereas no difference was observed between groups with respect to successful drainage rate (OR 1.73; 95% CI 0.89-3.37; I2=0%), early complications (OR 0.96; 95% CI 0.18-5.13; I2=60.4%), late complications (OR 1.41; 95% CI 0.54-3.67; I2=70.4%), stent patency (HR 0.57; 95% CI 0.19-1.73; I2=91.1%), and patient survival (HR 0.75; 95% CI 0.31-1.80; I2=94.3%). The performance of metallic stents was superior to that of plastic stents for hilar tumor palliation. Unilateral biliary drainage may be as effective as bilateral drainage for patients with hilar biliary obstruction.

Su1384 A Newly Designed Large Cell Stent for Endoscopic Bilateral Stent-in-Stent Placement in Patients With Malignant Hilar Biliary Obstruction

Su1384 A Newly Designed Large Cell Stent for Endoscopic Bilateral Stent-in-Stent Placement in Patients With Malignant Hilar Biliary Obstruction

Bilateral Metal Stents for Hilar Biliary Obstruction Using a 6Fr Delivery System: Outcomes Following Bilateral and Side-by-Side Stent Deployment

Controversy exists on optimal endoscopic management for palliation of malignant hilar obstruction, with advocates for metal "side-by-side" (SBS) and "stent-in-stent" (SIS) techniques. We sought to evaluate the technical feasibility, efficacy, and outcomes of bilateral biliary self-expanding metal stents (SEMS) for treatment of malignant hilar obstruction using a stent with a 6Fr delivery system. This was a single-center, retrospective review of all patients who underwent bilateral placement of Zilver® biliary SEMS for malignant hilar obstruction from January 2010 to August 2012. Patients underwent endoscopic retrograde cholangiopancreatography with placement of stents using either the SIS or SBS stent techniques. Twenty-four patients (19 men, mean age 63 years) underwent bilateral stenting for malignant hilar obstruction during the study period. Seventeen and seven patients underwent the SBS and SIS technique, respectively. Cholangiocarcinoma (n=14) was the most common cause of hilar obstruction. Initial technical success was achieved in 24/24 (100%) of patients; however, 12 (50%) patients required re-intervention during the study period (median 98 days). Comparison of the SBS and SIS groups revealed no statistical difference with respect to need for re-intervention (P=0.31), successful re-intervention (P=0.60), or procedural length (P=0.89). Use of bilateral Zilver® SEMS in either the SBS or SIS configuration is safe, technically feasible, and effective for drainage of malignant hilar obstruction; however, duration of stent patency and procedure-free survival remain variable.

Otaru consensus on biliary stenting for unresectable malignant hilar biliary obstruction

Biliary stenting for unresectable malignant biliary strictures is widely accepted and is routinely done as an effective palliation therapy. However, a consensus among experts is still far from being reached on the selection of stents, placement procedures etc. In 2012, the European Society of Gastrointestinal Endoscopy reported guidelines for biliary stenting. At the Endoscopic Forum Japan 2012, a consensus meeting was held to examine seven statements that had been prepared based on these guidelines.Herein, we report the contents and the results of the examination of three of these statements on biliary stenting for hilar strictures.

Newly designed plastic stent for endoscopic placement above the sphincter of Oddi in patients with malignant hilar biliary obstruction

Plastic stent (PS) occlusion occurs as a result of bacterial adherence to the stent's inner wall. To retain the bacteriological barrier, placing a PS above the sphincter of Oddi ('inside stent') has been investigated. We designed a new PS (inside stent with thread [IT] stent) with attachable nylon thread for use as an inside stent and for easy retrieval. The present study evaluated the IT stent's technical feasibility and efficacy for malignant hilar biliary obstruction. A total of 26 consecutive patients with unresectable malignant hilar biliary obstruction underwent placement of IT stents from August 2007 to February 2011. IT stents were placed across the strictures without sphincterotomy to achieve bilateral drainage. The overall technical success rate of the IT stent was 100% for one session. Multiple IT stents were inserted in 25 cases(two stents in 15 patients, three stents in 10 patients). No stent-related early complications occurred. The functional success rate was 92% (24/26). The rate of reintervention because of stent malfunction was 50% (13/26). In all 16 patients who underwent stent removal, IT stents were easily retrieved using the nylon thread. According to Kaplan-Meier analysis, the median stent patency period was 136 days. IT stents for endoscopic placement above the sphincter of Oddi can be used safely and effectively for malignant hilar biliary obstruction.

Percutaneous Bilateral Metallic Stent Placement Using a Stentin-Stent Deployment Technique in Patients With Malignant Hilar Biliary Obstruction

The purpose of this study is to investigate the technical and clinical efficacy of percutaneous bilateral stent-in-stent deployment using open cell-design stents and to compare the clinical outcomes of bilateral stent placement using T and Y configurations. From January 2006 to December 2010, 106 patients with malignant hilar biliary obstruction (Bismuth type II or higher) were included in this retrospective study. All patients were treated with percutaneous bilateral stent-in-stent deployment using open cell-design stents (64 in a T configuration and 42 in a Y configuration). Bilateral stent-in-stent deployment was technically successful in all patients. Seven patients (6.6%) had major complications, including one with severe hemobilia, two with acute cholecystitis, and four with cholangitis; seven (6.6%) patients had minor complications, including self-limiting hemobilia. Successful internal drainage was achieved in 94 patients (88.7%). Stent occlusion by tumor ingrowth, with or without overgrowth, occurred in 37 patients (34.9%). The median survival and stent patency times were 192 days (95% CI, 153.6-230.4 days) and 319 days (95% CI, 148.5-489.5 days), respectively. Stent configuration did not significantly affect technical success, complications, successful internal drainage, patient survival, or stent patency. Percutaneous bilateral stent-in-stent placement using open cell-design stents is effective for bilateral drainage in patients with malignant hilar biliary obstruction. In addition, there was no significant difference in technical and clinical outcomes between T and Y stent configurations.

High single‐session success rate of endoscopic bilateral stent‐in‐stent placement with modified large cell Niti‐S stents for malignant hilar biliary obstruction

Endoscopic bilateral self-expandable metallic stent (SEMS) placement in a stent-in-stent method for malignant hilar biliary obstruction is technically challenging. Technical difficulties in the initial placement and reinterventions for stent occlusion are disadvantages inherent to this stent-in-stent method. We previously reported the feasibility of Niti-S large cell D-type biliary stents (LCD). This multicenter prospective consecutive study evaluated the efficacy of bilateral SEMS placement using modified LCD with large and uniform cells, a slimmer delivery system and high radial force. From July 2010 to June 2011, 26 consecutive patients with unresectable malignant hilar biliary obstruction underwent endoscopic bilateral placement of modified LCD in a stent-in-stent method at three tertiary hospitals. Ten patients had gallbladder cancer, eight had cholangiocarcinoma, four had lymph node metastasis, two had intrahepatic cholangiocarcinoma, and two had liver metastasis. Single-session and final technical success rate was 96% and 100%, respectively. Functional success rate was 89%. Stent occlusion occurred in 11 patients (42%) because of sludge (n = 7) or tumor ingrowth (n = 4). Endoscopic bilateral reintervention was technically easy and successful: six patients had stent clearance by balloon sweeping and five had plastic stent placement. According to Kaplan-Meier analysis, median survival and stent patency were 220 days and 157 days, respectively. Modified LCD achieved a high technical success rate both in the initial stent-in-stent placement and in bilateral reinterventions in patients with malignant hilar biliary obstruction.

One-channel double stent implantation for hilar biliary obstructions

The aim of this study was to evaluate the effect of percutaneous one-channel double stent implantation on hilar biliary obstruction involving both hepatic ducts and its clinical value. A total of 8 patients with hilar biliary obstruction involving the left and right hepatic ducts were enrolled. A percutaneous unilateral approach was adopted. Two stents were implanted, one between the left and right hepatic ducts and the other between the hepatic ducts and the common bile duct for biliary drainage. Interventional therapies such as arterial chemoembolization were performed for antitumor treatment. All surgical procedures were successfully accomplished. At 2 weeks after stenting, total bilirubin decreased to 61.2±13.4 μmol/l (the preoperative value was 267.1±154.7 μmol/l). No severe complications or mortalities occurred. Single-channel double stent implantation should be the preferred method of treatment for patients with hilar biliary obstruction involving both hepatic ducts. Drainage and antitumor treatment should also be used when necessary.

Metal versus plastic stents for malignant biliary obstruction: An update meta-analysis

The data on comparisons of stent patency, re-intervention rate and patient survival between metal and plastic stents in palliation of malignant biliary obstruction have never been pooled. We carry out a meta-analysis to summarise current evidence for clinical efficacy of metal and plastic stents in the treatment of malignant biliary obstruction. A comprehensive search of several databases was conducted. A fixed-effects or random-effects model was used to pool data of all study endpoints. Sensitivity analysis and subgroup analysis (distal vs. hilar biliary obstruction) were also performed. Ten randomized clinical trials were identified. Compared with plastic stents, metal stents were associated with a significantly longer stent patency (HR=0.36; 95% CI: 0.28-0.47; I(2)=0%), fewer numbers of re-intervention (WMD=0.59; 95% CI: 0.28-0.90; I(2)=76.4%) and longer patient survival (HR=0.74; 95% CI: 0.64-0.85; I(2)=16.0%). These results were still significant by sensitivity analysis. All outcomes reached statistical significance except of the pooled WMD of number of re-intervention in the studies with hilar biliary obstruction. No publication bias was observed. Metal stents were associated with a significantly longer stent patency, lower re-intervention rate and longer patient survival in palliation of malignant biliary obstruction when compared to plastic stents.

TG13 miscellaneous etiology of cholangitis and cholecystitis

This paper describes typical diseases and morbidities classified in the category of miscellaneous etiology of cholangitis and cholecystitis. The paper also comments on the evidence presented in the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG 07) published in 2007 and the evidence reported subsequently, as well as miscellaneous etiology that has not so far been touched on. (1) Oriental cholangitis is the type of cholangitis that occurs following intrahepatic stones and is frequently referred to as an endemic disease in Southeast Asian regions. The characteristics and diagnosis of oriental cholangitis are also commented on. (2) TG 07 recommended percutaneous transhepatic biliary drainage in patients with cholestasis (many of the patients have obstructive jaundice or acute cholangitis and present clinical signs due to hilar biliary stenosis or obstruction). However, the usefulness of endoscopic naso-biliary drainage has increased along with the spread of endoscopic biliary drainage procedures. (3) As for biliary tract infections in patients who underwent biliary tract surgery, the incidence rate of cholangitis after reconstruction of the biliary tract and liver transplantation is presented. (4) As for primary sclerosing cholangitis, the frequency, age of predilection and the rate of combination of inflammatory enteropathy and biliary tract cancer are presented. (5) In the case of acalculous cholecystitis, the frequency of occurrence, causative factors and complications as well as the frequency of gangrenous cholecystitis, gallbladder perforation and diagnostic accuracy are included in the updated Tokyo Guidelines 2013 (TG13). Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

A Comparison of Y-Type and T-Type Metallic Bilateral Biliary Stents in Patients with Malignant Hilar Biliary Obstruction

A Comparison of Y-Type and T-Type Metallic Bilateral Biliary Stents in Patients with Malignant Hilar Biliary Obstruction