Malignant Hilar Obstruction Research Articles

Endoscopic bilateral stent-in-stent placement for malignant hilar obstruction using a large cell type stent

Bilateral stent-in-stent (SIS) self-expandable metal stent placement is technically challenging for palliation of unresectable malignant hilar obstruction. In the SIS technique, the uniform large cell type biliary stent facilitates contralateral stent deployment through the mesh of the first metallic stent. This study aimed to assess the technical success and clinical effectiveness of this technique with a uniform large cell type biliary stent. Thirty-one patients who underwent bilateral SIS placement using a large cell type stent were reviewed retrospectively. All patients showed malignant hilar obstruction (Bismuth types II, III, IV) with different etiologies. Sixteen (51.6%) patients were male. The mean age of the patients was 67.0+/-14.0 years. Most patients were diagnosed as having hilar cholangiocarcinoma (58.1%) and gallbladder cancer (29.0%). Technical success rate was 83.9%. Success was achieved more frequently in patients without masses obstructing the biliary confluence (MOC) than those with MOC (95.2% vs 60.0%, P=0.03). Functional success rate was 77.4%. Complications occurred in 29.0% of the patients. These tended to occur more frequently in patients with MOC (50.0% vs 19.0%, P=0.11). Median time to recurrent biliary obstruction was 188 days and median survival was 175 days. The large cell type stent can be used efficiently for bilateral SIS placement in malignant hilar obstruction. However, the risk of technical failure increases in patients with MOC, and caution is needed to prevent complications for these patients.

Safety and Efficacy of Percutaneous Biliary Covered Stent Placement in Patients with Malignant Biliary Hilar Obstruction; Correlation with Liver Function.

To estimate the safety and efficacy of percutaneous ePTFE-covered biliary stent placement and the relationship between underlying liver function and stent patency in patients with malignant hilar obstruction. From March 2012 to June 2015, 41 patients [22 females, 19 males; mean age 69.8 (range 34-94) years] with malignant biliary obstruction underwent percutaneous biliary stent placement (31 patients with unilateral, 10 patients with bilateral side-by-side). Cumulative patient survival and stent patency rate curves were derived using the Kaplan-Meier method. A Cox model was used to explore the relationship between liver function and patient survival, and also biliary stent patency. Pearson correlation coefficient was used to analyze the relationship between patient survival and stent patency. Technical success rate was 100% and clinical success rate was 95%. During follow-up, four complications occurred (two bilomas and two cases of acute cholecystitis) and were treated successfully with percutaneous drainage. No other complication occurred. Mean serum bilirubin level was 11.34±7.35mg/dL before drainage and 5.00±4.83mg/dL 2 weeks after stent placement. The median patent survival duration was 147days (95% CI, 69.6-224.4days). The median stent patency duration was 101days (95% CI, 70.0-132.0days). The cumulative stent patency rates at 1, 3, 6, and 12months were 97, 57.6, 30.3, and 17.0%, respectively. Child-Pugh score was correlated significantly with patient survival (P=0.011) and stent patency (P=0.007). MELD score was correlated significantly with stent patency (P=0.044). There was a correlation between patient survival and stent patency (r=0.778, P<0.001). Percutaneous placement of ePTFE-covered biliary stent was a safe and an effective method for malignant biliary obstruction. Underlying liver function seemed to be one of the important factors affecting patient survival and stent patency, and stent patency showed statistically significant correlation with patient survival.

Tu1583 A Newly Designed Cross-Wired Metallic Stent for Unresectable Malignant Hilar Bile Duct Obstruction

Tu1583 A Newly Designed Cross-Wired Metallic Stent for Unresectable Malignant Hilar Bile Duct Obstruction

Unilateral Versus Bilateral Placement of Percutaneous Metallic Stents in Malignant Hilar Obstruction

Purpose: and IV malignant hilar obstructions. Uncovered biliary Wallstents were placed percutaneously in 84 patients with unresectable malignant hilar obstructions. The patients included 67 men and 17 women with a median age of 66 years (range, 42-71 years). Unilateral drainage was achieved in 42 patients by placing one stent (n=35) or by placing an additional stent inserted telescopically through the first one (n=7) to achieve an adequate stent length for long strictures (group 1). In 42 patients, more than one stent was inserted through dual transhepatic tracts in a ''Y'' configuration to maintain two-duct drainage (group 2). There was no significant difference in patients' characteristics on entry to the study. (85%) and late (54%) clinical success rates were significantly higher in group 2 compared to (33%) and (15%) in group 1, respectively. The total re-intervention rate was significantly higher in group 1 (88%) compared to group 2 (46%), P< 0.05. The overall rates of major and minor complications were 5% and 21%, respectively, with no significant difference between both groups. and IV hilar obstructions, full drainage of the whole biliary system through deployment of multiple stents should be performed. To evaluate the necessity of draining more than one hepatic duct in Bisthmus types II, III. Patients and methods: One hundred sixty eight self-expandable. Results: The overall technical success rate was 100%. Early. Conclusion: In Bismuth types II, III,

Endoscopic unilateral versus bilateral biliary stenting for the palliation of malignant hilar obstruction: a meta-analysis

Objective To evaluate the efficacy and safety of the unilateral and bilateral drainage in with a meta-analysis of relevant studies. Methods A systematic electronic search with keywords biliary stent, hilar tumor and malignant obstruction was independently performed by two reviewers in major electronic databases of Pubmed, EMBASE, Cochrane Library and Web of Science. A meta-analysis was conducted using Revman 5.1 software. Results Six studies were included with a total number of 558 patients, of whom 307 patients underwent unilateral drainage and 251 patients bilateral drainage. There was no significant difference in early complications (OR=1.03, 95%CI: 0.58-1.81, P=0.93), later complications (OR=0.98, 95%CI: 0.46-2.07, P=0.95), operation success rate (OR=1.42, 95%CI: 0.76-2.66, P=0.28), drainage efficacy or median survival time between the two groups. Compared with unilateral drainage, bilateral drainage had a longer time of stent patency (MD=-29.12, 95%CI: -38.55--19.70, P<0.001). Conclusion Both unilateral and bilateral drainage are safe and effective for obstruction, but more high quality clinical researches are needed. Key words: Cholestasis; Stents; Drainage; Program evaluation; Meta-Analysis

Serial insertion of bilateral uncovered metal stents for malignant hilar obstruction using an 8 Fr biliary system: a case series of 17 consecutive patients.

Controversy exists over the need for unilateral versus bilateral stent placement in patients with malignant obstruction at the biliary hilum. Placement of bilateral uncovered self-expanding metal stent (UCSEMS) at this location is technically challenging, and generally associated with lower rates of procedural success. Serial insertion of side-by-side UCSEMS may be especially difficult when simultaneous deployment is not possible using larger stent delivery catheters. In this single-center, retrospective case series of all patients who underwent bilateral placement of uncovered Wallflex(TM) biliary stents between July 2008 and July 2014, we evaluate the feasibility, technical success, and safety of patients undergoing serial insertion of bilateral UCSEMS using the 8 Fr Wallflex(TM) biliary system for malignant hilar obstruction. A total of 17 patients were included. Primary cholangiocarcinoma, Bismuth IV, was the most common diagnosis. Mean procedure time was 54.4 minutes. Overall procedural technical success was achieved in 17/17 patients. Stricture dilation was necessary prior to Wallflex(TM) insertion in 8/17 patients (47.1%). Transpapillary extension of two stents was performed in all patients. There were no cases of stent deployment malfunction, or inability to insert or deploy the 2(nd) stent. Nine of 17 patients (52.9%) required inpatient hospitalization following ERCP; the most common indications were abdominal pain and need for IV antibiotics. There was one case of ERCP-related cholangitis otherwise; there were no other major complications. Bilateral, serial insertion of UCSEMS using the 8 Fr Wallflex(TM) biliary system in malignant hilar obstruction is feasible with an excellent technical success profile. Using this device for side-by-side deployment of UCSEMS appears to be safe in the majority of patients.

Unilateral versus bilateral biliary drainage for malignant hilar obstruction: a systematic review and meta-analysis

To assess the efficacy and safety of bilateral versus unilateral biliary drainage in malignant hilar obstruction. Topically relevant studies,regardless of randomized or observational design, were searched for in PubMed, EmBase and the Cochrane Library database. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated to compare the effect of the two treatments. Three randomized trials and 7 observational studies were included, involving 894 patients with malignant hilar obstruction. The meta-analysis assessment of primary outcomes showed that the stent patency rate was better in bilateral drainage than in unilateral drainage (Rr=2.03,95% CI [1.16-3.56], P=0.01), but there were no significant differences in successful drainage rate (Rr=1.07,95% CI [0.97-1.18], P=0.20) and patient survival rate (Rr=-0.16,95% CI [-0.40-0.08], P=0.20). In the analysis of secondary outcomes,there were also no significant differences in the technical success rate (Rr=1.05,95% CI [0.98-1.17], P=0.34),the early complication rate (Rr=1.15, 95% CI [0.75-1.76], P=0.52), late complication rate (Rr=1.09,95% CI [0.75-1.60], P=0.60) and 30-day mortality rate (Rr=0.68,95% CI [0.38-1.23], P=0.20). Although the cumulative stent patency was better for the bilateral than the unilateral drainage approach, based on the available data, there is not enough data to support bilateral drainage for malignant hilar obstruction. Well-designed randomized controlled trials are necessary to confirm it.

New tapered metallic stent for unresectable malignant hilar bile duct obstruction.

To examine the usefulness of a new tapered metallic stent (MS) in patients with unresectable malignant hilar bile duct obstruction. This new tapered MS was placed in 11 patients with Bismuth II or severer unresectable malignant hilar bile duct obstruction, as a prospective study. The subjects were six patients with bile duct carcinoma, three with gallbladder cancer, and two with metastatic bile duct obstruction. Stenosis morphology was Bismuth II: 7, IIIa: 3, and IV: 1. UMIN Clinical Trial Registry (UMIN000004758). MS placement was 100% (11/11) successful. There were no procedural accidents. The mean patency period was 208.401 d, the median survival period was 142.000 d, and the mean survival period was 193.273 d. Occlusion rate was 36.4% (4/11); the causes of occlusion were ingrowth and overgrowth in 2 patients each, 18.2%, respectively. Patients with occlusion underwent endoscopic treatment one more time and all were treatable. The tapered MS proved useful in patients with unresectable malignant hilar bile duct obstruction because it provided a long patency period, enabled re-treatment by re-intervention, and no procedural accidents occurred.

Percutaneous unilateral biliary metallic stent placement in patients with malignant obstruction of the biliary hila and contralateral portal vein steno-occlusion.

ObjectiveTo investigate the outcomes of percutaneous unilateral metallic stent placement in patients with a malignant obstruction of the biliary hila and a contralateral portal vein steno-occlusion.Materials and MethodsSixty patients with a malignant hilar obstruction and unilobar portal vein steno-occlusion caused by tumor invasion or preoperative portal vein embolization were enrolled in this retrospective study from October 2010 to October 2013. All patients were treated with percutaneous placement of a biliary metallic stent, including expanded polytetrafluoroethylene (ePTFE)-covered stents in 27 patients and uncovered stents in 33 patients.ResultsA total of 70 stents were successfully placed in 60 patients. Procedural-related minor complications, including self-limiting hemobilia (n = 2) and cholangitis (n = 4) occurred in six (10%) patients. Acute cholecystitis occurred in two patients. Successful internal drainage was achieved in 54 (90%) of the 60 patients. According to a Kaplan-Meier analysis, median survival time was 210 days (95% confidence interval [CI], 135-284 days), and median stent patency time was 133 days (95% CI, 94-171 days). No significant difference in stent patency was observed between covered and uncovered stents (p = 0.646). Stent dysfunction occurred in 16 (29.6%) of 54 patients after a mean of 159 days (range, 65-321 days).ConclusionUnilateral placement of ePTFE-covered and uncovered stents in the hepatic lobe with a patent portal vein is a safe and effective method for palliative treatment of patients with a contralateral portal vein steno-occlusion caused by an advanced hilar malignancy or portal vein embolization. No significant difference in stent patency was detected between covered and uncovered metallic stents.

Percutaneous transhepatic biliary metal stent for malignant hilar obstruction: results and predictive factors for efficacy in 159 patients from a single center.

To investigate and compare the efficacy and safety of percutaneous transhepatic biliary stenting (PTBS) using a one- or two-stage procedure and determine the predictive factors for the efficacious treatment of malignant hilar obstruction (MHO). 159 consecutive patients with MHO who underwent PTBS were enrolled between January 2010 and June 2013. Patients were classified into one- or two-stage groups. Independent predictors of therapeutic success were evaluated using a logistic regression model. 108 patients were treated with one-stage PTBS and 51 patients were treated with two-stage PTBS. The stents were technically successful in all patients. Successful drainage was achieved in 114 patients (71.4 %). A total of 42 early major complications were observed. Re-interventions were attempted in 23 patients during follow-up. The cumulative primary patency rates at 3, 6, and 12 months were 88, 71, and 48 %, respectively. Stent placement using a one- or two-stage procedure did not significantly affect therapeutic success, early major complications, median stent patency, or survival. A stent placed across the duodenal papilla was an independent predictor of therapeutic success (odds ratio = 0.262, 95 % confidence interval [0.107-0.642]). Patients with stents across papilla had a lower rate of cholangitis compared with patients who had a stent above papilla (7.1 vs. 20.3 %, respectively, p = 0.03). The majority of patients with MHO who underwent one-stage PTBS showed similar efficacy and safety outcomes compared with those who underwent two-stage PTBS. Stent placement across the duodenal papilla was associated with a higher therapeutic success rate.

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.

Risk factor analysis for 30-day mortality in patients with malignant hilar obstruction after percutaneous transhepatic biliary stent deployment

Risk factor analysis for 30-day mortality in patients with malignant hilar obstruction after percutaneous transhepatic biliary stent deployment

Bilateral metallic stenting in malignant hilar obstruction.

Endoscopic palliative biliary drainage is considered as a gold standard treatment in advanced or inoperable hilar cholangiocarcinoma. Also, metal stents are preferred over plastic stents in patients with >3 months life expectancy. However, the endoscopic intervention of advanced hilar obstruction is often more challenging and complex than that of distal malignant biliary obstructions. In this literature review, we describe the issues commonly encountered during endoscopic unilateral (single) versus bilateral (multiple) biliary stenting for malignant hilar obstruction. Also, we provide technical guidance to improve the technical success rates and patient outcomes, focusing on bilateral metallic stenting techniques such as stent-in-stent or side-by-side deployment.

Bilateral and unilateral stenting for malignant hilar obstruction: A systematic review and meta-analysis

Stents are used for palliating inoperable malignant bile duct hilar obstruction. It is not clear if bilateral stenting provides any advantage over unilateral stenting in these patients. Compare bilateral and unilateral stenting in malignant hilar obstruction. Studies using stents for palliation in patients with malignant hilar obstruction were selected. Articles were searched in MEDLINE, PubMed, Ovid journals, CINAH, International Pharmaceutical Abstracts, OLDMEDLINE, MEDLINE nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Two reviewers independently searched and extracted data. Any differences were resolved by mutual agreement. Pooled proportions were calculated using both the Mantel-Haenszel method (fixed effects model) and DerSimonian-Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights. The initial search identified 1,640 reference articles, of which 169 were selected and reviewed. Thirteen studies (n = 340) for bilateral metallic stents, eight studies (n = 575) for unilateral metallic stents, eight studies (n = 367) for bilateral plastic stenting, and seven studies (n = 850) for unilateral plastic stenting which met the inclusion criteria were included in this analysis. Pooled data are shown in Tables1 and 2. The pooled estimates by the fixed and random effect models were similar. The p for chi-squared heterogeneity for all the pooled accuracy estimates was >0.10. Bilateral metal stenting seems to have lower odds of overall complications when compared to unilateral metallic stenting. Bilateral metal stents seem to have higher odds of lowering bilirubin than unilateral metal stents, but the 30-day mortality was no different. For metal stents, bilateral metal stents are superior in palliating symptoms due to hyperbilirubinemia. Unilateral plastic stenting seems to have similar odds of overall complications, cholangitis, and 30-day mortality when compared to bilateral plastic stenting for malignant hilar strictures. In patients with malignant hilar stricture, unilateral plastic stenting is comparable to bilateral plastic stenting for adverse events.

Endoscopic bilateral stenting of malignant hilar bile duct obstruction using novel partially covered self-expandable metal stents

Endoscopic bilateral stenting using conventional metal stents is considered to be technically difficult in patients with malignant hilar bile duct obstruction because the second stent is not easily inserted through the cell of the first stent wall in the bile duct [1]. A variety of new self-expandable metal stents (SEMS) specially designed for stent-in-stent procedures to facilitate bilateral stents deployment have been recently reported [1] [2] [3] [4] [5]. We report two cases of malignant hilar bile duct obstruction which were managed by endoscopic bilateral stenting using novel metal stents (KEY stents; S&G BioTech Inc., Seongnam, Korea). These stents are self-expanding Nitinol stents partially covered with a silicone membrane and consisting of a body stent (first stent) and a limb stent (second stent). The body stent is composed of a body and two legs: a long leg and a short leg. The short leg facilitates insertion of a guide wire into the contralateral intrahepatic bile duct (IHD) for the limb stent ([Fig. 1]). After placement of the body stent to one side of both IHDs across the hilar stricture, the limb stent is introduced into another IHD through the short leg of the body stent ([Fig. 2]).

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 parallel placement of biliary double metal stents for advanced malignant hilar obstruction

Objective To explore the effects and safety of endoscopic parallel placement of double metal stents on unresectable hilar malignant obstruction. Methods The clinical data of 11 patients with ma- lignant hilar obstructive jaundice due to advanced carcinoma who were treated with parallel placement of double biliary stents from January 2011 to September 2012 were retrospectively analyzed. Results Out of 11 patients, 10（90. 9% ） were successfully embedded with double biliary stents and 4 were dead during the follow-up. There was no sign of stent occlusion during the follow-up period. The survival time ranges from 128 to 185 days. One case was lost during the follow-up and 5 others are still alive. Conclusion The endoscopic parallel placement of double biliary stents is effective and safe for patients with unresectable malignant hilar obstruction. Key words: Hilar cholangiocarcinoma; Malignant obstruction ; Endoscopic treatment ; Parallelmethod; Double metal stents

Su1383 Bilateral Hepatic Duct Drainage for Malignant Hilar Obstruction Utilizing Non-Foreshortening, 6F Self-Expanding Metal Stents

Endoscopic palliation of malignant hilar obstruction can be performed using a variety of techniques. Data suggest self-expandable metal stents (SEMS) are superior to plastic stents 1 while bilateral stents are superior to unilateral 2 with respect to stent patency and drainage adequacy. Our aim was to evaluate the technical feasibility, efficacy and outcomes following placement of bilateral SEMS (Zilver, Cook Medical) with a 6Fr delivery system for treatment of malignant hilar obstruction.

Su1381 Risk Factors for Cholecystitis After Bilateral Biliary Stent Placement in Patients With Klatskin Tumor

Endoscopic bilateral metal stenting is a rapidly evolving technique which allows the palliative treatment of malignant hilar obstruction including Klatskin tumor. But cholecystitis in patients with Klatskin tumor is bothersome event to patients and physicians. Biliary stent may be associated with cholecystitis for several reasons. The aim of this study to evaluate the prevalence and risk factors of cholecystitis after bilateral matal stent placement, especially in Klatskin tumor.

Effect of CO2 cholangiography on post-ERCP cholangitis in patients with unresectable malignant hilar obstruction – a prospective, randomized controlled study

Background:Air cholangiogram has been used in patients with malignant hilar obstruction to reduce cholangitis after endoscopic retrograde cholangiopancreatography (ERCP). However, it still remains unclear whether CO2 could be used as an alternative for air cholangiography in such patients. Objective:To investigate the effect of CO2 cholangiogram on post-ERCP complications. Design:Prospective, randomized controlled study. Setting:Tertiary care referral center. Patients:36 patients with Bismuth type II, III or IV were randomized into CO2 group or iodine contrast group (control group). Intervention:Cholangiography was performed by injection of either CO2 or iodine contrast through a sphincterotome. One or two metal stents were placed. Main outcome measures:Post-ERCP complications, length of hospital stay after ERCP, 1-month and 1-year mortality. Result:There was no significant difference in age, gender, symptoms, liver function tests, type of tumor origin and Bismuth type between patients in CO2 and contrast groups (p > 0.05). Compared with one-stent placement, more volume of CO2 and longer operation time were observed when performing two-stent placement (both p < 0.05). The rate of cholangitis in CO2 group was significantly lower than that in control group (5.6% vs. 33.3%, p = 0.04). After ERCP, mean hospital stay time was shorter in CO2 group compared with control (p < 0.05). The difference of 1-month and 1-year mortality between two groups was not significant (both p > 0.05). Conclusion:CO2 cholangiogram could be a safe method to visualize intrahepatic bile duct with low incidence of post-ERCP cholangitis, which could be considered for the patients with malignant hilar obstruction.