Biliary Metal Stents Research Articles

Endoscopic biliary stent insertion through specialized duodenal stent for combined malignant biliary and duodenal obstruction facilitated by stent or PTBD guidance

Objectives: Endoscopic stenting for combined malignant biliary and duodenal obstruction is technically demanding. However, this procedure can be facilitated when there is guidance from previously inserted stent or PTBD tube. This study aimed to evaluate the feasibility and clinical success rate of endoscopic placement of biliary self-expandable metal stent (SEMS) through duodenal SEMS in patients with combined biliary and duodenal obstruction due to inoperable or metastatic periampullary malignancy.Materials and methods: A total of 12 patients with combined malignant biliary and duodenal stricture underwent insertion of biliary SEMS through the mesh of specialized duodenal SEMS from July 2012 to October 2016. Technical and clinical success rate, adverse events and survival after completion of SEMS insertion were evaluated.Results: The duodenal strictures were located in the first portion of the duodenum in four patients (Type I), in the second portion in three patients (Type II), and in the third portion in five patients (Type III). Technical success rate of combined metallic stenting was 91.7%. Insertion of biliary SEMS was guided by previously inserted biliary SEMS in nine patients, plastic stent in one patient, and PTBD in two patients. Clinical success rate was 90.9%. There were no early adverse events after the procedure. Mean survival period after combined metallic stenting was 91.9 days (range: 15–245 days).Conclusions: Endoscopic placement of biliary SEMS through duodenal SEMS is feasible with high success rates and relatively easy when there is guidance. This method can be a good alternative for palliation in patients with combined biliary and duodenal obstruction.

Frequency, Severity, and Risk Factors for Acute Pancreatitis After Percutaneous Transhepatic Biliary Stent Placement Across the Papilla of Vater.

To clarify the frequency, severity, and risk factors for acute pancreatitis after percutaneous biliary stent placement across the papilla of Vater for malignant biliary obstruction. This retrospective study included 95 patients who underwent percutaneous biliary metallic stent placement (64 [67.4%] bare stents and 31 [32.6%] covered stents) across the papilla of Vater for malignant biliary obstruction between January 2010 and December 2012. The incidence of acute pancreatitis (Atlanta classification of acute pancreatitis) and its severity (Common Terminology Criteria for Adverse Events, version 4) were reviewed. Additionally, the characteristics of the patients and biliary stents, and the computed tomography findings of the pancreas were evaluated. Grade 3 acute pancreatitis was observed in 23 patients (24.2%); acute pancreatitis of grade 4 or higher was not observed. The incidence of acute pancreatitis was lower in patients with atrophic pancreas than in those with non-atrophic pancreas (7.5 vs. 36.4%, p=0.004). It was also lower in patients with main pancreatic duct (MPD) obstruction than in those without MPD obstruction (12.5 vs. 36.2%, p=0.026). There was no difference in the incidence of acute pancreatitis between bare and covered stents. Percutaneous biliary stent placement across the papilla of Vater for malignant biliary stricture caused acute pancreatitis requiring medication in 24.2% of patients. Atrophy of the pancreas and the presence of a dilated MPD may be associated with a decreased risk of acute pancreatitis. Level 4, Case Series.

Comparison of the therapeutic efficacy of combined intracavitary therapy with palliative surgery in patients with extrahepatic ductal cholangiocarcinoma

Objective To compare the therapeutic efficacy of combined biliary stent and 125I seed intracavity irradiation with palliative surgery in the treatment of extrahepatic ductal cholangiocarcinoma. Methods A prospective analysis was conducted on 142 patients with cholangiocarcinoma who were treated in The First Affiliated Hospital of Bengbu Medical College from January 2012 to December 2015. There were 80 patients who underwent percutaneous biliary metal stenting combined with 125I particles implantation (the stenting-particle group) and 62 patients who were treated by palliative biliary drainage (the surgical group). The surgical group included R1 resection in 17 patients, R2 resection in 26 patients and biliary enteric drainage in 19 patients). The levels of jaundice, liver function, survival time, hospitalization time and hospitalization cost before and after therapy were analyzed. Results Jaundice was effectively alleviated in the two groups after a short period. The liver function in the 2 groups improved significantly at 1, 3 and 6 months when compared with that before operation, (P 0.05). Conclusions For patients with extrahepatic ductal cholangiocarcinoma who were not suitable for radical surgery, percutaneous biliary stenting combined with 125I seed brachytherapy effectively reduced jaundice, improved liver function, shortened average length of hospital stay and reduced average cost of hospitalization. When compared with palliative surgery, it was a minimally invasive, easy, safe and efficacious treatment, especially for elderly patients with poor physical conditions. Key words: Cholangiocarcinoma; Palliative surgery; Biliary stent; 125I seed; Obstructive jaundice

An unusual cause of biliary metal stent obstruction

An unusual cause of biliary metal stent obstruction

Revision of biliary sphincterotomy by re-cut, balloon dilation or temporary stenting: comparison of clinical outcome and complication rate (with video).

Background and study aims Revision of endoscopic retrograde cholangiopancreatography (ERCP) may be necessary following previous biliary endoscopic sphincterotomy for recurrent biliary symptoms related to biliary stone recurrence, cholangitis or post-biliary endoscopic sphincterotomy (bEST) papillary stenosis and cholestasis. The aim of this retrospective study was to evaluate the clinical outcome and complication rate associated with re-cut, balloon dilation and biliary metal stenting in revision ERCP. Patients and methods From January 2010 to January 2015, 139 subjects with stigma of a previous sphincterotomy required a revision ERCP (64 Men/75 Women; mean age 71 years; range 32 – 101 years). The most appropriate technique (re-cut, balloon dilation or fully covered self-expandable metal stent [FCSEMS] placement) was tailored according to underlying pathologies and anatomical features. Results Technical success was achieved in all cases (100 %).Clinical success (definitive clearance of common bile duct stones and liver test normalization) was achieved in 127 out of 139 patients (91.4 %) with a mean follow up of 12 months.12 clinical failures occurred: 11 patients required a new ERCP after an average of 9 months meanwhile 1 patient required surgery for definite treatment. The overall complication rate was 9 % (13 /139) with 5 acute complications (intra-procedural) and 8 short-term complications (before 1 month). Group specific overall complication rates were as follow: re-cut 11.5 % (8 bleeds and 3 perforations), balloon dilation 25 % (4 mild PEP [post-ERCP pancreatitis]), FCSEMS 14.3 % (1 moderate PEP), re-cut + balloon dilation and re-cut + FCSEMS 0 %. A statistically significant higher risk of post-ERCP pancreatitis was highlighted in the balloon dilation group meanwhile re-cut was burdened by a higher risk of bleeding and perforation. Conclusions Revision ERCP following previous bEST is a feasible procedure enabling clinical success in most cases. Different approaches are available and must be considered according to underlying pathologies. Re-cut is burdened by a higher risk of perforation and bleeding compared to balloon dilation and SEMS meanwhile balloon dilation is associated to increased risk of PEP.

Sa1431 Lam$ for Pseudocyst Drainage: Is it Worth it? a Single Center Experience Demonstrating Low Adverse Events and High Efficacy With Self-Expandable Metal Esophageal and Biliary Stents for Pseudocyst and Walled Off Necrosis Drainage

Lumen-apposing metal stents (LAMS) have been designed as proprietary stents for the management of pseudocysts (PC)/walled off necrosis (WON). Recently, however there has been concern at our institution and others about a high adverse event rate with LAMS including bleeding, buried stent syndrome and migration (22% adverse event rate at our institution). Prior to LAMS becoming available, fully covered self-expandable metal esophageal and biliary stents (FCSEMSs) were used off-label for management of pseudocysts/WON with many centers demonstrating a low rate of adverse events. Furthermore, the cost of FCSEMS in the US is significantly less than LAMS. AIMS: The primary aim of this study was to study the safety and efficacy of FCSEMS for the management of pseudocysts/WON at our institution.

Sa1389 Ercp Placed Short Biliary Self-Expanding Metal Stents (SSEMS) and Neoadjuvant Therapy of Borderline Pancreatic Cancer in 100 Patients

Sa1389 Ercp Placed Short Biliary Self-Expanding Metal Stents (SSEMS) and Neoadjuvant Therapy of Borderline Pancreatic Cancer in 100 Patients

Sa1412 Utility of Biliary Self-Expandable Metallic Stents (Sems) in the Management of Non-Stricturing Disorders of Bile Duct (NSDBD)

Sa1412 Utility of Biliary Self-Expandable Metallic Stents (Sems) in the Management of Non-Stricturing Disorders of Bile Duct (NSDBD)

The safety and efficacy of percutaneous intraductal radiofrequency ablation in unresectable malignant biliary obstruction: A single-institution experience

BackgroundPatients with unresectable malignant biliary obstruction have limited life expectancy because of limited stent patency and tumor progression. The aim of our study was to retrospectively evaluate the safety and efficacy of combining intraductal RFA with biliary metal stent placement for patients with malignant biliary obstruction.MethodsPatients who received percutaneous intraductal RFA and biliary stent placement for malignant biliary obstruction between 2013 and 2015 were identified. Outcomes were stent patency, technique and clinical success rate, overall survival (OS) and complication rates. Kaplan-Meier and Cox regression analyses were used to examine the association of various factors with stent patency and OS. Complications and laboratory abnormalities were recorded.ResultsFifty patients were treated with percutaneous RFA and stent placement. The rates of technical success and clinical success were 98% and 92%, respectively. The median stent patency was 7.0 (95% confidence interval [CI]: 5.3, 8.7) months and OS was 5.0 (95% CI: 4.0, 6.0) months. On univariable analysis, previously cholangitis was an independent poor prognosis factor for recurrent biliary obstruction. OS was improved in patients who received more than one intervention compared to those who received only one intervention (log-rank P = 0.007), and in those treated without versus those treated with sequential chemotherapy (log-rank P = 0.017). On multivariable analysis, the occurrence of more than one intervention (P = 0.019) had independent prognostic significance for OS.ConclusionPercutaneous RFA and stent placement is a technically safe and feasible therapeutic option for the palliative treatment of malignant biliary obstruction. The long-term efficacy and safety of the procedure is promising, but further study is required via randomized and prospective trials.

Endoscopic intraductal radiofrequency ablation combined with biliary metal stent for biliary malignant tumor

Objective To evaluate the safety and efficacy of endoscopic intraductal radiofrequency ablation combined with biliary metal stent and biliary metal stent only for the treatment of biliary malignant tumor. Methods Data of 48 patients with biliary malignant tumor were reviewed. All patients were examined by ERCP for the range of obstruction. Twenty-four patients received combined therapy (combination group), while 24 others received stent placement only (control group). In the combination group, stenotic segments were treated with intraductal radiofrequency ablation, then metal stents were placed into the biliary duct. In the control group, only metal stents were placed. Changes of serum total bilirubin (TB), surgical complications, days of stent patency and median survival time were studied. Results In the combination group, TB level [median (min-max)]was 238.15 μmol/L (22.10-410.70 μmol/L) before treatment and it decreased to 113.40 μmol/L (9.80-243.70 μmol/L) after, while in the control group it was 239.70 μmol/L(112.30-558.50 μmol/L) before and 121.10 μmol/L (52.10-329.30 μmol/L) after respectively, significantly different in both groups (P<0.05). The time of stent patency was 156 days (44-530 days) in the combination group and 110 days (14-462 days) in the control group (P<0.05). The median survival time was 173 days (44-550 days) and 133 days (14-490 days) respectively(P<0.05). Conclusion The combination therapy of endoscopic intraductal radiofrequency ablation with biliary stent is safe and feasible for biliary malignant tumor. It can prolong the duration of stent patency and median survival time as well as improve postoperative survival quality. Key words: Biliary tract neoplasms; Stents; Radiofrequency ablation

Comparison of intraluminal radiofrequency ablation and stents vs. stents alone in the management of malignant biliary obstruction

Purpose: To retrospectively evaluate the added benefit of adding intraluminal radiofrequency ablation (RFA) to biliary metal stent placement for patients with malignant biliary obstruction (MBO).Methods: From November 2013 to December 2015, 89 patients with MBO who had undergone percutaneous intraluminal RFA and stent placement (RFA-stent group, n = 50) or stent placement only (stent group, n = 39) were included. Outcomes were compared according to the type of tumour: cholangiocarcinoma or non-cholangiocarcinoma.Results: Primary and secondary stent patency (PSP, SSP) were significantly higher for the RFA-stent group than the stent group (PSP: 7.0 months vs. 5.0 months, p = 0.006; SSP: 10.0 months vs. 5.6 months, p < 0.001), with overall survival being comparable (5.0 months vs. 4.7 months, p = 0.068). In subgroup analysis, RFA-stent showed significant PSP benefits compared to stent alone in patients with cholangiocarcinoma (7.4 months vs. 4.3 months; p = 0.009), but with comparable outcomes in patients with non-cholangiocarcinoma (6.3 months vs. 5.2 months; p = 0.266). The SSP was improved in both subgroups (cholangiocarcinoma, 12.6 months vs. 5.0 months, p < 0.001; non-cholangiocarcinoma, 10.3 months vs. 5.5 months, p = 0.013). Technical success and clinical success were not significantly different between the two groups. The rate of complication was higher for the RFA-stent group, but tolerable when compared to the stent group.Conclusions: Although survival was comparable between the groups, RFA-stent confers therapeutic benefits to patients with MBO in terms of stent patency compared to stent placement alone, especially in those with cholangiocarcinoma.

Endotherapy for bile leaks from isolated ducts after hepatic resection: A long awaited challenge

BackgroundBile leakage is a common complication after hepatic resection [1–4] (Donadon et al., 2016; Dechene et al., 2014; Zimmitti et al., 2013; Yabe et al., 2016). Endotherapy is the treatment of choice for this complication except for bile leaks originating from isolated ducts; a condition resembling the post laparoscopic cholecystectomy Strasberg type C lesions [5–9] (Lillemo et al., 2000; Gupta and Chandra, 2011; Park et al., 2005; Colovic, 2009; Mutignani et al., 2002). In such cases, surgical repair is complex, often of uncertain result and with a high morbidity and mortality [1] (Donadon et al., 2016). On the other hand, percutaneous interventions (i.e. plugging the isolated duct with glue) are technically difficult and risky [7,8] (Park et al., 2005; Colovic, 2009). Endoscopy, thus far, was not considered amongst treatment options. That is because the isolated duct cannot be opacified during cholangiography and is not accessible with the usual endoscopic methods [5,6] (Lillemo et al., 2000; Gupta and Chandra, 2011). MethodsConsidering the pathophysiology of this type of bile leaks, it is possible to change the pressure gradient endoscopically in order to direct bile flow from the isolated duct towards the duodenal lumen, thus creating an internal biliary fistula to restore bile flow. In order to achieve this goal, we have to perforate the biliary tree into the abdomen. The key element of endoscopic treatment is to create a direct connection between the abdominal cavity and the duodenal lumen by-passing the residual biliary tree with a new technique fully explained in the paper. Our case series (from 2011 to 2016) consists of 13 patients (eight male, five female, mean age 58 years) with fistulas from isolated ducts after various types of hepatic resection. ResultsWe performed sphincterotomy and placed a biliary stent with the proximal edge inside the intra-abdominal bile collection in 11 patients (eight biliary fully-covered self-expandable metal stents; three plastic stents). In the remaining two patients we successfully cannulated the involved isolated biliary duct and we placed a bridging stent (one fully covered self-expandable metal stent; one plastic stent). Technical and clinical success (considered as fistula healing) was achieved in all 13 patients (mean fistula healing time was four days). Biliary stents were removed three to six months after atrophy of the involved duct in nine cases. In two patients the stent is still in situ. Two patients died with stent in situ due to advanced cancer at 8 and 42 months respectively. Mean follow up was 18 months (range: 8–42 months). ConclusionsThe described endoscopic treatment is innovative, safe and effective. It is applicable in tertiary level endoscopic centers and requires considerable expertise. This minimally invasive procedure can increase the rate of fistula healing and will eventually reduce the need for more aggressive and risky surgical procedures.

Management of acute cholangitis as a result of occlusion from a self-expandable metallic stent in patients with malignant distal and hilar biliary obstructions.

Acute cholangitis as a result of common bile duct stones can be managed; however, cholangitis caused by occlusion with a biliary self-expandable metallic stent (SEMS) in patients with an unresectable malignant biliary obstruction has not been fully discussed. The acute cholangitis clinical guidelines (Tokyo Guidelines 2013) recommend following the same procedure as that used for cholangitis; however, the patient's condition, including performance status, tumor extension or staging, and prognosis must be considered. Most physicians manage cholangitis from a SEMS occlusion using a two-step procedure. They insert endoscopic drainage with a plastic stent or insert a nasobiliary drainage tube, which does not exacerbate sepsis. Addition or replacement of a biliary SEMS is required in many cases depending on the cause of the occlusion. Tumor ingrowth through the stent mesh is common in uncovered SEMS and requires placement of another stent in an in-stent method. However, covered SEMS tends to be occluded by sludge, so it must be replaced because of the bacterial biofilm that forms on the covering membrane. The location of the biliary stricture (hilar or distal) should also be considered. Strategies for managing cholangitis as a result of occlusion by a biliary SEMS remain controversial, so prospective clinical trials are needed.

Interventional endoscopic ultrasound: A new promising way for intrahepatic portosystemic shunt with portal pressure gradient.

Background and Objectives:Interventional endoscopic ultrasound (EUS) is a promising novel approach for intravascular interventions. The aim of this study was to assess the feasibility and safety of a EUS-guided intrahepatic portosystemic shunt (EGIPS) with portal pressure gradient measurement in a live porcine model.Methods:The left hepatic vein (LHV) or the inferior vena cava (IVC) was punctured with a needle that advanced into the portal vein (PV). A guidewire was then inserted into the PV, and a needle knife was used to create an intrahepatic fistula between LHV and PV. Portal pressure was recorded. The fistula was dilated with a balloon and a biliary metal stent was deployed between LHV and PV under sonographic and fluoroscopic observation. A portocavography validated the patency of the stent. Necropsies were realized after euthanasia.Results:Portosystemic stenting was achieved in 19/21 pigs. Final portocavography confirmed stent patency between PV and LHV or IVC in 17 pigs (efficacy of 81%): Four stents were dysfunctional as two were thrombosed and two were poor positioned. Portal pressure was documented before and after shunting in 20/21 pigs. Necropsies revealed that 19/21 procedures were transesophageal and two were transgastric. Hemoperitoneum and pneumothorax were found in one pig and hemothorax was found in two pigs. Morbidity was 14.2% (3/21 animals).Conclusion:EGIPS was feasible in 91% of cases, functional in 81%, with 14.2% per procedure morbidity. EGIPS still needs to be assessed in portal hypertension pig models with longer follow-up before being considered as an alternative when the transjugular intrahepatic portosystemic shunt fails.

Feasibility of conversion of percutaneous cholecystostomy to internal transmural endoscopic ultrasound-guided gallbladder drainage.

Background/Aim:Percutaneous cholecystostomy [percutaneous transhepatic gallbladder drainage (PTGBD)] is the treatment of choice in surgically unfit patients with acute cholecystitis. However, PTGBD tube removal after symptoms resolution results in 41–46% recurrence. This study aims to demonstrate the feasibility of the conversion of PTGBD to transmural endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using plastic stents in patients unfit for cholecystectomy.Patients and Methods:Patients who underwent internal transmural EUS-GBD as a conversion from PTGBD were reviewed. EUS-GBD was performed after the improvement of cholecystitis due to recurrent cholecystitis and PTGBD intolerance. One or two 7-Fr double pigtail plastic stent insertion with or without temporary endoscopic naso-gallbladder drainage (ENGBD) insertion was performed.Results:Six patients (age 61–88), with three cases of acute cholecystitis after metallic biliary stenting and three cases of calculus cholecystitis, who underwent PTGBD were included. EUS-GBD was performed 10–63 days after PTGBD, using one plastic stent in five cases, two stents in one case, with temporary ENGBD in two cases. The technical success and clinical success were achieved and the PTGBD tubes were subsequently removed in all patients. All ENGBD tubes were removed within 5 days after insertion. Bile leak with peritonitis was demonstrated in one case, which was treated conservatively. No recurrent cholecystitis was seen during 3–26 months of follow-up.Conclusion:The conversion of percutaneous cholecystostomy to internal transmural EUS-GBD with plastic stents is feasible for patients unfit for cholecystectomy. However, more studies are still needed to confirm the results.

Endoscopic ultrasound-guided biliary drainage: Experience from a tertiary center

Background and Objectives:Endoscopic retrograde cholangiopancreatography (ERCP) and palliative biliary stenting are an established therapy for malignant biliary obstruction that is unsuitable for curative surgery. In ERCP failure, EUS-guided biliary drainage (EUS-BD) procedures are evolving alternative endoscopic techniques.Methods:This was a retrospective analysis of patients who underwent EUS-BD.Results:There were 16 patients who underwent EUS-BD in the last 5 years. Male to female ratio was 9:7. Mean age was 63.56 years. Seven patients had carcinoma pancreas; six had periampullary carcinoma and one patient each had duodenal carcinoma, carcinoma colon with infiltration, and hepatocellular carcinoma with hepatic duct stricture. Indication for EUS-BD was inaccessible ampulla in ten, unidentified ampulla in one, failed biliary cannulation in four, and proximal migration of biliary plastic stent in one. Fifteen (93.75%) underwent EUS-guided choledochoduodenostomy (EUS-CDS), while one had EUS-guided hepaticogastrostomy (EUS-HGS). Covered biliary self-expandable metallic stent was used for EUS-CDS and Giobor biliary stent for EUS-HGS. The procedure was technically successful in all. There were no major immediate postprocedure complications. There was significant symptomatic and biochemical improvement in all. Thirty-day survival was 100%.Conclusion:In malignant biliary obstruction with failed ERCP, EUS-guided bile duct drainage has a high potential as an alternative biliary decompression procedure.

Clinical utility of endoscopic ultrasound-guided biliary drainage as a rescue of re-intervention procedure for high-grade hilar stricture.

Re-intervention after stent placement for malignant hepatic hilum obstruction (HBO) is challenging. endoscopic ultrasound-guided biliary drainage (EUS-BD) has been developed as an alternative method for failed endoscopic retrograde cholangiopancreatography (ERCP). In this retrospective study, the clinical utility of EUS-BD as a rescue drainage technique for HBO patients who failed re-intervention under ERCP guidance was evaluated. Between April 2012 and August 2015, patients with HBO were enrolled. Patients' characteristics, kinds of metallic stents, configuration of stent placement, overall survival, stent patency, and results of re-intervention were reviewed, along with the re-intervention technical success rate. The biliary stricture type was Bismuth type IV in 59% (23/39) and types IIIa and b in 20.5% (8/39) each. Biliary metallic stent placement was bilateral in 38.5% (15/39), and unilateral in 61.5% (24/39). Primary stent dysfunction was observed in 71.8% (28/39) of cases. Planned re-intervention under ERCP guidance was attempted in 26 patients. The technical success rate was 62% (16/26). For the 10 patients who failed re-intervention under ERCP guidance, EUS-BD was planned. The technical success rate was 100% (10/10). The procedure time was 25.8 min. Adverse events were not seen in any patients. Stent patency after re-intervention was not significantly different between ERCP (165 days) guidance and EUS-BD (152 days) guidance (P = 0.463) CONCLUSIONS: In conclusion, EUS-BD as a re-intervention method for metallic stent obstruction was safe and feasible. If ERCP was failed, EUS-BD may be one of option as re-intervention method for high-grade hilar stricture.

Endoscopic ultrasound-guided hepaticogastrostomy: Problems and solutions; some unsuccessful and then the right one!

A 36-year-old male presented with obstructive jaundice and acute pancreatitis. Both imaging and an upper gastrointestinal endoscopy revealed malignant duodenal obstruction involving first and second parts. The patient was managed conservatively for acute pancreatitis. Endoscopic retrograde cholangiopancreatography was not possible in view of duodenal pathology. Endoscopic ultrasound (EUS)-guided hepaticogastrostomy was planned. Walled-off pancreatic necrosis as well as ascites was noted on EUS. Hepatic duct access was gained; a guidewire placement with track dilation using 6 Fr cystotome (Endoflex) was performed. A Giobor stent (Taewoong Medical, 8 mm × 10 cm long) was placed between the liver and stomach; immediate migration of the stent was noted resulting in to the impaction of the proximal end in to the gastric wall. Retrieval attempts made over the in-stent placement of a 7 Fr. Double pigtail plastic stent was unsuccessful. Plastic stent was removed after stent intubation carried out over a guidewire placed through the side hole. Retrieval using a Hurricane balloon (8 mm, Boston Scientific) was also unsuccessful. Eventually, successful biliary drainage was performed using both bare (10 mm × 60 mm, Taewoong Medical) biliary metal stent placement through the Giobor stent. An enteral stent (WallFlex Duodenal, Boston Scientific) was placed for the duodenal obstruction.

Prognostic value of inflammation-based markers in patients with recurrent malignant obstructive jaundice treated by reimplantation of biliary metal stents: A retrospective observational study.

We aimed to assess the therapeutic effect of reimplantation of biliary metal stents by percutaneous transhepatic cholangial drainage (PTCD) in patients with recurrent malignant obstructive jaundice (MOJ). Furthermore, we explored the prognostic value of inflammation-based markers in these patients.We reviewed 33 cases of recurrent MOJ after implantation of biliary metal stents by PTCD, all of which underwent reimplantation of stents under digital subtraction angiography guidance. Levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin were compared between before and after reimplantation (1 week, 1 month, and 3 months postoperatively). Preoperative clinical data were collected to calculate the inflammation-based markers, including systemic immune-inflammation index (SII, neutrophil × platelets/ lymphocyte), platelets-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and monocyte-to-lymphocyte ratio (MLR). The primary outcome was overall survival (OS), which was estimated by the Kaplan–Meier method and Cox regression analysis.The levels of ALT, AST, total bilirubin, and direct bilirubin significantly reduced after the reimplantation operation. During a median follow-up time of 10 months, 18 (54.5%) patients died. Gender, albumin, SII, PLR, NLR, and MLR were found to be associated with OS by the log-rank test and univariate analysis. Multivariate Cox analysis identified elevated levels of SII and PLR as significant factors for predicting poor OS.Reimplantation is clinically feasible in patients with recurrent MOJ after implantation of biliary metal stents. SII and PLR are independent, useful inflammation-based prognostic models for predicting outcomes in these patients.

Cost Effectiveness of Metal Stents in Relieving Obstructive Jaundice in Patients with Pancreatic Cancer.

ASGE and ESGE guidelines recommend endoscopic metal stent placement for pancreatic carcinoma patients with biliary obstruction, and whose estimated life expectancy is greater than 6months. Because median overall survival (OS) of metastatic pancreatic adenocarcinoma until recently has been less than 6months, plastic biliary stents were preferentially placed rather than metal due to the greater upfront cost of the latter. Recent advances in the treatment of metastatic pancreatic cancer have extended median OS beyond the 6-month range. Given this improvement in OS, we performed a cost-effectiveness analysis of initial metal biliary versus plastic stent placement in metastatic pancreatic cancer patients with biliary obstruction. A Markov model was developed to predict lifetime costs, quality-adjusted life years (QALYs), and cost effectiveness of metal compared with plastic stents. Adult patients entered the model with locally advanced cancer and underwent endoscopic retrograde cholangiopancreatography (ERCP) with placement of metal or plastic stents. A targeted literature search was conducted to identify published sources, which were used to estimate clinical, cost, utility, and event rate inputs to the model. Results were estimated from the third-party payer perspective in 2012 US dollars per QALY. One-way and probabilistic sensitivity analyses were conducted to assess the impact on model outcomes resulting from uncertainty among inputs. Our analysis found that initial placement of metal stents was more cost effective than plastic biliary stents with lower overall costs due to lower restenting rates while at the same time associated with a better quality of life. Based on model projections, placement of metal stents could save approximately $1450 per patient over a lifetime, while simultaneously improving quality of life. These findings were robust in sensitivity analyses. Placement of metal biliary stents at initial onset of obstructive jaundice in adult patients with metastatic pancreatic carcinoma with an expected OS greater than 6months was found to be a more cost-effective strategy than plastic stents. These results reinforce guidelines' suggestions for metal stent placement.