Percutaneous Metallic Stent Placement Research Articles

Percutaneous metallic stent placement for malignant afferent loop syndrome via the blind end of the jejunal limb after biliary reconstruction

Yozo Sato, Shohei Chatani, Takaaki Hasegawa, Shinichi Murata, Takamichi Kuwahara, Kazuo Hara, Yasuhiro Shimizu, and Yoshitaka Inaba. Int J Gastrointest Interv 2021;10:23-7. https://doi.org/10.18528/ijgii200044

Percutaneous Metallic Stent Placement for Palliative Management of Malignant Biliary Hilar Obstruction.

ObjectiveTo investigate the outcomes of percutaneous metallic stent placements in patients with malignant biliary hilar obstruction (MBHO).Materials and MethodsFrom January 2007 to December 2014, 415 patients (mean age, 65 years; 261 men [62.8%]) with MBHO were retrospectively studied. All the patients underwent unilateral or bilateral stenting in a T, Y, or crisscross configuration utilizing covered or uncovered stents. The clinical outcomes evaluated were technical and clinical success, complications, overall survival rates, and stent occlusion-free survival.ResultsA total of 784 stents were successfully placed in 415 patients. Fifty-five patients had complications. These complications included hemobilia (n = 19), cholangitis (n = 13), cholecystitis (n = 11), bilomas (n = 10), peritonitis (n = 1), and hepatic vein-biliary fistula (n = 1). Clinical success was achieved in 370 patients (89.1%). Ninety-seven patients were lost to follow-up. Stent dysfunction due to tumor ingrowth (n = 107), sludge incrustation (n = 44), and other causes (n = 3) occurred in 154 of 318 patients. The median overall survival and the stent occlusion-free survival were 212 days (95% confidence interval [CI], 186−237 days) and 141 days (95% CI, 126−156 days), respectively. The stent type and its configuration did not affect technical success, complications, successful internal drainage, overall survival, or stent occlusion-free survival.ConclusionPercutaneous stent placement may be safe and effective for internal drainage in patients with MBHO. Furthermore, stent type and configuration may not significantly affect clinical outcomes.

Biliary intraductal metastasis from advanced gastric cancer: radiologic and histologic characteristics, and clinical outcomes of percutaneous metallic stent placement.

To investigate the radiologic and histological characteristics of biliary intraductal metastasis of advanced gastric cancer and the clinical outcomes of percutaneous, metallic stent placement. We retrospectively assessed 24 patients with obstructive jaundice related to biliary intraductal metastasis of gastric cancers who underwent PTBD and subsequent metallic stent placement between 2003 and 2012. Intraductal metastases appeared as uniform, concentric, linear (n = 17) or band-like (n = 7), enhanced wall thickening on CT, and 20 patients (83.3%) had cystic ductal lesions. On pathology specimens, malignant cells scattered in the submucosal layer caused a desmoplastic reaction. The technical and clinical success rate of stent placement was achieved in all 24 patients. The median survival time was 203days. Stent occlusion was observed in four patients with 49-278 days following stent placement. The median stent patency time was 156days. The radiologic and histological characteristics of biliary intraductal metastasis of advanced gastric cancer consist of uniform, linear or band-like, enhanced biliary wall thickening and malignant cells scattered in the submucosal layer, together with the desmoplastic reaction without any disruption of the epithelial layer. Uncovered metallic stent placement was also a safe and effective method of palliative treatment in these patients. • The CT findings of intraductal metastasis were linear/band-like, enhanced biliary wall thickening. • The histological finding was malignant cells scattered in the submucosal layer. • It showed a desmoplastic reaction without any disruption of the epithelial layer. • Uncovered metallic stent placement was a safe and effective palliative treatment.

Endoscopic ultrasonography‐guided trans‐Roux limb drainage of pancreatic duct to prevent pancreatitis as a result of percutaneous metallic stent placement for malignant biliary stricture

Endoscopic ultrasonography‐guided trans‐<scp>R</scp>oux limb drainage of pancreatic duct to prevent pancreatitis as a result of percutaneous metallic stent placement for malignant biliary stricture

Percutaneous Metallic Stent Placement in Patients with Cancer Recurrence at Bilioenterostomy Site

PurposeTo investigate the outcomes of percutaneous metallic stent placement in patients with malignant bilioenterostomy obstruction and to assess the risk factors influencing stent patency. Materials and MethodsFrom August 2008 to January 2012, 53 patients with malignant bilioenterostomy obstructions were treated with percutaneous placement of biliary metallic stents; this included expanded polytetrafluoroethylene (ePTFE)–covered stent placement in 36 patients and uncovered stent placement in 17 patients. ResultsA total of 75 stents were successfully placed in 53 patients. No major complications occurred in any patients, and minor complications occurred in nine patients (17%). The mean serum bilirubin level, which was 3.6 mg/dL ± 0.7 before drainage, decreased significantly to 2.5 mg/dL ± 0.4 at 1 month after stent placement (P = .041). Successful internal drainage was achieved in 44 of the 53 patients (83%). Kaplan–Meier analysis showed a median overall survival time of 145 days (95% confidence interval, 100–190 d), a median stent patency time of 313 days (95% confidence interval, 46–580 d), and cumulative stent patency rates at 1, 3, 6, 9, and 12 months of 91%, 75%, 64%, 56%, and 45%, respectively. Multivariate Cox regression analysis showed that the use of uncovered stents (odds ratio, 2.924; P = .033) was the only significant independent factor associated with stent occlusion. ConclusionsPercutaneous metallic stent placement is a safe and effective method for the treatment of patients with malignant bilioenterostomy obstruction. Moreover, as uncovered stent placement is the only significant independent factor associated with stent occlusion, ePTFE-covered stent placement is preferable in these patients.

A Survival Analysis of Patients with Malignant Biliary Strictures Treated by Percutaneous Metallic Stenting

Percutaneous metal stenting is an accepted palliative treatment for malignant biliary obstruction. Nevertheless, factors predicting survival are not known. Seventy-six patients with inoperable malignant biliary obstruction were treated with percutaneous placement of metallic stents. Twenty patients had non-hilar lesions. Fifty-six patients had hilar lesions classified as Bismuth type I (n = 15 patients), type II (n = 26), type III (n = 12), or type IV (n = 3 patients). Technical and clinical success rates, complications, and long-term outcome were recorded. Clinical success rates, patency, and survival rates were compared in patients treated with complete (n = 41) versus partial (n = 35) liver parenchyma drainage. Survival was calculated and analyzed for potential predictors such as the tumor type, the extent of the disease, the level of obstruction, and the post-intervention bilirubin levels. Stenting was technically successful in all patients (unilateral drainage in 70 patients, bilateral drainage in 6 patients) with an overall significant reduction of the post-intervention bilirubin levels (p < 0.001), resulting in a clinical success rate of 97.3%. Clinical success rates were similar in patients treated with whole-liver drainage versus partial liver drainage. Minor and major complications occurred in 8% and 15% of patients, respectively. Mean overall primary stent patency was 120 days, while the restenosis rate was 12%. Mean overall secondary stent patency was 242.2 days. Patency rates were similar in patients with complete versus partial liver drainage. Mean overall survival was 142.3 days. Survival was similar in the complete and partial drainage groups. The post-intervention serum bilirubin level was an independent predictor of survival (p < 0.001). A cut-off point in post-stenting bilirubin levels of 4 mg/dl dichotomized patients with good versus poor prognosis. Patient age and Bismuth IV lesions were also independent predictors of survival. Percutaneous metallic biliary stenting provides good palliation of malignant jaundice. Partial liver drainage achieved results as good as those after complete liver drainage. A serum bilirubin level of less than 4 mg/dl after stenting is the most important independent predictor of survival, while increasing age and Bismuth IV lesions represent dismal prognostic factors.

Percutaneous placement of metallic stents in the management of malignant biliary obstruction.

The placement of metallic stents is now a well-established method in the management of malignant biliary obstruction. This study evaluated the long-term clinical efficacy of percutaneous transhepatic insertion of metallic stents in the management of malignant biliary obstruction. From January 1999 to December 2002, 102 consecutive patients with malignant biliary obstruction were treated with percutaneous transhepatic placement of metallic stents at a medical center in Taipei. The level of obstruction was at the hepatic hilum in 44 patients, and common bile duct (CBD) in 58 patients. Memotherm stents were used in 78 patients and Wallstents in 38. Among the 44 patients with hilar obstruction, 30 received a single stent and 14 received bilateral stents. Among the 58 patients with CBD obstruction, the stents were placed across the ampulla of Vater in 27. Patient survival rates and stent patency rates were compared using the Kaplan-Meier method. Placement of stents was successful in all patients. The mean (range) serum bilirubin level before, 1 week after, and 1 month after stent insertion was 15.1 mg/dL (4.2-32.4 mg/dL), 7.8 mg/dL (0.5-19.4 mg/dL), and 1.8 mg/dL (0.2-8.2 mg/dL), respectively. The mean survival in all patients was 66.0 weeks (1-130 weeks) and the mean stent patency period (MSPP) in all patients was 59.9 weeks (1-130 weeks). The MSPP was 71.4 versus 49.9 weeks in hilar type versus CBD type patients (p = 0.047). The MSPP was 53.9 versus 73.0 weeks in patients who received Memotherm stents versus Wallstents (p = 0.115). In the hilar obstruction group, the MSPP was 82.1 versus 58.0 weeks in patients receiving bilateral versus a single stent (p = 0.039). In the CBD obstruction group, the MSPP was 46.3 versus 45.5 weeks in stents placed across versus not placed across the ampulla of Vater (p = 0.338). The efficacy and patency period of percutaneous transhepatic insertion of metallic stents in the management of malignant biliary obstruction is satisfactory in the relief of obstructive jaundice. Both types of metallic stents performed well in relieving malignant biliary obstruction. Bilateral stenting was more effective than single stenting in treating patients with hilar obstruction. In patients with CBD obstruction, no significant difference in the stent patency period was found between stents placed across or not across the ampulla of Vater.

Percutaneous Stent Placement as Treatment of Renal Vein Obstruction Due to Inferior Vena Caval Thrombosis

A patient who had undergone his third orthotopic liver transplantation nearly 9 years prior to presentation developed worsening hepatic and renal function, as well as severe bilateral lower extremity edema. Magnetic resonance imaging demonstrated vena caval thrombosis from the suprahepatic venous anastomosis to the infrarenal inferior vena cava, obstructing the renal veins. This was treated by percutaneous placement of metallic stents from the renal veins to the right atrium. At 16 months clinical follow-up, the patient continues to do well.

Percutaneous Cystic Duct Stent Placement for the Treatment of Acute Cholecystitis Resulting from Common Bile Duct Stent Placement for Malignant Obstruction

Common bile duct (CBD) stent placement to relieve malignant biliary obstruction can occasionally cause cystic duct obstruction and acute cholecystitis. Cholecystostomy tube placement is often performed in patients with limited life expectancy but can have a significant impact on quality of life. To allow cholecystostomy tube removal, percutaneous metallic stent placement was performed across the cystic duct via the tube tract in such a patient. The procedure included traversal across the previously placed CBD stent. At 5-month follow-up, the patient remained symptom-free. In select patients who develop acute cholecystitis after CBD stent placement for malignant obstruction, percutaneous stent placement across the cystic duct may be considered a treatment option.

Percutaneous Self-Expandable Uncovered Metallic Stents in Malignant Biliary Obstruction. Complications, follow-up and reintervention in 154 patients

Evaluation of technique, complications and the long-term follow-up data of 154 patients with inoperable malignant biliary obstruction who underwent percutaneous placement of metallic stents. During a 6-year period, 224 self-expanding metallic stents (150 biliary Wallstents and 74 Memotherm nitinol stents) were inserted in 154 patients with inoperable malignant biliary obstruction. 100 patients had obstructions at the proximal (supracystic) level, and 54 at the distal (infracystic) level. The causes of obstructions were hilar cholangiocarcinoma (n = 64), pancreatic carcinoma (n = 34), gallbladder carcinoma (n = 24), metastatic carcinoma (n = 21), common bile duct carcinoma (n = 8), and hepatocellular carcinoma (n = 3). A complete follow-up was available for all patients. The 30-day mortality was 9%, with no procedure-related deaths. The clinical success rate within the first 30 days was 88%. The total rate of early, procedure-related complications was 28%, and half of them were due to the percutaneous transhepatic catheter drainage procedure. Recurrent jaundice occurred in 28 (18%) patients and in 23 (82%) of these, reinterventions were made in order to relieve reobstructions. The mean length of survival for the entire patient group was 4 months, while the mean period of patency for all stents was 6 months. We found no statistically significant difference in patient survival or stent patency periods in regard to the level and cause of obstruction. Percutaneous metallic stent placement maintains equal palliation in patients with proximal and distal malignant biliary obstructions caused by any tumor type. Most of the early complications were due to procedures performed before stent insertion and could be decreased by direct stent insertions. The most common late complication, reobstruction, is inevitable but can be easily treated in the majority of patients.

Percutaneous self-expandable uncovered metallic stents in malignant biliary obstruction. Complications, follow-up and reintervention in 154 patients.

Evaluation of technique, complications and the long-term follow-up data of 154 patients with inoperable malignant biliary obstruction who underwent percutaneous placement of metallic stents. During a 6-year period, 224 self-expanding metallic stents (150 biliary Wallstents and 74 Memotherm nitinol stents) were inserted in 154 patients with inoperable malignant biliary obstruction. 100 patients had obstructions at the proximal (supracystic) level, and 54 at the distal (infracystic) level. The causes of obstructions were hilar cholangiocarcinoma (n = 64), pancreatic carcinoma (n = 34), gallbladder carcinoma (n = 24), metastatic carcinoma (n = 21), common bile duct carcinoma (n = 8), and hepatocellular carcinoma (n = 3). A complete follow-up was available for all patients. The 30-day mortality was 9%, with no procedure-related deaths. The clinical success rate within the first 30 days was 88%. The total rate of early, procedure-related complications was 28%, and half of them were due to the percutaneous transhepatic catheter drainage procedure. Recurrent jaundice occurred in 28 (18%) patients and in 23 (82%) of these, reinterventions were made in order to relieve reobstructions. The mean length of survival for the entire patient group was 4 months, while the mean period of patency for all stents was 6 months. We found no statistically significant difference in patient survival or stent patency periods in regard to the level and cause of obstruction. Percutaneous metallic stent placement maintains equal palliation in patients with proximal and distal malignant biliary obstructions caused by any tumor type. Most of the early complications were due to procedures performed before stent insertion and could be decreased by direct stent insertions. The most common late complication, reobstruction, is inevitable but can be easily treated in the majority of patients.

Percutaneous placement of metallic stents in malignant biliary obstruction: one-stage or two-stage procedure? Pre-dilate or not?

The aim of this paper was to evaluate the necessity of percutaneous transhepatic catheter drainage and balloon dilation procedures performed before stent insertion. One hundred and twenty-six patients with unresectable malignant biliary obstruction underwent palliative therapy by means of percutaneous transhepatic placement of 183 metallic biliary endoprotheses. Forty-four (35%) patients underwent metallic stent insertion in a one-stage procedure and 82 (65%) had undergone percutaneous transhepatic catheter drainage before stent insertion. Balloon dilation of the stenosis before stent placement (pre-dilation) was performed in 53 (42%) of 126 patients. The rate of the 30-day mortality was 11%, with no procedure-related deaths. The total rate of early complications was 29%, and 84% of these complications were due to percutaneous transhepatic catheter drainage and pre-dilation procedures. Percutaneous transhepatic catheter drainage and pre-dilation had no clinical or statistically significant effect on the patients' survival and stent patency rate. Percutaneous transhepatic catheter drainage and balloon dilation increased the cost of stent placement 18% and 19%, respectively. Palliation of malignant biliary obstruction with percutaneous transhepatic stent insertion should be done directly, in the simplest way, without performing percutaneous transhepatic catheter drainage and balloon dilation before stent placement. It is more useful, safe, and cost-effective.

Metallic stents in malignant biliary obstruction: prospective long-term clinical results.

The purpose of this prospective study was to evaluate the long-term clinical efficacy of metallic stents when used as the initial palliative treatment of patients with inoperable malignant biliary obstruction. From August 1991 through May 1995, 100 consecutive patients with malignant biliary obstruction were treated with percutaneous placement of metallic stents. The causes of obstruction were bile duct carcinoma (n = 50), pancreatic carcinoma (n = 17), gallbladder carcinoma (n = 6), hepatocellular carcinoma (n = 2), and metastatic lymphadenopathy in the hepatoduodenal ligament (n = 25). We used 123 stents: 64 Gianturco Z stents, 39 Hanaro spiral stents, 16 Wallstents, two tantalum Strecker stents, one Endocoil stent, and one Memotherm nitinol stent. Every 3 months we followed up all patients except those who died. The average length of follow-up was 220 days (range, 4-1125 days). Patient survival and stent patency rates were estimated by life-table analysis. The median length of survival for the entire patient group was 246 days: 25-week and 50-week survival rates were 62% and 25%, respectively. We found no statistically significant difference in the median length of survival between patients with hilar obstruction (256 days) and patients with common bile duct (CBD) obstruction (227 days). Patients with bile duct carcinoma had longer median survival (269 days) than did patients with other conditions (197 days). The overall median length of patency for all stents was 360 days; the 25-week and 50-week patency rates were 81% and 53%, respectively. The stent patency rate at the median length of survival was 71%. The median length of stent patency in patients with hilar obstruction (617 days) was nearly double that of patients with CBD obstruction (324 days). However, the median length of stent patency in patients with bile duct carcinoma showed no statistically significant difference from the median length in patients with other disease. Four patients (4%) died within 1 month after stent placement. Twenty-one patients (21%) developed recurrent jaundice or cholangitis. In order of frequency, the causes of recurrent jaundice were tumor overgrowth, incrustation of bile sludge, duodenal obstruction due to tumor invasion, stent impaction into the bile duct wall, stent malposition, and tumor ingrowth. Metallic stents showed a favorable patency rate with regard to patient survival. In patients with hilar obstruction, the clinical efficacy of metallic stents was superior to that in patients with CBD obstruction. We believe that placement of metallic stents is the procedure of choice for palliation of malignant biliary obstruction.