Endoscopic management of malignant biliary stenosis. Update and highlights for standard clinical practice (original) (raw)
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Unilateral versus bilateral endoscopic biliary stenting for malignant hilar biliary strictures
Digestive Endoscopy, 2013
The present review compared unilateral versus bilateral stenting in order to determine the optimal stenting strategy for malignant hilar biliary strictures based on the previous literature. The role of preoperative biliary drainage prior to liver resection for hilar cholangiocarcinoma remains under discussion. However, in Japan, endoscopic placement of single nasobiliary drainage in the future remnant hepatic lobe is currently considered the most suitable method. In most unresectable cases, unilateral stenting appears to be adequate for ameliorating jaundice. It is technically easier and less expensive than bilateral stenting, with reintervention for stent dysfunction also being considerably easier. However, contrast medium injection into undrained bile ducts is associated with uncontrolled cholangitis and poor prognosis. To prevent this complication, bilateral stenting may be preferred to unilateral stenting. Additionally, previous studies have demonstrated bilateral stenting to be associated with longer stent patency as compared to unilateral stenting. We consider that further large-scale studies are required to clarify whether unilateral or bilateral stenting is a better therapeutic technique for malignant hilar biliary stricture.
Unilateral versus bilateral endoscopic metal stenting for malignant hilar biliary obstruction
Journal of Gastroenterology and Hepatology, 2009
The extent of liver drainage for palliative treatment of malignant hilar biliary obstruction is controversial. The aim of this study was to compare endoscopic unilateral versus bilateral drainage in patients with malignant hilar biliary obstruction using a self-expanding metal stent (SEMS). Methods: We carried out a retrospective review of 46 consecutive patients with malignant hilar biliary obstruction who were treated by endoscopic biliary drainage using SEMS between 1997 and 2005. Unilateral metal stenting (group A) was performed in 17 patients between 1997 and 2000, and bilateral metal stenting (group B) was performed in 29 patients between 2001 and 2005. The successful stent insertion, successful drainage, early complications, late complications, stent patency, and survival rate for groups A and B were evaluated and compared retrospectively. Results: There were no significant differences between the two groups in successful stent insertion (100% vs 90%, group A vs B, respectively), successful drainage (100% vs 96%), early complications (0% vs 10%), or late complications (65% vs 54%). Cumulative stent patency was significantly better in group B than in group A (P = 0.009). In cases of cholangiocarcinoma, cumulative stent patency was significantly better in group B than in group A (P = 0.009), whereas there were no inter-group differences for gallbladder carcinoma. Cumulative survival did not differ significantly between the groups. Conclusions: Endoscopic bilateral drainage using SEMS for malignant hilar biliary obstruction is more effective than unilateral drainage in terms of cumulative stent patency, especially in cases of cholangiocarcinoma.
Digestive Endoscopy, 2011
The aim of this study was to evaluate the efficacy and safety of endoscopic bilateral biliary metal stent placement for hilar malignant obstruction. Patients and Methods: Twenty patients with unresectable malignant hilar biliary obstruction who had undergone endoscopic bilateral Y-configured biliary drainage with metal stents were enrolled as a study group (YMS group). Thirty-seven patients who had undergone bilateral drainage with plastic stents were selected as a historical control (PS group).Two newly designed metal stents for bilateral Y-configured placement were endoscopically deployed in a partial stent-in-stent manner in one session. Technical success, early complications, and stent patency were evaluated. Results: The technical success rate in the YMS group was 100%. Mild post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in one patient in the YMS group and in two in the PS group. The success rate of biliary decompression was 95% in the YMS group and 89% in the PS group (P = 0.65). During a median follow-up period of 7.3 months, the incidence of stent occlusion in the YMS group was significantly lower than that in the PS group (30% vs 62%, P = 0.028). Mean stent patency in the YMS group was 250 days and that in the PS group was 115 days (P = 0.0061). Risk factors for stent occlusion were bile duct cancer (P = 0.035) and the PS group (P = 0.07) by multivariate analysis. Conclusion: Single-session endoscopic bilateral biliary placement of newly designed metal stents for hilar malignant obstruction is safe and useful with a high technical success rate and a long patency period.
Endoscopy, 2018
Main RecommendationsESGE recommends against routine preoperative biliary drainage in patients with malignant extrahepatic biliary obstruction; preoperative biliary drainage should be reserved for patients with cholangitis, severe symptomatic jaundice (e. g., intense pruritus), or delayed surgery, or for before neoadjuvant chemotherapy in jaundiced patients. Strong recommendation, moderate quality evidence. ESGE recommends the endoscopic placement of a 10-mm diameter self-expandable metal stent (SEMS) for preoperative biliary drainage of malignant extrahepatic biliary obstruction. Strong recommendation, moderate quality evidence.ESGE recommends SEMS insertion for palliative drainage of of extrahepatic malignant biliary obstruction. Strong recommendation, high quality evidence. ESGE recommends against the insertion of uncovered SEMS for the drainage of extrahepatic biliary obstruction of unconfirmed etiology. Strong recommendation, low quality evidence. ESGE suggests against routine p...
Should endoscopic stenting be the initial treatment of malignant biliary obstruction?
Annals of the Royal College of Surgeons of England, 1992
Forty-two patients with biliary obstruction caused by a stricture had a diagnostic ERCP with subsequent insertion of a straight 10G endoprosthesis. These patients represented 70% of a cohort in which stent insertion had been attempted. The majority (63%) had pancreatic carcinoma, but 22% had malignant hilar obstruction. Five patients (12%) died within a few days of stent insertion; ERCP may have contributed to two deaths. Jaundice was relieved in all survivors. Median hospital stay was 6 days (range 2-32 days). After further investigation, nine patients were thought to be potentially curable and underwent laparotomy. Late complications after stent insertion alone included cholangitis (26%) and recurrent jaundice (28%). Only one patient developed gastric outlet obstruction and needed a gastroenterostomy. Median survival in the endoprosthesis group was 11 weeks (range 2-84 weeks). Survival was longer for patients with bile duct (14 weeks) rather than hilar strictures (6 weeks). Median...
BMC gastroenterology, 2015
BackgroundEndoscopic biliary stenting (EBS) is one of the most important palliative treatments for biliary tract cancer. However, reflux cholangitis arising from bacterial adherence to the inner wall of the stent must be avoided. We evaluated the use of EBS above the sphincter of Oddi to determine whether reflux cholangitis could be prevented in preoperative cases.MethodsFifty-seven patients with primary biliary tract cancer were retrospectively recruited for the evaluation of stent placement either above (n =25; inside stent group) or across (n =32; conventional stent group) the sphincter of Oddi. We compared the stent patency periods prior to the time of surgical resection.ResultsThe preoperative periods were 96.3 days in the conventional stent group and 96.8 days in the inside stent group (P =0.979). Obstructive jaundice and/or acute cholangitis occurred in 7 patients (28.0%) in the inside stent group and in 15 patients (46.9%) in the conventional stent group during the preoperat...
Malignant biliary stenosis treated with two percutaneous stents--case report
Chirurgia (Bucharest, Romania : 1990)
During last three decades interventional radiology became most powerfull tool in palliative treatment of patients with malignant biliary stenosis. We report a case of 62-year-old patient with malignant biliary obstruction caused by recidivant tumor of common bile duct remnant with infiltration of previously created hepaticojejunostomia. Biliary decompression was achieved by placement of two self-expanding metallic stents. In presented patient, due to previous surgery percutaneous approach was mandatory. Also, considering the unresectability of recidivant lesion and poor prognosis, definitive, preferable internal biliary drainage was to be achieved. Therefore the placement of metallic self-expanding stent was the therapeutic method of choice. The aim of percutaneous minimally invasive radiological interventions is to achieve effective biliary decompression with internal bile drainage if possible.
BMC Gastroenterology
Background: Biliary decompression can reduce symptoms and improve quality of life in patients with malignant biliary obstruction. Endoscopically placed stents have become the standard of care for biliary drainage with the aim of improving hepatic function, relieving jaundice, and reducing adverse effects of obstruction. The purpose of this study was to evaluate the performance characteristics of a newly-designed, uncovered metal biliary stent for the palliation of malignant biliary obstruction. Methods: This post-market, prospective study included patients with biliary obstruction due to a malignant neoplasm treated with a single-type, commercially available uncovered self-expanding metal stent (SEMS). Stents were placed as clinically indicated for palliation of jaundice and to potentially facilitate neo-adjuvant chemotherapy. The main outcome measure was freedom from recurrent biliary obstruction (within the stent) requiring reintervention within 1, 3, and 6 months of stent insertion. Secondary outcome measures included device-related adverse events and technical success of stent deployment. Results: SEMS were placed in 113 patients (73 men; mean age, 69); a single stent was inserted in 106 patients, and 2 stents were placed in 7 patients. Forty-eight patients survived and/or completed the 6 month study protocol. Freedom from symptomatic recurrent biliary obstruction requiring re-intervention was achieved in 108 of 113 patients (95.6, 95%CI = 90.0-98.6%) at study exit for each patient. Per interval analysis yielded the absence of recurrent biliary obstruction in 99.0% of patients at 1 month (n = 99; 95%CI = 97.0-100%), 96.6% of patients at 3 months (n = 77; 95%CI = 92.7-100%), and 93.3% of patients at 6 months (n = 48; 95%CI = 86.8-99.9%). In total, only 5 patients (4.4%) were considered failures of the primary endpoint. Most of these failures (4/5) were due to stent occlusion from tumor ingrowth or overgrowth. Overall technical success rate of stent deployment was 99.2%. There were 2 cases of stent-related adverse events (1.8%). There were no cases of post-procedure stent migration, stent-related perforation, or stent-related deaths.
Clinical and Translational Gastroenterology, 2020
INTRODUCTION: Data about the efficacy of palliative double stenting for malignant duodenal and biliary obstruction are limited. METHODS: A systematic literature search was performed to assess the feasibility and optimal method of double stenting for malignant duodenobiliary obstruction compared with surgical double bypass in terms of technical and clinical success, adverse events, reinterventions, and survival. Event rates with 95% confidence intervals were calculated. RESULTS: Seventy-two retrospective and 8 prospective studies published until July 2018 were included. Technical and clinical success rates of double stenting were 97% (95%-99%) and 92% (89%-95%), respectively. Clinical success of endoscopic biliary stenting was higher than that of surgery (97% [94%-99%] vs 86% [78%-92%]). Double stenting was associated with less adverse events (13% [8%-19%] vs 28% [19%-38%]) but more frequent need for reintervention (21% [16%-27%] vs 10% [4%-19%]) than double bypass. No significant difference was found between technical and clinical success and reintervention rate of endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic drainage, and endoscopic ultrasound-guided biliary drainage. ERCP was associated with the least adverse events (3% [1%-6%]), followed by percutaneous transhepatic drainage (10% [0%-37%]) and endoscopic ultrasound-guided biliary drainage (23% [15%-33%]). DISCUSSION: Substantially high technical and clinical success can be achieved with double stenting. Based on the adverse event profile, ERCP can be recommended as the first choice for biliary stenting as part of double stenting, if feasible. Prospective comparative studies with well-defined outcomes and cohorts are needed.