Unilateral versus bilateral hilar stents for the treatment of cholangiocarcinoma: a multicenter international study (original) (raw)
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Gastrointestinal Endoscopy, 2019
Backgrounds: Unlike uncovered SEMS (UCSEMS), fully covered self-expandable metal stents (FCSEMS) can resolve the problem of tumor ingrowth, however it still carries a risk of migration after placement. A newly design FCSEMS with side holes (multi-hole self-expandable metal stent (MHSEMS)) has been developed to prevent stent migration and also to reduce the risk of tumor ingrowth. This study aimed to compare the efficacy of MHSEMS vs. FCSEMS vs. UCSEMS for the treatment of malignant distal biliary obstruction (MDBO). Methods: A total of 169 patients with MDBO underwent ERCP with SEMS placement between January 2014 and October 2018 at our institute. Of those, 126, 28 and 15 patients received FCSEMS, UCSEMS and MHSEMS placement, respectively. All relevant clinical data and outcomes were retrospectively reviewed. Clinical success rate (CSR) was defined as a reduction of total bilirubin (TB) by at least 50% from the initial value after 14 days. Recurrent biliary obstruction (RBO) was defined as a composite endpoint of either occlusion or migration. Results: Baseline characteristics were not different among the three groups, including age, gender, type of cancer, the presence of liver metastasis, and initial TB (Table). There were no differences in CSR among those undergoing FCSEMS, UCSEMS and MHSEMS placement (94% vs. 96% vs. 93%; pZ0.64). RBO rate in the FCSEMS group was lower than those in the UCSEMS group (22.2% vs. 46.4%; pZ0.01). When compared MHSEMS with either FCSEMS (33.3% vs. 22.2%; pZ0.35) or UCSEMS (33.3% vs. 46.4%; pZ0.41), RBO rate was not significantly different. Using Kaplan-meier survival analysis(Figure), patients with FCSEMS had significantly longer stent patency time than those with UCSEMS (pZ0.01) whereas stent patency time in patients with MHSEMS was not different when compared to either those with FCSEMS (pZ0.19) or those with UCSEMS (pZ0.64). Stent occlusion rate in the FCSEMS group was lower than those in the UCSEMS group (15.9% vs. 46.4%; p<0.001). When compared MHSEMS with either FCSEMS (33.3% vs. 15.9%; pZ0.12) or UCSEMS (33.3% vs. 46.4%; pZ0.41), stent occlusion rate was not significantly different. In the FCSEMS group, stent migration occurred in 5.6%, whereas none was observed in the remaining two groups (pZ0.12). Median patient survival time was not different among the FCSEMS, UC-SEMS and MHSEMS groups (153.5 vs. 150 vs. 101 days; pZ0.44) Conclusions: Overall stent patency of MHSEMS is similar to that of FCSEMS and UCSEMS. The occlusion rate of MHSEMS and FCSEMS are not different while the migration rate of MHSEMS and UCSEMS are comparable.
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.
Metal stents: a bridge to surgery in hilar cholangiocarcinoma
HPB, 2013
Background: Obstructive jaundice in patients with hilar cholangiocarcinoma is a known risk factor for hepatic failure after liver resection. Plastic stents are most widely used for preoperative drainage. However, plastic stents are known to have limited patency time and therefore, in palliative settings, the self-expanding metal stent (SEMS) is used. This type of stent has been shown to be superior because it allows for rapid biliary decompression and a reduced complication rate after insertion. This study explores the use of the SEMS for biliary decompression in patients with operable hilar cholangiocarcinoma. Methods: A retrospective evaluation of a prospectively maintained database at a tertiary hepatobiliary referral centre was carried out. All patients with resectable cholangiocarcinoma were recorded. Results: Of 260 patients referred to this unit with cholangiocarcinoma between January 2008 and April 2012, 50 patients presented with operable cholangiocarcinoma and 27 of these had obstructive jaundice requiring stenting. Ten patients were initially treated with SEMSs; no stent failure occurred in these patients. Seventeen patients initially received plastic stents, seven of which failed in the interval between stent placement and laparotomy. These stents were replaced by SEMSs in four patients and by plastic stents in three patients. Median time to laparotomy was 45 days and 68 days in patients with SEMSs and plastic stents, respectively. Conclusions: Self-expanding metal stents provide adequate and rapid biliary drainage in patients with obstruction caused by hilar cholangiocarcinoma. No re-interventions were required. This probably reflects the relatively short interval between stent placement and laparotomy.
New technique for bilateral metal mesh stent insertion to treat hilar cholangiocarcinoma
Gastrointestinal Endoscopy, 1996
Placement of Wallstent expandable metal mesh stents (Schneider, Minneapolis, Minn.) in the biliary tree of patients with malignant biliary obstruction may result in increased duration of stent patency when compared with conventional polyethelene plastic stents. 1, 2 In cases involving Bismuth II and III lesions (which involve the proximal common hepatic duct and portions of the distal intrahepatic duct at the level of the hilum), bilateral Wallstent deployment can be technically problematic. 3 We present a novel method to endoscopically access and stent the left intrahepatic bile duct through a Wallstent previously placed in the right intrahepatic bile duct. A fenestration is created in the side of one Wallstent, allowing p l a c e m e n t of a second Wallstent into the contralateral i n t r a h e p a t i c biliary tree. This allows palliation of the left and the right i n t r a h e p a t i c ducts, without occlusion of either Wallstent.
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...
European Journal of Radiology, 2012
Purpose: Patients with advanced cholangiocarcinoma present with high rate of local complications. The primary aim of this study is to report clinical course of advanced cholangiocarcinoma patients those who were presented with biliary obstruction and treated with percutaneous biliary stenting. Material and methods: Patients with unresectable locally advanced or metastatic cholangiocarcinoma followed by our center for a period of 4 years were analyzed. For statistical analysis demographic and clinical characteristics of patients, primary biliary drainage method, metal stent occlusion rate, time to stent occlusion, and overall survival rates were recorded. Results: A total of 34 eligible patients were analyzed. 27 patients had metal stent placement. These 27 patients formed the basis of this study. Median overall survival (OS) was 6.0 months. After metal stent deployment bilurubin levels were normalized within a mean of 10 days. During the follow-up period, 13 patients were experienced metal stent occlusion. Median TtSO was 10 weeks. Cytotoxic chemotherapy was administered to 14 (52%) patients. Patients without stent dysfunction had significantly higher rate of chemotherapy exposure rate (p = 0.021). Statistical analysis, however, failed to exhibit significant effect of stent dysfunction on OS. Conclusion: In advanced cholangiocarcinoma, relief of bile duct obstruction is an important part of the initial patient management. This study therefore described the clinical value of percutaneous metal stent in cholangiocarcinoma patients and raises the question about patency of metal stent in cholangiocarcinoma whether we can expect success similar to the success achieved in pancreas carcinoma.
Factors associated with patency of self-expandable metal stents in malignant biliary obstruction
BMC Gastroenterology, 2023
Introduction Endoscopic self-expandable metal stent (SEMS) placement is the key endoscopic treatment for unresectable malignant biliary obstruction. The benefit of covered SEMS over uncovered SEMS remains unknown as are risk factors for SEMS dysfunction. This study aimed to determine the factors associated with patency of SEMS. Methods Patients with unresectable malignant biliary obstruction who underwent endoscopic SEMS placement at Ramathibodi Hospital, during January 2012 to March 2021 were included. Patient characteristics, clinical outcomes and patency of SEMS were collected. The primary outcome were stent patency and factors associated with patency of SEMS. The factors were analyzed by univariate and multivariate analyses. Median days of stent patency, median time of patient survival, rate of reintervention and complications after SEMS placement were collected. Results One hundred and fourteen patients were included. SEMS dysfunction was found in 37 patients (32.5%). Size of cancer (Hazard ratio (HR), 1.20, (95% CI 1.02, 1.40), p 0.025), presence of stones or sludge during SEMS placement (Hazard ratio (HR), 3.91, (95% CI 1.74, 8.75), p 0.001), length of SEMS, 8 cm (HR 2.96, (95% CI 1.06, 8.3), p 0.039), and total bilirubin level above 2 mg/dL at one month after SEMS placement (HR 1.14, (95% CI 1.06, 1.22), p < 0.001) were associated with SEMS dysfunction. The median stent patency was 97 days. The median patient survival was 133 days, (95% CI 75-165). The rate of reintervention was 86% in patients with SEMS dysfunction. Conclusion The size of cancer, presence of stones or sludge during SEMS placement, the length of SEMS, and total bilirubin level above 2 mg/dL at 1 month after SEMS placement were associated with SEMS dysfunction. The median time of stent patency were not statistically different in each type of stent, covered stent, partially covered stent and uncovered stent. Median survival time of patients did not associate with SEMS patency or dysfunction.
Journal of Gastroenterology, 2012
Background Although self-expandable metal stents (SEMS) are widely used for distal malignant biliary obstruction, one-step SEMS (direct placement without a prior plastic stent) and two-step SEMS (placement at second endoscopic retrograde cholangiopancreatography [ERCP] following plastic stent placement) have not been fully compared. Methods In this multicenter retrospective study, patients were included who underwent first-time endoscopic SEMS placement between September 1994 and December 2010. We compared the one-step and two-step strategies using a propensity analysis. Results In total, 370 patients were identified and one-step SEMS was performed in 59 patients. After adjustment using propensity scores, the median times to dysfunction were 116 and 219 days, respectively, for one-step and two-step SEMS (P = 0.058). Stent migration was more frequently observed in one-step SEMS as compared with two-step SEMS (25 vs. 11 %, P = 0.031). In one-step SEMS, the number of days of hospitalization associated with first-time SEMS placement was shorter compared with that in two-step SEMS (21 vs. 30 days, P = 0.001), and the total costs of SEMS-related interventions within 6 months were lower (6510 and 8100 USD, P = 0.004). The pathological diagnosis rates for pancreatic and biliary tract cancer at initial ERCP were 52 and 61 %. After failed diagnosis at initial ERCP, pathological diagnosis rates for pancreatic cancer were 32 versus 76 % (P = 0.005) by repeated ERCP versus endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). Conclusions One-step SEMS was associated with increased stent migration, despite having potential cost-effectiveness. The additional yield of pathological diagnosis at repeated ERCP was low compared with that yielded by EUS-guided FNA.
Endoscopy International Open, 2019
Background and aim To assess the rate of adverse events and the technical success rate of biliary stenting with or without EBS. Methods A literature search up to February 2017 was performed. Studies assessing adverse events (AEs) and technical success rates of stenting with or without EBS were considered. Results Seven studies (870 patients; 12 treatment arms) were included. Early AEs, i. e. those occurring within 30 days, were significantly lower in no-EBS vs. EBS-group (11 % vs. 20.1 %; OR: 0.36, 95 %CI: 0.13 – 1.00). Rates of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis were not significantly different in the two groups (no-EBS vs. EBS: 6.1 % vs 5 %; OR: 1.33, 95 %CI: 0.68 – 2.59). The rate of bleeding was significantly lower in patients without EBS (no-EBS vs EBS: 0 % vs 5 %; OR: 0.12, 95 % CI: 0.03 – 0.45). Rates of cholangitis were significantly lower in patients without EBS (no-EBS vs. EBS: 3.3 % vs. 7.4 %; OR: 0.38, 95 %CI: 0.17 – 0.83). Both late...