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Ohno A, Fujimori N, Kaku T, Shimokawa Y, Miyagahara T, Suehiro Y, Gerodias A, Kakehashi S, Matsumoto K, Murakami M, Ueda K, Ogawa Y. Feasibility of Endoscopic Ultrasound-Guided Hepaticogastrostomy for Malignant Hilar Biliary Obstruction. Dig Dis Sci 2025; 70:419-428. [PMID: 39342525 DOI: 10.1007/s10620-024-08652-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2024] [Accepted: 09/16/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Almost all previous reports on endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) involve malignant distal bile duct strictures. However, the feasibility of EUS-HGS for malignant hilar biliary obstruction (MHBO) remains unclear. AIMS This study aimed to evaluate the efficacy and safety of EUS-HGS for MHBO and identify the risk factors associated with technical failure. METHODS In this multicenter retrospective study, we reviewed consecutive patients who underwent EUS-HGS between April 2017 and March 2023 at five institutions. We assessed the overall feasibility and efficacy of EUS-HGS for MHBO, including the factors associated with technical failure, using multivariable logistic regression analysis. RESULTS A total of 85 patients were enrolled (mean age, 72 years; 36.4% female). Thirty-six patients (42.3%) had surgically altered anatomy, and 43 (50.6%) underwent biliary stenting by transpapillary or percutaneous biliary drainage before EUS-HGS. The rates of technical success, clinical success, and adverse events were 87.0% (74/85), 76.4% (65/85), and 11.8% (10/85), respectively. Multivariable analysis demonstrated that a bile duct diameter ≤ 4 mm was the only independent risk factor for technical failure (odds ratio, 6.12; 95% confidence interval, 1.02-36.6; P = 0.047). The most common reason for technical failure was cholangiography failure (45.4%), followed by inappropriate guidewire position (36.4%). CONCLUSIONS EUS-HGS is a challenging but promising treatment option for MHBO. Patients with a bile duct diameter ≤ 4 mm or inappropriate guidewire position should be careful as these factors can lead to the technical failure of EUS-HGS for MHBO.
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Affiliation(s)
- Akihisa Ohno
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
- Department of Gastroenterology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Nao Fujimori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Toyoma Kaku
- Department of Gastroenterology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Yuzo Shimokawa
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Fukuoka, Japan
- Department of Gastroenterology, Nakatsu Municipal Hospital, Nakatsu, Japan
| | - Tsukasa Miyagahara
- Department of Gastroenterology, National Hospital Organization Beppu Medical Center, Beppu, Japan
- Department of Gastroenterology, Nakatsu Municipal Hospital, Nakatsu, Japan
| | - Yuta Suehiro
- Department of Gastroenterology, Nakatsu Municipal Hospital, Nakatsu, Japan
| | - Anthony Gerodias
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
- Department of Medicine, Saint Luke's Medical Center, Institute of Digestive and Liver Diseases, Quezon City, Philippines
| | - Shotaro Kakehashi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Kazuhide Matsumoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Masatoshi Murakami
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Keijiro Ueda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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Okuno M, Iwata K, Mukai T, Ohashi Y, Iwata S, Iwasa Y, Yoshida K, Maruta A, Tezuka R, Ichikawa H, Mita N, Uemura S, Iwashita T, Tomita E, Shimizu M. The evaluation of bilateral stenting using braided or laser-cut self-expandable metallic stent for malignant hilar biliary obstruction. Surg Endosc 2023; 37:8489-8497. [PMID: 37759143 DOI: 10.1007/s00464-023-10457-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVES Bilateral self-expandable metallic stent (SEMS) placement for unresectable malignant hilar biliary obstruction (UMHBO) is an effective option for biliary drainage with long-term stent patency. Laser-cut and braided SEMS can be used for bilateral SEMS placement. This study aimed to clarify any differences in the clinical features and proper use of the laser-cut and braided SEMS placement using the stent-in-stent method for UMHBO. METHODS In this study, 78 patients who underwent bilateral stent-in-stent SEMS placement for UMHBO were included. The patients were divided into the laser-cut (n = 33) and braided groups (n = 45). Both groups were compared for technical and clinical success, adverse events (AEs), time to recurrent biliary obstruction (TRBO), overall survival, and endoscopic reintervention (ERI). RESULTS There were no significant differences in technical and clinical success rates (laser-cut vs. braided group, 97% vs. 95.6%, P = 1.0), AEs (21.2% vs. 15.6%. P = 0.56), median TRBO (242 days vs. 140 days, P = 0.36), and median overall survival (654 days vs. 675 days, P = 0.58). ERI was required in 15 patients in the laser-cut group and in 20 patients in the braided group. The technical and clinical success rates of ERI (60% vs. 85%) were not significantly different (P = 0.13); however, the median ERI procedure time was significantly longer in the laser-cut group (38 min) than in the braided group (22 min; P = 0.02). CONCLUSION No significant difference in initial SEMS placement was noted between the laser-cut and braided groups; however, the laser-cut group required a longer ERI procedure time than that required by the braided group. The use of braided SEMS may be a convenient option for ERI.
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Affiliation(s)
- Mitsuru Okuno
- Department of Gastroenterology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu City, Gifu, 500-8513, Japan.
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu City, Gifu, 500-8513, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu City, Gifu, 500-8513, Japan
- Department of Gastroenterological Endoscopy, Kanazawa Medical University, Kahoku, Ishikawa, Japan
| | - Yosuke Ohashi
- Department of Gastroenterology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu City, Gifu, 500-8513, Japan
| | - Shota Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu City, Gifu, 500-8513, Japan
| | - Yuhei Iwasa
- Department of Gastroenterology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu City, Gifu, 500-8513, Japan
| | - Kensaku Yoshida
- Department of Gastroenterology, Gifu Prefecture General Medical Center, Gifu City, Japan
| | - Akinori Maruta
- Department of Gastroenterology, Gifu Prefecture General Medical Center, Gifu City, Japan
| | - Ryuichi Tezuka
- First Department of Internal Medicine, Gifu University Hospital, Gifu City, Japan
| | - Hironao Ichikawa
- First Department of Internal Medicine, Gifu University Hospital, Gifu City, Japan
| | - Naoki Mita
- First Department of Internal Medicine, Gifu University Hospital, Gifu City, Japan
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, Gifu City, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu City, Japan
| | - Eiichi Tomita
- Department of Gastroenterology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu City, Gifu, 500-8513, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, Gifu City, Japan
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Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Ishizaki Y, Akatsuka H, Nakamura J, Takasumi M, Hashimoto M, Kato T, Kobashi R, Yanagita T, Marubashi S, Hikichi T, Ohira H. Efficacy of a novel large-cell Niti-S stent with a slim delivery system for hilar biliary obstruction: a preliminary study. Ann Med 2022; 54:953-961. [PMID: 35412414 PMCID: PMC9009962 DOI: 10.1080/07853890.2022.2056631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The large-cell Niti-S stent is useful for multiple stenting in patients with malignant hilar biliary obstruction (MHBO). Recently, a novel uncovered self-expandable metallic stent (USEMS) (a Niti-S large-cell SR slim delivery system) was developed. In this study, we aimed to evaluate the efficacy of this USEMS slim delivery system in MHBO patients. MATERIALS AND METHODS Outcomes related to USEMS placement, the clinical course, and the period to recurrent biliary obstruction (RBO) were evaluated in MHBO patients who received multiple USEMSs with the Niti-S large-cell SR slim delivery system. RESULTS Twenty-two MHBO patients underwent the placement of multiple USEMSs, including the novel slim-delivery stent. Six patients had a past history of upper gastrointestinal reconstruction (Billroth I: 1, Billroth II: 4, Roux-en-Y: 1). The number of USEMSs placed in each patient was 2-6. Three procedures were reinterventions. The new slim delivery system was placed as the first stent in ten patients and as an additional stent in the remaining patients. Seven patients were drained using only Niti-S large-cell SR slim delivery stents. The technical and clinical success rates were both 100%. CONCLUSIONS Placing multiple USEMSs in patients with a past history of abdominal surgery or in reintervention is difficult. Although difficult cases were included in this study, stent-in-stent placement with the novel Niti-S large-cell SR slim delivery system was useful in treating MHBO patients. In addition, this novel stent might be the first choice for MHBO patients.KEY MESSAGESEndoscopic multistenting for MHBO is challenging. In addition, reintervention or multistenting for MHBO patients with a past history of abdominal surgery becomes more difficult.The novel Niti-S large-cell SR slim delivery USEMS is useful as an additional stent because the delivery system is thin and suitable for a 0.025 guidewire. In addition, the novel stent is of the braided type and has a large mesh. Therefore, the novel stent is expected to have strong radial force and can be used as the first SEMS.The Niti-S large-cell SR slim delivery stent is long enough to be used in patients with upper gastrointestinal reconstruction. Although this study included patients with reintervention or a past history of upper gastrointestinal reconstruction, the technical success rate of multiple stenting for MHBO patients was 100%. The slim-delivery stent might overcome several difficulties of endoscopic multistenting.
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Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan.,Department of Gastroenterology, Saiseikai Fukushima General Hospital, Fukushima, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Rei Suzuki
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Naoki Konno
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan.,Department of Gastroenterology, Fukushima Red Cross Hospital, Fukushima, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan.,Department of Gastroenterology, Fukushima Red Cross Hospital, Fukushima, Japan
| | - Yuki Sato
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Hiroki Irie
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yuto Ishizaki
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan.,Department of Gastroenterology, Saiseikai Fukushima General Hospital, Fukushima, Japan
| | - Hidenobu Akatsuka
- Department of Gastroenterology, Saiseikai Fukushima General Hospital, Fukushima, Japan
| | - Jun Nakamura
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan.,Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Mika Takasumi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Minami Hashimoto
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan.,Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Tsunetaka Kato
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan.,Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Ryoichiro Kobashi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan.,Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Takumi Yanagita
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Shigeru Marubashi
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan
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Sekine M, Matsumoto K, Mashima H. Case of endoscopic bilateral stent-in-stent placement using long metallic stents for pancreatic cancer and plexus invasion. Dig Endosc 2022; 34:e60-e61. [PMID: 35243703 PMCID: PMC9314804 DOI: 10.1111/den.14246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 02/08/2023]
Abstract
Watch a video of this article.
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Affiliation(s)
- Masanari Sekine
- Department of GastroenterologyJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Keita Matsumoto
- Department of GastroenterologyJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Hirosato Mashima
- Department of GastroenterologyJichi Medical University Saitama Medical CenterSaitamaJapan
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Okamoto T. Malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer. World J Gastroenterol 2022; 28:985-1008. [PMID: 35431494 PMCID: PMC8968522 DOI: 10.3748/wjg.v28.i10.985] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/03/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Malignant biliary obstruction generally results from primary malignancies of the pancreatic head, bile duct, gallbladder, liver, and ampulla of Vater. Metastatic lesions from other primaries to these organs or nearby lymph nodes are rarer causes of biliary obstruction. The most common primaries include renal cancer, lung cancer, gastric cancer, colorectal cancer, breast cancer, lymphoma, and melanoma. They may be difficult to differentiate from primary hepato-pancreato-biliary cancer based on imaging studies, or even on biopsy. There is also no consensus on the optimal method of treatment, including the feasibility and effectiveness of endoscopic intervention or surgery. A thorough review of the literature on pancreato-biliary metastases and malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer is presented. The diagnostic modality and clinical characteristics may differ significantly depending on the type of primary cancer. Different primaries also cause malignant biliary obstruction in different ways, including direct invasion, pancreatic or biliary metastasis, hilar lymph node metastasis, liver metastasis, and peritoneal carcinomatosis. Metastasectomy may hold promise for some types of pancreato-biliary metastases. This review aims to elucidate the current knowledge in this area, which has received sparse attention in the past. The aging population, advances in diagnostic imaging, and improved treatment options may lead to an increase in these rare occurrences going forward.
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Affiliation(s)
- Takeshi Okamoto
- Department of Gastroenterology, St. Luke’s International Hospital, Chuo-ku 104-8560, Tokyo, Japan
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Noguchi Y, Sugimoto M, Kiko Y, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Nakamura J, Takasumi M, Hashimoto M, Kato T, Kobashi R, Hashimoto Y, Hikichi T, Ohira H. Hilar Malignant Biliary Obstruction Treated with Four Metallic Stents Involving a New Slim Device. Intern Med 2021; 60:1871-1876. [PMID: 33518571 PMCID: PMC8263184 DOI: 10.2169/internalmedicine.6356-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Endoscopic hilar multiple stenting is challenging. A 68-year-old patient had self-expandable metallic stents (SEMSs) inserted for unresectable hilar malignant biliary obstruction. After the SEMSs were inserted into the left hepatic duct and bile duct branch of segment (B) 6, a new SEMS with a wide mesh and slim delivery system was inserted into the right anterior hepatic duct. However, liver abscess and dilated B7 were observed on computed tomography; therefore, an additional new SEMS was quickly and easily inserted into B7. After the placement of these four SEMSs, the liver abscess improved. The new SEMS was effective for hilar multiple biliary drainage.
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Affiliation(s)
- Yuki Noguchi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Mitsuru Sugimoto
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Yuichiro Kiko
- Department of Diagnostic Pathology, School of Medicine, Fukushima Medical University, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Rei Suzuki
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Naoki Konno
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Yuki Sato
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Hiroki Irie
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Jun Nakamura
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Japan
| | - Mika Takasumi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Minami Hashimoto
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Japan
| | - Tsunetaka Kato
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Japan
| | - Ryoichiro Kobashi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Yuko Hashimoto
- Department of Diagnostic Pathology, School of Medicine, Fukushima Medical University, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
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Factors Associated with the Technical Success of Bilateral Endoscopic Metallic Stenting with Partial Stent-In-Stent Placement in Patients with Malignant Hilar Biliary Obstruction. Gastroenterol Res Pract 2019; 2019:5928040. [PMID: 31636662 PMCID: PMC6766084 DOI: 10.1155/2019/5928040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/22/2019] [Indexed: 12/31/2022] Open
Abstract
Background Bilateral biliary drainage decreases the risk of cholangitis, but bilateral endoscopic metallic stenting is technically challenging. Aim We retrospectively evaluated the factors associated with successful bilateral self-expanding metal stent (SEMS) placement using the partial stent-in-stent (PSIS) method for malignant hilar biliary obstruction and also assessed the safety and efficacy of this technique. Methods From April 2010 to February 2016, 47 consecutive patients (mean age, 73.0 ± 8.6 years; 32 males and 15 females) underwent PSIS placement for malignant hilar biliary obstruction in our hospital. The technical success of PSIS, clinical response, and complications were investigated. Factors associated with the technical success of PSIS were assessed. Using a propensity score-matched analysis, we compared the procedure time, clinical response, complications, stent patency, and survival time in 17 matched patients treated with bilateral SEMS placement using a SEMS delivery system of <6.0 or ≥6.0 Fr. Results The technical success rate was 77%. The clinical response rate was 91%, and the complication rate was 26%. Regarding complications, pancreatitis occurred in 5 patients (11%), cholangitis in 6 (13%), and cholecystitis in 1 (2%). A multiple logistic regression analysis identified the use of a SEMS with a delivery system < 6.0 Fr as a factor associated with technical success (P = 0.033; odds ratio, 10.769; 95% confidence interval, 1.205-96.212). In the 17 matched patients assigned according to the SEMS delivery system size, the procedure time was significantly shorter in those with a delivery system size < 6.0 Fr than in those with ≥6.0 Fr (P < 0.01). There were no significant differences in the clinical response, complication rate, stent patency, or survival time between the two groups. Conclusion Using a delivery system < 6.0 Fr in size helped improve the technical success and reduced the procedure time for the placement of a SEMS by the PSIS method.
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Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Watanabe K, Nakamura J, Kikuchi H, Waragai Y, Takasumi M, Sato Y, Hikichi T, Ohira H. Predictive factors for the failure of endoscopic stent-in-stent self-expandable metallic stent placement to treat malignant hilar biliary obstruction. World J Gastroenterol 2017; 23:6273-6280. [PMID: 28974893 PMCID: PMC5603493 DOI: 10.3748/wjg.v23.i34.6273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/04/2017] [Accepted: 08/08/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the factors predictive of failure when placing a second biliary self-expandable metallic stents (SEMSs).
METHODS This study evaluated 65 patients with an unresectable malignant hilar biliary obstruction who were examined in our hospital. Sixty-two of these patients were recruited to the study and divided into two groups: the success group, which consisted of patients in whom a stent-in-stent SEMS had been placed successfully, and the failure group, which consisted of patients in whom the stent-in-stent SEMS had not been placed successfully. We compared the characteristics of the patients, the stricture state of their biliary ducts, and the implemented endoscopic retrograde cholangiopancreatography (ERCP) procedures between the two groups.
RESULTS The angle between the target biliary duct stricture and the first implanted SEMS was significantly larger in the failure group than in the success group. There were significantly fewer wire or dilation devices (ERCP catheter, dilator, or balloon catheter) passing the first SEMS cell in the failure group than in the success group. The cut-off value of the angle predicting stent-in-stent SEMS placement failure was 49.7 degrees according to the ROC curve (sensitivity 91.7%, specificity 61.2%). Furthermore, the angle was significantly smaller in patients with wire or dilation devices passing the first SEMS cell than in patients without wire or dilation devices passing the first SEMS cell.
CONCLUSION A large angle was identified as a predictive factor for failure of stent-in-stent SEMS placement.
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Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Ko Watanabe
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Jun Nakamura
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Hitomi Kikuchi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Yuichi Waragai
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
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Park JM, Lee SH, Chung KH, Jang DK, Ryu JK, Kim YT, Lee JM, Paik WH. Endoscopic bilateral stent-in-stent placement for malignant hilar obstruction using a large cell type stent. Hepatobiliary Pancreat Dis Int 2016; 15:633-639. [PMID: 27919853 DOI: 10.1016/s1499-3872(16)60107-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Jin Myung Park
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Inoue T, Naitoh I, Okumura F, Ozeki T, Anbe K, Iwasaki H, Nishie H, Mizushima T, Sano H, Nakazawa T, Yoneda M, Joh T. Reintervention for stent occlusion after bilateral self-expandable metallic stent placement for malignant hilar biliary obstruction. Dig Endosc 2016; 28:731-737. [PMID: 27088888 DOI: 10.1111/den.12657] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/14/2016] [Accepted: 03/16/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Endoscopic reintervention for stent occlusions following bilateral self-expandable metallic stent (SEMS) placement for malignant hilar biliary obstruction (MHBO) is challenging, and time to recurrent biliary obstruction (RBO) of the revisionary stent remains unclear. We aimed to clarify a suitable reintervention method for stent occlusions following bilateral SEMS placement for MHBO. METHODS Between 2002 and 2014, 52 consecutive patients with MHBO who underwent endoscopic reintervention for stent occlusion after bilateral SEMS placement were enrolled at two university hospitals and one tertiary care referral center. We retrospectively evaluated the technical and functional success rates of the reinterventions, and the time to RBO of the revisionary stents. RESULTS Technical and functional success rates of the reinterventions were 92% (48/52) and 90% (43/48), respectively. Univariate analysis did not determine any significant predictive factors for technical and functional failures. Median time to RBO of the revisionary stents was 68 days. Median time to RBO was significantly longer for revisionary SEMS placement than for plastic stent placement (131 days vs 47 days, respectively; log-rank test, P = 0.005). Revisionary SEMS placement was the only independent factor that was significantly associated with a longer time to RBO of the revisionary stent in the multivariate Cox proportional hazards analysis (hazard ratio 0.37; 95% confidence interval 0.14-0.95; P = 0.039). CONCLUSION Revisionary SEMS placement is a suitable endoscopic reintervention method for stent occlusion following bilateral SEMS placement from the perspective of time to RBO of the revisionary stent.
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Affiliation(s)
- Tadahisa Inoue
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan.,Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Fumihiro Okumura
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takanori Ozeki
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Kaiki Anbe
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Hiroyasu Iwasaki
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Hirotada Nishie
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takashi Mizushima
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Hitoshi Sano
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takahiro Nakazawa
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masashi Yoneda
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Takashi Joh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Kawakubo K, Kawakami H, Kuwatani M, Haba S, Kudo T, Taya YA, Kawahata S, Kubota Y, Kubo K, Eto K, Ehira N, Yamato H, Onodera M, Sakamoto N. Lower incidence of complications in endoscopic nasobiliary drainage for hilar cholangiocarcinoma. World J Gastrointest Endosc 2016; 8:385-390. [PMID: 27170839 PMCID: PMC4861855 DOI: 10.4253/wjge.v8.i9.385] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/15/2016] [Accepted: 03/16/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma.
METHODS: In total, 118 patients with hilar cholangiocarcinoma underwent endoscopic management [endoscopic nasobiliary drainage (ENBD) or endoscopic biliary stenting] as a temporary drainage in our institution between 2009 and 2014. We retrospectively evaluated all complications from initial endoscopic drainage to surgery or palliative treatment. The risk factors for biliary reintervention, post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis, and percutaneous transhepatic biliary drainage (PTBD) were also analyzed using patient- and procedure-related characteristics. The risk factors for bilateral drainage were examined in a subgroup analysis of patients who underwent initial unilateral drainage.
RESULTS: In total, 137 complications were observed in 92 (78%) patients. Biliary reintervention was required in 83 (70%) patients. ENBD was significantly associated with a low risk of biliary reintervention [odds ratio (OR) = 0.26, 95%CI: 0.08-0.76, P = 0.012]. Post-ERCP pancreatitis was observed in 19 (16%) patients. An absence of endoscopic sphincterotomy was significantly associated with post-ERCP pancreatitis (OR = 3.46, 95%CI: 1.19-10.87, P = 0.023). PTBD was required in 16 (14%) patients, and Bismuth type III or IV cholangiocarcinoma was a significant risk factor (OR = 7.88, 95%CI: 1.33-155.0, P = 0.010). Of 102 patients with initial unilateral drainage, 49 (48%) required bilateral drainage. Endoscopic sphincterotomy (OR = 3.24, 95%CI: 1.27-8.78, P = 0.004) and Bismuth II, III, or IV cholangiocarcinoma (OR = 34.69, 95%CI: 4.88-736.7, P < 0.001) were significant risk factors for bilateral drainage.
CONCLUSION: The endoscopic management of hilar cholangiocarcinoma is challenging. ENBD should be selected as a temporary drainage method because of its low risk of complications.
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Naitoh I, Nakazawa T, Ban T, Okumura F, Hirano A, Takada H, Togawa S, Hayashi K, Miyabe K, Shimizu S, Kondo H, Nishi Y, Yoshida M, Yamashita H, Umemura S, Hori Y, Kato A, Sano H, Joh T. 8-mm versus 10-mm diameter self-expandable metallic stent in bilateral endoscopic stent-in-stent deployment for malignant hilar biliary obstruction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:396-401. [PMID: 25611012 DOI: 10.1002/jhbp.219] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 12/22/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND We aimed to clarify the clinical benefits of using 8-mm versus 10-mm diameter self-expandable metallic stent (SEMS) in bilateral endoscopic stent-in-stent (SIS) deployment for malignant hilar biliary obstruction (MHBO). METHODS A total of 72 consecutive patients with MHBO treated by endoscopic bilateral SIS deployment were enrolled. The 8-mm and 10-mm diameter SEMSs were used in 37 patients (8-mm group) and 35 patients (10-mm group), respectively. We retrospectively compared technical success, functional success, complications, successful re-intervention, time to recurrent biliary obstruction (RBO) and survival time between two groups. RESULTS There were no significant inter-group differences in terms of technical success (8-mm vs. 10-mm group, both 100%), functional success (96% vs. 100%), early (5% vs. 9%) and late (19% vs. 14%) complications other than RBO, and successful endoscopic re-intervention (94% vs. 100%), respectively. Time to RBO (median: 198 days vs. 222 days; log-rank, P = 0.440) and survival time (median: 186 days vs. 235 days; log-rank, P = 0.883) did not differ significantly between the two groups. However, the success rate of endoscopic bilateral revisionary stent insertion for RBO was significantly higher in the 10-mm compared to the 8-mm group (68% vs. 31%; P = 0.044). CONCLUSIONS The 10-mm diameter SEMS is more suitable with regard to endoscopic re-intervention.
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Affiliation(s)
- Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
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Kawakami H, Itoi T, Kuwatani M, Kawakubo K, Kubota Y, Sakamoto N. Technical tips and troubleshooting of endoscopic biliary drainage for unresectable malignant hilar biliary obstruction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:E12-21. [PMID: 25379788 DOI: 10.1002/jhbp.186] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Unresectable malignant hilar biliary obstruction (MHBO) occurs in various diseases, such as cholangiocarcinoma, gallbladder carcinoma, hepatocellular carcinoma, pancreatic cancer, and lymph node metastasis of the hilum of the liver. The majority of patients with advanced MHBO are not candidates for surgical resection because of the tumor location in the hepatic hilum and adjacent areas, advanced tumor stage, or comorbidities. Therefore, these patients often have a poor prognosis in terms of survival and quality of life. Most of these patients will require non-surgical, palliative biliary drainage. To date, various biliary drainage techniques for unresectable MHBO (UMHBO) have been reported. Of these techniques, endoscopic biliary drainage is currently considered to be the most safe and minimally invasive procedure. However, endoscopic biliary drainage for UMHBO is still not standardized regarding the optimal stent, drainage area, stenting method, and reintervention technique. Recently, towards standardization of this technique for UMHBO, clinical research and trials including randomized controlled trials have been performed. In this article, we reviewed the most important issues regarding endoscopic biliary drainage for UMHBO, focusing on prospective studies. We also described in detail the techniques and future perspectives of endoscopic biliary drainage in patients with UMHBO.
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Affiliation(s)
- Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Kita 14, Nishi 5, Kita-ku, Sapporo, 060-8648, Japan.
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