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Tejedor-Tejada J, Alvarez-Alvarez A, Olmos JM, González-Bernal AC, Jimenez-Jurado A, Robles-Gaitero S, Perez-Pariente JM. Secondary uncovered versus fully-covered metal stents for the management of occluded stent in unresectable distal malignant biliary obstruction. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:502218. [PMID: 38857753 DOI: 10.1016/j.gastrohep.2024.502218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Self-expandable metallic stents (SEMS) have been widely placed for unresectable distal malignant biliary obstruction (UDMBO). However, the dysfunction rate is 19-40% and its treatment is controversial. We aimed asses the efficacy and safety of a secondary biliary stents (uncovered (UC) versus fully-covered (FC) stent) for the management of occluded SEMS. PATIENTS AND METHODS Between 2015 and June 2023, 41 patients with UDMBO underwent secondary biliary stent placement as "stent-in-stent" (20 FCSEMS and 21 UCSEMS). The primary outcomes were technical and clinical success of SEMS placement. Secondary outcomes included adverse events (AEs), patency and survival. Patients were prospectively followed until death or loss of follow-up. RESULTS Technical (100% vs 85.5%) and clinical (100% vs 95.2%) success rates were similar in FCSEMS and UCSEMS groups. The median follow-up period was 510 days (range 290-630). The median duration of stent patency of FCSEMS (220 days, IQR 137.5-442.5) was longer than UCSEMS (150 days, IQR 110-362.5) (P=0.395), although stent dysfunction within 6 months was not different between groups. Multivariate analysis indicated that sex (HR=0.909, 0.852-0.970), antitumor treatment (HR=0.248, 0.032-0.441), stent patency (HR=0.992, 0.986-0.998) and clinical success (HR=0.133, 0.026-0.690) were significant factors for overall survival. There were no remarkable differences in AEs. CONCLUSIONS The placement of additional biliary stent using the stent-in-stent method is an effective and safe rescue treatment for patients with UDMBO and occluded stent. In addition, the use of FCSEMS compared UCSEMS has unclear benefits regarding stent patency and overall survival.
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Affiliation(s)
- Javier Tejedor-Tejada
- Department of Gastroenterology, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain.
| | | | - Jose Manuel Olmos
- Department of Gastroenterology, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
| | | | - Andrea Jimenez-Jurado
- Department of Gastroenterology, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
| | - Samuel Robles-Gaitero
- Department of Gastroenterology, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
| | - Jose M Perez-Pariente
- Department of Gastroenterology, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
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Miyazawa M, Takatori H, Okafuji H, Hayashi T, Toyama T, Yamada S, Kitamura K, Arai K, Sakai Y, Yamashita T, Yamashita T, Mizukoshi E, Honda M, Kaneko S. Efficacy of a novel self-expandable metal stent with dumbbell-shaped flare ends for distal biliary obstruction due to unresectable pancreatic cancer. Sci Rep 2022; 12:21100. [PMID: 36473910 PMCID: PMC9727129 DOI: 10.1038/s41598-022-25186-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
This study aimed to evaluate the efficacy of a novel fully covered self-expandable metal stent (SEMS) with dumbbell-shaped flare ends for the palliation of distal biliary obstruction (DBO) due to unresectable pancreatic cancer (UPC). Patients with DBO due to UPC who received the novel HILZO fully covered stent (HFS), the WALLFLEX partially covered stent (WPS) or fully covered stent (WFS) were analyzed. The incidence of recurrent biliary obstruction (RBO), time to RBO (TRBO), and the incidence of complications were compared among the three SEMS groups. Eighty-four patients (HFS, n = 36; WPS, n = 20; WFS, n = 28) were included. The incidence of RBO was low in the HFS group (versus the WPS and WFS group, p = 0.033 and 0.023, respectively). TRBO in the HFS group was longer than that in the WFS group (p = 0.049). Placement of the HFS was an independent factor for long TRBO in multivariable analysis (p = 0.040). The incidence of pancreatitis and cholecystitis in the HFS group was low (one for each). It is recommended to use the HFS for the palliation of DBO due to UPC from the viewpoint of the low incidence of RBO and complications.
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Affiliation(s)
- Masaki Miyazawa
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Hajime Takatori
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Hirofumi Okafuji
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Tomoyuki Hayashi
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Tadashi Toyama
- grid.9707.90000 0001 2308 3329Innovative Clinical Research Center, Kanazawa University, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Shinya Yamada
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Kazuya Kitamura
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Kuniaki Arai
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Yoshio Sakai
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Taro Yamashita
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Tatsuya Yamashita
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Eishiro Mizukoshi
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Masao Honda
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
| | - Shuichi Kaneko
- grid.412002.50000 0004 0615 9100Department of Gastroenterology, Kanazawa University Hospital, 13-1, Takara-Machi, Kanazawa City, Ishikawa Prefecture 920-8641 Japan
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Mohan BP, Canakis A, Khan SR, Chandan S, Ponnada S, McDonough S, Adler DG. Drug Eluting Versus Covered Metal Stents in Malignant Biliary Strictures-Is There a Clinical Benefit?: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2021; 55:271-277. [PMID: 32554989 DOI: 10.1097/mcg.0000000000001377] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/11/2020] [Indexed: 01/11/2023]
Abstract
GOALS/BACKGROUND Patients with malignant biliary obstruction (MBO) often require transpapillary stenting for symptomatic relief and biliary decompression. Plastic stents and uncovered metal stents are now replaced by covered self-expanding metal stents (SEMS). However, stent occlusion from tumor overgrowth and chronic inflammation continues to be an issue. Drug-eluting stents (DES), through an antitumor paclitaxel membrane, have been used to combat this problem. The aim of this study was to conduct a meta-analysis comparing DES to SEMS in MBO. STUDY Multiple databases were searched to identify studies that compared the clinical outcomes of SEMS and DES in patients with MBO. Random-effects model was used to calculate the pooled odds ratio and the pooled individual outcomes. Our primary goals were to assess the stent patency and overall survival in days. Secondary outcomes assessed the individual reported adverse events and/or complications. RESULTS Five studies including 348 patients (175 males and 173 females) were included. The pooled odds ratio of stent patency was 1.03 (95% confidence interval: 0.68-1.54, P=0.9) and overall survival was 1.16 (95% confidence interval: 0.63-2.11, P=0.6). The pooled rate of stent patency was 168.3 (95% 140.7-196.4) days for DES and 149.4 (117.6-181.2) days for SEMS. The pooled rate of overall survival was 267.2 (206.2-328.2) days for DES and 218.2 (148.5-287.8) days for SEMS. CONCLUSION On the basis of this meta-analysis, DES and SEMS seem to demonstrate comparable clinical outcomes in patients with malignant biliary strictures. Reported adverse events and/or complications were comparable as well.
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Affiliation(s)
- Babu P Mohan
- Department of Internal Medicine, Banner University Medical Center, University of Arizona, Tucson, AZ
| | - Andrew Canakis
- Department of Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Shahab R Khan
- Department of Gastroenterology, Rush University Medical Center, Chicago, IL
| | - Saurabh Chandan
- Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE
| | - Suresh Ponnada
- Department of Internal Medicine, Carilion Roanoke Memorial Hospital, Roanoke, VA
| | - Stephanie McDonough
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT
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Elshimi E, Morad W, Elshaarawy O, Attia A. Optimization of biliary drainage in inoperable distal malignant strictures. World J Gastrointest Endosc 2020; 12:285-296. [PMID: 32994859 PMCID: PMC7503617 DOI: 10.4253/wjge.v12.i9.285] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/03/2020] [Accepted: 07/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Given most patients with distal malignant biliary obstruction present in the non-resectable stage, palliative endoscopic biliary drainage with fully covered metal stent (FCMS) or uncovered metal stent (UCMS) is the only available measure to improve patients’ quality of life. Half covered metal stent (HCMS) has been recently introduced commercially. The adverse effects and stent function between FCMS and UCMS have been extensively discussed.
AIM To study the duration of stent patency of HCMS and compare it with FCMS and UCMS to optimize biliary drainage in inoperable patients with distal malignant obstruction. Secondary aims in our study included evaluation of patients’ survival and the rates of adverse events for each type of stent.
METHODS We studied 210 patients and randomized them into three equal groups; HCMS, FCMS and UCMS were inserted endoscopically.
RESULTS Stent occlusion occurred in (18.6%, 17.1% and 15.7% in HCMS, FCMS and UCMS groups, respectively, P = 0.9). Stent migration occurred only in patients with FCMS (8.6% of patients). Cholangitis and cholecystitis occurred in 11.4% and 5.7% of patients, respectively, in FCMS. Tumor growth occurred only in 10 cases among patients with UCMS after a median of 140 d, sludge occurred in nine, seven and one patients in HCMS, FCMS and UCMS, respectively (P = 0.04).
CONCLUSION Given the prolonged stent functioning time, the use of HCMS is preferred over the use of UCMS and FCMS for optimizing biliary drainage in patients with distal malignant biliary obstruction.
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Affiliation(s)
- Esam Elshimi
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebine Elkom 32111, Egypt
| | - Wesam Morad
- Department of Epidemiology and Preventive Medicine, National Liver Institute, Menoufia University, Shebine Elkom 32111, Egypt
| | - Omar Elshaarawy
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebine Elkom 32111, Egypt
| | - Ahmed Attia
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebine Elkom 32111, Egypt
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Conio M, Mangiavillano B, Caruso A, Filiberti RA, Baron TH, De Luca L, Signorelli S, Crespi M, Marini M, Ravelli P, Conigliaro R, De Ceglie A. Covered versus uncovered self-expandable metal stent for palliation of primary malignant extrahepatic biliary strictures: a randomized multicenter study. Gastrointest Endosc 2018; 88:283-291.e3. [PMID: 29653120 DOI: 10.1016/j.gie.2018.03.029] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 03/30/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Self-expandable metal stents (SEMSs) are used to relieve malignant biliary obstructions. We aimed to compare stent patency, the adverse events rate, and overall survival of covered versus uncovered self-conformable metal stents in patients with primary malignant extrahepatic biliary strictures, not eligible for surgery. METHODS This is a multicenter randomized trial analyzing 158 patients with inoperable distal malignant biliary obstruction conducted in 5 Italian referral centers between December 2014 and October 2016. Seventy-eight patients were randomized to receive a fully covered SEMS (FCSEMS), and 80 patients received uncovered SEMSs (USEMSs). Data from 148 (72 FCSEMSs and 76 USEMSs) of 158 patients were analyzed. RESULTS Median time of stent patency was lower for FCSEMSs (240 days vs 541 days for USEMSs; P = .031). Adverse events occurred with 19 FCSEMSs (26.4%) and 10 USEMSs (13.2%); P = .061. The main causes of FCSEMS dysfunction were migration (7% vs 0% in the USEMS group) and early occlusion mainly because of sludge or overgrowth; late stent occlusion because of tumor ingrowth occurred in 13.2% of patients in the USEMS group. There were no significant differences either in levels of conjugated bilirubin improvement or in overall survival between the FCSEMS and USEMS groups. Median survival was 134 days in the FCSEMS group and 112 days in the USEMS group (P = .23). CONCLUSION The number of stent-related adverse events was higher, although not significantly, among patients in the FCSEMS group. FCSEMSs had a significantly higher rate of migration than USEMSs, and stent occlusion occurred earlier. A significant difference in the patency rate was observed in favor of the USEMS group. (Clinical trial registration number: NCT02102984.).
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Affiliation(s)
- Massimo Conio
- Gastroenterology Department, General Hospital, Sanremo (IM)
| | | | - Angelo Caruso
- Gastroenterology and Digestive Endoscopy Department, Azienda Ospedaliera Universitaria di Modena, Sant'Agostino Estense Hospital, Baggiovara (MO)
| | | | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Luca De Luca
- Gastroenterology and Digestive Endoscopy Unit, Ospedali Riuniti Marche Nord, Pesaro
| | - Sergio Signorelli
- Gastroenterology and Gastrointestinal Endoscopy Unit, ASST, Papa Giovanni XXIII, Bergamo, Italy
| | - Mattia Crespi
- Gastroenterology Department, General Hospital, Sanremo (IM)
| | - Mario Marini
- Gastroenterology and Operative Endoscopy Unit, Santa Maria Alle Scotte Hospital, Siena, Italy
| | - Paolo Ravelli
- Gastroenterology and Gastrointestinal Endoscopy Unit, ASST, Papa Giovanni XXIII, Bergamo, Italy
| | - Rita Conigliaro
- Gastroenterology and Digestive Endoscopy Department, Azienda Ospedaliera Universitaria di Modena, Sant'Agostino Estense Hospital, Baggiovara (MO)
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Olsson G, Frozanpor F, Lundell L, Enochsson L, Ansorge C, Del Chiaro M, Reuterwall-Hansson M, Shetye A, Arnelo U. Preoperative biliary drainage by plastic or self-expandable metal stents in patients with periampullary tumors: results of a randomized clinical study. Endosc Int Open 2017; 5:E798-E808. [PMID: 28879225 PMCID: PMC5585071 DOI: 10.1055/s-0043-110565] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/15/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Preoperative biliary drainage in patients with periampullary tumors and jaundice has been popularized to improve the quality of life and minimize the risks associated with subsequent radical surgery. The aim of this study was to investigate the possible superiority of self-expandable metal stents (SEMS) over plastic stents, by comparing the amount of bacteria in intraoperatively collected bile and using this variable as a proxy for the efficacy of the respective biliary drainage modalities. PATIENTS AND METHODS In this randomized clinical trial, 92 patients with obstructive jaundice were enrolled; 45 were allocated to the plastic stent group and 47 to the SEMS group. The primary outcome was the extent and magnitude of biliary bacterial growth at the time of surgical exploration. Secondary outcomes were: macroscopic grading of inflammation of the stented bile ducts, occurrence of adverse events after stenting, stent dysfunction, recognized surgical complexities, and incidence of postoperative complications. RESULTS The patients were well matched regarding clinical and disease-specific characteristics. At surgery, there were no group differences in the bacterial amount and composition of the bile cultures or the perceived difficulty of surgical dissection. During the preoperative biliary drainage period, more instances of stent dysfunction requiring stent replacement were recorded in the plastic stent group (19 % vs. 0 %; P = 0.03). Postoperative complications in patients who underwent curative surgery were more common in patients with plastic stents (72 % vs. 52 %), among which clinically significant leakage from the pancreatic anastomoses seemed to predominate (12 % vs. 3.7 %); however, none of these differences in postoperative adverse events reached statistical significance. CONCLUSION This randomized clinical study was unable to demonstrate any superiority of SEMS in the efficacy of preoperative bile drainage, as assessed by the amount of bacteria in the intraoperatively collected bile. However, some data in favor of SEMS were observed among the clinical secondary outcomes variables (preoperative stent exchange rates) without increases in local inflammatory reactions.
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Affiliation(s)
- Greger Olsson
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden,Department of Surgery, Highland Hospital, Eksjö, Sweden,Corresponding author Greger Olsson, MD Department of SurgeryHighland HospitalSE-575 81 EksjöSweden
| | | | - Lars Lundell
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Lars Enochsson
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Christoph Ansorge
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Marco Del Chiaro
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Marcus Reuterwall-Hansson
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Alysha Shetye
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Urban Arnelo
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden,Urban Arnelo, MD PhD Center for Digestive Diseases, K53Karolinska University HospitalSE-141 86 StockholmSweden
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Shah T, Desai S, Haque M, Dakik H, Fisher D. Management of occluded metal stents in malignant biliary obstruction: similar outcomes with second metal stents compared to plastic stents. Dig Dis Sci 2012; 57:2765-73. [PMID: 22732833 PMCID: PMC3920578 DOI: 10.1007/s10620-012-2272-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 06/01/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND Covered or uncovered self expandable metallic stents (SEMS) placed in patients with malignant biliary obstruction can occlude in 19-40 %, but optimal management is unclear. AIM We sought to summarize current evidence regarding management of occluded SEMS in patients with malignant biliary obstruction. METHODS Two investigators independently searched Pubmed, Embase, and Web of Science using pre-defined search criteria, and reviewed bibliographies of included studies. Data were independently abstracted by two investigators, and analyzed using RevMan. We compared strategies of second SEMS versus plastic stents with respect to the following outcomes: rate of second stent re-occlusion, duration of second stent patency, and survival. RESULTS Ten retrospective studies met inclusion criteria for the systematic review. Management options described were placement of an uncovered SEMS (n = 125), covered SEMS (n = 106), plastic stent (n = 135), percutaneous biliary drain (n = 7), mechanical cleaning (n = 18), or microwave coagulation (n = 7). Relative risk of re-occlusion was not significantly different in patients with second SEMS compared to plastic stents (RR 1.24, 95 % CI 0.92, 1.67, I(2) = 0, p 0.16). Duration of second stent patency was not significantly different between patients who received second SEMS versus plastic stents (weighted mean difference 0.46, 95 % CI -0.30, 1.23, I(2) = 83 %). Survival was not significantly different among patients who received plastic stents versus SEMS (weighted mean difference -1.13, 95 % CI -2.33, 0.07, I(2) 86 %, p = 0.07). CONCLUSIONS Among patients with malignant biliary obstruction and occluded SEMS, available evidence suggests a strategy of placing a plastic stent may be as effective as second SEMS. Limitations of these findings were that all studies were retrospective and heterogeneity between studies was detected for two of the outcomes.
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Affiliation(s)
- Tilak Shah
- Division of Gastroenterology, Duke University Medical Center, Box 3913, Durham, NC 27710, USA.
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Pola S, Muralimohan R, Cohen B, Fehmi SMA, Savides TJ. Long-term risk of cholangitis in patients with metal stents for malignant biliary obstruction. Dig Dis Sci 2012; 57:2693-6. [PMID: 22543845 DOI: 10.1007/s10620-012-2204-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 04/14/2012] [Indexed: 12/09/2022]
Abstract
BACKGROUND Patients with malignant biliary obstruction are commonly living longer than previously due to improved oncologic therapies, often exceeding expected times of self-expanding metal stent patency. AIMS The purpose of this study was to assess the long-term risk and impact of cholangitis in these patients. METHODS Retrospective review of electronic medical records at an academic medical center. RESULTS One hundred and one patients had a self-expanding metal stent placed for malignant biliary obstruction. The median survival after SEMS was 214 days. Of these patients, 22 % developed at least one episode of cholangitis requiring inpatient admission, 20 % (9/45) of patients were hospitalized for cholangitis at 6 months, 40 % (8/20) at 1 year, and 75 % (3/4) at 2 years. All of the (8/8) patients receiving chemotherapy prior to hospitalization for cholangitis experienced delays in subsequent chemotherapy. Follow-up of 36 episodes of cholangitis revealed a 14 % 30-day mortality. CONCLUSIONS Cholangitis develops commonly in long-term survivors with self-expanding metal stents for malignant biliary obstruction, and is associated with delays in chemotherapy and a 14 % 30-day mortality.
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Affiliation(s)
- Suresh Pola
- Division of Gastroenterology, UC San Diego Health System, 9500 Gilman Drive MC 0063, San Diego, CA 92093-0063, USA.
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Luigiano C, Ferrara F, Cennamo V, Fabbri C, Bassi M, Ghersi S, Consolo P, Morace C, Polifemo AM, Billi P, Ceroni L, Alibrandi A, D'Imperio N. A comparison of uncovered metal stents for the palliation of patients with malignant biliary obstruction: nitinol vs. stainless steel. Dig Liver Dis 2012; 44:128-33. [PMID: 21924691 DOI: 10.1016/j.dld.2011.08.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 08/04/2011] [Accepted: 08/14/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Various types of self-expandable metal stents have been introduced for the palliation of malignant biliary obstruction. AIMS To compare the outcomes of WallFlex™ and Wallstent™ uncovered biliary self-expandable metal stents (SEMSs) for the palliation of patients with malignant biliary obstruction. METHODS Between October 2008 and December 2009, all SEMSs placed for malignant biliary obstruction were WallFlex™: all patients palliated were included in the study. Before October 2008, all the SEMSs placed for malignant biliary obstruction were Wallstent™, and the patients palliated from July 2007 to September 2008 were the comparative group. RESULTS A total of 58 WallFlex™ and 54 Wallstent™ SEMSs were placed, and efficacious biliary decompression was achieved in all patients. Early complications occurred in 5 patients in the WallFlex™ group and in 3 in the Wallstent™ group (p=ns). Late complications occurred in 6 patients in the WallFlex™ group and in 16 in the Wallstent™ group (p<0.01). The overall patency of the self-expandable metal stent in the WallFlex™ and the Wallstent™ groups was similar (227 days vs. 215 days, p=ns). Mean patient survival was 242 days in the WallFlex™ group and 257 days in the Wallstent™ group (p=ns). CONCLUSIONS We found no difference in terms of overall patency between the two types of SEMSs, but there was an increased rate of late adverse events in the Wallstent™ group.
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Affiliation(s)
- Carmelo Luigiano
- Unit of Gastroenterology and Digestive Endoscopy, AUSL Bologna Bellaria-Maggiore Hospital, Bologna, Italy.
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Sequential or simultaneous placement of self-expandable metallic stents for palliation of malignant biliary and duodenal obstruction due to unresectable pancreatic head carcinoma. Surg Laparosc Endosc Percutan Tech 2011; 20:410-5. [PMID: 21150420 DOI: 10.1097/sle.0b013e3182001f26] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pancreatic cancer is generally not amenable to curative resection, and self-expanding metallic stents have been used to relieve obstruction of bile duct and duodenum in patients with unresectable pancreatic cancer. However, both relative experience with sequential or simultaneous endoscopic stents placement in biliary and duodenal stricture and long-term efficacy of these stents are limited. The aim of this study was to present our experience on the effectiveness of this form of endoscopic treatment. PATIENTS AND METHODS We performed a retrospective review of all patients undergoing sequential or simultaneous biliary and duodenal stent placement for biliary and symptomatic duodenal obstruction due to unresectable pancreatic head carcinomas in 4 tertiary endoscopic centers. Data were collected from endoscopy and outpatient clinic reports, x-rays, and telephone calls. All patients were followed until their death. Endpoints included technical and clinical success, stent long-term patency, and survival. RESULTS Thirty-nine patients with unresectable pancreatic head cancer were included. Biliary or duodenal stenting was unsuccessful in 7 patients (17.9%). The remaining 32 patients (median age: 77 y; range: 52 to 82 y), with locally advanced (n=21) or metastatic disease (n=11), were studied. Twenty-one patients (65.6%) received at least first-line chemotherapy. Overall median survival was 9 months (range: 2 to 22 mo), being higher in locally advanced (median survival: 11.5 mo, range: 4 to 22 mo) than metastatic disease (median survival: 3 mo, range: 2 to 5.5 mo) (P<0.001). Median duodenal and biliary patency was 3 months (range: 1 to 12 mo) and 9 months (range: 2 to 22 mo), respectively (P<0.05). Nine of 32 patients (28.1%) required reintervention for recurrent symptoms. No major complications or death occurred in relation to endoscopic treatment. CONCLUSIONS Placement of self-expandable metal stents is a safe and efficacious palliation method for biliary and duodenal obstruction due to unresectable pancreatic head carcinoma. The majority of patients do not require reintervention and those who require can usually be managed nonoperatively.
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Kullman E, Frozanpor F, Söderlund C, Linder S, Sandström P, Lindhoff-Larsson A, Toth E, Lindell G, Jonas E, Freedman J, Ljungman M, Rudberg C, Ohlin B, Zacharias R, Leijonmarck CE, Teder K, Ringman A, Persson G, Gözen M, Eriksson O. Covered versus uncovered self-expandable nitinol stents in the palliative treatment of malignant distal biliary obstruction: results from a randomized, multicenter study. Gastrointest Endosc 2010; 72:915-23. [PMID: 21034892 DOI: 10.1016/j.gie.2010.07.036] [Citation(s) in RCA: 216] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 07/24/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Covered biliary metal stents have been developed to prevent tumor ingrowth. Previous comparative studies are limited and often include few patients. OBJECTIVE To compare differences in stent patency, patient survival, and complication rates between covered and uncovered nitinol stents in patients with malignant biliary obstruction. DESIGN Randomized, multicenter trial conducted between January 2006 and October 2008. SETTING Ten sites serving a total catchment area of approximately 2.8 million inhabitants. PATIENTS A total of 400 patients with unresectable distal malignant biliary obstruction. INTERVENTIONS ERCP with insertion of covered or uncovered metal stent. Follow-up conducted monthly for symptoms indicating stent obstruction. MAIN OUTCOME MEASUREMENTS Time to stent failure, survival time, and complication rate. RESULTS The patient survival times were 116 days (interquartile range 242 days) and 174 days (interquartile range 284 days) in the covered and uncovered stent groups, respectively (P = .320). The first quartile stent patency time was 154 days in the covered stent group and 199 days in the uncovered stent group (P = .326). There was no difference in the incidence of pancreatitis or cholecystitis between the 2 groups. Stent migration occurred in 6 patients (3%) in the covered group and in no patients in the uncovered group (P = .030). LIMITATIONS Randomization was not blinded. CONCLUSIONS There were no significant differences in stent patency time, patient survival time, or complication rates between covered and uncovered nitinol metal stents in the palliative treatment of malignant distal biliary obstruction. However, covered stents migrated significantly more often compared with uncovered stents, and tumor ingrowth was more frequent in uncovered stents.
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Loew BJ, Howell DA, Sanders MK, Desilets DJ, Kortan PP, May GR, Shah RJ, Chen YK, Parsons WG, Hawes RH, Cotton PB, Slivka AA, Ahmad J, Lehman GA, Sherman S, Neuhaus H, Schumacher BM. Comparative performance of uncoated, self-expanding metal biliary stents of different designs in 2 diameters: final results of an international multicenter, randomized, controlled trial. Gastrointest Endosc 2009; 70:445-53. [PMID: 19482279 DOI: 10.1016/j.gie.2008.11.018] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Accepted: 11/05/2008] [Indexed: 12/17/2022]
Abstract
BACKGROUND The Wallstent has remained the industry standard for biliary self-expanding metal stents (SEMSs). Recently, stents of differing designs, compositions, and diameters have been developed. OBJECTIVE To compare the new nitinol 6-mm and 10-mm Zilver stents with the 10-mm stainless steel Wallstent and determine the mechanism of obstruction. DESIGN Randomized, prospective, controlled study. SETTING Nine centers experienced in SEMS placement during ERCP. PATIENTS A total of 241 patients presenting between September 2003 and December 2005 with unresectable malignant biliary strictures at least 2 cm distal to the bifurcation. MAIN OUTCOME MEASUREMENT Stent occlusions requiring reintervention and death. RESULTS At interim analysis, a significant increase in occlusions was noted in the 6-mm Zilver group at the P = .04 level, resulting in arm closure but continued follow-up. Final study arms were 64, 88, and 89 patients receiving a 6-mm Zilver, 10-mm Zilver, and 10-mm Wallstent, respectively. Stent occlusions occurred in 25 (39.1%) of the patients in the 6-mm Zilver arm, 21 (23.9%) of the patients in the 10-mm Zilver arm, and 19 (21.4%) of the patients in the 10-mm Wallstent arm (P = .02). The mean number of days of stent patency were 142.9, 185.8, and 186.7, respectively (P = .057). No differences were noted in secondary endpoints, and the study was ended at the 95% censored study endpoints. Biopsy specimens of ingrowth occlusive tissue revealed that 56% were caused by benign epithelial hyperplasia. CONCLUSIONS SEMS occlusions were much more frequent with a 6-mm diameter SEMS and equivalent in the two 10-mm arms despite major differences in stent design, material, and expansion, suggesting that diameter is the critical feature. Malignant tumor ingrowth produced only a minority of the documented occlusions.
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Avaliani M, Chigogidze N, Nechipai A, Dolgushin B. Magnetic compression biliary-enteric anastomosis for palliation of obstructive jaundice: initial clinical results. J Vasc Interv Radiol 2009; 20:614-23. [PMID: 19393505 DOI: 10.1016/j.jvir.2009.01.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2008] [Revised: 12/08/2008] [Accepted: 01/07/2009] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To report initial clinical experience with a nonsurgical method for sutureless biliary-enteric anastomosis with use of two magnetic elements that potentially overcomes the disadvantages of other palliative methods. MATERIALS AND METHODS The technique involves percutaneous transhepatic insertion of one magnet into the bile duct under fluoroscopic guidance and insertion of a second magnet endoscopically into the duodenum. The adherence of the two magnets creates ischemic necrosis of bile duct and duodenal walls. When these tissues slough, the resulting hole allows enteric passage of the magnets and creates a biliary-enteric fistula for decompression of an obstructed biliary system. A magnetic compression biliary-enteric anastomosis (MCBEA) was created in 34 patients (nine men; mean age, 64 years; age range, 46-82 y) with malignant obstructive jaundice at the level of the middle or distal common bile duct. RESULTS There was no recurrent jaundice during the initial 30 postprocedural days. Total bilirubin levels decreased significantly in all patients 1 week after MCBEA formation (P < .0001), with normalization of bilirubin levels in eight of 34 patients. There was temporary occlusion caused by partial clogging of the bypass with coarse food in two cases, which was successfully revised endoscopically. Three patients required surgical revision as a result of tumor ingrowth. Median survival time was 10 months. The cause of death in all patients was progression of underlying malignancy. CONCLUSIONS Creation of a biliary-enteric anastomosis with magnetic compression is a feasible alternative for palliative treatment of obstructive jaundice with satisfactory results.
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Affiliation(s)
- Michael Avaliani
- Blokhin Russian Oncology Research Center, Russian Research Centre of Surgery, Moscow, Russia
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15
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Abstract
BACKGROUND Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction. Various types of self-expanding metal stents have been introduced in the market. Whether one type of stents is superior to the others in terms of stent patency remains undefined. GOALS This randomized trial compared 2 uncovered metal stents with similar technical characteristics, but significant cost difference, in the palliation of inoperable malignant biliary strictures. STUDY Ninety-two patients with inoperable biliary obstruction were randomized to receive either a 10-mm diameter Hanaro or Luminex uncovered metal stent. The duration of stent patency, the overall patient survival, the mechanism of stent occlusion, and the adverse events were analyzed. RESULTS Eighty-nine patients were included in the analysis; 44 received Hanaro stents and 45 Luminex stents. The overall median patency rates between the 2 stents did not differ (328 d for the Hanaro vs. 289 d for the Luminex stent; P=0.815). Similarly, no difference was found between the overall median survival rates by the 2 stents (347 d for the Hanaro vs. 307 d for the Luminex stent; P=0.654). Two major procedure-related complications occurred, perforation (Hanaro stent) and proximal stent migration (Luminex stent). Stent occlusion requiring reintervention occurred in 25 patients (11 with the Hanaro vs. 14 with the Luminex stent; P=0.521). CONCLUSIONS The 2 uncovered metal stents are comparable in terms of placement, occlusion rates, overall stent patency, and patient survival; Hanaro stent insertion, however, seems to be a cost-saving strategy at least in Greece.
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Cipolletta L, Rotondano G, Marmo R, Bianco MA. Endoscopic palliation of malignant obstructive jaundice: an evidence-based review. Dig Liver Dis 2007; 39:375-88. [PMID: 17317347 DOI: 10.1016/j.dld.2006.12.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Revised: 11/14/2006] [Accepted: 12/14/2006] [Indexed: 12/11/2022]
Abstract
Endoscopic stent insertion is considered the method of choice for palliative treatment of malignant biliary obstruction. Nonetheless, relevant studies are often underpowered or outdated and do not compare actual surgical outcomes with latest stent technology. Purpose of this review was to assess, with an evidence-based methodology, the role of endoscopic versus surgical palliation of patients with malignant obstructive jaundice with special reference to clinical effectiveness, safety aspects and economic outcomes.
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Affiliation(s)
- L Cipolletta
- Department of Gastroenterology and Digestive Endoscopy, Hospital Maresca, Torre del Greco, Naples, Italy
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Maire F, Hammel P, Ponsot P, Aubert A, O'Toole D, Hentic O, Levy P, Ruszniewski P. Long-term outcome of biliary and duodenal stents in palliative treatment of patients with unresectable adenocarcinoma of the head of pancreas. Am J Gastroenterol 2006; 101:735-42. [PMID: 16635221 DOI: 10.1111/j.1572-0241.2006.00559.x] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Life expectancy in patients with unresectable pancreatic cancer has improved by using new chemotherapeutic regimens. Biliary and digestive stenoses can be endoscopically treated in most cases. However, long-term efficacy of these stenting procedures remains unknown. AIM To evaluate the incidence of biliary and duodenal stenoses as well as technical success and short- and long-term patency of endoscopically deployed stents in patients with unresectable pancreatic cancer. PATIENTS AND METHODS All consecutive patients with unresectable cancer of the pancreatic head seen between January 1999 and September 2003 in our center were retrospectively studied. Patients with biliary and/or duodenal stenoses underwent endoscopic stent insertion as first intention therapy. Outcomes included technical and clinical success, stent patency, and survival. RESULTS One hundred patients, median age 65 yr (32-85), with locally advanced (62%) or metastatic (38%) pancreatic cancer were studied. Eighty-three percent received at least one line of chemotherapy. The actuarial median survival was 11 months (0.7-29.3). Biliary and duodenal stenoses occurred in 81 and 25 patients, respectively. A biliary stent was successfully placed in 74 patients (91%). When a self-expandable metallic stent was first introduced (N = 59), a single stent was sufficient in 41 patients (69%) (median duration of stent patency 7 months (0.4-21.1)). Duodenal stenting was successful in 24 patients (96%); among them, 96% required a single stent (median duration of stent patency 6 months [0.5-15.7]). In the 23 patients who developed both biliary and duodenal stenoses, combined stenting was successful in 91% of cases. No major complication or death occurred related to endoscopic treatment. CONCLUSION Endoscopic palliative treatment of both biliary and duodenal stenoses is safe and effective in the long term, including in patients with combined obstructions. Use of such palliative management is justified as repeat procedures are rarely required even in patients who have a long survival.
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Affiliation(s)
- Frédérique Maire
- Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
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Chen VK, Arguedas MR, Baron TH. Expandable metal biliary stents before pancreaticoduodenectomy for pancreatic cancer: a Monte-Carlo decision analysis. Clin Gastroenterol Hepatol 2005; 3:1229-37. [PMID: 16361049 DOI: 10.1016/s1542-3565(05)00886-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic placement of plastic or self-expandable metal biliary stents (SEMS) relieves obstructive jaundice from pancreatic cancer. Short-length, distally placed SEMS do not preclude subsequent pancreaticoduodenectomy. We sought to determine whether SEMS placement in patients whose surgical status is uncertain is cost-effective for management of obstructive jaundice. METHODS A Markov model was constructed to evaluate costs and outcomes associated with endoscopic biliary stenting for obstructive jaundice. Strategies evaluated were: (1) initial plastic stent with plastic stents for subsequent occlusions in nonsurgical candidates after staging (plastic followed-up by [f/u] plastic), (2) initial plastic with subsequent SEMS (plastic f/u metal), (3) initial short-length SEMS with subsequent plastic (metal f/u plastic), and (4) initial short-length SEMS with subsequent expandable metal stent (metal f/u metal). Published stent occlusion rates, ERCP complication rates and outcomes, cholangitis rates and outcomes, pancreatic cancer mortality rates, and Whipple complication rates were used. Costs were based on 2004 Medicare standard allowable charges and were accrued until all patients reached an absorbing health state (death or pancreaticoduodenectomy) or 24 cycles (24 mo) ended. RESULTS Average costs per patient from Monte Carlo simulation were: (1) metal f/u metal, $19,935; (2) plastic f/u metal, 20,157 dollars; (3) metal f/u plastic, 20,871 dollars; and (4) plastic f/u plastic, 20,878 dollars. For initial plastic stents to be preferred over short-length metal stents, 70% or more of pancreatic cancers would need to be potentially resectable by pancreaticoduodenectomy. CONCLUSIONS In patients undergoing ERCP before definitive cancer staging, short-length SEMS is the preferred initial cost-minimizing strategy.
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Affiliation(s)
- Victor K Chen
- Department of Medicine, Division of Gastroenterology and Hepatology, the University of Alabama at Birmingham, Birmingham, Alabama, USA
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19
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Hammarström LE. Endobiliary stents for palliation in patients with malignant obstructive jaundice. J Clin Gastroenterol 2005; 39:413-21. [PMID: 15815210 DOI: 10.1097/01.mcg.0000159270.35609.3a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Endobiliary drainage for malignant obstructive jaundice presents a viable palliative alternative. Its role and efficacy depend on factors related to the stent, procedure, and patient. GOALS To review the evidence in the literature in which settings plastic or metal stents are cost-effective, and whether adjuvant measures or patient-related factors affect duration of stent patency. STUDY Using databases a literature search was performed for papers published from 1979 to April 2004. All retrieved papers reporting experimental or clinical observations were rated according to strength of evidence, and carefully analyzed. RESULTS AND CONCLUSIONS Metal stents (Wallstent) stay patent longer than plastic stents (large-bore polyethylene with side-holes), overall median 250 and 110 days, respectively, and seem cost-effective in patients with longer than about 6 months survival, which cannot be accurately predicted. Antibiotics or choleretic agents do not prolong stent patency in clinical settings. In case of stent occlusion, indicated stent exchanges and insertion of a plastic stent, respectively, seem cost-effective in patients initially treated with plastic and metal stents.
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Hao CY, Su XQ, Ji JF, Huang XF, Xing BC. Stomach-interposed cholecystogastrojejunostomy: A palliative approach for periampullary carcinoma. World J Gastroenterol 2005; 11:2009-12. [PMID: 15800996 PMCID: PMC4305727 DOI: 10.3748/wjg.v11.i13.2009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: For patients of periampullary carcinoma found to be unresectable at the time of laparotomy, surgical palliation is the primary choice of treatment. Satisfactory palliation to maximize the quality of life with low morbidity and mortality is the gold standard for a good procedure. Our aim is to explore such a procedure as an alternative to the traditional ones.
METHODS: A modified double-bypass procedure is performed by, in addition to the usual gastrojejunostomy, implanting a mushroom catheter from the gall bladder into the jejunum through the interposed stomach as an internal drainage. A retrospective review was performed including 22 patients with incurable periampullary carcinomas who underwent this surgery.
RESULTS: Both jaundice and impaired liver function improved significantly after surgery. No postoperative deaths, cholangitis, gastrojejunal, biliary anastomotic leaks, recurrent jaundice or late gastric outlet obstruction occurred. Delayed gastric emptying occurred in two patients. The total surgical time was 150±26 min. The estimated blood loss was 160±25 mL. The mean length of hospital stay after surgery was 22±6 d. The mean survival was 8 mo (range 1.5-18 mo).
CONCLUSION: In patients of unresectable periampullary malignancies, stomach-interposed cholecystogastr-ojejunostomy is a safe, simple and efficient technique for palliation.
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Affiliation(s)
- Chun-Yi Hao
- Department of Surgery, Peking University School of Oncology, 52 Fu-Cheng-Lu Street, Beijing 100036, China.
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Yamaguchi Y, Morozumi K, Yamato T, Katsumi N, Abe N, Sugiyama M, Ishida H, Takahashi SI. New guide wire technique for stent placement through an occluded self-expandable metal stent: The hairpin technique. J Gastroenterol Hepatol 2005; 20:595-8. [PMID: 15836709 DOI: 10.1111/j.1440-1746.2005.03816.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Self-expandable metal stents (SEMS) for malignant biliary strictures sometimes occlude, requiring the insertion of another stent. When a guide wire is advanced conventionally through the proximal portion of an occluded SEMS, the guide wire sometimes penetrates the stent mesh. The present study reports a new guide wire insertion technique that prevents this problem from occurring. METHODS In this new method of advancing a guide wire, the tip is not straight but bent into a curve. Because the advancing end of the guidewire is rounded like a hairpin, it cannot penetrate the stent mesh. Before cannulation, the flexible tip of the guide wire is extended out of the tip of the cannula in the descending duodenum and then cannulation is carried out as the flexible tip makes a hairpin curve. The guide wire with a maintained hairpin curve is advanced through the proximal end of the SEMS. The hairpin curve pops open and the guide wire straightens out when the guide wire has passed through the SEMS. After that, a second stent can be inserted over the guide wire. This technique has been utilized 14 times for occluded SEMS in 10 patients between June 2001 and September 2003. RESULTS In all patients the technique served to ensure access to the biliary tree and successful placement of a second stent. CONCLUSIONS This new hairpin guide wire technique was effective in preventing the guide wire from penetrating the stent mesh and, therefore contributed to successful stent placement within occluded SEMS.
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Affiliation(s)
- Yasuharu Yamaguchi
- The Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan.
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Harewood GC, Baron TH, Rumalla A, Wang KK, Gores GJ, Stadheim LM, de Groen PC. Pilot study to assess patient outcomes following endoscopic application of photodynamic therapy for advanced cholangiocarcinoma. J Gastroenterol Hepatol 2005; 20:415-20. [PMID: 15740486 DOI: 10.1111/j.1440-1746.2005.03582.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Photodynamic therapy (PDT) has demonstrated promise in the palliative treatment of advanced cholangiocarcinoma. The aim of this pilot study was to assess the outcome in patients with non-resectable cholangiocarcinoma following endoscopic application of PDT directly into the biliary tract. METHODS In patients with advanced cholangiocarcinoma, endoscopic retrograde cholangiopancreatography (ERCP) was performed to define the proximal and distal extent of intraductal tumor. Sodium porfimer was administered intravenously to all patients. Forty-eight hours later, a commercially available cylindrical diffusing laser fiber (1-2.5 cm in length, OptiGuide) designed for esophageal use was advanced across the biliary strictures. Laser light was applied at a power of 400 mW/cm fiber for a total energy of 180 J/cm(2) using an argon-pumped tunable dye laser. Patients received endoscopic PDT every 3 months provided they maintained a favorable performance status. Plastic biliary stents were replaced immediately following light application and were maintained in all patients. RESULTS Using a preloaded catheter, adequate positioning of the laser fiber was achieved in all patients. Eight patients with advanced cholangiocarcinoma received a total of 19 PDT treatments, range 1-5 treatments/patient. All eight patients were followed until death; mean follow-up was 9.8 months. Median survival from the date of the first PDT treatment was 276 days, which compares favorably with published series that have reported median survival times between 45 and 127 days for patients with bismuth type III and IV tumors treated with stenting alone. CONCLUSIONS Endoscopic application of PDT demonstrates promise in prolonging survival in patients with advanced cholangiocarcinoma. Additional randomized clinical trials using commercially available fibers are needed to fully evaluate both the optimum frequency and treatment interval of endoscopic PDT in the management of advanced cholangiocarcinoma.
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Affiliation(s)
- Gavin C Harewood
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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Chen Y, Wang XL, Yan ZP, Cheng JM, Wang JH, Gong GQ, Qian S, Luo JJ, Liu QX. HDR- 192Ir intraluminal brachytherapy in treatment of malignant obstructive jaundice. World J Gastroenterol 2004; 10:3506-10. [PMID: 15526374 PMCID: PMC4576236 DOI: 10.3748/wjg.v10.i23.3506] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: To determine the feasibility and safety of intraluminal brachytherapy in treatment of malignant obstructive jaundice (MOJ) and to evaluate the clinical effect of intraluminal brachytherapy on stent patency and patient survival.
METHODS: Thirty-four patients with MOJ were included in this study. Having biliary stent placed, all patients were classified into intraluminal brachytherapy group (group A, n = 14) and control group (group B, n = 20) according to their own choice. Intraluminal brachytherapy regimen included: HDR-192Ir was used in the therapy, fractional doses of 4-7 Gy were given every 3-6 d for 3-4 times, and standard points were established at 0.5-1.0 cm. Some patients of both groups received transcatheter arterial chemoembolization (TACE) after stent placement.
RESULTS: In group A, the success rate of intraluminal brachytherapy was 98.0%, RTOG grade 1 acute radiation morbidity occurred in 3 patients, RTOG/EORTC grade 1 late radiation morbidity occurred in 1 patient. Mean stent patency of group A (12.6 mo) was significantly longer than that of group B (8.3 mo) (P < 0.05). There was no significant difference in the mean survival (9.4 mo vs 6.0 mo) between the two groups.
CONCLUSION: HDR-192Ir intraluminal brachytherapy is a safe palliative therapy in treating MOJ, and it may prolong stent patency and has the potentiality of extending survival of patients with MOJ.
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Affiliation(s)
- Yi Chen
- Department of Radiology, Affiliated Zhongshan Hospital, Medical Center of Fudan University, Shanghai 200032, China
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Bueno JT, Gerdes H, Kurtz RC. Endoscopic management of occluded biliary Wallstents: a cancer center experience. Gastrointest Endosc 2003; 58:879-84. [PMID: 14652557 DOI: 10.1016/s0016-5107(03)02309-5] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biliary obstruction caused by unresectable malignancy commonly is treated by placement of a biliary self-expandable metallic stent. The endoscopic and percutaneous techniques for self-expandable metallic stent placement are well established and can be performed with a high success rate. Self-expandable metallic stent placement affords palliation of pruritus and enables treatment of advanced cancer with chemotherapeutic agents metabolized by the liver. Unfortunately, these stents tend to occlude with time. Optimal management of an occluded self-expandable metallic stent remains to be determined. METHODS A retrospective review was undertaken to determine optimal management of the occluded self-expandable metallic stent. Patients with malignant biliary obstruction who had endoscopic management for occluded Wallstents that had been placed percutaneously and endoscopically were studied. All patients underwent ERCP with one of the following interventions: mechanical cleaning, insertion of a plastic stent within the Wallstent, or insertion of a second Wallstent. The effectiveness of the intervention and duration of stent patency thereafter was studied. RESULTS A total of 34 patients with occluded biliary Wallstents underwent the following procedures: mechanical cleaning (6 patients), placement of a second Wallstent (4), or insertion of a plastic stent (24). Mechanical cleaning was effective in only one of 6 patients. For all 4 patients who underwent placement of a second Wallstent, there was resolution of jaundice or cholangitis and no reocclusion. Plastic stent insertion was successful in 22 of 24 patients. Median duration of stent patency after intervention was 192 days (range 81-257 days) after second Wallstent placement, 90 days (11-393 days) after plastic stent insertion, and 21 days (3-263 days) after mechanical cleaning. Duration of stent patency was better when the initial malignant stricture involved the distal vs. the proximal bile duct. CONCLUSIONS Occlusion of a biliary Wallstent is best managed by endoscopic insertion of a second Wallstent or a plastic stent. Mechanical cleaning is less effective. The level of the initial biliary obstruction influences stent patency.
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Affiliation(s)
- Jack Thomas Bueno
- Current affiliations: Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center. New York, New York 10021, USA
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Ortner MEJ, Caca K, Berr F, Liebetruth J, Mansmann U, Huster D, Voderholzer W, Schachschal G, Mössner J, Lochs H. Successful photodynamic therapy for nonresectable cholangiocarcinoma: a randomized prospective study. Gastroenterology 2003; 125:1355-63. [PMID: 14598251 DOI: 10.1016/j.gastro.2003.07.015] [Citation(s) in RCA: 375] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In nonrandomized trials, photodynamic therapy (PDT) had a promising effect on nonresectable cholangiocarcinoma (NCC). This prospective, open-label, randomized, multicenter study with a group sequential design compared PDT in addition to stenting (group A) with stenting alone (group B) in patients with NCC. METHODS In patients with histologically confirmed cholangiocarcinoma, endoscopic or percutaneous double stenting was performed. Patients fulfilling inclusion criteria were randomized to group A (stenting and subsequent PDT) and group B (stenting alone). For PDT, Photofrin 2 mg/kg body wt was injected intravenously 2 days before intraluminal photoactivation (wavelength, 630 nm; light dose, 180 J/cm(2)). Further treatments were performed in cases of residual tumor in the bile duct. The primary outcome parameter was survival time. Secondary outcome parameters were cholestasis and quality of life. RESULTS PDT resulted in prolongation of survival (group A: n = 20, median 493 days; group B: n = 19, median 98 days; P < 0.0001). It also improved biliary drainage and quality of life. CONCLUSIONS PDT, given in addition to best supportive care, improves survival in patients with NCC. The study was terminated prematurely because PDT proved to be so superior to simple stenting treatment that further randomization was deemed unethical.
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Affiliation(s)
- Marianne E J Ortner
- Division de Gastro-entérologie et Hépatologie, BH-10N, Centre Hospitalier Universitaire Vaudois, CH-1011 CHUV-Lausanne, Switzerland.
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26
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Shah RJ, Howell DA, Desilets DJ, Sheth SG, Parsons WG, Okolo P, Lehman GA, Sherman S, Baillie J, Branch MS, Pleskow D, Chuttani R, Bosco JJ. Multicenter randomized trial of the spiral Z-stent compared with the Wallstent for malignant biliary obstruction. Gastrointest Endosc 2003; 57:830-6. [PMID: 12776028 DOI: 10.1016/s0016-5107(03)70016-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The industry standard since 1990 for self-expanding biliary metallic stents has been the Wallstent. In 1998 the Spiral Z-stent was released. This randomized trial compared the Z-stent with the Wallstent in the treatment of malignant biliary obstruction. METHODS Patients with unresectable malignant biliary obstruction distal to the bile duct bifurcation were randomized to receive a 10-mm diameter Wallstent or a 10-mm diameter Z-stent. RESULTS A total of 145 patients were randomized; 13 were excluded. Sixty-four patients who received a Z-stent and 68 who had a Wallstent are included in the analysis. Tumors responsible for bile duct obstruction were pancreatic cancer (108), cholangiocarcinoma (15), metastatic cancer (6), and papillary cancer (3). Metallic stents were successfully placed in all patients. Seven technical problems were encountered during placement of the Z-stent and 5 with the Wallstent. There were 21 occlusions requiring reintervention (8 Z-stent, 13 Wallstent; p = 0.30). Median time to reintervention was the following: Z-stent, 162 days; Wallstent, 150 days (p = 0.22). A total of 104 patients died of progressive disease or other cause; 7 patients remain alive with patent stents. The overall calculated median patency rates were: Z-stent, 152 days; Wallstent, 154 days (p = 0.90). CONCLUSIONS The Spiral Z-stent is comparable with the Wallstent in terms of placement, occlusion rates, and overall patency. Occasional early occlusion of both stents suggests tumor characteristics instead of the size of the mesh openings in the stents as important factors.
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Affiliation(s)
- Raj J Shah
- Maine Medical Center, Portland, Maine, USA
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Barnett JL. Endoscopic management of biliary disease. Curr Opin Gastroenterol 2002; 18:378-82. [PMID: 17033310 DOI: 10.1097/00001574-200205000-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Therapeutic biliary endoscopy continues to evolve. Key articles this year primarily involve biliary stenting and biliary stone removal, the two important maneuvers available to the biliary endoscopist. The issues addressed in this review include follow-up after the use of multiple stents for benign strictures, unilateral versus bilateral stenting for Klatskin tumors, stent types and placement positions, the timing and approach to choledocholithiasis in the context of anticipated cholecystectomy, and resistant biliary duct stones.
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Affiliation(s)
- Jeffrey L Barnett
- University of Michigan Medical Center, Ann Arbor, Michigan 48109, USA.
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