Third metal stent for revision of malignant hilar biliary strictures

Background and study aim: Endoscopic stent-in-stent (SIS) placement of multiple metal stents is technically demanding. In the present study, we explored the technical feasibility and efficacy of endoscopic deployment of a third metal stent to create a triple SIS placement in patients with a bilateral SIS configuration for inoperable high grade malignant hilar biliary stricture (HBS) that had failed clinically.

Methods: Eighteen patients with histologically proven inoperable HBS underwent deployment of an additional third metal stent as a revisionary method after early clinical failure following technically successful bilateral SIS placement using cross-wired metal stents. The main outcome measures were the technical and clinical success rates, and adverse events.

Results: The overall technical and clinical success rates were 88.9 % (16/18) and 87.5 % (14/16), respectively. The early and late complications were cholangitis (n = 2) and cholecystitis (n = 1). Stent occlusion developed in 35.7 % (5/14) of patients in whom a third metal stent for revision of a bilateral SIS configuration was clinically successful. The median (range) times for stent patency and patient survival were 176 days (49 – 372) and 216 days (52 – 384), respectively.

Conclusions: Endoscopic deployment of an additional third metal stent into a bilateral SIS configuration was technically feasible and effective in patients with inoperable high grade malignant HBS in whom bilateral SIS placement had failed clinically.

• References

• 1 Chang WH, Kortan P, Haber GB. Outcome in patients with bifurcation tumors who undergo unilateral versus bilateral hepatic duct drainage. Gastrointest Endosc 1998; 47: 354-362
• 2 Rerknimitr R, Angsuwatcharakon P, Ratanachu-ek T et al. Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma. J Gastroenterol Hepatol 2013; 28: 593-607
• 3 Lee TH, Moon JH, Kim JH et al. Primary and revision efficacy of cross-wired metallic stents for endoscopic bilateral stent-in-stent placement in malignant hilar biliary strictures. Endoscopy 2013; 45: 106-113
• 4 Lee TH, Park do H, Lee SS et al. Technical feasibility and revision efficacy of the sequential deployment of endoscopic bilateral side-by-side metal stents for malignant hilar biliary strictures: a multicenter prospective study. Dig Dis Sci 2013; 58: 547-555
• 5 Chennat J, Waxman I. Initial performance profile of a new 6F self-expanding metal stent for palliation of malignant hilar biliary obstruction. Gastrointest Endosc 2010; 72: 632-636
• 6 Hwang JC, Kim JH, Lim SG et al. Y-shaped endoscopic bilateral metal stent placement for malignant hilar biliary obstruction: prospective long-term study. Scand J Gastroenterol 2011; 46: 326-332
• 7 Kato H, Tsutsumi K, Harada R et al. Endoscopic bilateral deployment of multiple metallic stents for malignant hilar biliary strictures. Dig Endosc 2013; 25: 75-80
• 8 Kawamoto H, Tsutsumi K, Fujii M et al. Endoscopic 3-branched partial stent-in-stent deployment of metallic stents in high-grade malignant hilar biliary stricture (with videos). Gastrointest Endosc 2007; 66: 1030-1037
• 9 Kogure H, Isayama H, Nakai Y et al. Newly designed large cell Niti-S stent for malignant hilar biliary obstruction: a pilot study. Surg Endosc 2011; 25: 463-467
• 10 Park do H, Lee SS, Moon JH et al. Newly designed stent for endoscopic bilateral stent-in-stent placement of metallic stents in patients with malignant hilar biliary strictures: multicenter prospective feasibility study (with videos). Gastrointest Endosc 2009; 69: 1357-1360
• 11 Kawamoto H, Tsutsumi K, Harada R et al. Endoscopic deployment of multiple JOSTENT SelfX is effective and safe in treatment of malignant hilar biliary strictures. Clin Gastroenterol Hepatol 2008; 6: 401-408
• 12 Sawas T, Al Halabi S, Parsi MA et al. Self-expandable metal stents versus plastic stents for malignant biliary obstruction: a meta-analysis. Gastrointest Endosc 2015; 82: 256-267
• 13 Naitoh I, Hayashi K, Nakazawa T et al. Side-by-side versus stent-in-stent deployment in bilateral endoscopic metal stenting for malignant hilar biliary obstruction. Dig Dis Sci 2012; 57: 3279-3285
• 14 Chahal P, Baron TH. Expandable metal stents for endoscopic bilateral stent-within-stent placement for malignant hilar biliary obstruction. Gastrointest Endosc 2010; 71: 195-199
• 15 Cheng JL, Bruno MJ, Bergman JJ et al. Endoscopic palliation of patients with biliary obstruction caused by nonresectable hilar cholangiocarcinoma: efficacy of self-expandable metallic Wallstents. Gastrointest Endosc 2002; 56: 33-39
• 16 Moon JH, Rerknimitr R, Kogure H et al. Topic controversies in the endoscopic management of malignant hilar strictures using metal stent: side-by-side versus stent-in-stent techniques. J Hepatobiliary Pancreat Sci 2015; 22: 650-656