Side-by-side partially covered self-expandable metal stent placement for malignant hilar biliary obstruction

Abstract

Background and study aims This study investigated the feasibility of side-by-side (SBS) partially covered self-expandable metal stent (PCSEMS) placement for unresectable malignant hilar biliary obstruction (MHBO).

Patients and methods We retrospectively analyzed 33 patients from a single center who underwent endoscopic biliary drainage for unresectable MHBO from July 2013 to June 2015. In all patients with bilateral obstruction during complete bilateral intrahepatic cholangiograms, we performed endoscopic SBS placement of a 6-mm diameter PCSEMS using an 8-French delivery system. All patients underwent endoscopic sphincterotomy. Generally, patients with recurrent biliary obstruction (RBO) after stent placement underwent endoscopic reintervention. Our study outcomes included the technical and functional success rates, RBO rate, time to RBO (TRBO), reintervention rate, and incidence of adverse events.

Results Seventeen patients with unresectable MHBO during complete bilateral intrahepatic cholangiograms underwent endoscopic SBS PCSEMS placement (median age, 78 years; men, 9). Lesions were Bismuth types II (n = 10), III (n = 1), and IV (n = 6), including 10 cholangiocarcinomas, 3 gallbladder cancers, and 4 metastatic cancers. In all patients, the PCSEMS was placed across the duodenal papilla. The technical and functional success rates were 100 % and 82 %, respectively. The median procedure time was 43 minutes (interquartile range [IQR]: 36 – 52 minutes). Twelve patients had RBO (71 %), including 9 stent occlusions due to sludge and 3 stent migrations. The median TRBO was 79 days (IQR: 58 – 156 days) during the follow-up period (median 192 days [IQR: 88 – 551 days]). The median TRBO of patients with Bismuth type II lesions was significantly longer than that of patients with Bismuth types III and IV lesions (87 days [IQR: 70 – 244 days] vs. 54 days [IQR: 35 – 100 days]; P  = 0.030). Thirteen patients (76 %) required endoscopic reintervention. Endoscopic stent removal was possible in 6 patients without tumor ingrowth into the uncovered distal part of the stent. One late adverse event (≥ 31 days) occurred (cholangitis).

Conclusions Endoscopic SBS placement of a PCSEMS was feasible in patients with unresectable MHBO. Additionally, reinterventional stent removal was possible in the absence of tumor ingrowth.

• References

• 1 Sawas T, Al HalabiS, Parsi MA. et al. Self-expandable metal stents versus plastic stents for malignant biliary obstruction: a meta-analysis. Gastrointest Endosc 2015; 82: 256-267.e7
• 2 Freeman ML, Overby C. Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents. Gastrointest Endosc 2003; 58: 41-49
• 3 Naitoh I, Ohara H, Nakazawa T. et al. Unilateral versus bilateral endoscopic metal stenting for malignant hilar biliary obstruction. J Gastroenterol Hepatol 2009; 24: 552-557
• 4 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
• 5 Kim KM, Lee KH, Chung YH. et al. A comparison of bilateral stenting methods for malignant hilar biliary obstruction. Hepatogastroenterology 2012; 59: 341-346
• 6 Isayama H, Hamada T, Yasuda I. et al. TOKYO criteria 2014 for transpapillary biliary stenting. Dig Endosc 2015; 27: 259-264
• 7 Bismuth H, Castaing D, Traynor O. Resection or palliation: priority of surgery in the treatment of hilar cancer. World J Surg 1988; 12: 39-47
• 8 Dumas R, Demuth N, Buckley M. et al. Endoscopic bilateral metal stent placement for malignant hilar stenoses: identification of optimal technique. Gastrointest Endosc 2000; 51: 334-338
• 9 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
• 10 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
• 11 Lee TH, Park DH, 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
• 12 Wagner HJ, Knyrim K, Vakil N. et al. Plastic endoprostheses versus metal stents in the palliative treatment of malignant hilar biliary obstruction. A prospective and randomized trial. Endoscopy 1993; 25: 213-218
• 13 Perdue DG, Freeman ML, DiSario JA. et al. Plastic versus self-expanding metallic stents for malignant hilar biliary obstruction: a prospective multicenter observational cohort study. J Clin Gastroenterol 2008; 42: 1040-1046
• 14 Inoue T, Okumura F, Naitoh I. et al. Feasibility of the placement of a novel 6-mm diameter threaded fully covered self-expandable metal stent for malignant hilar biliary obstructions (with videos). Gastrointest Endosc 2016; 84: 352-357
• 15 Yoshida T, Hara K, Imaoka H. et al. Benefits of side-by-side deployment of 6-mm covered self-expandable metal stents for hilar malignant biliary obstructions. J Hepatobiliary Pancreat Sci 2016; 23: 548-555
• 16 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