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Endoscopic Sphincterotomy before Fully Covered Metal Stent Placement Is Not Required for Distal Malignant Biliary Stricture due to a Pancreatic Head Tumor. Gastroenterol Res Pract 2019; 2019:9675347. [PMID: 30774655 PMCID: PMC6350600 DOI: 10.1155/2019/9675347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/15/2018] [Accepted: 12/04/2018] [Indexed: 02/03/2023] Open
Abstract
Background/Aims Endoscopic sphincterotomy (EST) is often performed before fully covered self-expandable metal stent (FCSEMS) placement in order to prevent pancreatitis. However, it is not clear whether EST prevents pancreatitis or affects other adverse events (AEs). This study is conducted to evaluate the necessity of EST before FCSEMS placement for distal malignant biliary strictures due to a pancreatic head tumor. Methods This study included 68 patients who underwent FCSEMS placement for distal malignant biliary stricture due to a pancreatic head tumor. Treatment outcomes and AEs were retrospectively compared between 32 patients with EST before FCSEMS placement (EST group) and 36 patients without EST (non-EST group). Results The success rates of drainage for the EST and non-EST groups were 100% and 97.2%, respectively (P = 0.95). The incidence of pancreatitis in the EST and non-EST groups was 3.1% and 0%, respectively (P = 0.95). The incidence of hyperamylasemia in the EST and non-EST groups was 12.5% and 13.9%, respectively (P = 0.85). The incidence of all AEs in the EST and non-EST groups was 15.6% (pancreatitis: 1, cholecystitis: 2, and stent migration: 2) and 13.9% (cholecystitis: 3, stent migration: 2), respectively (P = 0.89). Conclusions EST before FCSEMS placement for distal malignant biliary stricture due to a pancreatic head tumor does not affect the successful drainage and incidence of adverse events. The necessity of EST to prevent pancreatitis before FCSEMS placement was deemed low.
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Li DF, Zhou CH, Wang LS, Yao J, Zou DW. Is ERCP-BD or EUS-BD the preferred decompression modality for malignant distal biliary obstruction? A meta-analysis of randomized controlled trials. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:953-960. [DOI: 10.17235/reed.2019.6125/2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Mangiavillano B, Montale A, Frazzoni L, Bianchetti M, Sethi A, Repici A, Fuccio L. Endoscopic biliary self-expandable metallic stent in malignant biliary obstruction with or without sphincterotomy: systematic review and meta-analysis. Endosc Int Open 2019; 7:E26-E35. [PMID: 30648136 PMCID: PMC6327725 DOI: 10.1055/a-0752-9956] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 09/04/2018] [Indexed: 02/07/2023] Open
Abstract
Background and aim To assess the rate of adverse events and the technical success rate of biliary stenting with or without EBS. Methods A literature search up to February 2017 was performed. Studies assessing adverse events (AEs) and technical success rates of stenting with or without EBS were considered. Results Seven studies (870 patients; 12 treatment arms) were included. Early AEs, i. e. those occurring within 30 days, were significantly lower in no-EBS vs. EBS-group (11 % vs . 20.1 %; OR: 0.36, 95 %CI: 0.13 - 1.00). Rates of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis were not significantly different in the two groups (no-EBS vs . EBS: 6.1 % vs 5 %; OR: 1.33, 95 %CI: 0.68 - 2.59). The rate of bleeding was significantly lower in patients without EBS (no-EBS vs EBS: 0 % vs 5 %; OR: 0.12, 95 % CI: 0.03 - 0.45). Rates of cholangitis were significantly lower in patients without EBS (no-EBS vs . EBS: 3.3 % vs. 7.4 %; OR: 0.38, 95 %CI: 0.17 - 0.83). Both late AEs and mortality rates did not significantly differ between no-EBS and EBS patients (19.9 % vs. 18.9 %; OR: 0.93, 95 %CI: 0.56 - 1.53, and 2.5 % vs. 2.9 %; OR: 1.18, 95 %CI: 0.22 - 6.29, respectively). The technical success rate for stent insertion also did not differ (98 % vs. 97.6 %; OR: 1.05, 95 %CI: 0.42 - 2.63). Conclusion EBS seems to be associated, in the first 30 days after the procedure, with an increased risk of cholangitis and bleeding. No difference was observed in the rate of post-ERCP pancreatitis.
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Affiliation(s)
- Benedetto Mangiavillano
- Gastrointestinal Endoscopy Unit; Humanitas – Mater Domini Castellanza, Italy,Humanitas University, Milan, Italy,Corresponding author Benedetto Mangiavillano, MD Gastrointestinal Endoscopy Unit, Humanitas – Mater DominiVia Gerenzano n. 2, 21053 – Castellanza (VA)21053 Italy+0039 0331 476205 – 381.
| | - Amedeo Montale
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Mario Bianchetti
- Gastrointestinal Endoscopy Unit; Humanitas – Mater Domini Castellanza, Italy
| | - Amrita Sethi
- New York-Presbyterian Medical Center/Columbia University Medical Center, New York, New York, United States
| | - Alessandro Repici
- Humanitas University, Milan, Italy,Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano (MI) Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Bologna, Italy
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Nakai Y, Isayama H, Kawakami H, Ishiwatari H, Kitano M, Ito Y, Yasuda I, Kato H, Matsubara S, Irisawa A, Itoi T. Prospective multicenter study of primary EUS-guided choledochoduodenostomy using a covered metal stent. Endosc Ultrasound 2019; 8:111-117. [PMID: 30168480 PMCID: PMC6482602 DOI: 10.4103/eus.eus_17_18] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background and Objectives: EUS-guided biliary drainage (EUS-BD) is increasingly reported as a salvage technique after failed endoscopic retrograde cholangiopancreatography, but it is still controversial whether EUS-BD can replace transpapillary biliary stenting. Therefore, we conducted this multicenter, prospective study of EUS-guided choledochoduodenostomy (EUS-CDS) using a covered metallic stent (CMS) as primary biliary drainage for unresectable distal malignant biliary obstruction (MBO). Methods: Patients with unresectable distal MBO without any prior drainage are enrolled. Primary endpoint is a technical success and secondary endpoints are adverse events, functional success, and recurrent biliary obstruction (RBO) of EUS-CDS. Clinical outcomes were compared between EUS-CDS and transpapillary stenting as a control. Results: A total of 34 patients were enrolled in 10 Japanese institutions. The cause of MBO was pancreatic cancer in 28 patients. Median tumor size and common bile duct diameter were 31 and 13 mm, respectively. Technical success rate was 97% with a median procedure time of 25 min and functional success rate was 100%. The rate of RBO was 29% and the causes of RBO were nontumor related: Migration in 18%, sludge/food impaction in 9%, and stent impaction to the duodenal wall in 3%. Other adverse events were abdominal pain in 6% and cholecystitis in 9%. A median cumulative time to RBO was 11.3 months. The rate of RBO and cumulative time to RBO of EUS-CDS were comparable to those of transpapillary stenting (36% and 9.1 months, respectively). Conclusion: EUS-CDS using a CMS as primary biliary drainage was technically feasible and its safety appeared comparable to transpapillary stenting.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo; Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Hokkaido University, Sapporo; Department of Gastroenterology and Hepatology, University of Miyazaki; Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki, Japan
| | - Hirotoshi Ishiwatari
- Department of Medical Oncology and Hematology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Masayuki Kitano
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kinki University, Osaka-Sayama, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Ichiro Yasuda
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine and Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Fukushima Medical University Aizu Medical Center, Aizuwakamatsu, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Li GZ, Wang F, Fang J, Zha HL, Zhao Q. Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Evidence from 1786 Cases. Med Sci Monit 2018; 24:8544-8552. [PMID: 30475792 PMCID: PMC6278246 DOI: 10.12659/msm.913314] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Postoperative pancreatitis is one of the most serious complications in endoscopic retrograde cholangiopancreatography (ERCP). To detect potential risk factors for post-ERCP hyperamylasemia and pancreatitis. MATERIAL AND METHODS We reviewed 1786 ERCP procedures in Zhongnan Hospital of Wuhan University from January 2015 to April 2018. Clinical data were extracted, and the complications after ERCP procedures were re-evaluated. Single- and multiple-variable analyses were conducted to detect the potential risk factors. RESULTS We found that 1786 procedures were applied on 1707 patients; 64 patients (3.58%) developed pancreatitis, while asymptomatic hyperamylasemia occurred in 263 cases (14.73%). In multivariate analysis, pancreatic deep wire pass (odds ratio [OR]: 2.280, 95% CI [confidence interval]: 1.129-4.605, P=0.022), endoscopic metal biliary endoprosthesis (OR: 2.399, 95% CI: 1.120-5.138, P=0.024), operation after liver transplantation (OR: 3.057, 95% CI: 1.110-8.422, P=0.031), and fistulotomy (OR: 3.148, 95% CI: 1.036-9.561, P=0.043) were identified as independent risk factors for post-ERCP pancreatitis. Pancreatic deep wire pass (OR: 1.678, 95% CI: 1.136-2.478, P=0.009), fistulotomy (OR: 2.553, 95% CI: 1.096-5.948, P=0.030), and younger age (OR: 0.990, 95% CI: 0.980-0.999, P=0.037) were identified as independent risk factors for hyperamylasemia. CONCLUSIONS To prevent post-ERCP pancreatitis, it is important to avoid high-risk procedures such as fistulotomy and pancreatic deep wire pass, especially in high-risk patients with liver transplantation. For patients with endoscopic metal biliary endoprosthesis, clinicians should pay more attention to the occurrence of post-ERCP pancreatitis.
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Affiliation(s)
- Guo-Zhen Li
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland).,Department of Gastroenterology, Wuhan Red Cross Hospital, Wuhan, Hubei, China (mainland)
| | - Fan Wang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Jun Fang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Huo-Long Zha
- Department of Gastroenterology, Shi Yan People's Hospital, Shiyan, Hubei, China (mainland)
| | - Qiu Zhao
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
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Nakaoka K, Hashimoto S, Kawabe N, Nakano T, Kan T, Ohki M, Ochi Y, Takamura T, Kurashita T, Nomura S, Koyama K, Fukui A, Yoshioka K. Evaluation of a 12-mm diameter covered self-expandable end bare metal stent for malignant biliary obstruction. Endosc Int Open 2018; 6:E1164-E1170. [PMID: 30302372 PMCID: PMC6175604 DOI: 10.1055/a-0627-7078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/27/2018] [Indexed: 12/17/2022] Open
Abstract
Background and study aims Biliary metallic stents are used to drain unresectable malignant distal biliary obstructions. This study aimed to evaluate the efficacy of a novel 12-mm-diameter covered, self-expandable end bare metal stent (12-mm CSEEMS). Patients and methods We evaluated 99 patients with unresectable malignant distal biliary obstructions treated with covered biliary metallic stents. Of the 99 patients, 33 underwent 12-mm CSEEMS placement between June 2015 and April 2017 (12-mm-CSEEMS group) and 66 underwent 10-mm fully-covered self-expandable metal stent (FCSEMS) placement between January 2010 and July 2015 (10-mm-FCSEMS group). The overall survival (OS), the recurrent biliary obstruction (RBO), cause of RBO, time to RBO (TRBO) and adverse events in 12-mm-CSEEMS group and 10-mm-FCSEMS group were evaluated retrospectively. Results The OS tended to be longer in the 12-mm-CSEEMS group (log rank, P = 0.081) and TRBO was significantly longer in the 12-mm-CSEEMS group (log rank, P = 0.001) than in the 10-mm-FCSEMS group. Both univariate (HR, 0.449; 95 % CI, 0.27967 - 0.72215; P = 0.001) and multivariate (HR, 0.458; 95 % CI, 0.28395 - 0.73744; P = 0.001) Cox hazard analysis found that risk of RBO was significantly lower in 12-mm CSEEMS than in 10-mm FCSEMS. There were no significant differences between the 12-mm-CSEEMS group and 10-mm-FCSEMS group regarding the cause of RBO and adverse events. Conclusions The 12-mm CSEEMS showed a low risk of RBO compared with 10-mm FCSEMS and was considered to be effective and safe for draining unresectable malignant distal biliary obstruction.
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Affiliation(s)
- Kazunori Nakaoka
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Senju Hashimoto
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan,Corresponding author Senju Hashimoto, MD Department of Liver, Biliary Tract and Pancreas DiseasesFujita Health University1-98 Dengakugakubo, KutsukakechoToyoake, Aichi 470-1192, Japan+81-562-93-8601
| | - Naoto Kawabe
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Takuji Nakano
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Toshiki Kan
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Masashi Ohki
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Yuka Ochi
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Tomoki Takamura
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Takamitsu Kurashita
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Sayuri Nomura
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Keishi Koyama
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Aiko Fukui
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Kentaro Yoshioka
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, Aichi, Japan
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A Prospective Multicenter Study of a Fully Covered Metal Stent in Patients with Distal Malignant Biliary Obstruction: WATCH-2 Study. Dig Dis Sci 2018; 63:2466-2473. [PMID: 29218484 DOI: 10.1007/s10620-017-4875-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 11/29/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Both fully covered (FC) and partially covered (PC) self-expandable metal stents (SEMSs) are now commercially available for distal malignant biliary obstruction (MBO). While FCSEMS can be easily removed at the time of re-interventions, it is theoretically prone to migration. However, few comparative data between FC and PC SEMSs have been reported. AIMS The aim of this study was to compare clinical outcomes of FCSEMS with those of PCSEMS. METHODS This was a multicenter, prospective study of FCSEMS for unresectable distal MBO with a historical control of PCSEMS, which was previously reported as the WATCH study. The primary outcome was recurrent biliary obstruction (RBO), and secondary outcomes were stent migration, stent removal, stent-related adverse events, and survival. RESULTS A total of 151 cases with unresectable distal MBO undergoing FCSEMS placement were enrolled and compared with a historical cohort of 141 cases undergoing PCSEMS placement. No significant differences were found in the rate of RBO (29 vs. 33%; P = 0.451), time to RBO (318 vs. 373 days; P = 0.382), and survival (229 vs. 196 days; P = 0.177) between FCSEMS and PCSEMS. The rate of stent migration also did not differ significantly between the two groups (14 vs. 8%; P = 0.113). The removal of FCSEMSs was successful in all 24 attempted cases (100%). CONCLUSIONS FCSEMSs appeared comparable to PCSEMSs in terms of RBO without a significant increase in stent migration rate in patients with unresectable distal MBO. CLINICAL TRIAL REGISTRATION NUMBER UMIN000007131.
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Hamada T, Nakai Y, Isayama H. TOKYO criteria: Standardized reporting system for endoscopic biliary stent placement. GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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EUS-Guided Biliary Drainage Versus ERCP for the Primary Palliation of Malignant Biliary Obstruction: A Multicenter Randomized Clinical Trial. Am J Gastroenterol 2018; 113:987-997. [PMID: 29961772 DOI: 10.1038/s41395-018-0122-8] [Citation(s) in RCA: 205] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/11/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The goal of the study was to determine whether endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) is comparable to conventional transpapillary stenting with endoscopic retrograde cholangiopancreatography (ERCP) in palliation of malignant distal biliary obstruction. Although ERCP for the palliation of malignant biliary obstruction is the standard of care, post-procedure pancreatitis and stent dysfunctions are not uncommon. While EUS-BD has garnered interest as a viable alternative when ERCP is impossible, its role as a primary palliation of malignant distal biliary obstruction is yet to be proven. METHODS We performed random allocation to EUS-BD or ERCP in 125 patients with unresectable malignant distal biliary obstruction at four tertiary academic referral centers in South Korea. RESULTS Technical success rates were 93.8% (60/64) for EUS-BD and 90.2% (55/61) for ERCP (difference 3.6%, 95% 1-sided confidence interval lower limit -4.4%, P = 0.003 for noninferiority margin of 10%). Clinical success rates were 90.0% (54/60) in EUS-BD and 94.5% (52/55) in ERCP (P = 0.49). Lower rates of overall adverse events (6.3% vs 19.7%, P = 0.03) including post-procedure pancreatitis (0 vs 14.8%), reintervention (15.6% vs 42.6%), and higher rate of stent patency (85.1% vs 48.9%) were observed with EUS-BD. EUS-BD was also associated with more preserved quality of life (QOL) than transpapillary stenting after 12 weeks of the procedure. CONCLUSIONS This study demonstrated comparable technical and clinical success rates between EUS-BD and ERCP in relief malignant distal biliary obstruction. Substantially longer duration of patency coupled with lower rates of adverse events and reintervention, and more preserved QOL were observed with EUS-BD (cris.nih.go.kr, Identifier: KCT0001396, https://cris.nih.go.kr/cris/search/search_result_st01_en.jsp?seq=9716<ype=&rtype= ).
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Kikuyama M, Shirane N, Kawaguchi S, Terada S, Mukai T, Sugimoto K. New 14-mm diameter Niti-S biliary uncovered metal stent for unresectable distal biliary malignant obstruction. World J Gastrointest Endosc 2018; 10:16-22. [PMID: 29375737 PMCID: PMC5768999 DOI: 10.4253/wjge.v10.i1.16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/24/2017] [Accepted: 11/03/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate whether an uncovered self-expandable metal stent (UCSEMS) with a large diameter could prevent recurrent biliary obstruction (RBO).
METHODS Thirty-eight patients with malignant biliary obstruction underwent treatment with an UCSEMS with a 14-mm diameter (Niti-S 14). Retrospectively, we evaluated technical and functional success rate, RBO rate, time to RBO, survival time, and adverse events in these patients.
RESULTS Stent placement success and functional success were achieved in all patients. Two patients (5.3%) had RBO due to tumor ingrowth or overgrowth. The median time to RBO was 190 (range, 164-215) d. The median survival time was 120 (range, 18-502) d. The 6-mo non-RBO rate was 91%. Other adverse events other than RBO occurred as follows: Acute cholecystitis, post-ERCP pancreatitis, hemobilia, and fever without exacerbation of liver injury, and liver abscess in 4 (10.3%), 3 (7.9%), 2 (5.3%), 1 (2.6%), and 1 (2.6%), respectively. Migration of the stents was not observed.
CONCLUSION Niti-S 14 is considered to be a preferable metal stent because of a low rate of RBO with no migration.
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Affiliation(s)
- Masataka Kikuyama
- Department of Gastroenterology, Komagome Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo 113-8677, Japan
| | - Naofumi Shirane
- Department of Gastroenterology, Komagome Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo 113-8677, Japan
- Department of Gastroenterology, Shizuoka General Hospital, Shizuoka 432-8021, Japan
| | - Shinya Kawaguchi
- Department of Gastroenterology, Komagome Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo 113-8677, Japan
| | - Shuzou Terada
- Department of Gastroenterology, Komagome Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo 113-8677, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Komagome Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo 113-8677, Japan
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu 500-8513, Japan
| | - Ken Sugimoto
- Department of Gastroenterology, Komagome Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo 113-8677, Japan
- Department of Gastroenterology, Hamamatsu University School of Medicine, Shizuoka 113-8677, Japan
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Hamada T, Nakai Y, Lau JY, Moon JH, Hayashi T, Yasuda I, Hu B, Seo DW, Kawakami H, Kuwatani M, Katanuma A, Kitano M, Ryozawa S, Hanada K, Iwashita T, Ito Y, Yagioka H, Togawa O, Maetani I, Isayama H. International study of endoscopic management of distal malignant biliary obstruction combined with duodenal obstruction. Scand J Gastroenterol 2018; 53:46-55. [PMID: 28982258 DOI: 10.1080/00365521.2017.1382567] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Endoscopic transpapillary or endoscopic ultrasound (EUS)-guided stent placement is used for nonresectable distal malignant biliary obstruction. We conducted a retrospective study to evaluate endoscopic biliary drainage in patients with duodenal obstruction. METHODS We included consecutive patients who underwent endoscopic biliary drainage combined with a duodenal stent at 16 referral centers in four Asian countries. The primary outcome was time to recurrent biliary obstruction (TRBO). We assessed TRBO according to the sequence of biliary and duodenal obstruction (group 1/2/3, biliary obstruction first/concurrent/duodenal obstruction first, respectively) or the location of duodenal obstruction (type I/II/III, proximal to/affecting/distal to the ampulla, respectively). We also evaluated functional success and adverse events. RESULTS We included 110 patients (group1/2/3, 67/29/14 patients; type I/II/III, 45/46/19 patients; endoscopic retrograde cholangiopancreatography [ERCP]/EUS-guided choledocoduodenostomy/EUS-guided hepaticogastrostomy, 90/10/10 patients, respectively). The median TRBO of all cases was 450 days (interquartile range, 212-666 days) and functional success was achieved in 105 cases (95%). The TRBO did not differ significantly by the timing or location of duodenal obstruction (p = .30 and .79, respectively). The TRBO of metal stents (n = 96) tended to be longer compared with plastic stents (n = 14, p = .083). Compared with ERCP, EUS-guided biliary drainage was associated with a higher rate of adverse events. CONCLUSION Transpapillary or transmural endoscopic biliary drainage with a duodenal stent was effective, irrespective of the timing or location of duodenal obstruction. A prospective study is required considering the tradeoff of technical success rate, stent patency, and adverse events (ClinicalTrials.gov number, NCT02376907).
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Affiliation(s)
- Tsuyoshi Hamada
- a Department of Gastroenterology, Graduate School of Medicine , The University of Tokyo , Tokyo , Japan
| | - Yousuke Nakai
- a Department of Gastroenterology, Graduate School of Medicine , The University of Tokyo , Tokyo , Japan
| | - James Y Lau
- b Department of Surgery , Prince of Wales Hospital, The Chinese University of Hong Kong , Shatin , Hong Kong SAR
| | - Jong Ho Moon
- c Department of Internal Medicine, Digestive Disease Center and Research Institute , Soon Chun Hyang University School of Medicine , Seoul , Korea
| | - Tsuyoshi Hayashi
- d Department of Medical Oncology and Hematology , Sapporo Medical University Hokkaido , Japan.,e Department of Gastroenterology , Hokkaido Cancer Center , Hokkaido , Japan
| | - Ichiro Yasuda
- f First Department of Internal Medicine , Gifu University Hospital , Gifu , Japan.,g Department of Gastroenterology , Teikyo University Mizonokuchi Hospital , Kanagawa , Japan
| | - Bing Hu
- h Department of Endoscopy , Eastern Hepatobiliary Hospital, Second Military Medical University , Shanghai , P.R. China
| | - Dong-Wan Seo
- i Department of Gastroenterology , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Korea
| | - Hiroshi Kawakami
- j Department of Gastroenterology and Hepatology , Hokkaido University Hospital , Hokkaido , Japan.,k Department of Gastroenterology and Hepatology , Center for Digestive Disease University of Miyazaki , Miyazaki , Japan
| | - Masaki Kuwatani
- j Department of Gastroenterology and Hepatology , Hokkaido University Hospital , Hokkaido , Japan
| | - Akio Katanuma
- l Center for Gastroenterology, Teine Keijin-kai Hospital , Hokkaido , Japan
| | - Masayuki Kitano
- m Department of Gastroenterology and Hepatology , Kinki University Faculty of Medicine , Osaka , Japan
| | - Shomei Ryozawa
- n Department of Gastroenterology , Saitama Medical University International Medical Center , Saitama , Japan
| | - Keiji Hanada
- o Department of Gastroenterology , Onomichi General Hospital , Hiroshima , Japan
| | - Takuji Iwashita
- f First Department of Internal Medicine , Gifu University Hospital , Gifu , Japan
| | - Yukiko Ito
- p Department of Gastroenterology , Japanese Red Cross Medical Center , Tokyo , Japan
| | - Hiroshi Yagioka
- q Department of Gastroenterology , Tokyo Metropolitan Police Hospital , Tokyo , Japan
| | - Osamu Togawa
- r Department of Gastroenterology , Kanto Central Hospital , Tokyo , Japan
| | - Iruru Maetani
- s Division of Gastroenterology and Hepatology, Department of Internal Medicine , Toho University Ohashi Medical Center , Tokyo , Japan
| | - Hiroyuki Isayama
- a Department of Gastroenterology, Graduate School of Medicine , The University of Tokyo , Tokyo , Japan
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62
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Hamada T, Isayama H, Nakai Y, Togawa O, Takahara N, Uchino R, Mizuno S, Mohri D, Yagioka H, Kogure H, Matsubara S, Yamamoto N, Ito Y, Tada M, Koike K. Antireflux Metal Stent as a First-Line Metal Stent for Distal Malignant Biliary Obstruction: A Pilot Study. Gut Liver 2017; 11:142-148. [PMID: 27282268 PMCID: PMC5221872 DOI: 10.5009/gnl15579] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/08/2015] [Accepted: 01/12/2016] [Indexed: 12/27/2022] Open
Abstract
Background/Aims In distal malignant biliary obstruction, an antireflux metal stent (ARMS) with a funnel-shaped valve is effective as a reintervention for metal stent occlusion caused by reflux. This study sought to evaluate the feasibility of this ARMS as a first-line metal stent. Methods Patients with nonresectable distal malignant biliary obstruction were identified between April and December 2014 at three Japanese tertiary centers. We retrospectively evaluated recurrent biliary obstruction and adverse events after ARMS placement. Results In total, 20 consecutive patients were included. The most common cause of biliary obstruction was pancreatic cancer (75%). Overall, recurrent biliary obstruction was observed in seven patients (35%), with a median time to recurrent biliary obstruction of 246 days (range, 11 to 246 days). Stent occlusion occurred in five patients (25%), the causes of which were sludge and food impaction in three and two patients, respectively. Stent migration occurred in two patients (10%). The rate of adverse events associated with ARMS was 25%: pancreatitis occurred in three patients, cholecystitis in one and liver abscess in one. No patients experienced non-occlusion cholangitis. Conclusions The ARMS as a first-line biliary drainage procedure was feasible. Because the ARMS did not fully prevent stent dysfunction due to reflux, further investigation is warranted.
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Affiliation(s)
- Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Togawa
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rie Uchino
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Dai Mohri
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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63
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Sugawara S, Arai Y, Sone M, Katai H. Frequency, Severity, and Risk Factors for Acute Pancreatitis After Percutaneous Transhepatic Biliary Stent Placement Across the Papilla of Vater. Cardiovasc Intervent Radiol 2017; 40:1904-1910. [DOI: 10.1007/s00270-017-1730-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 06/23/2017] [Indexed: 12/15/2022]
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64
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Understanding the Mechanical forces of Self-Expandable Metal Stents in the Biliary Ducts. Curr Gastroenterol Rep 2017; 18:64. [PMID: 27778304 DOI: 10.1007/s11894-016-0538-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Self-expandable metallic stent (SEMS) was an effective biliary endoprosthesis. Mechanical properties of SEMS, radial and axial force (RF, AF), may play important roles in the bile duct after placement. RF was well known dilation force and influenced on the occurrence of migration. AF, newly proposed by this author, was defined as the recovery force when the SEMS vended. AF was related with the cause of bile duct kinking, pancreatitis, and cholecystitis due to the compression of the bile duct, orifice of the cystic duct, and pancreatic orifice. Ideal SEMS may show high RF and low AF.
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65
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Nakai Y, Hamada T, Isayama H, Itoi T, Koike K. Endoscopic management of combined malignant biliary and gastric outlet obstruction. Dig Endosc 2017; 29:16-25. [PMID: 27552727 DOI: 10.1111/den.12729] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 08/19/2016] [Indexed: 12/13/2022]
Abstract
Patients with periampullary cancer or gastric cancer often develop malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), and combined MBO and GOO is not rare in these patients. Combined MBO and GOO is classified by its location and sequence, and treatment strategy can be affected by this classification. Historically, palliative surgery, hepaticojejunostomy and gastrojejunostomy were carried out, but the current standard treatment is combined transpapillary stent and duodenal stent placement. Although a high technical success rate is reported, the procedure can be technically difficult and duodenobiliary reflux with subsequent cholangitis is common after double stenting. Recent development of endoscopic ultrasound (EUS)-guided procedures enables the management of MBO as well as GOO under EUS guidance. EUS-guided biliary drainage is now increasingly reported as an alternative to percutaneous transhepatic biliary drainage in failed endoscopic retrograde cholangiopancreatography (ERCP), and GOO is one of the major reasons for failed ERCP. In addition to EUS-guided biliary drainage, the feasibility of EUS-guided double-balloon-occluded gastrojejunostomy bypass for MBO was recently reported, and EUS-guided double stenting can potentially become the treatment of choice in the future. However, as each procedure has its advantages and disadvantages, treatment strategy should be selected based on the type of obstruction and the prognosis and performance status of the patient.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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66
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Tol JAMG, van Hooft JE, Timmer R, Kubben FJGM, van der Harst E, de Hingh IHJT, Vleggaar FP, Molenaar IQ, Keulemans YCA, Boerma D, Bruno MJ, Schoon EJ, van der Gaag NA, Besselink MGH, Fockens P, van Gulik TM, Rauws EAJ, Busch ORC, Gouma DJ. Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer. Gut 2016; 65:1981-1987. [PMID: 26306760 DOI: 10.1136/gutjnl-2014-308762] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In pancreatic cancer, preoperative biliary drainage (PBD) increases complications compared with surgery without PBD, demonstrated by a recent randomised controlled trial (RCT). This outcome might be related to the plastic endoprosthesis used. Metal stents may reduce the PBD-related complications risk. METHODS A prospective multicentre cohort study was performed including patients with obstructive jaundice due to pancreatic cancer, scheduled to undergo PBD before surgery. This cohort was added to the earlier RCT (ISRCTN31939699). The RCT protocol was adhered to, except PBD was performed with a fully covered self-expandable metal stent (FCSEMS). This FCSEMS cohort was compared with the RCT's plastic stent cohort. PBD-related complications were the primary outcome. Three-group comparison of overall complications including early surgery patients was performed. RESULTS 53 patients underwent PBD with FCSEMS compared with 102 patients treated with plastic stents. Patients' characteristics did not differ. PBD-related complication rates were 24% in the FCSEMS group vs 46% in the plastic stent group (relative risk of plastic stent use 1.9, 95% CI 1.1 to 3.2, p=0.011). Stent-related complications (occlusion and exchange) were 6% vs 31%. Surgical complications did not differ, 40% vs 47%. Overall complication rates for the FCSEMS, plastic stent and early surgery groups were 51% vs 74% vs 39%. CONCLUSIONS For PBD in pancreatic cancer, FCSEMS yield a better outcome compared with plastic stents. Although early surgery without PBD remains the treatment of choice, FCSEMS should be preferred over plastic stents whenever PBD is indicated. TRIAL REGISTRATION NUMBER Dutch Trial Registry (NTR3142).
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Affiliation(s)
- J A M G Tol
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - J E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - R Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - F J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - F P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Q Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Y C A Keulemans
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - D Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - M J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - N A van der Gaag
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - M G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - P Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - E A J Rauws
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - O R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - D J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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67
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Song TJ, Lee JH, Lee SS, Jang JW, Kim JW, Ok TJ, Oh DW, Park DH, Seo DW, Lee SK, Kim MH, Kim SC, Kim CN, Yun SC. Metal versus plastic stents for drainage of malignant biliary obstruction before primary surgical resection. Gastrointest Endosc 2016; 84:814-821. [PMID: 27109456 DOI: 10.1016/j.gie.2016.04.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 04/07/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Preoperative biliary drainage (PBD) with stent placement has been commonly used for patients with malignant biliary obstruction. In PBD, the placement of fully covered self-expandable metal stents (FCSEMSs) may provide better patency duration and a lower incidence of cholangitis compared with plastic stents. We aimed to evaluate which type of stent showed better outcomes in PBD. METHODS In this multicenter, prospective randomized trial, we compared PBD with FCSEMSs versus plastic stents in 86 patients with malignant biliary obstruction between January 2012 and December 2014. Patients with obstructive jaundice were randomly assigned to undergo PBD either with plastic stents or FCSEMS placement. RESULTS Baseline characteristics were not significantly different between the 2 groups. Endoscopic stent placement was technically successful in all patients. Procedure-related adverse events were not significantly different between the 2 groups (plastic vs FCSEMS group; 16.3% vs 16.3%, P = 1.0). Reintervention was required in 16.3% of the plastic stent group and 14.0% of the FCSEMS group (P = .763). The interval to surgery after PBD (plastic vs FCSEMS group; 14.2 ± 8.3 vs 12.3 ± 6.9 days, P = .426) was not significantly different between groups. Surgery-related adverse events occurred in 43.6% of the plastic stent group and 40.0% of the FCSEMS group (P = .755). CONCLUSIONS In patients with resectable malignant biliary obstruction, the outcomes of PBD with plastic stents and FCSEMSs were similar. Considering the cost-effectiveness, PBD with plastic stents may be preferable to FCSEMS placement. (Clinical trial registration number: NCT01789502.).
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Affiliation(s)
- Tae Jun Song
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Hoon Lee
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Soo Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Woong Jang
- Department of Internal Medicine, Eulgi University College of Medicine, Daejeon, Korea
| | - Jung Wook Kim
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Tae Jin Ok
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Wook Oh
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Do Hyun Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Wan Seo
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Koo Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Song Cheol Kim
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chul Nam Kim
- Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sung Cheol Yun
- Department of Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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68
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Mukai T, Yasuda I, Isayama H, Iwashita T, Itoi T, Kawakami H, Kogure H, Nakai Y. Pilot study of a novel, large-bore, fully covered self-expandable metallic stent for unresectable distal biliary malignancies. Dig Endosc 2016; 28:671-9. [PMID: 26927207 DOI: 10.1111/den.12643] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 02/11/2016] [Accepted: 02/24/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM In patients with unresectable malignant distal biliary obstruction, covered self-expandable metallic stents (CSEMS) may remain patent longer than uncovered self-expandable metallic stents as a result of tumor ingrowth prevention. One main cause of recurrent biliary obstruction (RBO) in CSEMS is sludge formation, which can be prevented using a large-bore stent. Therefore, we developed a novel, 12-mm diameter fully covered SEMS (FCSEMS) and investigated its clinical safety, efficacy, and rate of adverse events. METHODS This prospective, multicenter pilot study, which ran between June 2011 and November 2012, included 38 consecutive patients with unresectable malignant distal biliary obstruction. All patients underwent endoscopic insertion of our novel stent. Primary endpoint was non-RBO rate 6 months after placement. RESULTS Technical and functional success rates of the procedures were 100%. Six-month non-RBO rate was 50%, and median time to RBO was 184 days. Median survival time was 241 days. Twelve patients died within 6 months after stent placement without RBO. RBO was observed in 10 patients (26%), with seven experiencing stent occlusion and three experiencing stent migration. Adverse events other than RBO (at <30 days) developed in six patients (16%; cholecystitis, one; pancreatitis, one; hyperamylasemia, one; pancreatic ductitis, one; abdominal pain, two). Stent removal for reintervention was successfully completed in eight patients. CONCLUSION Our novel FCSEMS may be safe and effective for managing malignant distal obstruction with an acceptable incidence of adverse events.
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Affiliation(s)
- Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takuji Iwashita
- Department of Gastroenterology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Gastroenterology and Hepatology, Center for Digestive Disease, The University of Miyazaki, Miyazaki, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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69
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Covered versus uncovered self-expandable metal stents for malignant biliary strictures: A meta-analysis and systematic review. Indian J Gastroenterol 2016; 35:323-330. [PMID: 27566620 DOI: 10.1007/s12664-016-0682-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/17/2016] [Indexed: 02/04/2023]
Abstract
Self-expandable metal stents (SEMS) are used for palliating inoperable malignant biliary strictures. It is unclear if covered metal stents are superior to uncovered metal stents in these patients. We compared clinical outcomes in patients with covered and uncovered stents. Studies using covered and uncovered metallic stents for palliation in patients with malignant biliary stricture were reviewed. Articles were searched in MEDLINE, PubMed, and Ovid journals. Fixed and random effects models were used to calculate the pooled proportions. Initial search identified 1436 reference articles, of which 132 were selected and reviewed. Thirteen studies (n = 2239) for covered and uncovered metallic stents which met the inclusion criteria were included in this analysis. Odds ratio for stent occlusion rates in covered vs. uncovered stents was 0.79 (95 % CI = 0.65 to 0.96). Survival benefit in patients with covered vs. uncovered stents showed the odds ratio to be 1.29 (95 % CI = 0.95 to 1.74). Pooled odds ratio for migration of covered vs. uncovered stents was 9.9 (95 % CI = 4.5 to 22.3). Covered stents seemed to have significantly lesser occlusion rates, increased odds of migration, and increased odds of pancreatitis compared to uncovered stents. There was no statistically significant difference in the survival benefit, overall adverse event rate, and patency period of covered vs. uncovered metal stents in patients with malignant biliary strictures.
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70
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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: 25] [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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71
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Sofi AA, Nawras A, Alaradi OH, Alastal Y, Khan MA, Lee WM. Does endoscopic sphincterotomy reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis after biliary stenting? A systematic review and meta-analysis. Dig Endosc 2016; 28:394-404. [PMID: 26636754 DOI: 10.1111/den.12584] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 11/12/2015] [Accepted: 11/30/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Endoscopic biliary sphincterotomy (ES) is often carried out prior to placement of a biliary stent apparently to reduce the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, the protective effect of ES prior to biliary stenting is controversial. The objective of this meta-analysis is to compare the risk of PEP and other complications after the placement of biliary stent with or without ES in patients with biliary obstruction and bile leak. METHODS We carried out a systematic search in several electronic databases for randomized controlled trials (RCT) and observational studies (OS) comparing the risk of PEP after biliary stenting with or without ES. The Mantel-Haenszel method was used to pool data of adverse outcomes into fixed or random effect model meta-analyses. RESULTS Seventeen studies (five RCT and 12 OS) with a total of 2710 patients met the inclusion criteria. No significant difference was observed in the risk of PEP with biliary stenting with and without ES (RD -0.01; 95% confidence interval [CI] -0.03, 0.01). In a subgroup analysis of stenting for biliary obstruction, no difference in the risk of PEP was observed with or without ES. However, ES was associated with lower risk of PEP in patients undergoing biliary stenting for bile leak (RD -0.05; CI -0.10, -0.01). CONCLUSIONS ES shows risk reduction in prevention of PEP in patients undergoing endoscopic stenting for bile leak. However, placement of biliary stent without ES is not associated with an increased risk of PEP in patients with distal bile duct obstruction with involvement of pancreatic duct.
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Affiliation(s)
- Aijaz Ahmed Sofi
- Departments of Medicine, Division of Gastroenterology, University of Toledo Medical Center, Toledo, USA
| | - Ali Nawras
- Departments of Medicine, Division of Gastroenterology, University of Toledo Medical Center, Toledo, USA
| | - Osama Habib Alaradi
- Departments of Medicine, Division of Gastroenterology, University of Toledo Medical Center, Toledo, USA
| | - Yaseen Alastal
- Departments of Internal Medicine, University of Toledo Medical Center, Toledo, USA
| | - Muhammed Ali Khan
- Departments of Medicine, Division of Gastroenterology, University of Toledo Medical Center, Toledo, USA
| | - Wade M Lee
- Departments of Internal Medicine, University of Toledo Medical Center, Toledo, USA
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72
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Sasahira N, Hamada T, Togawa O, Yamamoto R, Iwai T, Tamada K, Kawaguchi Y, Shimura K, Koike T, Yoshida Y, Sugimori K, Ryozawa S, Kakimoto T, Nishikawa K, Kitamura K, Imamura T, Mizuide M, Toda N, Maetani I, Sakai Y, Itoi T, Nagahama M, Nakai Y, Isayama H. Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction. World J Gastroenterol 2016; 22:3793-3802. [PMID: 27076764 PMCID: PMC4814742 DOI: 10.3748/wjg.v22.i14.3793] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/03/2016] [Accepted: 01/30/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.
METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent (PS) or nasobiliary catheter (NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedure-related adverse events, stent/catheter dysfunction (occlusion or migration of PS/NBC, development of cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution (bilirubin level < 3.0 mg/dL) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.
RESULTS: In total, 419 patients were included in the study (PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients (46%), bile duct cancer in 172 (41%), gallbladder cancer in three (1%), and ampullary cancer in 50 (12%). The median serum total bilirubin was 7.8 mg/dL and 324 patients (77%) had ≥ 3.0 mg/dL. During the median time to surgery of 29 d [interquartile range (IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio (SHR) = 4.76; 95%CI: 2.44-10.0, P < 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method (PS or NBC).
CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.
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Impact of Preoperative Biliary Drainage on Surgical Outcomes in Periampullary and Hilar Malignancy. Surg Laparosc Endosc Percutan Tech 2016; 26:150-5. [DOI: 10.1097/sle.0000000000000252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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74
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Jeong S. Basic Knowledge about Metal Stent Development. Clin Endosc 2016; 49:108-12. [PMID: 27000423 PMCID: PMC4821512 DOI: 10.5946/ce.2016.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 02/03/2016] [Accepted: 02/03/2016] [Indexed: 12/29/2022] Open
Abstract
Biliary self-expandable metal stents (SEMS), a group of non-vascular stents, have been used in the palliative management of biliary obstruction around the world. However, there are still unmet needs in the clinical application of biliary SEMS. Comprehensive understanding of the SEMS is required to resolve the drawbacks and difficulties of metal stent development. The basic structure of SEMS, including the materials and knitting methods of metal wires, covering materials, and radiopaque markers, are discussed in this review. What we know about the physical and mechanical properties of the SEMS is very important. With an understanding of the basic knowledge of metal stents, hurdles such as stent occlusion, migration, and kinking can be overcome to develop more ideal SEMS.
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Affiliation(s)
- Seok Jeong
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
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75
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Kim JW, Gwon DIL, Han YM, Won JH, Hong HP, Ko GY, Yoon HK, Sung KB. A prospective, multicenter study of a double stent system for palliative treatment of malignant extrahepatic biliary obstructions. Acta Radiol 2015; 56:1209-15. [PMID: 25260418 DOI: 10.1177/0284185114550702] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 08/18/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND A double stent system (covered stent in uncovered stent) was designed to provide long-term patency without tumor ingrowth or stent-related complications, such as stent migration, cholecystitis, or pancreatitis. PURPOSE To investigate the safety and efficacy of double stents in patients with malignant extrahepatic biliary obstructions. MATERIAL AND METHODS This prospective, nonrandomized, multicenter study enrolled 160 consecutive patients (102 men; mean age, 64 years; range, 33-91 years) with malignant extrahepatic biliary obstructions treated with a double stent system from January 2010 to March 2012. RESULTS The technical success rate of the double stent placement was 100%. No stent migration was observed. Procedure-related minor (self-limiting hemobilia [n = 6] and cholangitis [n = 2]) and major (pancreatitis [n = 16], cholecystitis [n = 3], and hepatic abscess [n = 2]) complications occurred in a total of 29 patients. The mean serum bilirubin level, which was 8.9 ± 5.6 mg/dL before drainage, decreased to 2.2 ± 4.6 mg/dL 1 month after stent placement (P < 0.001). Successful internal drainage was achieved in 148 patients (92.5%). During the mean follow-up period of 205 days, acute cholecystitis (n = 3) and hepatic abscess (n = 2) occurred in five patients. The median patient survival and stent patency time were 135 days (95% confidence interval [CI], 96-160 days) and 114 days (95% CI, 83-131 days), respectively. Of 153 patients, 22 (14.4%) presented with stent dysfunction due to sludge incrustation (n = 17), tumor overgrowth (n = 4), or blood clot (n = 1), and required repeat intervention. Tumor ingrowth was not observed in any of these patients. CONCLUSION Percutaneous treatment of malignant extrahepatic biliary obstruction using a double stent safely and effectively achieves internal biliary drainage.
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Affiliation(s)
- Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Republic of Korea
| | - Dong I l Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Republic of Korea
| | - Young-Min Han
- Department of Radiology, Chonbuk National University Medical School and Hospital, Republic of Korea
| | - Je Hwan Won
- Department of Radiology, Ajou University college of Medicine and Hospital, Republic of Korea
| | - Hyun Pyo Hong
- Department of Radiology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Republic of Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Republic of Korea
| | - Hyun-Ki Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Republic of Korea
| | - Kyu-Bo Sung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Republic of Korea
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76
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Jun CH, Park CH, Jeon J, Park IH, Lee HJ, Park SY, Kim HS, Choi SK, Rew JS. Feasibility of self-expandable metal stents for preservation of sphincter of Oddi function in patients with common bile duct stones: a pilot study. Gastrointest Endosc 2015; 82:719-23. [PMID: 25887719 DOI: 10.1016/j.gie.2015.01.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/11/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Chung-Hwan Jun
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Chang-Hwan Park
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jin Jeon
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - In-Hyung Park
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Ho-Jun Lee
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Seon-Young Park
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun-Soo Kim
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Sung-Kyu Choi
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jong-Sun Rew
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Abstract
Endoscopic stenting is a widely accepted strategy for providing effective drainage in both extrahepatic and intrahepatic malignant strictures. In patients with extrahepatic malignancies, uncovered self-expanding metal stents (SEMS) provide excellent palliation. Hilar malignancies are probably best palliated by placement of uncovered SEMS although some disagreement exists among experts regarding the type and number of stents for optimal palliation. Preoperative biliary drainage (PBD) is commonly performed although a higher risk of complications and the lack of clear benefit raise questions about this practice. Certain groups of patients such as those with markedly elevated bilirubin levels, and in those in whom neoadjuvant therapy is planned, are good candidates for PBD. Considerable controversy exists regarding the optimal method as well as type of stent for PBD in patients with hilar malignancies. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have emerged as potential adjuvant therapies in the management of malignant bile duct strictures but need further long-term evaluation to establish survival benefit. This review focuses on the current status of endoscopic therapies for malignant biliary obstructions.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, PO Box 208019, New Haven, CT, 06520, USA,
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78
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Isayama H, Nakai Y, Hamada T, Yamamoto N, Koike K. Development of an ideal self-expandable metallic stent design. GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.1016/j.gii.2015.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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79
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Hayashi T, Kawakami H, Osanai M, Ishiwatari H, Naruse H, Hisai H, Yanagawa N, Kaneto H, Koizumi K, Sakurai T, Sonoda T. No benefit of endoscopic sphincterotomy before biliary placement of self-expandable metal stents for unresectable pancreatic cancer. Clin Gastroenterol Hepatol 2015; 13:1151-8.e2. [PMID: 25632802 DOI: 10.1016/j.cgh.2015.01.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 01/10/2015] [Accepted: 01/13/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Endoscopic sphincterotomy (ES) is performed routinely before self-expandable metallic stents (SEMS) are placed in malignant distal biliary strictures to prevent postprocedural pancreatitis. However, it is not clear whether ES actually prevents pancreatitis or affects other adverse events (AEs). We conducted a noninferiority trial to examine the necessity of ES before SEMS placement. METHODS Two hundred patients with distal biliary strictures caused by unresectable pancreatic cancer were assigned randomly to groups that received ES or did not receive ES (non-ES) before SEMS placement, at 25 hospitals in Hokkaido, Japan, from August 2010 through November 2012. The primary outcome was early AEs (≤30 d) specifically related to the presence or absence of ES (pancreatitis, bleeding, or perforation). Secondary outcomes measured included the effect of ES omission on time to SEMS dysfunction and patient survival times. RESULTS The proportions of patients with early AEs were 9.2% in the non-ES group and 10.4% in the ES group (a difference of 1.2%, noninferior). The median times to SEMS dysfunction was longer than 594 days in the non-ES group and 541 days in the ES group (P = .88). The median overall survival times were 202 in the ES group vs 255 days in the non-ES group; P = .20). CONCLUSIONS ES before SEMS does not affect the incidence of AEs, SEMS patency, or patient survival times. Our data provide no evidence for a benefit of ES to patients undergoing SEMS placement for a biliary stricture caused by pancreatic cancer. UMIN clinical trials registry number: 000004044.
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Affiliation(s)
- Tsuyoshi Hayashi
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Manabu Osanai
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Hirotoshi Ishiwatari
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hirohito Naruse
- Department of Gastroenterology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Hiroyuki Hisai
- Department of Gastroenterology, Japan Red Cross Date General Hospital, Date, Japan
| | - Nobuyuki Yanagawa
- Department of Gastroenterology, Asahikawa-Kosei General Hospital, Asahikawa, Japan
| | - Hiroyuki Kaneto
- Department of Gastroenterology, Muroran City General Hospital, Muroran, Japan
| | - Kazuya Koizumi
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Tamaki Sakurai
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, Japan
| | - Tomoko Sonoda
- Department of Public Health, Sapporo Medical University School of Medicine, Sapporo, Japan
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80
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Jo JH, Park BH. Suprapapillary versus transpapillary stent placement for malignant biliary obstruction: which is better? J Vasc Interv Radiol 2015; 26:573-82. [PMID: 25680281 DOI: 10.1016/j.jvir.2014.11.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 11/13/2014] [Accepted: 11/27/2014] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To compare the complications, stent patency, and patient survival with self-expandable metal stents (SEMSs) placed above or across the sphincter of Oddi in malignant biliary obstruction. MATERIALS AND METHODS From January 2008 to December 2012, 155 patients were treated with percutaneous transhepatic SEMS placement. Seventy-four patients underwent suprapapillary stent placement (group A), and 81 patients underwent transpapillary stent placement (group B). Complications rates, stent patency, and patient survival were evaluated and analyzed for potential predictors. RESULTS In group A, 68 covered and 28 uncovered SEMSs were placed, and, in group B, 78 covered and 19 uncovered SEMSs were placed. Thirty-six stent-related early complications were observed in a total of 154 patients (23.4%): pancreatitis (n = 23), cholangitis (n = 12), and cholecystitis (n = 1). The early complication rates for groups A and B were 14.9% (11 of 74) and 31.3% (25 of 80), respectively (P = .016). Pancreatitis occurred in three patients (4.1%) in group A and 20 patients (25.0%) in group B (P = .001). Stent location was a single independent predictor of pancreatitis (P < .001). Stent occlusions by tumor growth was more frequently observed in group A than in group B (P = .007), whereas stent occlusion by sludge incrustation was more frequently found in group B than in group A (P = .007). There was no significant difference in cumulative stent patency (P = .401) or patient survival (P = .792) between groups. CONCLUSIONS To decrease the incidence of pancreatitis, suprapapillary placement of SEMSs is recommended for malignant biliary obstruction, but not in the lower 2 cm of the common bile duct.
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Affiliation(s)
- Jeong-Hyun Jo
- Department of Radiology, Dong-A University, College of Medicine, 26, Daesingongwon-ro, Seo-gu, Busan 602-715, Republic of Korea
| | - Byeong-Ho Park
- Department of Radiology, Dong-A University, College of Medicine, 26, Daesingongwon-ro, Seo-gu, Busan 602-715, Republic of Korea.
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81
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Rustagi T, Jamidar PA. Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events: post-ERCP pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:107-21. [PMID: 25442962 DOI: 10.1016/j.giec.2014.09.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), and not uncommonly is the reason behind ERCP-related lawsuits. Patients at high risk for PEP include young women with abdominal pain, normal liver tests, and unremarkable imaging. Procedure-related factors include traumatic and persistent cannulation attempts, multiple injections of the pancreatic duct, pancreatic sphincterotomy, and, possibly, use of precut sphincterotomy. Aggressive hydration, use of rectal indomethacin, and prophylactic pancreatic stenting can diminish the risk (and likely severity) of PEP. Though hugely beneficial, these measures do not supersede careful patient selection and technique.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA.
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82
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Park AW. Covered metallic stents in malignant common bile duct obstruction: to use or not to use--that is the question! J Vasc Interv Radiol 2014; 25:1920-1. [PMID: 25457140 DOI: 10.1016/j.jvir.2014.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 09/12/2014] [Accepted: 09/15/2014] [Indexed: 10/24/2022] Open
Affiliation(s)
- Auh Whan Park
- Vascular and Interventional Radiology Section, University of Virginia Health System, 1215 Lee St., Charlottesville, VA 22908.
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83
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Cui PJ, Yao J, Zhao YJ, Han HZ, Yang J. Biliary stenting with or without sphincterotomy for malignant biliary obstruction: a meta-analysis. World J Gastroenterol 2014; 20:14033-9. [PMID: 25320543 PMCID: PMC4194589 DOI: 10.3748/wjg.v20.i38.14033] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 05/15/2014] [Accepted: 06/14/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the benefits of endoscopic sphincterotomy (EST) before stent placement by meta-analysis of randomized controlled trials (RCTs). METHODS PubMed, EMBASE, Cochrane Library, and Science Citation Index databases up to March 2014 were searched. The primary outcome was incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and successful stent insertion rate. The secondary outcomes were the incidence of post-ERCP bleeding, stent migration and occlusion. The free software Review Manager was used to perform the meta-analysis. RESULTS Three studies (n = 338 patients, 170 in the EST group and 168 in the non-EST group) were included. All three studies described a comparison of baseline patient characteristics and showed that there were no statistically significant differences between the two groups. Three RCTs, including 338 patients, were included in this meta-analysis. Most of the analyzed outcomes were similar between the groups. Although EST reduced the incidence of PEP, it also led to a higher incidence of post-ERCP bleeding (OR = 0.34, 95%CI: 0.12-0.93, P = 0.04; OR = 9.70, 95%CI: 1.21-77.75, P = 0.03, respectively). CONCLUSION EST before stent placement may be useful in reducing the incidence of PEP. However, EST-related complications, such as bleeding and perforation, may offset this effect.
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84
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Nakai Y, Isayama H, Kogure H, Hamada T, Togawa O, Ito Y, Matsubara S, Arizumi T, Yagioka H, Mizuno S, Sasaki T, Yamamoto N, Hirano K, Tada M, Koike K. Risk factors for covered metallic stent migration in patients with distal malignant biliary obstruction due to pancreatic cancer. J Gastroenterol Hepatol 2014; 29:1744-9. [PMID: 24720610 DOI: 10.1111/jgh.12602] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Covered metallic stents (CMSs) were developed to overcome tumor ingrowth in uncovered metallic stents (UMSs) for malignant biliary obstruction, but superiority of CMSs over UMSs is still controversial due to the high migration rate in CMS. Therefore, we conducted this retrospective analysis to clarify risk factors for stent migration, including mechanical properties of CMSs. METHODS Patients with unresectable pancreatic cancer, receiving CMS for distal malignant biliary obstruction in five tertiary care centers, were retrospectively studied. Univariate and multivariate analyses to identify prognostic factors for early (< 6 months) stent migration were performed using a proportional hazards model with death or stent occlusion without stent migration as a competing risk. Two mechanical properties were included in the analysis: axial force, the recovery force that leads to a CMS straightening, and radial force (RF), the expansion force against the stricture. RESULTS Among 290 patients who received CMS placement for distal malignant biliary obstruction, stent migration rate was 15.2%. CMS migrated early (< 6 months) in 10.0% and distally in 11.7%, respectively. In the multivariate analysis, significant risk factors for early stent migration were chemotherapy (subdistribution hazard ratios [SHR] 4.46, P = 0.01), CMS with low RF (SHR 2.23, P = 0.03), and duodenal invasion (SHR 2.25, P = 0.02). CONCLUSION CMS with low RF, chemotherapy, and duodenal invasion were associated with CMS migration from our study.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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85
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Transmural biliary drainage can be an alternative to transpapillary drainage in patients with an indwelling duodenal stent. Dig Dis Sci 2014; 59:1931-8. [PMID: 24839917 DOI: 10.1007/s10620-014-3062-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 02/05/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Self-expandable metal stents (SEMS) are widely utilized to relieve symptoms of malignant gastric outlet obstruction (GOO), but GOO is frequently complicated by nonresectable distal biliary obstruction. The optimal endoscopic approach to biliary drainage in this setting remains controversial and has yet to be resolved. AIMS To compare the safety and efficacy of endoscopic ultrasound-guided transmural biliary drainage (EUS-BD) and transpapillary drainage in patients with an indwelling duodenal SEMS. METHODS Patients who underwent EUS-BD or transpapillary drainage for distal malignant biliary obstruction with an indwelling duodenal SEMS between June 2007 and August 2012 at three Japanese tertiary referral centers were identified retrospectively. We compared times to stent dysfunction, causes of dysfunction, and procedural related complications between these two groups. RESULTS Twenty patients were included in the study (7 EUS-BD and 13 transpapillary drainage). EUS-BD was performed via hepaticogastrostomy using a SEMS in three patients and via choledochoduodenostomy using a SEMS or a plastic stent in two patients each. Transpapillary drainage was performed using a SEMS in all patients. The stent patency rate in the EUS-BD group was higher than that in the transpapillary drainage group (100 vs. 71% at 1 month and 83 vs. 29% at 3 months, respectively). The rate of stent dysfunction in the EUS-BD group tended to be lower than that in the transpapillary group (14 vs. 54%; P = 0.157). Complication rates were similar between the groups (P = 1.000), with moderate bleeding in one patient in the EUS-BD group and mild pancreatitis in one patient in the transpapillary group. CONCLUSION Endoscopic ultrasound-guided transmural biliary drainage is an alternative to transpapillary drainage in patients with an indwelling duodenal SEMS.
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86
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Nakai Y, Isayama H, Kawakubo K, Kogure H, Hamada T, Togawa O, Ito Y, Matsubara S, Arizumi T, Yagioka H, Takahara N, Uchino R, Mizuno S, Miyabayashi K, Yamamoto K, Sasaki T, Yamamoto N, Hirano K, Tada M, Koike K. Metallic stent with high axial force as a risk factor for cholecystitis in distal malignant biliary obstruction. J Gastroenterol Hepatol 2014; 29:1557-62. [PMID: 24628054 DOI: 10.1111/jgh.12582] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Tumor involvement to the orifice of cystic duct (OCD) is a risk factor for cholecystitis after self-expandable metallic stent (SEMS) placement, but its prevention is still difficult. We conducted this multicenter analysis to clarify a type of SEMS or a method to place SEMS which would decrease the incidence of cholecystitis after SEMS placement. METHODS The incidence of cholecystitis was studied in consecutive patients receiving SEMS for distal malignant biliary obstruction in five tertiary care centers. Multiple logistic regression analysis was performed to evaluate risk factors for cholecystitis. RESULTS A total of 376 patients who received SEMS placement for distal malignant biliary obstruction were analyzed. Tumor involvement to OCD was diagnosed in 25.3%. Overall incidence of cholecystitis was 6.9%. Cholecystitis was observed in 8.0% of 300 patients with covered SEMS, 16.8% of 95 patients with tumor involvement to OCD, 10.8% of 234 patients with SEMS of high axial force (AF), and 12.0% of 158 patients with SEMS length ≤ 60 mm. In the multivariate analysis, tumor involvement to OCD (odds ratio [OR] 5.40, P < 0.001), SEMSs with high AF (OR 5.33, P = 0.002), and SEMS length ≤ 60 mm (OR 3.19, P = 0.010) are risk factors. Among patients with tumor involvement to OCD, the incidence of cholecystitis in SEMS with high and low AF was 25.0% and 5.0%, respectively. CONCLUSION This study with an expanded cohort reconfirmed tumor involvement to OCD as a risk factor for cholecystitis after SEMS placement. SEMS with low AF might decrease cholecystitis.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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87
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Abstract
Cholangiocarcinomas are often locally advanced or have metastasized, and at the time of diagnosis individuals often have a poor prognosis. Endoscopic treatment options traditionally include biliary decompression via stenting to allow for systemic chemotherapy and radiotherapy, with self-expanding metal biliary stents being preferred. Recent developments in locoregional therapy delivered endoscopically, such as photodynamic therapy and radiofrequency abalation, have shown promising results in improving patient survival.
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Affiliation(s)
- Linda Ann Hou
- Division of Gastrointestinal and Liver Diseases, LAC+USC Medical Center, Keck School of Medicine of USC, 1983 Marengo Avenue, D & T Building, Room B4H100, Los Angeles, CA 90033, USA
| | - Jacques Van Dam
- Digestive Health Institute, The Keck Medical Center of USC, 1510 San Pablo Street, Suite 322R, CA, USA
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88
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Covered metal stenting for malignant lower biliary stricture with pancreatic duct obstruction: is endoscopic sphincterotomy needed? Gastroenterol Res Pract 2013; 2013:375613. [PMID: 24324486 PMCID: PMC3845734 DOI: 10.1155/2013/375613] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 10/17/2013] [Accepted: 10/17/2013] [Indexed: 01/02/2023] Open
Abstract
Aims. To evaluate the need for endoscopic sphincterotomy (EST) before covered self-expandable metal stent (CSEMS) deployment for malignant lower biliary stricture with pancreatic duct obstruction. Methods. This study included 79 patients who underwent CSEMS deployment for unresectable malignant lower biliary stricture with pancreatic duct obstruction. Treatment outcomes and complications were compared between 38 patients with EST before CSEMS deployment (EST group) and 41 without EST (non-EST group). Results. The technical success rates were 100% in both the EST and the non-EST group. The incidence of pancreatitis was 2.6% in the EST, and 2.4% in the non-EST group (P = 0.51). The incidences of overall complications were 18.4% and 14.6%, respectively, (P = 0.65). Within the non-EST groups, the incidence of pancreatitis was 0% in patients with fully covered stent deployment and 3.6% in those with partially covered stent deployment (P = 0.69). In the multivariate analysis, younger age (P = 0.003, OR 12) and nonpancreatic cancer (P = 0.001, OR 24) were significant risk factors for overall complications after CSEMS deployment. EST was not identified as a risk factor. Conclusions. EST did not reduce the incidence of pancreatitis after CSEMS deployment in patients of unresectable distal malignant obstruction with pancreatic duct obstruction.
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Isayama H, Kawakubo K, Nakai Y, Inoue K, Gon C, Matsubara S, Kogure H, Ito Y, Tsujino T, Mizuno S, Hamada T, Uchino R, Miyabayashi K, Yamamoto K, Sasaki T, Yamamoto N, Hirano K, Sasahira N, Tada M, Koike K. A novel, fully covered laser-cut nitinol stent with antimigration properties for nonresectable distal malignant biliary obstruction: a multicenter feasibility study. Gut Liver 2013; 7:725-30. [PMID: 24312715 PMCID: PMC3848551 DOI: 10.5009/gnl.2013.7.6.725] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 02/08/2013] [Accepted: 02/17/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIMS Stent migration occurs frequently, but the prevention of complications resulting from covered self-expandable metal stents (C-SEMSs) remains unresolved. We prospectively assessed a newly developed C-SEMS, a modified covered Zeo stent (m-CZS), in terms of its antimigration effect. METHODS Between February 2010 and January 2011, an m-CZS was inserted into 42 patients (31 initial drainage cases and 11 reintervention cases) at a tertiary referral center and three affiliated hospitals. The laser-cut stent was flared for 1.5 cm at both ends, with a 1 cm raised bank located 1 cm in from each flared end. The main outcome of this study was the rate of stent migration, and secondary outcomes were the rate of recurrent biliary obstruction (RBO), the time to RBO, the frequencies of complications, and overall survival. RESULTS Of the 31 patients with initial drainage, stent migration occurred in four (12.9%, 95% confidence interval, 5.1% to 29.0%), with a mean time of 131 days. RBO occurred in 18 (58%), with a median time to RBO of 107 days. Following previous C-SEMS migration, seven of 10 patients (70%) did not experience m-CZS migration until death. CONCLUSIONS m-CZSs with antimigration properties effectively, although not completely, prevented stent migration after stent insertion.
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Affiliation(s)
- Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazumichi Kawakubo
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kouta Inoue
- Research and Development Center, ZEON Medical Inc., Kawasaki, Japan
| | - Chimyon Gon
- Research and Development Center, ZEON Medical Inc., Kawasaki, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Tokyo Police Hospital, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Takeshi Tsujino
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Kanto Central Hospital, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rie Uchino
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koji Miyabayashi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keisuke Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Sasaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kenji Hirano
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naoki Sasahira
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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90
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Hamada T, Isayama H, Nakai Y, Kogure H, Yamamoto N, Koike K. Tips and troubleshooting for transpapillary metal stenting for distal malignant biliary obstruction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:E12-8. [DOI: 10.1002/jhbp.51] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Tsuyoshi Hamada
- Department of Gastroenterology; Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo Bunkyo-ku Tokyo 113-8655 Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology; Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo Bunkyo-ku Tokyo 113-8655 Japan
| | - Yousuke Nakai
- Department of Gastroenterology; Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo Bunkyo-ku Tokyo 113-8655 Japan
| | - Hirofumi Kogure
- Department of Gastroenterology; Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo Bunkyo-ku Tokyo 113-8655 Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology; Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo Bunkyo-ku Tokyo 113-8655 Japan
| | - Kazuhiko Koike
- Department of Gastroenterology; Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo Bunkyo-ku Tokyo 113-8655 Japan
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91
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Shimizu S, Naitoh I, Nakazawa T, Hayashi K, Miyabe K, Kondo H, Yoshida M, Yamashita H, Ohara H, Joh T. Feasibility of one-step endoscopic metal stenting for distal malignant biliary obstruction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:219-25. [DOI: 10.1002/jhbp.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Shuya Shimizu
- Department of Gastroenterology and Metabolism; Nagoya City University Graduate School of Medical Sciences; 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism; Nagoya City University Graduate School of Medical Sciences; 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Takahiro Nakazawa
- Department of Gastroenterology and Metabolism; Nagoya City University Graduate School of Medical Sciences; 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Kazuki Hayashi
- Department of Gastroenterology and Metabolism; Nagoya City University Graduate School of Medical Sciences; 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Katsuyuki Miyabe
- Department of Gastroenterology and Metabolism; Nagoya City University Graduate School of Medical Sciences; 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Hiromu Kondo
- Department of Gastroenterology and Metabolism; Nagoya City University Graduate School of Medical Sciences; 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Michihiro Yoshida
- Department of Gastroenterology and Metabolism; Nagoya City University Graduate School of Medical Sciences; 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Hiroaki Yamashita
- Department of Gastroenterology and Metabolism; Nagoya City University Graduate School of Medical Sciences; 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Hirotaka Ohara
- Department of Community-based Medical Education; Nagoya City University Graduate School of Medical Sciences; Nagoya Japan
| | - Takashi Joh
- Department of Gastroenterology and Metabolism; Nagoya City University Graduate School of Medical Sciences; 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
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92
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Yasuda I. Endoscopic biliary stenting and pancreatitis. Clin J Gastroenterol 2013; 6:193-7. [PMID: 26181594 DOI: 10.1007/s12328-013-0394-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 05/21/2013] [Indexed: 11/27/2022]
Abstract
Endoscopic biliary stenting across the duodenal papilla can obstruct the adjacent pancreatic orifice and disturb the flow of pancreatic juice, which may result in pancreatitis. However, the relationship of endoscopic biliary stenting to post-procedure pancreatitis has not been thoroughly examined. Therefore, we have reviewed the published literature on this issue. Although biliary stenting, especially with large-bore and self-expandable metallic stents (SEMSs), has been considered a possible additional risk factor for pancreatitis following biliary stenting, most studies have not provided convincing supporting evidence; this failure may be due to inadequate study design or insufficient numbers of subjects. It also remains unclear whether endoscopic sphincterotomy (EST) performed prior to biliary stenting decreases the incidence of post-stenting pancreatitis; some recent studies have claimed that EST is not necessary before biliary stenting, even with placement of SEMSs. Well-designed studies with a large number of subjects will be needed to clarify these issues.
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Affiliation(s)
- Ichiro Yasuda
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan.
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93
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Irisawa A, Katanuma A, Itoi T. Otaru consensus on biliary stenting for unresectable distal malignant biliary obstruction. Dig Endosc 2013; 25 Suppl 2:52-7. [PMID: 23617650 DOI: 10.1111/den.12069] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Accepted: 12/26/2012] [Indexed: 12/21/2022]
Abstract
Endoscopic biliary drainage with biliary stent placement is the treatment of choice for palliation in patients with malignant biliary obstruction caused by unresectable neoplasms. Various biliary stent designs have become available, but lack of a clear consensus persists on the use of covered versus uncovered metal stents in malignant distal bile duct obstructions, and plastic versus metal stents. In 2012, the European Society of Gastrointestinal Endoscopy indicated guidelines for biliary stenting. Accordingly, the consensus meeting for biliary stenting was held at the Endoscopic Forum Japan 2012, and four selected statements related to stent placement for distal malignant biliary obstruction were discussed to produce a consensus. Two of four statements (related to the usefulness of self-expandable metallic stents, and reintervention after stenting) were agreed upon by almost all participants. Nevertheless, our opinions were divided on the other two statements (necessity of sphincterotomy for stenting, and covered metal stent versus uncovered metal stent). We herein report the results of the meeting, and present proposed new statements via discussion.
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Affiliation(s)
- Atsushi Irisawa
- Department of Gastroenterology, Fukushima Medical University Aizu Medical Center, Aizuwakamatsu, Japan.
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94
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Okano N, Igarashi Y, Kishimoto Y, Mimura T, Ito K. Necessity for endoscopic sphincterotomy for biliary stenting in cases of malignant biliary obstruction. Dig Endosc 2013; 25 Suppl 2:122-5. [PMID: 23617662 DOI: 10.1111/den.12071] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 01/07/2013] [Indexed: 02/08/2023]
Abstract
Endoscopic biliary stenting is a useful way to treat distal malignant biliary strictures that are not eligible for surgery. A 10-Fr plastic or metal stent is used for stenting. Typically, endoscopic sphincterotomy (EST) has often been carried out as a way to prevent pancreatitis after stent placement given the ease of stent insertion, but EST has flaws such as bleeding and stent migration.The present study describes the need for EST prior to stent placement.
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Affiliation(s)
- Naoki Okano
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan.
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95
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Itoi T, Tsuchiya T, Tanaka R, Ikeuchi N, Sofuni A. Lethal post-endoscopic retrograde cholangiopancreatography pancreatitis following fully covered metal stent placement in distal biliary obstruction due to unresectable cholangiocarcinoma. Dig Endosc 2013; 25 Suppl 2:117-21. [PMID: 23617661 DOI: 10.1111/den.12064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 01/08/2013] [Indexed: 02/08/2023]
Abstract
Biliary self-expandable metallic stent (SEMS) is the preferred and first-line therapy for unresectable malignant biliary obstruction. To date, several reports have revealed the relatively high incidence of acute complications such as pancreatitis and cholecystitis due to mechanical stent compression. In the present case, we encountered fatal pancreatitis following fully covered metal stent placement. An 85-year-old man had middle bile duct strictures due to cholangiocarcinoma. A 10-mm diameter fully covered SEMS was placed across the papilla for biliary decompression. Laboratory data and physical evidence the following day revealed acute pancreatitis. Therefore, antibiotics and protein degeneration enzyme inhibitors were given. However, his condition did not improve. Two days after the procedure, we removed the stent and returned him to his original hospital. Serum amylase level decreased below 400 mg/dL 6 h after the procedure. However, the acute pancreatitis worsened. Although we treated the patient in the intensive care unit, he died 32 days after the second admission.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
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96
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Isayama H, Nakai Y, Kogure H, Yamamoto N, Koike K. Biliary self-expandable metallic stent for unresectable malignant distal biliary obstruction: which is better: covered or uncovered? Dig Endosc 2013; 25 Suppl 2:71-4. [PMID: 23617653 DOI: 10.1111/den.12078] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 02/01/2013] [Indexed: 01/07/2023]
Abstract
Self-expandable metallic stents (SEMS) are a widely accepted biliary endoprosthesis for patients with unresectable malignant distal biliary obstruction. There are two types of SEMS: covered and uncovered. Uncovered SEMS (UCSEMS) embed into the biliary wall due to their mesh structure and self-expandability, and are resistant to migration. However, the disadvantage of UCSEMS is occlusion due to tumor ingrowth (TI) via the stent mesh, and TI is the main cause of UCSEMS occlusion. To overcome this, covered SEMS (CSEMS) were developed and showed longer patency than UCSEMS. However, migration due to the non-embedded stent body is the main cause of CSEMS dysfunction. There are some randomized studies comparing CSEMS and UCSEMS; however, the results are different according to each study. From one meta-analysis, CSEMS showed longer patency than UCSEMS. A literature review revealed that covered SEMS showed longer patency than UCSEMS. Some studies cannot clearly demonstrate the superiority of CSEMS, as the CSEMS used did not prevent TI or migration. Mechanical properties of SEMS may influence the occurrence of complications. A recent clinical study comparing the Covered Wallstent and the Covered WallFlex revealed superiority of the WallFlex for the prevention of migration. Reducing the axial force and increasing the radial force may lead to good results. Migration of CSEMS should be prevented by taking into consideration the mechanical properties of stents and development of anti-migration systems.
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Affiliation(s)
- Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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97
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Shimizu S, Naitoh I, Nakazawa T, Hayashi K, Miyabe K, Kondo H, Yoshida M, Yamashita H, Umemura S, Hori Y, Ohara H, Joh T. Predictive factors for pancreatitis and cholecystitis in endoscopic covered metal stenting for distal malignant biliary obstruction. J Gastroenterol Hepatol 2013; 28:68-72. [PMID: 23020651 DOI: 10.1111/j.1440-1746.2012.07283.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Pancreatitis and cholecystitis are major complications after self-expandable metal stent (SEMS) placement in distal malignant biliary obstruction. We aimed to clarify predictive factors for pancreatitis and cholecystitis after covered SEMS placement. METHODS We retrospectively reviewed 74 consecutive patients with distal malignant biliary obstruction who underwent initial endoscopic drainage using covered SEMS. Predictive factors for pancreatitis and cholecystitis were evaluated in the 74 patients described above and in 66 patients who had not undergone cholecystectomy. RESULTS The incidences of pancreatitis and cholecystitis were 10.8% (8/74) and 6.1% (4/66), respectively. Univariate analysis revealed that non-pancreatic cancer (P = 0.018) and contrast injection into the pancreatic duct (P = 0.030) were significant predictive factors for pancreatitis. Multivariate analysis revealed that non-pancreatic cancer (odds ratio [OR], 4.21; 95% confidence interval [CI], 1.63-14.18; P = 0.007) and contrast injection into the pancreatic duct (OR, 3.34; 95% CI, 1.33-9.60; P = 0.016) were significant independent predictive factors for pancreatitis. On the other hand, univariate and multivariate analyses revealed that tumor involvement to the orifice of the cystic duct (OCD) was a significant independent predictive factor for cholecystitis (OR, 5.85; 95% CI, 1.91-27.74; P = 0.005). CONCLUSIONS Non-pancreatic cancer and contrast injection into the pancreatic duct were predictive factors for pancreatitis, and tumor involvement to the OCD was a positive predictive factor for cholecystitis after endoscopic covered SEMS placement for distal malignant biliary obstruction.
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Affiliation(s)
- Shuya Shimizu
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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98
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Isayama H, Nakai Y, Kawakubo K, Kogure H, Hamada T, Togawa O, Sasahira N, Hirano K, Tsujino T, Koike K. Endoscopic retrograde cholangiopancreatography for distal malignant biliary stricture. Gastrointest Endosc Clin N Am 2012; 22:479-90. [PMID: 22748244 DOI: 10.1016/j.giec.2012.04.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic biliary stent placement is widely accepted as palliation for malignant biliary obstruction or as a treatment of benign biliary stricture. Although various biliary stent designs have become available since self-expandable metallic stents were introduced, no single ideal stent has been developed. An ideal stent should be patent until death, or surgery, in patients with resectable malignant biliary obstruction. Fewer complications, maneuverability, cost-effectiveness, and removability are also important factors. Alternatively, should we develop a novel method for biliary drainage other than biliary stenting via endoscopic retrograde cholangiopancreatography? This article reviews the current status of biliary stenting for malignant biliary obstructions.
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Affiliation(s)
- Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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99
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Isayama H, Mukai T, Itoi T, Maetani I, Nakai Y, Kawakami H, Yasuda I, Maguchi H, Ryozawa S, Hanada K, Hasebe O, Ito K, Kawamoto H, Mochizuki H, Igarashi Y, Irisawa A, Sasaki T, Togawa O, Hara T, Kamada H, Toda N, Kogure H. Comparison of partially covered nitinol stents with partially covered stainless stents as a historical control in a multicenter study of distal malignant biliary obstruction: the WATCH study. Gastrointest Endosc 2012; 76:84-92. [PMID: 22482918 DOI: 10.1016/j.gie.2012.02.039] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Accepted: 02/20/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Covered self-expandable metal stents (CSEMSs) were developed to prevent tumor ingrowth, but stent migration is one of the problems with CSEMSs. OBJECTIVE To evaluate a new, commercially available CSEMS with flared ends and low axial force compared with a commercially available CSEMS without the anti-migration system and high axial force. DESIGN Multicenter, prospective study with a historical cohort. SETTING Twenty Japanese referral centers. PATIENTS This study involved patients with unresectable distal malignant biliary obstruction. INTERVENTION Placement of a new, commercially available, partially covered SEMS. MAIN OUTCOME MEASUREMENTS Recurrent biliary obstruction rate, time to recurrent biliary obstruction, stent-related complications, survival. RESULTS Between April 2009 and March 2010, 141 patients underwent partially covered nitinol stent placement, and between May 2001 and January 2007, 138 patients underwent placement of partially covered stainless stents as a historical control. The silicone cover of the partially covered nitinol stents prevented tumor ingrowth. There were no significant differences in survival (229 vs 219 days; P = .250) or the rate of recurrent biliary obstruction (33% vs 38%; P = .385) between partially covered nitinol stents and partially covered stainless stents. Stent migration was less frequent (8% vs 17%; P = .019), and time to recurrent biliary obstruction was significantly longer (373 vs 285 days; P = .007) with partially covered nitinol stents. Stent removal was successful in 26 of 27 patients (96%). LIMITATIONS Nonrandomized, controlled trial. CONCLUSION Partially covered nitinol stents with an anti-migration system and less axial force demonstrated longer time to recurrent biliary obstruction with no tumor ingrowth and less stent migration.
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Affiliation(s)
- Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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