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Guzmán-Calderón GE, Chirinos J, Díaz-Arocutipa C, Vesco E, Huerta-Mercado J, Cedrón H, Montezuma D, Poppele G, Aparicio JR. Covered Versus Uncovered Metal Stents for the Drainage of the Malignant Distal Biliary Obstruction With ERCP: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2024:00004836-990000000-00312. [PMID: 38995024 DOI: 10.1097/mcg.0000000000002011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 03/17/2024] [Indexed: 07/13/2024]
Abstract
INTRODUCTION AND AIM Unresectable malignant distal biliary obstruction is a condition that should be treated with drainage and clearance of the biliary duct. self-expanded metal stents (SEMS) are known to be better and more effective than plastic stents because the patency is longer. The actual evidence is insufficient to recommend if it is better the use of SEMSu over SEMSc or vice versa for the drainage of the malignant distal biliary obstruction during ERCP. We performed a systematic review and meta-analyses to demonstrate if exists superiority between one or other type of SEMS performed by ERCP. MATERIALS AND METHODS We conducted a systematic review in different databases, such as PubMed, Cochrane, Medline, and OVID database. A search was made of all studies published up to May 2023. RESULTS Seven studies were analyzed. A total of 1070 patients were included. Of the total of patients, 48.9% were male. The cumulative stent patency, the failure rate, the survival probably and the adverse events rate, were similar between SEMSc and SEMSu groups. The stent migration rate was higher in the SEMSc group (RR=2.34 [95% CI: 1.35-4.08]). The tumor overgrowth was higher in the SEMSc group (RR=2.05 [95% CI: 1.13-3.72]). The tumor ingrowth was higher in the SEMSu group (RR=0.25 [95% CI: 0.11-0.61]). CONCLUSIONS The conclusions of our study show that there are no differences between the use of uncovered SEMS and covered SEMS for palliative treatment of distal biliopancreatic obstructions, and it has no impact on mortality or patient survival. New functional studies regarding the type of stent cover, radial force or length thereof are required.
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Affiliation(s)
- Gerly Edson Guzmán-Calderón
- Gastroenterology Unit of Angloamericana Clinic
- Gastroenterology Unit of Hospital Nacional Edgardo Rebagliati Martins
| | | | | | | | | | - Hugo Cedrón
- Gastroenterology Unit of Angloamericana Clinic
| | | | | | - José Ramón Aparicio
- Gastroenterology Unit oh Hospital General Universitario de Alicante, Alicante, Spain
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2
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Kim HS, Kang MJ, Kang J, Kim K, Kim B, Kim SH, Kim SJ, Kim YI, Kim JY, Kim JS, Kim H, Kim HJ, Nahm JH, Park WS, Park E, Park JK, Park JM, Song BJ, Shin YC, Ahn KS, Woo SM, Yu JI, Yoo C, Lee K, Lee DH, Lee MA, Lee SE, Lee IJ, Lee H, Im JH, Jang KT, Jang HY, Jun SY, Chon HJ, Jung MK, Chung YE, Chong JU, Cho E, Chie EK, Choi SB, Choi SY, Choi SJ, Choi JY, Choi HJ, Hong SM, Hong JH, Hong TH, Hwang SH, Hwang IG, Park JS. Practice guidelines for managing extrahepatic biliary tract cancers. Ann Hepatobiliary Pancreat Surg 2024; 28:161-202. [PMID: 38679456 PMCID: PMC11128785 DOI: 10.14701/ahbps.23-170] [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: 12/13/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 05/01/2024] Open
Abstract
Backgrounds/Aims Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021. Methods Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop. Results In November 2021, the finalized draft was presented for public scrutiny during a formal hearing. Conclusions The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.
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Affiliation(s)
- Hyung Sun Kim
- Department of Surgery, Pancreatobiliary Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Mee Joo Kang
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Jingu Kang
- Department of Internal Medicine, Kangdong Sacred Heart Hospital of Hallym University Medical Center, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Bohyun Kim
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Seong-Hun Kim
- Department of Internal Medicine, Jeonbuk National University Medical School and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Soo Jin Kim
- Department of Radiology, National Cancer Center, Goyang, Korea
| | - Yong-Il Kim
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Young Kim
- Department of Pathology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jin Sil Kim
- Department of Radiology, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo Jung Kim
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Ji Hae Nahm
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Suk Park
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Eunkyu Park
- Division of HBP Surgery, Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Joo Kyung Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Myung Park
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Byeong Jun Song
- Department of Internal Medicine, Myongji Hospital, Goyang, Korea
| | - Yong Chan Shin
- Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Keun Soo Ahn
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Sang Myung Woo
- Center for Liver and Pancreatobiliary Cancer, Hospital, Immuno-Oncology Branch Division of Rare and Refractory Center, Research Institute of National Cancer Center, Goyang, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoungbun Lee
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Myung Ah Lee
- Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Eun Lee
- Department of Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Huisong Lee
- Department of Surgery, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Jung Ho Im
- Department of Radiation Oncology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kee-Taek Jang
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Young Jang
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun-Young Jun
- Department of Pathology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hong Jae Chon
- Department of Medical Oncology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Min Kyu Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yong Eun Chung
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Uk Chong
- Department of Surgery, National Health Insurance Services Ilsan Hospital, Goyang, Korea
| | - Eunae Cho
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Sae Byeol Choi
- Department of Surgery, Korea Universtiy Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seo-Yeon Choi
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Ji Choi
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye-Jeong Choi
- Department of Pathology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hyung Hong
- Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Ho Hong
- Division of Hepato-Biliary and Pancreas Surgery, Department of Surgery, Seoul St. Mary’s Hospital College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Shin Hye Hwang
- Department of Radiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - In Gyu Hwang
- Division of Hemato-Oncology, Department of Internal Medicine, Chung-Ang University Hospital Chung-Ang University College of Medicine, Seoul, Korea
| | - Joon Seong Park
- Department of Surgery, Pancreatobiliary Clinic, Yonsei University College of Medicine, Seoul, Korea
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Sakai A, Masuda A, Eguchi T, Furumatsu K, Iemoto T, Yoshida S, Okabe Y, Yamanaka K, Miki I, Kakuyama S, Yagi Y, Shirasaka D, Kohashi S, Kobayashi T, Shiomi H, Kodama Y. A novel fully covered metal stent for unresectable malignant distal biliary obstruction: results of a multicenter prospective study. Clin Endosc 2024; 57:375-383. [PMID: 37430394 PMCID: PMC11133982 DOI: 10.5946/ce.2023.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic self-expandable metal stent (SEMS) placement is currently the standard technique for treating unresectable malignant distal biliary obstructions (MDBO). Therefore, covered SEMS with longer stent patency and fewer migrations are required. This study aimed to assess the clinical performance of a novel, fully covered SEMS for unresectable MDBO. METHODS This was a multicenter single-arm prospective study. The primary outcome was a non-obstruction rate at 6 months. The secondary outcomes were overall survival (OS), recurrent biliary obstruction (RBO), time to RBO (TRBO), technical and clinical success, and adverse events. RESULTS A total of 73 patients were enrolled in this study. The non-obstruction rate at 6 months was 61%. The median OS and TRBO were 233 and 216 days, respectively. The technical and clinical success rates were 100% and 97%, respectively. Furthermore, the rate of occurrence of RBO and adverse events was 49% and 21%, respectively. The length of bile duct stenosis (<2.2 cm) was the only significant risk factor for stent migration. CONCLUSIONS The non-obstruction rate of a novel fully covered SEMS for MDBO is comparable to that reported earlier but shorter than expected. Short bile duct stenosis is a significant risk factor for stent migration.
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Affiliation(s)
- Arata Sakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takaaki Eguchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Keisuke Furumatsu
- Department of Gastroenterology, Akashi Medical Center, Akashi, Japan
| | - Takao Iemoto
- Department of Gastroenterology, Kita-Harima Medical Center, Ono, Japan
| | - Shiei Yoshida
- Department of Gastroenterology, Kobe Medical Center, Kobe, Japan
| | - Yoshihiro Okabe
- Department of Gastroenterology, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Kodai Yamanaka
- Division of Gastroenterology, Konan Medical Center, Kobe, Japan
| | - Ikuya Miki
- Department of Gastroenterology, Hyogo Cancer Center, Akashi, Japan
| | - Saori Kakuyama
- Department of Gastroenterology, Takatsuki General Hospital, Takatsuki, Japan
| | - Yosuke Yagi
- Department of Internal Medicine, Shiso Municipal Hospital, Shiso, Japan
| | - Daisuke Shirasaka
- Department of Gastroenterology, Kobe Red Cross Hospital, Kobe, Japan
| | - Shinya Kohashi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takashi Kobayashi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Mukai T, Iwata K, Iwashita T, Doi S, Kawakami H, Okuno M, Maruta A, Uemura S, Shimizu M, Yasuda I. Comparison of covered self-expandable metallic stents with 12-mm and 10-mm diameters for unresectable malignant distal biliary obstructions: a prospective randomized trial. Gastrointest Endosc 2024; 99:732-738. [PMID: 38000479 DOI: 10.1016/j.gie.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/26/2023] [Accepted: 11/19/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND AND AIMS Covered self-expandable metallic stents have longer patency than uncovered self-expandable metallic stents for unresectable malignant distal biliary obstruction because of the prevention of tumor ingrowth, and they are removable during reintervention. One main cause of recurrent biliary obstruction in covered self-expandable metallic stents is sludge formation, which can be prevented by using large-bore stents. We evaluated the treatment results of 12-mm and 10-mm covered self-expandable metallic stents for unresectable malignant distal biliary obstructions using a randomized controlled trial. METHODS This study was conducted between May 2016 and January 2019 and included 81 consecutive patients with unresectable malignant distal biliary obstruction. The primary endpoint was the rate of nonrecurrent biliary obstruction at 6 months after stent placement. RESULTS The primary endpoint in the 12-mm group was significantly higher than that in the 10-mm group (P = .0369). Therefore, the median time to recurrent biliary obstruction was 172 days in the 12-mm group and 120 days in the 10-mm group. The median time to recurrent biliary obstruction in the 12-mm group was significantly longer than that in the 10-mm group (P = .0168). Using the 12-mm covered self-expandable metallic stents and receiving chemotherapy were factors affecting the rate of recurrent biliary obstruction in the multivariate analysis. CONCLUSIONS The 12-mm covered self-expandable metallic stents provide a longer time to recurrent biliary obstruction than do 10-mm covered self-expandable metallic stents for managing unresectable malignant distal biliary obstruction. (Clinical trial registration number: UMIN000016911.).
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Affiliation(s)
- Tsuyoshi Mukai
- Department of Gastroenterological Endoscopy, Kanazawa Medical University Hospital, Ishikawa, Japan; Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan.
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan; Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Shinpei Doi
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Hiroshi Kawakami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Mitsuru Okuno
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Akinori Maruta
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan; Third Department of Internal Medicine, University of Toyama, Toyama, Japan
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Brinkmann F, Uhlig K, Sambale A, Stommel M, Berning M, Babatz J, Sulk S, Krasz S, Schmelz R, Brückner S, Hampe J, Zeissig S. Anchoring fins of fully covered self-expandable metal stents affect pull-out force and stent migration. Gastrointest Endosc 2024; 99:377-386.e3. [PMID: 37863243 DOI: 10.1016/j.gie.2023.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/29/2023] [Accepted: 10/06/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND AND AIMS Stent migration and subsequent adverse events are frequently observed in the use of fully covered self-expandable metal stents (FCSEMSs) for distal biliary stenosis. In this study, we identified predictors for stent migration based on biomechanical stent characteristics and associated these findings with clinical outcomes. METHODS The migration resistance of FCSEMSs was quantified by measuring the pull-out force. We analyzed a single-center retrospective cohort of 178 FCSEMSs for treatment success and adverse events occurring during 180 days of follow-up. RESULTS Biomechanical measurements revealed a 4-fold higher migration resistance of FCSEMSs with anchoring fins (AF-FCSEMSs; Fmax = 14.2 ± .1 N) compared with FCSEMSs with flared ends (FE-FCSEMSs; Fmax = 3.8 ± 1.0 N; P < .0001). Clinically, AF-FCSEMSs showed lower rates of migration compared with FE-FCSEMSs (5% vs 34%, P < .0001). Unscheduled ERCP procedures because of stent dysfunction were less frequent in the AF group compared with the FE group (15% vs 29%, P = .046). Cholangitis because of stent dysfunction was observed in 5% of the AF group compared with 19% in the FE group (P = .02). Stent patency rates at 1, 3, and 6 months were higher in the AF group (96%, 90%, and 80%, respectively) compared with the FE group (90%, 74%, and 66%; log-rank test: P = .03). CONCLUSIONS The pull-out force as a biomechanical stent property predicts the migration resistance of FCSEMSs in distal biliary stenosis and may thus be used to classify stents for this application. AF-FCSEMSs showed a significantly lower rate of migration and adverse events compared with FE-FCSEMSs.
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Affiliation(s)
- Franz Brinkmann
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany; Else Kröner Fresenius Center for Digital Health, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Kai Uhlig
- Department Materials Engineering, Leibniz Institute of Polymer Materials, Dresden, Germany
| | - Anna Sambale
- Department Materials Engineering, Leibniz Institute of Polymer Materials, Dresden, Germany
| | - Markus Stommel
- Department Materials Engineering, Leibniz Institute of Polymer Materials, Dresden, Germany; Institute for Materials Science, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Marco Berning
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Jana Babatz
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Stefan Sulk
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Susanne Krasz
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Renate Schmelz
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Stefan Brückner
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Jochen Hampe
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany; Else Kröner Fresenius Center for Digital Health, Technische Universität Dresden (TU Dresden), Dresden, Germany; Center for Regenerative Therapies Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Sebastian Zeissig
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany; Center for Regenerative Therapies Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
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Torisu Y, Chiba M, Kato M, Kinoshita Y, Akasu T, Kanai T, Tomita Y, Shimamoto N, Abe T, Kanazawa K, Tsukinaga S, Nakano M, Saeki C, Sumiyama K, Saruta M. Potential significance of uncovered self‐expandable metal stents for distal malignant biliary obstruction: A propensity score‐adjusted competing risk regression analysis. DEN OPEN 2023; 3:e166. [PMID: 36189168 PMCID: PMC9490143 DOI: 10.1002/deo2.166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/20/2022] [Accepted: 08/28/2022] [Indexed: 11/28/2022]
Abstract
Objectives Selection criteria for self‐expandable metal stents (SEMSs) with or without cover during palliative treatment of distal malignant biliary obstruction (DMBO) remain unclear. We evaluated factors associated with time to recurrent biliary obstruction (TRBO) in fully covered SEMSs (FCSEMSs) and uncovered SEMSs (UCSEMSs). Methods We retrospectively analyzed consecutive patients with DMBO who received a SEMS. TRBO was determined using the Kaplan–Meier analysis, and complications were compared between the FCSEMS and UCSEMS groups. After TRBO‐associated factors were extracted using multivariate competing‐risks regression (CRR), propensity score‐adjusted CRRs were performed to verify their robustness. Results There were 180 patients (66 FCSEMSs and 114 UCSEMSs) enrolled in this study. There was no significant difference between median TRBO in the FCSEMS and UCSEMS groups (275 vs. 255 days, p = 0.67). Complications were more frequent in the FCSEMS than UCSEMS group (21.2% vs. 8.8%; p = 0.023). Multivariate CRR for TRBO‐associated factors revealed that “pancreatic ductal carcinoma (PDAC) treated with UCSEMS” was the only independent predictor of TRBO (p = 0.03). Similarly, the propensity score‐adjusted CRRs showed no significant difference in TRBO in “FCSEMS” vs “UCSEMS” (p = 0.96); however, there was a significant difference in “PDAC using UCSEMS” vs “other” (p = 0.043). In the palliative care group including any DMBO without chemotherapy, the first quartile of the TRBO of UCSEMS was 100 days. Conclusions UCSEMSs are a possible option for both patients with DMBO arising from PDAC and for patients with any DMBO receiving palliative care who should avoid SEMS‐related complications.
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Affiliation(s)
- Yuichi Torisu
- Department of Internal Medicine Division of Gastroenterology and Hepatology, The Jikei University School of Medicine Tokyo Japan
| | - Masafumi Chiba
- Department of Endoscopy The Jikei University School of Medicine Tokyo Japan
| | - Masayuki Kato
- Department of Endoscopy The Jikei University School of Medicine Tokyo Japan
| | - Yuji Kinoshita
- Department of Internal Medicine Division of Gastroenterology and Hepatology, The Jikei University School of Medicine Tokyo Japan
| | - Takafumi Akasu
- Department of Internal Medicine Division of Gastroenterology and Hepatology, The Jikei University School of Medicine Tokyo Japan
| | - Tomoya Kanai
- Department of Internal Medicine Division of Gastroenterology, Fuji City General Hospital Shizuoka Japan
| | - Yoichi Tomita
- Department of Internal Medicine Division of Gastroenterology and Hepatology, The Jikei University School of Medicine Tokyo Japan
| | - Nana Shimamoto
- Department of Endoscopy The Jikei University School of Medicine Tokyo Japan
| | - Takahiro Abe
- Department of Endoscopy The Jikei University School of Medicine Tokyo Japan
| | - Keisuke Kanazawa
- Department of Endoscopy The Jikei University School of Medicine Tokyo Japan
| | - Shintaro Tsukinaga
- Department of Endoscopy The Jikei University School of Medicine Tokyo Japan
| | - Masanori Nakano
- Department of Internal Medicine Division of Gastroenterology and Hepatology, The Jikei University School of Medicine Tokyo Japan
| | - Chisato Saeki
- Department of Internal Medicine Division of Gastroenterology and Hepatology, The Jikei University School of Medicine Tokyo Japan
| | - Kazuki Sumiyama
- Department of Endoscopy The Jikei University School of Medicine Tokyo Japan
| | - Masayuki Saruta
- Department of Internal Medicine Division of Gastroenterology and Hepatology, The Jikei University School of Medicine Tokyo Japan
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7
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Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Okubo Y, Nakamura J, Takasumi M, Hashimoto M, Kato T, Kobashi R, Yanagita T, Hikichi T, Ohira H. Biliary metal stents should be placed near the hilar duct in distal malignant biliary stricture patients. World J Gastroenterol 2022; 28:1860-1870. [PMID: 35633904 PMCID: PMC9099198 DOI: 10.3748/wjg.v28.i17.1860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/04/2021] [Accepted: 03/25/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic biliary drainage using a self-expandable metallic stent (SEMS) has been widely performed to treat distal malignant biliary obstruction (DMBO). However, the optimal position of the stent remains unclear. AIM To determine the ideal position for SEMS placement. METHODS In total, 135 DMBO patients underwent SEMS (uncovered or covered) placement over a ten-year period. A total of 127 patients with biliary obstruction between the junction of the cystic duct and Vater's papilla were enrolled. An SEMS was placed through the upper common bile duct 2 cm from the biliary hilar duct in 83 patients (Hilar group) or near the top of the biliary obstruction in 44 patients (Lower group). Technical and functional success, adverse events, and risk factors for SEMS dysfunction were evaluated. RESULTS The stent patency period was significantly longer in the Hilar group than in the Lower group (P value < 0.01). In multivariate analysis, the only statistically significant risk factor for SEMS dysfunction was being in the Lower group (hazard ratio: 9.94, 95% confidence interval: 2.25-44.0, P < 0.01). CONCLUSION A longer patency period was achieved by positioning the SEMS near the biliary hilar duct.
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Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
| | - Hiroki Irie
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
| | - Yoshinori Okubo
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Jun Nakamura
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
| | - Minami Hashimoto
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Tsunetaka Kato
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Ryoichiro Kobashi
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Takumi Yanagita
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, Fukushima 9601295, Japan
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8
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Mocan T, Horhat A, Mois E, Graur F, Tefas C, Craciun R, Nenu I, Spârchez M, Sparchez Z. Endoscopic or percutaneous biliary drainage in hilar cholangiocarcinoma: When and how? World J Gastrointest Oncol 2021; 13:2050-2063. [PMID: 35070041 PMCID: PMC8713328 DOI: 10.4251/wjgo.v13.i12.2050] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/28/2021] [Accepted: 10/14/2021] [Indexed: 02/06/2023] Open
Abstract
Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dim prognosis. The role of preoperative and palliative biliary drainage has long been debated. The most common techniques are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD); however, recently developed endoscopic ultrasound-assisted methods are gaining more atention. Selecting the best available method in any specific scenario is crucial, yet sometimes challenging. Thus, this review aimed to discuss the available techniques, indications, perks, pitfalls, and timing-related issues in the management of hCCA. In a preoperative setting, PTBD appears to have some advantages: low risk of postprocedural complications (namely cholangitis) and better priming for surgery. For palliative purposes, we propose ERCP/PTBD depending on the experience of the operators, but also on other factors: the level of bilirubin (if very high, rather PTBD), length of the stenosis and the presence of cholangitis (PTBD), ERCP failure, or altered biliary anatomy.
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Affiliation(s)
- Tudor Mocan
- Third Medical Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Institute for Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Adelina Horhat
- Third Medical Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Institute for Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Emil Mois
- Third Medical Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Institute for Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Florin Graur
- Third Medical Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Institute for Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Cristian Tefas
- Third Medical Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Institute for Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Rares Craciun
- Third Medical Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Institute for Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Iuliana Nenu
- Third Medical Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Institute for Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Mihaela Spârchez
- Second Pediatric Department, University of Medicine and Pharmacy, "Iuliu Hatieganu", Cluj-Napoca 400162, Romania
| | - Zeno Sparchez
- Third Medical Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
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9
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Choi W, Gwon DI, Kim JW, Kim JH, Shin JH, Ko GY, Hur J. Percutaneous cholecystostomy for acute cholecystitis after stent insertion in patients with malignant biliary obstruction: clinical outcomes of 107 patients. Acta Radiol 2021; 63:1315-1322. [PMID: 34623186 DOI: 10.1177/02841851211041816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The outcome of percutaneous cholecystostomy (PC) in malignant patients with acute cholecystitis (AC) after biliary stent insertion has not been investigated in a large group. PURPOSE To evaluate the clinical outcomes of PC for AC after stent insertion in patients with malignant biliary obstruction. MATERIAL AND METHODS From April 2007 to February 2019, 107 patients (57 men, 52 women; mean age = 67.5 years; age range = 27-93 years) who had undergone PC for AC after biliary stent insertion were retrospectively evaluated. Of the 107 patients, 86 underwent biliary stent insertion by the endoscopic approach and the remaining 21 patients by the percutaneous approach. All patients were classified into three groups: those with stent-induced AC; those with cancer-induced AC; and those with AC without mechanical cause (biliary stent, GB stone, or cancer invasion). The mean survival time, recurrence rate, symptom improvement, and cystic duct patency in each patient group were analyzed. RESULTS Stent-induced AC (n = 40, 37.4%) developed with a mean onset time of six days (range = 0-14 days), AC without mechanical cause (n = 27, 25.2%), 87 days (range = 15-273 days), and cancer-induced AC (n = 40, 37.4%), 137 days (range = 15-447 days) after stent insertion. Symptom resolution and significant improvement in laboratory test values were achieved in 95 patients (88.8%) within four days after PC. CONCLUSION PC is a technically safe and effective method for the treatment of AC after biliary stent insertion in patients with malignant biliary obstruction.
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Affiliation(s)
- Woosun Choi
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Joonho Hur
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
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10
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CIRSE Standards of Practice on Percutaneous Transhepatic Cholangiography, Biliary Drainage and Stenting. Cardiovasc Intervent Radiol 2021; 44:1499-1509. [PMID: 34327586 DOI: 10.1007/s00270-021-02903-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 06/14/2021] [Indexed: 10/20/2022]
Abstract
This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing percutaneous transhepatic cholangiography, biliary drainage and stenting. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.
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11
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Park CH, Park SW, Jung JH, Jung ES, Kim JH, Park DH. Comparative Efficacy of Various Stents for Palliation in Patients with Malignant Extrahepatic Biliary Obstruction: A Systematic Review and Network Meta-Analysis. J Pers Med 2021; 11:jpm11020086. [PMID: 33573288 PMCID: PMC7912345 DOI: 10.3390/jpm11020086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/20/2021] [Accepted: 01/27/2021] [Indexed: 11/16/2022] Open
Abstract
Although many studies have investigated the efficacy of stent placement for patients with malignant extrahepatic biliary obstruction, the clinical outcomes and adverse events of biliary stenting have not been comprehensively evaluated. We searched all relevant randomized-controlled trials that evaluated the comparative efficacy of biliary stents, including the plastic stents, uncovered self-expandable metal stents (SEMSs), and covered SEMSs in patients with malignant extrahepatic biliary obstructions. Twenty-one studies with 2326 patients were included. Both uncovered and covered SEMSs had a lower risk of recurrent biliary obstruction (RBO) compared to plastic stents (risk ratio (RR) (95% confidence interval [CI]): uncovered vs. plastic, 0.46 (0.35–0.62); covered vs. plastic, 0.46 (0.34–0.62)). A comparison of the groups using SEMSs revealed that tumor ingrowth was common in the uncovered SEMS group, while stent migration, tumor overgrowth, and occlusion by sludge were common in the covered SEMS group; however, the overall risk of RBO did not differ between these groups (RR (95% CI): uncovered vs. covered: 1.02 (0.80–1.30)). Although the main causes of RBO vary across stents, RBO risk was similar between uncovered and covered SEMS groups. Both SEMSs have superior efficacy in terms of RBO compared to plastic stents.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri 11923, Korea;
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
- Correspondence: ; Tel.: +82-31-8086-2858
| | - Jang Han Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
| | - Eun Suk Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
| | - Jung Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
| | - Da Hae Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
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12
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Randomized Controlled Study to Compare Uncovered Stent Versus Covered Stent as Percutaneous Endoprosthesis for Malignant Biliary Obstruction (JIVROSG-0207). Am J Clin Oncol 2021; 43:784-787. [PMID: 32826390 DOI: 10.1097/coc.0000000000000750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to compare the clinical effectiveness of uncovered stent and covered stent as percutaneous endoprosthesis for malignant biliary obstruction of the extrahepatic bile duct. MATERIALS AND METHODS After completion of percutaneous internal and external tube placement for unresectable malignant biliary obstruction, 60 patients were registered and randomly assigned in a 1:1 ratio to an uncovered or covered stent group. Metallic stent placement was performed within 1 week after registration, and an external biliary drainage tube was removed >3 days after stent placement. The primary endpoint was the obstructive jaundice-free survival rate at 24 weeks after registration, and the secondary endpoints were the success rate of percutaneous tube removal and adverse events. RESULTS The obstructive jaundice-free survival rate at 24 weeks after registration was 13/29 (44.8%, 95% confidence interval [CI]: 28.4%-62.5%) and 15/30 (50.0%, 95% CI: 33.2%-66.8%) in the uncovered and covered stent groups, respectively. The success rate of percutaneous tube removal was 28/29 (96.6%, 95% CI: 82.8%-99.4%) and 30/30 (100%, 95% CI: 90.5%-100%) in the uncovered and covered stent groups, respectively. There were no procedure-related deaths. Twenty-eight adverse events were observed in 21 patients (7 in the uncovered stent group and 14 in the covered stent group). CONCLUSIONS There was no significant difference in the obstructive jaundice-free survival rate at 24 weeks between the 2 groups. Considering the technical difficulty and invasiveness of covered stent placement, the placement of covered stents may not be needed in patients with a short prognosis of <24 weeks.
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13
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Xiang Y, Lu S, Li Y, Liu Z, Wang W. Iodine-125 Seeds Combined With Biliary Stent Placement Versus Stent Placement Alone For Unresectable Malignant Biliary Obstruction: A Meta-Analysis Of Randomized Controlled Trials. J Cancer 2021; 12:1334-1342. [PMID: 33531978 PMCID: PMC7847662 DOI: 10.7150/jca.49663] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 12/03/2020] [Indexed: 11/30/2022] Open
Abstract
Background and Aims: Malignant biliary obstruction is always caused by tumors which are unresectable so that palliative stent placement is conducted for drainage of bile duct tree. Recently, irradiation stent with 125I seeds has been used to improve the stent patency and survival time of patients. We conducted this meta-analysis to evaluate the therapeutic efficacy and safety of biliary stent placement with 125I seeds compared with stent placement alone in patients with malignant biliary obstruction. Methods: We searched Pubmed, Web of Science, ClinicalTrials.gov, Cochrane Library, Embase and CNKI databases for all relevant studies up to 1 May 2020. Patient survival, stent patency, and adverse events were the primary outcome measured. Also, Review Manager 5.3 and Stata/SE15.0 were used to perform the analysis. Results: Eleven randomized controlled trials with a total of 767 patients were included for meta-analysis. Stent combined with 125I seeds showed lower risk of stent occlusion at 3 month (Odds Ratios(OR) = 0.15; 95%CI: 0.05-0.49, P =0.002), 6 month (OR = 0.18; 95%CI: 0.08-0.44, P = 0.0001), 9 month (OR = 0.10; 95%CI: 0.05-0.20, P < 0.00001) and 1 year (OR = 0.15; 95%CI: 0.07-0.31, P < 0.00001) and better mean survival (MD = 125days; 95% CI 91-159 days; P < 0.00001) compared with stent placement alone. Also, reconstructed Kaplan-Meier data demonstrated improved survival in patients treated with stent plus 125I seeds (hazard ratio(HR)= 1.886; 95% CI: 1.609 to 2.210; P < 0.0001) Moreover, our analysis did not show significant difference between the two groups about the risk of adverse events including abdominal pain, hemobilia, pancreatitis, cholangitis and cholecystitis. Conclusion: 125I seeds combined with stent demonstrated superior stent patency and improved survival time compared to stent alone with acceptable complications.
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Affiliation(s)
- Yucheng Xiang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310009
| | - Sinan Lu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310009
| | - Yufeng Li
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310009
| | - Zhenghao Liu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310009
| | - Weilin Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310009
- Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou, Zhejiang 310009
- Clinical Research Center of Hepatobiliary and Pancreatic diseases of Zhejiang Province, Hangzhou, Zhejiang 310009
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14
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Nagino M, Hirano S, Yoshitomi H, Aoki T, Uesaka K, Unno M, Ebata T, Konishi M, Sano K, Shimada K, Shimizu H, Higuchi R, Wakai T, Isayama H, Okusaka T, Tsuyuguchi T, Hirooka Y, Furuse J, Maguchi H, Suzuki K, Yamazaki H, Kijima H, Yanagisawa A, Yoshida M, Yokoyama Y, Mizuno T, Endo I. Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:26-54. [PMID: 33259690 DOI: 10.1002/jhbp.870] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014. METHODS In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. RESULTS The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded. CONCLUSIONS This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.
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Affiliation(s)
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideyuki Yoshitomi
- Department of Surgery, Saitama Medical Center, Dokkyo Medical University, Koshigaya, Japan
| | - Taku Aoki
- Second Department of Surgery, Dokkyo Medical University, Mibu, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Nagaizumi, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomoki Ebata
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaru Konishi
- Department of Hepatobiliary Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Kazuaki Shimada
- Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroaki Shimizu
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshifumi Wakai
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Toshio Tsuyuguchi
- Department of Gastroenterology, Chiba Prefectural Sawara Hospital, Sawara, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Gastroenterological Oncology, Fujita Health University, Toyoake, Japan
| | - Junji Furuse
- Department of Medical Oncology, Faculty of Medicine, Kyorin University, Mitaka, Japan
| | - Hiroyuki Maguchi
- Education and Research Center, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Kojiro Suzuki
- Department of Radiology, Aichi Medical University, Nagakute, Japan
| | - Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroshi Kijima
- Department of Pathology and Bioscience, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Akio Yanagisawa
- Department of Pathology, Japanese Red Cross Kyoto Diichi Hospital, Kyoto, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic & Gastrointestinal Surgery, International University of Health and Welfare, Ichikawa, Japan
| | - Yukihiro Yokoyama
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Mizuno
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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15
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Elkilany A, Alwarraky M, Geisel D, Maaly MA, Denecke T. Stent performance in palliative transhepatic treatment of malignant biliary obstruction: a randomized study comparing covered versus uncovered stents. Acta Radiol 2020; 61:1591-1599. [PMID: 32212829 DOI: 10.1177/0284185120911187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Considering the limitations in both uncovered self-expandable metallic stents (USEMS) and covered self-expandable metallic stents (CSEMS), it is difficult to make a general recommendation for their application in percutaneous decompression of malignant biliary obstruction (MBO). PURPOSE To compare percutaneous transhepatic CSEMSs versus USEMSs for the palliative treatment of MBO in terms of technical success, clinical success, stent patency, patient survival, complications, and stent dysfunction. MATERIAL AND METHODS This prospective randomized study included 66 patients with unresectable MBO. CSEMSs were inserted in 31 patients (26 men, 5 women; mean age = 63.8 ± 7.96 years) and USEMSs were inserted in 35 patients (26 men, 9 women; mean age = 62.3 ± 11.7 years). RESULTS Mean primary stent patency duration was 138 ± 92.7 days in CSEMSs versus 150 ± 77.9 days in USEMSs (P = 0.578). Tumor overgrowth occurred exclusively in one patient with CSEMS (P = 0.470) and tumor ingrowth exclusively in two patients with USEMS (P = 0.494). Stent migration occurred in two patients with CSEMSs versus one patient with USEMSs (P = 0.579). Hemobilia occurred in five patients with CSEMSs versus three patients with USEMSs while bile leakage occurred in one patient in each group despite the larger introducer sheath caliber with CSEMSs (9 F vs. 6-7 F). There was no significant difference regarding patient survival (P = 0.969). CONCLUSION In our cohort of patients with rather poor life expectancy, there was no significant difference between covered and uncovered stents for the palliative treatment of MBO. However, considering the higher cost of CSEMs and the larger introducer diameter necessary for their placement, USEMSs can be preferred.
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Affiliation(s)
- Aboelyazid Elkilany
- Department of Diagnostic Medical Imaging and Interventional Radiology, National Liver Institute, Menoufia University, Menoufia, Egypt
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mohamed Alwarraky
- Department of Diagnostic Medical Imaging and Interventional Radiology, National Liver Institute, Menoufia University, Menoufia, Egypt
| | - Dominik Geisel
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mohamed A Maaly
- Department of Radiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, Leipzig University Hospital, Leipzig, Germany
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Yousaf MN, Ehsan H, Wahab A, Muneeb A, Chaudhary FS, Williams R, Haas CJ. Endoscopic retrograde cholangiopancreatography guided interventions in the management of pancreatic cancer. World J Gastrointest Endosc 2020; 12:323-340. [PMID: 33133370 PMCID: PMC7579529 DOI: 10.4253/wjge.v12.i10.323] [Citation(s) in RCA: 3] [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: 06/16/2020] [Revised: 07/23/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9% in the United States. At presentation, the majority of patients have painless jaundice, pruritis, and malaise, a triad that develops secondary to obstruction, which often occurs late in the course of the disease process. The technical advancements in radiological imaging and endoscopic interventions have played a crucial role in the diagnosis, staging, and management of patients with pancreatic cancer. Endoscopic retrograde cholangiopancreatography (ERCP)-guided diagnosis (with brush cytology, serial pancreatic juice aspiration cytologic examination technique, or biliary biopsy) and therapeutic interventions such as pancreatobiliary decompression, intraductal and relief of gastric outlet obstruction play a pivotal role in the management of advanced pancreatic cancer and are increasingly used due to improved morbidity and complication rates compared to surgical management. In this review, we highlight various ERCP-guided diagnostic and therapeutic interventions for the management of pancreatic cancer.
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Affiliation(s)
- Muhammad Nadeem Yousaf
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
- Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD 21239, United States
- Department of Medicine, Medstar Franklin Square Medical Center, Baltimore, MD 21237, United States
- Department of Medicine, MedStar Harbor Hospital, Baltimore, MD 21225, United States
| | - Hamid Ehsan
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
| | - Ahsan Wahab
- Department of Hospital Medicine, Baptist Medical Center South, Montgomery, AL 36116, United States
| | - Ahmad Muneeb
- Department of Medicine, Faisalabad Medical University, Faisalabald 38000, Punjab, Pakistan
| | - Fizah S Chaudhary
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
- Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD 21239, United States
- Department of Medicine, Medstar Franklin Square Medical Center, Baltimore, MD 21237, United States
- Department of Medicine, MedStar Harbor Hospital, Baltimore, MD 21225, United States
| | - Richard Williams
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
- Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD 21239, United States
- Department of Medicine, Medstar Franklin Square Medical Center, Baltimore, MD 21237, United States
- Department of Medicine, MedStar Harbor Hospital, Baltimore, MD 21225, United States
| | - Christopher J Haas
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
- Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD 21239, United States
- Department of Medicine, Medstar Franklin Square Medical Center, Baltimore, MD 21237, United States
- Department of Medicine, MedStar Harbor Hospital, Baltimore, MD 21225, United States
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Nakai Y, Isayama H, Wang H, Rerknimitr R, Khor C, Yasuda I, Kogure H, Moon JH, Lau J, Lakhtakia S, Ratanachu‐ek T, Seo DW, Lee DK, Makmun D, Dy F, Liao W, Draganov PV, Almadi M, Irisawa A, Katanuma A, Kitano M, Ryozawa S, Fujisawa T, Wallace MB, Itoi T, Devereaux B. International consensus statements for endoscopic management of distal biliary stricture. J Gastroenterol Hepatol 2020; 35:967-979. [PMID: 31802537 PMCID: PMC7318125 DOI: 10.1111/jgh.14955] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 02/05/2023]
Abstract
Distal biliary strictures (DBS) are common and may be caused by both malignant and benign pathologies. While endoscopic procedures play a major role in their management, a comprehensive review of the subject is still lacking. Our consensus statements were formulated by a group of expert Asian pancreatico-biliary interventional endoscopists, following a proposal from the Digestive Endoscopy Society of Taiwan, the Thai Association for Gastrointestinal Endoscopy, and the Tokyo Conference of Asian Pancreato-biliary Interventional Endoscopy. Based on a literature review utilizing Medline, Cochrane library, and Embase databases, a total of 19 consensus statements on DBS were made on diagnosis, endoscopic drainage, benign biliary stricture, malignant biliary stricture, and management of recurrent biliary obstruction and other complications. Our consensus statements provide comprehensive guidance for the endoscopic management of DBS.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of MedicineThe University of TokyoTokyoJapan,Department of Endoscopy and Endoscopic Surgery, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of MedicineThe University of TokyoTokyoJapan,Department of Gastroenterology, Graduate School of MedicineJuntendo UniversityTokyoJapan
| | - Hsiu‐Po Wang
- Department of Internal Medicine, College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of MedicineChulalongkorn UniversityBangkokThailand
| | - Christopher Khor
- Department of Gastroenterology and HepatologySingapore General Hospital and Duke‐NUS Medical SchoolSingaporeSingapore
| | - Ichiro Yasuda
- Third Department of Internal Medicine, Graduate School of MedicineUniversity of ToyamaToyamaJapan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal MedicineSoonChunHyang University School of MedicineBucheon/SeoulSouth Korea
| | - James Lau
- Department of Surgery, Endoscopic Center, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong, China
| | | | | | - Dong Wan Seo
- Department of Internal MedicineUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulSouth Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance HospitalYonsei University College of MedicineSeoulSouth Korea
| | - Dadang Makmun
- Division of Gastroenterology, Department of Internal Medicine, Faculty of MedicineUniversitas Indonesia/Cipto Mangunkusumo National General HospitalJakartaIndonesia
| | - Frederick Dy
- Section of Gastroenterology, Department of Internal Medicine, Faculty of Medicine and SurgeryUniversity of Santo Tomas HospitalManilaPhilippines
| | - Wei‐Chih Liao
- Department of Internal Medicine, College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Peter V Draganov
- Department of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Majid Almadi
- Division of Gastroenterology, King Khalid University HospitalKing Saud UniversityRiyadhSaudi Arabia
| | - Atsushi Irisawa
- Department of GastroenterologyDokkyo Medical UniversityTochigiJapan
| | - Akio Katanuma
- Center for GastroenterologyTeine‐Keijinkai HospitalSapporoJapan
| | - Masayuki Kitano
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Shomei Ryozawa
- Department of GastroenterologySaitama Medical University International Medical CenterSaitamaJapan
| | - Toshio Fujisawa
- Department of Gastroenterology, Graduate School of MedicineJuntendo UniversityTokyoJapan
| | | | - Takao Itoi
- Department of Gastroenterology and HepatologyTokyo Medical UniversityTokyoJapan
| | - Benedict Devereaux
- University of QueenslandRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
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Percutaneous Intraductal Microwave Ablation of Malignant Biliary Strictures: Initial Experience. AJR Am J Roentgenol 2020; 215:753-759. [PMID: 32406771 DOI: 10.2214/ajr.19.21897] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE. Metallic stenting of malignant biliary strictures is the preferred method of palliation, because most patients present when the condition is inoperable. Most metallic stents, however, are occluded 6-8 months after deployment. Intraductal radiofrequency ablation has been used in previous studies to improve stent patency. The purpose of this study was to assess a single-center experience with percutaneous intraductal microwave ablation of malignant biliary strictures. MATERIALS AND METHODS. In this retrospective case series study, data on 12 patients with malignant biliary obstruction who underwent percutaneous intraductal microwave ablation followed by metallic stenting were evaluated. Ablation procedures were performed with generator frequencies of 902-928 MHz, power set at 6-10 W, and ablation time of 60-90 seconds in a temperature-controlled manner with target temperature set at 80°C. RESULTS. Causes of malignant biliary obstruction were pancreatic carcinoma in four patients, gastric antrum carcinoma in three, cholangiocarcinoma in two, metastasis in two, and gallbladder carcinoma in one patient. Percutaneous intraductal microwave ablation and metallic stenting were performed successfully in all patients. There was no procedural mortality or major complication. The most common minor complication was abdominal pain. Biliary decompression was achieved in all patients at the end of the first month. The mean follow-up time was 9.4 months. The median primary stent patency period was 231 days. There were two stent occlusions due to sludge formation, and two patients died during follow-up. CONCLUSION. Percutaneous intraductal microwave ablation of malignant biliary strictures is safe and feasible. Prospective randomized controlled studies with long-term results are warranted to determine the effectiveness of this technique in lengthening the stent patency period.
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Dhondt E, Vanlangenhove P, De Man M, Huyck L, Defreyne L. No Advantage of Expanded Polytetrafluoroethylene and Fluorinated Ethylene Propylene–Covered Stents over Uncovered Nitinol Stents for Percutaneous Palliation of Malignant Infrahilar Biliary Obstruction: Results of a Single-Center Prospective Randomized Trial. J Vasc Interv Radiol 2020; 31:82-92. [DOI: 10.1016/j.jvir.2019.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 07/13/2019] [Accepted: 07/17/2019] [Indexed: 12/16/2022] Open
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Renno A, Abdel-Aziz Y, Ahmed T, Alastal Y, Toseef J, Al-Abboodi Y, Nawras A. Antireflux valve metal stent versus conventional self-expandable metal stent in distal malignant biliary obstruction: a systematic review and meta-analysis. Ann Gastroenterol 2019; 32:605-613. [PMID: 31700238 PMCID: PMC6826073 DOI: 10.20524/aog.2019.0427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/23/2019] [Indexed: 12/15/2022] Open
Abstract
Background: In patients with distal malignant biliary obstruction (MBO), endoscopic biliary drainage using the conventional self-expandable metal stent (SEMS) is the gold standard method for palliative treatment. However, there are limited data on the role of the antireflux valve metal stent (ARVMS). The aim of this study was to compare the safety and efficacy of ARVMS and SEMS in patients with distal MBO. Methods: We searched PubMed, Ovid, Embase and the Cochrane Library from inception until April 2019 for relevant randomized controlled trials (RCTs). The selected studies provided data regarding technical and clinical success rates, adverse events, and stent dysfunction. Data were meta-analyzed using RevMan software. Results: Three RCTs were selected, enrolling 293 patients (147 ARVMS and 146 SEMS). The rates of technical success were 95.23% and 99.31% for ARVMS and SEMS groups, respectively (odds ratio [OR] 0.13, 95% confidence interval [CI] 0.01-1.06; P=0.06). The clinical success rates were 91.57% and 89.36% for ARVMS and SEMS groups, respectively (OR 1.30, 95%CI 0.48-3.51; P=0.61). There was no significant difference between the ARVMS and SEMS groups in terms of adverse events (OR 0.61, 95%CI 0.35-1.05; P=0.07) or stent dysfunction (OR 0.77, 95%CI 0.31-1.95; P=0.58), while the incidence of stent occlusion was significantly lower in the ARVMS group (OR 0.44, 95%CI 0.26-0.76; P=0.003). Conclusion: Our study showed that ARVMS and SEMS had similar technical and clinical success rates. Adverse events were comparable between the 2 arms; however, ARVMS was associated with a lower risk of stent occlusion. Larger RCTs are required to verify the benefit of ARVMS in distal MBO patients.
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Affiliation(s)
- Anas Renno
- Department of Internal Medicine (Anas Renno, Yousef Abdel-Aziz, Tamer Ahmed, Yaseen Alastal, Javaid Toseef, Yasir Al-Abboodi, Ali Nawras)
| | - Yousef Abdel-Aziz
- Department of Internal Medicine (Anas Renno, Yousef Abdel-Aziz, Tamer Ahmed, Yaseen Alastal, Javaid Toseef, Yasir Al-Abboodi, Ali Nawras)
| | - Tamer Ahmed
- Department of Internal Medicine (Anas Renno, Yousef Abdel-Aziz, Tamer Ahmed, Yaseen Alastal, Javaid Toseef, Yasir Al-Abboodi, Ali Nawras)
| | - Yaseen Alastal
- Department of Internal Medicine (Anas Renno, Yousef Abdel-Aziz, Tamer Ahmed, Yaseen Alastal, Javaid Toseef, Yasir Al-Abboodi, Ali Nawras).,Division of Gastroenterology and Hepatology, University of Toledo Medical Center (Yaseen Alastal, Javaid Toseef, Yasir Al-Aboodi, Ali Nawras), OH, USA
| | - Javaid Toseef
- Department of Internal Medicine (Anas Renno, Yousef Abdel-Aziz, Tamer Ahmed, Yaseen Alastal, Javaid Toseef, Yasir Al-Abboodi, Ali Nawras).,Division of Gastroenterology and Hepatology, University of Toledo Medical Center (Yaseen Alastal, Javaid Toseef, Yasir Al-Aboodi, Ali Nawras), OH, USA
| | - Yasir Al-Abboodi
- Department of Internal Medicine (Anas Renno, Yousef Abdel-Aziz, Tamer Ahmed, Yaseen Alastal, Javaid Toseef, Yasir Al-Abboodi, Ali Nawras).,Division of Gastroenterology and Hepatology, University of Toledo Medical Center (Yaseen Alastal, Javaid Toseef, Yasir Al-Aboodi, Ali Nawras), OH, USA
| | - Ali Nawras
- Department of Internal Medicine (Anas Renno, Yousef Abdel-Aziz, Tamer Ahmed, Yaseen Alastal, Javaid Toseef, Yasir Al-Abboodi, Ali Nawras).,Division of Gastroenterology and Hepatology, University of Toledo Medical Center (Yaseen Alastal, Javaid Toseef, Yasir Al-Aboodi, Ali Nawras), OH, USA
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Anderloni A, Troncone E, Fugazza A, Cappello A, Del Vecchio Blanco G, Monteleone G, Repici A. Lumen-apposing metal stents for malignant biliary obstruction: Is this the ultimate horizon of our experience? World J Gastroenterol 2019; 25:3857-3869. [PMID: 31413524 PMCID: PMC6689812 DOI: 10.3748/wjg.v25.i29.3857] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/20/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023] Open
Abstract
In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic interventions. Among these, EUS-guided biliary drainage (BD) is gaining popularity as a therapeutic approach after failed endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction (MBO), due to the avoidance of external drainage, a lower rate of adverse events and re-interventions, and lower costs compared to percutaneous trans-hepatic BD. Initially, devices created for luminal procedures (e.g., luminal biliary stents) have been adapted to the new trans-luminal EUS-guided interventions, with predictable shortcomings in technical success, outcome and adverse events. More recently, new metal stents specifically designed for transluminal drainage, namely lumen-apposing metal stents (LAMS), have been made available for EUS-guided procedures. An electrocautery enhanced delivery system (EC-LAMS), which allows direct access of the delivery system to the target lumen, has subsequently simplified the classic multi-step procedure of EUS-guided drainages. EUS-BD using LAMS and EC-LAMS has been demonstrated effective and safe, and currently seems one of the most performing techniques for EUS-BD. In this Review, we summarize the evolution of the EUS-BD in distal MBO, focusing on the novelty of LAMS and analyzing the unresolved questions about the possible role of EUS as the first therapeutic option to achieve BD in this setting of patients.
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Affiliation(s)
- Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan 20089, Italy
| | - Edoardo Troncone
- Department of Systems Medicine, University of Rome “Tor Vergata”, Rome 00133, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan 20089, Italy
| | - Annalisa Cappello
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan 20089, Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome “Tor Vergata”, Rome 00133, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan 20089, Italy
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas University, Milan 20089, Italy
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No evidence of improved efficacy of covered stents over uncovered stents in percutaneous palliation of malignant hilar biliary obstruction: results of a prospective randomized trial. Eur Radiol 2019; 30:175-185. [PMID: 31385047 DOI: 10.1007/s00330-019-06374-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/30/2019] [Accepted: 07/15/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate whether covered stents show a higher efficacy than uncovered stents in percutaneous treatment of malignant hilar biliary obstruction. METHODS Patients with obstructive jaundice caused by an unresectable hilar malignancy were included after failed endoscopic intervention in a prospective randomized trial comparing expanded polytetrafluoroethylene and fluorinated ethylene propylene (ePTFE-FEP)-covered nitinol stents with uncovered nitinol stents. Exclusion criteria were as follows: primary tumors existing more than 3 months, a biliodigestive anastomosis, previous stenting, and a Karnofsky score of less than 50. Safety, clinical success, and adjuvant chemotherapy were compared as well as occlusion rate, patency, and survival. RESULTS A total of 120 patients were included. One patient was post hoc excluded. Fourteen patients who died within 7 days and one patient without patency data were excluded from patency analysis. Serious adverse events (p = 0.4), 30-day mortality (p = 0.5), and clinical success (p = 0.8) were equivalent for both stent groups. Twenty-one out of 61 (34%) patients in the covered and 24/58 (41%) in the uncovered stent groups received adjuvant chemotherapy (p = 0.5). Occlusion rate was 54% (27/50) in the covered stent group and 57% (31/54) in the uncovered stent group (p = 0.8). Median patency was 229 days (95% CI 113-345) for covered stents and 130 days (95% CI 75-185) for uncovered stents (p = 0.1). Median survival in patients with covered stents was 79 days (95% CI 52-106) and with uncovered stents 92 days (95% CI 60-124) (p = 0.3). CONCLUSION In malignant hilar biliary obstruction, there is no evidence that ePTFE-FEP-covered stents are superior to uncovered stents in terms of safety, clinical success, adjuvant chemotherapy, patency, or survival. KEY POINTS • Percutaneous palliation of hilar biliary obstruction is feasible with both uncovered and covered stents. • Clinical success in terms of bilirubin decrease and adjuvant chemotherapy is achievable with both stents. • Thirty-day mortality is considerable when stenting is also offered to patients with a low performance status.
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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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Yokota Y, Fukasawa M, Takano S, Kadokura M, Shindo H, Takahashi E, Hirose S, Kawakami S, Fukasawa Y, Sato T, Enomoto N. Partially covered metal stents have longer patency than uncovered and fully covered metal stents in the management of distal malignant biliary obstruction: a retrospective study. BMC Gastroenterol 2017; 17:105. [PMID: 29020933 PMCID: PMC5637084 DOI: 10.1186/s12876-017-0662-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/02/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) are widely used for malignant biliary obstructions. Nitinol-covered SEMSs have been developed to improve stent patency. Currently, SEMSs may be uncovered, partially covered, or fully covered; however, there is no consensus on the best stent type for the management of malignant distal biliary obstruction (MDBO). METHODS Patients with unresectable MDBO receiving SEMS (Wallflex™) were retrospectively analyzed. Time to recurrent biliary obstruction (TRBO) and survival time were compared among the three types of SEMSs. Univariate and multivariate analyses were performed to identify risk factors for stent dysfunction. RESULTS In total, 101 patients received SEMSs for unresectable MDBO (44 uncovered, 28 partially covered, and 29 fully covered SEMSs). Median survival time was 200, 168, and 276 days in the uncovered, partially covered, and fully covered SEMSs groups, respectively. There were no differences in survival among the three groups. Median TRBO was 199, 444, and 194 days in the uncovered, partially covered, and fully covered SEMSs groups, respectively. Partially covered SEMSs had longer TRBO than uncovered (p = 0.013) and fully covered (p = 0.010) SEMSs. Tumor ingrowth occurred only with uncovered SEMSs and stent migration occurred only with fully covered SEMSs. Multivariate analyses confirmed that partially covered SEMSs have lower risk of dysfunction. CONCLUSIONS Partially covered SEMSs with a proximal uncovered flared end have longer patency than uncovered and fully covered SEMSs by preventing tumor ingrowth and stent migration.
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Affiliation(s)
- Yudai Yokota
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Mitsuharu Fukasawa
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan.
| | - Shinichi Takano
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Makoto Kadokura
- Department of Gastroenterology, Kofu Municipal Hospital, 366, Masutsubo, Kofu, Yamanashi, 400-0832, Japan
| | - Hiroko Shindo
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Ei Takahashi
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Sumio Hirose
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Satoshi Kawakami
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Yoshimitsu Fukasawa
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Tadashi Sato
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Nobuyuki Enomoto
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
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Matsumoto K, Takeda Y, Onoyama T, Kawata S, Kurumi H, Koda H, Yamashita T, Isomoto H. Endoscopic treatment for distal malignant biliary obstruction. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:190. [PMID: 28616405 DOI: 10.21037/atm.2017.02.22] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Distal malignant biliary obstruction (MBO) leads to obstructive jaundice as a result of when the bile excretion from the liver is disturbed and induces hepatic failure and sepsis, which when complicated with cholangitis, it becomes necessary to perform drainage for the MBO. For biliary drainage, we can perform a surgical bypass operation, percutaneous transhepatic biliary drainage (PTBD), endoscopic biliary drainage (EBD) via duodenal papilla, or endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD), which is a transgastrointestinal biliary drainage. Although currently we usually perform EBD for distal MBO to begin with, the choice is different for biliary drainage in patients in whom EBD has failed in a preoperative case or an unresectable case. In other words, we choose PTBD for preoperative cases, and PTBD or EUS-BD according to the ability of the institution for their procedures when EBD has failed. It is desirable not to choose a plastic stent (PS) but a self-expandable metallic stent (SEMS), in particular for the unresectable cases of pancreatic cancer it is desirable not to choose an uncovered SEMS but a covered SEMS in EBD. Nevertheless, further examinations are expected to decide which, a covered or uncovered SEMS, we should choose in unresectable biliary tract cancer (BTC) and whether we should select PS, SEMS or ENBD in preoperative cases.
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Affiliation(s)
- Kazuya Matsumoto
- Department of Gastroenterology, Tottori University Hospital, Yonago, Japan
| | - Yohei Takeda
- Department of Gastroenterology, Tottori University Hospital, Yonago, Japan
| | - Takumi Onoyama
- Department of Gastroenterology, Tottori University Hospital, Yonago, Japan
| | - Soichiro Kawata
- Department of Gastroenterology, Tottori University Hospital, Yonago, Japan
| | - Hiroki Kurumi
- Department of Gastroenterology, Tottori University Hospital, Yonago, Japan
| | - Hiroki Koda
- Department of Gastroenterology, Tottori University Hospital, Yonago, Japan
| | - Taro Yamashita
- Department of Gastroenterology, Tottori University Hospital, Yonago, Japan
| | - Hajime Isomoto
- Department of Gastroenterology, Tottori University Hospital, Yonago, Japan
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Hasimu A, Gu JP, Ji WZ, Zhang HX, Zhu DW, Ren WX. Comparative Study of Percutaneous Transhepatic Biliary Stent Placement with or without Iodine-125 Seeds for Treating Patients with Malignant Biliary Obstruction. J Vasc Interv Radiol 2017; 28:583-593. [PMID: 28162906 DOI: 10.1016/j.jvir.2016.11.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 10/03/2016] [Accepted: 11/11/2016] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To prospectively evaluate safety and efficacy of biliary stent placement with iodine-125 (125I) seeds in patients with malignant obstructive jaundice (MOJ). MATERIALS AND METHODS From July 2011 to June 2014, 55 patients were enrolled (group A, 11 men and 17 women, mean age 70.93 y ± 8.58; group B, 14 men and 13 women, mean age 70.26 y ± 9.71). All patients were randomly assigned to placement of a biliary stent with 125I seeds (group A) or biliary stent only (group B). After stent placement, outcomes were measured regarding relief of MOJ. Clinical success rate, survival time, and safety were recorded. P < .05 was considered to indicate significant difference. RESULTS Stents were successfully placed in all 55 patients. MOJ was relieved in all patients, and there were no significant differences in complications related to stent insertion between the 2 groups. Mean and median stent patency were 191 days ± 19.8 (95% confidence interval [CI], 152-230 d) and 179 days ± 191.4 (95% CI, 87-267 d) in group A and 88.3 days ± 16.3 (95% CI, 61-114 d) and 77 days ± 88.2 (95% CI, 65-86 d) in group B (P < .001, log-rank test). Mean and median survival time were 222.6 days ± 21.0 (95% CI, 181-263 d) and 241 days ± 18.2 (95% CI, 179-270 d) in group A and 139.1 days ± 14.5 (95% CI, 110-167 d) and 142 days ± 16.3 (95% CI, 83-177 d) in group B (P < .001, log-rank test). CONCLUSIONS 125I seeds combined with biliary stent placement could significantly improve stent patency. The procedure seems to be safe and to extend survival compared with self-expandable biliary stent placement.
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Affiliation(s)
- Asihaer Hasimu
- Department of Radiology, The First Affiliated Hospital of XinJiang Medical University, Urumqi, XinJiang830054, China
| | - Jun-Peng Gu
- Department of Radiology, The First Affiliated Hospital of XinJiang Medical University, Urumqi, XinJiang830054, China
| | - Wei-Zheng Ji
- Department of Radiology, The First Affiliated Hospital of XinJiang Medical University, Urumqi, XinJiang830054, China
| | - Hai-Xiao Zhang
- Department of Radiology, The First Affiliated Hospital of XinJiang Medical University, Urumqi, XinJiang830054, China
| | - Di-Wen Zhu
- Department of Radiology, The First Affiliated Hospital of XinJiang Medical University, Urumqi, XinJiang830054, China
| | - Wei-Xin Ren
- Department of Radiology, The First Affiliated Hospital of XinJiang Medical University, Urumqi, XinJiang830054, China.
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Lee HJ, Chung MJ, Park JY, Park SW, Nam CM, Song SY, Bang S. A prospective randomized study for efficacy of an uncovered double bare metal stent compared to a single bare metal stent in malignant biliary obstruction. Surg Endosc 2016; 31:3159-3167. [DOI: 10.1007/s00464-016-5341-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 11/09/2016] [Indexed: 01/21/2023]
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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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Li M, Li K, Qi X, Wu W, Zheng L, He C, Yin Z, Fan D, Zhang Z, Han G. Percutaneous Transhepatic Biliary Stent Implantation for Obstructive Jaundice of Perihilar Cholangiocarcinoma: A Prospective Study on Predictors of Stent Patency and Survival in 92 Patients. J Vasc Interv Radiol 2016; 27:1047-1055.e2. [PMID: 27241392 DOI: 10.1016/j.jvir.2016.02.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/12/2016] [Accepted: 02/28/2016] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To evaluate prognostic factors for stent patency and survival in patients with perihilar cholangiocarcinoma (pCCA) who underwent percutaneous biliary stent placement. MATERIALS AND METHODS This prospective study followed 92 consecutive patients with pCCA who underwent metal stent placement between January 2013 and July 2014. Of the total number of patients, 11 had ascites, and 36 had biliary obstruction for > 1 month at the time of stent placement. Cumulative patency and survival rates were assessed with Kaplan-Meier curves, and independent predictors were calculated with Cox regression. A new formula was developed to predict patient survival. RESULTS Tumor size was significantly associated with stent patency (hazard ratio = 2.425; 95% confidence interval, 1.134-5.168). Independent predictors of survival included lymph node metastasis, intrahepatic mass lesion, cancer antigen 19-9 (CA19-9), ascites, and duration of jaundice. A new equation was developed to assess risk: R = 7 × (duration of biliary obstruction-0 if < 30 d, 1 if > 30 d) + 7 × (CA19-9-0 if < 500, 1 if > 500) + 7 × (ascites-0 if none present, 1 if ascites present) + 10 × (lymph node metastasis-0 if no metastasis, 1 if metastasis present) + 9 (intrahepatic mass lesion-0 if absent, 1 if present). Among patients who developed stent occlusion, patients who underwent recanalization of the occluded stent had longer survival compared with patients who did not undergo recanalization (109 d vs 29 d, P = .001). CONCLUSIONS Prognostic factors for survival after percutaneous stent placement in patients with pCCA were tumor stage, duration of jaundice, CA19-9, and ascites. Tumor size affected stent patency. Prognosis for patients with reintervention after occlusion of the stent improved.
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Affiliation(s)
- Mingwu Li
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 127 West Chang le Road, Xi'an 710032, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 127 West Chang le Road, Xi'an 710032, China
| | - Xingshun Qi
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 127 West Chang le Road, Xi'an 710032, China
| | - Wenbin Wu
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 127 West Chang le Road, Xi'an 710032, China
| | - Luanluan Zheng
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 127 West Chang le Road, Xi'an 710032, China
| | - Chuangye He
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 127 West Chang le Road, Xi'an 710032, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 127 West Chang le Road, Xi'an 710032, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 127 West Chang le Road, Xi'an 710032, China
| | - Zhuoli Zhang
- Department of Radiology, Northwestern University, Chicago, Illinois
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 127 West Chang le Road, Xi'an 710032, China.
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Hyun H, Choi SY, Kim KA, Ko SB. Safety and Efficacy of Percutaneous Biliary Covered Stent Placement in Patients with Malignant Biliary Hilar Obstruction; Correlation with Liver Function. Cardiovasc Intervent Radiol 2016; 39:1298-305. [PMID: 27224987 DOI: 10.1007/s00270-016-1375-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 05/17/2016] [Indexed: 12/20/2022]
Abstract
PURPOSE To estimate the safety and efficacy of percutaneous ePTFE-covered biliary stent placement and the relationship between underlying liver function and stent patency in patients with malignant hilar obstruction. MATERIALS AND METHODS From March 2012 to June 2015, 41 patients [22 females, 19 males; mean age 69.8 (range 34-94) years] with malignant biliary obstruction underwent percutaneous biliary stent placement (31 patients with unilateral, 10 patients with bilateral side-by-side). Cumulative patient survival and stent patency rate curves were derived using the Kaplan-Meier method. A Cox model was used to explore the relationship between liver function and patient survival, and also biliary stent patency. Pearson correlation coefficient was used to analyze the relationship between patient survival and stent patency. RESULTS Technical success rate was 100 % and clinical success rate was 95 %. During follow-up, four complications occurred (two bilomas and two cases of acute cholecystitis) and were treated successfully with percutaneous drainage. No other complication occurred. Mean serum bilirubin level was 11.34 ± 7.35 mg/dL before drainage and 5.00 ± 4.83 mg/dL 2 weeks after stent placement. The median patent survival duration was 147 days (95 % CI, 69.6-224.4 days). The median stent patency duration was 101 days (95 % CI, 70.0-132.0 days). The cumulative stent patency rates at 1, 3, 6, and 12 months were 97, 57.6, 30.3, and 17.0 %, respectively. Child-Pugh score was correlated significantly with patient survival (P = 0.011) and stent patency (P = 0.007). MELD score was correlated significantly with stent patency (P = 0.044). There was a correlation between patient survival and stent patency (r = 0.778, P < 0.001). CONCLUSION Percutaneous placement of ePTFE-covered biliary stent was a safe and an effective method for malignant biliary obstruction. Underlying liver function seemed to be one of the important factors affecting patient survival and stent patency, and stent patency showed statistically significant correlation with patient survival.
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Affiliation(s)
- Hyeran Hyun
- Department of Radiology and Medical Research Institute, School of Medicine Ewha Womans University, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 158-710, Republic of Korea
| | - Sun Young Choi
- Department of Radiology and Medical Research Institute, School of Medicine Ewha Womans University, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 158-710, Republic of Korea.
| | - Kyung Ah Kim
- Department of Radiology, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Gyeonggi-do, 442-723, Republic of Korea
| | - Soo Bin Ko
- Department of Biology, College of Arts and Science Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106, USA
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Yang MJ, Kim JH, Yoo BM, Hwang JC, Yoo JH, Lee KS, Kang JK, Kim SS, Lim SG, Shin SJ, Cheong JY, Lee KM, Lee KJ, Cho SW. Partially covered versus uncovered self-expandable nitinol stents with anti-migration properties for the palliation of malignant distal biliary obstruction: A randomized controlled trial. Scand J Gastroenterol 2016; 50:1490-9. [PMID: 26133200 DOI: 10.3109/00365521.2015.1057219] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Covered self-expandable metal stents (SEMSs) are increasingly used as alternatives to uncovered SEMSs for the palliation of inoperable malignant distal biliary obstruction to counteract tumor ingrowth. We aimed to compare the outcomes of partially covered and uncovered SEMSs with identical mesh structures and anti-migration properties, such as low axial force and flared ends. MATERIALS AND METHODS One hundred and three patients who were diagnosed with inoperable malignant distal biliary obstruction between January 2006 and August 2013 were randomly assigned to either the partially covered (n = 51) or uncovered (n = 52) SEMS group. RESULTS There were no significant differences in the cumulative stent patency, overall patient survival, stent dysfunction-free survival and overall adverse events, including pancreatitis and cholecystitis, between the two groups. Compared to the uncovered group, stent migration (5.9% vs. 0%, p = 0.118) and tumor overgrowth (7.8% vs. 1.9%, p = 0.205) were non-significantly more frequent in the partially covered group, whereas tumor ingrowth showed a significantly higher incidence in the uncovered group (5.9% vs. 19.2%, p = 0.041). Stent migration in the partially covered group occurred only in patients with short stenosis of the utmost distal bile duct (two in ampullary cancer, one in bile duct cancer), and did not occur in any patients with pancreatic cancer. CONCLUSIONS For the palliation of malignant distal biliary obstruction, endoscopic placement of partially covered SEMSs with anti-migration designs and identical mesh structures to uncovered SEMSs failed to prolong cumulative stent patency or reduce stent migration.
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Affiliation(s)
- Min Jae Yang
- Department of Gastroenterology, Ajou University School of Medicine , Suwon , South Korea
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Covered Stents versus Uncovered Stents for Unresectable Malignant Biliary Strictures: A Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6408067. [PMID: 27051667 PMCID: PMC4802019 DOI: 10.1155/2016/6408067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 01/29/2016] [Accepted: 02/17/2016] [Indexed: 12/17/2022]
Abstract
Aim. To summarize the covered or uncovered SEMS for treatment of unresectable malignant distal biliary obstruction, comparing the stent patency, patient survival, and incidence of adverse events between the two SEMSs. Methods. The meta-analysis search was performed independently by two of the authors, using MEDLINE, EMBASE, OVID, and Cochrane databases on all studies between 2010 and 2015. Pooled effect was calculated using either the fixed or the random effects model. Results. Statistics shows that there is no difference between SEMSs in the hazard ratio for patient survival (HR 1.04; 95% CI, 0.92–1.17; P = 0.55) and stent patency (HR 0.87, 95% CI: 0.58 to 1.30, P = 0.5). However, incidence of adverse events (OR: 0.74, 95% CI: 0.57 to 0.97, P = 0.03) showed significant different results in the covered SEMS, with dysfunctions events (OR: 0.75, 95% CI: 0.56 to 1.00, P = 0.05) playing a more important role than complications (OR: 0.87, 95% CI: 0.58 to 1.30, P = 0.50). Conclusions. Covered SEMS group had lower incidence of adverse events. There is no significant difference in dysfunctions, but covered SEMS trends to be better, with no difference in stent patency, patient survival, and complications.
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Salgado SM, Gaidhane M, Kahaleh M. Endoscopic palliation of malignant biliary strictures. World J Gastrointest Oncol 2016; 8:240-7. [PMID: 26989459 PMCID: PMC4789609 DOI: 10.4251/wjgo.v8.i3.240] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 10/19/2015] [Accepted: 12/18/2015] [Indexed: 02/05/2023] Open
Abstract
Malignant biliary strictures often present late after the window for curative resection has elapsed. In such patients, the goal of therapy is typically focused on palliation. While historically, palliative measures were performed surgically, the advent of endoscopic intervention offers minimally invasive options to provide relief of symptoms, improve quality of life, and in some cases, increase survival of these patients. Some of these therapies, such as endoscopic biliary decompression, have become mainstays of treatment for decades, whereas newer modalities, including radiofrequency ablation, and photodynamic therapy offer additional options for patients with incurable biliary malignancies.
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Li J, Li T, Sun P, Yu Q, Wang K, Chang W, Song Z, Zheng Q. Covered versus Uncovered Self-Expandable Metal Stents for Managing Malignant Distal Biliary Obstruction: A Meta-Analysis. PLoS One 2016; 11:e0149066. [PMID: 26859673 PMCID: PMC4747571 DOI: 10.1371/journal.pone.0149066] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 01/27/2016] [Indexed: 12/15/2022] Open
Abstract
AIM To compare the efficacy of using covered self-expandable metal stents (CSEMSs) and uncovered self-expandable metal stents (UCSEMSs) to treat objective jaundice caused by an unresectable malignant tumor. METHODS We performed a comprehensive electronic search from 1980 to May 2015. All randomized controlled trials comparing the use of CSEMSs and UCSEMSs to treat malignant distal biliary obstruction were included. RESULTS The analysis included 1417 patients enrolled in 14 trials. We did not detect significant differences between the UCSEMS group and the CSEMS group in terms of cumulative stent patency (hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.19-4.53; p = 0.93, I2 = 0%), patient survival (HR 0.77, 95% CI 0.05-10.87; p = 0.85, I2 = 0%), overall stent dysfunction (relative ratio (RR) 0.85, M-H, random, 95% CI 0.57-1.25; p = 0.83, I2 = 63%), the overall complication rate (RR 1.26, M-H, fixed, 95% CI 0.94-1.68; p = 0.12, I2 = 0%) or the change in serum bilirubin (weighted mean difference (WMD) -0.13, IV fixed, 95% CI 0.56-0.3; p = 0.55, I2 = 0%). However, we did detect a significant difference in the main causes of stent dysfunction between the two groups. In particular, the CSEMS group exhibited a lower rate of tumor ingrowth (RR 0.25, M-H, random, 95% CI 0.12-0.52; p = 0.002, I2 = 40%) but a higher rate of tumor overgrowth (RR 1.76, M-H, fixed, 95% CI 1.03-3.02; p = 0.04, I2 = 0%). Patients with CSEMSs also exhibited a higher migration rate (RR 9.33, M-H, fixed, 95% CI 2.54-34.24; p = 0.008, I2 = 0%) and a higher rate of sludge formation (RR 2.47, M-H, fixed, 95% CI 1.36-4.50; p = 0.003, I2 = 0%). CONCLUSIONS Our meta-analysis indicates that there is no significant difference in primary stent patency and stent dysfunction between CSEMSs and UCSEMSs during the period from primary stent insertion to primary stent dysfunction or patient death. However, when taking further management for occluded stents into consideration, CSEMSs is a better choice for patients with malignant biliary obstruction due to their removability.
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Affiliation(s)
- Jinjin Li
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tong Li
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ping Sun
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qihong Yu
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kun Wang
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weilong Chang
- Department of Gastrointestinal Surgery, Union hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zifang Song
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- * E-mail: (ZFS); (QCZ)
| | - Qichang Zheng
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- * E-mail: (ZFS); (QCZ)
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Drainage-related Complications in Percutaneous Transhepatic Biliary Drainage: An Analysis Over 10 Years. J Clin Gastroenterol 2015; 49:764-70. [PMID: 25518004 DOI: 10.1097/mcg.0000000000000275] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Procedure-related complications of percutaneous transhepatic biliary drainage (PTBD) have been well documented in the literature. However, relatively restricted data are available concerning drainage-related complication rates in long-term PTBD therapy. The present retrospective study evaluated the extent and the nature of drainage complications during PTBD therapy and associated risk factors for these complications. PATIENTS AND METHODS Between June 1997 and May 2007, a total of 385 patients with PTBD were identified by analyzing the PTBD database and hospital charts, with a total of 2468 percutaneous biliary drainages being identified. RESULTS Among the identified patients, 243 (63%) had malignant and 142 (37%) had benign bile duct strictures. At least 1 drainage-related complication was observed in 40% of the patients. With respect to the total number of drains, prosthesis complications occurred in 23%. Occlusion, dislocation, and cholangitis were the most common complications observed during PTBD therapy. Risk factors for cholangitis and occlusion were malignant disease, prior occurrence of complications, and bilateral drainage. Proximal stenosis of the biliary system was close to significant. CONCLUSIONS Drainage-related complications are a major problem in PTBD therapy. The risk factors for occlusion and cholangitis discovered in this study can help to refine individual strategies to reduce the rate of these drainage complications.
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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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Abstract
Decompression of the biliary system in patients with malignant biliary obstruction has been widely accepted and implemented as part of the care. Despite a wealth of literature, there remains a significant amount of uncertainty as to which approach would be most appropriate in different clinical settings. This review covers stenting of the biliary system in cases of resectable or palliative malignant biliary obstruction, potential candidates for biliary drainage, technical aspects of the procedure, as well as management of biliary stent dysfunction. Furthermore, periprocedural considerations including proper mapping of the location of obstruction and the use of antibiotics are addressed.
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Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University Medical City, King Saud University, Riyadh 11461, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montréal, Quebec H3G 1A4, Canada
| | - Jeffrey S Barkun
- Division of General Surgery, The McGill University Health Centre, McGill University, 1650 Cedar Avenue, Montréal, Quebec H3G 1A4, Canada
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montréal, Quebec H3G 1A4, Canada; Division of Clinical Epidemiology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montréal, Quebec H3G 1A4, Canada.
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Abstract
Malignancy resulting in impaired biliary drainage includes a number of diagnoses familiar to the interventional radiologist. Adequate drainage of such a system can significantly improve patient quality of life, and can facilitate the further treatment options and care of such patients. In the setting of prior instrumentation, cholangitis can present as an urgent indication for drainage. Current initial interventional management of malignant biliary duct obstruction frequently includes endoscopic or percutaneous intervention, with local practices and preprocedural imaging guiding interventional approaches and subsequent management. This article addresses the indications for percutaneous drainage, technical considerations in performing such drainage, and specific techniques useful in attempting to achieve clinical end points in patients with malignant biliary duct obstruction.
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Affiliation(s)
| | - Robert K Ryu
- Department of Radiology, University of Colorado, Aurora, CO.
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Walter D, van Boeckel PGA, Groenen MJ, Weusten BLAM, Witteman BJ, Tan G, Brink MA, Nicolai J, Tan AC, Alderliesten J, Venneman NG, Laleman W, Jansen JM, Bodelier A, Wolters FL, van der Waaij LA, Breumelhof R, Peters FTM, Scheffer RCH, Leenders M, Hirdes MMC, Steyerberg EW, Vleggaar FP, Siersema PD. Cost Efficacy of Metal Stents for Palliation of Extrahepatic Bile Duct Obstruction in a Randomized Controlled Trial. Gastroenterology 2015; 149:130-8. [PMID: 25790742 DOI: 10.1053/j.gastro.2015.03.012] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 02/10/2015] [Accepted: 03/09/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Endoscopic stents are placed for palliation of extrahepatic bile duct obstruction. Although self-expandable metal stents (SEMS) remain patent longer than plastic stents, they are more expensive. We aimed to evaluate which type of stent (plastic, uncovered SEMS [uSEMS], or partially covered SEMS [pcSEMS]) is the most effective and we assessed costs. METHODS We performed a multicenter randomized trial in 219 patients at 18 hospitals in The Netherlands from February 2008 through February 2013. Patients were assigned randomly for placement of a plastic stent (n = 73), uSEMS (n = 75), or pcSEMS (n = 71) during endoscopic retrograde cholangiopancreatography. Patients were followed up for up to 1 year. Researchers were not blinded to groups. The main study end points included functional stent time and costs. RESULTS The mean functional stent times were 172 days for plastic stents, 288 days for uSEMS, and 299 days for pcSEMS (P < .005 for uSEMS and pcSEMS vs plastic). The initial placement of plastic stents (€1042 or $1106) cost significantly less than placement of SEMS (€1973 or $2094) (P = .001). However, the total cost per patient at the end of the follow-up period did not differ significantly between plastic stents (€7320 or $7770) and SEMS (€6932 or $7356) (P = .61). Furthermore, in patients with short survival times (≤3 mo) or metastatic disease, the total cost per patient did not differ between plastic stents and SEMS. No differences in costs were found between pcSEMS and uSEMS. CONCLUSIONS Although placement of SEMS (uncovered or partially covered) for palliation of extrahepatic bile duct obstruction initially is more expensive than placement of plastic stents, SEMS have longer functional time. The total costs after 1 year do not differ significantly with stent type. Dutch Clinical Trial Registration no: NTR1361.
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Affiliation(s)
- Daisy Walter
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Petra G A van Boeckel
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcel J Groenen
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Gi Tan
- Department of Gastroenterology and Hepatology, Twente Hospital, Hengelo, The Netherlands
| | - Menno A Brink
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Jan Nicolai
- Department of Gastroenterology and Hepatology, Haga Hospital, Den Haag, The Netherlands
| | - Adriaan C Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Joyce Alderliesten
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Alexander Bodelier
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Frank L Wolters
- Department of Gastroenterology and Hepatology, VieCuri Hospital, Venlo, The Netherlands
| | | | - Ronald Breumelhof
- Department of Gastroenterology and Hepatology, Diakonessen Hospital, Utrecht, The Netherlands
| | - Frank T M Peters
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Robbert C H Scheffer
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Max Leenders
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Meike M C Hirdes
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ewout W Steyerberg
- Department of Decision Analysis, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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Miyazaki M, Yoshitomi H, Miyakawa S, Uesaka K, Unno M, Endo I, Ota T, Ohtsuka M, Kinoshita H, Shimada K, Shimizu H, Tabata M, Chijiiwa K, Nagino M, Hirano S, Wakai T, Wada K, Isayama H, Iasayama H, Okusaka T, Tsuyuguchi T, Fujita N, Furuse J, Yamao K, Murakami K, Yamazaki H, Kijima H, Nakanuma Y, Yoshida M, Takayashiki T, Takada T. Clinical practice guidelines for the management of biliary tract cancers 2015: the 2nd English edition. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:249-73. [PMID: 25787274 DOI: 10.1002/jhbp.233] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract and ampullary carcinomas in 2008. Novel treatment modalities and handling of clinical issues have been proposed after the publication. New approaches for editing clinical guidelines, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, also have been introduced for better and clearer grading of recommendations. METHODS Clinical questions (CQs) were proposed in seven topics. Recommendation, grade of recommendation and statement for each CQ were discussed and finalized by evidence-based approach. Recommendation was graded to grade 1 (strong) and 2 (weak) according to the concept of GRADE system. RESULTS The 29 CQs covered seven topics: (1) prophylactic treatment, (2) diagnosis, (3) biliary drainage, (4) surgical treatment, (5) chemotherapy, (6) radiation therapy, and (7) pathology. In 27 CQs, 19 recommendations were rated strong and 11 recommendations weak. Each CQ included the statement of how the recommendation was graded. CONCLUSIONS This guideline provides recommendation for important clinical aspects based on evidence. Future collaboration with cancer registry will be a key for assessment of the guidelines and establishment of new evidence. Free full-text articles and a mobile application of this guideline are available via http://www.jshbps.jp/en/guideline/biliary-tract2.html.
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Affiliation(s)
- Masaru Miyazaki
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Isayama H, Hamada T, Yasuda I, Itoi T, Ryozawa S, Nakai Y, Kogure H, Koike K. TOKYO criteria 2014 for transpapillary biliary stenting. Dig Endosc 2015; 27:259-64. [PMID: 25209944 DOI: 10.1111/den.12379] [Citation(s) in RCA: 214] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 09/05/2014] [Indexed: 02/08/2023]
Abstract
It is difficult to carry out meta-analyses or to compare the results of different studies of biliary stents because there is no uniform evaluation method. Therefore, a standardized reporting system is required. We propose a new standardized system for reporting on biliary stents, the 'TOKYO criteria 2014', based on a consensus among Japanese pancreatobiliary endoscopists. Instead of stent occlusion, we use recurrent biliary obstruction, which includes occlusion and migration. The time to recurrent biliary obstruction was estimated using Kaplan-Meier analysis with the log-rank test. We can evaluate both plastic and self-expandable metallic stents (uncovered and covered). We also propose specification of the cause of recurrent biliary obstruction, identification of complications other than recurrent biliary obstruction, indication of severity, measures of technical and clinical success, and a standard for clinical care. Most importantly, the TOKYO criteria 2014 allow comparison of biliary stent quality across studies. Because blocked stents can be drained not only using transpapillary techniques but also by an endoscopic ultrasonography-guided transmural procedure, we should devise an evaluation method that includes transmural stenting in the near future.
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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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43
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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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44
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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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Lee SJ, Kim MD, Lee MS, Kim IJ, Park SI, Won JY, Lee DY. Comparison of the efficacy of covered versus uncovered metallic stents in treating inoperable malignant common bile duct obstruction: a randomized trial. J Vasc Interv Radiol 2014; 25:1912-20. [PMID: 25085230 DOI: 10.1016/j.jvir.2014.05.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 05/26/2014] [Accepted: 05/28/2014] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To compare patency and overall survival achieved with covered versus uncovered metallic stents among patients with inoperable malignant extrahepatic biliary obstruction. MATERIALS AND METHODS There were 40 patients enrolled in this prospective randomized study between January 2012 and July 2013. Mean age of patients was 62.6 years (range, 43-86 y). The malignancies causing extrahepatic biliary obstruction were pancreatic cancer (n = 18), stomach cancer (n = 13), gallbladder cancer (n = 3), common bile duct cancer (n = 2), and other cancer types (n = 4). Uncovered (n = 20) and covered (n = 20) stents were used. Stent patency, overall survival, and complications were evaluated and statistically compared. RESULTS Mean patency of uncovered stents (413.3 d ± 63.0) was significantly longer than mean patency of covered ones (207.5 d ± 46.0; P = .041). Mean overall survival was 359.9 days ± 61.5 for uncovered stents, which was statistically similar to survival of 350.5 days ± 43.8 for covered stents (P = .271). Causes of recurrent obstruction included tumor ingrowth (n = 2), tumor overgrowth (n = 5), debris or food material (n = 5), and stent migration (n = 2). One case of acute cholecystitis occurred in covered stent group. CONCLUSIONS Uncovered metallic stents had superior patency duration than covered stents for patients with malignant extrahepatic biliary obstruction. However, the overall complication and survival rates achieved with covered and uncovered stents were similar.
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Affiliation(s)
- Shin Jae Lee
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - Man Deuk Kim
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul 120-752, Republic of Korea.
| | - Myung Su Lee
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - Il Jung Kim
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - Sung Il Park
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - Jong Yoon Won
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - Do Yun Lee
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul 120-752, Republic of Korea
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Zurstrassen CE, Santos ACB, Tyng CJ, Matushita JP, Coimbra FJ, Diniz AL, Ribeiro HS, Costa WL, Lima DC. Percutaneous use of ePTFE/FEP-covered metallic stent for palliation of malignant biliary obstruction. MINIM INVASIV THER 2014; 23:366-73. [PMID: 25025653 DOI: 10.3109/13645706.2014.939590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Placement of self-expanding metallic stents has been a standard palliative treatment for patients with inoperable biliary malignancy, aiming at improving quality of life via a minimally invasive procedure. This study aimed to evaluate the efficacy of percutaneous placement of expanded polytetrafluoroethylene/fluorinated ethylene propylene-covered metallic stents for palliation of inoperable biliary malignancy. MATERIAL AND METHODS Between February 2012 and April 2013, 11 patients with inoperable malignant biliary obstruction were treated with stent implantation. Serum bilirubin and liver enzyme levels were measured before/immediately after stent placement and at one, three, and six months. Patient survival and stent patency were calculated using Kaplan-Meier analysis. RESULTS No migration occurred. Patients showed clinical improvement immediately and one month after stent placement, with a significant reduction in mean serum bilirubin level (p < 0.05). At six months, bilirubin levels were <1.5 mg/dL in all cases. One patient developed acute liver failure four days after stent implantation, leading to death. Survival rates were 90% at three months and 70% at six months. Primary patency rates were 100%, 100%, and 90% at one, three, and six months, respectively. CONCLUSION Percutaneous placement of expanded polytetrafluoroethylene/fluorinated ethylene propylene-covered metallic stents offered an effective palliative therapy for patients with inoperable biliary malignancy.
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Abstract
Cholangiocarcinoma represents a diverse group of epithelial cancers united by late diagnosis and poor outcomes. Specific diagnostic and therapeutic approaches are undertaken for cholangiocarcinomas of different anatomical locations (intrahepatic, perihilar, and distal). Mixed hepatocellular cholangiocarcinomas have emerged as a distinct subtype of primary liver cancer. Clinicians need to be aware of intrahepatic cholangiocarcinomas arising in cirrhosis and properly assess liver masses in this setting for cholangiocarcinoma. Management of biliary obstruction is obligatory in perihilar cholangiocarcinoma, and advanced cytological tests such as fluorescence in-situ hybridisation for aneusomy are helpful in the diagnosis. Liver transplantation is a curative option for selected patients with perihilar but not with intrahepatic or distal cholangiocarcinoma. International efforts of clinicians and scientists are helping to identify the genetic drivers of cholangiocarcinoma progression, which will unveil early diagnostic markers and direct development of individualised therapies.
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Affiliation(s)
- Nataliya Razumilava
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Gregory J Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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Veal DR, Lee AY, Kerlan RK, Gordon RL, Fidelman N. Outcomes of metallic biliary stent insertion in patients with malignant bilobar obstruction. J Vasc Interv Radiol 2014; 24:1003-10. [PMID: 23796087 DOI: 10.1016/j.jvir.2013.03.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 03/14/2013] [Accepted: 03/15/2013] [Indexed: 01/23/2023] Open
Abstract
PURPOSE To assess clinical outcomes of metal stent insertion in patients with bilobar bile duct obstruction by malignant tumors. MATERIALS AND METHODS Records of 120 consecutive patients who underwent placement of metallic stents for palliation of malignant bilobar biliary obstruction between 1995 and 2010 were retrospectively reviewed. Single-duct stent insertion was performed in 44 patients with one liver lobe that accounted for more than 70% of total liver volume or only one patent lobar portal vein (group 1). Bilobar stent insertion was performed in 60 patients with approximately equal lobe sizes, patent lobar portal veins, or cholangitis at presentation (group 2). In 16 patients with discontiguous right anterior and posterior segmental ducts (group 3), three stents were deployed in the left lobar and right anterior and posterior segmental ducts. Overall survival, primary patency, and patient morbidity rates following stent insertion were assessed. RESULTS No significant differences in mean overall survival (group 1, 7.3 mo; group 2, 10.3 mo; group 3, 6.5 mo; P = .21) or mean primary stent patency (group 1, 4.2 mo; group 2, 5.9 mo; group 3, 3.5 mo; P = .17) were demonstrated. However, patients in group 3 were significantly more likely to require hospitalizations for cholangitis and additional invasive procedures for recurrent biliary obstruction than patients in groups 1 and 2. CONCLUSIONS Unilobar and bilobar metal stent insertion led to similar outcomes when treatment decision was based on relative liver lobe volumes, lobar portal vein patency, and presence of cholangitis on presentation.
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Affiliation(s)
- David R Veal
- Department of Radiology, University of California, San Francisco, San Francisco, CA 94143, USA
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Abstract
Cholangiocarcinoma (CC) is a rare cancer arising from the epithelium of the biliary tree, anywhere from the small peripheral hepatic ducts to the distal common bile duct. Classification systems for CC typically group tumours by anatomical location into intrahepatic, hilar or extrahepatic subtypes. Surgical resection or liver transplantation remains the only curative therapy for CC, but up to 80% of patients present with advanced, irresectable disease. Unresectable CC remains resistant to many chemotherapeutic agents, although gemcitabine, particularly in combination with other agents, has been shown to improve overall survival. Ongoing investigation of biological agents has also yielded some promising results. Several novel interventional and endoscopic techniques for the diagnosis and management of non-operable CC have been developed: initial results show improvements in symptoms and progression-free survival, but further randomised studies are required to establish their role in the management of CC.
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Affiliation(s)
- J R A Skipworth
- Department of Surgery and Interventional Science, University College London, London, UK
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50
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Moses PL, AlNaamani KM, Barkun AN, Gordon SR, Mitty RD, Branch MS, Kowalski TE, Martel M, Adam V. Randomized trial in malignant biliary obstruction: plastic vs partially covered metal stents. World J Gastroenterol 2013; 19:8638-46. [PMID: 24379581 PMCID: PMC3870509 DOI: 10.3748/wjg.v19.i46.8638] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 07/17/2013] [Accepted: 09/04/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To compare efficacy and complications of partially covered self-expandable metal stent (pcSEMS) to plastic stent (PS) in patients treated for malignant, infrahilar biliary obstruction. METHODS Multicenter prospective randomized clinical trial with treatment allocation to a pcWallstent(®) (SEMS) or a 10 French PS. Palliative patients aged ≥ 18, for infrahilar malignant biliary obstruction and a Karnofsky performance scale index > 60% from 6 participating North American university centers. Primary endpoint was time to stent failure, with secondary outcomes of death, adverse events, Karnofsky performance score and short-form-36 scale administered on a three-monthly basis for up to 2 years. Survival analyses were performed for stent failure and death, with Cox proportional hazards regression models to determine significant predictive characteristics. RESULTS Eighty-five patients were accrued over 37 mo, 42 were randomized to the SEMS group and 83 patients were available for analyses. Time to stent failure was 385.3 ± 52.5 d in the SEMS and 153.3 ± 19.8 d in the PS group, P = 0.006. Time to death did not differ between groups (192.3 ± 23.4 d for SEMS vs 211.5 ± 28.0 d for PS, P = 0.70). The only significant predictor was treatment allocation, relating to the time to stent failure (P = 0.01). Amongst other measured outcomes, only cholangitis differed, being more common in the PS group (4.9% vs 24.5%, P = 0.029). The small number of patients in follow-up limits longitudinal assessments of performance and quality of life. From an initially planned 120 patients, only 85 patients were recruited. CONCLUSION Partially covered SEMS result in a longer duration till stent failure without increased complication rates, yet without accompanying measurable benefits in survival, performance, or quality of life.
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