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De Ponthaud C, Bozkirli B, Rizzo GEM, Robinson S, Vilas-Boas F, Capurso G, Gaujoux S, Vanella G. Management of malignant Gastric Outlet Obstruction (mGOO) due to pancreatic cancer in the era of EUS-Gastrojejunostomy: an international practice survey and case vignette study by Pancreas 2000 from the European Pancreatic Club. Surg Endosc 2024; 38:3231-3240. [PMID: 38649494 DOI: 10.1007/s00464-024-10803-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/17/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Malignant Gastric Outlet Obstruction (mGOO) has been standardly treated by surgical Gastrojejunostomy (S-GJ) or Endoscopic Stenting (ES). Recently, EUS-Gastrojejunostomy (EUS-GJ) has emerged as an alternative, despite its worldwide diffusion is heterogeneous. The aim of this survey was to assess clinical decision-making around mGOO and to explore current opinions regarding EUS-GJ. METHODS An online survey, spread through social networks and EPC newsletter, was created exploring opinions regarding indications, contraindications, benefits/risks, availability of mGOO treatments; 2 case vignettes explored clinical decision-making in different scenarios. RESULTS Overall, 290 pancreatologists from 44 countries responded, of whom 35% surgeons and 65% gastroenterologists. The most common treatment for mGOO was ES (86%), followed by laparoscopic GJ (76%). EUS-GJ was accessible to 59% of respondents, with 10% proficient in this technique. Gold-standard treatment for mGOO varied by specialty; 45% of gastroenterologists preferred ES, 20% EUS-GJ, and 10% surgical GJ, while among surgeons, these were 24%, 8%, and 25%, respectively. A higher annual volume of mGOO treated correlated with increased EUS-GJ adoption and reduced surgical advice. For 51%, EUS-GJ will become the primary treatment for mGOO, notably higher among gastroenterologists and high-volume centers. For 14%, EUS-GJ spread will be limited in the future, or used only when ES fails (19%). Life expectancy, disease stage and patient's frailty are the main decision driver in therapeutic choice, whereas future surgical resectability does not contraindicate any treatment for 75%. EUS-GJ's main advantages were its minimally invasive nature and clinical efficacy, offset by its steep learning curve. CONCLUSIONS This survey revealed significant differences in the management of mGOO, depending on specialties, local expertise and treatment volume, suggesting the lack of standardized algorithms. Life expectancy and patients' frailty are the main decision drivers. Regarding EUS-GJ, its availability remains suboptimal, with learning curve as the main perceived barrier.
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Affiliation(s)
- Charles De Ponthaud
- Department of Digestive, Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtriere, Sorbonne Université, Paris, France
- Department of General, Visceral, and Endocrine Surgery, AP-HP Pitié-Salpêtriere, Sorbonne Université, Paris, France
- HeKA, Inria, Paris, France
| | - Bahadir Bozkirli
- Department of General Surgery, HPB-Unit, Acıbadem Maslak Hospital, Istanbul, Türkiye
| | - Giacomo Emanuele Maria Rizzo
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
| | - Stuart Robinson
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Filipe Vilas-Boas
- Department of Gastroenterology, São João University Hospital, Alameda Professor Hernâni Monteiro, 4200-427, Porto, Portugal
| | - Gabriele Capurso
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy
- Vita Salute San Raffaele University, Milan, Italy
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtriere, Sorbonne Université, Paris, France
- Department of General, Visceral, and Endocrine Surgery, AP-HP Pitié-Salpêtriere, Sorbonne Université, Paris, France
| | - Giuseppe Vanella
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy.
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Oh CH, Gwon DI, Chu HH, Ko GY, Kim GH, Choi SL, Kim SW. Percutaneous insertion of long-covered biliary stents in patients with malignant duodenobiliary stricture. Eur Radiol 2024; 34:538-547. [PMID: 37540317 DOI: 10.1007/s00330-023-10024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 06/11/2023] [Accepted: 06/13/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE To investigate the technical feasibility, safety, and efficacy of a long-covered biliary stent in patients with malignant duodenobiliary stricture. METHODS This retrospective study enrolled 57 consecutive patients (34 men, 23 women; mean age, 64 years; range, 32-85 years) who presented with malignant duodenobiliary stricture between February 2019 and November 2020. All patients were treated with a long (18 or 23 cm)-covered biliary stent. RESULTS The biliary stent deployment was technically successful in all 57 patients. The overall adverse event rate was 17.5% (10 of 57 patients). Successful internal drainage was achieved in 55 (96.5%) of 57 patients. The median patient survival and stent patency times were 99 days (95% confidence interval [CI], 58-140 days) and 73 days (95% CI, 60-86 days), respectively. Fourteen (25.5%) of the fifty-five patients presented with biliary stent dysfunction due to sludge (n = 11), tumor overgrowth (n = 1), collapse of the long biliary stent by a subsequently inserted additional duodenal stent (n = 1), or rapidly progressed duodenal cancer (n = 1). A univariate Cox proportional hazards model did not reveal any independent predictor of biliary stent patency. CONCLUSIONS Percutaneous insertion of a subsequent biliary stent was technically feasible after duodenal stent insertion. Percutaneous insertion of a long-covered biliary stent was safe and effective in patients with malignant duodenobiliary stricture. CLINICAL RELEVANCE STATEMENT In patients with malignant duodenobiliary stricture, percutaneous insertion of a long-covered biliary stent was safe and effective regardless of duodenal stent placement. KEY POINTS • Percutaneous insertion of long-covered biliary stents in patients with malignant duodenobiliary stricture is a safe and effective procedure. • Biliary stent deployment was technically successful in all 57 patients and successful internal drainage was achieved in 55 (96.5%) of 57 patients. • The median patient survival and stent patency times were 99 days and 73 days, respectively, after placement of a long-covered biliary stent in patients with duodenobiliary stricture.
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Affiliation(s)
- Chang Hoon Oh
- Department of Radiology, Ewha Womans Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea.
| | - Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Gun Ha Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Sang Lim Choi
- Department of Radiology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | - Sung Won Kim
- Department of Radiology, Research Institute of Radiological Science, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
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Suksai N, Kamalaporn P, Chirnaksorn S, Siriyotha S. Factors associated with patency of self-expandable metal stents in malignant biliary obstruction. BMC Gastroenterol 2023; 23:392. [PMID: 37964198 PMCID: PMC10644517 DOI: 10.1186/s12876-023-03028-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 11/01/2023] [Indexed: 11/16/2023] Open
Abstract
INTRODUCTION Endoscopic self-expandable metal stent (SEMS) placement is the key endoscopic treatment for unresectable malignant biliary obstruction. The benefit of covered SEMS over uncovered SEMS remains unknown as are risk factors for SEMS dysfunction. This study aimed to determine the factors associated with patency of SEMS. METHODS Patients with unresectable malignant biliary obstruction who underwent endoscopic SEMS placement at Ramathibodi Hospital, during January 2012 to March 2021 were included. Patient characteristics, clinical outcomes and patency of SEMS were collected. The primary outcome were stent patency and factors associated with patency of SEMS. The factors were analyzed by univariate and multivariate analyses. Median days of stent patency, median time of patient survival, rate of reintervention and complications after SEMS placement were collected. RESULTS One hundred and fourteen patients were included. SEMS dysfunction was found in 37 patients (32.5%). Size of cancer (Hazard ratio (HR), 1.20, (95% CI 1.02, 1.40), p 0.025), presence of stones or sludge during SEMS placement (Hazard ratio (HR), 3.91, (95% CI 1.74, 8.75), p 0.001), length of SEMS, 8 cm (HR 2.96, (95% CI 1.06, 8.3), p 0.039), and total bilirubin level above 2 mg/dL at one month after SEMS placement (HR 1.14, (95% CI 1.06, 1.22), p < 0.001) were associated with SEMS dysfunction. The median stent patency was 97 days. The median patient survival was 133 days, (95% CI 75-165). The rate of reintervention was 86% in patients with SEMS dysfunction. CONCLUSION The size of cancer, presence of stones or sludge during SEMS placement, the length of SEMS, and total bilirubin level above 2 mg/dL at 1 month after SEMS placement were associated with SEMS dysfunction. The median time of stent patency were not statistically different in each type of stent, covered stent, partially covered stent and uncovered stent. Median survival time of patients did not associate with SEMS patency or dysfunction.
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Affiliation(s)
- Nottawan Suksai
- Division of Gastroenterology and Hepatology, Department of medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Patarapong Kamalaporn
- Division of Gastroenterology and Hepatology, Department of medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Supphamat Chirnaksorn
- Division of Gastroenterology and Hepatology, Department of medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sukanya Siriyotha
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Rizzo GEM, Carrozza L, Rancatore G, Binda C, Fabbri C, Anderloni A, Tarantino I. The Role of Endoscopy in the Palliation of Pancreatico-Biliary Cancers: Biliary Drainage, Management of Gastrointestinal Obstruction, and Role in Relief of Oncologic Pain. Cancers (Basel) 2023; 15:5367. [PMID: 38001627 PMCID: PMC10670525 DOI: 10.3390/cancers15225367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/20/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Therapeutic endoscopy permits many and various treatments for cancer palliation in patients with bilio-pancreatic cancers, enabling different options, supporting patients during their route to oncologic treatments, and trying to improve their quality of life. Therefore, both endoscopic and endoscopic ultrasound (EUS)-guided techniques are performed in this scenario. We performed a literature review focusing on the role of endoscopy in the palliation of those advanced pancreatic and biliary cancers developing malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and pain unresponsive to medical therapies. Therefore, we explored and focused on the clinical outcomes of endoscopic procedures in this scenario. In fact, the endoscopic treatment is based on achieving biliary drainage in the case of MBO through endoscopic retrograde cholangiopancreatography (ERCP) or EUS-guided biliary drainage (EUS-BD), while GOO is endoscopically treated through the deployment of an enteral stent or the creation of EUS-guided gastro-entero-anastomosis (EUS-GEA). Furthermore, untreatable chronic abdominal pain is a major issue in patients unresponsive to high doses of painkillers, so EUS-guided celiac plexus neurolysis (CPN) or celiac ganglia neurolysis (CGN) helps to reduce dosage and have better pain control. Therefore, therapeutic endoscopy in the palliative setting is an effective and safe approach for managing most of the clinical manifestations of advanced biliopancreatic tumors.
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Affiliation(s)
- Giacomo Emanuele Maria Rizzo
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
- Ph.D. Program, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, 90133 Palermo, Italy
| | - Lucio Carrozza
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
| | - Gabriele Rancatore
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 48100 Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 48100 Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy;
| | - Ilaria Tarantino
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
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Vanella G, Bronswijk M, van Wanrooij RLJ, Dell'Anna G, Laleman W, van Malenstein H, Voermans RP, Fockens P, Van der Merwe S, Arcidiacono PG. Combined endoscopic mAnagement of BiliaRy and gastrIc OutLET obstruction (CABRIOLET Study): A multicenter retrospective analysis. DEN OPEN 2023; 3:e132. [PMID: 35898844 PMCID: PMC9307724 DOI: 10.1002/deo2.132] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/02/2022] [Accepted: 05/15/2022] [Indexed: 11/11/2022]
Abstract
Objectives Combined biliary obstruction and gastric outlet obstruction (GOO) represent a challenging clinical scenario despite developments in therapeutic endoscopic ultrasonography (EUS) as GOO might impair EUS‐guided biliary drainage. Little is known about the effectiveness of different therapeutic combinations used to treat double obstruction, especially regarding stent patency. Methods All consecutive patients with double obstruction treated between 2016 and 2021 in three tertiary academic centres were eligible for inclusion. Five combinations involving enteral stenting (ES), EUS‐guided gastroenterostomy (EUS‐GE), hepaticogastrostomy (EUS‐HGS), choledochoduodenostomy (EUS‐CDS), and transpapillary biliary stenting (TPS) were evaluated for dysfunction during follow‐up, either as proportions or dysfunction‐free survival (DFS) using Kaplan–Meier estimates. Results Ninety‐three patients were included (male 46%; age 67 [interquartile range 60–76] years; pancreatic cancer 73%, metastatic 57%), resulting in 103 procedure combinations. Different combinations showed significantly different overall dysfunction rates (p = 0.009), ranging from the null rate of EUS‐GE+HG to the 18% rate of EUS‐GE+TPS, 31% of EUS‐GE+EUS‐CD, 53% of ES+TPS and 83% of ES+EUS‐CDS. Sub‐analyses restricted to biliary dysfunction confirmed these trends. A multivariate Cox proportional‐hazards regression of DFS, a stenosis distal to the papilla (HR 3.2 [1.5–6.9]) and ES+EUS‐CDS (HR 5.6 [2–15.7]) independently predicted dysfunction. Conclusions Despite a lack of statistical power per combination, this study introduces new associations beyond the increased risk of GOO recurrence with ES versus EUS‐GE. EUS‐CDS showed reduced effectiveness and frequent dysfunction in the context of GOO, especially when combined with ES. EUS‐GE+HGS or EUS‐GE+TPS in this setting might result in superior patency. These results suggest that a prospective evaluation of the optimal endoscopic approach to malignant double obstruction is needed.
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Affiliation(s)
- Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre IRCCS San Raffaele Scientific Institute and University Milan Italy
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology University Hospitals Gasthuisberg University of Leuven Leuven Belgium
- Department of Gastroenterology and Hepatology Imelda General Hospital Bonheiden Belgium
| | - Roy LJ van Wanrooij
- Department of Gastroenterology and Hepatology Amsterdam UMC, Vrije Universiteit, Amsterdam Gastroenterology Endocrinology and Metabolism Amsterdam the Netherlands
| | - Giuseppe Dell'Anna
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre IRCCS San Raffaele Scientific Institute and University Milan Italy
| | - Wim Laleman
- Department of Gastroenterology and Hepatology University Hospitals Gasthuisberg University of Leuven Leuven Belgium
| | - Hannah van Malenstein
- Department of Gastroenterology and Hepatology University Hospitals Gasthuisberg University of Leuven Leuven Belgium
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism Amsterdam the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology Amsterdam UMC, Vrije Universiteit, Amsterdam Gastroenterology Endocrinology and Metabolism Amsterdam the Netherlands
- Department of Gastroenterology and Hepatology Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism Amsterdam the Netherlands
| | - Schalk Van der Merwe
- Department of Gastroenterology and Hepatology University Hospitals Gasthuisberg University of Leuven Leuven Belgium
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre IRCCS San Raffaele Scientific Institute and University Milan Italy
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McCullers MR, Pinnola AD, de la Fuente SG. Comparison between transpapillary versus transmural endoscopic ultrasound-guided decompression for biliary obstruction: a meta-analysis. HPB (Oxford) 2023:S1365-182X(23)00078-3. [PMID: 37012179 DOI: 10.1016/j.hpb.2023.03.005] [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: 08/05/2022] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Recent advances have led to the development of transmural endoscopic ultrasound guided biliary drainage (EUS-BD) for cases where the duodenal papilla cannot be accessed. OBJECTIVES We performed a meta-analysis comparing efficacy and complications of both approaches for biliary drainage. REVIEW METHODS English articles were searched in PubMed. Primary outcomes included technical success and complications. Secondary outcomes were clinical success and subsequent stent malfunction. Patient demographics and etiology of obstruction were collected and relative risk ratios and 95% CIs were calculated. P-value <0.05 was considered as statistically significant. RESULTS Initial database search yielded 245 studies from which 7 were chosen based upon inclusion criteria for final analysis. There was no statistically different relative risk for technical success when comparing primary EUS-BD to endoscopic retrograde cholangiopancreatography (ERCP) (RR: 1.04) or overall procedural complication rate (RR 1.39). EUS-BD did have increased specific risk of cholangitis (RR: 3.01). Likewise, primary EUS-BD and ERCP had similar RR for clinical success (RR: 1.02) and overall stent malfunction (RR: 1.55), but stent migration was higher in the primary EUS-BD group (RR: 5.06). CONCLUSIONS Primary EUS-BD may be considered when the ampulla cannot be accessed, when there is gastric outlet obstruction, or presence of a duodenal stent.
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Affiliation(s)
| | - Aaron D Pinnola
- Department of Surgery, AdventHealth, Orlando, FL, United States
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Takeda T, Sasaki T, Yamada Y, Okamoto T, Mie T, Furukawa T, Kasuga A, Matsuyama M, Ozaka M, Sasahira N. The efficacy and safety of a duckbill-type anti-reflux metal stent as the initial metal stent for distal malignant biliary obstruction in unresectable pancreatic cancer. DEN OPEN 2023; 3:e205. [PMID: 36636718 PMCID: PMC9829095 DOI: 10.1002/deo2.205] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/03/2022] [Accepted: 12/17/2022] [Indexed: 01/11/2023]
Abstract
Background The usefulness of duckbill-type anti-reflux metal stent (DMS) in self-expandable metal stent-naïve pancreatic cancer (PC) patients has not been well-studied. This study aimed to evaluate the efficacy and safety of DMS in such patients. Methods We analyzed consecutive patients with unresectable PC who received a covered metal stent (CMS) as the initial self-expandable metal stent at our institution. Technical success, functional success, causes of recurrent biliary obstruction (RBO), time to RBO (TRBO), adverse events (AEs), and reintervention rates were compared between DMS and conventional CMS (c-CMS). Results A total of 69 patients were included (DMS: 28, c-CMS: 41). Technical success, functional success, and AEs were similar between groups. Tumor ingrowth was more common in the DMS group (18% vs. 0%, p = 0.009), while non-occlusion cholangitis tended to be more common in the c-CMS group (0% vs. 15%, p = 0.074). Median time to RBO was similar between groups (276 vs. 273 days, p = 0.915). The anti-reflux valve of DMS was found torn in 56% of patients. Endoscopic reintervention was successful in all cases, despite failed stent removal in 88% of patients in the DMS group. Conclusions DMS was not associated with longer time to RBO compared to c-CMS in self-expandable metal stent-naïve patients.
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Affiliation(s)
- Tsuyoshi Takeda
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital of Japanese Foundation for Cancer ResearchTokyoJapan
| | - Takashi Sasaki
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital of Japanese Foundation for Cancer ResearchTokyoJapan
| | - Yuto Yamada
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital of Japanese Foundation for Cancer ResearchTokyoJapan,Department of Internal medicineDivision of Gastroenterology and HepatologyToho UniversityTokyoJapan
| | - Takeshi Okamoto
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital of Japanese Foundation for Cancer ResearchTokyoJapan
| | - Takafumi Mie
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital of Japanese Foundation for Cancer ResearchTokyoJapan
| | - Takaaki Furukawa
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital of Japanese Foundation for Cancer ResearchTokyoJapan
| | - Akiyoshi Kasuga
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital of Japanese Foundation for Cancer ResearchTokyoJapan
| | - Masato Matsuyama
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital of Japanese Foundation for Cancer ResearchTokyoJapan
| | - Masato Ozaka
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital of Japanese Foundation for Cancer ResearchTokyoJapan
| | - Naoki Sasahira
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital of Japanese Foundation for Cancer ResearchTokyoJapan
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8
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Long-term outcomes of duckbill-type anti-reflux metal stents versus conventional covered metal stents in reinterventions after covered biliary metal stent dysfunction in unresectable pancreatic cancer. Surg Endosc 2022; 37:3498-3506. [PMID: 36581786 DOI: 10.1007/s00464-022-09836-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 12/16/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The use of duckbill-type anti-reflux metal stents (DMS) in reinterventions after covered metal stent (CMS) dysfunction has been reported in patients with distal malignant biliary obstruction (MBO). However, the superiority of DMS over conventional CMS (c-CMS) has not been established. Therefore, we conducted this retrospective study to evaluate the long-term efficacy and safety of DMS as a second stent in comparison with c-CMS. METHODS We investigated consecutive patients with distal MBO due to unresectable pancreatic cancer who underwent reintervention after dysfunction of initial biliary CMS at our institution. We compared causes of recurrent biliary obstruction (RBO), time to RBO (TRBO), adverse events (AEs), and reintervention rates of DMS and c-CMS in this stenting. RESULTS A total of 76 patients were included (DMS 41 and c-CMS 35). While overall RBO rates were similar between the two groups (46% vs. 63%, p = 0.172), RBO due to non-occlusion cholangitis tended to be less frequent in the DMS group than in the c-CMS group (2% vs. 14%, p = 0.089). Median TRBO was significantly longer in the DMS group (286 days vs. 112 days, p = 0.029). DMS was identified as the only significant risk factor for TRBO (hazard ratio, 0.52; p = 0.044). Overall AE rates were significantly lower in the DMS group (2% vs. 23%, p = 0.010), with non-occlusion cholangitis being the most common AE in the c-CMS group. Endoscopic reintervention was successfully performed in all patients in both groups, despite failed stent removal in 15% of patients in DMS group. CONCLUSIONS DMS was associated with a significantly longer TRBO and lower rate of AEs compared with c-CMS in reinterventions after initial CMS dysfunction. DMS may be preferable to c-CMS as a second stent after biliary CMS dysfunction.
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Harima H, Kaino S, Fujimoto Y, Amano S, Kawano M, Suenaga S, Uekitani T, Sen-Yo M, Kaino M, Takami T, Sakaida I. Comparison of Duodenal Stenting and Gastrojejunostomy for Duodenal Obstruction with Biliary Obstruction. J Gastrointest Surg 2022; 26:1853-1862. [PMID: 35618992 DOI: 10.1007/s11605-022-05353-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 05/07/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The best palliation for double obstruction (duodenal obstruction with biliary obstruction) remains unclear. We aimed to compare outcomes of duodenal stenting (DuS) with gastrojejunostomy (GJ) and identify factors associated with survival time and time to recurrent biliary obstruction (TRBO). METHODS Patients who underwent DuS or GJ combined with biliary stenting for double obstruction due to unresectable malignancy were retrospectively enrolled. RESULTS In total, 111 patients were included; 84 underwent DuS, and 27 underwent GJ. The weighted survival time of the DuS group was significantly shorter than that of the GJ group (86 days vs 134 days, P < 0.01). Although the weighted TRBO was not significantly different between the two groups, when limited to patients with distal duodenal obstruction, the weighted TRBO was significantly longer in the DuS group than in the GJ group (207 days vs. 32 days, P < 0.01). GJ for distal duodenal obstruction was identified as the factor with the highest hazard ratio and was associated with a shorter TRBO (hazard ratio 8.5, P < 0.01). CONCLUSIONS Regarding survival time, GJ should be considered the primary treatment for patients with double obstruction. However, for patients with distal duodenal obstruction, DuS should be considered because GJ may be a risk factor for a shorter TRBO.
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Affiliation(s)
- Hirofumi Harima
- Department of Gastroenterology, Saiseikai Shimonoseki General Hospital, 8-5-1 Yasuoka-cho, Shimonoseki, Yamaguchi, 759-6603, Japan.
| | - Seiji Kaino
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, 755-8505, Japan
| | - Yuko Fujimoto
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, 755-8505, Japan
| | - Shogo Amano
- Department of Gastroenterology, Tokuyama Central Hospital, Syunan, Yamaguchi, 745-8522, Japan
| | - Michitaka Kawano
- Department of Gastroenterology, Kokura Memorial Hospital, Kokura, Fukuoka, 802-8555, Japan
| | - Shigeyuki Suenaga
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, 755-8505, Japan
| | - Toshiyuki Uekitani
- Department of Gastroenterology, Tokuyama Central Hospital, Syunan, Yamaguchi, 745-8522, Japan
| | - Manabu Sen-Yo
- Department of Gastroenterology, Ube Industries Central Hospital, Ube, Yamaguchi, 755-0042, Japan
| | - Miyuki Kaino
- Department of Gastroenterology, Yamaguchi Rosai Hospital, Sanyo-Onoda, Yamaguchi, 756-0095, Japan
| | - Taro Takami
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, 755-8505, Japan
| | - Isao Sakaida
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, 755-8505, Japan
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10
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Maetani I. How to successfully administer palliative treatment with a stent for malignant gastric outlet obstruction? Front Med (Lausanne) 2022; 9:967740. [PMID: 36017000 PMCID: PMC9395687 DOI: 10.3389/fmed.2022.967740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Although endoscopic stenting (ES) has been widely used as a less-invasive palliation method for malignant gastric outlet obstruction (GOO), recent reports have highlighted issues related to the procedure. For successful treatment, various aspects must be assessed before considering the practices. First, it is necessary to eliminate cases with contraindications such as coexistence of distal small-bowel obstruction or perforation. Other factors potentially related to clinical failure (i.e., peritoneal carcinomatosis) may require consideration but remain controversial. ES has better short-term outcomes than surgical gastrojejunostomy (GJ). GJ has recently been considered preferable in cases with longer life expectancy because of superior sustainability. Various types of stents are now commercially available, but their ideal structure and mechanical properties have not yet been clarified. Covered metal stent may reduce stent obstruction but is prone to increase stent migration, and its significance remains uncertain. Subsequent chemotherapy after stenting should be considered, as it is expected to prolong patient survival without increasing the risk of adverse events. Furthermore, it may be helpful in preventing tumor ingrowth. In cases with GOO combined with biliary obstruction, biliary intervention is often difficult. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely used as an alternative procedure for endoscopic transpapillary biliary drainage (ETBD). Despite the lack of consensus as to whether ETBD or EUS-BD is preferred, EUS-BD is useful as a salvage technique for cases where ETBD is difficult. To perform stent placement successfully, it is important to pay attention to the above points; however, many remaining issues need to be clarified in the future.
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11
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Kaneko J, Ishiwatari H, Asakura K, Satoh T, Sato J, Ishikawa K, Matsubayashi H, Yabuuchi Y, Kishida Y, Yoshida M, Ito S, Kawata N, Imai K, Takizawa K, Hotta K, Ono H. Biliary obstruction and pancreatitis after duodenal stent placement in the descending duodenum: a retrospective study. BMC Gastroenterol 2022; 22:257. [PMID: 35597896 PMCID: PMC9123653 DOI: 10.1186/s12876-022-02333-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/13/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Metallic stents placed in the descending duodenum can cause compression of the major duodenal papilla, resulting in biliary obstruction and pancreatitis. These are notable early adverse events of duodenal stent placement; however, they have been rarely examined. This study aimed to assess the incidence of and risk factors for biliary obstruction and/or pancreatitis after duodenal stent placement in the descending duodenum. METHODS We retrospectively reviewed data of consecutive patients who underwent metallic stent placement in the descending duodenum for malignant gastric outlet obstruction at a tertiary referral cancer center between April 2014 and December 2019. Risk factors for biliary obstruction and/or pancreatitis were analyzed using a logistic regression model. RESULTS Sixty-five patients were included. Biliary obstruction and/or pancreatitis occurred in 12 patients (18%): 8 with biliary obstruction, 2 with pancreatitis, and 2 with both biliary obstruction and pancreatitis. Multivariate analysis indicated that female sex (odds ratio: 9.2, 95% confidence interval: 1.4-58.6, P = 0.02), absence of biliary stents (odds ratio: 12.9, 95% confidence interval: 1.8-90.2, P = 0.01), and tumor invasion to the major duodenal papilla (odds ratio: 25.8, 95% confidence interval: 2.0-340.0, P = 0.01) were significant independent risk factors for biliary obstruction and/or pancreatitis. CONCLUSIONS The incidence of biliary obstruction and/or pancreatitis after duodenal stent placement in the descending duodenum was non-negligible. Female sex, absence of biliary stents, and tumor invasion to the major duodenal papilla were the primary risk factors. Risk stratification can allow endoscopists to better identify patients at significant risk and permit detailed informed consent.
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Affiliation(s)
- Junichi Kaneko
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Hirotoshi Ishiwatari
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Koiku Asakura
- Division of Diagnostic Radiology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Tatsunori Satoh
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Junya Sato
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kazuma Ishikawa
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yohei Yabuuchi
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Yoshihiro Kishida
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
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12
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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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13
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Kobori I, Katayama Y, Hayakawa F, Fujiwara T, Kuwada M, Gyotoku Y, Kitahama A, Kusano Y, Tamano M. Usefulness of duckbill‐type anti‐reflux self‐expandable metal stents for distal malignant biliary obstruction with duodenal invasion: A pilot study. DEN OPEN 2022; 2:e103. [PMID: 35873508 PMCID: PMC9302046 DOI: 10.1002/deo2.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/24/2022] [Accepted: 02/05/2022] [Indexed: 12/05/2022]
Abstract
Objectives Early obstruction of a self‐expandable metal stent placed for distal malignant biliary obstruction is more likely to occur in the presence of duodenal invasion. An anti‐reflux self‐expandable metal stent (ARMS) has been developed for the purpose of preventing duodenal fluid reflux into the bile duct. In this study, we evaluated the usefulness and safety of a duckbill‐type ARMS (D‐ARMS) in the situation of duodenal invasion. Methods We retrospectively analyzed 10 consecutive patients who received D‐ARMS for distal malignant biliary obstruction with duodenal invasion. We evaluated non‐occlusion cholangitis, recurrent biliary obstruction (RBO), and adverse events after D‐ARMS placement. Results There were no cases of non‐occlusion cholangitis. RBO was observed in 2 patients (20%), and time to RBO was 236 days and 117 days, respectively. The causes of RBO were overgrowth and sludge formation. The median time to RBO was 382 days (range, 117–382 days). Only one adverse event was observed (cholecystitis). Conclusions D‐ARMS shows potential as an optimal ARMS.
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Affiliation(s)
- Ikuhiro Kobori
- Department of Gastroenterology Dokkyo Medical University Saitama Medical Center Saitama Japan
| | - Yasumi Katayama
- Endoscopy Center, Dokkyo Medical University Saitama Medical Center Saitama Japan
| | - Fuki Hayakawa
- Department of Gastroenterology Dokkyo Medical University Saitama Medical Center Saitama Japan
| | - Takeshi Fujiwara
- Department of Gastroenterology Dokkyo Medical University Saitama Medical Center Saitama Japan
| | - Masaru Kuwada
- Department of Gastroenterology Dokkyo Medical University Saitama Medical Center Saitama Japan
| | - Yoshinori Gyotoku
- Department of Gastroenterology Dokkyo Medical University Saitama Medical Center Saitama Japan
| | - Akihiro Kitahama
- Department of Gastroenterology Dokkyo Medical University Saitama Medical Center Saitama Japan
| | - Yumi Kusano
- Department of Gastroenterology Dokkyo Medical University Saitama Medical Center Saitama Japan
| | - Masaya Tamano
- Department of Gastroenterology Dokkyo Medical University Saitama Medical Center Saitama Japan
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14
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Wu CH, Lee MH, Tsou YK, Lin CH, Sung KF, Pan KT, Liu NJ. Risk Factors of Duodenobiliary Reflux-Related Dysfunction of Covered Biliary Metal Stents after Treatment of Duodenal Stricture in Patients with Malignant Biliary and Duodenal Obstruction. Curr Oncol 2021; 28:3738-3747. [PMID: 34677237 PMCID: PMC8534963 DOI: 10.3390/curroncol28050319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 02/05/2023] Open
Abstract
Duodenal obstruction is often accompanied with unresectable malignant distal biliary obstruction in patients who have undergone biliary self-expandable metal stent (SEMS) placement. Duodenobiliary reflux (DBR) is a major cause of recurrent biliary obstruction (RBO) after covered biliary SEMS placement. We analyzed the risk factors for DBR-related SEMS dysfunction following treatment for malignant duodenal obstruction. Sixty-one patients with covered SEMS who underwent treatment for duodenal obstruction were included. We excluded patients with tumor-related stent dysfunction (n = 6) or metal stent migration (n = 1). Fifty-four patients who underwent covered biliary SEMS placement followed by duodenal metal stenting or surgical gastrojejunostomy were included. Eleven patients had DBR-related biliary SEMS dysfunction after treatment of duodenal obstruction. There was no difference between the duodenal metal stenting group and the surgical gastrojejunostomy group. Duodenal obstruction below the papilla of Vater and a score of ≤2 on the Gastric Outlet Obstruction Scoring System after treatment for duodenal obstruction were associated with DBR-related covered biliary SEMS dysfunction. Thus, creating a reliable route for ensuring good oral intake and avoiding DBR in patients with duodenal obstruction below the papilla of Vater are both important factors in preventing DBR-related covered biliary SEMS dysfunction.
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Affiliation(s)
- Chi-Huan Wu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (C.-H.W.); (M.-H.L.); (Y.-K.T.); (C.-H.L.); (K.-F.S.)
| | - Mu-Hsien Lee
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (C.-H.W.); (M.-H.L.); (Y.-K.T.); (C.-H.L.); (K.-F.S.)
| | - Yung-Kuan Tsou
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (C.-H.W.); (M.-H.L.); (Y.-K.T.); (C.-H.L.); (K.-F.S.)
| | - Cheng-Hui Lin
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (C.-H.W.); (M.-H.L.); (Y.-K.T.); (C.-H.L.); (K.-F.S.)
| | - Kai-Feng Sung
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (C.-H.W.); (M.-H.L.); (Y.-K.T.); (C.-H.L.); (K.-F.S.)
| | - Kuang-Tse Pan
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- Correspondence: (K.-T.P.); (N.-J.L.); Tel.: +886-3-328-1200 (ext. 8107) (N.-J.L.)
| | - Nai-Jen Liu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (C.-H.W.); (M.-H.L.); (Y.-K.T.); (C.-H.L.); (K.-F.S.)
- Correspondence: (K.-T.P.); (N.-J.L.); Tel.: +886-3-328-1200 (ext. 8107) (N.-J.L.)
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15
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Nakai Y, Smith Z, Chang KJ, Dua KS. Advanced Endoscopic Techniques for the Diagnosis of Pancreatic Cancer and Management of Biliary and GastricOutlet Obstruction. Surg Oncol Clin N Am 2021; 30:639-656. [PMID: 34511187 DOI: 10.1016/j.soc.2021.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Following high-quality imaging studies for staging, endoscopic ultrasound examination fine needle aspiration/biopsy is the preferred modality for tissue diagnosis of pancreatic cancer. Endoscopic retrograde cholangiopancreatography with metal stent placement is used for palliation of malignant biliary obstruction. Metal stents can be placed in patients with resectable pancreatic cancer in whom surgery is going to be delayed. For palliation of gastric outlet obstruction, endoscopic enteral stenting is often selected because of its less invasiveness. Endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction or gastrojejunostomy for gastric outlet obstruction are emerging less invasive techniques as compared with palliative surgery.
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Affiliation(s)
- Yousuke Nakai
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Zachary Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200, West Wisconsin Avenue, Milwaukee, WI, USA
| | - Kenneth J Chang
- Division of Gastroenterology and Hepatology, Digestive Health Institute, University of California, Irvine, 101 The City Drive, Building 22C, Orange, CA, USA
| | - Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200, West Wisconsin Avenue, Milwaukee, WI, USA.
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16
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Takeda T, Sasaki T, Okamoto T, Sasahira N. Endoscopic Double Stenting for the Management of Combined Malignant Biliary and Duodenal Obstruction. J Clin Med 2021; 10:jcm10153372. [PMID: 34362153 PMCID: PMC8347422 DOI: 10.3390/jcm10153372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/25/2021] [Accepted: 07/28/2021] [Indexed: 12/21/2022] Open
Abstract
Periampullary cancers are often diagnosed at advanced stages and can cause both biliary and duodenal obstruction. As these two obstructions reduce patients’ performance status and quality of life, appropriate management of the disease is important. Combined malignant biliary and duodenal obstruction is classified according to the location and timing of the duodenal obstruction, which also affect treatment options. Traditionally, surgical bypass (gastrojejunostomy and hepaticojejunostomy) has been performed for the treatment of unresectable periampullary cancer. However, it has recently been substituted by less invasive endoscopic procedures due to its high morbidity and mortality. Thus, endoscopic double stenting (transpapillary stenting and enteral stenting) has become the current standard of care. Limitations of transpapillary stenting include its technical difficulty and the risk of duodenal-biliary reflux. Recently, endoscopic ultrasound-guided procedures have emerged as a novel platform and have been increasingly utilized in the management of biliary and duodenal obstruction. As the prognosis of periampullary cancer has improved due to recent advances in chemotherapy, treatment strategies for biliary and duodenal obstruction are becoming more important. In this article, we review the treatment strategies for combined malignant biliary and duodenal obstruction based on the latest evidence.
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Affiliation(s)
| | - Takashi Sasaki
- Correspondence: ; Tel.: +81-3-3520-0111; Fax: +81-3-3520-0141
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17
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Abstract
Data about the efficacy of palliative double stenting for malignant duodenal and biliary obstruction are limited.
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18
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Hamada T, Nakai Y, Isayama H, Koike K. Antireflux metal stent for biliary obstruction: Any benefits? Dig Endosc 2021; 33:310-320. [PMID: 32250476 DOI: 10.1111/den.13679] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/10/2020] [Accepted: 03/26/2020] [Indexed: 12/12/2022]
Abstract
Endoscopic retrograde cholangiopancreatography with stent placement has been utilized as standard palliative management of distal malignant biliary obstruction (MBO). Compared to plastic stents, metal stents can provide longer-term relief of symptoms. When a large-bore metal stent is placed across the ampulla, patients are predisposed to the risk of cholangitis or stent dysfunction due to reflux of duodenal contents. To mitigate the risk of adverse events associated with the duodenobiliary reflux, efforts have been directed to development of antireflux metal stents (ARMSs). The antireflux property has been introduced through adding of an antireflux valve to the duodenal stent end. Evidence from clinical studies indicates that ARMSs may not only reduce the risk of ascending cholangitis during follow-up but also prolong stent patency time. However, the results of clinical studies testing ARMSs are inconsistent owing to heterogeneous designs of antireflux valves and stent bodies. Metal stents are increasingly indicated for benign biliary strictures and MBO in the setting of neoadjuvant chemotherapy, and therefore, research is warranted to evaluate ARMSs for those indications. Given that endoscopic ultrasound (EUS)-guided transmural biliary drainage has gained popularity, the optimal timing of placing an ARMS in relation to EUS-guided and percutaneous drainage should be investigated. Development and evaluation of ARMSs require an integrative approach utilizing phantom and animal models, measurements of stent mechanical properties, and in vivo functional study after stent placement. In this review article, we summarize updated evidence on ARMSs for MBO and discuss issues that should be addressed in future studies.
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Affiliation(s)
- Tsuyoshi Hamada
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of, Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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19
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Debourdeau A, Caillol F, Zemmour C, Winkler JP, Decoster C, Pesenti C, Ratone JP, Boher JM, Giovannini M. Endoscopic management of concomitant biliary and duodenal malignant obstruction: Impact of the timing of drainage for one vs. two procedures and the modalities of biliary drainage. Endosc Ultrasound 2021; 10:124-133. [PMID: 33818527 PMCID: PMC8098836 DOI: 10.4103/eus-d-20-00159] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background and Objectives Concomitant biliary and duodenal malignant obstruction are a severe condition mainly managed by duodenal and biliary stenting, which can be performed simultaneously (SAMETIME) or in two distinct procedures (TWO-TIMES). We conducted a single-center retrospective study to evaluate the feasibility of a SAMETIME procedure and the impact of endoscopic ultrasound (EUS)-hepaticogastrostomy in double malignant obstructions. Patients and Methods From January 1, 2011, to January 1, 2018, patients with concomitant malignant bilioduodenal obstruction treated endoscopically were included. The primary endpoint was hospitalization duration. The secondary endpoints were bilioduodenal reintervention rates, adverse event rates, and overall survival. Patients were divided into groups for statistical analysis: (i) divided according to the timing of biliary drainage: SAMETIME vs. TWO-TIMES group, (ii) divided based on the biliary drainage method: EUS-HG group underwent hepaticogastrostomy, while DUODENAL ACCESS group underwent endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic drainage (PCTD) or EUS-guided choledocoduodenostomy (EUS-CD). Results Thirty-one patients were included (19 women, median age = 71 years). Stenosis was mainly related to pancreatic cancer (17 patients, 54.8%). Sixteen patients were in the SAMETIME group, and 15 were in the TWO-TIMES group. Biliary drainage was performed by EUS-HG in 11 (35.%) patients, PCTD in 11 (35.%), ERCP in 8 (25.8%) and choledoduodenostomy in 1. Thirty patients died during follow-up. The median survival was 77 days (9% confidence interval [37-140]). The mean hospitalization duration was lower in the SAMETIME group: 7.5 vs. 12.6 days, P = 0.04. SAMETIME group patients tended to have a lower complication than TWO-TIMES (26.7% vs. 56.3%, P = 0.10). The EUS-HG group tended to have a lower complication rate (5% vs. 18.2%, P = 0.07) and less biliary endoscopic revision (30% vs. 9.1%, P = 0.37) than DUODENAL ACCESS. Conclusions SAMETIME drainage is associated with a lower hospital stay without increased morbidity. EUS-HG could provide better access because it did not exhibit a higher complication rate and showed a tendency toward better patency and fewer complications.
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Affiliation(s)
- Antoine Debourdeau
- Endoscopy Unit, Paoli Calmette Institute, Marseille; Gastroenterology and Hepatology Unit, CHU, Montpellier University, Montpellier, France
| | | | | | - Jérome Polypo Winkler
- Endoscopy Unit, Paoli Calmette Institute; Gastroenterology and Hepatology Unit, Assistance Publique Hopitaux Marseille AP-HM, Aix Marseille University, Marseille, France
| | - Claire Decoster
- Endoscopy Unit, Paoli Calmette Institute; Gastroenterology and Hepatology Unit, Assistance Publique Hopitaux Marseille AP-HM, Aix Marseille University, Marseille, France
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20
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Kwon JH, Gwon DI, Kim JW, Chu HH, Kim JH, Ko GY, Yoon HK, Sung KB. Percutaneous Biliary Metallic Stent Insertion in Patients with Malignant Duodenobiliary Obstruction: Outcomes and Factors Influencing Biliary Stent Patency. Korean J Radiol 2020; 21:695-706. [PMID: 32410408 PMCID: PMC7231609 DOI: 10.3348/kjr.2019.0753] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 01/04/2023] Open
Affiliation(s)
- Ji Hye Kwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Gi Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hyun Ki Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kyu Bo Sung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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21
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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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22
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Zu QQ, Zhang JX, Wang B, Ye W, Liu S, Shi HB. Percutaneous transpapillary biliary stent placement for distal malignant biliary obstruction: Outcomes and survival analysis. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 30:714-721. [PMID: 31418416 DOI: 10.5152/tjg.2019.18317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS For distal malignant biliary obstruction (MBO), a percutaneous metal stent is usually inserted by the transpapillary method. However, stent-related complications and recurrent biliary obstruction following transpapillary stent placement are concerns, and survival analysis of patients with distal MBO has rarely been done. MATERIALS AND METHODS From January 2012 to March 2016, 104 patients underwent transpapillary uncovered metal stent placement for distal MBO at our institution. Clinical success, complications, recurrent biliary obstruction rates, and predictors of survival were analyzed. RESULTS Of the total 104 patients, clinical success after stent insertion was achieved in 93 patients (90.3%). Major complications were observed in 24 patients (23.1%), which were as follows: cholangitis in 19 patients; pancreatitis in four patients; and biloma in one patient. Recurrent biliary occlusion was observed in 28 patients (26.9%). The median overall survival period was 162 days. The 3-, 6-, and 12-month overall survival rates after stent insertion were 64.4%, 41.3%, and 10.6%, respectively. Results of multivariate analysis indicated that metastatic carcinoma compared with ampullary carcinoma (HR=3.82; 95% CI, 1.30-11.24; p=0.015) and longer biliary stricture (HR=1.04; 95% CI, 1.02-1.06; p<0.001) were independent risk factors for worse survival after metal stent insertion. CONCLUSION Transpapillary stent placement was found to be effective with acceptable complication rates for treating distal MBO. Primary tumor and length of biliary stricture were found to be statistically significant independent prognostic factors for survival.
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Affiliation(s)
- Qing-Quan Zu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Jin-Xing Zhang
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Bin Wang
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Wei Ye
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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23
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Hamada T, Isayama H, Nakai Y, Iwashita T, Ito Y, Mukai T, Yagioka H, Saito T, Togawa O, Ryozawa S, Hirano K, Mizuno S, Yamamoto N, Kogure H, Yasuda I, Koike K. Antireflux covered metal stent for nonresectable distal malignant biliary obstruction: Multicenter randomized controlled trial. Dig Endosc 2019; 31:566-574. [PMID: 30803046 DOI: 10.1111/den.13381] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/22/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIM An antireflux metal stent (ARMS) for nonresectable distal malignant biliary obstruction (MBO) may prevent recurrent biliary obstruction (RBO) as a result of duodenobiliary reflux and prolong time to RBO (TRBO). Superiority of ARMS over conventional covered self-expandable metal stents (SEMS) has not been fully examined. METHODS We conducted a multicenter randomized controlled trial to examine whether TRBO of an ARMS with a funnel-shaped valve was longer than that of a covered SEMS in SEMS-naïve patients. We enrolled 104 patients (52 patients per arm) at 11 hospitals in Japan. Secondary outcomes included causes of RBO, adverse events, and patient survival. RESULTS TRBO did not differ significantly between the ARMS and covered SEMS groups (median, 251 vs 351 days, respectively; P = 0.11). RBO as a result of biliary sludge or food impaction was observed in 13% and 9.8% of patients who received an ARMS and covered SEMS, respectively (P = 0.83). ARMS was associated with a higher rate of stent migration compared with the covered SEMS (31% vs 12%, P = 0.038). Overall rates of adverse events were 20% and 18% in the ARMS and covered SEMS groups, respectively (P = 0.97). No significant between-group difference in patient survival was observed (P = 0.26). CONCLUSIONS The current ARMS was not associated with longer TRBO compared with the covered SEMS. Modifications including addition of an anti-migration system are required to use the current ARMS as first-line palliative treatment of distal MBO (UMIN-CTR clinical trial registration number: UMIN000014784).
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Affiliation(s)
- Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo.,Department of Oncologic Pathology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, USA
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo.,Department of Gastroenterology, JR Tokyo General Hospital
| | - Osamu Togawa
- Department of Gastroenterology, Kanto Central Hospital
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama
| | - Kenji Hirano
- Department of Gastroenterology, JCHO Tokyo Takanawa Hospital
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo.,Department of Gastroenterology, Toshiba General Hospital, Tokyo
| | | | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo
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24
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Mangiavillano B, Khashab MA, Tarantino I, Carrara S, Semeraro R, Auriemma F, Bianchetti M, Eusebi LH, Chen YI, De Luca L, Traina M, Repici A. Success and safety of endoscopic treatments for concomitant biliary and duodenal malignant stenosis: A review of the literature. World J Gastrointest Surg 2019; 11:53-61. [PMID: 30842812 PMCID: PMC6397798 DOI: 10.4240/wjgs.v11.i2.53] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 12/30/2018] [Accepted: 01/23/2019] [Indexed: 02/06/2023] Open
Abstract
Synchronous biliary and duodenal malignant obstruction is a challenging endoscopic scenario in patients affected with ampullary, peri-ampullary, and pancreatic head neoplasia. Surgical bypass is no longer the gold-standard therapy for these patients, as simultaneous endoscopic biliary and duodenal stenting is currently a feasible and widely used technique, with a high technical success in expert hands. In recent years, endoscopic ultrasonography (EUS) has evolved from a diagnostic to a therapeutic procedure, and is now increasingly used to guide biliary drainage, especially in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). The advent of lumen-apposing metal stents (LAMS) has expanded EUS therapeutic options, and changed the management of synchronous bilioduodenal stenosis. The most recent literature regarding endoscopic treatments for synchronous biliary and duodenal malignant stenosis has been reviewed to determine the best endoscopic approach, also considering the advent of an interventional EUS approach using LAMS.
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Affiliation(s)
- Benedetto Mangiavillano
- Gastrointestinal Endoscopy Unit; Humanitas - Mater Domini, Castellanza 21053, Italy
- Humanitas Huniversity, Hunimed, Pieve Emanuele, Milano 20090, Italy
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, Baltimore 21218, United States
| | - Ilaria Tarantino
- Gastroenterology and Endoscopy Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo 90100, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center IRCCS, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Rossella Semeraro
- Digestive Endoscopy Unit, Istituto Clinico Humanitas Research Hospital, Rozzano 20089, Italy
| | - Francesco Auriemma
- Gastrointestinal Endoscopy Unit; Humanitas - Mater Domini, Castellanza 21053, Italy
| | - Mario Bianchetti
- Gastrointestinal Endoscopy Unit; Humanitas - Mater Domini, Castellanza 21053, Italy
| | - Leonardo Henry Eusebi
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna 40138, Italy
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, Baltimore 21218, United States
| | - Luca De Luca
- Gastroenterology and Digestive Endoscopy Unit, Ospedali Riuniti Marche Nord, Pesaro 61122, Italy
| | - Mario Traina
- Gastroenterology and Endoscopy Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo 90100, Italy
| | - Alessandro Repici
- Humanitas Huniversity, Hunimed, Pieve Emanuele, Milano 20090, Italy
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
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25
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Nakai Y, Isayama H, Kawakami H, Ishiwatari H, Kitano M, Ito Y, Yasuda I, Kato H, Matsubara S, Irisawa A, Itoi T. Prospective multicenter study of primary EUS-guided choledochoduodenostomy using a covered metal stent. Endosc Ultrasound 2019; 8:111-117. [PMID: 30168480 PMCID: PMC6482602 DOI: 10.4103/eus.eus_17_18] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background and Objectives: EUS-guided biliary drainage (EUS-BD) is increasingly reported as a salvage technique after failed endoscopic retrograde cholangiopancreatography, but it is still controversial whether EUS-BD can replace transpapillary biliary stenting. Therefore, we conducted this multicenter, prospective study of EUS-guided choledochoduodenostomy (EUS-CDS) using a covered metallic stent (CMS) as primary biliary drainage for unresectable distal malignant biliary obstruction (MBO). Methods: Patients with unresectable distal MBO without any prior drainage are enrolled. Primary endpoint is a technical success and secondary endpoints are adverse events, functional success, and recurrent biliary obstruction (RBO) of EUS-CDS. Clinical outcomes were compared between EUS-CDS and transpapillary stenting as a control. Results: A total of 34 patients were enrolled in 10 Japanese institutions. The cause of MBO was pancreatic cancer in 28 patients. Median tumor size and common bile duct diameter were 31 and 13 mm, respectively. Technical success rate was 97% with a median procedure time of 25 min and functional success rate was 100%. The rate of RBO was 29% and the causes of RBO were nontumor related: Migration in 18%, sludge/food impaction in 9%, and stent impaction to the duodenal wall in 3%. Other adverse events were abdominal pain in 6% and cholecystitis in 9%. A median cumulative time to RBO was 11.3 months. The rate of RBO and cumulative time to RBO of EUS-CDS were comparable to those of transpapillary stenting (36% and 9.1 months, respectively). Conclusion: EUS-CDS using a CMS as primary biliary drainage was technically feasible and its safety appeared comparable to transpapillary stenting.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo; Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Hokkaido University, Sapporo; Department of Gastroenterology and Hepatology, University of Miyazaki; Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki, Japan
| | - Hirotoshi Ishiwatari
- Department of Medical Oncology and Hematology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Masayuki Kitano
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kinki University, Osaka-Sayama, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Ichiro Yasuda
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine and Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Fukushima Medical University Aizu Medical Center, Aizuwakamatsu, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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26
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Chantarojanasiri T, Kogure H, Hamada T, Nakai Y, Isayama H. Usefulness of stent placement above the papilla, so-called, 'inside stent'. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - 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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27
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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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28
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Uemura S, Iwashita T, Iwata K, Mukai T, Osada S, Sekino T, Adachi T, Kawai M, Yasuda I, Shimizu M. Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer. Pancreatology 2018; 18:601-607. [PMID: 29753623 DOI: 10.1016/j.pan.2018.04.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/27/2018] [Accepted: 04/28/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Malignant gastric outlet obstruction (GOO) often develops in patients with advanced pancreatic cancer (APC). It is not clear whether endoscopic duodenal stenting (DS) or surgical gastrojejunostomy (GJJ) is preferable as palliative treatment. AIMS To compare the efficacy and safety of GJJ and DS for GOO with APC. METHODS Consecutive 99 patients who underwent DS or GJJ for GOO with APC were evaluated. We compared the technical and clinical success rates, the incidence of adverse event (AE), the time to start chemotherapy and discharge and survival durations between DS and GJJ. Prognostic factors for overall survival (OS) were investigated on the multivariate analysis. RESULTS GOO was managed with GJJ in 35 and DS in 64. The technical and clinical success rates were comparable. DS was associated with shorter time to start oral intake and earlier chemotherapy start and discharge. No difference was seen in the early and late AE rates. Multivariate analyses of prognostic factors for OS showed that performance status ≧2, administration of chemotherapy, and presence of obstructive jaundice to be significant factors. There were no significant differences in survival durations between the groups, regardless of the PS. CONCLUSIONS There were no significant differences in the technical and clinical success and AE rates and survival duration between DS and GJJ in management of GOO by APC. DS may be a preferable option over GJJ given that it will lead to an earlier return to oral intake, a shortened length of hospital stay, and finally an earlier referral for chemotherapy.
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Affiliation(s)
- Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Shinji Osada
- Multidisciplinary Therapy for Hepato-Biliary-Pancreatic Cancer, Gifu University School of Medicine, Gifu, Japan
| | - Takafumi Sekino
- Department of General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | | | - Masahiko Kawai
- Department of Surgery, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
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29
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Manuel-Vázquez A, Latorre-Fragua R, Ramiro-Pérez C, López-Marcano A, De la Plaza-Llamas R, Ramia JM. Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature. World J Gastroenterol 2018; 24:1978-1988. [PMID: 29760541 PMCID: PMC5949711 DOI: 10.3748/wjg.v24.i18.1978] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 04/26/2018] [Accepted: 05/06/2018] [Indexed: 02/06/2023] Open
Abstract
The major symptoms of advanced hepatopancreatic-biliary cancer are biliary obstruction, pain and gastric outlet obstruction (GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decision-making must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation of the patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.
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Affiliation(s)
- Alba Manuel-Vázquez
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara 19002, Spain
| | - Raquel Latorre-Fragua
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara 19002, Spain
| | - Carmen Ramiro-Pérez
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara 19002, Spain
| | - Aylhin López-Marcano
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara 19002, Spain
| | - Roberto De la Plaza-Llamas
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara 19002, Spain
| | - José Manuel Ramia
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara 19002, Spain
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30
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Hori Y, Naitoh I, Hayashi K, Kondo H, Yoshida M, Shimizu S, Hirano A, Okumura F, Ando T, Jinno N, Takada H, Togawa S, Joh T. Covered duodenal self-expandable metal stents prolong biliary stent patency in double stenting: The largest series of bilioduodenal obstruction. J Gastroenterol Hepatol 2018; 33:696-703. [PMID: 28902972 DOI: 10.1111/jgh.13977] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/14/2017] [Accepted: 08/28/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM Endoscopic biliary and duodenal stenting (DS; double stenting) is widely accepted as a palliation therapy for malignant bilioduodenal obstruction. The aim of the current study was to investigate the patency and adverse events of duodenal and biliary stents in patients with DS. METHODS Patients who underwent DS from April 2004 to March 2017 were analyzed retrospectively with regard to clinical outcomes and predictive factors of recurrent biliary and duodenal obstruction (recurrent biliary obstruction [RBO] and recurrent duodenal obstruction [RDO]). RESULTS A total of 109 consecutive patients was enrolled. Technical success of DS was achieved in 108 patients (99.1%). Symptoms due to biliary and duodenal obstruction were improved in 89 patients (81.7%). RBO occurred in 25 patients (22.9%) and RDO in 13 (11.9%). The median times to RBO and RDO from DS were 87 and 76 days, respectively. Placement of a duodenal uncovered self-expandable metal stent (U-SEMS) was significantly associated with RBO in the multivariable analysis (P = 0.007). Time to RBO was significantly longer in the duodenal covered self-expandable metal stent group than in the U-SEMS group (P = 0.003). No predictive factors of RDO were detected, and duodenal stent type was not associated with the time to RDO (P = 0.724). CONCLUSIONS Double stenting was safe and effective for malignant bilioduodenal obstruction. Duodenal U-SEMS is a risk factor for RBO. The covered self-expandable metal stent is the preferred type of duodenal SEMS in patients with DS (Clinical trial registration number: UMIN000027606).
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Affiliation(s)
- Yasuki Hori
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kazuki Hayashi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiromu Kondo
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Michihiro Yoshida
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shuya Shimizu
- Department of Gastroenterology, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Atsuyuki Hirano
- Department of Gastroenterology, Nagoya City West Medical Center, Nagoya, Japan
| | - Fumihiro Okumura
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Tomoaki Ando
- Department of Gastroenterology, Gamagori City Hospital, Gamagori, Japan
| | - Naruomi Jinno
- Department of Gastroenterology, Toyokawa City Hospital, Toyokawa, Japan
| | - Hiroki Takada
- Department of Gastroenterology, Kasugai Municipal Hospital, Kasugai, Japan
| | - Shozo Togawa
- Department of Gastroenterology, Japan Community Healthcare Organization Chukyo Hospital, Nagoya, Japan
| | - Takashi Joh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Hamada T, Nakai Y, Lau JY, Moon JH, Hayashi T, Yasuda I, Hu B, Seo DW, Kawakami H, Kuwatani M, Katanuma A, Kitano M, Ryozawa S, Hanada K, Iwashita T, Ito Y, Yagioka H, Togawa O, Maetani I, Isayama H. International study of endoscopic management of distal malignant biliary obstruction combined with duodenal obstruction. Scand J Gastroenterol 2018; 53:46-55. [PMID: 28982258 DOI: 10.1080/00365521.2017.1382567] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Endoscopic transpapillary or endoscopic ultrasound (EUS)-guided stent placement is used for nonresectable distal malignant biliary obstruction. We conducted a retrospective study to evaluate endoscopic biliary drainage in patients with duodenal obstruction. METHODS We included consecutive patients who underwent endoscopic biliary drainage combined with a duodenal stent at 16 referral centers in four Asian countries. The primary outcome was time to recurrent biliary obstruction (TRBO). We assessed TRBO according to the sequence of biliary and duodenal obstruction (group 1/2/3, biliary obstruction first/concurrent/duodenal obstruction first, respectively) or the location of duodenal obstruction (type I/II/III, proximal to/affecting/distal to the ampulla, respectively). We also evaluated functional success and adverse events. RESULTS We included 110 patients (group1/2/3, 67/29/14 patients; type I/II/III, 45/46/19 patients; endoscopic retrograde cholangiopancreatography [ERCP]/EUS-guided choledocoduodenostomy/EUS-guided hepaticogastrostomy, 90/10/10 patients, respectively). The median TRBO of all cases was 450 days (interquartile range, 212-666 days) and functional success was achieved in 105 cases (95%). The TRBO did not differ significantly by the timing or location of duodenal obstruction (p = .30 and .79, respectively). The TRBO of metal stents (n = 96) tended to be longer compared with plastic stents (n = 14, p = .083). Compared with ERCP, EUS-guided biliary drainage was associated with a higher rate of adverse events. CONCLUSION Transpapillary or transmural endoscopic biliary drainage with a duodenal stent was effective, irrespective of the timing or location of duodenal obstruction. A prospective study is required considering the tradeoff of technical success rate, stent patency, and adverse events (ClinicalTrials.gov number, NCT02376907).
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Affiliation(s)
- Tsuyoshi Hamada
- a Department of Gastroenterology, Graduate School of Medicine , The University of Tokyo , Tokyo , Japan
| | - Yousuke Nakai
- a Department of Gastroenterology, Graduate School of Medicine , The University of Tokyo , Tokyo , Japan
| | - James Y Lau
- b Department of Surgery , Prince of Wales Hospital, The Chinese University of Hong Kong , Shatin , Hong Kong SAR
| | - Jong Ho Moon
- c Department of Internal Medicine, Digestive Disease Center and Research Institute , Soon Chun Hyang University School of Medicine , Seoul , Korea
| | - Tsuyoshi Hayashi
- d Department of Medical Oncology and Hematology , Sapporo Medical University Hokkaido , Japan.,e Department of Gastroenterology , Hokkaido Cancer Center , Hokkaido , Japan
| | - Ichiro Yasuda
- f First Department of Internal Medicine , Gifu University Hospital , Gifu , Japan.,g Department of Gastroenterology , Teikyo University Mizonokuchi Hospital , Kanagawa , Japan
| | - Bing Hu
- h Department of Endoscopy , Eastern Hepatobiliary Hospital, Second Military Medical University , Shanghai , P.R. China
| | - Dong-Wan Seo
- i Department of Gastroenterology , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Korea
| | - Hiroshi Kawakami
- j Department of Gastroenterology and Hepatology , Hokkaido University Hospital , Hokkaido , Japan.,k Department of Gastroenterology and Hepatology , Center for Digestive Disease University of Miyazaki , Miyazaki , Japan
| | - Masaki Kuwatani
- j Department of Gastroenterology and Hepatology , Hokkaido University Hospital , Hokkaido , Japan
| | - Akio Katanuma
- l Center for Gastroenterology, Teine Keijin-kai Hospital , Hokkaido , Japan
| | - Masayuki Kitano
- m Department of Gastroenterology and Hepatology , Kinki University Faculty of Medicine , Osaka , Japan
| | - Shomei Ryozawa
- n Department of Gastroenterology , Saitama Medical University International Medical Center , Saitama , Japan
| | - Keiji Hanada
- o Department of Gastroenterology , Onomichi General Hospital , Hiroshima , Japan
| | - Takuji Iwashita
- f First Department of Internal Medicine , Gifu University Hospital , Gifu , Japan
| | - Yukiko Ito
- p Department of Gastroenterology , Japanese Red Cross Medical Center , Tokyo , Japan
| | - Hiroshi Yagioka
- q Department of Gastroenterology , Tokyo Metropolitan Police Hospital , Tokyo , Japan
| | - Osamu Togawa
- r Department of Gastroenterology , Kanto Central Hospital , Tokyo , Japan
| | - Iruru Maetani
- s Division of Gastroenterology and Hepatology, Department of Internal Medicine , Toho University Ohashi Medical Center , Tokyo , Japan
| | - Hiroyuki Isayama
- a Department of Gastroenterology, Graduate School of Medicine , The University of Tokyo , Tokyo , Japan
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32
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Hamada T, Isayama H, Nakai Y, Togawa O, Takahara N, Uchino R, Mizuno S, Mohri D, Yagioka H, Kogure H, Matsubara S, Yamamoto N, Ito Y, Tada M, Koike K. Antireflux Metal Stent as a First-Line Metal Stent for Distal Malignant Biliary Obstruction: A Pilot Study. Gut Liver 2017; 11:142-148. [PMID: 27282268 PMCID: PMC5221872 DOI: 10.5009/gnl15579] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/08/2015] [Accepted: 01/12/2016] [Indexed: 12/27/2022] Open
Abstract
Background/Aims In distal malignant biliary obstruction, an antireflux metal stent (ARMS) with a funnel-shaped valve is effective as a reintervention for metal stent occlusion caused by reflux. This study sought to evaluate the feasibility of this ARMS as a first-line metal stent. Methods Patients with nonresectable distal malignant biliary obstruction were identified between April and December 2014 at three Japanese tertiary centers. We retrospectively evaluated recurrent biliary obstruction and adverse events after ARMS placement. Results In total, 20 consecutive patients were included. The most common cause of biliary obstruction was pancreatic cancer (75%). Overall, recurrent biliary obstruction was observed in seven patients (35%), with a median time to recurrent biliary obstruction of 246 days (range, 11 to 246 days). Stent occlusion occurred in five patients (25%), the causes of which were sludge and food impaction in three and two patients, respectively. Stent migration occurred in two patients (10%). The rate of adverse events associated with ARMS was 25%: pancreatitis occurred in three patients, cholecystitis in one and liver abscess in one. No patients experienced non-occlusion cholangitis. Conclusions The ARMS as a first-line biliary drainage procedure was feasible. Because the ARMS did not fully prevent stent dysfunction due to reflux, further investigation is warranted.
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Affiliation(s)
- Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Togawa
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rie Uchino
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Dai Mohri
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Hamada T, Hakuta R, Takahara N, Sasaki T, Nakai Y, Isayama H, Koike K. Covered versus uncovered metal stents for malignant gastric outlet obstruction: Systematic review and meta-analysis. Dig Endosc 2017; 29:259-271. [PMID: 27997723 DOI: 10.1111/den.12786] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Self-expandable metal stents (SEMS) are used for non-resectable malignant gastric outlet obstruction (GOO). Studies of covered versus uncovered SEMS have yielded inconsistent results as a result of heterogeneity in design and patient population. We carried out a meta-analysis to compare covered and uncovered gastroduodenal SEMS. METHODS Using MEDLINE, Embase, and the Cochrane database, we identified 1624 patients from 13 prospective and retrospective studies that evaluated covered and uncovered SEMS for malignant GOO and were published until October 2016. We pooled data on SEMS dysfunction, technical and clinical success, and adverse events using the fixed-effect or random-effects model. RESULTS Compared with uncovered SEMS, covered SEMS did not show any significant difference in stent dysfunction risk (risk ratio [RR], 1.02; 95% confidence interval [CI], 0.79-1.32). A subgroup analysis of five randomized trials suggested a trend toward a lower dysfunction risk in covered SEMS (RR, 0.63; 95% CI, 0.45-0.88). Covered SEMS were associated with a lower occlusion risk (RR, 0.44; 95% CI, 0.28-0.68), but with a higher migration risk (RR, 4.28; 95% CI, 2.89-6.34). Technical and clinical success rates were comparable between the groups. Overall adverse events tended to be more frequent in covered SEMS (RR, 1.75; 95% CI, 1.09-2.83). CONCLUSIONS Outcomes of covered and uncovered gastroduodenal SEMS were comparable, although the lower dysfunction rate of covered SEMS observed in the analysis of randomized trials needs further investigation. Antimigration mechanisms for covered SEMS and identification of patients who can achieve longer patency from uncovered SEMS would help improve the outcomes of gastroduodenal SEMS.
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Affiliation(s)
- Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokoyo, Japan.,Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, USA
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokoyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokoyo, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokoyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokoyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokoyo, Japan
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34
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Nakai Y, Isayama H, Yamamoto N, Matsubara S, Ito Y, Sasahira N, Umefune G, Takahara N, Hamada T, Mohri D, Kogure H, Tada M, Koike K. Conversion to endoscopic ultrasound-guided biliary drainage by temporary nasobiliary drainage placement in patients with prior biliary stenting. Endosc Ultrasound 2017; 6:323-328. [PMID: 28663533 PMCID: PMC5664853 DOI: 10.4103/2303-9027.199763] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background and Objectives: Endoscopic ultrasound-guided biliary drainage (EUS-BD), first reported as an alternative to percutaneous transhepatic BD in failed endoscopic retrograde cholangiography, is sometimes performed as reintervention for transpapillary stent dysfunction such as in patients with new onset gastric outlet obstruction, but direct conversion to EUS-BD can potentially have a risk of leakage of infected bile. The aim of this study is to evaluate the safety and efficacy of conversion to EUS-BD using a temporary endoscopic nasobiliary drainage (ENBD) tube placement as a reintervention for prior BD. Patients and Methods: Sixteen patients with prior BD for malignant biliary obstruction undergoing conversion to EUS-BD using a temporary ENBD tube placement were studied. Technical and clinical success rate and adverse events were evaluated. Results: The major reason for conversion to EUS-BD was recurrent cholangitis due to duodenobiliary reflux (n = 13). In 14 patients with an indwelling covered metal or plastic stent, the stents were removed before temporary ENBD placement. After a median duration of 6 days, subsequent conversion to EUS-BD using a covered metal stent was performed, which was technically and clinically successful in all 16 patients (14 hepaticogastrostomy and 2 choledochoduodenostomy). Adverse events were observed in 3 patients (19%): one bleeding, one cholecystitis, and one cholangitis. No bile leak, peritonitis, or sepsis was observed. Conclusions: Conversion to EUS-BD using temporary ENBD tube placement in patients with prior BD was technically feasible and relatively safe without infectious complications related to bile leakage.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo; Department of Gastroenterology, Tokyo Metropolitan Police Hospital, , Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Naoki Sasahira
- Department of Gastroenterology, Tokyo Takanawa Hospital, Tokyo, Japan
| | - Gyotane Umefune
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo; Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Dai Mohri
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Nakai Y, Hamada T, Isayama H, Itoi T, Koike K. Endoscopic management of combined malignant biliary and gastric outlet obstruction. Dig Endosc 2017; 29:16-25. [PMID: 27552727 DOI: 10.1111/den.12729] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 08/19/2016] [Indexed: 12/13/2022]
Abstract
Patients with periampullary cancer or gastric cancer often develop malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), and combined MBO and GOO is not rare in these patients. Combined MBO and GOO is classified by its location and sequence, and treatment strategy can be affected by this classification. Historically, palliative surgery, hepaticojejunostomy and gastrojejunostomy were carried out, but the current standard treatment is combined transpapillary stent and duodenal stent placement. Although a high technical success rate is reported, the procedure can be technically difficult and duodenobiliary reflux with subsequent cholangitis is common after double stenting. Recent development of endoscopic ultrasound (EUS)-guided procedures enables the management of MBO as well as GOO under EUS guidance. EUS-guided biliary drainage is now increasingly reported as an alternative to percutaneous transhepatic biliary drainage in failed endoscopic retrograde cholangiopancreatography (ERCP), and GOO is one of the major reasons for failed ERCP. In addition to EUS-guided biliary drainage, the feasibility of EUS-guided double-balloon-occluded gastrojejunostomy bypass for MBO was recently reported, and EUS-guided double stenting can potentially become the treatment of choice in the future. However, as each procedure has its advantages and disadvantages, treatment strategy should be selected based on the type of obstruction and the prognosis and performance status of the patient.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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36
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Varadarajulu S, Lakhtakia S. Moving away from the tumor zone: A work in progress. Dig Endosc 2017; 29:35. [PMID: 28067004 DOI: 10.1111/den.12753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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37
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Hamada T, Nakai Y, Isayama H, Koike K. Against duodenobiliary reflux: implications from a randomized controlled trial. Gastrointest Endosc 2016; 83:673-4. [PMID: 26897052 DOI: 10.1016/j.gie.2015.09.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 09/30/2015] [Indexed: 12/11/2022]
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, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Abstract
Upper gastrointestinal (GI) stents are increasingly being used to manage upper GI obstructions. Initially developed for palliative treatment of esophageal cancer, upper GI stents now play an emerging role in benign strictures of the upper GI tract. Because recurrent obstruction and stent-related complications are common, new modifications of stents have been implemented. Self-expandable metal stents (SEMS) have replaced older plastic stents. In addition, newly designed SEMS have been developed to prevent complications. This review provides an overview of the various types, indications, methods, complications, and clinical outcomes of upper GI stents in a number of malignant and benign disorders dividing the esophagus and gastroduodenum.
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Affiliation(s)
- Hyoun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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39
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Antireflux Metal Stent With an Antimigration System for Distal Malignant Biliary Obstruction. Surg Laparosc Endosc Percutan Tech 2015; 25:212-7. [PMID: 25856131 DOI: 10.1097/sle.0000000000000149] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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40
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Isayama H, Nakai Y, Hamada T, Yamamoto N, Koike K. Development of an ideal self-expandable metallic stent design. GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.1016/j.gii.2015.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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41
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Kang HW, Kim SG. Upper Gastrointestinal Stent Insertion in Malignant and Benign Disorders. Clin Endosc 2015; 48:187-93. [PMID: 26064817 PMCID: PMC4461661 DOI: 10.5946/ce.2015.48.3.187] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 04/22/2015] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal (GI) stents are increasingly being used to manage upper GI obstructions. Initially developed for palliative treatment of esophageal cancer, upper GI stents now play an emerging role in benign strictures of the upper GI tract. Because recurrent obstruction and stent-related complications are common, new modifications of stents have been implemented. Self-expandable metal stents (SEMS) have replaced older plastic stents. In addition, newly designed SEMS have been developed to prevent complications. This review provides an overview of the various types, indications, methods, complications, and clinical outcomes of upper GI stents in a number of malignant and benign disorders dividing the esophagus and gastroduodenum.
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Affiliation(s)
- Hyoun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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42
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Lee E, Gwon DI, Ko GY, Sung KB, Yoon HK, Shin JH, Kim JH, Ko HK, Song HY. Percutaneous biliary covered stent insertion in patients with malignant duodenobiliary obstruction. Acta Radiol 2015; 56:166-73. [PMID: 24518689 DOI: 10.1177/0284185114523267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Although the use of polytetrafluoroethylene (PTFE)-covered biliary stents has proven to be feasible for the treatment of benign and malignant biliary disease, less is known regarding the outcomes of percutaneous placement of a covered stent in patients with malignant duodenobiliary obstruction. PURPOSE To investigate the technical and clinical efficacy of the percutaneous placement of a PTFE-covered biliary stent in patients with malignant duodenobiliary obstruction. MATERIAL AND METHODS From April 2007 to September 2012, the medical records of 45 consecutive patients with malignant duodenobiliary obstruction were retrospectively reviewed. All percutaneous biliary stent deployment was performed using PTFE-covered stents, whereas duodenal stent insertion was performed either fluoroscopically or endoscopically using covered or uncovered stents. RESULTS Biliary stent deployment was technically successful in all patients. None of the stents migrated after deployment. Procedure-related minor complications, including self-limiting hemobilia, occurred in three (7%) patients. Successful internal drainage was achieved in 39 (87%) of the 45 patients. The median survival time after biliary stent placement was 62 days (95% confidence interval, 8-116 days), and the cumulative stent patency rates at 1, 3, 6, and 12 months were 96%, 92%, 75%, and 38%, respectively. The causes of biliary stent dysfunction included stent occlusion caused by a subsequently inserted duodenal stent (n = 7), food impaction (n = 3), and sludge incrustation (n = 1). One patient developed acute cholecystitis 131 days after biliary stent placement and underwent percutaneous transhepatic gallbladder drainage. CONCLUSION Percutaneous insertion of a PTFE-covered stent is a safe and effective method for palliative treatment of patients with malignant duodenobiliary obstruction. If possible, subsequent biliary stent insertion is preferable in order to prevent possible biliary stent dysfunction caused by subsequent insertion of a duodenal stent.
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Affiliation(s)
- Eunsol Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 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
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Kyu-Bo Sung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hyun-Ki Yoon
- 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
| | - Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Heung Kyu Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Self-expanding metal stents for pancreatic tumors: expanding the possibilities, decreasing the costs and risks. Dig Dis Sci 2014; 59:2613-5. [PMID: 25239497 DOI: 10.1007/s10620-014-3366-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Increased rates of duodenal obstruction in pancreatic cancer patients receiving modern medical management. Dig Dis Sci 2014; 59:2294-8. [PMID: 24781163 DOI: 10.1007/s10620-014-3170-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/15/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Duodenal obstruction from pancreatic cancer historically occurs in 2-25 % of patients without surgery, but with new advances in chemotherapy and radiation therapy, the life expectancy of pancreatic cancer has increased. AIM The aim of the study was to determine the rate of development of duodenal obstruction requiring intervention in patients with pancreatic head adenocarcinoma who do not undergo surgical resection, but receive modern chemoradiation. METHODS It is a retrospective single center study. Inclusion criteria were patients with pancreatic cancer who underwent ERCP with metal biliary stent and then chemoradiation who subsequently developed symptomatic duodenal obstruction and underwent either metal duodenal stent placement or surgical duodenal bypass. RESULTS Twenty-four of 63 patients (38 %, 95 % CI 26-50 %) with unresectable pancreatic cancer and biliary stents who received chemotherapy and/or radiation therapy developed duodenal obstruction. The average length of time from diagnosis of pancreatic adenocarcinoma to development of outlet obstruction was 11.4 ± 4.9 months (range 1.5-40 months). Average length of time from development of duodenal obstruction to death was 4.8 ± 2.1 months (range 0.5-60 months). Average survival time from diagnosis to death was 16.6 ± 5.6 months (range 4.5-58 months). CONCLUSION Thirty-eight percent of patients with unresectable pancreatic head adenocarcinoma and metal biliary stents who receive chemotherapy and/or radiation therapy eventually develop symptomatic duodenal obstruction requiring duodenal stent or surgical bypass. This rate of duodenal obstruction is nearly twice that of previous reports using older oncologic therapy and will likely increase as patients survive longer with advances in medical therapy for pancreatic cancer.
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Transmural biliary drainage can be an alternative to transpapillary drainage in patients with an indwelling duodenal stent. Dig Dis Sci 2014; 59:1931-8. [PMID: 24839917 DOI: 10.1007/s10620-014-3062-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 02/05/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Self-expandable metal stents (SEMS) are widely utilized to relieve symptoms of malignant gastric outlet obstruction (GOO), but GOO is frequently complicated by nonresectable distal biliary obstruction. The optimal endoscopic approach to biliary drainage in this setting remains controversial and has yet to be resolved. AIMS To compare the safety and efficacy of endoscopic ultrasound-guided transmural biliary drainage (EUS-BD) and transpapillary drainage in patients with an indwelling duodenal SEMS. METHODS Patients who underwent EUS-BD or transpapillary drainage for distal malignant biliary obstruction with an indwelling duodenal SEMS between June 2007 and August 2012 at three Japanese tertiary referral centers were identified retrospectively. We compared times to stent dysfunction, causes of dysfunction, and procedural related complications between these two groups. RESULTS Twenty patients were included in the study (7 EUS-BD and 13 transpapillary drainage). EUS-BD was performed via hepaticogastrostomy using a SEMS in three patients and via choledochoduodenostomy using a SEMS or a plastic stent in two patients each. Transpapillary drainage was performed using a SEMS in all patients. The stent patency rate in the EUS-BD group was higher than that in the transpapillary drainage group (100 vs. 71% at 1 month and 83 vs. 29% at 3 months, respectively). The rate of stent dysfunction in the EUS-BD group tended to be lower than that in the transpapillary group (14 vs. 54%; P = 0.157). Complication rates were similar between the groups (P = 1.000), with moderate bleeding in one patient in the EUS-BD group and mild pancreatitis in one patient in the transpapillary group. CONCLUSION Endoscopic ultrasound-guided transmural biliary drainage is an alternative to transpapillary drainage in patients with an indwelling duodenal SEMS.
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Hamada T, Isayama H, Nakai Y, Kogure H, Yamamoto N, Koike K. Tips and troubleshooting for transpapillary metal stenting for distal malignant biliary obstruction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:E12-8. [DOI: 10.1002/jhbp.51] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Tsuyoshi Hamada
- Department of Gastroenterology; Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo Bunkyo-ku Tokyo 113-8655 Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology; Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo Bunkyo-ku Tokyo 113-8655 Japan
| | - Yousuke Nakai
- Department of Gastroenterology; Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo Bunkyo-ku Tokyo 113-8655 Japan
| | - Hirofumi Kogure
- Department of Gastroenterology; Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo Bunkyo-ku Tokyo 113-8655 Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology; Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo Bunkyo-ku Tokyo 113-8655 Japan
| | - Kazuhiko Koike
- Department of Gastroenterology; Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo Bunkyo-ku Tokyo 113-8655 Japan
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Maire F, Sauvanet A. Palliation of biliary and duodenal obstruction in patients with unresectable pancreatic cancer: endoscopy or surgery? J Visc Surg 2013; 150:S27-31. [PMID: 23597937 DOI: 10.1016/j.jviscsurg.2013.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patients with unresectable pancreatic adenocarcinoma often develop biliary and/or duodenal obstruction during the course of their disease. Jaundice, pruritis, nausea and vomiting impact negatively on the quality of life and chemotherapy must often be withheld until these symptoms are resolved. In the past, an open surgical palliative bypass was proposed, but the development of endoprosthetic stents has changed the management of these patients. The success rate for placement of duodenal and biliary stents is greater than 90% with low morbidity. Classical surgical bypass surgery includes biliary-digestive and gastro-jejunal anastomoses. Many studies have compared endoscopic and surgical treatment, and there is a clear advantage to endoscopic treatment in terms of quality of life and cost.
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Affiliation(s)
- F Maire
- Service de gastroentérologie-pancréatologie, université Paris VII, hôpital Beaujon, AP-HP, 100, boulevard du Général-Leclerc, 92118 Clichy cedex, France
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Hamada T, Nakai Y, Isayama H, Koike K. Transpapillary versus transmural biliary drainage in patients with an indwelling duodenal stent: when is one indicated over the other? Gastrointest Endosc 2013; 77:670. [PMID: 23498146 DOI: 10.1016/j.gie.2012.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 11/19/2012] [Indexed: 12/11/2022]
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