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Ledenko M, Toskich B, Mehner C, Ceylan H, Patel T. Therapeutic biliary stents: applications and opportunities. Expert Rev Med Devices 2024; 21:399-409. [PMID: 38716580 DOI: 10.1080/17434440.2024.2341960] [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: 01/05/2024] [Accepted: 04/08/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Biliary stents are used to optimize ductal patency and enable bile flow in the management of obstruction or injury related to biliary tract tumors, strictures, stones, or leaks. Although direct therapeutic applications of biliary stents are less well developed, stents can be used to deliver drugs, radioisotopes, and photodynamic therapy. AREAS COVERED This report provides an in-depth overview of the clinical indications, and therapeutic utility of biliary stents. Unique considerations for the design of biliary stents are described. The properties and functionalities of materials used for stents such as metal alloys, plastic polymers, or biodegradable materials are described, and opportunities for design of future stents are outlined. Current and potential applications of stents for therapeutic applications for biliary tract diseases are described. EXPERT OPINION Therapeutic biliary stents could be used to minimize inflammation, prevent stricture formation, reduce infections, or provide localized anti-cancer therapy for biliary tract cancers. Stents could be transformed into therapeutic platforms using advanced materials, 3D printing, nanotechnology, and artificial intelligence. Whilst clinical study and validation will be required for adoption, future advances in stent design and materials are expected to expand the use of therapeutic biliary stents for the treatment of biliary tract disorders.
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Affiliation(s)
- Matthew Ledenko
- Department of Transplantation, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Beau Toskich
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Christine Mehner
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Jacksonville, FL, USA
| | - Hakan Ceylan
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Jacksonville, FL, USA
| | - Tushar Patel
- Department of Transplantation, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Jacksonville, FL, USA
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Paik WH, Jung MK, Kim DU, Song TJ, Yang MJ, Choi YH, Kim JS, Lee MW, Choi JH, Lee SH. Side-by-side placement of fully covered metal stents versus conventional 7F plastic stents in malignant hilar biliary obstruction: Prospective randomized controlled trial. Dig Endosc 2024; 36:473-480. [PMID: 37612129 DOI: 10.1111/den.14669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/20/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVES We aimed to evaluate the efficacy and safety of metal stents compared with plastic stents when bilateral side-by-side stents were deployed for malignant hilar biliary obstruction (MHBO). METHODS Fifty patients with unresectable advanced MHBO were randomly assigned to the metal stent (MS, n = 25) or plastic stent group (PS, n = 25). Fully covered self-expandable metal stents with 6 mm diameter and plastic stents with either 7F straight or double pigtail were used for MS and PS groups, respectively. Time to recurrent biliary obstruction (TRBO) was evaluated as the primary outcome. RESULTS Both groups had 100% technical success rates; 88% and 76% of clinical success rates were obtained in MS and PS, respectively. Although stent migrations were more frequent in MS than PS (48% vs. 16%, P = 0.02), the mean TRBO was significantly longer in MS (190 days; 95% confidence interval [CI] 121-260 days vs. 96 days; 95% CI 50-141 days, P = 0.02). The placement of plastic stents (hazard ratio 2.42; 95% CI 1.24-4.73; P = 0.01) was the only significant risk factor associated with TRBO in multivariable analysis. The rates of adverse events were similar between the two groups (difference 0%; 95% CI -25% to 25%; P > 0.99). CONCLUSIONS During bilateral side-by-side deployment in MHBO, the use of metal stents appears to be preferable to plastic stents in terms of TRBO, despite a higher frequency of stent migration.
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Affiliation(s)
- Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Min Kyu Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dong Uk Kim
- Department of Internal Medicine, College of Medicine, Pusan National University, Yangsan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Tae Jun Song
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Min Jae Yang
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Young Hoon Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joo Seong Kim
- Department of Internal Medicine, Dongguk University Medical Center, Dongguk University College of Medicine, Goyang, Korea
| | - Min Woo Lee
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - Jin Ho Choi
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Nishikawa T, Takeuchi D, Yokosuka O. Two salvage techniques using a large dilation balloon: Endoscopic recovery of a migrated biliary metal stent and endoscope passage through a difficult duodenal stricture in combination with a duodenal stent. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:e78-e80. [PMID: 37803811 DOI: 10.1002/jhbp.1361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/24/2023] [Accepted: 06/10/2023] [Indexed: 10/08/2023]
Abstract
There have been several reports of endoscopic removal of biliary metal stents using forceps or stent-in-stent techniques. Nishikawa and colleagues describe the endoscopic recovery of a proximally migrated biliary metal stent using a large dilation balloon and endoscope passage through a difficult duodenal stricture in combination with a duodenal stent.
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Affiliation(s)
- Takao Nishikawa
- Department of Gastroenterology, Matsudo City General Hospital, Matsudo, Chiba, Japan
| | - Dan Takeuchi
- Department of Surgery, Matsudo City General Hospital, Matsudo, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology, Matsudo City General Hospital, Matsudo, Chiba, Japan
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Yamamoto K, Tsuchiya T, Tanaka R, Tonozuka R, Mukai S, Nagai K, Matsunami Y, Kojima H, Minami H, Itoi T. Endoscopic retrieval of a proximally migrated fully covered self-expandable metal stent using biopsy forceps with a guiding sheath cannula. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:e81-e83. [PMID: 37907833 DOI: 10.1002/jhbp.1360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/27/2023] [Accepted: 06/10/2023] [Indexed: 11/02/2023]
Abstract
Transpapillary endoscopic biliary drainage is the gold standard for resolving malignant biliary obstruction. Stent migration occasionally occurs and is troublesome to retrieve. Yamamoto and colleagues report with accompanying video on the successful retrieval of a proximally migrated stent using biopsy forceps through a guiding sheath cannula.
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Affiliation(s)
- Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kazumasa Nagai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yukitoshi Matsunami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Hiroyuki Kojima
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Hirohito Minami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Petit S, Puyade M, Pichon M, Wangermez M, Velasco S, Roblot F, Isambert N, Evrard C, Rammaert B. Risk factors for biliary stent infections in malignant biliary obstruction secondary to unresectable malignancies. Support Care Cancer 2022; 30:6937-6946. [PMID: 35543817 DOI: 10.1007/s00520-022-07106-2] [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: 01/20/2022] [Accepted: 04/29/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Palliative biliary drainage in patients with unresectable malignant biliary obstruction (MBO) frequently leads to biliary stent infection (BI), which could impact medical care. The aim of this study was to assess the risk factors for BI occurrence in patients after stenting procedure and the impact of BI on patient survival. METHODS All consecutive patients hospitalized from 2014 to 2018 for MBO and biliary stenting were retrospectively included. Demographic, clinical, and microbiological characteristics of each BI episode during a 1-year follow-up were described. Documented BI was defined as the association of BI episode and confirmed blood stream infection (BSI). Univariate and multivariate analyses were performed to evaluate risk factors for the first BI occurrence. RESULTS Among 180 patients, 56% were men (mean age of 69±12), and 54% have pancreatic cancer, 16% biliary cancer, 2% hepatic cancer, and 28% lymph node or metastatic compression; metallic stent was placed in 92%. A total of 113 BI episodes occurred in 74 patients, 55% of the first episodes occurring within 3 months after stenting. BI was documented in 56% of the episodes. Enterobacteriaceae were the most frequent pathogens found, while no yeasts were documented. Mortality rate in patients with BI was 64%. Multivariate analysis showed a significant difference in BI occurrence for two criteria: WHO score 3-4 (OR=8.79 [1.79-42.89]; p=0.007) and transpapillary stenting location (OR=3.72 [1.33-10.44]; p=0.013). CONCLUSION Since transpapillary stenting is a risk factor for BI, preserving the papilla as much as possible is a priority so as to avoid BI.
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Affiliation(s)
- Sébastien Petit
- Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France
| | - Mathieu Puyade
- Service de Médecine Interne et Maladies Infectieuses et Tropicales, CHU Poitiers, 2 rue de la Milétrie, CS 90577, 86021, Poitiers Cedex, France
| | - Maxime Pichon
- Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France
- Laboratoire de Bactériologie et Hygiène Hospitalière, Département des Agents Infectieux, CHU Poitiers, Poitiers, France
- INSERM U1070, Poitiers, France
| | - Marc Wangermez
- Service d'Hépato Gastro-Entérologie, CHU Poitiers, Poitiers, France
| | - Stéphane Velasco
- Service de Radiologie Interventionnelle, CHU Poitiers, Poitiers, France
| | - France Roblot
- Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France
- Service de Médecine Interne et Maladies Infectieuses et Tropicales, CHU Poitiers, 2 rue de la Milétrie, CS 90577, 86021, Poitiers Cedex, France
- INSERM U1070, Poitiers, France
| | - Nicolas Isambert
- Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France
- Service d'Oncologie Médicale, Pôle Régional de Cancérologie, CHU Poitiers, Poitiers, France
| | - Camille Evrard
- Service d'Oncologie Médicale, Pôle Régional de Cancérologie, CHU Poitiers, Poitiers, France
| | - Blandine Rammaert
- Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France.
- Service de Médecine Interne et Maladies Infectieuses et Tropicales, CHU Poitiers, 2 rue de la Milétrie, CS 90577, 86021, Poitiers Cedex, France.
- INSERM U1070, Poitiers, France.
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Paik WH, Woo SM, Chun JW, Song BJ, Lee WJ, Ahn DW, Lee YS, Choi YH, Ryu JK, Kim YT, Lee SH. Efficacy of an internal anchoring plastic stent to prevent migration of a fully covered metal stent in malignant distal biliary strictures: a randomized controlled study. Endoscopy 2021; 53:578-585. [PMID: 32886935 DOI: 10.1055/a-1256-0571] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Two types of self-expandable metal stents (SEMS) are available for malignant distal biliary obstruction: fully covered SEMS (FCSEMS) and uncovered SEMS. FCSEMS can prevent stent ingrowth, but a major concern is spontaneous migration. This study aimed to determine whether the additional insertion of a double-pigtail plastic stent to anchor the FCSEMS can prevent migration. METHODS 68 patients with unresectable, malignant, distal, biliary obstruction were included in this multicenter, randomized, superiority trial. The patients were randomly assigned to receive either the FCSEMS plus an anchoring plastic stent (n = 33) or an FCSEMS alone (n = 35). After placement of the FCSEMS, the anchoring stent was inserted inside the FCSEMS. The primary outcome was the rate of stent migration during the 6-month follow-up. The secondary outcomes were stent-related adverse events, stent patency, and survival rates. RESULTS The baseline characteristics were similar between the two groups. The rate of stent migration at 6 months was significantly lower in patients with the FCSEMS plus anchoring stent (15 % vs. 40 %; P = 0.02). The mean stent patency was significantly longer in the FCSEMS plus anchoring group (237 days [95 % confidence interval [CI] 199 to 275] vs. 173 days [95 %CI 130 to 217]; P = 0.048). There were no significant differences in stent-related adverse events and overall survival rates at 6 months between the two groups. CONCLUSIONS Our data suggest that the additional double-pigtail plastic stent anchored the FCSEMS to prevent migration and prolonged patency without any serious adverse events.
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Affiliation(s)
- Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Myung Woo
- Center for Liver and Pancreatobiliary Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jung Won Chun
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byeong Jun Song
- Department of Internal Medicine, Myongji Hospital, Goyang, Korea
| | - Woo Jin Lee
- Center for Liver and Pancreatobiliary Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dong-Won Ahn
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Yoon Suk Lee
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Young Hoon Choi
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yong-Tae Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Park CH, Park SW, Jung JH, Jung ES, Kim JH, Park DH. Comparative Efficacy of Various Stents for Palliation in Patients with Malignant Extrahepatic Biliary Obstruction: A Systematic Review and Network Meta-Analysis. J Pers Med 2021; 11:jpm11020086. [PMID: 33573288 PMCID: PMC7912345 DOI: 10.3390/jpm11020086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/20/2021] [Accepted: 01/27/2021] [Indexed: 11/16/2022] Open
Abstract
Although many studies have investigated the efficacy of stent placement for patients with malignant extrahepatic biliary obstruction, the clinical outcomes and adverse events of biliary stenting have not been comprehensively evaluated. We searched all relevant randomized-controlled trials that evaluated the comparative efficacy of biliary stents, including the plastic stents, uncovered self-expandable metal stents (SEMSs), and covered SEMSs in patients with malignant extrahepatic biliary obstructions. Twenty-one studies with 2326 patients were included. Both uncovered and covered SEMSs had a lower risk of recurrent biliary obstruction (RBO) compared to plastic stents (risk ratio (RR) (95% confidence interval [CI]): uncovered vs. plastic, 0.46 (0.35–0.62); covered vs. plastic, 0.46 (0.34–0.62)). A comparison of the groups using SEMSs revealed that tumor ingrowth was common in the uncovered SEMS group, while stent migration, tumor overgrowth, and occlusion by sludge were common in the covered SEMS group; however, the overall risk of RBO did not differ between these groups (RR (95% CI): uncovered vs. covered: 1.02 (0.80–1.30)). Although the main causes of RBO vary across stents, RBO risk was similar between uncovered and covered SEMS groups. Both SEMSs have superior efficacy in terms of RBO compared to plastic stents.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri 11923, Korea;
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
- Correspondence: ; Tel.: +82-31-8086-2858
| | - Jang Han Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
| | - Eun Suk Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
| | - Jung Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
| | - Da Hae Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea; (J.H.J.); (E.S.J.); (J.H.K.); (D.H.P.)
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Yamakawa K, Masuda A, Kodama Y. Troubleshooting for severe acute cholangitis caused by proximally migrated metal stent into the intrahepatic bile duct: Stent shortening via a balloon catheter. Dig Endosc 2020; 32:e112-e113. [PMID: 32472625 DOI: 10.1111/den.13711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Kohei Yamakawa
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
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Chang A, Prachayakul V. Endoscopic Management of a Proximally Migrated Fully Covered SEMS Using the Stent-in-Stent Technique. Case Rep Med 2020; 2020:3438469. [PMID: 32273895 PMCID: PMC7136765 DOI: 10.1155/2020/3438469] [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: 01/26/2020] [Accepted: 03/09/2020] [Indexed: 02/05/2023] Open
Abstract
Endoscopic biliary decompression via stent placement is an important approach for the palliative management of distal malignant biliary obstruction. However, migration of the inserted stent can occur, either distally or proximally; proximal migration is less common, but it also presents a greater challenge for endoscopic resolution. We present a case of a 67-year-old woman who had locally advanced pancreatic cancer and developed a common bile duct obstruction. Upon clinical presentation of chronic, painless, progressive jaundice, the obstruction was managed by placing of a 10 mm × 60 mm covered self-expandable metal stent (CSEMS), which successfully facilitated palliative biliary drainage. Six months later, however, the patient developed recurrent jaundice, which was determined to be due to proximal migration of the CSEMS. Repeat endoscopic retrograde cholangiography was performed, and initial attempts to retrieve the migrated stent failed. Finally, another 10 mm × 60 mm CSEMS was placed across the stricture site, inside the previous stent, which remained in place. The treatment resolved the obstruction and jaundice, and the patient experienced no adverse events.
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Affiliation(s)
- Arunchai Chang
- Division of Gastroenterology, Department of Internal Medicine, Hatyai Hospital, Songkhla, Thailand
| | - Varayu Prachayakul
- Siriraj Gastrointestinal Endoscopy Center, Division of Gastroenterology, Department of Internal Medicine, Siriraj Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand
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Akpınar MY, Saygılı F, Öztaş E, Coşkun O, Ödemiş B. Deforme biliyer metal stente bağlı gelişen gastrointestinal sistem kanaması. EGE TIP DERGISI 2018. [DOI: 10.19161/etd.414399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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11
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Yokota Y, Fukasawa M, Takano S, Kadokura M, Shindo H, Takahashi E, Hirose S, Kawakami S, Fukasawa Y, Sato T, Enomoto N. Partially covered metal stents have longer patency than uncovered and fully covered metal stents in the management of distal malignant biliary obstruction: a retrospective study. BMC Gastroenterol 2017; 17:105. [PMID: 29020933 PMCID: PMC5637084 DOI: 10.1186/s12876-017-0662-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/02/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) are widely used for malignant biliary obstructions. Nitinol-covered SEMSs have been developed to improve stent patency. Currently, SEMSs may be uncovered, partially covered, or fully covered; however, there is no consensus on the best stent type for the management of malignant distal biliary obstruction (MDBO). METHODS Patients with unresectable MDBO receiving SEMS (Wallflex™) were retrospectively analyzed. Time to recurrent biliary obstruction (TRBO) and survival time were compared among the three types of SEMSs. Univariate and multivariate analyses were performed to identify risk factors for stent dysfunction. RESULTS In total, 101 patients received SEMSs for unresectable MDBO (44 uncovered, 28 partially covered, and 29 fully covered SEMSs). Median survival time was 200, 168, and 276 days in the uncovered, partially covered, and fully covered SEMSs groups, respectively. There were no differences in survival among the three groups. Median TRBO was 199, 444, and 194 days in the uncovered, partially covered, and fully covered SEMSs groups, respectively. Partially covered SEMSs had longer TRBO than uncovered (p = 0.013) and fully covered (p = 0.010) SEMSs. Tumor ingrowth occurred only with uncovered SEMSs and stent migration occurred only with fully covered SEMSs. Multivariate analyses confirmed that partially covered SEMSs have lower risk of dysfunction. CONCLUSIONS Partially covered SEMSs with a proximal uncovered flared end have longer patency than uncovered and fully covered SEMSs by preventing tumor ingrowth and stent migration.
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Affiliation(s)
- Yudai Yokota
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Mitsuharu Fukasawa
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan.
| | - Shinichi Takano
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Makoto Kadokura
- Department of Gastroenterology, Kofu Municipal Hospital, 366, Masutsubo, Kofu, Yamanashi, 400-0832, Japan
| | - Hiroko Shindo
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Ei Takahashi
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Sumio Hirose
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Satoshi Kawakami
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Yoshimitsu Fukasawa
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Tadashi Sato
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Nobuyuki Enomoto
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
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Páramo M, García-Barquín P, Carrillo M, Millor Muruzábal M, Vivas I, Bilbao J. Treatment of benign biliary leaks with transhepatic placement of coated self-expanding metallic stents. RADIOLOGIA 2017. [DOI: 10.1016/j.rxeng.2016.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Páramo M, García-Barquín P, Carrillo M, Millor Muruzábal M, Vivas I, Bilbao JI. Treatment of benign biliary leaks with transhepatic placement of coated self-expanding metallic stents. RADIOLOGIA 2016; 59:47-55. [PMID: 27814912 DOI: 10.1016/j.rx.2016.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 09/01/2016] [Accepted: 09/09/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To analyze the safety and efficacy of percutaneous placement of coated self-expanding metallic stents (SEMS) in patients with biliary leaks. MATERIAL AND METHODS This ethics committee at our center approved this study. We retrospectively reviewed all coated SEMS placed between October 2008 and September 2015. We analyzed patient-related factors such as the primary underlying disease, prior hepatic procedures, and clinical outcome. We evaluated the location, the number and type of leak (anastomotic or non-anastomotic), and the characteristics of the interventional procedure (number of stents deployed, location of the stents, technical success, and primary functionality). We recorded the complications registered. RESULTS We studied 14 patients (11 men and 3 women). The mean follow-up period was 375.5 days (range 15-1920 days). Leaks were postsurgical in 12 patients. One patient developed an arteriobilioportal fistula. In another, the biliary leak occurred secondary to the rupture of the common bile duct after ERCP. A total of 23 coated SEMS were placed, including 21 Fluency® stents (Bard, Tempe, AZ, USA) and 2 Wallflex® stents (Boston Scientific, Galway, Republic of Ireland). The technical success of the procedure was considered total in 11 (78.6%) patients, partial in 2 (14.3%) patients, and null in 1 (7.2%) patient. The clinical outcome was good in 13 of the 14 patients. The mean period of primary functionality of the coated SEMS was 331 days (range 15-1920 days). No major complications were observed in 11 (78.6%) patients. CONCLUSIONS Percutaneous placement of coated SEMS for the treatment of benign biliary leaks is safe and efficacious, with a high rate of technical and clinical success and a moderate rate of complications.
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Affiliation(s)
- M Páramo
- Departamento de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España.
| | - P García-Barquín
- Departamento de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - M Carrillo
- Departamento de Radiología, Hospital Morales Meseguer, Murcia, España
| | - M Millor Muruzábal
- Departamento de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - I Vivas
- Departamento de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - J I Bilbao
- Departamento de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España
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Covered versus uncovered self-expandable metal stents for malignant biliary strictures: A meta-analysis and systematic review. Indian J Gastroenterol 2016; 35:323-330. [PMID: 27566620 DOI: 10.1007/s12664-016-0682-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/17/2016] [Indexed: 02/04/2023]
Abstract
Self-expandable metal stents (SEMS) are used for palliating inoperable malignant biliary strictures. It is unclear if covered metal stents are superior to uncovered metal stents in these patients. We compared clinical outcomes in patients with covered and uncovered stents. Studies using covered and uncovered metallic stents for palliation in patients with malignant biliary stricture were reviewed. Articles were searched in MEDLINE, PubMed, and Ovid journals. Fixed and random effects models were used to calculate the pooled proportions. Initial search identified 1436 reference articles, of which 132 were selected and reviewed. Thirteen studies (n = 2239) for covered and uncovered metallic stents which met the inclusion criteria were included in this analysis. Odds ratio for stent occlusion rates in covered vs. uncovered stents was 0.79 (95 % CI = 0.65 to 0.96). Survival benefit in patients with covered vs. uncovered stents showed the odds ratio to be 1.29 (95 % CI = 0.95 to 1.74). Pooled odds ratio for migration of covered vs. uncovered stents was 9.9 (95 % CI = 4.5 to 22.3). Covered stents seemed to have significantly lesser occlusion rates, increased odds of migration, and increased odds of pancreatitis compared to uncovered stents. There was no statistically significant difference in the survival benefit, overall adverse event rate, and patency period of covered vs. uncovered metal stents in patients with malignant biliary strictures.
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Yang MJ, Kim JH, Yoo BM, Hwang JC, Yoo JH, Lee KS, Kang JK, Kim SS, Lim SG, Shin SJ, Cheong JY, Lee KM, Lee KJ, Cho SW. Partially covered versus uncovered self-expandable nitinol stents with anti-migration properties for the palliation of malignant distal biliary obstruction: A randomized controlled trial. Scand J Gastroenterol 2016; 50:1490-9. [PMID: 26133200 DOI: 10.3109/00365521.2015.1057219] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Covered self-expandable metal stents (SEMSs) are increasingly used as alternatives to uncovered SEMSs for the palliation of inoperable malignant distal biliary obstruction to counteract tumor ingrowth. We aimed to compare the outcomes of partially covered and uncovered SEMSs with identical mesh structures and anti-migration properties, such as low axial force and flared ends. MATERIALS AND METHODS One hundred and three patients who were diagnosed with inoperable malignant distal biliary obstruction between January 2006 and August 2013 were randomly assigned to either the partially covered (n = 51) or uncovered (n = 52) SEMS group. RESULTS There were no significant differences in the cumulative stent patency, overall patient survival, stent dysfunction-free survival and overall adverse events, including pancreatitis and cholecystitis, between the two groups. Compared to the uncovered group, stent migration (5.9% vs. 0%, p = 0.118) and tumor overgrowth (7.8% vs. 1.9%, p = 0.205) were non-significantly more frequent in the partially covered group, whereas tumor ingrowth showed a significantly higher incidence in the uncovered group (5.9% vs. 19.2%, p = 0.041). Stent migration in the partially covered group occurred only in patients with short stenosis of the utmost distal bile duct (two in ampullary cancer, one in bile duct cancer), and did not occur in any patients with pancreatic cancer. CONCLUSIONS For the palliation of malignant distal biliary obstruction, endoscopic placement of partially covered SEMSs with anti-migration designs and identical mesh structures to uncovered SEMSs failed to prolong cumulative stent patency or reduce stent migration.
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Affiliation(s)
- Min Jae Yang
- Department of Gastroenterology, Ajou University School of Medicine , Suwon , South Korea
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Kuwatani M, Kawamoto Y, Nakamura T. Eccentric Abscess Due to Bile Duct Microperforation Caused by Self-expandable Metal Stent and Neoadjuvant Chemoradiation. Clin Gastroenterol Hepatol 2016; 14:A29-30. [PMID: 26851708 DOI: 10.1016/j.cgh.2016.01.013] [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: 12/25/2015] [Revised: 01/19/2016] [Accepted: 01/24/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Masaki Kuwatani
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Kita-ku, Sapporo, Japan
| | - Yasuyuki Kawamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Kita-ku, Sapporo, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Hospital, Kita-ku, Sapporo, Japan
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Abstract
Many advances have been achieved in biliary stenting over the past 30 years. Endoscopic stent placement has become the primary management therapy to relieve obstruction in patients with benign or malignant biliary tract diseases. Compared with plastic stents, a self-expandable metallic stent (SEMS) has been used for management in patients with malignant strictures because of a larger lumen and longer stent patency. Recently, SEMS has been used for various benign biliary strictures and leaks. In this article, we briefly review the characteristics of SEMS as well as complications of stent placement. We review the current guidelines for managing malignant and benign biliary obstructions. Recent developments in biliary stenting are also discussed.
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Affiliation(s)
- Hyeong Seok Nam
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dae Hwan Kang
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Martins FP, Kahaleh M, Ferrari AP. Management of liver transplantation biliary stricture: Results from a tertiary hospital. World J Gastrointest Endosc 2015; 7:747-757. [PMID: 26140103 PMCID: PMC4482835 DOI: 10.4253/wjge.v7.i7.747] [Citation(s) in RCA: 23] [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: 08/28/2014] [Revised: 09/30/2014] [Accepted: 05/11/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To review results of endoscopic treatment for anastomotic biliary strictures after orthotopic liver transplantation (OLT) during an 8-year period.
METHODS: This is a retrospective review of all endoscopic retrograde cholangiopancreatographys (ERCPs) performed between May 2006 and June 2014 in deceased OLT recipients with anastomotic stricture at a tertiary care hospital. Patients were divided into 2 groups, according to the type of stent used (multiple plastic or covered self-expandable metal stents), which was chose on a case-by-case basis and their characteristics. The primary outcome was anastomotic stricture resolution rate determined if there was no more than a minimum waist at cholangiography and a 10 mm balloon could easily pass through the anastomosis with no need for further intervention after final stent removal. Secondary outcomes were technical success rate, number or ERCPs required per patient, number of stents placed, stent indwelling, stricture recurrence rate and therapy for recurrent anastomotic biliary stricture (AS). Stricture recurrence was defined as clinical laboratorial and/or imaging evidence of obstruction at the anastomosis level, after it was considered completely treated, requiring subsequent interventional procedure.
RESULTS: A total of 195 post-OLT patients were assessed for eligibility. One hundred and sixty-four (164) patients were diagnosed with anastomotic biliary stricture. ERCP was successfully performed in 157/164 (95.7%) patients with AS, that were treated with either multiple plastic (n = 109) or metallic billiary stents (n = 48). Mean treatment duration, number of procedures and stents required were lower in the metal stent group. Acute pancreatitis was the most common procedure related complication, occurring in 17.1% in the covered self-expandable metal stents (cSEMS) and 4.1% in the multiple plastic stent (MPS) group. Migration was the most frequent stent related complication, observed in 4.3% and 5.5% (cSEMS and MPS respectively). Stricture resolution was achieved in 86.8% in the cSEMS group and in 91% in MPS group. Stricture recurrence after a median follow up of 20 mo was observed in 10 (30.3%) patients in the cSEMS and 7 (7.7%) in the plastic stent group, a statistically significant difference (P = 0.0017). Successful stricture resolution after secondary treatment was achieved in 66.6% and 62.5% of patients respectively in the cSEMS and plastic stents groups.
CONCLUSION: Multiple plastic stents are currently the first treatment option for AS in patients with duct-to-duct anastomosis. cSEMS was associated with increased pancreatitis risk and higher recurrence rate.
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Zheng YG, Wang T, Li F, Cheng ZB. Use of stents in treatment of malignant biliary obstruction. Shijie Huaren Xiaohua Zazhi 2014; 22:5279-5284. [DOI: 10.11569/wcjd.v22.i34.5279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Stents are now recognized as the first choice of palliative therapy for malignant biliary obstruction. Since stents can effectively relieve obstruction, reduce jaundice, and improve the quality of life, their usage in inoperable biliary tract cancer patients has broad prospects. This paper reviews the use of stents in the treatment of malignant biliary obstruction with regards to stent type, selection, placement and the combination of stenting with other means of treatment.
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20
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Covered self-expanding metal stents may be preferable to plastic stents in the treatment of chronic pancreatitis-related biliary strictures: a systematic review comparing 2 methods of stent therapy in benign biliary strictures. J Clin Gastroenterol 2014; 48:635-43. [PMID: 24275713 DOI: 10.1097/mcg.0000000000000020] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Covered self-expanding metal stents (CSEMS) are being increasingly used in the endoscopic treatment of benign biliary strictures (BBS). There is no solid evidence yet to support their routine use. GOALS To evaluate feasibility, success rate, and complications of CSEMS compared with multiple plastic stents (PS) in BBS in a systematic review. STUDY A systematic search of electronic databases (Medline, Scopus, and Embase) for studies published from 2000 to 2012 combined to hand-search of reference lists resulted 4977 articles. Out of 99 potentially relevant studies selected for full-text review, 12 CSEMS (376 patients) and 13 PS studies (570 patients) met the final inclusion criteria. A systematic review comparing the 2 methods was made using proportion meta-analysis. RESULTS A tendency to successful use of CSEMS in strictures related to chronic pancreatitis (CP) was shown: clinical success of 77% and 33% [95% confidence interval (CI), 61%-94% vs. 4%-63%, P=0.06] was achieved with CSEMS and PS at 12 months follow-up, respectively. There were no differences in the success rates of other etiologies except CP or in the early complications. In CSEMS, incidence of late adverse events was lower in CP-related strictures (3% vs. 67%, 95% CI, 0%-13% vs. 17%-99%, P=0.02). The median number of endoscopic retrograde cholangiopancreatographies was lower with CSEMSs: 1.5 versus 3.9 (P=0.002). CONCLUSIONS Improved clinical success with fewer endoscopic sessions and corresponding complication rate may be achieved with CSEMS treatment compared with PS in BBS secondary to CP. In other BBS etiologies, this systematic review remains inconclusive.
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Kitano M, Yamashita Y, Tanaka K, Konishi H, Yazumi S, Nakai Y, Nishiyama O, Uehara H, Mitoro A, Sanuki T, Takaoka M, Koshitani T, Arisaka Y, Shiba M, Hoki N, Sato H, Sasaki Y, Sato M, Hasegawa K, Kawabata H, Okabe Y, Mukai H. Covered self-expandable metal stents with an anti-migration system improve patency duration without increased complications compared with uncovered stents for distal biliary obstruction caused by pancreatic carcinoma: a randomized multicenter trial. Am J Gastroenterol 2013; 108:1713-22. [PMID: 24042190 DOI: 10.1038/ajg.2013.305] [Citation(s) in RCA: 159] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 08/06/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The requirements of biliary stents used in the palliation of malignant biliary obstruction are a long duration of patency and minimal adverse effects. Covered self-expandable metal stents (SEMSs) have been shown to prevent tumor ingrowth, which is the most frequent complication of uncovered SEMSs. However, because they are prone to migration, the superiority of covered SEMS has yet to be convincingly demonstrated. The aim of this study was to evaluate the superiority of covered over uncovered SEMSs in the palliation of distal biliary obstruction due to unresectable pancreatic carcinoma, using both stent types with relatively low axial force and uncovered flared ends to prevent their migration. METHODS From April 2009 to December 2010, 120 patients who were admitted to 22 tertiary-care centers because of distal biliary obstruction from unresectable pancreatic carcinomas were enrolled in this prospective randomized multicenter study. Patients were randomly assigned to receive a covered or uncovered SEMS deployed at the site of the biliary stricture during endoscopic retrograde cholangiopancreatography. Stent patency time, patient survival time, patient survival time without stent dysfunction (time to stent dysfunction or patient death), cause of stent dysfunction (ingrowth, overgrowth, migration, or sludge formation), and serious adverse events were compared between covered and uncovered SEMS groups. RESULTS Patient survival time in the two groups did not significantly differ (median: 285 and 223 days, respectively; P=0.68). Patient survival time without stent dysfunction was significantly longer in the covered than in the uncovered SEMS group (median: 187 vs. 132 days; P=0.043). Stent patency was also significantly longer in the covered than in the uncovered SEMS group (mean±s.d.: 219.3±159.1 vs. 166.9±124.9 days; P=0.047). Reintervention for stent dysfunction was performed in 14 of 60 patients with covered SEMSs (23%) and in 22 of 60 patients with uncovered SEMSs (37%; P=0.08). Stent dysfunction was caused by tumor ingrowth, tumor overgrowth, and sludge formation in 0 (0%), 3 (5%), and 11 (18%) patients in the covered SEMSs group, and in 15 (25%), 2 (3%), and 6 (10%) patients in the uncovered SEMSs group, respectively. Stent migration was not observed in either group. Rates of tumor overgrowth and sludge formation did not significantly differ between the two groups, whereas the rate of tumor ingrowth was significantly lower in the covered than in the uncovered SEMS group (P<0.01). Acute pancreatitis occurred in only one patient in the covered SEMS group. Acute cholecystitis occurred in one patient in the covered SEMS group and in two patients in the uncovered SEMS group. There was no significant difference between the two groups in the incidence of serious adverse events. CONCLUSIONS By preventing tumor ingrowth and migration, covered SEMSs with an anti-migration system had a longer duration of patency than uncovered SEMSs, which recommends their use in the palliative treatment of patients with biliary obstruction due to pancreatic carcinomas.
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Affiliation(s)
- Masayuki Kitano
- Department of Gastroenterology and Hepatology, Kinki University, Osaka-sayama, Japan
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Cho NJ, Lee TH, Park SH, Lee HM, Hyun KH, Lee SH, Chung IK, Kim SJ. Endoscopic Removal of a Proximally Migrated Metal Stent during Balloon Sweeping after Stent Trimming. Clin Endosc 2013; 46:418-22. [PMID: 23964344 PMCID: PMC3746152 DOI: 10.5946/ce.2013.46.4.418] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 06/19/2012] [Accepted: 06/23/2012] [Indexed: 01/07/2023] Open
Abstract
Placement of a self-expanding metal stent (SEMS) is an effective method for palliation of a malignant biliary obstruction. However, metal stents can cause various complications, including stent migration. Distally migrated metal stents, particularly covered SEMS, can be removed successfully in most cases. Stent trimming using argon plasma coagulation may be helpful in difficult cases despite conventional methods. However, no serious complications related to the trimming or remnant stent removal method have been reported due to the limited number of cases. In particular, proximal migration of a remnant fragmented metal stent after stent trimming followed by balloon sweeping has not been reported. We report an unusual case of proximal migration of a remnant metal stent during balloon sweeping following stent trimming by argon plasma coagulation. The remnant metal stent was successfully removed with rotation technique using a basket and revised endoscopically.
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Affiliation(s)
- Nam Jun Cho
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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Percutaneous Intraductal Radiofrequency Ablation for Clearance of Occluded Metal Stent in Malignant Biliary Obstruction: Feasibility and Early Results. Cardiovasc Intervent Radiol 2013; 37:235-40. [DOI: 10.1007/s00270-013-0688-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 04/23/2013] [Indexed: 12/11/2022]
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Abu-Wasel B, Keough V, Renfrew PD, Molinari M. Biliary stent therapy for dominant strictures in patients affected by primary sclerosing cholangitis. Pathobiology 2013; 80:182-93. [PMID: 23652282 DOI: 10.1159/000347057] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The diagnosis and the treatment of dominant strictures (DS) in patients with primary sclerosing cholangitis (PSC) is challenging and the scientific literature on the subject is quite limited. Only level II and level III evidence is available to guide physicians managing patients with DS and PSC. For the diagnosis, intraductal endoscopic ultrasound is the most sensitive (64%) and specific (95%) test. However, the majority of cases require a combination of several different diagnostic tests, as there is no single investigation that can rule out malignancy in this group of patients. For the treatment, serial endoscopic or percutaneous dilatations provide 1- and 3-year biliary duct patency in 80 and 60% of patients, respectively. Dilatation and stenting are the most common interventions, although the optimal duration of treatment has still not been clearly defined. Bile duct resection and/or bilioenteric bypass are currently indicated only for patients with preserved liver function. For all other patients, benign DS can be treated with endoscopic dilatation with short-term stenting. This approach is effective and safe and does not increase the risk of malignant transformation or complications for liver transplant candidates. During the last decade, the use of self-expandable metallic stents for benign diseases has become an innovative option. The aim of this article is to review the diagnostic and therapeutic strategies for patients affected by PSC and DS with specific emphasis on the outcomes of patients treated with temporary stents.
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Affiliation(s)
- Bassam Abu-Wasel
- Department of Surgery, Dalhousie University, Queen Elizabeth II Health Science Center, Halifax, Canada
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Canena J, Liberato M, Horta D, Romão C, Coutinho A. Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations. Surg Endosc 2012; 27:313-24. [DOI: 10.1007/s00464-012-2368-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 05/02/2012] [Indexed: 12/15/2022]
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Isayama H, Nakai Y, Kawakubo K, Kogure H, Hamada T, Togawa O, Sasahira N, Hirano K, Tsujino T, Koike K. Endoscopic retrograde cholangiopancreatography for distal malignant biliary stricture. Gastrointest Endosc Clin N Am 2012; 22:479-90. [PMID: 22748244 DOI: 10.1016/j.giec.2012.04.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic biliary stent placement is widely accepted as palliation for malignant biliary obstruction or as a treatment of benign biliary stricture. Although various biliary stent designs have become available since self-expandable metallic stents were introduced, no single ideal stent has been developed. An ideal stent should be patent until death, or surgery, in patients with resectable malignant biliary obstruction. Fewer complications, maneuverability, cost-effectiveness, and removability are also important factors. Alternatively, should we develop a novel method for biliary drainage other than biliary stenting via endoscopic retrograde cholangiopancreatography? This article reviews the current status of biliary stenting for malignant biliary obstructions.
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Affiliation(s)
- Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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27
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Prevention of biliary stent occlusion. Dig Dis Sci 2012; 57:1971; author reply 1971-2. [PMID: 22395960 DOI: 10.1007/s10620-012-2109-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 02/21/2012] [Indexed: 12/14/2022]
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Biliary leak in post-liver-transplant patients: is there any place for metal stent? HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2012; 2012:684172. [PMID: 22619479 PMCID: PMC3350842 DOI: 10.1155/2012/684172] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 02/29/2012] [Indexed: 12/15/2022]
Abstract
Objectives. Endoscopic management of bile leak after orthotopic liver transplant (OLT) is widely accepted. Preliminary studies demonstrated encouraging results for covered self-expandable metal stents (CSEMS) in complex bile leaks. Methods. Thirty-one patients with post-OLT bile leaks underwent endoscopic temporary placement of CSEMS (3 partially CSEMS , 18 fully CSEMS with fins and 10 fully CSEMS with flare ends) between December 2003 and December 2010. Long-term clinical success and safety were evaluated. Results. Median stent indwelling and follow-up were 89 and 1,353 days for PCSEMS, 102 and 849 for FCSEMS with fins and 98 and 203 for FCSEMS with flare ends. Clinical success was achieved in 100%, 77.8%, and 70%, respectively. Postplacement complications: cholangitis (1) and proximal migration (1), both in the FCSEMS with fins. Postremoval complications were biliary strictures requiring drainage: PCSEMS (1), FCSEMS with fins (6) and with flare ends (1). There was no significant differences in the FCSEMS groups regarding clinical success, age, gender, leak location, previous treatment, stent indwelling, and complications. Conclusion. Temporary placement of CSEMS is effective to treat post-OLT biliary leaks. However, a high number of post removal biliary strictures occurred especially in the FCSEMS with fins. CSEMS cannot be recommended in this patient population.
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Pausawasadi N, Soontornmanokul T, Rerknimitr R. Role of fully covered self-expandable metal stent for treatment of benign biliary strictures and bile leaks. Korean J Radiol 2012; 13 Suppl 1:S67-73. [PMID: 22563290 PMCID: PMC3341463 DOI: 10.3348/kjr.2012.13.s1.s67] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 12/02/2011] [Indexed: 12/23/2022] Open
Abstract
Endoscopic therapy by balloon dilation and placement of multiple large-bore plastic stents is the treatment of choice for benign biliary stricture. This approach is effective but it typically requires multiple endoscopic sessions given the short duration of stent patency. The endoscopic approach for treatment of bile leak involves the placement of a stent with or without biliary sphincterotomy. The self-expandable metal stent (SEMS) has traditionally been used for palliation of malignant biliary strictures given the long duration of stent patency owing to their larger stent diameter. Recently, SEMS has been used in a variety of benign biliary strictures and leaks, especially with the design of the covered self-expandable metal stent (CSEMS), which permits endoscopic-mediated stent removal. The use of CSEMS in benign biliary stricture could potentially result in a decrease in endoscopic sessions and it is technically easier when compared to placement of multiple plastic stents. However, complications such as cholecystitis due to blockage of cystic duct, stent migration, infection and pancreatitis have been reported. The potential subsegmental occlusion of contralateral intrahepatic ducts also limits the use of CSEMS in hilar stricture. Certain techniques and improvement of stent design may overcome these challenges in the future. Thus, CSEMS may be appropriate in only highly selected conditions, such as refractory benign biliary stricture, despite multiple plastic stent placement or difficult to treat bile duct stricture from chronic pancreatitis, and should not be used routinely. This review focuses on the use of fully covered self-expandable metal stent for benign biliary strictures and bile leaks.
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Affiliation(s)
- Nonthalee Pausawasadi
- Division of Gastroenterology, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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García-Cano J. Use of fully covered self-expanding metal stents in benign biliary diseases. World J Gastrointest Endosc 2012; 4:142-7. [PMID: 22523615 PMCID: PMC3329614 DOI: 10.4253/wjge.v4.i4.142] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Revised: 02/24/2012] [Accepted: 03/30/2012] [Indexed: 02/05/2023] Open
Abstract
Biliary fully covered self-expanding metal stents (FCSEMS) are now being used to treat several benign biliary conditions. Advantages include small predeployment and large postexpansion diameters in addition to an easy insertion technique. Lack of imbedding of the metal into the bile duct wall enables removability. In benign biliary strictures that usually require multiple procedures, despite the substantially higher cost of FCSEMS compared with plastic stents, the use of FCSEMS is offset by the reduced number of endoscopic retrograde cholangiopancreatography interventions required to achieve stricture resolution. In the same way, FCSEMS have also been employed to treat complex bile leaks, perforation and bleeding after endoscopic biliary sphincterotomy and as an aid to maintain permanent drainage tracts obtained by means of Endoscopic Ultrasound-guided biliary drainage. Good success rates have been achieved in all these conditions with an acceptable number of complications. FCSEMS were successfully removed in all patients. Comparative studies of FCSEMS and plastic stents are needed to demonstrate efficacy and cost-effectiveness
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Affiliation(s)
- Jesús García-Cano
- Jesús García-Cano, Department of Digestive Diseases, Hospital Virgen de la Luz, 16002 Cuenca, Spain
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Jaganmohan S, Lee JH. Self-expandable metal stents in malignant biliary obstruction. Expert Rev Gastroenterol Hepatol 2012; 6:105-14. [PMID: 22149586 DOI: 10.1586/egh.11.95] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Malignant biliary obstruction can be due to direct tumor infiltration, extrinsic compression, adjacent inflammation, desmoplastic reaction from tumors or, more commonly, a combination of the above factors. Pancreatic cancer is the most common cause of malignant biliary obstruction, and jaundice occurs in 70-90% of the patients during the course of the disease. Compared with the uncovered metal stents, covered metal stents have longer patency and a lower rate of tumor ingrowth, but have a higher rate of stent migration. To combat the occlusion and provide an antitumor effect, drug-eluting stents were developed. A duodenal stricture complicates biliary stent placement in 10-20% of patients with distal biliary obstruction due to pancreatic cancer. When both strictures are considered, a biliary stent can be placed either preceding or following duodenal stent placement. Complications of self-expandable metal stents include stent occlusion, stent migration, cholecystitis and pancreatitis.
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Affiliation(s)
- Sathya Jaganmohan
- Department of Gastroenterology, Hepatology, and Nutrition, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
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Saleem A, Leggett CL, Murad MH, Baron TH. Meta-analysis of randomized trials comparing the patency of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction. Gastrointest Endosc 2011; 74:321-327.e1-3. [PMID: 21683354 DOI: 10.1016/j.gie.2011.03.1249] [Citation(s) in RCA: 175] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 03/28/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) are used for palliation of malignant biliary obstruction. OBJECTIVE We performed a meta-analysis to compare stent patency and stent survival of covered SEMSs (CSEMSs) and uncovered SEMSs (USEMSs) in patients with unresectable distal malignant biliary obstruction. DESIGN Meta-analysis. SETTING Tertiary-care facility. PATIENTS A comprehensive search of several databases (from each database's earliest inclusive dates to November 2010, any language, and any population) was conducted. The search identified 337 potential abstracts and titles, of which 16 were retrieved in full text. Review of references identified 17 additional studies. We found 5 multicenter, randomized trials involving 781 patients. INTERVENTION Placement of covered and uncovered SEMSs for treatment of distal malignant biliary obstruction. MAIN OUTCOME MEASUREMENTS Stent patency, stent survival, patient survival, and cause for stent dysfunction (ingrowth, overgrowth, migration, and sludge formation). RESULTS The median length of follow-up was 212 days. Compared with USEMSs, CSEMSs were associated with significantly prolonged stent patency (weighted mean difference [WMD] 60.56 days; 95% confidence interval [CI], 25.96, 95.17; I² = 0%) and longer stent survival (WMD 68.87 days; 95% CI, 25.64, 112.11; I(2) = 79%). Stent migration, tumor overgrowth, and sludge formation were significantly higher with CSEMSs (relative risk [RR] 8.11; 95% CI, 1.47, 44.76; I² = 0%), (RR 2.02; 95% CI, 1.08, 3.78; I² = 0%), (RR 2.89; 95% CI, 1.27, 6.55; I² = 0%). LIMITATIONS Relatively low number of studies available and the fact that 2 of the 5 studies were from one institution. Also, the limited availability of some stents used in the trials may limit the applicability of these results. CONCLUSION CSEMSs have a significantly longer duration of patency compared with USEMSs in patients with distal malignant biliary obstruction. Stent dysfunction occurs at a similar rate, although there is a trend toward later obstruction with CSEMSs.
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Affiliation(s)
- Atif Saleem
- Department of Internal Medicine, Mayo Clinic, College of Medicine, Rochester, Minnesota, USA
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Lee JH. Self-expandable metal stents for malignant distal biliary strictures. Gastrointest Endosc Clin N Am 2011; 21:463-80, viii-ix. [PMID: 21684465 DOI: 10.1016/j.giec.2011.04.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Obstructive jaundice can result from benign or malignant etiologies. The common benign conditions include primary sclerosing cholangitis, chronic pancreatitis, and gallstones. Malignant biliary obstruction can be caused by direct tumor infiltration, extrinsic compression by enlarged lymph nodes or malignant lesions, adjacent inflammation, desmoplastic reaction from a tumor, or a combination of these factors. Malignant diseases causing biliary obstruction include pancreatic cancer, ampullary cancer, cholangiocarcinoma, and metastatic diseases. This article focuses on malignant distal biliary obstruction and its management.
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Affiliation(s)
- Jeffrey H Lee
- Department of Gastroenterology, Hepatology, and Nutrition, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030-4009, USA.
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Bakhru MR, Foley PL, Gatesman J, Schmitt T, Moskaluk CA, Kahaleh M. Fully covered self-expanding metal stents placed temporarily in the bile duct: safety profile and histologic classification in a porcine model. BMC Gastroenterol 2011; 11:76. [PMID: 21689439 PMCID: PMC3142530 DOI: 10.1186/1471-230x-11-76] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 06/20/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Fully covered Self-Expanding metal stents (FCSEMS) have been shown efficacious in palliating malignant biliary obstructions. There is little data analyzing mucosal response to their temporary placement in the bile duct. METHODS Ten mini pigs underwent endoscopic placement of a FCSEMS (Wallflex, Boston Scientific). FCSEMS were kept in place for three months. At the end of the 3 months, FCSEMS were removed endoscopically. Five pigs were euthanized and their bile ducts harvested. The other five were kept alive for another month post removal. A single pathologist, created a scoring system (to determine degree of inflammation, fibrosis, and epithelial injury), examined all specimens in a blinded fashion. RESULTS Four FCSEMS spontaneously migrated in the duodenum. On post mortem examination, mild mucosal thickness was noted in three bile duct specimens while superficial inflammation of the bile duct was noted in five animals. Histologic examination of the bile duct revealed focal acute inflammation in both groups. For the 5 animals euthanized immediately after stent removal, there was a tendency to have superficial mucosal erosion and fibrosis. In contrast, increased chronic inflammation was more commonly seen in the animals 1 month post stent removal, with all animals in this group showing moderate degrees of mononuclear inflammatory cell mucosal infiltrates. No severe inflammatory or fibrotic duct injury was observed in any of the study animals, with degree of injury graded as mild to moderate. CONCLUSION FCSEMS appear to induce minimal tissue overgrowth or fibrosis post placement. Ease of removability and no significant histologic injury are advantages noted with FCSEMS., however, further studies are needed to evaluate treating benign biliary strictures with FCSEMS in humans.
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Affiliation(s)
- Mihir R Bakhru
- Digestive Health, University of Virginia, Charlottesville, VA, USA
| | - Patricia L Foley
- Office of Animal Welfare, University of Virginia, Charlottesville, VA, USA
| | - Jeremy Gatesman
- Office of Animal Welfare, University of Virginia, Charlottesville, VA, USA
| | - Timothy Schmitt
- Division of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Michel Kahaleh
- Digestive Health, University of Virginia, Charlottesville, VA, USA
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Bakhru M, Ho HC, Gohil V, Wang AY, Ellen K, Sauer BG, Shami VM, Kahaleh M. Fully-covered, self-expandable metal stents (CSEMS) in malignant distal biliary strictures: mid-term evaluation. J Gastroenterol Hepatol 2011; 26:1022-7. [PMID: 21299614 DOI: 10.1111/j.1440-1746.2011.06682.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIMS Limited data exist regarding fully-covered, self-expandable metal stents (CSEMS) with anchoring fins for the management of malignant distal biliary strictures. The aim of this study is to evaluate their safety and patency. METHODS Over a period of 2 years, 70 patients (45 males, 66 ± 13 years) underwent endoscopic retrograde cholangiopancreatography (ERCP) with placement of a 10-mm (67 patients) or 8-mm diameter (3 patients) CSEMS for the palliation of distal malignant biliary obstruction (pancreatic [53] or other [17]). Data were collected prospectively for survival and stent patency; complications were evaluated retrospectively. RESULTS After CSEMS placement, 17 patients proceeded to surgery, and 53 patients were deemed unresectable. Mean survival for non-surgical candidates was 180 days (range: 15-1091), and 170 days (range: 9-589) for patients who underwent surgical management. CSEMS were left in place and remained patent for a mean of 163 days (range: 15-1091) in non-surgical candidates, and a mean of 55 days (range: 5-126) in surgical candidates. Complications during placement included wire perforations (4) and proximal deployment requiring repositioning (4), one of which was complicated by a bile leak. Post-procedure complications were observed in 24 cases (34%) and included post-ERCP pancreatitis (8, with 2 of them severe), post-procedure pain (5, with 3 requiring admission), cholecystitis (3), stent occlusion (3), cholangitis (2), proximal migration (1), post-sphincterotomy bleeding (1), and sepsis leading to death (1). CONCLUSION CSEMS appear to provide acceptable short-term patency rates; however, their limited long-term patency and high complication rate might limit their widespread use. Further long-term prospective data are required to confirm this observation.
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Affiliation(s)
- Mihir Bakhru
- Digestive Health Center of Excellence, University of Virginia, Charlottesville, Virginia, USA
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Abstract
PURPOSE OF REVIEW Benign biliary diseases are often managed endoscopically using plastic stents. Benign biliary strictures (BBS) respond to placement of multiple large-bore plastic stents, though requiring multiple procedures to place stents, and to exchange stents to prevent and/or treat stent occlusion. Bile leaks close using plastic stents, which divert bile away from the leak into the duodenum. Covered self-expandable metal stents (CSEMS), intended for palliation of malignant biliary obstruction, have been used to treat benign biliary diseases. Advantages include small predeployment and large postexpansion diameters. Lack of imbedding of the metal into the bile duct wall enables removability. RECENT FINDINGS For strictures, one CSEMS is inserted without need for dilation and remains in place for up to 6 months. Successful removal has been reported in all cases. Long-term stricture resolution is achieved in up to 92%. Adverse events include migration and new stricture formation. For treatment of complex bile leaks, the covering and large diameter allow successful closure in nearly all cases. Other uses of CSEMS include treatment of postsphincterotomy bleeding and closure of perforations. SUMMARY CSEMS show promise for treatment of BBS and complex biliary leaks. Successful resolution can be achieved in the majority of patients with the advantage of fewer procedures, which offsets their higher cost.
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Anchoring flap versus flared end, fully covered self-expandable metal stents to prevent migration in patients with benign biliary strictures: a multicenter, prospective, comparative pilot study (with videos). Gastrointest Endosc 2011; 73:64-70. [PMID: 21184871 DOI: 10.1016/j.gie.2010.09.039] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 09/24/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recently, placement of fully covered self-expandable metal stents (FCSEMSs) has been proposed as an alternative treatment for the management of benign biliary strictures. However, the major limitations of FCSEMSs are frequent migration and removal complications. OBJECTIVE We conducted this study to compare the antimigration effects, complication rates, and short-term efficacy of 2 FCSEMSs with either an anchoring flap (AF) or a flared end (FE) at the proximal end of the stent. DESIGN A multicenter, prospective comparative pilot study. SETTING Two tertiary referral centers. PATIENTS A total of 43 patients with benign biliary stricture who were candidates for placement of FCSEMSs were assigned to the AF (n = 22) or the FE group (n = 21). INTERVENTIONS Predefined duration of placement and removal of FCSEMSs. RESULTS After a median period of placement of 6 months (interquartile range 4-6), no patients in the AF group and 33% of patients (7 of 21, 1 in proximal and 6 in distal) in the FE group had stent migration (P = .004). The removal rate of the FCSEMSs was 100% in both groups (per protocol, n = 22 in the AF group and n = 17 in the FE group). Immediate improvement of biliary stricture was 91% (20/22, per protocol) in the AF group and 88% (15/17, per protocol) in the FE group. All stents were removed without difficulty. LIMITATIONS Short-term follow-up after the removal of FCSEMSs. CONCLUSIONS With regard to the antimigration effect of FCSEMSs for benign biliary stricture, the AF design may be superior to the FE. For up to 6 months, both FCSEMSs can be endoscopically removed without complications. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00945516.).
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The long term use of covered metal stents in managing malignant biliary obstruction. Are we changing outcomes? Dig Liver Dis 2010; 42:765-6. [PMID: 20869924 DOI: 10.1016/j.dld.2010.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 08/21/2010] [Indexed: 12/11/2022]
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Abstract
PURPOSE OF REVIEW The role of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) continues to mature. We will review the progress of pancreatobiliary endoscopy in the evaluation and treatment of benign and malignant pancreatobiliary diseases. RECENT FINDINGS First, minimizing contrast injection of the pancreas, wire-guided cannulation and prophylactic pancreatic stenting have been re-emphasized in recent studies as the most important endoscopic interventions that can lower the risk of post-ERCP pancreatitis. The role of preoperative ERCP in patients with jaundice secondary to pancreatic cancer was raised in a randomized trial; the widespread use of preoperative biliary drainage is now up for debate. The use of ERCP, intraoperative cholangiography, endoscopic ultrasound and magnetic resonance cholangiopancreatography in the evaluation of suspected common bile duct stones is discussed. We conclude by evaluating studies of fully covered, self-expandable metallic stents, with an emphasis on their potential use in benign biliary disease. SUMMARY Given the risk of complications and development of alternative imaging modalities, diagnostic ERCP is rarely indicated. However, therapeutic ERCP has been bolstered by advances such as fully covered metallic stents and cholangioscopy.
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Krokidis M, Fanelli F, Orgera G, Tsetis D, Mouzas I, Bezzi M, Kouroumalis E, Pasariello R, Hatzidakis A. Percutaneous palliation of pancreatic head cancer: randomized comparison of ePTFE/FEP-covered versus uncovered nitinol biliary stents. Cardiovasc Intervent Radiol 2010; 34:352-61. [PMID: 20467870 DOI: 10.1007/s00270-010-9880-4] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 04/20/2010] [Indexed: 02/08/2023]
Abstract
The purpose of this study was to compare the clinical effectiveness of expanded polytetrafluoroethylene/fluorinated-ethylene-propylene (ePTFE/FEP)-covered stents with that of uncovered nitinol stents for the palliation of malignant jaundice caused by inoperable pancreatic head cancer. Eighty patients were enrolled in a prospective randomized study. Bare nitinol stents were used in half of the patients, and ePTFE/FEP-covered stents were used in the remaining patients. Patency, survival, complications, and mean cost were calculated in both groups. Mean patency was 166.0 ± 13.11 days for the bare-stent group and 234.0 ± 20.87 days for the covered-stent group (p = 0.007). Primary patency rates at 3, 6, and 12 months were 77.5, 69.8, and 69.8% for the bare-stent group and 97.5, 92.2, and 87.6% for the covered-stent group, respectively. Mean secondary patency was 123.7 ± 22.5 days for the bare-stent group and 130.3 ± 21.4 days for the covered-stent group. Tumour ingrowth occurred exclusively in the bare-stent group in 27.5% of cases (p = 0.002). Median survival was 203.2 ± 11.8 days for the bare-stent group and 247.0 ± 20 days for the covered-stent group (p = 0.06). Complications and mean cost were similar in both groups. Regarding primary patency and ingrowth rate, ePTFE/FEP-covered stents have shown to be significantly superior to bare nitinol stents for the palliation of malignant jaundice caused by inoperable pancreatic head cancer and pose comparable cost and complications. Use of a covered stent does not significantly influence overall survival rate; nevertheless, the covered endoprosthesis seems to offer result in fewer reinterventions and better quality of patient life.
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Early infectious complications of percutaneous metallic stent insertion for malignant biliary obstruction. AJR Am J Roentgenol 2010; 194:261-5. [PMID: 20028931 DOI: 10.2214/ajr.09.2474] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE This study was designed to evaluate predisposing factors for early infectious complications after percutaneous metallic biliary stent insertion in patients with malignant biliary obstruction. MATERIALS AND METHODS From August 1999 to June 2008, 215 consecutively registered patients with inoperable malignant biliary obstruction were treated with percutaneous placement of a metallic stent. The incidence of early infectious complications was evaluated. Sex, age, level of obstruction, type and number of stents, and stent position (across or above the main duodenal papilla) were retrospectively reviewed. The findings in patients with early infectious complications were compared with those in patients without early infectious complications. RESULTS Infectious complications occurred within 30 days after stent placement in 14 of 215 (6.5%) patients. Univariate analysis showed a significant difference between the two groups with respect to nontranspapillary stent placement (p=0.003). In the multiple logistic regression analysis, age, sex, level of obstruction, and type and number of stents were negatively associated with the development of early infectious complications (p>0.05). CONCLUSION Our study data showed that stent placement across the main duodenal papilla seemed to prevent early infectious complications after percutaneous metallic biliary stent insertion in patients with malignant biliary obstruction.
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