Covered stents versus uncovered stents for the palliation of malignant extrahepatic biliary obstruction caused by direct tumor invasion: a cohort comparative study

Stent performance in palliative transhepatic treatment of malignant biliary obstruction: a randomized study comparing covered versus uncovered stents

BACKGROUND

Considering the limitations in both uncovered self-expandable metallic stents (USEMS) and covered self-expandable metallic stents (CSEMS), it is difficult to make a general recommendation for their application in percutaneous decompression of malignant biliary obstruction (MBO).

PURPOSE

To compare percutaneous transhepatic CSEMSs versus USEMSs for the palliative treatment of MBO in terms of technical success, clinical success, stent patency, patient survival, complications, and stent dysfunction.

MATERIAL AND METHODS

This prospective randomized study included 66 patients with unresectable MBO. CSEMSs were inserted in 31 patients (26 men, 5 women; mean age = 63.8 ± 7.96 years) and USEMSs were inserted in 35 patients (26 men, 9 women; mean age = 62.3 ± 11.7 years).

RESULTS

Mean primary stent patency duration was 138 ± 92.7 days in CSEMSs versus 150 ± 77.9 days in USEMSs (P = 0.578). Tumor overgrowth occurred exclusively in one patient with CSEMS (P = 0.470) and tumor ingrowth exclusively in two patients with USEMS (P = 0.494). Stent migration occurred in two patients with CSEMSs versus one patient with USEMSs (P = 0.579). Hemobilia occurred in five patients with CSEMSs versus three patients with USEMSs while bile leakage occurred in one patient in each group despite the larger introducer sheath caliber with CSEMSs (9 F vs. 6-7 F). There was no significant difference regarding patient survival (P = 0.969).

CONCLUSION

In our cohort of patients with rather poor life expectancy, there was no significant difference between covered and uncovered stents for the palliative treatment of MBO. However, considering the higher cost of CSEMs and the larger introducer diameter necessary for their placement, USEMSs can be preferred.

Outcomes of endoscopic biliary drainage in pancreatic cancer patients with an indwelling gastroduodenal stent: a multicenter cohort study in West Japan

BACKGROUND AND AIMS

Gastroduodenal and biliary obstruction may occur synchronously or asynchronously in advanced pancreatic cancer, and endoscopic double stent placement may be required. EUS-guided biliary drainage (EUS-BD) often is performed after unsuccessful placement of an endoscopic transpapillary stent (ETS), and EUS-BD may be beneficial in double stent placement. This retrospective multicenter cohort study compared the outcomes of ETS placement and EUS-BD in patients with an indwelling gastroduodenal stent (GDS).

METHODS

We recorded the clinical outcomes of patients at 5 tertiary-care medical centers who required biliary drainage after GDS placement between March 2009 and March 2014.

RESULTS

Thirty-nine patients were included in this study. Patients' mean age was 68.5 years; 23 (59.0%) were men. The GDS overlay the papilla in 23 patients (59.0%). The overall technical success rate was significantly higher with EUS-BD (95.2%) than with ETS placement (56.0%; P < .01). Furthermore, the technical success rate was significantly higher with EUS-BD (93.3%) than with ETS placement (22.2%; P < .01) when the GDS overlies the papilla. The overall clinical success rate of EUS-BD also was significantly higher than for ETS placement (90.5% vs 52.0%, respectively; P = .01), and there was no significant difference in the incidence of adverse events (ETS, 32.0% vs EUS-BD, 42.9%; P = .65).

CONCLUSION

Endoscopic double stent placement with EUS-BD is technically and clinically superior to ETS placement in patients with an indwelling GDS. EUS-BD should be considered the first-line treatment option for patients with an indwelling GDS that overlies the papilla. ETS placement remains a reasonable alternative when the papilla is not covered by the GDS.

Irradiation stents vs. conventional metal stents for unresectable malignant biliary obstruction: A multicenter trial

BACKGROUND & AIMS

Placement of an irradiation stent has been demonstrated to offer longer patency and survival than an uncovered self-expandable metallic stent (SEMS) in patients with unresectable malignant biliary obstruction (MBO). We aim to further assess the efficacy of an irradiation stent compared to an uncovered SEMS in those patients.

METHODS

We performed a randomized, open-label trial of participants with unresectable MBO at 20 centers in China. A total of 328 participants were allocated in parallel to the irradiation stent group (ISG) or the uncovered SEMS group (USG). Endpoints included stent patency (primary), technical success, relief of jaundice, overall survival, and complications.

RESULTS

The first quartile stent patency time (when 25% of the patients experienced stent restenosis) was 212 days for the ISG and 104 days for the USG. Irradiation stents were significantly associated with a decrease in the rate of stent restenosis (9% vs. 15% at 90 days; 16% vs. 27% at 180 days; 21% vs. 33% at 360 days; p = 0.010). Patients in the ISG obtained longer survival time (median 202 days vs. 140 days; p = 0.020). No significant results were observed in technical success rate (93% vs. 95%; p = 0.499), relief of jaundice (85% vs. 80%; p = 0.308), and the incidence of grade 3 and 4 complications (8.5% vs. 7.9%; p = 0.841).

CONCLUSIONS

Insertion of irradiation stents instead of uncovered SEMS could improve patency and overall survival in patients with unresectable MBO.

LAY SUMMARY

For patients with unresectable malignant biliary obstruction (MBO), placement of a self-expandable metallic stent (SEMS) is a recommended palliative modality to relieve pruritus, cholangitis, pain, and jaundice. However, restenosis is a main pitfall after stent placement. Data from this first multicenter randomized controlled trial showed that insertion of an irradiation stent provided longer patency and better survival than a conventional metal stent. ClinicalTrials.gov ID: NCT02001779.

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

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.

Comparative Study of Percutaneous Transhepatic Biliary Stent Placement with or without Iodine-125 Seeds for Treating Patients with Malignant Biliary Obstruction

PURPOSE

To prospectively evaluate safety and efficacy of biliary stent placement with iodine-125 (¹²⁵I) seeds in patients with malignant obstructive jaundice (MOJ).

MATERIALS AND METHODS

From July 2011 to June 2014, 55 patients were enrolled (group A, 11 men and 17 women, mean age 70.93 y ± 8.58; group B, 14 men and 13 women, mean age 70.26 y ± 9.71). All patients were randomly assigned to placement of a biliary stent with ¹²⁵I seeds (group A) or biliary stent only (group B). After stent placement, outcomes were measured regarding relief of MOJ. Clinical success rate, survival time, and safety were recorded. P < .05 was considered to indicate significant difference.

RESULTS

Stents were successfully placed in all 55 patients. MOJ was relieved in all patients, and there were no significant differences in complications related to stent insertion between the 2 groups. Mean and median stent patency were 191 days ± 19.8 (95% confidence interval [CI], 152-230 d) and 179 days ± 191.4 (95% CI, 87-267 d) in group A and 88.3 days ± 16.3 (95% CI, 61-114 d) and 77 days ± 88.2 (95% CI, 65-86 d) in group B (P < .001, log-rank test). Mean and median survival time were 222.6 days ± 21.0 (95% CI, 181-263 d) and 241 days ± 18.2 (95% CI, 179-270 d) in group A and 139.1 days ± 14.5 (95% CI, 110-167 d) and 142 days ± 16.3 (95% CI, 83-177 d) in group B (P < .001, log-rank test).

CONCLUSIONS

¹²⁵I seeds combined with biliary stent placement could significantly improve stent patency. The procedure seems to be safe and to extend survival compared with self-expandable biliary stent placement.

Covered versus uncovered self-expandable metal stents for malignant biliary strictures: A meta-analysis and systematic review

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.

Covered Stents versus Uncovered Stents for Unresectable Malignant Biliary Strictures: A Meta-Analysis

Aim. To summarize the covered or uncovered SEMS for treatment of unresectable malignant distal biliary obstruction, comparing the stent patency, patient survival, and incidence of adverse events between the two SEMSs. Methods. The meta-analysis search was performed independently by two of the authors, using MEDLINE, EMBASE, OVID, and Cochrane databases on all studies between 2010 and 2015. Pooled effect was calculated using either the fixed or the random effects model. Results. Statistics shows that there is no difference between SEMSs in the hazard ratio for patient survival (HR 1.04; 95% CI, 0.92–1.17; P = 0.55) and stent patency (HR 0.87, 95% CI: 0.58 to 1.30, P = 0.5). However, incidence of adverse events (OR: 0.74, 95% CI: 0.57 to 0.97, P = 0.03) showed significant different results in the covered SEMS, with dysfunctions events (OR: 0.75, 95% CI: 0.56 to 1.00, P = 0.05) playing a more important role than complications (OR: 0.87, 95% CI: 0.58 to 1.30, P = 0.50). Conclusions. Covered SEMS group had lower incidence of adverse events. There is no significant difference in dysfunctions, but covered SEMS trends to be better, with no difference in stent patency, patient survival, and complications.

Use of stents in treatment of malignant biliary obstruction

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.

Comparison of the utility of covered metal stents versus uncovered metal stents in the management of malignant biliary strictures in 749 patients

BACKGROUND

Self-expandable metal stents (SEMSs) are used to relieve malignant biliary obstruction.

OBJECTIVE

To compare outcomes between covered self-expandable metal stents (CSEMSs) and uncovered self-expandable metal stents (USEMSs) in malignant biliary obstruction.

DESIGN

Retrospective cohort study.

SETTING

Tertiary cancer center.

PATIENTS

Patients with malignant biliary obstruction.

INTERVENTIONS

Placement of CSEMS or USEMS.

MAIN OUTCOME MEASUREMENTS

Time to recurrent biliary obstruction (TRO), overall survival (OS), and adverse events.

RESULTS

From January 2000 to June 2011, 749 patients received SEMSs: 171 CSEMSs and 578 USEMSs. At 1 year, there was no significant difference in the percentage of patients with recurrent obstruction (CSEMSs, 35% vs USEMSs, 38%) and survival (CSEMSs, 45% vs USEMSs, 49%). There was no significant difference in the median OS (CSEMSs, 10.4 months vs USEMSs, 11.8 months; P = .84) and the median TRO (CSEMSs, 15.4 months vs USEMSs, 26.3 months; P = .61). The adverse event rate was 27.5% for the CSEMS group and 27.7% for the USEMS group. Although tumor ingrowth with recurrent obstruction was more common in the USEMS group (76% vs 9%, P < .001), stent migration (36% vs 2%, P < .001) and acute pancreatitis (6% vs 1%, P < .001) were more common in the CSEMS group.

LIMITATIONS

Retrospective study.

CONCLUSIONS

There was no significant difference in the patency rate or overall survival between CSEMSs and USEMSs for malignant distal biliary strictures. The CSEMS group had a significantly higher rate of migration and pancreatitis than the USEMS group. No significant SEMS-related adverse events were observed in patients undergoing neoadjuvant chemoradiation or surgical resection.

Endoscopic drainage in patients with inoperable hilar cholangiocarcinoma

Hilar cholangiocarcinoma has an extremely poor prognosis and is usually diagnosed at an advanced stage. Palliative management plays an important role in the treatment of patients with inoperable hilar cholangiocarcinoma. Surgical, percutaneous, and endoscopic biliary drainage are three modalities available to resolve obstructive jaundice. Plastic stents were widely used in the past; however, self-expanding metal stents (SEMS) have become popular recently due to their long patency and reduced risk of side branch obstruction, and SEMS are now the accepted treatment of choice for hilar cholangiocarcinoma. Bilateral drainage provides more normal and physiological biliary flow through the biliary ductal system than that of unilateral drainage. Unilateral drainage was preferred until recently because of its technical simplicity. But, with advancements in technology, bilateral drainage now achieves a high success rate and is the preferred treatment modality in many centers. However, the choice of unilateral or bilateral drainage is still controversial, and more studies are needed. This review focuses on the endoscopic method and discusses stent materials and types of procedures for patients with a hilar cholangiocarcinoma.