Percutaneous Transhepatic Biliary Stent Implantation for Obstructive Jaundice of Perihilar Cholangiocarcinoma: A Prospective Study on Predictors of Stent Patency and Survival in 92 Patients

Correlation between functional drainage and survival in malignant biliary obstruction after percutaneous biliary drainage

Purpose

Malignant biliary obstruction (MBO) is common in patients with advanced malignant tumors, leading to poor prognosis and hindering antitumor therapy. The purpose of our study was to assess the survival outcomes for patients under therapy after percutaneous transhepatic biliary drainage (PTBD) and identify prognostic factors associated with survival in patients with MBO.

Methods

From July 2010 to February 2021, 269 patients with MBO secondary to malignant tumor were divided into two groups (functional success and non-functional success). Survival time and prognostic factors were analyzed by Kaplan-Meier curves and the Cox model.

Results

The overall median survival time after PTBD was 4.6 months (95 % IC:3.9-5.3). The 3- and 6-month survival rates were 68.0 % and 38.7 %, respectively. The median survival improved from 3.2 months to 8.4 months when the procedure achieved functional success. Multivariate analysis demonstrated that functionally successful drainage and antitumor treatment after PTBD were independent positive prognostic factors, but the total bilirubin after drainage and tumor size were independent negative predictive values.

Conclusions

Functionally successful drainage could prolong survival time in patients with malignant biliary obstruction. Palliative care after drainage can prolong patient survival and improve their quality of life.

Machine learning-based nomogram for 30-day mortality prediction for patients with unresectable malignant biliary obstruction after ERCP with metal stent: a retrospective observational cohort study

BACKGROUND

This study aimed to investigate the risk factors for 30-day mortality in patients with malignant biliary obstruction (MBO) after endoscopic retrograde cholangiopancreatography (ERCP) with endobiliary metal stent placement. Furthermore, we aimed to construct and visualize a prediction model based on LASSO-logistic regression.

METHODS

Data were collected from 245 patients who underwent their first ERCP with endobiliary metal stent placement for unresectable MBO between June 1, 2013, and August 31, 2021. Univariable and multivariable logistic regression analyses were conducted to identify the risk factors for 30-day mortality. We subsequently developed a logistic regression model that incorporated multiple parameters identified by LASSO regression. The model was visualized and the nomogram was plotted. Risk stratification was performed based on nomogram-derived scores.

RESULTS

The 30-day mortality rate was 10.7% (23/245 patients). Distant metastasis, total bilirubin, post-ERCP complications, and successful drainage were independent risk factors of 30-day mortality. The variables screened by LASSO regression, including distant metastasis, total bilirubin, post-ERCP complications, and successful drainage, were incorporated into the logistic model. The results were visualized through a nomogram based on the model. To assess the model's performance, discrimination was evaluated using the area-under-the-curve values obtained from receiver operating characteristic analyses with 10-fold cross-validation in the training group and validated in the testing group. The calibration curve showed the good predictive ability of the model. Decision curve analysis is used to evaluate the clinical application of nomogram. Finally, we performed risk stratification based on the risk calculated using the nomogram. Patients were assigned to the low-, moderate-, and high-risk groups based on their probability scores. The Kaplan-Meier survival curves for the different nomogram-based groups were significantly different (p < 0.001).

CONCLUSIONS

We developed a nomogram using the LASSO-logistic regression model to forecast the 30-day mortality rate in patients who had undergone ERCP with endobiliary metal stent placement due to MBO. This nomogram can assist in identifying individuals at high-risk of 30-day mortality following ERCP.

The Prognostic Value of Sarcopenia and Myosteatosis in Biliary Tract Cancer After Palliative Treatment With Radiation-Emitting Metallic Stent

Background:

Radiation-emitting metallic stent (REMS) placement is increasingly used for malignant biliary obstruction (MBO) caused by unresectable biliary tract carcinoma (UBTC) in clinical practice. The study is aimed to evaluate the prognostic value of sarcopenia, myosteatosis, and their combination on overall survival (OS) in patients treated with REMS for UBTC.

Methods

Patients diagnosed with UBTC who underwent REMS placement between January 2013 and May 2021 were included consecutively in this retrospective study. Sarcopenia and myosteatosis were defined based on skeletal muscle index (SMI) and skeletal muscle attenuation (SMA), respectively, which were measured by computer tomography (CT) images on the level of the third lumbar vertebral body before REMS placement. Patients were categorized into two groups by sex-specific cutoff value for sarcopenia and myosteatosis, and OS rates were compared between the groups. Univariate and multivariate cox regression analyses were used to assess factors associated with OS.

Results

Data of 135 patients included were retrospectively reviewed and analyzed. Median OS was 7.17 months in total cohort. Patients in the sarcopenia group had significant poorer OS than those in the non-sarcopenia group (median: 3.23 vs. 11.60 months, p < 0.001). OS was shorter in patients with myosteatosis than those without myosteatosis (median: 4.40 vs. 9.17 months, p < 0.001). Sarcopenia (odds ratio [OR] = 9.61; 95% CI = 5.41–17.09; p < 0.001) and myosteatosis (OR = 1.70; 95% CI = 1.13–2.57; p = 0.012) were significantly associated with OS. Combining sarcopenia and myosteatosis (CSM) showed a better predictive accuracy in OS than either one (area under curves: CSM vs. sarcopenia = 0.760 vs. 0.698, p = 0.049; CSM vs. myosteatosis = 0.760 vs. 0.671, p = 0.006).

Conclusion

Sarcopenia and myosteatosis are negative predictors of survival in patients who underwent REMS placement for UBTC. CSM seemed to show a better prognostic value than either sarcopenia or myosteatosis alone. They can be used preoperatively for risk evaluation.

Stent insertion for hilar cholangiocarcinoma: a meta-analysis of comparison between unilateral and bilateral stenting

Introduction

Metal stenting can be used as a primary treatment option for alleviating malignant hilar biliary obstruction (MHBO) symptoms. Although many studies have focused on the topic of unilateral or bilateral stenting for MHBO, there is a clear need for a study comparing these two stenting types in patients with a single type of cancer.

Aim

This meta-analysis was conducted to evaluate the relative clinical efficacy of unilateral and bilateral metal stent insertion for hilar cholangiocarcinoma (HCCA).

Material and methods

The PubMed, Embase, and Cochrane Library databases were searched to identify all relevant studies. This meta-analysis was conducted using RevMan v5.3.

Results

We initially identified 154 studies, seven of which were included in the final meta-analysis. These studies contained 524 HCCA patients treated by either unilateral (n = 215) or bilateral (n = 309) stent insertion. No significant differences were observed between groups in rates of technical success (OR = 0.93; 95% CI: 0.34-2.54, p = 0.88), clinical success (OR = 1.03; 95% CI: 0.49-2.15, p = 0.94), stent dysfunction (OR = 1.47; 95% CI: 0.91-2.39, p = 0.12), or survival (HR = 0.85; 95% CI: 0.50-1.42, p = 0.53). However, the unilateral group exhibited significantly lower complication rates (OR = 0.34; 95% CI: 0.13-0.88, p = 0.03). Significant heterogeneity was found in the endpoint of survival. Funnel plot analysis did not suggest any publication bias relating to the selected study endpoints.

Conclusions

Compared to bilateral metal stenting, unilateral metal stenting could provide a similar clinical efficacy for patients with HCCA with a lower complication rate.

Chemotherapy plus concurrent irreversible electroporation improved local tumor control in unresectable hilar cholangiocarcinoma compared with chemotherapy alone

INTRODUCTION

Unresectable hilar cholangiocarcinoma (UHC) is a malignant tumor and has a poor prognosis. IRE is a novel non-thermal ablative therapy that causes cellular apoptosis via electrical impulses. To compare the curative effect for UHC, chemotherapy plus concurrent IRE and chemotherapy alone were set up.

MATERIALS AND METHODS

From July 2015 to May 2019, 47 patients with UHC were analyzed to chemotherapy + IRE group (n = 23) or chemotherapy alone group (n = 24) in this study. Treatment response was assessed with computed tomography (CT) or magnetic resonance imaging (MRI) 1 month after treatment and every 3 months thereafter. Local tumor progression (LTP), time to LTP, overall survival (OS) and procedure-related complications were compared between the two groups.

RESULTS

Chemotherapy plus concurrent IRE group showed a tendency toward a decreased rate of LTP (16.7% vs. 39.5%; p = 0.039) and an increased complete response rate (52.2% vs. 12.5%; p = 0.011) compared with chemotherapy alone group. Time to LTP was significantly longer in the chemotherapy plus concurrent IRE group compared to chemotherapy alone group (11.2 months vs. 4.2 months; p = 0.001). Median OS was significantly longer in the chemotherapy plus concurrent IRE group compared to chemotherapy alone group (19.6 months vs. 10.2 months; p = 0.001).

CONCLUSIONS

Chemotherapy plus concurrent IRE improved local control and prolonged time to LTP and OS in patients with UHC.

Endoscopic metal stenting for malignant hilar biliary obstruction: an update meta-analysis of unilateral versus bilateral stenting

Introduction

Malignant hilar biliary obstruction (MHBO) can arise in patients with malignant hilar hepatobiliary tumors or lymph nodules. Most MHBO patients are not suitable for surgical resection due to the advanced tumor stage. The only palliative treatment available is provided by endoscopic or percutaneous stenting.

Aim

To compare the efficacy of endoscopic unilateral versus bilateral metal stent insertion for treating MHBO.

Material and methods

A search of the PubMed, Embase, and Cochrane Library databases identified all relevant studies published until June 2020. The meta-analysis was undertaken using RevMan v5.3.

Results

We identified 154 studies initially, eight of which were used in our meta-analysis. The eight studies included 818 MHBO patients treated using either endoscopic unilateral (n = 396) or bilateral (n = 422) metal stenting. No significant differences were observed between the two groups in clinical success rate (OR = 2.64; p = 0.18), complication rate (OR = 0.63; p = 0.46), or OS (HR = 1.03; p = 0.53). The bilateral group had a lower stent dysfunction rate without significance (OR = 1.43; p = 0.09). Significantly longer stent patency was observed in the bilateral group (HR = 1.28; p = 0.01). Technical success rate was significantly higher in the unilateral group (OR = 0.26; p = 0.04). Funnel plot analysis indicated an absence of publication bias related to the selected study endpoints.

Conclusions

Our meta-analysis indicated that endoscopic unilateral stenting had a greater technical success rate for MHBO patients than bilateral stenting. However, the bilateral stenting could achieve longer stent patency.

A preliminary single-center investigation of percutaneous biliary stenting in malignant hilar biliary obstruction: what impacts the clinical success and the long-term outcomes?

PURPOSE

The purpose of this study is to investigate the influencing factors that may impact the clinical success, jaundice-free time, and overall survival in patients of malignant hilar biliary obstruction (MHBO) treated with a self-expanding metallic stent (SEMS).

MATERIALS AND METHODS

Patients diagnosed with MHBO and treated with SEMS through percutaneous access from 1 Jul. 2013 to 1 Jul. 2018 were enrolled in this monocentric study. Demographic information, disease baseline measurements, and interventional strategies were collected and examined. Bilirubin was measured 1-3 days before and 3-7 days after stenting using the unit of "μmol/L." The bilirubin reduction ratio was compared between different study groups, which were separated by specific characteristics. Univariate and multivariate analyses were performed to evaluate each characteristic's impact on jaundice-free time (JF) and overall survival time (OS). Statistical analyses were conducted using SPSS 14.0, p < 0.05 indicated significance.

RESULTS

Eighty patients were enrolled. Direct bilirubin (DB) and indirect bilirubin (IB) both significantly decreased after stenting (U = 1575.0, p < 0.001; U = 1541.0, p < 0.001). The DB reduction ratio of the "nearby lymph metastases" group was significantly higher (U = 566.0, p = 0.037). The IB reduction ratio in the "single stent" group was significantly higher (U = 554.0, p = 0.018). Sixty-six cases reached jaundice recurrence, the median JF was 6 months, and the 95% confidence interval was 4.411 ~ 7.589 months. Fifty-eight cases ended in death, the median OS was 7 months, and the 95% confidence interval was 5.759 ~ 8.241 months. "Nearby lymph metastases" and "distant metastases" independently impacted OS (OR = 2.344, p = 0.013; OR = 3.239, p = 0.042). "IB reduction ratio" independently impacted both JF and OS (OR = 0.422, p = 0.021; OR = 0.315, p = 0.001).

CONCLUSION

The goal of treatment in patients with MHBO is to recover liver function. However, the overall survival is greatly impacted by the presence of metastases. Managing to obtain adequate liver function recovery may improve the long-term outcomes in affected patients.

Irradiation stent insertion for distal biliary obstruction secondary to primary common biliary cancer

PURPOSE

To assess the effectiveness and safety of irradiation stent insertion for patients with distal biliary obstruction (DBO) secondary to primary common biliary cancer.

MATERIAL AND METHODS

Eighty-two consecutive patients with DBO secondary to primary common biliary cancer were treated via either normal (n = 45) or irradiation stenting (n = 37) between January 2013 and December 2019. The instant and long-term outcomes were compared.

RESULTS

Technical success rates of normal and irradiation stenting were both 100%. Clinical success rates of normal and irradiation stenting were 91.1 and 100%, respectively (p = .179). Stent reobstruction was observed in 13 and 7 patients in the normal and irradiation stenting groups, respectively (p = .295). The median stent patency was 162 and 225 days in the normal and irradiation stenting groups, respectively (p < .001). The median survival was 178 and 250 days in the normal and irradiation stenting groups, respectively (p < .001). Cholangitis was, respectively, observed in 8 and 12 patients in normal and irradiation stenting groups (p = .124).

CONCLUSION

Irradiation stenting is effective and safe for patients with DBO secondary to primary common biliary cancer and can prolong stent patency and survival.

Covered vs bare stent for distal malignant biliary obstruction due to primary common biliary cancer

This study was designed as a means of comparing the clinical efficacy and long-term outcomes of covered vs bare stent insertion as a treatment for distal malignant biliary obstruction (DMBO) caused by primary common biliary cancer (PCBC).This retrospective study was designed using data collected between January 2012 and December 2019 to assess the short- and long-term outcomes in patients with DMBO caused by PCBC treated by inserting either bare or covered stents were compared.Ninety two patients with DMBO caused by PCBC were divided between bare (n = 51) or covered (n = 41) stent groups. Technical success rates in both groups were 100%. Clinical success of bare vs covered stent use were 96.1% and 97.6% (P = 1.00). Stent dysfunction was seen in 17 and 6 patients in the bare and covered stent groups, respectively (P = .04). The median stent patency for bare and covered stents was 177 and 195 days, respectively (P = .51). The median survival was 188 and 200 days in the bare and covered stent groups, respectively (P = .85).For patients with DMBO caused by PCBC, using bare vs covered stents yields similar clinical efficacy and long term outcomes.

Skeletal-muscle index predicts survival after percutaneous transhepatic biliary drainage for obstructive jaundice due to perihilar cholangiocarcinoma

BACKGROUND

Sarcopenia is emerging as a prognostic factor in patients with malignant diseases. The prognostication of perihilar cholangiocarcinoma (PHC) with obstructive jaundice was complex, because these patients suffered compete mortality events beyond cancer itself. Our study was to investigate the association between low skeletal-muscle index and overall survival (OS) after percutaneous transhepatic biliary drainage (PTBD) for obstructive jaundice due to PHC.

METHODS

We performed a retrospective survival analysis of patients undergoing PTBD for PHC-related obstructive jaundice between January 2016 and March 2019. Using computed tomography, we measured skeletal-muscle mass at the third lumbar vertebra (L3) to obtain a skeletal-muscle index (SMI). Then, we compared OS between low- and high-SMI groups. Furthermore, factors that could potentially affect OS were assessed.

RESULTS

One hundred and four patients (56 males; mean age 66 ± 12 years) were analyzed. Median OS after PTBD was 150 days. OS was shorter in patients with low SMI than in those with high SMI (median OS, 120 vs. 270 days; P < 0.001). Multivariate analysis indicated that low SMI (hazard ratio [HR] 3.46; 95% confidence interval [CI] 1.14-5.60; P < 0.001), intrahepatic metastasis (HR 2.98; 95% CI 1.89-4.69; P < 0.001) and elevated carbohydrate antigen (CA) 19-9 level (HR 1.00; 95% CI 1.00-1.00; P = 0.04) were significantly associated with OS.

CONCLUSION

Low SMI was a predictor of dismal OS after PTBD for patients with PHC-related obstructive jaundice.

Retrospective comparison of different percutaneous approaches to manage occluded primary uncovered self-expandable metal stents in patients with unresectable malignant hilar biliary obstruction

Purpose: To compare different percutaneous approaches to manage occluded primary uncovered self-expandable metal stents (SEMS) in patients with unresectable malignant hilar biliary obstruction (MHBO).Materials and Methods: A retrospective study was performed in patients with MHBO who underwent percutaneous management of occluded primary uncovered SEMS between January 2014 and January 2018. Patients were assigned into three groups based on the types of secondary stents, which included SEMS, internal-external drainage (IED), and external drainage (ED). Clinical success, requirement for reintervention, survival times, complications, and cost were evaluated.Results: A total of 58 patients were identified, with 21, 9, and 28 patients received SEMS, IED, and ED treatments, respectively. The overall clinical success rate was 67.2% (39/58), with no significant difference among three groups (p = .489). The median time to reintervention was 82, 57, and 61 days for the SEMS, IED, and ED groups, respectively (p = .045 for SEMS vs. IED; p = .011 for SEMS vs. ED). There was no significant difference in the median survival times among three groups (p = .308). Seven patients (12.7%) experienced minor complications including self-limiting haemobilia (n = 3) and catheter-related pain (n = 4). Fourteen patients (24.1%) had major complications, including early cholangitis (n = 8), pancreatitis (n = 3), stent dislodgement (n = 2), and bile leakage (n = 1). There was no statistical difference in the mean cost of the management of occluded primary SEMS between the three groups (p = .162).Conclusion: Uncovered SEMS could provide a longer duration to reintervention compared to the catheter drainages to manage occluded primary SEMS in patients with unresectable MHBO.

Early Warning Models to Estimate the 30-Day Mortality Risk After Stent Placement for Patients with Malignant Biliary Obstruction

PURPOSE

To develop, validate, and compare early warning models of the 30-day mortality risk for patients with malignant biliary obstruction (MBO) undergoing percutaneous transhepatic biliary stent placement (PTBS).

MATERIALS AND METHODS

Between January 2013 and October 2018, this multicenter retrospective study included 299 patients with MBOs who underwent PTBS. The training set consisted of 166 patients from four cohorts, and another two independent cohorts were allocated as external validation sets A and B with 75 patients and 58 patients, respectively. A logistic model and an artificial neural network (ANN) model were developed to predict the risk of 30-day mortality after PTBS. The predictive performance of these two models was validated internally and externally.

RESULTS

The ANN model had higher values of area under the curve than the logistic model in the training set (0.819 vs 0.797), especially in the validation sets A (0.802 vs 0.714) and B (0.732 vs 0.568). Both models had high accuracy in the three sets (75.9-83.1%). Along with a high specificity, the ANN model improved the sensitivity. The net reclassification improvement and integrated discrimination improvement also demonstrated that the ANN model led to improvements in predictive ability compared with the logistic model.

CONCLUSIONS

Early warning models were proposed to predict the risk of 30-day mortality after PTBS in patients with MBO. The ANN model has higher accuracy and better generalizability than the logistic model.

Percutaneous stenting for malignant hilar biliary obstruction: a randomized controlled trial of unilateral versus bilateral stenting

PURPOSE

To compare the clinical outcomes between unilateral and bilateral metal stenting for patients with malignant hilar biliary obstruction (MHO).

METHODS

This is a single-center, open-label, prospective, randomized study. Between January 2016 and March 2018, patients with MHO who were treated by percutaneous unilateral or bilateral metal stenting were enrolled. The primary endpoint was stent dysfunction. The secondary endpoints included technical success, clinical success, adverse events, and death. The protocol is registered at ClinicalTrials.gov (identifier: NCT02649712).

RESULTS

A total of 72 patients were randomly grouped for the unilateral (n = 36) or bilateral (n = 36) stenting. The bilateral stenting was performed through the side-by-side technique. While technically, the rates of success of unilateral and bilateral stenting were 83.3% (30/36) in both the cases (P = 1.000), the clinical rates of success in unilateral and bilateral stenting were 90.0% (27/30) and 96.7% (29/30), respectively (P = 0.605). Based on the per-protocol analysis, stent dysfunction was found in 5 and 3 patients in unilateral and bilateral groups, respectively (16.7% vs. 10.0%, P = 0.704). No predictor was observed to influence stent dysfunction. The median cumulative survival in the unilateral group was 122 days and in the bilateral group was 125 days (P = 0.844). We also observed higher levels of post-operative total bilirubin and pre-operative alanine aminotransferase, and the absence of post-operative anticancer treatment as predictors of worse survival.

CONCLUSION

When compared, the bilateral and unilateral stentings provide a similar clinical effectiveness in patients with MHO.

Comparison of Unilateral With Bilateral Metal Stenting for Malignant Hilar Biliary Obstruction

PURPOSE

The main purpose of this study was to compare the clinical effectiveness between unilateral and bilateral metal stenting for malignant hilar biliary obstruction (MHBO).

METHODS

From January 2012 to October 2017, consecutive patients with MHBO underwent unilateral or bilateral stent insertion at our center. Technical and clinical success, stent patency, and survival were compared between these 2 groups.

RESULTS

A total of 110 patients with MHBO were included in this study. Technical successful rates of unilateral and bilateral stenting were 93.1% (54/58) and 90.4% (47/52), respectively (P=0.864). Clinical successful rates of unilateral and bilateral stenting were 96.4% (53/55) and 97.9% (46/47), respectively (P=1.000). There was no significant difference in stent patency period (unilateral, 182 d; bilateral, 198 d; P=0.999) and survival (unilateral, 189 d; bilateral, 199 d; P=0.867) between 2 groups.

CONCLUSIONS

Unilateral and bilateral metal stenting had similar clinical effectiveness and long-term outcomes in patients with MHBO.

Percutaneous Metallic Stent Placement for Palliative Management of Malignant Biliary Hilar Obstruction

Objective

To investigate the outcomes of percutaneous metallic stent placements in patients with malignant biliary hilar obstruction (MBHO).

Materials and Methods

From January 2007 to December 2014, 415 patients (mean age, 65 years; 261 men [62.8%]) with MBHO were retrospectively studied. All the patients underwent unilateral or bilateral stenting in a T, Y, or crisscross configuration utilizing covered or uncovered stents. The clinical outcomes evaluated were technical and clinical success, complications, overall survival rates, and stent occlusion-free survival.

Results

A total of 784 stents were successfully placed in 415 patients. Fifty-five patients had complications. These complications included hemobilia (n = 19), cholangitis (n = 13), cholecystitis (n = 11), bilomas (n = 10), peritonitis (n = 1), and hepatic vein-biliary fistula (n = 1). Clinical success was achieved in 370 patients (89.1%). Ninety-seven patients were lost to follow-up. Stent dysfunction due to tumor ingrowth (n = 107), sludge incrustation (n = 44), and other causes (n = 3) occurred in 154 of 318 patients. The median overall survival and the stent occlusion-free survival were 212 days (95% confidence interval [CI], 186-237 days) and 141 days (95% CI, 126-156 days), respectively. The stent type and its configuration did not affect technical success, complications, successful internal drainage, overall survival, or stent occlusion-free survival.

Conclusion

Percutaneous stent placement may be safe and effective for internal drainage in patients with MBHO. Furthermore, stent type and configuration may not significantly affect clinical outcomes.

Post-operative care of interventional therapy for 40 liver cancer patients with obstructive jaundice

The care of 40 patients with primary liver cancer with obstructive jaundice treated with liver puncture bile drainage or biliary stent implantation was reported. Treated with the interventional therapy, patients were observed closely to identify symptoms of hepatic encephalopathy and pain; diet care was well performed. Bile drainage tube and skin acre were performed carefully. Liver function, bilirubin and other biochemical indicators were monitored; occurrence of bleeding, acute pancreatitis, biliary tract infection, leakage of ascites around drainage tube and other complication were observed with good discharge instruction. After this operation, three rounds of liver had poor function, and hepatic encephalopathy and death occurred during hospitalisation. Seven patients had bloody bile drainage fluid after operation; eight had increased blood amylase; nine had biliary infection and four had leakage of ascites around the drainage tube. After positive treatment and care, the situation was improved with varied degrees of jaundice increase.

Management of occluded self-expanding biliary metal stents in malignant biliary disease

BACKGROUND

Occlusion of self-expanding metal stents (SEMS) in malignant biliary obstruction occurs in up to 40% of patients. This study aimed to compare the different techniques to resolve stent occlusion in our collective of patients.

METHODS

Patients with malignant biliary obstruction and occlusion of biliary metal stent at a tertiary referral endoscopic center were retrospectively identified between April 1, 1994 and May 31, 2014. The clinical records were further analyzed regarding the characteristics of patients, malignant strictures, SEMS, management strategies, stent patency, subsequent interventions, survival time and case charges.

RESULTS

A total of 108 patients with biliary metal stent occlusion were identified. Seventy-nine of these patients were eligible for further analysis. Favored management was plastic stent insertion in 73.4% patients. Second SEMS were inserted in 12.7% patients. Percutaneous transhepatic biliary drainage and mechanical cleansing were conducted in a minority of patients. Further analysis showed no statistically significant difference in median overall secondary stent patency (88 vs. 143 days, P = 0.069), median survival time (95 vs. 192 days, P = 0.116), median subsequent intervention rate (53.4% vs. 40.0%, P = 0.501) and median case charge (€5145 vs. €3473, P = 0.803) for the treatment with a second metal stent insertion compared to plastic stent insertion. In patients with survival time of more than three months, significantly more patients treated with plastic stents needed re-interventions than patients treated with second SEMS (93.3% vs. 57.1%, P = 0.037).

CONCLUSIONS

In malignant biliary strictures, both plastic and metal stent insertions are feasible strategies for the treatment of occluded SEMS. Our data suggest that in palliative biliary stenting, patients especially those with longer expected survival might benefit from second SEMS insertion. Careful patient selection is important to ensure a proper decision for either management strategy.

Unilateral versus bilateral stent insertion for malignant hilar biliary obstruction

PURPOSE

To determine the clinical efficiency and long-term outcomes between unilateral and bilateral stent insertion in patients with malignant hilar biliary obstruction.

METHODS

From August 2012 to February 2016, 63 consecutive patients with malignant hilar biliary obstruction were treated with unilateral or bilateral stent insertion at our center. The bilateral stents were inserted using the side-by-side technique. The clinical efficiency and long-term outcomes were compared between the two groups.

RESULTS

Unilateral and bilateral stent insertions were successfully performed in 31 of 33 and 27 of 30 patients, respectively (P = 0.912). No procedure-related complication occurred. Clinical success was achieved in 29 of 31 patients in the unilateral stent group and in 26 of 27 patients in the bilateral stent group (P = 0.637). During the follow-up, re-obstruction of stent occurred in five patients in the unilateral stent group and in three patients in the bilateral stent group (P = 0.58). The significant differences were not observed in the stent patency time (368 vs. 387 days, P = 0.685) and survival (200 vs. 198 days, P = 0.751) between two groups. Based on the univariate and multivariate analyses, the independent risk factors for decreasing the survival time included higher Eastern Cooperative Oncology Group performance status (P = 0.018), higher alanine aminotransferase level (P = 0.009), and absence of anticancer treatment after stent insertion (P = 0.002).

CONCLUSION

Compared to bilateral stent insertion for malignant hilar biliary obstruction, unilateral stent insertion can provide comparable clinical efficiency and long-term outcomes.