Self-Expanded Metallic Stent Insertion for Hilar Cholangiocarcinoma: Comparison of Unilateral and Bilateral Stenting

Retrospective comparative study of new slim-delivery and conventional large-cell stents for stent-in-stent methods for hilar malignant biliary obstruction

OBJECTIVES

Endoscopic management of unresectable hilar malignant biliary obstruction (HMBO) is technically challenging, and effectiveness of stent-in-stent using large-cell, metal stents was reported. A new, large-cell stent with a 6F tapered delivery system was recently developed. The aim of this study was to compare clinical outcomes of slim-delivery and conventional large-cell stents.

METHODS

This was a multicenter retrospective comparative study of stent-in-stent methods using slim-delivery stents (Niti-S Large Cell SR Slim Delivery [LC slim-delivery]) and conventional stents (Niti-S large-cell D-type; LCD) for unresectable HMBO.

RESULTS

Eighty-three patients with HMBO were included; 31 LC slim-delivery and 52 LCD. Overall technical and clinical success rates were 100% and 90% in LC slim-delivery group and 98% and 88% in LCD group. Use of the LC slim-delivery was associated with shorter stent placement time in the multiple regression analysis, with a stent placement time of 18 and 23 min in LC slim-delivery and LCD groups, respectively. The early adverse event (AE) rate of LC slim-delivery was 10%, with no cholangitis or cholecystitis as compared to 23% in the LCD group. Recurrent biliary obstruction (RBO) rates and time to RBO were comparable between the two groups: 35% and 44%, and 8.5 and 8.0 months in LC slim-delivery and LCD groups, respectively. The major cause of RBO was tumor ingrowth (82%) in the LC slim-delivery group and sludge (43%) and ingrowth (48%) in LCD group.

CONCLUSION

Stent-in-stent methods using LC slim-delivery shortened stent placement time with low early AE rates and comparable time to RBO in patients with HMBO.

Meta-analysis on clinical outcomes of suprapapillary versus transpapillary stent insertion in malignant biliary obstruction

BACKGROUND/AIMS

Endoscopic biliary stenting is an essential treatment for malignant biliary obstruction (MBO). However, the optimal location for the placement of metal stents (MS) or plastic stents (PS) during the management of MBO, whether above (suprapapillary) or across (transpapillary) the sphincter of Oddi (SO), has not been thoroughly evaluated. This meta-analysis aims to compare the clinical outcomes associated with endoscopic retrograde cholangiopancreatography (ERCP)-guided biliary stents placed above and across the SO in patients with MBO.

METHODS

A comprehensive search of electronic databases was carried out to identify studies published from inception to April 2022. The clinical outcomes examined including stent patency, stent occlusion, and overall adverse events (AEs) such as cholangitis, post-ERCP pancreatitis (PEP), cholecystitis, stent migration, and bleeding. The selection of a random-effects model or fixed-effects model was based on the presence of heterogeneity.

RESULTS

A total of 12 articles involving 751 patients were analyzed. The findings showed that the suprapapillary approach had longer stent patency compared to the transpapillary approach (mean difference: 38.58; 95% confidence interval 16.02-61.14, P < 0.0001). Additionally, the suprapapillary approach was associated with a lower risk of stent occlusion and overall AEs (P = 0.04, P = 0.002, respectively), particularly in the incidence of PEP (P = 0.009). The incidence of cholangitis, cholecystitis, stent migration, and bleeding were similar between the suprapapillary and transpapillary approaches. The subgroup analyses indicated that suprapillary PS had a significant decrease in the incidence of stent occlusion and longer stent patency, while suprapillary MS had a significant decrease in the incidence of overall AEs and PEP than the transpapillary approach.

CONCLUSION

Compared with the transpapillary approach, the suprapapillary stent had superiority in longer stent patency, lower rates of stent occlusion and overall AEs, and notably, a lower incidence of PEP. The incidence of cholangitis, cholecystitis, stent migration, and bleeding were similar between the suprapapillary and transpapillary approaches. Further large-scale randomized controlled studies are needed to confirm our findings.

REGISTRATION NO

CRD42022336435.

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.

Stent with radioactive strand insertion for inoperable hilar cholangiocarcinoma: comparison of unilateral and bilateral insertion

PURPOSE

To evaluate the relative clinical efficacy associated with the unilateral and bilateral insertion of a stent with a radioactive strand (RS) for the treatment of inoperable hilar cholangiocarcinoma (HCCA) patients.

METHODS

From January 2017 to June 2020, consecutive patients diagnosed with inoperable HCCA underwent either unilateral or bilateral stent with RS insertion in our hospital. Outcomes compared between these groups included rates of technical success, clinical success, stent-related complications, stent patency and overall survival (OS).

RESULTS

Unilateral and bilateral stent with RS insertion procedures were performed in 36 and 30 patients over the study period, respectively, with 100% technical and clinical success rates in both groups. No instances of procedure-related complications were reported. Cholangitis was observed in 7 (19.4%) and 6 (20%) patients in unilateral and bilateral groups (p= .955), respectively, while these groups exhibited respective cholecystitis in 2 (5.5%) and 1 (3.3%) cases, respectively (p=.662), and stent restenosis in 9 (25%) and 7 (23.3%) cases, respectively (p=.661). The median duration of stent patency in the unilateral and bilateral groups was comparable at 208 and 222 d, respectively (p=.889). All patients died over the course of follow-up, with similar median OS rates in the unilateral and bilateral groups of 250 and 246 d, respectively (p=.483).

CONCLUSIONS

These data indicated that similar inoperable HCCA patient clinical outcomes are achieved following stent with RS insertion regardless of whether it is conducted via a unilateral or bilateral approach.

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.

Stent insertion for inoperable hilar cholangiocarcinoma: Comparison of radioactive and normal stenting

To assess effectiveness and safety associated with radioactive stenting for hilar cholangiocarcinoma (HCCA) patients.This single-center retrospective study compared baseline and treatment data of recruited consecutive patients with HCCA underwent either normal or radioactive stenting between January 2016 and December 2019. Clinical success was defined by total bilirubin (TBIL) levels falling below 70% of the preoperative baseline within 2 weeks post stent insertion.Sixty-five patients with inoperable HCCA underwent normal (n = 35) or radioactive (n = 30) stenting at our center. Technical success of both types of the normal and radioactive stent insertion was 100%. Each patient received 1 stent. In the radioactive stent group, each patient received 1 radioactive seed strand (RSS), containing 10 to 12 radioactive seeds. Clinical success rates were 86.8% and 100% in normal and radioactive groups, respectively (P = .495). We observed stent dysfunction in 9 patients (normal group) and 7 patients (radioactive group) (P = .824). Median duration of stent patency was 165 days (normal group) and 226 days (radioactive group) (P < .001). During follow-up, all patients died from tumor progression, with respective median survival of 198 days (normal group) and 256 days (radioactive group) (P < .001). Seven and 5 patients in the normal and radioactive groups suffered from stent-related complications (P = .730).Radioactive stenting is effective and safe for inoperable HCCA patient and may prolong stent patency and survival.

Irradiation stent insertion for inoperable malignant biliary obstruction: a meta-analysis of randomized controlled trials

The purpose of the study was to compare the relative clinical efficacies of irradiation stent (IRS) and conventional stent (CVS) insertions for the treatment of patients with malignant biliary obstruction (MBO). Pubmed, Embase, and Cochrane Library databases were searched for relevant randomized controlled trials (RCTs) from the date of inception through to August 2020. Data analysis was performed using RevMan v5.3. This meta-analysis included eight RCTs which included a total of 319 patients who had undergone IRS insertion, and 328 who had undergone CVS insertion. No significant differences in pooled Δ total bilirubin values (MD 0.34; P = 0.92), incident rates of cholangitis (P = 0.47), hemobilia (P = 0.60), or pancreatitis (P = 0.89) were detected between two groups. The rate of stent dysfunction was significantly lower in the IRS group compared to the CVS group (22.2% vs. 37.7%, P = 0.02). The pooled stent patency (P < 0.00001) and survival (P < 0.00001) were significantly longer in the IRS group compared to the CVS group. Significant heterogeneity was detected in the endpoints of rate of stent dysfunction (I² = 52%; P = 0.08) and survival (I² = 77%; P = 0.0005). Subgroup analysis was performed based on the different IRS types and showed significantly longer survival in the IRS group based on both types of IRS. Funnel plot analyses did not detect any evidence of publication bias. This meta-analysis included eight RCTs which included a total of 319 patients who had undergone IRS insertion, and 328 who had undergone CVS insertion. No significant differences in pooled Δ total bilirubin values (MD 0.34; P = 0.92), incident rates of cholangitis (P = 0.47), hemobilia (P = 0.60), or pancreatitis (P = 0.89) were detected between 2 groups. The rate of stent dysfunction was significantly lower in the IRS group compared to the CVS group (22.2% vs. 37.7%, P = 0.02). The pooled stent patency (P < 0.00001) and survival (P < 0.00001) were significantly longer in the IRS group compared to the CVS group. Significant heterogeneity was detected in the endpoints of rate of stent dysfunction (I² = 52%; P = 0.08) and survival (I² = 77%; P = 0.0005). Subgroup analysis was performed based on the different IRS types and showed significantly longer survival in the IRS group based on both types of IRS. Funnel plot analyses did not detect any evidence of publication bias. Our meta-analysis demonstrates that IRS insertion can prolong stent patency and the survival of patients with MBO compared to CVS insertion.

Unilateral Stent Insertion With High-intensity Focused Ultrasound Ablation for Hilar Cholangiocarcinoma

PURPOSE

To evaluate the clinical effectiveness and long-term outcomes of unilateral stent insertion with high-intensity focused ultrasound ablation (HIFUA) in patients with hilar cholangiocarcinoma (HCCA).

MATERIALS AND METHODS

From March 2016 to June 2019, consecutive patients presenting with HCCA were treated with single stent insertion or stent with HIFUA. The long-term outcomes of the 2 groups were compared.

RESULTS

During the study period, 37 patients were included who underwent single stent insertion and 32 patients who underwent stent insertion with HIFUA. Eight (21.6%) patients in the single stent group and 6 (18.8%) in the combined group experienced stent dysfunction (P=0.767). Median stent patency in the single stent and combined groups was 169 and 225 days, respectively (P<0.001). All patients died because of tumor progression. The median poststent overall survival for patients in the single stent and combined groups were 178 and 246 days, respectively (P<0.001).

CONCLUSION

HIFUA after unilateral stent insertion can prolong stent patency and survival of patients with inoperable HCCA.

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.

A stent with radioactive seed strand insertion for inoperable malignant biliary obstruction: A meta-analysis

PURPOSE

The purpose of the study was to assess the relative clinical effectiveness of stent insertion with or without radioactive seed strand (RSS) insertion in patients suffering from malignant biliary obstruction (MBO).

METHODS AND MATERIALS

Relevant articles published as of November 2020 in the Embase, PubMed, and Cochrane Library databases were identified and analyzed. Primary study endpoints for this meta-analysis were stent dysfunction, stent patency, and overall survival (OS), whereas secondary endpoints were rates of clinical success and complications. RevMan v5.3 was used to perform all meta-analyses.

RESULTS

In total, there were nine studies incorporating 643 patients (280 and 363 who underwent stent insertion with and without RSS, respectively). No differences were observed between these groups with respect to pooled rates of clinical success (p = 0.25), stent dysfunction (p = 0.47), cholangitis (p = 0.97), cholecystitis (p = 0.95), or pancreatitis (p = 0.66). However, stent patency duration (p < 0.00001) and patients' OS (p < 0.00001) were significantly increased in patients in the stent + RSS group. No heterogeneity was detected for any of these endpoints, nor did funnel plots yield any publication bias. A subgroup analysis of patients with hilar MBO similarly exhibited stent + RSS insertion to be associated with longer stent patency and OS as compared with stent insertion alone.

CONCLUSIONS

These findings showed that relative to stent insertion, stent + RSS insertion is associated with longer OS and stent patency in patients with inoperable MBO.

Percutaneous metal stenting for malignant hilar biliary obstruction: a systematic review and meta-analysis of unilateral versus bilateral stenting

The purpose of this study is to assess the relative clinical efficacy of treating malignant hilar biliary obstruction (MHBO) via percutaneous unilateral or bilateral metal stenting. Relevant articles up to December 2019 were identified within the Web of science, Pubmed, Embase, and Cochrane Library databases. Stent dysfunction served as the primary endpoint, while we assessed technical success, clinical success, early and late complication incidence, and overall survival as secondary outcomes. Pooled odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated for dichotomous variables. Hazard ratio (HR) with 95% CI were determined for overall survival. This meta-analysis included seven studies. Six studies were non-randomized controlled trials (RCTs) and one study was a RCT. A total of 888 MHBO patients underwent either percutaneous unilateral (n = 376) or bilateral (n = 512) metal stenting in these seven studies. We detected no significant differences in stent dysfunction rates (OR 0.97; 95% CI 0.67, 1.41, P = 0.89), technical success rates (OR 1.10; 95% CI 0.53, 2.29, P = 0.81), clinical success rates (OR 0.72; 95% CI 0.43, 1.22, P = 0.22), early complication rates (OR 0.82; 95% CI 0.34, 1.98, P = 0.66), late complication rates (OR 0.87; 95% CI 0.29, 2.63, P = 0.81), or overall survival (HR: 0.99; 95% CI 0.83, 1.17, P = 0.88) between unilateral and bilateral groups. Funnel plots demonstrated no obvious publication bias of these primary and secondary endpoints. From a clinical perspective, percutaneous unilateral and bilateral metal stenting are similarly effective for treatment of patients with MHBO.

Stent insertion with high-intensity focused ultrasound ablation for malignant biliary obstruction: A protocol of systematic review and meta-analysis

BACKGROUND

This meta-analysis was conducted in order to understand the clinical efficacy of stent insertion with high-intensity focused ultrasound (HIFU) ablation for the treatment of malignant biliary obstruction (MBO).

METHODS

The Pubmed, Embase, and Cochrane Library databases were searched for all relevant studies published through July 2020. The meta-analysis was conducted using RevMan v5.3, with analyzed study endpoints including the rate of stent dysfunction, time to stent dysfunction, stent patency, complication rate, and overall survival (OS).

RESULTS

In total, 35 potentially relevant studies were initially identified, of which 6 were ultimately included in the present meta-analysis. These 6 studies included 429 MBO patients that were treated either only via stenting (n = 221) or via stenting in combination with HIFU ablation (n = 208). Pooled stent dysfunction rates in the stent and stent with HIFU groups were 25.9% and 18.0%, respectively (OR: 1.59; 95% CI: 0.88, 2.84, P = .12). The average time to stent dysfunction was significantly longer in the stent with HIFU group relative to the stent group (MD: -3.15; 95% CI: -3.53, -2.77, P < .0001). Pooled complication rates in the stent and stent with HIFU groups were 17.1% and 19.6%, respectively (OR: 0.88; 95% CI: 0.49, 1.58, P = .67). Stent patency and OS were both significantly longer in the stent with HIFU group relative to the stent group (P < .0001 and.0001, respectively). Funnel plot analyses did not reveal any significant evidence of publication bias linked to the selected study endpoints.

CONCLUSIONS

This meta-analysis found that a combined stenting and HIFU ablation approach can achieve better stent patency and OS in MBO patients relative to stent insertion alone.

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.

Bilateral stenting for hilar biliary obstruction: a meta-analysis of side-by-side versus stent-in-stent

PURPOSE

To evaluate the efficacy of stent-in-stent (SIS) and side-by-side (SBS) bilateral stenting for treating malignant hilar biliary obstruction (MHBO).

MATERIAL AND METHODS

Relevant studies in Pubmed, Embase, and Cochrane Library were identified through June 2020. This meta-analysis was conducted using RevMan v5.3, using relevant endpoint data relating to clinical and technical success, complications, stent dysfunction, and overall survival (OS) rates extracted from these studies.

RESULTS

We identified six relevant studies which included 315 MHBO patients treated with either SBS (n = 161) or SIS bilateral (n = 154) stenting. We saw no significant difference between these two groups with respect to clinical success (OR: 1.07; 95% CI: 0.46, 2.49, p = .87), complication (HR: 0.12; 95% CI: -0.04, 0.27, p = .15), stent dysfunction (OR: 0.68; 95% CI: 0.42, 1.10, p = .11), or OS (HR: 0.97; 95% CI: 0.82, 1.16, p = .74). However, the SBS group exhibited significantly lower technical success rates (OR: 6.55; 95% CI: 1.10, 38.83, p = .04). Significant heterogeneity was only detected for the endpoint of complication rates (I² = 60%).

CONCLUSION

These results suggest that SIS bilateral stenting yields better rates of technical success than does SBS bilateral stenting in MHBO patients.

Stent with radioactive seeds strand insertion for malignant hilar biliary obstruction

Purpose: This study aimed to assess clinical efficacy and long-term patient outcomes in individuals with malignant hilar biliary obstruction (MHBO) that had been treated via insertion of a stent with a radioactive seed strand (RSS).Material and methods: A total of 84 MHBO patients were treated via either normal stent insertion (n = 48) or stent with RSS insertion (n = 36) from January 2015 to December 2018.Results: The technical success rates of normal stent insertion and stent with RSS insertion were 93.8% (45/48) and 97.2% (35/36), respectively (p = .632), with clinical success rates of 93.3% (42/45) and 100% (35/35), respectively (p = .252). In these two patient groups, 11 and seven patients, respectively, suffered from stent dysfunction (p = .637). In the normal and RSS groups, median stent patency was 165 and 225 days, respectively (p < .001). All patients in the present study died due to tumor progression, with median survival times of 188 and 250 days in the normal and RSS stent groups, respectively (p < .001).Conclusion: Relative to normal stent insertion, combined stent with RSS insertion can effectively prolong both stent patency and patient survival in patients with MHBO.