Covered duodenal self-expandable metal stents prolong biliary stent patency in double stenting: The largest series of bilioduodenal obstruction

Percutaneous insertion of long-covered biliary stents in patients with malignant duodenobiliary stricture

OBJECTIVE

To investigate the technical feasibility, safety, and efficacy of a long-covered biliary stent in patients with malignant duodenobiliary stricture.

METHODS

This retrospective study enrolled 57 consecutive patients (34 men, 23 women; mean age, 64 years; range, 32-85 years) who presented with malignant duodenobiliary stricture between February 2019 and November 2020. All patients were treated with a long (18 or 23 cm)-covered biliary stent.

RESULTS

The biliary stent deployment was technically successful in all 57 patients. The overall adverse event rate was 17.5% (10 of 57 patients). Successful internal drainage was achieved in 55 (96.5%) of 57 patients. The median patient survival and stent patency times were 99 days (95% confidence interval [CI], 58-140 days) and 73 days (95% CI, 60-86 days), respectively. Fourteen (25.5%) of the fifty-five patients presented with biliary stent dysfunction due to sludge (n = 11), tumor overgrowth (n = 1), collapse of the long biliary stent by a subsequently inserted additional duodenal stent (n = 1), or rapidly progressed duodenal cancer (n = 1). A univariate Cox proportional hazards model did not reveal any independent predictor of biliary stent patency.

CONCLUSIONS

Percutaneous insertion of a subsequent biliary stent was technically feasible after duodenal stent insertion. Percutaneous insertion of a long-covered biliary stent was safe and effective in patients with malignant duodenobiliary stricture.

CLINICAL RELEVANCE STATEMENT

In patients with malignant duodenobiliary stricture, percutaneous insertion of a long-covered biliary stent was safe and effective regardless of duodenal stent placement.

KEY POINTS

• Percutaneous insertion of long-covered biliary stents in patients with malignant duodenobiliary stricture is a safe and effective procedure. • Biliary stent deployment was technically successful in all 57 patients and successful internal drainage was achieved in 55 (96.5%) of 57 patients. • The median patient survival and stent patency times were 99 days and 73 days, respectively, after placement of a long-covered biliary stent in patients with duodenobiliary stricture.

How to successfully administer palliative treatment with a stent for malignant gastric outlet obstruction?

Although endoscopic stenting (ES) has been widely used as a less-invasive palliation method for malignant gastric outlet obstruction (GOO), recent reports have highlighted issues related to the procedure. For successful treatment, various aspects must be assessed before considering the practices. First, it is necessary to eliminate cases with contraindications such as coexistence of distal small-bowel obstruction or perforation. Other factors potentially related to clinical failure (i.e., peritoneal carcinomatosis) may require consideration but remain controversial. ES has better short-term outcomes than surgical gastrojejunostomy (GJ). GJ has recently been considered preferable in cases with longer life expectancy because of superior sustainability. Various types of stents are now commercially available, but their ideal structure and mechanical properties have not yet been clarified. Covered metal stent may reduce stent obstruction but is prone to increase stent migration, and its significance remains uncertain. Subsequent chemotherapy after stenting should be considered, as it is expected to prolong patient survival without increasing the risk of adverse events. Furthermore, it may be helpful in preventing tumor ingrowth. In cases with GOO combined with biliary obstruction, biliary intervention is often difficult. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely used as an alternative procedure for endoscopic transpapillary biliary drainage (ETBD). Despite the lack of consensus as to whether ETBD or EUS-BD is preferred, EUS-BD is useful as a salvage technique for cases where ETBD is difficult. To perform stent placement successfully, it is important to pay attention to the above points; however, many remaining issues need to be clarified in the future.

Endoscopic stenting for malignant biliary obstruction is technically successful in patients with preexisting duodenal stents

Background and study aims  There are limited data on the success of endoscopic retrograde cholangiopancreatography (ERCP) in patients with malignant biliary and duodenal obstruction with a preexisting duodenal stent. The aim of this study was to evaluate patient and procedural outcomes of a cohort of patients with preexisting duodenal stents who underwent an attempt at ERCP for malignant biliary obstruction (MBO). Patients and methods  This was a single-center retrospective study on consecutive patients with a preexisting duodenal stent who underwent attempted ERCP for MBO. Technical success was defined as successful cannulation of the common bile duct, with successful dilation and/or deployment of a biliary stent under fluoroscopy. Clinical success was defined as number of patients in the entire group who underwent ERCP successfully with resolution of symptoms. Results  We identified 64 patients (73 % men, 74 % white, median age 62 years) with a preexisting duodenal stent who underwent 85 attempts at ERCP. ERCP was technically successful in 50 of 85 procedures (59 %). Overall ERCP was successful in 41 of 85 patients (48 %). ERCP was more likely to be successful in patients with Type 1 and 3 duodenal strictures than with Type 2 strictures (83 % and 92 % vs. 42 %, P  < 0.01), in patients with a preexisting sphincterotomy (79% vs. 20 %, P  = 0.01) or preexisting biliary stent (66 % vs. 34 %, P  = 0.04). Adverse events included bleeding (n = 3), post-procedure fever (n = 3) and abdominal pain (n = 1). Conclusions  Although biliary stenting via ERCP is often technically challenging in patients with a prior duodenal stent, it is a safe and effective method of biliary drainage. ERCP should be attempted in patients with Type 1 and 3 duodenal strictures, a prior sphincterotomy or an indwelling biliary stent.

Endoscopic Double Stenting for the Management of Combined Malignant Biliary and Duodenal Obstruction

Periampullary cancers are often diagnosed at advanced stages and can cause both biliary and duodenal obstruction. As these two obstructions reduce patients’ performance status and quality of life, appropriate management of the disease is important. Combined malignant biliary and duodenal obstruction is classified according to the location and timing of the duodenal obstruction, which also affect treatment options. Traditionally, surgical bypass (gastrojejunostomy and hepaticojejunostomy) has been performed for the treatment of unresectable periampullary cancer. However, it has recently been substituted by less invasive endoscopic procedures due to its high morbidity and mortality. Thus, endoscopic double stenting (transpapillary stenting and enteral stenting) has become the current standard of care. Limitations of transpapillary stenting include its technical difficulty and the risk of duodenal-biliary reflux. Recently, endoscopic ultrasound-guided procedures have emerged as a novel platform and have been increasingly utilized in the management of biliary and duodenal obstruction. As the prognosis of periampullary cancer has improved due to recent advances in chemotherapy, treatment strategies for biliary and duodenal obstruction are becoming more important. In this article, we review the treatment strategies for combined malignant biliary and duodenal obstruction based on the latest evidence.

[Palliative endoscopy]

Endoscopy is the leading method in the diagnostics of gastrointestinal malignancies. With the increasing incidences of various tumor entities, a palliative treatment situation is already present in many patients despite an increasing number of screening strategies. Palliative endoscopy can make an essential contribution to alleviation of tumor-related symptoms, such as dysphagia, malnutrition, cholestasis, ileus and pain. Various approaches can be offered to safeguard the nutrition, e.g. percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ), for maintenance of the gastrointestinal passage (stents) and secretion drainage or to drain congested hollow organs. Furthermore, in cases of inaccessibility or impassability of stenoses due to tumors, endosonographically assisted punctures offer the possibility to guarantee new drainage options or continuities by stent placement. In all interventions possible contraindications and complications must be taken into account.

Double Stenting for Malignant Biliary and Duodenal Obstruction: A Systematic Review and Meta-Analysis

Data about the efficacy of palliative double stenting for malignant duodenal and biliary obstruction are limited.

Percutaneous Intraductal Microwave Ablation and Self-expandable Metallic Stenting: A New Treatment Method for Malignant Extrahepatic Biliary Obstruction

PURPOSE

To evaluate the patency and clinical efficacy of percutaneous intraductal microwave ablation (PIMWA) and uncovered self-expandable metallic stents (USEMs) in inoperable malignant extrahepatic biliary obstruction.

MATERIALS AND METHODS

The procedures to be performed on patients with malignant inoperable extrahepatic biliary obstruction were decided by a multidisciplinary team including an interventional radiologist. In our study, 141 patients were evaluated retrospectively. Twenty-one patients who underwent PIMWA + USEMs with the MedWaves AveCure microwave system (AveCure^® Intelligent Controller and Super-Flex Smart Catheter) and met the inclusion criteria were included in the study. Complications related to the intervention, stent patency, survival time, serum bilirubin levels, and the general condition of the patients were noted.

RESULTS

The median stent patency and the median survival time were 108 and 143 days, respectively. The rates of 30-day, 2-month, 6-month and 8-month survival were 95.2%, 85.7%, 38.1%, and 14.3%, respectively.

CONCLUSION

The PIMWA + USEMs procedure is a safe, effective, and minimally invasive alternative palliative treatment method in patients with malignant inoperable extrahepatic biliary obstruction.

Success and safety of endoscopic treatments for concomitant biliary and duodenal malignant stenosis: A review of the literature

Synchronous biliary and duodenal malignant obstruction is a challenging endoscopic scenario in patients affected with ampullary, peri-ampullary, and pancreatic head neoplasia. Surgical bypass is no longer the gold-standard therapy for these patients, as simultaneous endoscopic biliary and duodenal stenting is currently a feasible and widely used technique, with a high technical success in expert hands. In recent years, endoscopic ultrasonography (EUS) has evolved from a diagnostic to a therapeutic procedure, and is now increasingly used to guide biliary drainage, especially in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). The advent of lumen-apposing metal stents (LAMS) has expanded EUS therapeutic options, and changed the management of synchronous bilioduodenal stenosis. The most recent literature regarding endoscopic treatments for synchronous biliary and duodenal malignant stenosis has been reviewed to determine the best endoscopic approach, also considering the advent of an interventional EUS approach using LAMS.

Feasibility and safety of duodenal covered self-expandable metallic stent fixation: an experimental study

BACKGROUND AND AIMS

Migration of duodenal covered self-expandable metallic stents (C-SEMS) is the main cause of stent dysfunction in patients with malignant gastric outlet obstruction. However, the ideal method to prevent migration has not been clarified. We aimed to evaluate the feasibility and safety of duodenal C-SEMS fixation in this experimental study.

METHODS

We used the over-the-scope clip (OTSC), suture, and clip methods to fix duodenal C-SEMS and evaluated the gripping force of each device and invasion depth based on pathological findings.

RESULTS

The OTSC and suturing systems had a significantly higher mean gripping force compared with the clipping system (OTSC vs. clip: 13.2 vs. 1.0 Newtons [N], P < 0.001; suture vs. clip: 8.5 vs. 1.0 N, P < 0.001). OTSC compression was stronger compared with suturing (OTSC vs. suture: 13.2 vs. 8.5 N, P = 0.006). The submucosal layer, but not the muscle layer, was compressed more widely and deeply by OTSC compared with clips based on pathological findings by hematoxylin and eosin staining.

CONCLUSION

Both OTSC and suturing methods used for duodenal C-SEMS fixation were feasible compared with the clipping method. The pathological evaluation of invasion depth indicated that OTSC may be safe even for preventive use. This study suggested that these methods can be applied clinically for duodenal C-SEMS fixation.