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

Risk factors for acute pancreatitis post percutaneous transhepatic biliary stenting in patients with distal malignant obstruction

Background

Percutaneous transhepatic biliary stenting (PTBS) is an effective treatment for distal malignant biliary obstruction (MBO). Postoperative acute pancreatitis (AP) is a dangerous complication of this procedure. This study sought to investigate the risk factors for AP after PTBS.

Methods

A total of 463 patients who underwent PTBS to treat suspected MBO from October 2012 to October 2021 were enrolled in this retrospective study. Among them, 26 individuals met the diagnostic criteria for postoperative pancreatitis following PTBS. The incidence of AP at 1 month postoperatively was recorded and analyzed. Several risk factors for AP were analyzed, and the odds ratios (ORs) were calculated by univariate and multivariate logistic analyses.

Results

The incidence of AP after PTBS was 10.88% (26/239). The results of the multivariate analyses showed that repeated bile duct hemorrhage (OR =14.370, P=0.0001), intraoperative dilation (OR =7.848, P=0.0003), an operation time >50 min (OR =5.783, P=0.0009), and previous endoscopic intervention (OR =5.468, P=0.0021) were correlated with a high incidence of AP, while sex, age, time to biliary obstruction, body mass index, Eastern Cooperative Oncology Group score, previous anticancer treatments, forceps biopsy, obstruction length, stent size, contrast volume, operators, 125I strand placement, and blood parameters were not significantly correlated with AP (all P>0.05).

Conclusions

A long operation time, intraoperative dilation, repeated bile duct hemorrhage, and previous endoscopic intervention were independent risk factors for AP. These factors should be considered by clinicians in future practice.

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.

Comparison of the clinical effectiveness of hepaticojejunostomy and self-expanding metal stents for bypassing the bile ducts in patients with unresectable pancreatic head cancer complicated by obstructive jaundice

OBJECTIVE

Aim: To improve treatment outcomes of patients with unresectable pancreatic head cancer complicated by obstructive jaundice by improving the tactics and techniques of surgical interventions.

PATIENTS AND METHODS

Materials and Methods: Depending on the treatment tactics, patients were randomised to the main group (53 people) or the comparison group (54 people). The results of correction of obstructive jaundice by Roux-en-Y end to side hepaticojejunostomy (main group) and common bile duct prosthetics with self-expanding metal stents (comparison group) were compared.

RESULTS

Results: The use of self-expanding metal stents for internal drainage of the biliary system compared to hepaticojejunostomy operations reduced the incidence of postoperative complications by 29.9% (χ2=13.7, 95% CI 14.38-44.08, p=0.0002) and mortality by 7.5% (χ2=4.16, 95% CI -0.05-17.79, p=0.04). Within 8-10 months after biliary stenting, 11.1% (6/54) of patients developed recurrent jaundice and cholangitis, and another 7.4% (4/54) of patients developed duodenal stenosis with a tumour. These complications led to repeated hospitalisation and biliary restentation in 4 (7.4%) cases, and duodenal stenting by self-expanding metal stents in 4 (7.4%) patients.

CONCLUSION

Conclusions: The choice of biliodigestive shunting method should be selected depending on the expected survival time of patients. If the prognosis of survival is up to 8 months, it is advisable to perform prosthetics of the common bile duct with self-expanding metal stents, if more than 8 months, it is advisable to perform hepaticojejunal anastomosis with prophylactic gastrojejunal anastomosis.

Best Practices in Esophageal, Gastroduodenal, and Colonic Stenting

Endoscopic stenting is an area of endoscopy that has witnessed noteworthy advancements over the last decade, resulting in evolving clinical practices among gastroenterologists around the world. Indications for endoscopic stenting have progressively expanded, becoming a frequent part of the management algorithm for various benign and malignant conditions of the gastrointestinal tract, from esophagus to rectum. In addition to expanded indications, continuous technological enhancements and development of novel endoscopic stents have resulted in an increased success of these approaches and, in some cases, allowed new applications. This review aimed to summarize best practices in esophageal, gastroduodenal, and colonic stenting.

Clinical Advances in the Diagnosis and Treatment of Biliary Tract Diseases

Although the biliary tract is a small organ, it is diverse in location (intrahepatic bile ducts, extrahepatic bile ducts, gallbladder, and ampulla) and disease (including benign and malignant), thus a multidisciplinary approach involving endoscopists, surgeons, oncologists, radiologists, and infectious disease specialists is often required to treat biliary tract disease [...]

Long-term outcomes of endoscopic double stenting using an anti-reflux metal stent for combined malignant biliary and duodenal obstruction

PURPOSE

To evaluate long-term outcomes of endoscopic double stenting using anti-reflux metal stents (ARMS) for combined malignant biliary and duodenal obstruction.

METHODS

Consecutive patients with advanced pancreatic cancer who received endoscopic double stenting with self-expandable metal stents (SEMS) for combined malignant biliary and duodenal obstruction at our institution between July 2014 and March 2021 were evaluated. Patients were divided into the ARMS group, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) group, and covered metal stent-transpapillary (CMS-transpapillary) group. A Duckbill-type metal stent was used in all ARMS cases.

RESULTS

Thirty-eight patients were enrolled: ARMS group (n = 16), EUS-HGS group (n = 13), and CMS-transpapillary group (n = 9). Overall survival among three groups were not significantly different. Recurrent biliary obstruction (RBO) rates of the ARMS, EUS-HGS, and CMS-transpapillary groups were 12.5%, 61.5%, and 88.9% (P < .01) and median time to recurrent biliary obstructions (TRBOs) were not reached, 125 days, and 7 days (P < .01). Median TRBOs of ARMS-choledochoduodenostomy and ARMS-transpapillary were not statistically different. Major causes of RBO were stent occlusion and symptomatic stent migration in the ARMS group, hyperplasia in the EUS-HGS group, and non-occlusion cholangitis in the CMS-transpapillary group.

CONCLUSIONS

Endoscopic double stenting with ARMS might be an option for combined malignant biliary and duodenal obstruction.