Biliary stenting for hilar malignant biliary obstruction

Abstract

Although endoscopic intervention is the mainstay for palliation of malignant biliary obstruction, a percutaneous approach has been preferred, particularly in patients with advanced highgrade hilar malignant biliary obstruction, because of the technical difficulty and risk of complications. However, recently, primary endoscopic palliation using plastic or metal stents has had higher technical and clinical success with fewer adverse events than the percutaneous approach. Endoscopic interventions are being done more and more frequently because of advances in metal stents, accessories, and techniques.However, several concerns, such as optimal stent type, number, and deployment method, remain to be resolved. Therefore, we reviewed the literature in order to identify the optimal biliary stenting strategy for patients with hilar malignant biliary obstruction, focusing on stent type (plastic vs metal), number (unilateral [single] vs bilateral [multiple]), and deployment method (stent-in-stent vs stent-by-stent). NA, not available; NS, not significant; RCT, randomized controlled trial; SEMS, self-expandable metal stent. † 30-day mortality. ‡ Six-month patency rate. Digestive Endoscopy 2020; 32: 275-286 Biliary stenting for HMBO 277 157 180 26 Kawakubo et al. 70 SBS Zilver 84.6 (11/13) NA 38 (5/13) 263 206 194 NA, not available; SBS, stent-by-stent; SEMS, self-expandable metal stents; SIS, stent-in-stent. Digestive Endoscopy 2020; 32: 275-286 Biliary stenting for HMBO 281 Digestive Endoscopy 2020; 32: 275-286 Biliary stenting for HMBO 285

Endoscopic revision efficacy after clinically successful bilateral metal stenting for advanced malignant hilar obstruction

“…The RBO rate after placement of bilateral SEMS in MHO has been reported to range from 3% to 45%. 3 Therefore, following successful endoscopic deployment of bilateral SEMS, endoscopic or percutaneous reintervention for the previously inserted SEMS should be considered when RBO develops. However, various reinterventions, as well as the primary deployment of bilateral SEMS, are deemed to be technically difficult in MHO.…”

“…However, nowadays, the technical feasibility and clinical success rate of bilateral SEMS have been improved according to numerous recent studies, and bilateral drainage might be more effective physiologically for stent patency. [1][2][3][4][5][6][7][8][9][10][11][12][13][14] A recent comparative study also showed that bilateral drainage using SEMS was more beneficial in stent patency than was unilateral drainage in advanced (MHO) without a difference in technical difficulty or adverse event rates. 2 For adequate liver drainage, multiple drainages are now considered as a primarily recommended method.…”

“…Notably, the bilateral stent-in-stent (SIS) deployment method is considered to be a more technically difficult situation than is the stent-by-stent (SBS) method. 3,7 SBS is considered to be relatively easy, uniquely when the stents were placed across the papilla. Also, the time to recurrent biliary obstruction (RBO) of the revisionary stent remains unclear.…”

Simultaneous triple side‐by‐side metal stent deployment for malignant hilar biliary obstruction

“…Triple deployment of metal stents (MSs) in high‐grade malignant hilar biliary obstruction (MHBO) is technically challenging . Although combined side‐by‐side (SBS) and stent‐in‐stent deployment might reduce its difficulty, the insertion of the third MS remains a concern .…”

“…T RIPLE DEPLOYMENT OF metal stents (MSs) in highgrade malignant hilar biliary obstruction (MHBO) is technically challenging. [1][2][3][4] Although combined side-by-side (SBS) and stent-in-stent deployment might reduce its difficulty, the insertion of the third MS remains a concern. 5 A new MS that has a 5.4-Fr ultra-thin delivery system (Zeo Stent V; Zeon Medical, Tokyo, Japan) was recently developed, and it facilitates simultaneous triple SBS deployment ( Fig.…”