Factors Associated with the Technical Success of Bilateral Endoscopic Metallic Stenting with Partial Stent-In-Stent Placement in Patients with Malignant Hilar Biliary Obstruction

Abstract

Background. Bilateral biliary drainage decreases the risk of cholangitis, but bilateral endoscopic metallic stenting is technically challenging. Aim. We retrospectively evaluated the factors associated with successful bilateral self-expanding metal stent (SEMS) placement using the partial stent-in-stent (PSIS) method for malignant hilar biliary obstruction and also assessed the safety and efficacy of this technique. Methods. From April 2010 to February 2016, 47 consecutive patients (mean age, 73.0±8.6 years; 32 males and 15 females) underwent PSIS placement for malignant hilar biliary obstruction in our hospital. The technical success of PSIS, clinical response, and complications were investigated. Factors associated with the technical success of PSIS were assessed. Using a propensity score-matched analysis, we compared the procedure time, clinical response, complications, stent patency, and survival time in 17 matched patients treated with bilateral SEMS placement using a SEMS delivery system of <6.0 or ≥6.0 Fr. Results. The technical success rate was 77%. The clinical response rate was 91%, and the complication rate was 26%. Regarding complications, pancreatitis occurred in 5 patients (11%), cholangitis in 6 (13%), and cholecystitis in 1 (2%). A multiple logistic regression analysis identified the use of a SEMS with a delivery system<6.0 Fr as a factor associated with technical success (P=0.033; odds ratio, 10.769; 95% confidence interval, 1.205-96.212). In the 17 matched patients assigned according to the SEMS delivery system size, the procedure time was significantly shorter in those with a delivery system size<6.0 Fr than in those with ≥6.0 Fr (P<0.01). There were no significant differences in the clinical response, complication rate, stent patency, or survival time between the two groups. Conclusion. Using a delivery system<6.0 Fr in size helped improve the technical success and reduced the procedure time for the placement of a SEMS by the PSIS method.

Percutaneous stent-in-stent placement with large cell-type stents for malignant hilar biliary obstruction

“…The median stent patency and stent occlusion rate in our study (179 days and 35.6%, respectively) showed comparable outcomes to those reported by the aforementioned studies applying an endoscopic method using LCD stents (105-202 days and 42.0%-63.2%, respectively) (12,13,15,16,18,28), open-weave, crosswired stents (150-253 days and 6.0%-44.1%, respectively) (14,16,17,(29)(30)(31), or a percutaneous method with conventional open-cell and partially covered large cell or covered stents (75-330 days and 17.5%-48.4%, respectively) (11,(20)(21)(22)(23)(24)(25)(26). The differences in the definitions of the stent patency period do have to be taken into account.…”

“…Our median survival time (285.5 days) was comparable to those of previous studies with endoscopic methods and LCD stents (114-300 days) (13,16,18), open-weave, cross-wired stents (180-383 days) (14,16,17,(29)(30)(31), or those with percutaneous open-cell, partially covered large cell, or covered stents placement (143-299 days) (11,(20)(21)(22)(24)(25)(26), although a direct comparison is impossible. One study noticed that once successful biliary drainage had been obtained, median stent patency and survival time were similar between the percutaneous and endoscopic approaches (20).…”

Partial Stent-in-Stent Method with an Uncovered Self-Expandable Metallic Stent for Unresectable Malignant Hilar Bile Duct Obstruction

“…This is because the already placed SEMS can be used to approach the obstructed bile duct, to which a new SEMS can be added. Furthermore, newer devices are expected to improve the technical success rate and may become more common in the future [22][23][24][25].…”

Unilateral versus Bilateral Endoscopic Nasobiliary Drainage and Subsequent Metal Stent Placement for Unresectable Malignant Hilar Obstruction: A Multicenter Randomized Controlled Trial

“…Traditionally, bilateral SEMS deployment for malignant hilar biliary obstruction is not widely accepted because of the complicated endoscopic maneuver. Recently, the improvement of metallic stents allows easy bilateral SEMS deployment [ 13 , 14 , 15 , 16 ] but technical success rates of bilateral SEMS deployment still vary among studies [ 3 , 4 , 9 ]. Furthermore, it is also controversial whether this technical difficulty of bilateral SEMS deployment can lead to better long term outcomes or not.…”