Self-expandable metallic stent placement above the papilla without endoscopic sphincterotomy in patients with distal malignant biliary obstruction

Abstract

Background and study aims The best method for endoscopic placement of self-expandable metallic stents (SEMS) for distal malignant biliary obstruction (MBO) has not yet been determined. The aim of this study was to evaluate how SEMS placement above the papilla and without endoscopic sphincterotomy (EST) impacts the time to recurrent biliary obstruction (RBO) in patients with distal MBO. Patients and methods We retrospectively reviewed data for 73 consecutive patients with unresectable distal MBO who underwent endoscopic SEMS placement for the first time at our institution between April 2014 and March 2016. We compared time to RBO of SEMS placement above the papilla (intraductal placement) with SEMS placement across the papilla (transpapillary placement). In the intraductal placement group, we also compared time to RBO of placement without EST with placement with EST. Results Endoscopic SEMS placement was performed in 30 patients with intraductal placement and in 43 patients with transpapillary placement. The median time to RBO was significantly longer with intraductal placement (307 days) than with transpapillary placement (161 days) (P = 0.022). Complication rates did not differ between the two groups. In both univariate and multivariate analysis, intraductal placement was an independent factor contributing to prolonged time to RBO. In intraductal placement, time to RBO was significantly longer in SEMS placement without EST than with EST (363 days vs. 227 days, respectively; P = 0.026). Conclusions Intraductal SEMS placement, especially without EST for distal MBO contributed to longer time to RBO.

Possible reasons for the regrettable results of patency of an inside stent in endoscopic transpapillary biliary stenting

“…In the literature, there have been six comparative studies on EBS for DBO in which the stent was placed above or across the SO, including two randomized controlled trials (RCTs) with negative results of stent placement above the SO (Table 1). [41][42][43][44][45][46] Pedersen et al 41 reported the first clinical case series in patients with malignancy (n = 34), from their 1998 RCT using a 10-Fr straight "inside stent" made of Teflon (Table 1). They reported that the median duration of stent patency was 110 days (interquartile range [IQR] 61-320 days) for stents placed above the SO and 126 days (IQR 89-175 days) for stents placed across the SO (not significant).…”

“…Thereafter, two retrospective studies comparing an MS or a PS placed above and across the SO for DBO were performed. 45,46 The retrospective study by Takada et al 46 showed the superiority of an MS placed above the SO compared with that across the SO (USEMS, 490.7 days vs. 307.8 days, P = 0.023; USEMS/fully CSEMS/partially CSEMS, 307 days vs. defined the criterion for EBS above the SO as >1 cm from the biliary obstruction to the SO, which differs from the criterion (≥0.5 cm) of Cho et al In summary, for unresectable malignant DBO, the distance >1 cm from the biliary obstruction to the SO would be the necessary criterion of placement of an inside stent, which would be a demerit of an inside stent, followed by a 'curved' but not 'straight' inside stent if a plastic type. The appropriate type of a metal inside stent (USEMS/fully CSEMS/partially CSEMS or other future stent) needs to be further investigated (Table 3).…”

“…26,44,69 However, the utility of ES with inside stent placement has not been verified. Takada et al 46 indicated that ES could affect stent patency in the intraductal placement group (no ES [n = 20], 363 days vs. ES [n = 10], 227 days, P = 0.026), while Inatomi et al 58 reported different results. Considering the initial concept of using an inside stent, namely prevention of duodenocholedochal reflux, ES should be avoided.…”

A case of refractory tumor bleeding from an ampullary adenocarcinoma: Compression hemostasis with a self‐expandable metallic stent

“…Fully covered SEMS in patients with distal malignant biliary obstruction (MBO) have a high risk of migration. 8 Furthermore, in this case, stent migration may have caused the recurrent bleeding. Considering these risks, we also placed a double pigtail plastic stent as an anchoring stent for anti‐migration.…”

“…Although a meta‐analysis found that uncovered SEMSs have a lower risk of migration than covered SEMS, 7 we chose to place a covered SEMS to prepare for future exchange of a pancreatic plastic stent. Fully covered SEMS in patients with distal malignant biliary obstruction (MBO) have a high risk of migration 8 . Furthermore, in this case, stent migration may have caused the recurrent bleeding.…”