Unilateral versus bilateral endoscopic metal stenting for malignant hilar biliary obstruction

Naitoh, Itaru; Ohara, Hirotaka; Nakazawa, Takahiro; Ando, Tomoaki; Hayashi, Kazuki; Okumura, Fumihiro; Okayama, Yasutaka; Sano, Hitoshi; Kitajima, Yasuhiro; Hirai, Masaaki; Ban, Tessin; Miyabe, Katsuyuki; Ueno, Koichiro; Yamashita, Hiroaki; Joh, Takashi

doi:10.1111/j.1440-1746.2008.05750.x

Cited by 187 publications

(201 citation statements)

References 17 publications

(64 reference statements)

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“…Nonetheless, although no control group was available, the authors support the notion that in the specific population of end-stage, advanced, hilar disease, bilateral decompression was vital for the clinical success and survival rates achieved. Recently published data coming from a single-center study comparing endoscopic bilateral versus unilateral stent deployment demonstrated the superior cumulative stent patency of the bilateral approach, further supporting this suggestion [26] . Moreover, in our study, the long-term clinical effectiveness was maintained by the successful revisions resulting in high secondary patency rates following stent occlusion.…”

Section: Discussionsupporting

confidence: 60%

Percutaneous trans-hepatic bilateral biliary stenting in Bismuth IV malignant obstruction

Karnabatidis

Spiliοpoulos²,

Katsakiori³

et al. 2013

WJH

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AIM:To investigate the clinical efficiency of percutaneous trans-hepatic bilateral biliary metallic stenting for the management of Bismuth Ⅳ malignant obstructive disease. METHODS:Our hospital's database was searched for all patients suffering from the inoperable malignant biliary obstruction Bismuth Ⅳ, and treated with percutaneous bilateral trans-hepatic placement of selfexpandable nitinol stents. The indication for percutaneous stenting was an inoperable, malignant, symptomatic, biliary obstruction. An un-correctable coagulation disorder was the only absolute contra-indication for treatment. Bismuth grading was performed using magnetic resonance cholangiopancreatography. Computed tomography evaluation of the lesion and the dilatation status of the biliary tree was always performed prior to the procedure. All procedures were performed under conscious sedation. A single trans-hepatic track technique was preferred (T-configuration stenting) and a second, contra-lateral trans-hepatic track (Y-configuration stenting) was used only in cases of inability to access the contra-lateral lobe using a single track technique. The study's primary endpoints were clinical success, defined as a decrease in bilirubin levels within 10 d and patient survival rates. Secondary endpoints included peri-procedural complications, primary and secondary patency rates. RESULTS:A total of 35 patients (18 female, 51.4%) with a mean age 69 ± 13 years (range 33-88) were included in the study. The procedures were performed between March 2000 and June 2008 and mean time follow-up was 13.5 ± 22.0 mo (range 0-96). The underlying malignant disease was cholangiocarcinoma (n = 10), hepatocellular carcinoma (n = 9), pancreatic carcinoma (n = 5), gastric cancer (n = 2), bile duct tumor (n = 2), colorectal cancer (n = 2), gallbladder carcinoma (n = 2), lung cancer (n = 1), breast cancer (n = 1) or non-Hodgkin lymphoma (n = 1). In all cases, various self-expandable bare metal stents with diameters ranging from 7 to 10 mm were used. Stents were placed in Y-configuration in 24/35 cases (68.6%) using two stents in 12/24 patients and three stents in 12/24 cases (50%). A T-configuration stent placement was performed in 11/35 patients (31.4%), using two stents in 4/11 cases (36.4%) and three stents in 7/11 cases (63.6%). Follow-up was available in all patients (35/35). Patient survival ranged from 0 to 1763 d and the mean survival time was 168 d. Clinical success rate was 77.1% (27/35 cases), and peri-procedural mortality rate was 5.7% (2/35 patients). Biliary reobstruction due to stent occlusion occurred in 25.7% of the cases (9/35 patients), while in 7/11 (63.6%) one additional percutaneous re-intervention due to stent occlusion resulting in clinical relapse of symptomatology was successfully performed. In the remaining Karnabatidis D et al . Percutaneous bilateral biliary stenting 4/11 patients (36.4%) more than 1 additional reintervention was performed. The median decrease of total serum bilirubin was 60.5% and occurred in 81.8% of the cases (27/...

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Section: Discussionsupporting

confidence: 60%

Percutaneous trans-hepatic bilateral biliary stenting in Bismuth IV malignant obstruction

Karnabatidis

Spiliοpoulos²,

Katsakiori³

et al. 2013

WJH

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“…A study of bilateral versus unilateral SEMS found greater patency with bilateral SEMS [9]. The recent availability of smaller SEMS delivery systems allows sideby side pre-deployment insertion of bilateral SEMS; however, this procedure remains technically challenging even for experienced biliary endoscopists.…”

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confidence: 99%

Ongoing Challenges in the Endoscopic Management of Hilar Cholangiocarcinoma

Aslanian

Jamidar

2011

Dig Dis Sci

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The majority of patients with cholangiocarcinoma present with locally unresectable disease and the median survival with radiation and chemotherapy is 7-12 months. The endoscopic palliation of inoperable hilar cholangiocarcinoma remains one of the more challenging cases for the biliary endoscopist. The endoscopist must define the anatomy without injecting contrast into ducts that will not be drained, achieve guide-wire access for unilateral or bilateral stent placement and determine what type of stent-plastic or self-expanding metal (SEMS), will best serve the patient to relieve pain and jaundice and prevent cholangitis.Raju et al.[1] present a retrospective review of 100 patients who underwent endoscopic plastic or SEMS placement for inoperable hilar cholangiocarcinoma. Patients were regularly followed to death or reintervention, and stent patency and survival were examined. In 48 patients uncovered (as expected due to the hilar location of obstruction) SEMS were placed, with plastic stents (at least one of which was 10 French) in the other 52 patients. The Bismuth Classification of lesions was similar between the groups. There was however, a greater number of Type 3 and 4 cases that received plastic stents (73.1% vs. 56.3%), potentially favoring a better outcome with SEMS. The technical success rate was high in both groups (95.8% vs. 94.2%). Bilateral stenting was performed successfully in 20/23 plastic stent patients and 5/5 SEMS. The SEMS group demonstrated significantly better stent patency (5.56 vs. 1.86 months) and required fewer re-interventions for stent obstruction (1.53 vs.4.6). The complication rate was similar in both groups (8.3% SEMS and 7.7% plastic) and there was a non-significant trend towards greater survival in the SEMS group (9.08 vs. 8.22 months). During the study time period, routine stent changes in patients with plastic stents were not performed; however, the median patency was only 1.5 months. No difference between the patency of straight and pigtail plastic stents was seen, nor was there a difference between unilateral and bilateral plastic stents or SEMS. All re-interventions were performed endoscopically, nine patients with plastic stents were converted to SEMS and plastic stents were placed within SEMS in four patients.The results of Raju et al. are similar to those of prior studies identifying less stent failure with the use of SEMS versus plastic stents for hilar tumors [2,3]. There is scant information in the way of randomized comparisons between plastic and metal stents. A study by Wagner et al.[2] is the only prospective, randomized study. Twenty patients were randomized between metal stents placed percutaneously or endoscopic stents placed by a combination of endoscopic-percutaneous technique. Perdue et al.[3] reviewed a multicenter database of 62 consecutivelyreported endoscopically-placed metal or plastic stents for hilar obstruction. Outcomes in favor of metals stents were reported in both studies.

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“…In biliary obstruction in the hepatic hilum, effective drainage is difficult to achieve because of the anatomical complexity of the bile ducts. Various procedures of biliary drainage of hilar biliary obstruction have been performed: percutaneous or endoscopic routes [1][2][3][4][5] , plastic or metallic stents [6][7][8][9][10][11] , and unilateral or bilateral hepatic duct drainage [11][12][13][14][15][16][17][18][19][20][21] . However, no consensus has been reached on the optimal drainage strategy for treating biliary obstruction.…”

Section: Introductionmentioning

confidence: 99%

Biliary drainage strategy of unresectable malignant hilar strictures by computed tomography volumetry

Takahashi

Fukasawa

Satô

et al. 2015

WJG

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AIM:To identify criteria for predicting successful drainage of unresectable malignant hilar biliary strictures (UMHBS) because no ideal strategy currently exists. METHODS:We examined 78 patients with UMHBS who underwent biliary drainage. Drainage was considered effective when the serum bilirubin level decreased by ≥ 50% from the value before stent placement within 2 wk after drainage, without additional intervention. Complications that occurred within 7 d after stent placement were considered as early complications. Before drainage, the liver volume of each section (lateral and medial sections of the left liver and anterior and posterior sections of the right liver) was measured using computed tomography (CT) volumetry. Drained liver volume was calculated based on the volume of each liver section and the type of bile duct stricture (according to the Bismuth classification). Tumor volume, which was calculated by using CT volumetry, was excluded from the volume of each section. Receiver operating characteristic (ROC) analysis was performed to identify the optimal cutoff values for drained liver volume. In addition, factors associated with the effectiveness of drainage and early complications were evaluated. cirrhosis) and 50% for patients with impaired liver function (with decompensated liver cirrhosis). The sensitivity and specificity of these cutoff values were 82% and 80% for preserved liver function, and 100% and 67% for impaired liver function, respectively. Among patients who met these criteria, the rate of effective drainage among those with preserved liver function and impaired liver function was 90% and 80%, respectively. The rates of effective drainage in both groups were significantly higher than in those who did not fulfill these criteria (P < 0.001 and P = 0.02, respectively). Drainage-associated cholangitis occurred in 9 patients (12%). A smaller drained liver volume was associated with drainage-associated cholangitis (P < 0.01). RESULTS: CONCLUSION:Liver volume drainage ≥ 33% in patients with preserved liver function and ≥ 50% in patients with impaired liver function correlates with effective biliary drainage in UMHBS. Core tip: An ideal biliary drainage strategy for unresectable malignant hilar biliary strictures (UMHBS) has not been defined. The aim of our study was to identify useful criteria for predicting successful drainage of UMHBS. In the present study, multivariate analysis revealed that liver function and drained liver volume calculated by computed tomography volumetry (CTV) are independent factors of drainage effectiveness for UMHBS. Receiver operating characteristic analysis showed cutoff values of 33% of liver volume for patients with preserved liver function and 50% for patients with impaired liver function. Before attempting biliary drainage procedures, establishing an appropriate drainage strategy using CTV is important.Takahashi E, Fukasawa M, Sato T, Takano S, Kadokura M, Shindo H, Yokota Y, Enomoto N. Biliary drainage strategy of unresectable malignant hilar strictures by...

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Unilateral versus bilateral endoscopic metal stenting for malignant hilar biliary obstruction

Abstract: Endoscopic bilateral drainage using SEMS for malignant hilar biliary obstruction is more effective than unilateral drainage in terms of cumulative stent patency, especially in cases of cholangiocarcinoma.

Cited by 187 publications

References 17 publications

Percutaneous trans-hepatic bilateral biliary stenting in Bismuth IV malignant obstruction

Percutaneous trans-hepatic bilateral biliary stenting in Bismuth IV malignant obstruction

Ongoing Challenges in the Endoscopic Management of Hilar Cholangiocarcinoma

Biliary drainage strategy of unresectable malignant hilar strictures by computed tomography volumetry

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