Endoscopic deployment of multiple (≥ 3) metal stents for unresectable malignant hilar biliary strictures

Abstract

Background and study aims Endoscopic deployment of multiple (≥ 3) self-expandable metal stents (SEMS) for high-grade unresectable malignant hilar biliary strictures (UMHBS) is technically challenging. Eleven consecutive patients with high-grade UMHBS (mean age: 76 years, male/female: 5/6, Bismuth-Corlette classification IIIa/IV: 7/4) underwent endoscopic deployment of multiple SEMS using a combination of side-by-side (SBS) and stent-in-stent (SIS) methods. Technical and clinical success rates were 11/11. More than three SEMS were successfully deployed, and obstructive jaundice was fully improved in all cases. Stent occlusion was recognized in four of 11 patients (mean: 134 days, range: 28 – 232). Reinterventions for both liver lobes were feasible by passing the guide wire inside the previously placed stents in three of four patients. Median stent patency was 150 days during a mean follow-up period of 184 days (range: 37 – 558). Three patients developed self-limiting cholangitis without definite stent occlusion as late (> 30 days) adverse events. Employing the combination of SBS and SIS methods may facilitate endoscopic deployment of multiple SEMS to treat high-grade UMHBS.

• References

• 1 Naitoh I, Hayashi K, Nakazawa T. et al. Side-by-side versus stent-in-stent deployment in bilateral endoscopic metal stenting for malignant hilar biliary obstruction. Dig Dis Sci 2012; 57: 3279-3285
• 2 Kim KM, Lee KH, Chung YH. et al. A comparison of bilateral stenting methods for malignant hilar biliary obstruction. Hepatogastroenterology 2012; 59: 341-346
• 3 Kawamoto H, Tsutsumi K, Fujii M. et al. Endoscopic 3-branched partial stent-in-stent deployment of metallic stents in high-grade malignant hilar biliary stricture (with videos). Gastrointest Endosc 2007; 66: 1030-1037
• 4 Lee TH, Moon JH, Choi HJ. et al. Third metal stent for revision of malignant hilar biliary strictures. Endoscopy 2016; 48: 1129-1133
• 5 Koshitani T, Nakagawa S, Itoh Y. Multiple self-expandable metal stent deployment for unresectable malignant hilar biliary strictures: combination of side-by-side and stent-in-stent methods. Dig Endosc 2016; 28: 621
• 6 Isayama H, Hamada T, Yasuda I. et al. Tokyo Criteria 2014 for transpapillary biliary stenting. Dig Endosc 2015; 27: 259-264
• 7 Sawas T, Al Halabi S, Parsi MA. et al. Self-expandable metal stents versus plastic stents for malignant biliary obstruction: a meta-analysis. Gastrointest Endosc 2015; 82: 256-267
• 8 Hong W, Sun X, Zhu Q. Endoscopic stenting for malignant hilar biliary obstruction: should it be metal or plastic and unilateral or bilateral?. Eur J Gastroenterol Hepatol 2013; 25: 1105-1112
• 9 Vienne A, Hobeika E, Gouya H. et al. Prediction of drainage effectiveness during endoscopic stenting of malignant hilar strictures: the role of liver volume assessment. Gastrointest Endosc 2010; 72: 728-735
• 10 Lee TH, Kim TH, Moon JH. et al. Bilateral versus unilateral placement of metal stents for inoperable high-grade malignant hilar biliary strictures: a multicenter, prospective, randomized study (with video). Gastrointest Endosc 2017; 86: 817-827