Endoscopy 2007; 39(5): 440-447
DOI: 10.1055/s-2007-966327
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Combined endoscopic stent insertion in malignant biliary and duodenal obstruction

M.  Mutignani1 , A.  Tringali1 , S.  G.  Shah2 , V.  Perri1 , P.  Familiari1 , F.  Iacopini1 , C.  Spada1 , G.  Costamagna1
  • 1Digestive Endoscopy Unit, Catholic University, Rome, Italy
  • 2Bradford Royal Infirmary, Bradford, West Yorkshire, United Kingdom
Further Information

Publication History

submitted 4 May 2006

accepted after revision 5 December 2006

Publication Date:
22 May 2007 (online)

Background and study aims: Self-expandable metal stents (SEMS) are an effective palliative treatment for malignant biliary and duodenal strictures. Combined biliary and duodenal stenting remains a technical challenge, however. The aim of this study was to evaluate the technical feasibility of an endoscopic approach to double stenting of malignant biliary and duodenal strictures.

Patients and methods: Consecutive patients referred for palliative gastroduodenal and biliary stenting were followed up prospectively. Patients’ demographic characteristics, the site and nature of the strictures, success rates, complications, and survival time were recorded.

Results: A total of 64 patients underwent double stenting. In 46 patients, biliary obstruction occurred before the onset of duodenal obstruction (by a median of 107 days) (group 1); in 14 patients, biliary obstruction occurred concurrently with duodenal obstruction (group 2); and in four patients the duodenal obstruction preceded the biliary obstruction (by a median of 121 days) (group 3). The duodenal strictures were proximal to the papilla in 31 patients, adjacent to the papilla in 25 patients and distal to the papilla in eight patients. The majority of biliary strictures were in the middle or distal third of the bile duct (in 52/64 patients). Duodenal SEMS were successfully deployed in all patients. Combined endoscopic stenting was successful in 100 % of patients in group 1, 86 % of patients in group 2, and in 100 % of patients in group 3. Taking the three groups together, early complications occurred in 6 % of patients and late complications occurred in 16 % of patients. The overall median survival after combined stenting was 81 days (range 2 - 447 days).

Conclusions: Combined endoscopic biliary and duodenal SEMS insertion is safe and effective for palliation in malignant biliary and duodenal obstruction. Biliary stenting through the mesh of the duodenal SEMS is technically feasible and has a high success rate.

References

  • 1 Baron T H, Harewood G C. Enteral self-expandable stents.  Gastrointest Endosc. 2003;  58 421-433
  • 2 Maetani I, Tada T, Ukita T. et al . Comparison of duodenal stent placement with surgical gastrojejunostomy for palliation in patients with duodenal obstructions caused by pancreaticobiliary malignancies.  Endoscopy. 2004;  36 73-78
  • 3 Wong Y T, Brams D M, Munson L. et al . Gastric outlet obstruction secondary to pancreatic cancer: surgical vs endoscopic palliation.  Surg Endosc. 2002;  16 310-312
  • 4 Laasch H U, Martin D F, Maetani I. Enteral stents in the gastric outlet and duodenum.  Endoscopy. 2005;  27 74-81
  • 5 Shepherd H A, Royle G, Ross A P. Endoscopic biliary endoprosthesis in the palliation of malignant obstruction of the distal common bile duct: a randomized trial.  Br J Surg. 1988;  75 1166-1168
  • 6 Profili S, Feo C F, Meloni G B. et al . Combined biliary and duodenal stenting for palliation of pancreatic cancer.  Scand J Gastroenterol. 2003;  38 1099-1102
  • 7 Vanbiervliet G, Demarquay J F, Dumas R. et al . Endoscopic insertion of biliary stents in 18 patients with metallic duodenal stents who developed secondary malignant obstructive jaundice.  Gastroenterol Clin Biol. 2004;  28 1209-1213
  • 8 Kaw M, Singh S, Gagneja H. Clinical outcome of simultaneous self-expandable metal stents for palliation of malignant biliary and duodenal obstruction.  Surg Endosc. 2003;  17 457-461
  • 9 Feretis C, Benakis P, Dimopoulos C. et al . Palliation of malignant gastric outlet obstruction with self-expanding metal stents.  Endoscopy. 1996;  28 225-228
  • 10 Novacek G, Potzi R, Kornek G. et al . Endoscopic placement of a biliary expandable metal stent through the mesh wall of a duodenal stent.  Endoscopy. 2003;  35 982-983
  • 11 Freeman M L, Cass O W. Interlocking expandable metal stents for simultaneous treatment of malignant biliary and duodenal obstruction.  Gastrointest Endosc. 1996;  44 98-99
  • 12 Lichtenstein D R. Endoscopic palliation for unresectable pancreatic carcinoma.  Surg Clin North Am. 1995;  75 969-988
  • 13 Lillemoe K D, Cameron J L, Hardacre J M. et al . Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial.  Ann Surg. 1999;  230 322-328
  • 14 van Wagensveld B A, Coene P P, van Gulik T M. et al . Outcome of palliative biliary and gastric bypass surgery for pancreatic head carcinoma in 126 patients.  Br J Surg. 1997;  84 1402-1406
  • 15 Rhodes M, Nathanson L, Fielding G. Laparoscopically biliary and gastric bypass: a useful adjunct in the treatment of carcinoma of the pancreas.  Gut. 1995;  36 778-780
  • 16 Nagy A, Brosseuk D, Fielding G. Laparoscopic gastroenterostomy for duodenal onstruction.  Am J Surg. 1995;  169 539-542
  • 17 Andersen J R, Sorensen S M, Kruse A. et al . Randomised trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice.  Gut. 1989;  30 1132-1135
  • 18 Davids P H, Groen A K, Rauws E A. Randomized trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction.  Lancet. 1992;  340 1488-1492
  • 19 Knyrim K, Wagner H J, Pauch J, Vakil N. A prospective randomized, controlled trial of metal stents for malignant obstruction of the common bile duct.  Endoscopy. 1993;  25 207-212
  • 20 Prat F, Chapat O, Ducot B. et al . A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct.  Gastrointest Endosc. 1998;  47 1-7
  • 21 O’Brien S, Hatfield A R, Craig P I, Williams S P. A three-year follow-up of self-expanding metal stents in the endoscopic palliation of long-term survivors with malignant biliary obstruction.  Gut. 1995;  36 618-621
  • 22 Del Piano M, Ballare M, Montino F. et al . Endoscopy or surgery for malignant GI outlet obstruction?.  Gastrointest Endosc. 2005;  61 421-426
  • 23 Mittal A, Windsor J, Woodfield J. et al . Matched study of three methods for palliation of malignant pyloroduodenal obstruction.  Br J Surg. 2004;  91 205-209
  • 24 Adler D G, Baron T H. Endoscopic palliation of malignant gastric outlet obstruction using self-expanding metal stents: experience in 36 patients.  Am J Gastroenterol. 2002;  97 72-78
  • 25 Bessoud B, de Baere T, Denys A. et al . Malignant gastroduodenal obstruction: palliation with self-expanding metallic stents.  J Vasc Interven Radiol. 2005;  16 247-253
  • 26 Nassif T, Prat F, Meduri B. et al . Endoscopic palliation of malignant gastric outlet obstruction using self-expandable metallic stents: results of a multicenter study.  Endoscopy. 2003;  35 483-489
  • 27 Maire F, Hammel P, Ponsot P. et al . Long-term outcome of biliary and duodenal stents in palliative treatment of patients with unresectable adenocarcinoma of the head of pancreas.  Am J Gastroenterol. 2006;  101 735-742
  • 28 Inal M, Akgul E, Aksungar E. et al . Percutaneous self-expandable uncovered metallic stents in malignant biliary obstruction: complications, follow-up and reintervention in 154 patients.  Acta Radiol. 2003;  44 139-146
  • 29 Stocker J, Lameris J S. Complications of percutaneously inserted biliary Wallstents.  J Vasc Interv Radiol. 1993;  4 767-772
  • 30 Lindsay J O, Andreyev H J, Vlavianos P, Westaby D. Self-expanding metal stents for the palliation of malignant gastroduodenal obstruction in patients unsuitable for surgical bypass.  Aliment Pharmacol Ther. 2004;  19 901-905
  • 31 Telford J J, Carr-Locke D L, Baron T H. et al . Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study.  Gastrointest Endosc. 2004;  60 916-920

G. Costamagna, MD

Digestive Endoscopy Unit

Università Cattolica del Sacro Cuore

”A. Gemelli” University Hospital

Largo A. Gemelli 8

00168 Rome

Italy

Fax: +39-06-30156581

Email: gcostamagna@rm.unicatt.it