Biliary stenting: Indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline

Dumonceau, Jean‐Marc; Tringali, Andrea; Bléro, Daniel; Devière, Jacques; Laugiers, R.; Héresbach, D.; Costamagna, Guido

doi:10.1055/s-0031-1291633

Cited by 500 publications

(561 citation statements)

References 158 publications

(143 reference statements)

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“…The procedure can thus be performed to improve patients' clinical status before major surgery or as definitive palliative therapy in the case of malignant biliary obstruction. The prosthesis can be positioned with the aid of endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) [15]. In the first case, before inserting the stent, a sphincterectomy is performed which allows direct access to the interior of the biliary ducts; in some cases, however, before inserting the stent the obstructed biliary duct is expanded by inflating a balloon in its interior.…”

Section: Biliary Stentingmentioning

confidence: 99%

Evolution of surgical techniques for a progressive risk reduction

Amato

Santoro

Izzo

et al. 2017

Monaldi Arch Chest Dis

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Advanced age is a strong predictor of high perioperative mortality in surgical patients and patients aged 75 years and older have an elevated surgical risk, much higher than that of younger patients. Progressive advances in surgical techniques now make it possible to treat high-risk surgical patients with minimally invasive procedures. Endovascular techniques have revolutionized the treatment of several vascular diseases, in particular carotid stenosis, aortic pathologies, and severely incapacitating intermittent claudication or critical limb ischemia. The main advantages of the endovascular approach are the low complication rate, high rate of technical success and a good clinical outcome. Biliary stenting has improved the clinical status of severely ill patients with bile duct stricture before major surgery, and represents a good palliative therapy in the case of malignant biliary obstruction.

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Section: Biliary Stentingmentioning

confidence: 99%

Evolution of surgical techniques for a progressive risk reduction

Amato

Santoro

Izzo

et al. 2017

Monaldi Arch Chest Dis

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“…Complications such as the liver abscesses, are being reduced by the use of covered self expandable metal stents that have a lower risk of cholangitis and infection [2]. Stenting shows a shortened time to resumption of fluids and food, reduced hospital stay and costs when compared with surgery [3].…”

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confidence: 99%

Complications from Stents and Lack of Conversations

Gallagher¹

2016

JGPLD

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was decompressed. Significant biliary duct dilatation, not present on his last CT scan, was noted and there were two irregular fluid collections containing small bubbles of air -probable liver abscesses -that had also developed. The liver metastases had all grown in size in the interim. Clostridium perfringens and Streptococcus anginosus grew in his blood and were susceptible to the antibiotics.The fentanyl infusion was titrated to effective pain relief but he remained delirious and died three days later.The oncologist called the wife several days after he became aware he was in the hospital and was surprised to find he had died. He notes that the wife was angry and told him that both the patient and she felt let down by the medical system and the physicians and nurses who had seen them for his illness. The physician noted "unfortunately clinical deterioration in such as this is all too common in the context of metastatic pancreatic cancer". This case is instructive for two reasons: the risk of serious sepsis in patients with stents and the bereavement reaction of the spouse.Clostridium perfringens is an anaerobic normal inhabitant of the bowel and genital tract. Septicemia from this bacteria usually occurs in patients who are immunocompromized (malignancy, diabetes etc) and have had a recent abdominal or pelvic procedure [1]. The mortality rate is extremely high. Streptococcus anginosus is also associated with abscesses in those who are immunocompromized.Therapy for the complications of pancreatic cancer has evolved tremendously over the last 20 years with the introduction of stenting by endoscopy. Complications such as the liver abscesses, are being reduced by the use of covered self expandable metal stents that have a lower risk of cholangitis and infection [2]. Stenting shows a shortened time to resumption of fluids and food, reduced hospital stay and costs when compared with surgery [3].A recent review [4] of pancreatic cancer noted that on diagnosis 90% of tumors are already locally or systemically involved and therefore not operable. The average survival for those who are not operable is 4 months with the range of 3-11 Case ReportA 59 year-old man had several months of epigastric distress and pain radiating to the back before presenting with obstructive jaundice. CT scan of the abdomen showed a 4cm mass in the pancreas. The biliary obstruction was located 4cm above the ampulla and resolved with the insertion of a Cotton Leung plastic stent. Lesions in the liver, seen on ultrasound, could not be confirmed as metastases on CT scan. Biopsy of the liver lesions by laparoscopy confirmed them as metastases so he was referred for chemotherapy.One month later he developed increasing epigastric pain and vomiting. CT scan showed duodenal obstruction secondary to local tumor growth. An expanding metal stent was inserted via endoscopy and the vomiting stopped the next day. X-ray confirmed good position of the duodenal stent and since he was tolerating fluids he was discharged home the next day.Fatigue, weakness and p...

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“…Identifying patients early as candidates for neoadjuvant treatments is important because they may increase the probability of having negative surgical margins and reduce the number of micrometastases [14]. The European Society of Gastrointestinal Endoscopy recommends preoperative biliary drainage for patients with potentially resectable obstructive biliary malignancy who are candidates for neoadjuvant therapies, in those with acute cholangitis, or in patients with intense pruritus in which surgery has been delayed for other reasons [15]. Regarding the type of stent, it is preferable to use SEMS in patients who are candidates for neoadjuvant therapies, since plastic stents are more prone to complications.…”

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confidence: 99%

To Drain or Not to Drain? That Is the Question

Costamagna

Boškoski

2013

Dig Dis Sci

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The paper by Siddiqui et al. [1] reports on a retrospective, multicenter study of self-expandable metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline resectable carcinoma of the pancreatic head. Two-hundred and forty-one patients (resectable 174, borderline resectable 67) were evaluated. The primary outcome was the effectiveness of SEMS for adequate biliary decompression; secondary outcomes were safety of SEMS in preoperative patients and patency rates and long-term clinical outcomes. Patients with T4 disease were also included because some studies have reported that neoadjuvant therapy downstages tumors, enabling safe tumor margin-negative resection [2][3][4]. The overall survival was 49 % at 27 months. The authors concluded that SEMS should be considered for patients with resectable or borderline resectable pancreatic cancer with the initial finding of obstructive jaundice, particularly if neoadjuvant therapy is planned. Although retrospective, this study is unique because it shows that SEMS are safe and effective in achieving durable biliary drainage in patients with pancreatic cancer receiving neoadjuvant therapy.In patients who are candidates for neoadjuvant therapy, initial biliary drainage is advisable since neoadjuvant therapy can take up to several months to accomplish prior to surgery [5]. Biliary drainage before neoadjuvant therapy gives symptomatic relief, reduces the risk of cholangitis due to chemotherapy-related immunosuppression (although cholangitis is rare in malignant biliary obstruction in patients with an intact papilla), prevents coagulopathy, and normalizes liver function tests. Biliary drainage might not be necessary if patients are candidates for early surgery, and, in contrast, in some cases might even be harmful. Preoperative biliary drainage with plastic stents is associated with a higher rate of complications than in non-stented subjects [6]. Cholangitis in stented patients can delay surgery due to interruptions in therapy, increasing the probability of disease progression.In the last two decades, SEMS, in comparison with plastic stents, have been inserted more frequently for benign and malignant biliary strictures. SEMS are superior to plastic stents due to their larger diameter, facilitating preoperative biliary decompression, coupled with a lower incidence of complications such as cholangitis [7,8], but are much more expensive, limiting their use. However, plastic stents can be placed without the need for a tissue diagnosis, and are inexpensive. Nevertheless, placing a metal stent during the first drainage is advantageous over plastic since the drainage is more effective and durable, obviating the need for exchange in the case of nonresectability. It is our practice to obtain tissue when placing SEMS either by brushing, biopsies, or endoscopic ultrasound-guided fine needle aspiration.In a recent prospective study by Aadam et al. [9], SEMS were placed in 55 patients with resectable and borderline resectable pancreatic head adenocarc...

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Biliary stenting: Indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline

Cited by 500 publications

References 158 publications

Evolution of surgical techniques for a progressive risk reduction

Evolution of surgical techniques for a progressive risk reduction

Complications from Stents and Lack of Conversations

To Drain or Not to Drain? That Is the Question

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