Combined side‐by‐side and stent‐in‐stent method for triple metal stenting in patients with malignant hilar biliary obstruction

Abstract

Background and Aim Endoscopic placement of three branched self‐expandable metallic stents (SEMS) for high‐grade malignant hilar biliary obstruction (MHBO) is technically challenging. We examined the feasibility and efficacy of a novel stenting method combining side‐by‐side and stent‐in‐stent (SBSIS) placement for MHBO. Methods Between January 2015 and December 2018, 27 consecutive patients with high‐grade MHBO underwent SBSIS placement. We evaluated the technical success, functional success, recurrent biliary obstruction (RBO), adverse events other than RBO, and reintervention success rates associated with SBSIS placement. Results Technical success rate was 85% (23/27). Insertion of the third SEMS failed in four patients, and median diameter of the common bile duct (CBD) was significantly smaller in patients in whom technical failure occurred (5 mm vs 8 mm; P = 0.004). Functional success was achieved in all patients in whom the procedure was a technical success. Rate of adverse events other than RBO was 15% (4/27). RBO rate was 43% (10/23), and median time to RBO was 157 days. Success rate of endoscopic reintervention for RBO was 89% (8/9). Conclusion SBSIS placement showed favorable results and is a promising option in patients with high‐grade MHBO requiring triple metal stenting. However, it might be preferable to avoid SBSIS in patients with a narrow CBD. Clinical Trial Registry: UMIN000035721

Biliary stenting for hilar malignant biliary obstruction

“…Also, bilateral drainage is more physiologically sound than unilateral drainage. Various bilateral drainage techniques and SEMS that facilitate bilateral deployment are available . Nonetheless, multiple metal stenting for bilateral or multi‐sectoral drainage is still technically difficult.…”

Modified combined stent‐by‐stent and stent‐in‐stent method for tri‐sectoral metal stenting in patients with malignant hilar biliary obstruction

“…It has recently been reported that combined simultaneous stent‐by‐stent (SBS) and stent‐in‐stent (SIS) method (SBSIS) can reduce the technical difficulty of tri‐sectoral metal stenting for high‐grade malignant hilar biliary obstruction (MHBO) 1–4 . However, inserting a third metal stent (MS) remains challenging 4 .…”

“…It has recently been reported that combined simultaneous stent‐by‐stent (SBS) and stent‐in‐stent (SIS) method (SBSIS) can reduce the technical difficulty of tri‐sectoral metal stenting for high‐grade malignant hilar biliary obstruction (MHBO) 1–4 . However, inserting a third metal stent (MS) remains challenging 4 . More recently, simultaneous triple SBS placement using ultra‐thin delivery systems has helped avoid failures of the third MS insertion, but this technique cannot be performed for non‐large‐diameter common bile ducts 5 .…”

Side‐by‐side placement of four fully covered self‐expandable metal stents for malignant hilar biliary obstruction

“…Multiple stent deployments are often needed, and plastic stents (PS) or uncovered self‐expandable metal stents (SEMS) are commonly used. However, a recent study showed that the efficiency of the use of PS for HMBO was inferior to that of SEMS 1 . Additionally, the uncovered SEMS has the disadvantage of being non‐removable, precluding re‐interventions.…”