Endoscopic inside stent placement is suitable as a bridging treatment for preoperative biliary tract cancer

Abstract

BackgroundEndoscopic biliary stenting (EBS) is one of the most important palliative treatments for biliary tract cancer. However, reflux cholangitis arising from bacterial adherence to the inner wall of the stent must be avoided. We evaluated the use of EBS above the sphincter of Oddi to determine whether reflux cholangitis could be prevented in preoperative cases.MethodsFifty-seven patients with primary biliary tract cancer were retrospectively recruited for the evaluation of stent placement either above (n = 25; inside stent group) or across (n = 32; conventional stent group) the sphincter of Oddi. We compared the stent patency periods prior to the time of surgical resection.ResultsThe preoperative periods were 96.3 days in the conventional stent group and 96.8 days in the inside stent group (P = 0.979). Obstructive jaundice and/or acute cholangitis occurred in 7 patients (28.0%) in the inside stent group and in 15 patients (46.9%) in the conventional stent group during the preoperative period (P = 0.150). The average patency periods of the stents were 85.2 days (range, 13–387 days) for the inside stent group and 49.1 days (range, 9–136 days) for the conventional stent group (log-rank test: P = 0.009). The mean numbers of re-interventions because of stent occlusion were 0.32 for the inside stent group and 1.03 for the conventional stent group (P = 0.026). Post-endoscopic retrograde cholangiopancreatography complications occurred in 2 patients in the inside stent group and 4 patients in the conventional stent group (P = 0.516). Postoperative liver abscess occurred in 1 patient in the inside stent group and 5 patients in the conventional stent group (P = 0.968). Inside stent placement was the only significant preventative factor associated with stent obstruction based on univariate (hazard ratio [HR], 0.286; 95% confidence interval [CI], 0.114-0.719; P = 0.008) and multivariate (HR, 0.292; 95% CI, 0.114-0.750; P = 0.011) analyses.ConclusionTemporary plastic stent placement above the sphincter of Oddi is a better bridging treatment than conventional stent placement in preoperative primary biliary tract cancer.

Stent placement above the sphincter of Oddi permits implementation of neoadjuvant chemotherapy in patients with initially unresectable Klatskin tumor

“…However, it was possible that undrained areas of cholangitis developed if we conducted drainage for additional lobes for the control of cholangitis during NAC. The time of emergency endoscopic retrograde cholangiopancreatography (ERCP) was indicated when a patient developed acute cholangitis or jaundice because of a drained/undrained hepatic lobe after stent placement 16 . The stent patency period was determined by the interval between stent placement and occlusion or the day of the surgery.…”

Modified non‐flared fully covered self‐expandable metal stent versus plastic stent for preoperative biliary drainage in patients with resectable malignant biliary obstruction

“…We performed intraductal placement in more than half of the M‐FCSEMS patients to abate difficulties during surgery and stent‐related perioperative AEs by minimizing duodenobiliary reflux, PEP, and unnecessary covering of the bile duct. Thus, Japanese randomized controlled trial proposed that suprapapillary stent for PBD might be useful than transpapillary placement due to lower incidence of cholangitis and longer duration of stent patency, even inside PS . We thought that intraductal placement of the M‐FCSEMS would prolong the time to stent occlusion by minimizing of duodenobiliary reflux, like an inside PS.…”

“…Thus, Japanese randomized controlled trial proposed that suprapapillary stent for PBD might be useful than transpapillary placement due to lower incidence of cholangitis and longer duration of stent patency, even inside PS. 21 We thought that intraductal placement of the M-FCSEMS would prolong the time to stent occlusion by minimizing of duodenobiliary reflux, like an inside PS. Suprapapillary PS placement with some modifications of the PS design such as adding lasso may help to minimize the risk of duodenobiliary reflux and PEP, like the M-FCSEMS.…”

Intraductal placement of a fully covered metal stent with a long string for distal malignant biliary obstruction without endoscopic sphincterotomy: Prospective multi‐center feasibility study

“…Another approach to improve stent patency for MBO treatment is intraductal placement. 8,10,[21][22][23] In theory, positioning the distal end of the stent in the bile duct may reduce duodenobiliary reflux; however, placing the stent in this location may make it difficult to remove. Recent studies on modified plastic stents with a long string demonstrated a lower incidence of cholangitis with longer patency and easy removal using the string.…”

“…Recent studies on modified plastic stents with a long string demonstrated a lower incidence of cholangitis with longer patency and easy removal using the string. 22,23 Although robust evidence demonstrating the efficacy of intraductal placement of a covered SEMS is lacking, a prospective study of intraductal placement of a saddle-shaped covered SEMS with a long lasso has recently been reported. 21 The study showed durable stent patency (mean, 297 days), and removal at reintervention was successful in 87.5% of cases; however, the sludge formation rate was relatively high.…”