Percutaneous stent placement for malignant hilar biliary obstruction: side-by-side versus stent-in-stent technique

Abstract

Background: Currently, side-by-side (SBS) and stent-in-stent (SIS) are the two main techniques for stent deployment to treat hilar biliary obstructions. Previous studies comparing these two techniques are very limited, and thus, no consensus has been reached on which technique is better. The purpose of this study is to compare the clinical efficacy and safety of SBS and SIS deployment via a percutaneous approach for malignant hilar biliary obstruction. Methods: From July 2012 to April 2019, 65 patients with malignant hilar biliary obstruction who underwent bilateral stenting using either the SBS or SIS techniques were included in this study. Among them, 27 patients underwent SIS stent insertion (SIS group), and the remaining 38 patients underwent SBS stent insertion (SBS group). Technical success, improvement of jaundice, complications, duration of stent patency, and overall survival were evaluated. Results: Technical success was achieved in all patients in the two groups. The serum bilirubin level decreased more rapidly 1 week after the procedures in the SBS group than in the SIS group (P = 0.02). Although the total complication rate did not differ between the two groups, cholangitis was found to be more frequent in the SIS group (P = 0.04). The median stent patency was significantly longer in the SBS group (149 days) than in the SIS group (75 days; P = 0.02). The median overall survival did not significantly differ between the two groups (SBS vs. SIS, 155 days vs. 143 days; P > 0.05). Conclusions: Percutaneous transhepatic bilateral stenting using either the SBS or SIS technique is safe and effective in the management of malignant hilar biliary obstruction. However, SBS offers a quicker improvement of jaundice, a lower incidence of cholangitis after the procedure, and a longer stent patency period than SIS.

Endoscopic or percutaneous biliary drainage in hilar cholangiocarcinoma: When and how?

“…However, the left lobe, right anterior, or right posterior biliary tree should be selected based on pre-interventional CT or MRI imaging to ensure the best drainage. Atrophied liver secondary to longstanding biliary obstruction or portal vein thrombosis should be avoided[ 22 ].…”

“…Regarding their efficacy, one prospective ( n = 69) and one retrospective ( n = 64) study showed that SIS and SBS deployment seem to be similar in terms of clinical success, stent patency and adverse events[ 22 , 23 ] . In addition, a meta-analysis of four studies which included 158 patients in total revealed no significant differences with respect to the rates of successful placement ( P = 0.799), successful drainage ( P = 0.617), early complications ( P = 0.738), late complications ( P = 0.744) and stent occlusions ( P = 0.606)[ 24 ].…”

Side-by-side versus stent-in-stent bilateral stenting for malignant hilar biliary obstruction: a meta-analysis.

“…SBS technique involves parallel stenting using two stents [ 10 ], and SIS technique involves placing a second SEMS contralaterally through the first stent mesh [ 10 ]. Successful bilateral stent deployment in an appropriate position with the ability of contrast to readily flow through the stent and into the duodenum was used to define technical success [ 17 ]. Functional success is defined as at least a 30% reduction in total bilirubin within 2 weeks postoperatively, or 50% within 4 weeks [ 20 ].…”

“…Asia-Pacific Working Group recommended that biliary stent should drain more than 50% of the entire liver [ 7 ]. Therefore, bilateral stenting is preferred among a majority of researchers [ 11 – 17 ]. There are two commonly used bilateral stenting techniques, which include side-by-side (SBS) and stent-in-stent (SIS) strategies.…”

“…There are two commonly used bilateral stenting techniques, which include side-by-side (SBS) and stent-in-stent (SIS) strategies. However, few comparative studies of the two techniques have been performed and they have yielded inconsistent findings [ 11 – 17 ], making the relative superiority of these techniques uncertain [ 10 ]. Therefore, a meta-analysis should be performed to detect the comparative results between SBS and SIS techniques.…”