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Su1623 Endoscopic Bilateral Stent-in-Stent Placement for Malignant Hilar Obstruction Using a Large Cell Type Stent
Abstracts Table 1. Characteristics and outcomes of FCSEMS in BBS
Diagnosis - Post transplant - Post cholecystectomy - Ischemic Oriental cholangitis - Chronic pancreatitis - Stricture with stone(s) - Other Bismuth - I - II - III - IV Duration (days) Success rate Migration rate - Total - With stent lock - Without stent lock
Hilar (N[10)
Non-Hilar (N [ 9)
P-value
2322001
2100222
NA
0118 135 60% 50% 0/3 (0%) 5/7 (71.4%)
9000 102 100% 44.4%
NA 0.627 0.033 0.809 0.038*
*between with and without stent lock
Su1623 Endoscopic Bilateral Stent-in-Stent Placement for Malignant Hilar Obstruction Using a Large Cell Type Stent Jin Myung Park*, Sang Hyub Lee, Kwang Hyun Chung, Jae MIN Lee, Ji Kon Ryu, Yong-Tae Kim Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea Background and Aims: Biliary self-expandable metal stent (SEMS) insertion is effective for palliation of unresectable malignant hilar obstruction. But bilateral stent-instent placement may be technically challenging. We performed this study to assess the technical success and clinical effectiveness of this technique with Niti-S large cell D-type biliary stent (LCD stent, Taewoong). Patients and Methods: The patients who underwent bilateral stent-in-stent placement using LCD stent were retrospectively reviewed in Seoul National College of Medicine. All patients showed malignant hilar obstruction (Bismuth type II, III, IV). Only procedures done by one endoscopist were analyzed to reduce the influence of inter-endoscopist difference. Results: Bilateral stent-in-stent placement was attempted in 33 patients between December 2011 and July 2013. Mean age was 66 years, and 18 patients were male. Most patients were diagnosed as hilar cholangiocarcinoma (21/33, 63.6%), gallbladder cancer (8/ 33,24.2%), and the others (4/33, 12.2%) were metastasis cases. Technical success rate was 75.8% with LCD stent (25/33). The 1st stent insertion was successful in all cases, but the guidewire could not be inserted into the contralateral side via the mesh of the 1st stent in 2 cases. In 6 cases the 2nd stent could not be passed via the mesh of the 1st stent. Different types of stents could be advanced via the mesh of the 1st stent for 3 of them. Finally bilateral stent-in-stent placement was technically successful in 84.8% of patients (28/33). Functional success was achieved in 88.0% of patients who were technically successful cases with only LCD stent (22/25). Median stent patency was 277 days. Procedure related complication occurred in 30.3% (10/ 33). Conclustions: Bilateral stent-in-stent placement by using a large cell type SEMS is technically and clinically considerable for palliation of malignant hilar obstruction.
Su1624 Biliary Stenting for Benign and Malignant Hilar Biliary Obstruction Using Very Long Multi-Sidehole Soft Plastic Stents: a 5-Year Experience From a Single Center Tossapol Kerdsirichairat*, Rajeev Attam, Mustafa a. Arain, Martin L. Freeman University of Minnesota, Minneapolis, MN Background: Conventional polyethylene plastic stents are associated with high rates of occlusion, migration and cholangitis when used for hilar stenoses. Alternative stents which are very long, pliable, and have multiple sideholes are available for use in the pancreas, and may be well suited to hilar strictures. We report our experience using such stents for hilar strictures. Methods: JohlinÒ pancreatic wedge stents are soft stents made of PellethaneÒ, fenestrated with multiple large sideholes, 8.5 Fr and 10 Fr, up to 22 cm in length. 20cm stents were used for left hepatic duct, resulting in approximately half the stent above and half below the hilum; stents were trimmed to a shorter length for right anterior and posterior sectoral ducts. Patients undergoing stenting for benign and malignant hilar strictures between 1/2009-5/2013 using one or more JohlinÒ stents were included. Baseline parameters included age, gender, indication of initial stenting (malignant vs benign hilar and/or intrahepatic biliary obstruction), and presence of prior indwelling stenting. Procedural data analysis included size and length of stents used, average duration of stent placement, interval placement of other stents between JohlinÒ stents, stent migration, significant improvement of cholangiogram and biliary drainage, and complications. Results: One or more JohlinÒ stents were inserted in 261 ERCPs in 97 patients (pt)(8.5 Fr in 63 ERCPs / 10 Fr in 217 ERCPs). Stents were single in 140, multiple
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in 77. Strictures were benign in 59 pts (post liver transplant anastomotic stricture [25], ischemic stricture [12], primary sclerosing cholangitis [5], post cholecystectomy [4]). Strictures were malignant in 38 pt (cholangiocarcinoma [20], hepatocellular carcinoma [3 ], metastatic cancer [ 15]). Median stent length, duration, overall complications are shown in Table 1. Complications occurred in 10/261 (3.8%). Early complications (! 1 week) occurred in one pt (post-ERCP pancreatitis). Late complications (O 1 week) included stent occlusion causing cholangitis in 9 pt (median of 3 weeks, IQR 2-6 weeks). 95 of 97 (98%) pt had follow-up to evaluate for stent migration. No stent migration occurred after 252/261 ERCPs (96.5%); proximal migration into the bile duct occurred in 3/261 ERCPs (1.1%); partial distal migration into the lumen in 6 (2.3%) without clinical consequence. All were easily retrieved without complications. 39/97 deaths identified, of which 24/39 were from malignant obstruction at median of 8 weeks (IQR 3-22) after initial JohlinÒ stent. Conclusions: Use of JohlinÒ stents for long-term biliary stenting is a feasible and safe option for benign and malignant hilar biliary obstruction. Advantages of these stents appear to be related to extreme length and flexibility, large diameter, and presence of multiple large side-holes which minimize migration and occlusion.
Table 1. Stent size, length, duration, and complications of Johlinâ stent placement for hilar biliary obstruction Stent diameter Median stent length Median stent duration Complications 8.5 Fr (nZ63) 10 Fr (nZ217)
16 (12-20 cm) 18 (9-20 cm)
4 weeks (IQR3-7) 5 weeks (IQR 3-7)
1/63 (1.6%) 9/217 (4.1%)
Su1625 Y-Shaped Bilateral Self Expandable Metallic Stent Placement (Stent-in-Stent Technique) for Malignant Hilar Biliary Obstruction: Data From a Large Saries of Patients Treated in a Tertiary Referral Center Roberto Di Mitri*, Filippo Mocciaro, Sandro Sferrazza, Rosalba Orlando Gastroenterology and Endoscopy unit, ARNAS Civico-Di CristinaBenfratelli Hospital, Palermo, Italy Introduction: Malignant hilar strictures (MHS) are a clinical challenge. Self expandable metallic stents (SEMS) have proven more effective than plastic stents for palliation of MHS registering a high success rate. Aims and Methods: We report data from a large series of patients treated with the "stent-in-stent" technique. From Apr. 2009 to Nov. 2013 we prospectively treated 22 consecutive patients with unrespectable MHS performing endoscopic bilateral stent-in-stent deployment (Niti-S Biliary Y stent; TaeWoong, Seoul, Korea). The first uncovered SEMS, with a central wide-open mesh, was placed across the hilar stricture (if needed balloon dilation was performed), afterwards the guidewire was withdrawn slowly and was inserted under fluoroscopic guidance into the central wide-open mesh identified by radiopaque markers. The second uncovered SEMS was so placed through the central crossed mesh of the primary stent (Y-shaped configuration). Results: Ten male and 12 female were treated (mean age 64.915.7 years): 10 had a cholangiocarcinoma (46%), 6 a metastatic colon cancer (27%), 4 a metastatic pancreatic cancer (18%), 2 a hepatocarcinoma (9%). The types of MHS according to the Bismuth classification were II in 5 patients (23%), IIIa in 1 (4%), and IV in 16 (73%). The mean bilirubin level was 15.14.8 mg/dL. Technical success (outflow of contrast medium and/or bile through the stents) was achieved in all patients with a significant reduction in bilirubin levels (2.91.8 mg/dL); 54% [12/22] patients were treated with balloon dilation before stent placement. One patient experienced cholangitis as early complication (!30 days) while in 2, at 3 and 10 months respectively, SEMS ingrowth was observed (occlusion were managed with the insertion of a plastic stent or a new SEMS through the occluded stent). No SEMS migration or other complications were recorded. At the end of the follow-up (mean 7.43.3 months) 15 out of 22 patients (68%) died. Conclusions: Our experience confirms as endoscopic bilateral SEMS placement with stent-in-stent technique (Y-shaped configuration) is a feasible, effective, and safe procedure for palliation of unresectable MHS.
Su1626 Metal or Plastic Stent for Hilar Duct Obstruction in Unresectable Gallbladder Cancer? Dao-Jian Gao*, Bing Hu, Tian-Tian Wang, Jun Wu, Xin Ye, Xiao-Ming Yang Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China Background: Most of patients with gallbladder cancer(GC) presenting with jaundice are considered unresectable. Endoscopic endoprosthesis is the first-line palliative treatment. The metal stent is associated with a longer stent patency than plastic stent. However stent patency and patient survival may differ depending on the causative disease and type of stent. Previous reports regarding biliary stenting pooled various types of malignancy together. So far there are no data concerning
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB237
Diagnosis - Post transplant - Post cholecystectomy - Ischemic Oriental cholangitis - Chronic pancreatitis - Stricture with stone(s) - Other Bismuth - I - II - III - IV Duration (days) Success rate Migration rate - Total - With stent lock - Without stent lock
Hilar (N[10)
Non-Hilar (N [ 9)
P-value
2322001
2100222
NA
0118 135 60% 50% 0/3 (0%) 5/7 (71.4%)
9000 102 100% 44.4%
NA 0.627 0.033 0.809 0.038*
*between with and without stent lock
Su1623 Endoscopic Bilateral Stent-in-Stent Placement for Malignant Hilar Obstruction Using a Large Cell Type Stent Jin Myung Park*, Sang Hyub Lee, Kwang Hyun Chung, Jae MIN Lee, Ji Kon Ryu, Yong-Tae Kim Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea Background and Aims: Biliary self-expandable metal stent (SEMS) insertion is effective for palliation of unresectable malignant hilar obstruction. But bilateral stent-instent placement may be technically challenging. We performed this study to assess the technical success and clinical effectiveness of this technique with Niti-S large cell D-type biliary stent (LCD stent, Taewoong). Patients and Methods: The patients who underwent bilateral stent-in-stent placement using LCD stent were retrospectively reviewed in Seoul National College of Medicine. All patients showed malignant hilar obstruction (Bismuth type II, III, IV). Only procedures done by one endoscopist were analyzed to reduce the influence of inter-endoscopist difference. Results: Bilateral stent-in-stent placement was attempted in 33 patients between December 2011 and July 2013. Mean age was 66 years, and 18 patients were male. Most patients were diagnosed as hilar cholangiocarcinoma (21/33, 63.6%), gallbladder cancer (8/ 33,24.2%), and the others (4/33, 12.2%) were metastasis cases. Technical success rate was 75.8% with LCD stent (25/33). The 1st stent insertion was successful in all cases, but the guidewire could not be inserted into the contralateral side via the mesh of the 1st stent in 2 cases. In 6 cases the 2nd stent could not be passed via the mesh of the 1st stent. Different types of stents could be advanced via the mesh of the 1st stent for 3 of them. Finally bilateral stent-in-stent placement was technically successful in 84.8% of patients (28/33). Functional success was achieved in 88.0% of patients who were technically successful cases with only LCD stent (22/25). Median stent patency was 277 days. Procedure related complication occurred in 30.3% (10/ 33). Conclustions: Bilateral stent-in-stent placement by using a large cell type SEMS is technically and clinically considerable for palliation of malignant hilar obstruction.
Su1624 Biliary Stenting for Benign and Malignant Hilar Biliary Obstruction Using Very Long Multi-Sidehole Soft Plastic Stents: a 5-Year Experience From a Single Center Tossapol Kerdsirichairat*, Rajeev Attam, Mustafa a. Arain, Martin L. Freeman University of Minnesota, Minneapolis, MN Background: Conventional polyethylene plastic stents are associated with high rates of occlusion, migration and cholangitis when used for hilar stenoses. Alternative stents which are very long, pliable, and have multiple sideholes are available for use in the pancreas, and may be well suited to hilar strictures. We report our experience using such stents for hilar strictures. Methods: JohlinÒ pancreatic wedge stents are soft stents made of PellethaneÒ, fenestrated with multiple large sideholes, 8.5 Fr and 10 Fr, up to 22 cm in length. 20cm stents were used for left hepatic duct, resulting in approximately half the stent above and half below the hilum; stents were trimmed to a shorter length for right anterior and posterior sectoral ducts. Patients undergoing stenting for benign and malignant hilar strictures between 1/2009-5/2013 using one or more JohlinÒ stents were included. Baseline parameters included age, gender, indication of initial stenting (malignant vs benign hilar and/or intrahepatic biliary obstruction), and presence of prior indwelling stenting. Procedural data analysis included size and length of stents used, average duration of stent placement, interval placement of other stents between JohlinÒ stents, stent migration, significant improvement of cholangiogram and biliary drainage, and complications. Results: One or more JohlinÒ stents were inserted in 261 ERCPs in 97 patients (pt)(8.5 Fr in 63 ERCPs / 10 Fr in 217 ERCPs). Stents were single in 140, multiple
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in 77. Strictures were benign in 59 pts (post liver transplant anastomotic stricture [25], ischemic stricture [12], primary sclerosing cholangitis [5], post cholecystectomy [4]). Strictures were malignant in 38 pt (cholangiocarcinoma [20], hepatocellular carcinoma [3 ], metastatic cancer [ 15]). Median stent length, duration, overall complications are shown in Table 1. Complications occurred in 10/261 (3.8%). Early complications (! 1 week) occurred in one pt (post-ERCP pancreatitis). Late complications (O 1 week) included stent occlusion causing cholangitis in 9 pt (median of 3 weeks, IQR 2-6 weeks). 95 of 97 (98%) pt had follow-up to evaluate for stent migration. No stent migration occurred after 252/261 ERCPs (96.5%); proximal migration into the bile duct occurred in 3/261 ERCPs (1.1%); partial distal migration into the lumen in 6 (2.3%) without clinical consequence. All were easily retrieved without complications. 39/97 deaths identified, of which 24/39 were from malignant obstruction at median of 8 weeks (IQR 3-22) after initial JohlinÒ stent. Conclusions: Use of JohlinÒ stents for long-term biliary stenting is a feasible and safe option for benign and malignant hilar biliary obstruction. Advantages of these stents appear to be related to extreme length and flexibility, large diameter, and presence of multiple large side-holes which minimize migration and occlusion.
Table 1. Stent size, length, duration, and complications of Johlinâ stent placement for hilar biliary obstruction Stent diameter Median stent length Median stent duration Complications 8.5 Fr (nZ63) 10 Fr (nZ217)
16 (12-20 cm) 18 (9-20 cm)
4 weeks (IQR3-7) 5 weeks (IQR 3-7)
1/63 (1.6%) 9/217 (4.1%)
Su1625 Y-Shaped Bilateral Self Expandable Metallic Stent Placement (Stent-in-Stent Technique) for Malignant Hilar Biliary Obstruction: Data From a Large Saries of Patients Treated in a Tertiary Referral Center Roberto Di Mitri*, Filippo Mocciaro, Sandro Sferrazza, Rosalba Orlando Gastroenterology and Endoscopy unit, ARNAS Civico-Di CristinaBenfratelli Hospital, Palermo, Italy Introduction: Malignant hilar strictures (MHS) are a clinical challenge. Self expandable metallic stents (SEMS) have proven more effective than plastic stents for palliation of MHS registering a high success rate. Aims and Methods: We report data from a large series of patients treated with the "stent-in-stent" technique. From Apr. 2009 to Nov. 2013 we prospectively treated 22 consecutive patients with unrespectable MHS performing endoscopic bilateral stent-in-stent deployment (Niti-S Biliary Y stent; TaeWoong, Seoul, Korea). The first uncovered SEMS, with a central wide-open mesh, was placed across the hilar stricture (if needed balloon dilation was performed), afterwards the guidewire was withdrawn slowly and was inserted under fluoroscopic guidance into the central wide-open mesh identified by radiopaque markers. The second uncovered SEMS was so placed through the central crossed mesh of the primary stent (Y-shaped configuration). Results: Ten male and 12 female were treated (mean age 64.915.7 years): 10 had a cholangiocarcinoma (46%), 6 a metastatic colon cancer (27%), 4 a metastatic pancreatic cancer (18%), 2 a hepatocarcinoma (9%). The types of MHS according to the Bismuth classification were II in 5 patients (23%), IIIa in 1 (4%), and IV in 16 (73%). The mean bilirubin level was 15.14.8 mg/dL. Technical success (outflow of contrast medium and/or bile through the stents) was achieved in all patients with a significant reduction in bilirubin levels (2.91.8 mg/dL); 54% [12/22] patients were treated with balloon dilation before stent placement. One patient experienced cholangitis as early complication (!30 days) while in 2, at 3 and 10 months respectively, SEMS ingrowth was observed (occlusion were managed with the insertion of a plastic stent or a new SEMS through the occluded stent). No SEMS migration or other complications were recorded. At the end of the follow-up (mean 7.43.3 months) 15 out of 22 patients (68%) died. Conclusions: Our experience confirms as endoscopic bilateral SEMS placement with stent-in-stent technique (Y-shaped configuration) is a feasible, effective, and safe procedure for palliation of unresectable MHS.
Su1626 Metal or Plastic Stent for Hilar Duct Obstruction in Unresectable Gallbladder Cancer? Dao-Jian Gao*, Bing Hu, Tian-Tian Wang, Jun Wu, Xin Ye, Xiao-Ming Yang Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China Background: Most of patients with gallbladder cancer(GC) presenting with jaundice are considered unresectable. Endoscopic endoprosthesis is the first-line palliative treatment. The metal stent is associated with a longer stent patency than plastic stent. However stent patency and patient survival may differ depending on the causative disease and type of stent. Previous reports regarding biliary stenting pooled various types of malignancy together. So far there are no data concerning
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB237