Partially Covered Metal Stents May Not Prolong Stent Patency Compared to Uncovered Stents in Unresectable Malignant Distal Biliary Obstruction

( Jae Yun Kim ),( Gyu Bong Ko ),( Tae Hoon Lee ),( Sang-heum Park ),( Yun Nah Lee ),( Young Sin Cho ),( Yunho Jung ),( Il-kwun Chung ),( Hyun Jong Choi ),( Sang-woo Cha ),( Jong Ho Moon ),( Young Deok 대한간학회 2017 Gut and Liver Vol.11 No.3

Background/Aims: Controversy still exists regarding the benefits of covered self-expandable metal stents (SEMSs) compared to uncovered SEMSs. We aimed to compare the patency and stent-related adverse events of partially covered SEMSs (PC-SEMSs) and uncovered SEMSs in unresectable malignant distal biliary obstruction. Methods: A total of 134 patients who received a PC-SEMS or uncovered SEMS for palliation of unresectable malignant distal biliary obstruction were reviewed retrospectively. The main outcome measures were stent patency, stent-related adverse events, and overall survival. Results: The median stent patency was 118 days (range, 3 to 802 days) with PC-SEMSs and 105 days (range, 2 to 485 days) with uncovered SEMSs (p=0.718). The overall endoscopic revision rate due to stent dysfunction was 36.6% (26/71) with PC-SEMSs and 36.5% (23/63) with uncovered SEMSs (p=0.589). Tumor ingrowth was more frequent with uncovered SEMSs (4.2% vs 19.1%, p=0.013), but migration was more frequent with PC-SEMSs (11.2% vs 1.5%, p=0.04). The incidence of stent-related adverse events was 2.8% (2/71) with PC-SEMSs and 9.5% (6/63) with uncovered SEMSs (p=0.224). The median overall survival was 166 days with PC-SEMSs and 168 days with uncovered SEMSs (p=0.189). Conclusions: Compared to uncovered SEMSs, PC-SEMSs did not prolong stent patency in unresectable malignant distal biliary obstruction. Stent migration was more frequent with PC-SEMSs. However, tumor ingrowth was less frequent with PC-SEMSs compared to uncovered SEMSs. (Gut Liver 2017;11:440-446)

담관 협착 치료를 위한 스텐트 삽입술

조영권,박상수,권동일,강성권 한국생체재료학회 2012 생체재료학회지 Vol.16 No.3

Stenting is the most common palliative treatment for patients suffering from either benign or malignant biliary strictures. First introduced in late 1970s, polymeric tube stent has been the most common stent but has had a problem of stent obstruction with sludge within 3-4 months. Self-expandable metallic stent (SEMS), with much larger diameter, considerably prolonged the stent patency period in biliary stenting. SEMS, however, has its own problem of tissue ingrowth through the stent wire mesh and difficulty in repositioning or removal when it is necessary. Polymer-covered selfexpandable metallic stent (PC-SEMS) is widening its application scope, as it has both large lumen and protection from tissue ingrowth through the stent wire mesh. PC-SEMS, however, has yet to solve its own problem of dislocation. Various aspects of the three biliary stent types are discussed in this paper.

Stepwise Algorithmic Approach to Endoscopic Removal of Biliary Partially Covered and Uncovered Self-Expanding Metal Stents

Deepanshu Jain,Assaf Stein,Muhammad K. Hasan 대한소화기내시경학회 2021 Clinical Endoscopy Vol.54 No.4

Self-expanding metal stents play a crucial role in the management of patients with biliary obstruction. Endoscopic extraction ofuncovered metal stents (UCMSs) and partially covered metal stents (PCMSs) could be challenging because of tissue ingrowth. Nostandardized technique can guarantee universal success. We present our technique and experience of endoscopic extraction of biliarystents in two patients with a UCMS and three patients with a PCMS. Three of the five patients had a previous failed attempt of stentextraction at an outside hospital. Overall, our composite success rate was 80% (4/5). The individual success rate was 100% (3/3) forPCMSs and 50% (1/2) for UCMSs. The stent-in-stent technique, in which a fully covered metal stent is placed through an existingUCMS/PCMS, was used in 60% (3/5) of the cases, with a success rate of 66.7% (2/3). We share our algorithmic approach to eachcase, with detailed emphasis on the technical aspects of the procedure.

Antireflux Metal Stent as a First-Line Metal Stent for Distal Malignant Biliary Obstruction: A Pilot Study

( Tsuyoshi Hamada ),( Hiroyuki Isayama ),( Yousuke Nakai ),( Osamu Togawa ),( Naminatsu Takahara ),( Rie Uchino ),( Suguru Mizuno ),( Dai Mohri ),( Hiroshi Yagioka ),( Hirofumi Kogure ),( Saburo Matsu 대한소화기학회 2017 Gut and Liver Vol.11 No.1

Background/Aims: In distal malignant biliary obstruction, an antireflux metal stent (ARMS) with a funnel-shaped valve is effective as a reintervention for metal stent occlusion caused by reflux. This study sought to evaluate the feasibility of this ARMS as a first-line metal stent. Methods: Patients with nonresectable distal malignant biliary obstruction were identified between April and December 2014 at three Japanese tertiary centers. We retrospectively evaluated recurrent biliary obstruction and adverse events after ARMS placement. Results: In total, 20 consecutive patients were included. The most common cause of biliary obstruction was pancreatic cancer (75%). Overall, recurrent biliary obstruction was observed in seven patients (35%), with a median time to recurrent biliary obstruction of 246 days (range, 11 to 246 days). Stent occlusion occurred in five patients (25%), the causes of which were sludge and food impaction in three and two patients, respectively. Stent migration occurred in two patients (10%). The rate of adverse events associated with ARMS was 25%: pancreatitis occurred in three patients, cholecystitis in one and liver abscess in one. No patients experienced nonocclusion cholangitis. Conclusions: The ARMS as a first-line biliary drainage procedure was feasible. Because the ARMS did not fully prevent stent dysfunction due to reflux, further investigation is warranted. (Gut Liver 2017;11:142-148)

양성 간외 담관 협착에서 완전 피막형 자가팽창성 금속 스텐트의 유용성과 안전성

김병욱,구자충,조영심,한정호,윤순만,채희복,박선미,윤세진,유봉규 대한소화기내시경학회 2011 Clinical Endoscopy Vol.42 No.1

Background/Aims: For the endoscopic treatment of benign biliary strictures (BBS), it has been a drawback to use plastic stents or uncovered self-expandable metal stents. We investigated the efficacy and safety of temporary placing fully covered self-expandable metal stents (FCSEMS) in BBS. Methods: We enrolled 12 cases that followed up more than 6 months after insertion of a FCSEMS in BBS via ERCP. The cohort consisted of 9 patients with recurrent cholangitis, 2 patients with postcholecystectomy and 1 patient with chronic pancreatitis. The efficacy was assessed according to the resolution of strictures and also the restricture after stent removal, and the safety was evaluated according to the complications associated with stent placement. Finally, the removability of FCSEMSs was assessed. Results: The median time of FCSEMS placement was 6.0 months. Resolution of the BBS was confirmed in 8 cases (67%) after a median post-removal follow-up of 8.5 months. Restricture after stent removal happened in 4 cases (33%). The complications were severe abdominal pain (n=2), pancreatic abscess (n=1) and stent migration (n=6). In 7 cases, all the FCSEMSs were successfully removed by grasping them with forceps. Conclusions: Temporary placement of a FCSEMS in BBS showed good therapeutic effects, relative safety and easy removability. Further evaluation is needed for determining the causes of restricture and for developing a new stent with antimigration features. 목적: 플라스틱 스텐트는 내경이 제한되어 있어 양성 담관 협착의 치료로 널리 이용하기에는 어려운 점이 있다. 저자들은 양성 담관 협착에서 완전 피막형 자가팽창성 금속 스텐트(fully covered self-expandable metal stent, FCSEMS)의 유용성과 안전성을 알아보고자 하였다. 대상 및 방법: 양성 담관 협착으로 FCSEMS를 삽입한 후 6개월 이상 추적한 12예(남:여=4:8, 평균나이 67세)를 대상으로 하였다. 담관 협착 12예(재발성 담관염 9예, 담낭절제술 후 손상 2예, 만성 췌장염 1예)에서 내시경 역행성 담췌관조영술로 각각 1개의 FCSEMS를 유두부를 관통하여 삽입하였다. 스텐트 유치와 관련된 합병증을 조사하여 안정성을 평가하였고, 협착 해소 여부와 스텐트 제거 후 재협착으로 스텐트의 효능을 평가하였으며, 스텐트의 제거 용이성을 조사하였다. 결과: 담관 협착이 있었던 12예는 모두 시술 당일부터 증상이 완화되었다. FCSEMS는 6.0개월(중앙값)간 유치하였으며, 스텐트 제거 후 8.5개월(중앙값)에 8명은 지속적으로 협착 증상이 해소되었고 4명은 스텐트 제거 후 재협착이 발생하였다. 스텐트 유치와 관련한 합병증은 심한 복통 2예, 췌장농양 1예, 스텐트 이탈 6예(십이지장 이탈 5예, 근위부 담관 이탈 1예)였다. 스텐트를 제거를 시도한 7예 모두 겸자로 쉽게 제거하였다. 결론: 양성 담관 협착에서 FCSEMS는 치료 효과가 신속하고 안전하며 쉽게 제거할 수 있는 장점이 있다. 그러나, 스텐트 제거 후 재협착의 빈도가 높고 이탈율이 높은 점은 향후 해결해야 할 과제로 생각한다.

A prospective study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures

Bhavik Bharat Shah,Gajanan Ashokrao Rodge,Usha Goenka,Shivaraj Afzalpurkar,Mahesh Kumar Goenka 대한소화기내시경학회 2022 Clinical Endoscopy Vol.55 No.6

Background/Aims: Fully covered self-expanding metal stents (FCSEMSs) are a relatively novel option for treating painful main pan-creatic duct refractory strictures in patients with chronic pancreatitis. Herein, we aimed to assess the efficacy, feasibility, and safety ofFCSEMSs in this patient group. Methods: This prospective single-center study included patients who underwent endoscopic retrograde pancreatography withFCSEMS placement. The primary endpoints were the technical and clinical success rates. A reduction in visual analog scale pain scoreof >50% compared with that before stent placement was defined as clinical success. Secondary endpoints were resolution of pancreaticstrictures on fluoroscopy during endoscopic retrograde pancreatography and the development of stent-related adverse events. Results: Thirty-six patients were included in the analysis. The technical success rate was 100% (n=36) and the clinical success rate was86.1% (n=31). There was a significant increase in stricture diameter from 1.7 mm to 3.5 mm (p<0.001) after stent removal. The meanvisual analog scale pain score showed statistically significant improvement. At 19 months of follow-up, 55.6% of the patients were as-ymptomatic. Stent migration (16.7%), intolerable abdominal pain (8.3%), development of de novo strictures (8.3%), and mild pancre-atitis (2.8%) were the most common adverse events. Conclusions: FCSEMS placement showed good technical and clinical success rates for achieving pain relief in patients with refractorymain pancreatic duct strictures.

Impact of sarcopenia on biliary drainage during neoadjuvant therapy for pancreatic cancer

Kunio Kataoka,Eizaburo Ohno,Takuya Ishikawa,Kentaro Yamao,Yasuyuki Mizutani,Tadashi Iida,Hideki Takami,Osamu Maeda,Junpei Yamaguchi,Yukihiro Yokoyama,Tomoki Ebata,Yasuhiro Kodera,Hiroki Kawashima 대한소화기내시경학회 2024 Clinical Endoscopy Vol.57 No.1

Background/Aims: Since the usefulness of neoadjuvant chemo(radiation) therapy (NAT) for pancreatic cancer has been demonstrated, recurrent biliary obstruction (RBO) in patients with pancreatic cancer with a fully covered self-expandable metal stent (FCSEMS) during NAT is expected to increase. This study investigated the impact of sarcopenia on RBO in this setting. Methods: Patients were divided into normal and low skeletal muscle index (SMI) groups and retrospectively analyzed. Patient characteristics, overall survival, time to RBO (TRBO), stent-related adverse events, and postoperative complications were compared between the two groups. A Cox proportional hazard model was used to identify the risk factors for short TRBO. Results: A few significant differences were observed in patient characteristics, overall survival, stent-related adverse events, and postoperative complications between 38 patients in the normal SMI group and 17 in the low SMI group. The median TRBO was not reached in the normal SMI group and was 112 days in the low SMI group (p=0.004). In multivariate analysis, low SMI was the only risk factor for short TRBO, with a hazard ratio of 5.707 (95% confidence interval, 1.148–28.381; p=0.033). Conclusions: Sarcopenia was identified as an independent risk factor for RBO in patients with pancreatic cancer with FCSEMS during NAT.

Management of Benign and Malignant Pancreatic Duct Strictures

Enad Dawod,Michel Kahaleh 대한소화기내시경학회 2018 Clinical Endoscopy Vol.51 No.2

The diagnosis and management of pancreatic strictures, whether malignant or benign, remain challenging. The last 2 decades haveseen dramatic progress in terms of both advanced imaging and endoscopic therapy. While plastic stents remain the cornerstone of thetreatment of benign strictures, the advent of fully covered metal stents has initiated a new wave of interest in calibrating the pancreaticduct with fewer sessions. In malignant disease, palliation remains the priority and further data are necessary before offering systematicpancreatic stenting.

A Case of Spontaneous Esophagopleural Fistula Successfully Treated by Endoscopic Stent Insertion

강구흠,윤범용,김범희,문희석,정현용,성재규,Eaum Seok Lee 대한소화기내시경학회 2013 Clinical Endoscopy Vol.46 No.1

The most common cause of esophagorespiratory fistulas (ERFs) is associated with malignancy. The use of self-expandable metal stents is effective for the treatment of malignant ERFs, but benign ERF is rare, which is why its optimal treatment is not defined yet. There have been few reports describing benign esophagopleural fistula and its treatments in South Korea. Here, we report a rare case of spontaneous esophagopleural fistula, which was successfully treated by endoscopic placement of a membrane covered metal stent.

A Prospective Randomized Comparison of a Covered Metallic Ureteral Stent and a Double-J Stent for Malignant Ureteral Obstruction

김종우,Bumsik Hong,신지훈,Jihong Park,김진형,권동일,Min-Hee Ryu,Baek-Yeol Ryoo 대한영상의학회 2018 Korean Journal of Radiology Vol.19 No.4

Objective: To compare the safety and efficacy between a covered metallic ureteral stent (CMS) and a double-J ureteral stent (DJS) for the treatment of a malignant ureteral obstruction (MUO). Materials and Methods: Nineteen patients (seven men and 12 women; mean age, 53.4 years) were randomly assigned to the CMS (n = 10) or DJS (n = 9) group. The following were compared between the two groups: technical success, i.e., successful stent placement into desired locations; stent malfunction; stent patency, i.e., no obstruction and no additional intervention; complications; and patient survival. Results: The technical success rate was 100% in all 10 and 12 ureteral units in the CMS and DJS groups, respectively. During the mean follow-up period of 253.9 days (range, 63−655 days), stent malfunction was observed in 40.0% (4/10) and 66.7% (8/12) in the CMS and DJS groups, respectively. In the per-ureteral analysis, the median patency time was 239.0 days and 80.0 days in the CMS and DJS groups, respectively. The CMS group yielded higher patency rates compared with the DJS group at three months (90% vs. 35%) and at six months (57% vs. 21%). The overall patency rates were significantly higher in the CMS group (p = 0.041). Complications included the migration of two metallic stents in one patient in the CMS group, which were removed in a retrograde manner. The two patient groups did not differ significantly regarding their overall survival rates (p = 0.286). Conclusion: Covered metallic ureteral stent may be effective for MUO.