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Background: Endoscopic trisectoral metal stent (MS) placement for malignant hilar biliary obstruction (MHBO) poses technical challenges, although it may prolong survival and stent patency. Combined stent-by-stent and stent-in-stent (SBSIS) methods can reduce technical difficulty. This study aimed to examine the use of the SBSIS in patients with Bismuth type III or IV MHBO. Methods: This prospective pilot study enrolled 30 eligible patients between January 2020 and October 2022. The study outcomes included technical and clinical success, recurrent biliary obstruction (RBO), and adverse events (AE) besides RBO associated with SBSIS for MHBO. Results: The technical success rate was 93.3% (28/30 patients). Clinical success was achieved in all patients with technical success. The early and late AEs rates were 6.7% (2/30) and 7.1% (2/28), respectively. The incidence of RBO was 35.7% (10/28). RBO was treated with an endoscopic transpapillary approach in eight patients and an endoscopic ultrasound-guided transmural approach in two patients. The median time to RBO was 162 days, and the median overall survival was 148 days. Conclusions: This first prospective study investigating the SBSIS method demonstrated good technical feasibility with a low AE rate. Therefore, it can be considered a better option when contemplating trisectoral MS placement for high-grade MHBO. [ABSTRACT FROM AUTHOR]

Objectives: The placement of plastic stents (PS), including intraductal PS (IS), is useful in patients with unresectable malignant hilar biliary obstruction (UMHBO) because of patency and ease of endoscopic reintervention (ERI). However, the optimal stent replacement method for PS remains unclear. Methods: This retrospective study included 322 patients with UMHBO. Among them, 146 received PS placement as initial drainage (across‐the‐papilla PS [aPS], 54; IS, 92), whereas 75 required ERI. Eight bilateral aPS, 21 bilateral IS, and 17 bilateral self‐expandable metallic stent (SEMS) placements met the inclusion criteria. Rates of technical and clinical success, adverse events, recurrent biliary obstruction (RBO), time to RBO (TRBO), overall survival, and secondary ERI were compared. Results: There were no significant intergroup differences in rates of technical or clinical success, adverse events, RBO occurrence, or overall survival. The median TRBO was significantly shorter in the aPS group (47 days) than IS (91 days; P = 0.0196) and SEMS (143 days; P < 0.01) groups. Median TRBO did not differ significantly between the IS and SEMS groups (P = 0.44). On Cox multivariate analysis, the aPS group had the shortest stent patency (hazard ratio 2.67 [95% confidence interval 1.05–6.76], P = 0.038). For secondary ERI, the median endoscopic procedure time was significantly shorter in the IS (22 min) vs. SEMS (40 min) group (P = 0.034). Conclusions: Bilateral IS and SEMS placement featured prolonged patency after first ERI. Because bilateral IS placement is faster than SEMS placement and IS can be removed during secondary ERI, it may be a good option for first ERI. [ABSTRACT FROM AUTHOR]

Malignant hilar biliary obstruction (MHBO) can cause obstructive jaundice and/or cholangitis necessitating appropriate biliary drainage. Endoscopic biliary stenting is the first-choice treatment, especially in unresectable cases, owing to its minimally invasive nature and utility. However, the hilar region is complex because of the branching and curving of bile ducts, making strictures in this area more complicated. Therefore, MHBO stenting is challenging, and treatment strategies have yet to be established. Furthermore, recent advances in antitumor therapies have altered the background surrounding the development of stenting strategies. Therefore, it is necessary to understand and grasp the current evidence well and to accumulate additional evidence reflecting the current situation. This study reviews the current status, issues, and prospects of endoscopic stenting for MHBO, especially in unresectable cases. [ABSTRACT FROM AUTHOR]

Objectives: For preoperative biliary drainage (PBD) of malignant hilar biliary obstruction (MHBO), current guidelines recommend endoscopic nasobiliary drainage (ENBD) due to the higher risk of cholangitis after endoscopic biliary stenting (EBS) during the waiting period before surgery. However, few studies have supported this finding. Therefore, we aimed to compare the outcomes of preoperative ENBD and EBS in patients with MHBO. Methods: Patients with MHBO who underwent laparotomy for radical surgery after ENBD or EBS were included from retrospectively collected data from 13 centers (January 2014 to December 2018). We performed a 1:1 propensity score matching between the ENBD and EBS groups. These patients were compared for the following: cholangitis and all adverse events (AEs) after endoscopic biliary drainage (EBD) until surgery, time to cholangitis development after EBD, postsurgical AEs, and in‐hospital death after surgery. Results: Of the 414 patients identified, 355 were analyzed in this study (226 for ENBD and 129 for EBS). The matched cohort included 63 patients from each group. The proportion of cholangitis after EBD was similar between the two groups (20.6% vs. 25.4%, P = 0.67), and no significant difference was observed in the time to cholangitis development. The proportions of surgical site infections, bile leaks, and in‐hospital mortality rates were similar between the groups. Conclusion: For PBD of MHBO, the proportion of AEs, including cholangitis, after EBD until surgery was similar when either ENBD or EBS was used. [ABSTRACT FROM AUTHOR]

Simple Summary: Biliary stenting is today the primary method of palliative and bridging treatment in patients with malignant hilar biliary obstructions. Systematization, collection and interpretation of the studies performed so far is necessary to form appropriate recommendations and guidelines for the management, selection of drainage methods, selection of appropriate types of stents, their quantity and possible additional methods of endoscopic treatment. Stent implantation is an effective approach for palliative treatment of Bismuth-Corlette type III–IV malignant hilar biliary obstructions (MHBOs). In this article, we reviewed the currently used access methods for biliary stent placement (percutaneous transhepatic biliary drainage, endoscopic biliary drainage, endosonography guided biliary drainage), the available stent types (plastic stent, self-expanding metallic stent, full cover self-expanding metallic stent, radioactive self-expanding metallic stent), major approaches (unilateral, bilateral) and deployment methods (stent-in-stent, stent-by-stent). Finally, this review gives an outlook on perspectives of development in stenting and other palliative methods in MHBO. [ABSTRACT FROM AUTHOR]

Objectives: Bilateral self-expandable metallic stent (SEMS) placement for unresectable malignant hilar biliary obstruction (UMHBO) is an effective option for biliary drainage with long-term stent patency. Laser-cut and braided SEMS can be used for bilateral SEMS placement. This study aimed to clarify any differences in the clinical features and proper use of the laser-cut and braided SEMS placement using the stent-in-stent method for UMHBO. Methods: In this study, 78 patients who underwent bilateral stent-in-stent SEMS placement for UMHBO were included. The patients were divided into the laser-cut (n = 33) and braided groups (n = 45). Both groups were compared for technical and clinical success, adverse events (AEs), time to recurrent biliary obstruction (TRBO), overall survival, and endoscopic reintervention (ERI). Results: There were no significant differences in technical and clinical success rates (laser-cut vs. braided group, 97% vs. 95.6%, P = 1.0), AEs (21.2% vs. 15.6%. P = 0.56), median TRBO (242 days vs. 140 days, P = 0.36), and median overall survival (654 days vs. 675 days, P = 0.58). ERI was required in 15 patients in the laser-cut group and in 20 patients in the braided group. The technical and clinical success rates of ERI (60% vs. 85%) were not significantly different (P = 0.13); however, the median ERI procedure time was significantly longer in the laser-cut group (38 min) than in the braided group (22 min; P = 0.02). Conclusion: No significant difference in initial SEMS placement was noted between the laser-cut and braided groups; however, the laser-cut group required a longer ERI procedure time than that required by the braided group. The use of braided SEMS may be a convenient option for ERI. [ABSTRACT FROM AUTHOR]

Abstract Purpose To explore clinical outcomes of percutaneous stent implantation using volumetric criteria for unresectable malignant hilar biliary obstruction (MHBO). Additionally, aimed to identify the predictors of patients' survival. Methods Seventy‐two patients who were initially diagnosed with MHBO between January 2013 to December 2019 in our center were retrospectively included. Patients were stratified according to the drainage achieved ≥50%,

Objectives The large-cell Niti-S stent is useful for multiple stenting in patients with malignant hilar biliary obstruction (MHBO). Recently, a novel uncovered self-expandable metallic stent (USEMS) (a Niti-S large-cell SR slim delivery system) was developed. In this study, we aimed to evaluate the efficacy of this USEMS slim delivery system in MHBO patients.Materials and methods Outcomes related to USEMS placement, the clinical course, and the period to recurrent biliary obstruction (RBO) were evaluated in MHBO patients who received multiple USEMSs with the Niti-S large-cell SR slim delivery system.Results Twenty-two MHBO patients underwent the placement of multiple USEMSs, including the novel slim-delivery stent. Six patients had a past history of upper gastrointestinal reconstruction (Billroth I: 1, Billroth II: 4, Roux-en-Y: 1). The number of USEMSs placed in each patient was 2-6. Three procedures were reinterventions. The new slim delivery system was placed as the first stent in ten patients and as an additional stent in the remaining patients. Seven patients were drained using only Niti-S large-cell SR slim delivery stents. The technical and clinical success rates were both 100%.Conclusions Placing multiple USEMSs in patients with a past history of abdominal surgery or in reintervention is difficult. Although difficult cases were included in this study, stent-in-stent placement with the novel Niti-S large-cell SR slim delivery system was useful in treating MHBO patients. In addition, this novel stent might be the first choice for MHBO patients.KEY MESSAGESEndoscopic multistenting for MHBO is challenging. In addition, reintervention or multistenting for MHBO patients with a past history of abdominal surgery becomes more difficult.The novel Niti-S large-cell SR slim delivery USEMS is useful as an additional stent because the delivery system is thin and suitable for a 0.025 guidewire. In addition, the novel stent is of the braided type and has a large mesh. Therefore, the novel stent is expected to have strong radial force and can be used as the first SEMS.The Niti-S large-cell SR slim delivery stent is long enough to be used in patients with upper gastrointestinal reconstruction. Although this study included patients with reintervention or a past history of upper gastrointestinal reconstruction, the technical success rate of multiple stenting for MHBO patients was 100%. The slim-delivery stent might overcome several difficulties of endoscopic multistenting.

Background: There is insufficient information regarding the optimal guidewire for managing malignant hilar biliary obstruction (MHBO). Therefore, a newly designed 0.025-inch guidewire was compared with the conventional 0.035-inch guidewire for selective cannulation of both intrahepatic ducts (IHDs) in patients with MHBO. Methods: Patients were randomly enrolled into the curved type newly designed 0.025-inch guidewire group (0.025 group) or the curved type conventional 0.035-inch guidewire group (0.035 group). The primary outcome was the selective cannulation rate of IHD. If the assigned guidewire failed to pass the stricture within 5 min, the crossover guidewire was selected. If the crossover guidewire failed to cross the stricture within the next 5 min, it was judged as a failed selective cannulation of both IHDs. Results: A total of 90 patients were enrolled (0.025 group, n = 47; 0.035 group, n = 43). There was no significant difference in baseline characteristics between the groups regarding sex, age, BMI, obstruction level, and clinical presentation. Four patients (8.5%) in the 0.025 group the cannulation of the IHD failed and the conventional 0.035-inch guidewire was substituted in a second attempt; the 0.035-inch guidewire failed to cross the stricture in all four patients. In the 0.035 group, eleven patients (25.6%) failed to achieve selective cannulation of IHD, and the 0.025-inch guidewire was substituted; the newly designed 0.025-inch guidewire crossed the stricture in ten of these (10/11, 90.9%). The selective cannulation rate of IHD was significantly higher in the 0.025 group (95.1% vs. 85.5%, p = 0.043). Conclusions: The 0.025 group exhibited a higher success rate for selective cannulation of both IHDs in MHBO than did the 0.035 group. [ABSTRACT FROM AUTHOR]

Purpose: To explore clinical outcomes of percutaneous stent implantation using volumetric criteria for unresectable malignant hilar biliary obstruction (MHBO). Additionally, aimed to identify the predictors of patients' survival. Methods: Seventy‐two patients who were initially diagnosed with MHBO between January 2013 to December 2019 in our center were retrospectively included. Patients were stratified according to the drainage achieved ≥50%, <50% of the total liver volume. Patients were divided into two groups: Group A (≥50% drainage), and Group B (<50% drainage). The main outcomes were evaluated in terms of relief of jaundice, effective drainage rate, and survival. Related factors that affect survival were analyzed. Results: 62.5% of the included patients reached effective biliary drainage. The successful drainage rate was significantly higher in Group B than in Group A (p < 0.001). The median overall survival (mOS) of included patients was 6.4 months. Patients who received drainage ≥50% of hepatic volume achieved longer mOS than those who received drainage <50% of hepatic volume (7.6 months vs. 3.9 months, respectively, p = 0. 011). Patients who received effective biliary drainage had longer mOS than those who received ineffective biliary drainage (10.8 months vs. 4.4 months, respectively, p < 0.001). Patients who received anticancer treatment had longer mOS than those who only received palliative therapy (8.7 months vs. 4.6 months, respectively, p = 0.014). In the multivariate analysis, KPS Score ≥ 80 (p = 0.037), ≥50% drainage achieved (p = 0.038), and effective biliary drainage (p = 0.036) were protective prognostic factors that affected patients' survival. Conclusion: Drainage achieved ≥50% of the total liver volume by percutaneous transhepatic biliary stenting seemed to have a higher effective drainage rate in MHBO patients. Effective biliary drainage may create chances for these patients to receive anticancer therapies that seem to provide survival benefits. [ABSTRACT FROM AUTHOR]

Background: There have been few reports of covered self-expandable metallic stent (SEMS) placement for malignant hilar-biliary obstruction (MHBO) because of risk of biliary branch obstruction. We studied feasibility and efficacy of 6-mm- diameter, slim, fully covered SEMS (SFCSEMS) in a relatively large cohort. Methods: We retrospectively evaluated SFCSEMS in unresectable MHBO from December 2016 to September 2021 in Juntendo University Hospital. Results: We enrolled consecutive 54 unresectable MHBO (18 bile duct, 11 gallbladder, eight pancreatic, two hepatocellular, and 15 metastatic cancer cases) including Bismuth-type II (n = 11), III (n = 17), and IV (n = 26), and placed two (n = 35) or three (n = 19) SFCSEMS. The technical and clinical success rate was 100% and 92.5%, respectively, with 76.3 min of mean procedure time. Recurrent biliary obstruction (RBO) was observed in 35.2% and the median cumulative time to RBO (TRBO) was 181 days. Other adverse events were 11.1% (four mildpancreatitis, one segmental-cholangitis, and one cholecystitis). There were no failed cases of stent exchange and second SFCSEMS (n = 6) showed significantly lower RBO (16.7% vs. 81.8%, P = .0364) and longer TRBO (undefined vs 86 days; P = .0617) than plastic stent (n = 11). Conclusions: Endoscopic placement of SFCSEMS for unresectable MHBO was effective and feasible with low incidence of segmental cholangitis, and exchange strategy of SFCSEMS was promising. [ABSTRACT FROM AUTHOR]

The large-cell Niti-S stent is useful for multiple stenting in patients with malignant hilar biliary obstruction (MHBO). Recently, a novel uncovered self-expandable metallic stent (USEMS) (a Niti-S large-cell SR slim delivery system) was developed. In this study, we aimed to evaluate the efficacy of this USEMS slim delivery system in MHBO patients. Outcomes related to USEMS placement, the clinical course, and the period to recurrent biliary obstruction (RBO) were evaluated in MHBO patients who received multiple USEMSs with the Niti-S large-cell SR slim delivery system. Twenty-two MHBO patients underwent the placement of multiple USEMSs, including the novel slim-delivery stent. Six patients had a past history of upper gastrointestinal reconstruction (Billroth I: 1, Billroth II: 4, Roux-en-Y: 1). The number of USEMSs placed in each patient was 2-6. Three procedures were reinterventions. The new slim delivery system was placed as the first stent in ten patients and as an additional stent in the remaining patients. Seven patients were drained using only Niti-S large-cell SR slim delivery stents. The technical and clinical success rates were both 100%. Placing multiple USEMSs in patients with a past history of abdominal surgery or in reintervention is difficult. Although difficult cases were included in this study, stent-in-stent placement with the novel Niti-S large-cell SR slim delivery system was useful in treating MHBO patients. In addition, this novel stent might be the first choice for MHBO patients. Endoscopic multistenting for MHBO is challenging. In addition, reintervention or multistenting for MHBO patients with a past history of abdominal surgery becomes more difficult. The novel Niti-S large-cell SR slim delivery USEMS is useful as an additional stent because the delivery system is thin and suitable for a 0.025 guidewire. In addition, the novel stent is of the braided type and has a large mesh. Therefore, the novel stent is expected to have strong radial force and can be used as the first SEMS. The Niti-S large-cell SR slim delivery stent is long enough to be used in patients with upper gastrointestinal reconstruction. Although this study included patients with reintervention or a past history of upper gastrointestinal reconstruction, the technical success rate of multiple stenting for MHBO patients was 100%. The slim-delivery stent might overcome several difficulties of endoscopic multistenting. [ABSTRACT FROM AUTHOR]

Background and Aim: Bilateral stent deployment for malignant biliary obstruction (MHBO) can be achieved using side‐by‐side (SBS) or stent‐in‐stent (SIS) procedures. Compared with SBS techniques, the procedural steps of SIS are technically complex due to the necessity of introducing the delivery system into a contralateral biliary tract through the mesh of the SEMS. To overcome this issue, a novel uncovered SEMS, the HILZO Moving Cell Stent (MCS) has been released. The present study examined the technical feasibility of treating MHBO using bilateral deployment of this novel stent without dilating the mesh of the first stent to achieve insertion of the second stent within a single session, using a prospective, multicenter setting. Method: The primary outcome in the present study was the technical success rate. Technical success was defined as deployment of bilateral MCSs into two or more biliary tracts using SIS without a dilation device in a single‐session. Results: A total of 27 patients with complications of MHBO were enrolled in this study. Bilateral SIS using two MCS was successfully performed in 23 patients without using dilation devices among 27 patients (initial technical success rate; 85.2%). Median time to recurrent biliary obstruction (TRBO) was 271 days. Stent dysfunction was observed in 12 patients (44.4%), and re‐intervention was successfully performed in all patients without one patient who instead received best supportive care. Conclusions: The SIS technique using MCS without dilation of the mesh may be technically feasible and safe. In addition, this may be useful for re‐intervention. Further comparative randomized trials are needed. [ABSTRACT FROM AUTHOR]

Background: In the case of an unresectable malignant hilar biliary obstruction (MHBO), the optimal drainage method has not yet been established. Recently, an 8 mm, fully covered, self-expandable metal stent (FCSEMS) with an ultra-slim introducer has become available. In this article, the results of whole-liver drainage tests using this novel FCSEMS for MHBO are reported. Methods: Unresectable MHBOs up to Bismuth IIIa with strictures limited to the secondary branches were eligible. The proximal end of the stent was placed in such a way as to avoid blocking the side branches, and the distal end was placed above the papilla when possible. Consecutive patients treated between April 2017 and January 2021 were retrospectively analyzed. The technical and functional success rates, rates and causes of recurrent biliary obstruction (RBO), time to RBO (TRBO), revision for RBO, and adverse events (AEs) were evaluated. Results: Eleven patients (Bismuth I/II/IIIa: 1/7/3) were enrolled. Two stents were placed in nine patients and three were placed in two patients. Both the technical and functional success rates were 100%. RBO occurred in four (36%) patients due to sludge formation. Revision was performed for three patients, with the successful removal of all stents. The median TRBO was 187 days, and no late AEs other than the RBO occurred. Regarding the distal position of the stent, the RBO rate was significantly lower (14.3% vs. 75%, p = 0.041) and the cumulative TRBO was significantly longer (median TRBO: not reached vs. 80 days, p = 0.031) in the case of the placement above the papilla than the placement across the papilla. Conclusion: For unresectable MHBOs of Bismuth I, II, and IIIa, whole-liver drainage with a novel 8 mm FCSEMS possessing an ultra-slim introducer was feasible and potentially safe, with favorable stent patency. Placement above the papilla might be preferrable to placement across the papilla. [ABSTRACT FROM AUTHOR]

Background: Stenting malignant hilar biliary obstruction (MHBO) is challenging due to its complex structure, and it is less effective than blockages in the distal bile duct area. Plastic stents (PSs) and metal stents (MSs) are commonly used for stenting MHBO. This study aims to compare the outcomes of PSs and MSs in MHBO patients., Methods: We conducted a search of medical databases up to March 2024. Using a fixed-effect model, we analyzed the risk ratios (RRs) of the outcomes between the PS and MS groups. We calculated the RR for clinical and technical success, reinterventions, and adverse events, as well as the hazard ratio (HR) for survival and stent patency., Results: This analysis includes five randomized controlled trials (RCTs) that met the inclusion criteria, comprising a total of 322 patients (156 in the PS group and 166 in the MS group). Significant differences (P < .05) in favor of the MS group were found in the reinterventions (RR 1.80, 95% CI 1.07-3.04), and stent patency (HR 0.54, 95% CI 0.32-0.90). There were no significant differences (P > 0.05) between the PS and MS groups regarding technical success (RR 1.01, 95% CI 0.94-1.09), clinical success (RR 0.86, 95% CI 0.69-1.07), overall survival (HR 0.71, 95% CI 0.47-1.05), stent migration (RR 0.69, 95% CI 0.08-6.02), stent occlusion (RR1.32, 95% CI 0.97-1.81), and adverse events (RR 0.80, 95% CI 0.53-1.20)., Conclusion: Both PS and MS are effective for managing MHBO, while MS offers greater efficacy in increased stent patency and lower reintervention rates. Key message What is already known on this topic Metal stents (MSs) and plastic stents (PSs) are used for palliative treatment of malignant hilar biliary obstruction (MHBO). MSs significantly reduced the need for reinterventions compared to PSs in patients with MHBO. What this study adds There were no significant differences between MSs and PSs in terms of technical success, clinical success, overall survival, stent migration, stent occlusion, or adverse events. How this study might affect research, practice, or policy The study's findings may prompt researchers to design more targeted studies to further investigate these specific outcomes in MHBO patients. The results encourage endoscopists to consider patient-specific factors, such as life expectancy and preference for minimizing recurrent procedures, when choosing between MSs and PSs for MHBO., (© The Author(s) 2024. Published by Oxford University Press on behalf of Fellowship of Postgraduate Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Abstract Background and aims Stent migration is one of the most common complications during the placement of multiple plastic biliary stents (MPBS) under endoscopy. This study aims to evaluate the feasibility and efficiency of the fishing line assisted (FLA) method for preventing the complication. Methods Patients with unresectable malignant hilar biliary obstruction (MHBO) who undergone endoscopic placement of MPBS using the FLA or conventional method from May 2018 to April 2021 in our center were enrolled in the study. The endpoints of this study were the stent migration rate, technical success rates, adverse events rates, times of stent migration, and the procedure time. Results FLA group (N = 19) and conventional group (N = 22) had similar baseline characteristics of the patients. The technical success rates (100% vs. 95.5%; P > 0.05), ERCP-related adverse events rates (5.3% vs. 4.5%; P > 0.05), and the stent-related adverse events rates (0% vs. 4.5%; P > 0.05) were no significant differences between the FLA and conventional groups. MPBS inserted using the conventional method consumed more time (median, 33.9 min vs. 15.6 min; P 0.05). Conclusions FLA method is an effective technique for MPBS implantation to prevent stent migration during endoscopic retrograde cholangiography (ERCP). The method should be applied to patients with unresectable MHBO who need to place MPBS.

Background and Aim: Endoscopic bilateral self‐expandable metallic stent (SEMS) placement for unresectable malignant hilar biliary obstruction (MHBO) is widely performed; however, re‐intervention after recurrent biliary obstruction (RBO) is often challenging. We compared stent‐in‐stent (SIS) and side‐by‐side (SBS) SEMS placement for MHBO considering re‐intervention for RBO. Methods: One hundred five consecutive patients with MHBO who underwent endoscopic bilateral SEMS placement in our hospital and its affiliated institutions were enrolled in this study; 75 patients underwent partial SIS deployment between December 2005 and December 2012; and 30 underwent SBS deployment between January 2013 and March 2019. Initial treatments and re‐interventions in each group were retrospectively evaluated. Results: Technical success rate (92% vs 100%, P = 0.179), procedure duration (46 vs 35 min, P = 0.382), functional success rate (97.1% vs 100%, P = 1.00), complication rate (24.6% vs 20.0%, P = 0.797), time to RBO (260 vs 312 days; Gray test, P = 0.815), and rate of RBO (59.4% vs 70.0%, P = 0.371) were not significantly different between the SIS and SBS groups. However, bilateral re‐stenting with plastic stents through SEMS was successful in 63.4% of patients in the SIS group compared with 100% of patients in the SBS group (P = 0.0013). Median time to RBO upon first re‐stenting with a plastic stent was 75 days (range, 11–195 days). Conclusions: Endoscopic re‐stenting after RBO was significantly more successful in the SBS group than in the SIS group. SBS method is suitable for MHBO considering revisionary stent placement. [ABSTRACT FROM AUTHOR]

Introduction: Preoperative endoscopic biliary drainage (PEBD) for malignant hilar biliary obstruction (MHBO) is widely accepted. Recent PEBD consists of endoscopic nasobiliary drainage (ENBD), conventional endoscopic biliary stenting (CEBS) with plastic stents across the papilla, and endoscopic biliary inside stenting (EBIS) with plastic stents above the papilla, while ENBD is the primary procedure in Asian countries. Thus, we aimed to compare the efficacy of ENBD with those of CEBS and EBIS as a means of PEBD for MHBO. Methods: We retrospectively identified patients with MHBO who underwent upfront surgery between January 2011 and December 2018 in a multicenter setting. The outcome measures were cumulative dysfunction of PEBD, risk factors for PEBD dysfunction, and adverse events. Results: We analyzed a total of 219 patients, comprising 163 males (74.4%); mean age, 69.7 (±7.6) years; Bismuth-Corlette (BC) classification I, II, IIIa, IIIb, and IV in 68, 49, 43, 30, and 29 patients, respectively; and diagnosis of hilar cholangiocarcinoma and gallbladder cancer in 188 and 31 patients, respectively. PEBD procedures were performed in 160 patients with ENBD, 31 patients with CEBS, and 28 patients with EBIS. PEBD dysfunction occurred in 58 patients (26.5%), and the cumulative dysfunction rates were not significantly different among PEBD methods (p = 0.60). Multivariate analysis showed that BC-IV was significantly associated with the occurrence of PEBD dysfunction (hazard ratio = 2.10, p = 0.02). The adverse event rates were not significantly different among PEBD groups (p = 0.70). Conclusion: ENBD as a means of PEBD for MHBO is comparable with CEBS and EBIS in rates of dysfunction and adverse events. [ABSTRACT FROM AUTHOR]

Background and Aims: Endoscopic biliary drainage (EBD) is essential for the management of malignant hilar biliary obstruction (MHBO). We prospectively evaluated the efficacy and safety of "inside-stent" therapy, where a plastic stent is placed above the sphincter of Oddi without endoscopic sphincterotomy, in patients with inoperable MHBO. Methods: This study was a multicenter, single-blinded, randomized controlled trial at three centers. Patients with inoperable MHBO were enrolled in this study, and randomly assigned to receive an inside-stent or conventional-stent therapy. The primary endpoint was cumulative stent patency of the initial stent. The secondary endpoints were second stent patency, technical and clinical success rate, adverse events, re-intervention rate, and overall patient survival. Results: Forty-three patients were randomly assigned to the inside-stent group (n = 21) or the conventional-stent group (n = 22). The median cumulative stent patency of the initial stent was 123 days in the inside-stent group and 51 days in the conventional-stent group (P =.031). For patients with the initial stent dysfunction in the conventional-stent group, the inside-stent was placed as a second stent, and its patency was significantly longer than that of the initial stent (P =.0001). The technical and clinical success rate, re-intervention rate, second stent patency, adverse events, and survival probability did not differ between the groups. Conclusions: Inside-stent therapy appears to be useful not only as an initial stent but also as a second stent for patients with inoperable MHBO. Trial registration number: UMIN000004587. [ABSTRACT FROM AUTHOR]

Abstract Biliary drainage for unresectable malignant hilar biliary obstruction (UMHBO) is still associated with a number of controversies to be resolved. The superiority of bilateral drainage in comparison to unilateral drainage has not been proven obviously yet. However, bilateral drainage is necessary to treat obstructive jaundice in some UMHBO patients, and this may be connected with preservation of the functional liver volume. The partial stent‐in‐stent (SIS) method and side‐by‐side (SBS) method developed as bilateral drainage methods. There is no significant difference in the technical or clinical success rates of the SIS and SBS methods. In addition, these methods are comparable in terms of adverse events, patency period, and survival period. On the other hand, reintervention for recurrent biliary obstruction (RBO) after the SBS method seems to be easier in comparison to cases with RBO after the SIS method; however, there is no remarkable difference in the clinical results of these procedures. Endoscopic ultrasound (EUS)‐guided biliary drainage also has become an option for patients with UMHBO. Left hepatic drainage using EUS‐guided hepaticogastrostomy (EUS‐HGS) has become common; however, few studies have reported the results of bridging drainage for the right lobe using the EUS‐HGS route or EUS‐guided hepaticojejunostomy. A few studies addressed the results of newly designed stents, such as the 6‐mm braided metal stent and inside stent. The development of various drainage methods and new devices is necessary for the further advancement of endoscopic biliary drainage for patients with UMHBO, further studies to evaluate those methods and devices are warranted.

Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) is still performed using two-dimensional (2D) X-ray images. The success rate and risk of complications are considered operator-dependent. We explored performing an ERCP-related procedure with 3D-computed tomography (CT) biliary imaging for preoperative simulation and intraoperative reference in a patient with malignant biliary obstruction. Case presentation The patient was a 66-year-old man who underwent rectal resection and postoperative chemotherapy for rectal cancer. A liver metastasis caused obstructive jaundice and acute cholangitis, necessitating emergency hospitalization. A 3.5 cm mass in the hilar region of the biliary tree caused type IV biliary obstruction according to the Bismuth-Corlette classification of hilar cholangiocarcinoma. ERCP and biliary drainage were performed repeatedly, but had no effect. Given that selective bile duct drainage had proven extremely difficult with the conventional procedures, three-dimensional (3D) images were created from preoperative CT image data using a 3D image reconstruction system (SYNAPSE VINCENT version 5, FUJIFILM Corporation, Tokyo, Japan). Using the 3D images for preoperative planning and intraoperative reference, biliary drainage and stent placement were successfully performed without complications. Postoperatively, the patient had no further cholangitis or need for stent replacement up to his death. Conclusions We report the first case of an ERCP-related procedure with 3D biliary imaging for preoperative simulation and intraoperative reference in a patient with malignant biliary obstruction. The 3D image reconstruction is useful for preoperative planning and could contribute to an increased success rate, decreased complications, a shorter operation time, and reduced radiation exposure to the operator.

Objectives: To evaluate the results of inside stent therapy for unresectable malignant hilar biliary obstruction and identify factors related to stent patency duration., Methods: Of 44 patients who underwent initial inside-stent placement above the sphincter of Oddi from April 2017 to December 2022, 42 with the resolution of jaundice (clinical success rate, 95.5%) were retrospectively analyzed. Univariate and multivariate logistic regression analysis identified factors associated with stent patency duration., Results: Univariate analysis revealed significant differences in the drainage method (406 days for unilateral drainage vs. 305 days for bilateral drainage of the right and left liver lobes, p = 0.022) with or without chemotherapy (406 days with vs. 154 days without, p = 0.038). Multivariate analysis (Cox proportional hazards analysis) revealed similar results, with unilateral drainage ( p = 0.031) and chemotherapy ( p = 0.048) identified as independent factors associated with prolonged stent patency. Early adverse events were observed in two patients (4.8%; one cholangitis, one pancreatitis)., Conclusions: Inside-stent therapy was safely performed in patients with malignant hilar biliary obstruction. Simple unilateral drainage and chemotherapy may prolong stent patency., Competing Interests: None., (© 2024 The Author(s). DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

This study aimed to assess clinical efficacy and long-term patient outcomes in individuals with malignant hilar biliary obstruction (MHBO) that had been treated via insertion of a stent with a radioactive seed strand (RSS). A total of 84 MHBO patients were treated via either normal stent insertion (n = 48) or stent with RSS insertion (n = 36) from January 2015 to December 2018. The technical success rates of normal stent insertion and stent with RSS insertion were 93.8% (45/48) and 97.2% (35/36), respectively (p =.632), with clinical success rates of 93.3% (42/45) and 100% (35/35), respectively (p =.252). In these two patient groups, 11 and seven patients, respectively, suffered from stent dysfunction (p =.637). In the normal and RSS groups, median stent patency was 165 and 225 days, respectively (p <.001). All patients in the present study died due to tumor progression, with median survival times of 188 and 250 days in the normal and RSS stent groups, respectively (p <.001). Relative to normal stent insertion, combined stent with RSS insertion can effectively prolong both stent patency and patient survival in patients with MHBO. [ABSTRACT FROM AUTHOR]

Background and Aims: Stent migration is one of the most common complications during the placement of multiple plastic biliary stents (MPBS) under endoscopy. This study aims to evaluate the feasibility and efficiency of the fishing line assisted (FLA) method for preventing the complication.Methods: Patients with unresectable malignant hilar biliary obstruction (MHBO) who undergone endoscopic placement of MPBS using the FLA or conventional method from May 2018 to April 2021 in our center were enrolled in the study. The endpoints of this study were the stent migration rate, technical success rates, adverse events rates, times of stent migration, and the procedure time.Results: FLA group (N = 19) and conventional group (N = 22) had similar baseline characteristics of the patients. The technical success rates (100% vs. 95.5%; P > 0.05), ERCP-related adverse events rates (5.3% vs. 4.5%; P > 0.05), and the stent-related adverse events rates (0% vs. 4.5%; P > 0.05) were no significant differences between the FLA and conventional groups. MPBS inserted using the conventional method consumed more time (median, 33.9 min vs. 15.6 min; P < 0.05) method and increased the times of stent migration (median, 3 times vs. 0 times; P < 0.05) than using the FLA method. Even if no statistical difference was detected in the stent migration rate between groups, this rate was lower in the FLA group than the conventional group (0% vs. 13.6%; P > 0.05).Conclusions: FLA method is an effective technique for MPBS implantation to prevent stent migration during endoscopic retrograde cholangiography (ERCP). The method should be applied to patients with unresectable MHBO who need to place MPBS. [ABSTRACT FROM AUTHOR]

Background: The recent development of ultra‐thin delivery systems, which enable simultaneous insertion of two metal stents, has encouraged wider adoption of side‐by‐side (SBS) stent placement for malignant hilar biliary obstruction (MHBO). However, the management of stent occlusion after SBS placement has not been well‐characterized. This study aimed to examine the outcomes of endoscopic reintervention (E‐RI) after SBS placement in patients with MHBO. Methods: Sixty‐seven patients who underwent E‐RI for stent occlusion after SBS placement between 2013 and 2020 at three tertiary‐care referral centers were investigated. We evaluated the technical success, clinical success, recurrent biliary obstruction (RBO), and adverse events other than RBO rates associated with E‐RI. Furthermore, the factors associated with successful E‐RI were also evaluated. Results: The technical success and clinical success rates were 79.1% (53/67) and 76.1% (51/67), respectively. Early adverse events other than RBO occurred in 4.5% (3/67) and late events in 3.9% (2/51). The RBO rate after E‐RI was 52.9% (27/51), and the median time to RBO after E‐RI was 85 days. Common bile duct (CBD) diameter (odds ratio 2.62; 95% confidence interval, 1.37–5.01; P = 0.003) and metastatic disease (odds ratio, 0.11; 95% confidence interval, 0.02–0.64; P = 0.015) were independently correlated with E‐RI success in the multivariate analysis. Conclusions: This study demonstrated that E‐RI after SBS placement is technically feasible and safe, but the success rate was significantly lower in patients with narrow CBDs and metastatic diseases. These factors may be useful for the selection of the initial stenting method. [ABSTRACT FROM AUTHOR]

The purpose of this study is to assess the relative clinical efficacy of treating malignant hilar biliary obstruction (MHBO) via percutaneous unilateral or bilateral metal stenting. Relevant articles up to December 2019 were identified within the Web of science, Pubmed, Embase, and Cochrane Library databases. Stent dysfunction served as the primary endpoint, while we assessed technical success, clinical success, early and late complication incidence, and overall survival as secondary outcomes. Pooled odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated for dichotomous variables. Hazard ratio (HR) with 95% CI were determined for overall survival. This meta-analysis included seven studies. Six studies were non-randomized controlled trials (RCTs) and one study was a RCT. A total of 888 MHBO patients underwent either percutaneous unilateral (n = 376) or bilateral (n = 512) metal stenting in these seven studies. We detected no significant differences in stent dysfunction rates (OR 0.97; 95% CI 0.67, 1.41, P = 0.89), technical success rates (OR 1.10; 95% CI 0.53, 2.29, P = 0.81), clinical success rates (OR 0.72; 95% CI 0.43, 1.22, P = 0.22), early complication rates (OR 0.82; 95% CI 0.34, 1.98, P = 0.66), late complication rates (OR 0.87; 95% CI 0.29, 2.63, P = 0.81), or overall survival (HR: 0.99; 95% CI 0.83, 1.17, P = 0.88) between unilateral and bilateral groups. Funnel plots demonstrated no obvious publication bias of these primary and secondary endpoints. From a clinical perspective, percutaneous unilateral and bilateral metal stenting are similarly effective for treatment of patients with MHBO. [ABSTRACT FROM AUTHOR]

Purpose: The present meta-analysis was designed to compare the relative clinical efficacy of unilateral and side-by-side metal stenting for the treatment of malignant hilar biliary obstruction (MHBO). Materials and Methods: The PubMed, Embase, and Cochrane Library databases were searched to identify all relevant studies published as of May 2020. This meta-analysis was conducted using RevMan v5.3, and relevant endpoint data pertaining to rates of technical and clinical success, overall survival, complications, and stent dysfunction were extracted from all studies. Results: In total, we identified seven relevant studies that were included in the present meta-analysis, with these studies including 683 total MHBO patients who were treated via either unilateral (n = 366) or side-by-side bilateral (n = 317) metal stenting. We observed no significant differences between these two groups with respect to technical success rates (odds ratio [OR]: 0.81; 95% confidence interval [CI]: 0.40-1.63, P = .56) or overall survival (hazard ratio: 1.03; 95% CI: 0.83-1.28, P = .79). However, the side-by-side group exhibited significantly higher clinical success (OR: 3.56; 95% CI: 1.62-7.82, P = .002) and stent patency (OR: 1.74; 95% CI: 1.16-2.61, P = .007) rates, whereas complication rates trended toward being lower in the unilateral group (OR: 0.51; 95% CI: 0.30-1.00, P = .05). No significant heterogeneity among included studies was detected for any of these endpoints. Conclusion: These results suggest that side-by-side metal stenting can yield better clinical success rates and a reduced incidence of stent dysfunction compared with unilateral stenting in MHBO patients. [ABSTRACT FROM AUTHOR]

Background: Few studies have focused on the risk factors for dysfunction of endoscopic biliary drainage (EBD) in preoperative patients with malignant hilar biliary obstruction (MHBO). Methods: We searched the database between February 2011 and December 2018 and identified patients with MHBO who underwent radical operation. The rate of dysfunction of the initial EBD, risk factors for dysfunction of the initial EBD and survival after surgery were retrospectively evaluated. Results: We analyzed a total of 131 patients [95 males (72.5%); mean age, 69.5 (±7.3) years; Bismuth‐Corlette classification (BC) I/II/IIIa/IIIb/IV, 50/26/22/17/16; hilar cholangiocarcinoma/gall bladder cancer, 115/16]. Dysfunction of the initial EBD occurred in 28 patients (21.4%). The cumulative incidences of dysfunction of the initial EBD in all patients were 18.4%, 38.2% and 47.0% at 30, 60 and 90 days, respectively (Kaplan–Meier method). The rate of dysfunction of the initial EBD increased in patients with BC‐IV (P =.03). Multivariate analysis showed that BC‐IV and pre‐EBD cholangitis were significantly associated with the occurrence of dysfunction of the initial EBD. Survival rates were not significantly different according to the initial biliary drainage methods and presence/absence of the initial EBD dysfunction. Conclusions: Dysfunction of the initial EBD frequently occurs in patients with the BC‐IV and those with pre‐EBD cholangitis. [ABSTRACT FROM AUTHOR]

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is still performed using two-dimensional (2D) X-ray images. The success rate and risk of complications are considered operator-dependent. We explored performing an ERCP-related procedure with 3D-computed tomography (CT) biliary imaging for preoperative simulation and intraoperative reference in a patient with malignant biliary obstruction.Case Presentation: The patient was a 66-year-old man who underwent rectal resection and postoperative chemotherapy for rectal cancer. A liver metastasis caused obstructive jaundice and acute cholangitis, necessitating emergency hospitalization. A 3.5 cm mass in the hilar region of the biliary tree caused type IV biliary obstruction according to the Bismuth-Corlette classification of hilar cholangiocarcinoma. ERCP and biliary drainage were performed repeatedly, but had no effect. Given that selective bile duct drainage had proven extremely difficult with the conventional procedures, three-dimensional (3D) images were created from preoperative CT image data using a 3D image reconstruction system (SYNAPSE VINCENT version 5, FUJIFILM Corporation, Tokyo, Japan). Using the 3D images for preoperative planning and intraoperative reference, biliary drainage and stent placement were successfully performed without complications. Postoperatively, the patient had no further cholangitis or need for stent replacement up to his death.Conclusions: We report the first case of an ERCP-related procedure with 3D biliary imaging for preoperative simulation and intraoperative reference in a patient with malignant biliary obstruction. The 3D image reconstruction is useful for preoperative planning and could contribute to an increased success rate, decreased complications, a shorter operation time, and reduced radiation exposure to the operator. [ABSTRACT FROM AUTHOR]

Background: Malignant hilar biliary obstruction (MHBO) can be treated with bilateral self‐expandable metal stents (SEMS) deployed using side‐by‐side (SBS) or stent‐in‐stent (SIS) techniques. Moving cell stents (MCS) are a novel type of SEMS. The present study evaluated the technical feasibility of treating MHBO using bilateral novel uncovered SEMS to insert an SIS technique without dilating the mesh of a first stent within a single session. Method: We retrospectively assessed patients who were complicated with obstructive jaundice due to MHBO between August and December 2018. Technical success was defined as the deployment of a bilateral MCS into two or more biliary tracts using SIS technique without a dilation device. Results: The present study analyzed data from 23 consecutive patients who were complicated with MHBO. Bilateral SIS technique with MCS was deployed in 22 (95.6%) of the 23 patients without dilating the mesh of the first stent. Multiple guidewire insertion failed in one patient with Bismuth‐type IV. The median procedural duration was 33.6 min. Time to recurrent biliary obstruction was 230 days. Severe adverse events were not seen in any patients. Conclusion: In conclusion, uncovered moving cell SEMS might facilitate bilateral stent deployment using SIS technique. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to ascertain the relative outcomes in patients with hilar cholangiocarcinoma (HCCA) undergoing either unilateral or bilateral self-expanded metallic stent (SEMS) insertion. Materials and Methods: In this retrospective single-center study, 93 patients with HCCA were treated through percutaneous insertion of either unilateral or bilateral SEMS during January 2012 to December 2018. We compared technical success, clinical success, and long-term outcomes of the treatment method. Results: Overall, 51 and 42 patients were treated through unilateral and bilateral SEMS insertion, respectively, with technical success rates of 92.2% (47/51) and 95.3% (40/42), respectively, (P = .859). No patients experienced any procedure-related complications, with unilateral and bilateral clinical success rates of 95.7% (45/47) and 97.4% (38/39), respectively, (P = 1.000) and with comparable adverse event rates between these groups (3/47 vs. 5/40; P = .541). Moreover, 8 and 3 patients treated with unilateral and bilateral stents exhibited stent dysfunction, respectively, (P = .183). In unilateral and bilateral groups, median patency rates were189 and 198 days, respectively, (P = .887). During the follow-up period, all patients died, with respective mean overall survival rates of 222 and 202 days for those treated using unilateral and bilateral stents (P = .755). Both Bismuth type III HCCA (P = .025) and a lack of chemotherapy (P = .000) correlated with reduced survival in univariate and multivariate regression analyses. Conclusion: Insertion of unilateral and bilateral SEMS exhibits similar clinical efficacy and long-term outcomes in patients with HCCA. [ABSTRACT FROM AUTHOR]

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 [ABSTRACT FROM AUTHOR]

Background: Bilateral self‐expandable metallic stent (SEMS) placement is effective for long‐term management of unresectable malignant hilar biliary obstruction (UMHBO). However, endoscopic reintervention (ERI) for bilateral SEMSs is not well‐studied. This study aimed to evaluate ERI efficacy after stent‐in‐stent placement. Methods: Data of 31 patients who underwent ERI from May 2000 to July 2018 were analyzed. Results: The technical success rate was 80.7% (25/31) and no adverse events occurred. The functional success rate was 100% (25/25). In a multivariate logistic regression analysis, the angle between the bilateral SEMSs (ABBS) >104° (odds ratio 50.49, 95% CI 3.370–2131, P = 0.0039) and overgrowth (odds ratio 25.70, 95% CI 1.121–1234, P = 0.0423) were risk factors for ERI failure. Multiple liver metastases, which sometimes cause overgrowth, were also risk factors. After ERI, some patients underwent additional SEMS (n = 4), plastic stent (n = 14) placement, or internal cleaning of the initial SEMS alone (n = 7). There were no significant intergroup differences in the 50% time to recurrent biliary obstruction. Conclusions: ABBS >104° and overgrowth were risk factors for ERI failure after stent‐in‐stent placement. In the decision‐making process for initial SEMS placement for UMHBO, patient condition should be considered, including the angle between bilateral bile ducts and multiple liver metastases. [ABSTRACT FROM AUTHOR]

Objective: To assess the feasibility, safety, and efficacy of Y-shaped jogged stent in patients with malignant hilar biliary obstruction.Methods: A total of 196 patients with malignant hilar biliary obstruction treated by biliary tract stent implantation from August 2010 to August 2017 were retrospectively reviewed. Seventeen consecutive patients who were treated with Y-shaped jogged stent implantation were identified as the Y-shaped jogged stent implantation group. Seventeen matched patients undergoing unilateral stent placement combined with percutaneous transhepatic cholangial drainage (PTCD) were enrolled as the control group. Baseline characteristics of patients, stent patency time, and survival time were compared.Results: There was no significant difference in the age, gender, tumor type and stage, biliary obstruction classification, bilirubin level at diagnosis, presence of metastasis, or chemotherapy between the Y-stent group and the control group (P > 0.05). One week after surgery, the reduction rate of bilirubin was significantly higher in the Y-stent group (88.2% vs 53.0%, P < 0.05). The mean stent patency time was longer in the Y-stent group (7.3 ± 1.0 months vs 5.7 ± 0.9 months, P < 0.05). The mean survival time of the Y-stent group (9.1 ± 1.5 months) was longer than the control group (7.2 ± 1.1 months, P > 0.05). There was no severe complication occurred in both two groups.Conclusion: Y-shaped jogged stent implantation was a safe, feasible, and effective approach in the treatment of patients with malignant hilar biliary obstruction, with the significantly prolonged stent patency time and survival time. [ABSTRACT FROM AUTHOR]

Purpose: Endoscopic bile duct decompression using bilateral self-expandable metallic stents (SEMSs) deployed via a stent-instent (SIS) method is considered a preferred procedure for malignant hilar biliary obstruction (MHBO). However, occlusion thereof occurs frequently. Here, we investigated stent patency duration and risk factors related to stent obstruction with bilateral SIS placement for MHBO at two large centers. Materials and Methods: The present study reviewed data on patients with MHBO who underwent endoscopic biliary drainage using the SIS method. Clinical outcomes, including stent patency duration and patient overall survival, were analyzed. Factors associated with stent patency were evaluated using Cox proportional hazards models. Results: Seventy patients with MHBO underwent endoscopic biliary drainage using the SIS method. Median age was 68 years old, and median follow-up duration was 140 days (interquartile range, 57-329). The proportion of high-grade MHBOs (Bismuth type IV) was 57.1%. Median stent patency duration with the SIS method was 108 days according to Kaplan-Meier curves. Median patient survival analyzed by the Kaplan-Meier method was 181 days. Multivariate analysis indicated that higher baseline bilirubin (> 6.1 mg/dL) as an independent risk factor related to stent patency (p<0.05). Conclusion: In endoscopic biliary decompression using SEMS placed with the SIS method, obstructive jaundice was a risk factor for stent patency. The SIS method for high-grade MHBO showed short stent patency. [ABSTRACT FROM AUTHOR]

Background: Long-term studies evaluating self-expandable metal stents in patients who have unresectable malignant hilar biliary obstruction (UMHBO) after surgical reconstruction of the intestine remain inadequate. We developed a side-by-side (SBS) technique using a two-channel endoscope to place self-expandable metal stents in patients with UMHBO occurring after Billroth II reconstruction.Aims: We validated the long-term outcomes obtained with this technique.Methods: The study group comprised seven patients with UMHBO in whom we attempted to place metal stents by the SBS technique using a two-channel scope. The procedure was validated retrospectively.Results: The technical success rate was 86% and functional success rate was 100%. The median time to recurrent biliary obstruction (RBO) was 222 days (95% CI 4.9-439.1). Besides RBO, there were no other complications.Conclusions: The SBS procedure performed using a two-channel scope is a safe and useful new technique for the treatment of UMHBO occurring after Billroth II reconstruction. [ABSTRACT FROM AUTHOR]

Background: Endoscopic bilateral self-expandable metallic stent (SEMS) placement for malignant hilar biliary obstructions (MHBOs) is technically demanding, and a second SEMS insertion is particularly challenging. A simultaneous side-by-side (SBS) placement technique using a thinner delivery system may mitigate these issues. Aims: We aimed to examine the feasibility and efficacy of simultaneous SBS SEMS placement for treating MHBOs using a novel SEMS that has a 5.7-Fr ultra-thin delivery system. Methods: Thirty-four patients with MHBOs underwent SBS SEMS placement between 2010 and 2016. We divided the patient cohort into those who underwent sequential (conventional) SBS placement between 2010 and 2014 (sequential group) and those who underwent simultaneous SBS placement between 2015 and 2016 (simultaneous group), and compared the groups with respect to the clinical outcomes. Results: The technical success rates were 71% (12/17) and 100% (17/17) in the sequential and simultaneous groups, respectively, a difference that was significant ( P = .045). The median procedure time was significantly shorter in the simultaneous group (22 min) than in the sequential group (52 min) ( P = .017). There were no significant group differences in the time to recurrent biliary obstruction (sequential group: 113 days; simultaneous group: 140 days) or other adverse event rates (sequential group: 12%; simultaneous group: 12%). Conclusions: Simultaneous SBS placement using the novel 5.7-Fr SEMS delivery system may be more straightforward and have a higher success rate compared to that with sequential SBS placement. This new method may be useful for bilateral stenting to treat MHBOs. [ABSTRACT FROM AUTHOR]

Competing Interests: The authors have no conflicts of interest to declare.

Background and Aim Endoscopic reintervention for stent occlusions following bilateral self-expandable metallic stent (SEMS) placement for malignant hilar biliary obstruction (MHBO) is challenging, and time to recurrent biliary obstruction (RBO) of the revisionary stent remains unclear. We aimed to clarify a suitable reintervention method for stent occlusions following bilateral SEMS placement for MHBO. Methods Between 2002 and 2014, 52 consecutive patients with MHBO who underwent endoscopic reintervention for stent occlusion after bilateral SEMS placement were enrolled at two university hospitals and one tertiary care referral center. We retrospectively evaluated the technical and functional success rates of the reinterventions, and the time to RBO of the revisionary stents. Results Technical and functional success rates of the reinterventions were 92% (48/52) and 90% (43/48), respectively. Univariate analysis did not determine any significant predictive factors for technical and functional failures. Median time to RBO of the revisionary stents was 68 days. Median time to RBO was significantly longer for revisionary SEMS placement than for plastic stent placement (131 days vs 47 days, respectively; log-rank test, P = 0.005). Revisionary SEMS placement was the only independent factor that was significantly associated with a longer time to RBO of the revisionary stent in the multivariate Cox proportional hazards analysis (hazard ratio 0.37; 95% confidence interval 0.14-0.95; P = 0.039). Conclusion Revisionary SEMS placement is a suitable endoscopic reintervention method for stent occlusion following bilateral SEMS placement from the perspective of time to RBO of the revisionary stent. [ABSTRACT FROM AUTHOR]

Background: Although endoscopic bilateral stent-in-stent (SIS) placement of self-expandable metallic stents (SEMS) is one of the major palliative treatments for unresectable malignant hilar biliary obstruction, post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis can occur frequently due to inadequate drainage, especially after contrast injection into the biliary tree. The aim of this study is to evaluate the efficacy and safety of air cholangiography-assisted stenting. Methods: This study included 47 patients with malignant hilar biliary obstruction who underwent endoscopic bilateral SEMS placement using the SIS technique. They were divided into two groups, air (n = 23) or iodine contrast (n = 24) cholangiography. We retrospectively compared comprehensive clinical and laboratory data of both groups. Results: There were no significant differences found between the two groups with respect to technical success (87% versus 87.5%, air versus contrast group, respectively), functional success (95% versus 95.2%), 30-day mortality (8.3% versus 8.7%) and stent patency. Post-ERCP adverse events occurred in 5 (21.7%) of the patients in the air group and 8 (33.3%) of the patients in the contrast group. Among these, the rate of cholangitis was significantly lower in the air group (4.8% versus 29.2%, p = 0.048). In multivariate analysis, air cholangiography, technical success and a shorter procedure time were significantly associated with a lower incidence of post-ERCP cholangitis. Conclusions: Air cholangiography-assisted stenting can be a safe and effective method for endoscopic bilateral SIS placement of SEMS in patients with malignant hilar biliary obstruction. [ABSTRACT FROM AUTHOR]