Endoscopic Biliary Stenting for Malignant Obstructive Jaundice

Aim. To identify opportunities for endoscopic retrograde biliary stenting for malignant obstructive jaundice and to compare long-term results of stenting using plastic and self-expanding metal stents.
Material and Methods. We analyzed the results of endoscopic methods of di-agnostics and treatment of inoperable patients with malignant obstructive jaundice, as well as incidence of early and late complications of biliary stenting as the final treatment. Total number of patients were 160 people which were divided into 2 groups by 80 patients. In the 1st group plastic biliary stents with the diameter of 3–3.5 mm (10–11.5 Fr) were used for bile ducts drainage. In the
2nd group covered self-expanding metal stents with the diameter of 10 mm (28–30 Fr) were applied. All patients underwent a comprehensive diagnostic program including traditional ultrasound (US), computer tomography (CT), EUS (EUS) and endoscopic retrograde cholangiopancreaticography (ERCP).
Results. Early postoperative complications were observed in 7 (8.7%) and 5 (6.7%) patients in the 1st and 2nd group respectively. Remote complications such as recurrent obstructive jaundice and/or cholangitis in various time periods after discharge occurred 2 times more often in the 1st group (28 out of 80 patients) than in the 2nd group (12 out of 80 patients) that required repeated hospitalizations and re-stenting. Malignant duodenal stenosis arose in 20 (12.5%)
patients. Average time was 8.2 months.
Conclusion. Endoscopic retrograde stenting can be used as an effective final method of bile ducts decompression in patients with inoperable pancreatobiliary tumors complicated by obstructive jaundice. The term of plastic biliary and self-expanding metal stents function was 119.9 ± 131.4 days (4 months) and 257.5 ± 91.3 days (8.6 months) respectively. Improvement of equipment and tools, use of antegrade techniques combined with EUS-guided interventions,

pyloroduodenal self-expanding stents allow to bypass pre-existing limitation with duodenal neoplastic stenosis.

1. Шевченко Ю.Л., Ветшев П.С., Стойко Ю.М., Левчук А.Л., Бардаков В.Г., Степанюк И.В. Хирургическая тактика при синдроме механической желтухи. Вестник Национального медико-хирургического центра им. Н.И. Пирогова. 2009; 4 (1): 10–13.

2. Ветшев П.С. Механическая желтуха: причины и диагностические подходы (лекция). Анналы хирургической гепатологии. 2011; 16 (3): 50–57.

3. Руководство по хирургии желчных путей; Под ред. Гальперина Э.И., Ветшева П.С. 2-е изд. М.: Видар-М, 2009. 568 с.

4. Галлингер Ю.И., Хрусталева М.В. Эндоскопическое лечение механической желтухи бластоматозной этиологии с ис пользованием транспапиллярных протезов. Сборник трудов международной конференции “Новые технологии в диагностике и хирургии органов билиопанкреатодуоденальной зоны”. М., 1995. С. 139–148.

5. Хрусталева М.В. Современные эндоскопические транспапапиллярные методы лечения механической желтухи. Анналы НЦХ РАМН. 1997; 6: 39–42.

6. Гальперин Э.И., Котовский А.Е., Момунова О.Н. Темп декомпрессии желчных протоков при механической желтухе опухолевой этиологии. Хирургия. 2011; 8: 33–40.

7. O’Brien S., Hatfield A.R.W., Craig P.I., Williams S.P. A three year follow-up of self-expanding metal stents in the endoscopic palliation of longterm surviors with malignant biliary obstruction. Gut. 1995; 36 (4): 618–621.

8. Jaganmohan S., Lee J.H. Self-expandable metal stents in malignant biliary obstruction. Expert. Rev. Gastroenterol. Hepatol. 2012; 6 (1): 105–114. doi: 10.1586/egh.11.95.

9. Matsuda Y., Shimakura Akamatsu T. Factors affecting the patency of stents in malignant biliary obstructions desease: univariate and multivariate analysis. Am. J. Gastroenterol. 1991; 86 (7): 843–849.

10. van Berkel A.M., Bruno M.J., Bergman J.J., van Deventer S.J., Tytgat G.N., Huibregtse K. A prospective randomised stady of hydrophilic polimer-coated polyurethane versus polyethylene stents in distal malignant biliary obstruction. Endoscopy. 2003; 35 (6): 478–482.

11. Чжао А.В. Опухоли печени и внутрипеченочных желчных протоков (диагностика и лечение): дис. … докт. мед. наук. М., 1999. 285 c.

12. Алексеев К.И., Васильев И.В., Осипов А.С., Маады А.С., Будзинский С.А., Шаповальянц С.Г., Федоров Е.Д., Галкова З.В., Чернякевич П.Л., Андреева О.Н. Первый отечест венный опыт выполнения холедоходуоденостомии под контролем эндоскопической ультрасонографии. Вестник Национального медико-хирургического центра им. Н.И. Пиро гова. 2013; 8 (2): 139–141.

13. Wiersema M.J., Sandusky D., Carr R., Wiersema L.M., Erdel W.C., Frederick P.K. Endosonography-guided cholangiopancreato graphy. Gastrointest. Endoscopy. 1996; 43 (2): 102–106.

14. Giovannini M., Moutardier V., Pesenti C., Bories E., Lelong B., Delpero J.R. Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage. Endoscopy. 2001; 33 (10): 898–900.

15. Itoi T., Itokawa F., Sofuni A., Kurihara T., Tsuchiya T., Ishii K., Tsuji S., Ikeuchi N., Moriyasu F. Endoscopic ultrasound-guided choledochoduodenostomy for patients with failed endoscopic retrograde cholangiopancreatography. World J. Gastroenterol. 2008; 14 (39): 6078–6082.

16. Iwashita T., Lee J.G., Shinoura S., Nakai Y., Park D.H., Muthusamy V.R., Chang K.J. Endoscopic ultrasound-guided rendezvous for biliary access after failed cannulation. Endoscopy. 2012; 44 (1): 60–65. doi: 10.1055/s-0030-1256871.

17. Moss A.C., Morris E., Leyden J., MacMathuna P. Malignant distal biliary obstruction: a systematic review and meta-analysis of endoscopic and surgical bypass results. Cancer Treat. Rev. 2007; 33 (2): 213–221.

18. Choi J.M., Kim J.H., Kim S.S., Yu J.H., Hwang J.C., Yoo B.M., Park S.H., Kim H.G., Lee D.K., Ko K.H., Yoo K.S., Park do H. A comparative study on the efficacy of covered metal stent and plastic stent in unresectable malignant biliary obstruction. Clin. Endosc. 2012; 45 (1): 78–83. doi: 10.5946/ce.2012.45.1.78.

19. Saleem A., Leggett C.L., Murad M.H., Baron T.H. Metaanalysis of randomized trials comparing the patency of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction. Gastrointest. Endosc. 2011; 74 (2): 321–327.e1-3. doi: 10.1016/j.gie.2011.03.1249.

20. Samie A.A., Dette S., Vohringer U., Stumpf M., Kopischke K., Theilmann L. Fully covered self-expandable metal stents for treatment of malignant and benign biliary strictures. World J. Gastrointest. Endosc. 2012; 4 (9): 405–408. doi: 10.4253/wjge.v4.i9.405.

21. Baron T.H. Management of simultaneous biliary and duodenal obstruction: the endoscopic perspective. Gut Liver. 2010; 4 (1): 50–56. doi: 10.5009/gnl.2010.4.S1.S50