Iwai Tomohisa, Kida Mitsuhiro, Okuwaki Kosuke, Yamauchi Hiroshi, Kaneko Toru, Hasegawa Rikiya, Watanabe Masafumi, Kurosu Takahiro, Imaizumi Hiroshi, Koizumi Wasaburo
Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan.
J Gastroenterol Hepatol. 2022 Jun;37(6):1060-1066. doi: 10.1111/jgh.15822. Epub 2022 Mar 16.
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.
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.
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).
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.
内镜下双侧自膨式金属支架（SEMS）置入术用于不可切除的恶性肝门部胆管梗阻（MHBO）已广泛开展；然而，复发性胆管梗阻（RBO）后的再次干预往往具有挑战性。我们比较了用于MHBO的支架套叠（SIS）和并排（SBS）SEMS置入术在RBO再次干预方面的情况。
连续纳入在我院及其附属医院接受内镜下双侧SEMS置入术的105例MHBO患者；75例患者于2005年12月至2012年12月接受了部分SIS置入术；30例患者于2013年1月至2019年3月接受了SBS置入术。对每组的初始治疗和再次干预进行回顾性评估。
SIS组和SBS组在技术成功率（92%对100%，P = 0.179）、手术时长（46对35分钟，P = 0.382）、功能成功率（97.1%对100%，P = 1.00）、并发症发生率（24.6%对20.0%，P = 0.797）、至RBO的时间（260对312天；Gray检验，P = 0.815）以及RBO发生率（59.4%对70.0%，P = 0.371）方面均无显著差异。然而，SIS组63.4%的患者通过SEMS成功进行了双侧塑料支架再置入，而SBS组这一比例为100%（P = 0.0013）。首次使用塑料支架再置入时至RBO的中位时间为75天（范围11 - 195天）。
RBO后的内镜下再置入支架在SBS组比SIS组显著更成功。考虑到支架的修正置入，SBS方法适用于MHBO。
