Best Conformation for Hilar Self-Expanding Metal Stents Remains Undefined
Bret T. Petersen, MD, MASGE, reviewing Ishigaki K, et al. Dig Dis Sci 2020 Dec.
Bilateral placement of metal stents for malignant hilar strictures (MHS) can be challenging. Two approaches have been used, each with potential benefits and challenges.
In a retrospective study of data from 4 centers, the authors compared the outcomes of 64 patients with MHS managed with placement of either bare, braided mesh stents in side-by-side (SBS) positions extending across the papilla (n=24) or bare, large mesh stents in a stent-in-stent (SIS) position above the papilla (n=40). Patients were treated with SIS or SBS placement during separate time frames (SIS, 2010-2012; SBS, 2013-2016).
Technical success (SBS, 96%; SIS, 100%) and functional success (SBS, 96%; SIS, 93%) rates were essentially equivalent. Early adverse events were proportionally, but not statistically, more common in SBS than SIS placement (46% vs 23%; P=.09). Post-ERCP pancreatitis occurred only in the SBS group (29%). Recurrent obstruction rates (SBS, 43%; SIS, 48%) and time to obstruction (SBS, 205 days; SIS, 169 days) were similar between groups, whereas survival rates were equivalent.
COMMENTBilateral drainage of malignant hilar obstruction is advisable, but the modality of drainage remains highly varied and is often dependent on potential subsequent therapies, anatomy, institutional skill sets, and device availability. As nicely outlined in the accompanying editorial, this study suggests that variation in metal stent selection and placement conformation is acceptable, given the absence of major differences in outcome between stent-in-stent and stent-by-stent palliation. Potential candidates for resection or transplantation should be managed with internal plastic stents, pending management decisions.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
Ishigaki K, Hamada T, Nakai Y, et al. Retrospective comparative study of side‑by‑side and stent‑in‑stent metal stent placement for hilar malignant biliary obstruction. Dig Dis Sci 2020;65:3710-3718. (https://doi.org/10.1007/s10620-020-06155-z)
