Clin Endosc.  2021 Sep;54(5):713-721. 10.5946/ce.2021.016.

Endoscopic Stenting for Malignant Biliary Obstruction: Results of a Nationwide Experience

• Lubbe J
• Sandblom G
• Arnelo U
• Jonas E
• Enochsson L

• KMID: 2520555
• DOI: http://doi.org/10.5946/ce.2021.016

Abstract

Background/Aims
Many unanswered questions remain about the treatment of malignant hilar obstruction. We investigated endoscopic stenting for malignant biliary strictures, as reported in a nationwide registry.
Methods
All endoscopic retrograde cholangiopancreatography (ERCP) procedures entered in the Swedish Registry of Gallstone Surgery and ERCP from January 2010 to December 2017 in which stenting was performed for malignant biliary stricture management were included in this study. Patency was estimated by determining the time to reintervention.
Results
Endoscopic stenting was performed for malignant stricture management in 4623 ERCP procedures, of which 1364 (29.5%) were performed for hilar strictures. Of the hilar strictures, 320 (23.5%) were intrahepatic strictures (Bismuth–Corlette III–IV). Adverse events were more common after hilar stenting than after distal stenting (17.2% vs. 12.0%, p<0.0001). The 6-month reintervention rate was 73.4% after hilar stenting compared with 55.9% after distal stenting (p<0.0001). The 6-month reintervention rates for Bismuth–Corlette types I, II, IIIa, IIIb, and IV were 70.4%, 75.6%, 90.0%, 87.5%, and 85.7%, respectively. In multivariate analysis, the risk for reintervention was three times higher after hilar stenting than after distal stenting (hazard ratio 3.47, 95% confidence interval 2.01–6.00, p<0.001).
Conclusions
This study with a relatively large patient cohort undergoing endoscopic stenting confirms that stenting for malignant hilar obstruction has more adverse events and lower patency than stenting for distal malignant obstruction.

Keyword

Endoscopic; Hilar; Malignant; Obstruction; Stent

Figure

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  Fig. 1. Flowchart of the included ERCP procedures in this study. ERCP, endoscopic retrograde cholangiopancreatography; ICD, International Classification of Diseases.

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  Fig. 2. Flowchart indicating the position of strictures. B–C, Bismuth–Corlette.

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  Fig. 3. Time to the need for endoscopic reintervention (in months) after hilar and distal single metal stent placement. SEMS, self-expanding metal stent (log-rank: chi-square [ChiSq] 47.07, p>ChiSq<0.0001; Wilcoxon: ChiSq 66.13, p>ChiSq<0.0001).

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  Fig. 4. Time to the need for endoscopic reintervention (in months) after single metal stent placement for B–C types I–IV. SEMS, self-expanding metal stent; B–C, Bismuth–Corlette (log-rank: chi-square [ChiSq] 58.85, p>ChiSq<0.0001; Wilcoxon: ChiSq 74.04, p>ChiSq< 0.0001).

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