Usefulness of slimmer and open-cell-design stents for endoscopic bilateral stenting and endoscopic revision in patients with hilar cholangiocarcinoma (with video)

Background Although endoscopic bilateral metal stenting using a “stent-in-stent” method is currently used to treat patients with unresectable hilar cholangiocarcinoma, this method has limited application in cases of tight strictures or endoscopic revision in case of tumor recurrence, especially on the first stent (initial Y stent placed) side. Objective To evaluate the clinical efficacy of bilateral metal stenting with the use of a slimmer (7F), open-cell-design stent. Design Prospective, uncontrolled, single center. Setting Tertiary referral university hospital. Patients This study involved 34 patients with unresectable hilar cholangiocarcinoma (Bismuth type II-IV). Intervention Endoscopic bilateral metal stenting using a stent-in-stent method was performed. First, a Y stent with a central, wide-open mesh was inserted, then a Zilver stent, with a preloaded delivery system that is slimmer (7F) than those (7.5-8.5F) of conventional stents, was placed into the contralateral hepatic duct through the central portion of the Y stent. The Zilver stent has an open-cell design, and it can be dilated easily. Thus, revision with bilateral plastic stents was tried in cases of stent obstruction. Main Outcome Measurements Technical success, functional success, complications, and revision method. Results Technical success (bilateral stenting using Y and Zilver stents) was achieved in 29 of 34 (85.3%) patients. Functional success was noted in 29 of the 29 (100.0%) patients who received bilateral stenting. Early complications such as pancreatitis and cholecystitis occurred in 3 (10.3%) patients. Late complications occurred in 11 (37.9%) patients. Cholecystitis, which occurred in 2 patients, was managed by percutaneous transhepatic gallbladder drainage. Stent obstruction by tumor ingrowth or overgrowth occurred in 9 of 29 (31.0%) patients. These patients were managed by placement of bilateral plastic stents (4 of 9), percutaneous transhepatic biliary drainage (4 of 9), and a combined method (1 of 9). Of the 5 patients in whom endoscopic revision was attempted, 4 (80%) were managed endoscopically with bilateral plastic stents. Limitations Small number of patients, uncontrolled study. Conclusion A slimmer (7F), open-cell-design stent is effective in endoscopic bilateral stenting for advanced hilar cholangiocarcinoma and endoscopic revision in case of tumor recurrence.