• hilar malignant biliary obstruction
• slim-delivery uncovered metallic stent

• Humans
• Retrospective Studies
• Bile Duct Neoplasms/complications
• Bile Duct Neoplasms/surgery
• Stents/adverse effects
• Cholestasis/surgery
• Cholestasis/complications
• Cholangitis/complications
• Treatment Outcome

• Braided
• Laser-cut
• Malignant hilar biliary obstruction
• Self-expandable metallic stent
• Stent-in-stent

• Humans
• Bile Duct Neoplasms/complications
• Bile Duct Neoplasms/surgery
• Retrospective Studies
• Self Expandable Metallic Stents/adverse effects
• Stents
• Cholestasis/etiology
• Cholestasis/surgery
• Treatment Outcome

• JP23K14646 JSPS KAKENHI Grant

Background and study aims  The clinical outcome of the new hybrid drainage method for unresectable malignant hilar biliary obstruction (UMHBO) has not yet been compared with that of the partial stent-in-stent (PSIS) method with three or more stents.

Patients and methods  Patients with UMHBO underwent drainage of three segments using the hybrid or PSIS method. The clinical outcomes of both methods were compared retrospectively.

Results  Overall, 54 patients underwent the hybrid (n = 31) or PSIS (n = 23) method of drainage with three or more stents for UMHBO. There were no significant differences in the technical success rate (hybrid vs. PSIS, 87.1 % vs. 87 %), clinical success rate according to per-protocol analysis (81.5 % vs. 70 %), early adverse events rate (14.8 % vs. 10%), late adverse events rate (7.4 % vs. 0 %), and technical success rate of the endoscopic transpapillary reintervention (90.9 % vs. 100 %). Time to recurrent biliary obstruction (TRBO) of the hybrid and PSIS methods was 178 and 231 days, respectively, with no significant difference ( P  = 0.354).

Conclusions  The choice between the two methods should be made at the physician’s discretion.

• Large-cell stent
• malignant hilar biliary obstruction
• slim delivery

Malignant biliary obstruction often presents with challenges requiring the endoscopist to assess the location of the lesion, the staging of the disease, the eventual resectability and patient preferences in term of biliary decompression. This review will focus on the different modalities available in order to offer the most appropriate palliation, such as conventional endoscopic retrograde cholangiopancreatography, endoscopic ultrasound guided biliary drainage as well as ablative therapies including photodynamic therapy or radiofrequency ablation.

• Biliary obstruction
• Endoscopic retrograde cholangiopancreatography
• Endoscopic ultrasonography
• Stenting
• Ablation therapy

• Drainage
• Endoscopy
• Malignant Hilar Obstruction

• Malignant biliary obstruction
• percutaneous biliary stent
• stent-in-stent

• bilateral biliary drainage
• hilar malignant biliary obstruction
• self-expandable metallic stent

• Aged
• Bile Duct Neoplasms/complications
• Cholestasis/etiology
• Cholestasis/surgery
• Drainage
• Humans
• Self Expandable Metallic Stents
• Stents/adverse effects

Biliary drainage, either by the stent-in-stent (SIS) or side-by-side (SBS) technique, is often required when treating a malignant hilar biliary obstruction (MHBO). Both methods differ from each other and have distinct advantages.

To compare both techniques regarding their efficacy and safety in achieving drainage of MHBO.

A comprehensive search of multiple electronic databases (MEDLINE, Embase, LILACS, BIREME, Cochrane) was conducted and grey literature from their inception until December 2020 with no restrictions regarding the year of publication or language, since there was at least an abstract in English. The included studies compared SIS and SBS techniques through endoscopic retrograde cholangiopancreatography. Outcomes analyzed included technical and clinical success, early and late adverse events (AEs), stent patency, reintervention, and procedure-related mortality.

Four cohort studies and one randomized controlled trial evaluating a total of 250 patients (127 in the SIS group and 123 in the SBS group) were included in this study. There were no statistically significant differences between the two groups concerning the evaluated outcomes, except for stent patency, which was higher in the SIS compared with the SBS technique [mean difference (d) = 33.31; 95% confidence interval: 9.73 to 56.90, I² = 45%, P = 0.006].

The SIS method showed superior stent patency when compared to SBS for achieving bilateral drainage in MHBO. Both techniques are equivalent in terms of technical success, clinical success, rates of both early and late AEs, reintervention, and procedure-related mortality.

• Endoscopic retrograde cholangiopancreatography
• Biliary tract neoplasms
• Biliary
• Hilar
• Stenting
• Drainage

• biliary tract cancer
• clinical practice
• guideline

• Hilar malignant biliary obstruction
• Side-by-side deployment
• Stent-in-stent deployment

Biliary and pancreatic cancers occur silently in the initial stage and become unresectable within a short time. When these diseases become symptomatic, biliary obstruction, either with or without infection, occurs frequently due to the anatomy associated with these cancers. The endoscopic management of these patients has changed, both with time and with improvements in medical devices. In this review, we present updated and integrated concepts for the endoscopic management of malignant biliary stricture. Endoscopic biliary drainage had been indicated in malignant biliary obstruction, but the concept of endoscopic management has changed with time. Although routine endoscopic stenting should not be performed in resectable malignant distal biliary obstruction (MDBO) patients, endoscopic biliary drainage is the treatment of choice for palliation in unresectable MDBO patients. Self-expanding metal stents (SEMS) have better stent patency and lower costs compared with plastic stents (PS). For malignant hilum obstruction, PS and uncovered SEMS yield similar short-term outcomes, while a covered stent is not usually used due to a potential unintentional obstruction of contralateral ducts.

• biliary stricture
• endoscopic management
• malignancy

• Bile Duct Neoplasms/complications
• Bile Ducts, Extrahepatic/surgery
• Bile Ducts, Intrahepatic/surgery
• Cholangiocarcinoma/complications
• Cholangiopancreatography, Magnetic Resonance
• Cholestasis/etiology
• Cholestasis/surgery
• Drainage/methods
• Endoscopy, Digestive System/methods
• Humans
• Magnetic Resonance Imaging
• Stents
• Tomography, X-Ray Computed
• Treatment Outcome
• Ultrasonography

• biliary
• drainage
• hilar
• obstruction
• stent

• Angle between bilateral self-expandable metallic stent
• Endoscopic reintervention
• Malignant hilar biliary obstruction
• Recurrent biliary obstruction
• Stent-in-stent placement

Although endoscopic bilateral stent-in-stent placement is challenging, many recent studies have reported promising outcomes regarding technical success and endoscopic re-intervention. This study aimed to evaluate the technical accessibility of stent-in-stent placement using large cell-type stents in patients with inoperable malignant hilar biliary obstruction.

Forty-three patients with inoperable malignant hilar biliary obstruction from four academic centers were prospectively enrolled from March 2013 to June 2015.

Bilateral stent-in-stent placement using two large cell-type stents was successfully performed in 88.4% of the patients (38/43). In four of the five cases with technical failure, the delivery sheath of the second stent became caught in the hook-cross-type vertex of the large cell of the first stent, and subsequent attempts to pass a guidewire and stent assembly through the mesh failed. Functional success was achieved in all cases of technical success. Stent occlusion occurred in 63.2% of the patients (24/38), with a median patient survival of 300 days. The median stent patency was 198 days. The stent patency rate was 82.9%, 63.1%, and 32.1% at 3, 6, and 12 months postoperatively, respectively. Endoscopic re-intervention was performed in 14 patients, whereas 10 underwent percutaneous drainage.

Large cell-type stents for endoscopic bilateral stent-in-stent placement had acceptable functional success and stent patency when technically successful. However, the technical difficulty associated with the entanglement of the second stent delivery sheath in the hook-cross-type vertex of the first stent may preclude large cell-type stents from being considered as a dedicated standard tool for stent-in-stent placement.

• Cholangiopancreatography, endoscopic retrograde
• Cholestasis, intrahepatic
• Klatskin tumor
• Self expandable metallic stents

• Malignant hilar biliary obstruction
• Revision
• Self-expandable metallic stent
• Stent-in-stent

• Malignant hilar biliary obstruction
• self-expandable metallic stent
• stent patency
• stent-in-stent

• Adult
• Aged
• Bile Duct Neoplasms/complications
• Bile Duct Neoplasms/surgery
• Carcinoma/complications
• Carcinoma/surgery
• Cholestasis/etiology
• Cholestasis/therapy
• Drainage/methods
• Endoscopy, Digestive System/methods
• Female
• Humans
• Male
• Middle Aged
• Proportional Hazards Models
• Prosthesis Implantation/methods
• Risk Factors
• Self Expandable Metallic Stents
• Stents/adverse effects
• Treatment Outcome

• ercp
• malfunction
• malignant bile duct obstruction
• self expandable metallic stents

• Aged
• Aged, 80 and over
• Bile Duct Neoplasms/diagnostic imaging
• Bile Duct Neoplasms/surgery
• Cholestasis, Intrahepatic/diagnostic imaging
• Cholestasis, Intrahepatic/surgery
• Disease Progression
• Endoscopy/methods
• Equipment Failure
• Female
• Humans
• Male
• Middle Aged
• Reoperation
• Stents
• Tomography, X-Ray Computed
• Treatment Outcome

• Bilateral stenting
• Biliary drainage
• Drainage liver volume
• Hilar biliary obstruction
• Unilateral stenting

To investigate the factors predictive of failure when placing a second biliary self-expandable metallic stents (SEMSs).

This study evaluated 65 patients with an unresectable malignant hilar biliary obstruction who were examined in our hospital. Sixty-two of these patients were recruited to the study and divided into two groups: the success group, which consisted of patients in whom a stent-in-stent SEMS had been placed successfully, and the failure group, which consisted of patients in whom the stent-in-stent SEMS had not been placed successfully. We compared the characteristics of the patients, the stricture state of their biliary ducts, and the implemented endoscopic retrograde cholangiopancreatography (ERCP) procedures between the two groups.

The angle between the target biliary duct stricture and the first implanted SEMS was significantly larger in the failure group than in the success group. There were significantly fewer wire or dilation devices (ERCP catheter, dilator, or balloon catheter) passing the first SEMS cell in the failure group than in the success group. The cut-off value of the angle predicting stent-in-stent SEMS placement failure was 49.7 degrees according to the ROC curve (sensitivity 91.7%, specificity 61.2%). Furthermore, the angle was significantly smaller in patients with wire or dilation devices passing the first SEMS cell than in patients without wire or dilation devices passing the first SEMS cell.

A large angle was identified as a predictive factor for failure of stent-in-stent SEMS placement.

• Endoscopic stent-in-stent self-expandable metallic stent placement
• Predictive factor
• Endoscopic retrograde cholangiopancreatography
• Malignant hilar biliary obstruction
• Self-expandable metallic stent

• Adolescent
• Adult
• Aged
• Aged, 80 and over
• Bile Duct Neoplasms/complications
• Bile Duct Neoplasms/pathology
• Bile Duct Neoplasms/surgery
• Bile Ducts/pathology
• Bile Ducts/surgery
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/instrumentation
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholangiopancreatography, Endoscopic Retrograde/statistics & numerical data
• Cholestasis/etiology
• Cholestasis/surgery
• Constriction, Pathologic/etiology
• Constriction, Pathologic/surgery
• Female
• Humans
• Male
• Middle Aged
• Operative Time
• Retrospective Studies
• Risk Assessment/methods
• Risk Factors
• Self Expandable Metallic Stents/adverse effects
• Self Expandable Metallic Stents/statistics & numerical data
• Treatment Failure
• Young Adult

• EUS-guided biliary drainage
• Endoscopic ultrasonography
• Hilar malignant biliary stricture
• Interventional EUS

• ERCP
• EUS-BD
• EUS-FNA
• EUS-guided biliary drainage
• hepatic hilum

• Fluoroscopy
• Hilar biliary obstruction
• Klatskin tumor
• Stent

Stenting in the gastrointestinal tract is a common procedure used for palliation of obstruction in the enteral and biliary tract. Today, stenting of malignant and benign strictures is performed at almost every major tertiary hospital in Korea. Moreover, Korea has become a major global supplier of cutting edge technology in the field of self-expanding metal stents. However, the history of stenting in Korea is relatively short and was far behind that of other nations such as Japan and Germany. The authors are humbled and gratified to have been able to observe the development and application of these stents in Korea, first hand. In this article, the authors review the overall history of stenting with a specific focus on the development of stenting in Korea. The development of esophageal, gastroduodenal, biliary, and colonic stents in Korea are reviewed in this article from a chronological and historical point of view, and a personal account of some of the significant moments of stent development in Korea are described.

• Biliary stent
• Enteral stent
• Korea
• Self expandable metallic stents

• Bile duct malignancy
• Gallbladder malignancy
• Jaundice
• Malignant
• Palliative care
• Pancreas malignancy
• Stents

• Biliary Tract Neoplasms/surgery
• Biliary Tract Surgical Procedures/instrumentation
• Biliary Tract Surgical Procedures/methods
• Cholestasis/pathology
• Cholestasis/surgery
• Drainage
• Humans
• Palliative Care/methods
• Stents

• cell size
• endoscopic retrograde cholangiopancreatography (ERCP)
• malignant hilar biliary obstruction
• self-expandable metallic stent (SEMS)
• stent-in-stent

• Aged
• Aged, 80 and over
• Bile Duct Neoplasms/complications
• Bile Duct Neoplasms/diagnostic imaging
• Cholangiocarcinoma/complications
• Cholangiocarcinoma/diagnostic imaging
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholestasis, Intrahepatic/diagnostic imaging
• Cholestasis, Intrahepatic/etiology
• Cholestasis, Intrahepatic/therapy
• Cohort Studies
• Female
• Gallbladder Neoplasms/complications
• Gallbladder Neoplasms/diagnostic imaging
• Humans
• Kaplan-Meier Estimate
• Male
• Middle Aged
• Palliative Care
• Prosthesis Design
• Prosthesis Failure
• Retrospective Studies
• Risk Assessment
• Statistics, Nonparametric
• Stents
• Survival Rate
• Ultrasonography

The management of jaundice and cholangitis is important for improving the prognosis and quality of life of patients with unresectable malignant hilar biliary strictures (UMHBS). In addition, effective chemotherapy, such as a combination of gemcitabine and cisplatin, requires the successful control of jaundice and cholangitis. However, endoscopic drainage for UMHBS is technical demanding, and continuing controversies exist in the selection of the most appropriate devices and techniques for stent deployment. Although metallic stents (MS) are superior to the usual plastic stents in terms of patency, an extensive comparison between MS and “inside stents”, which are deployed above the sphincter of Oddi, is necessary. Which techniques are preferred remains as yet unresolved: for instance, whether to use a unilateral or bilateral drainage, or a stent-in-stent or side-by-side method for the deployment of bilateral MS, although a new cell design and thin delivery system for MS allowed us to accomplish successful deployments of bilateral MS. The development of techniques and devices for re-intervention after stent occlusion is also imperative. Further critical investigations of more effective devices and techniques, and increased randomized controlled trials are warranted to resolve these important issues.

• Malignant hilar biliary obstruction
• Biliary drainage
• Metallic stents
• Stent-in-stent
• Side-by-side

• Biliary stent
• Biliary stricture
• Endoscopic procedure
• Hilar stricture
• Self-expandable metal stent

Palliative drainage is the main treatment option for inoperable hilar cholangiocarcinoma to improve symptoms, which include cholangitis, pruritus, high-grade jaundice, and abdominal pain. Although there is no consensus on the optimal method for biliary drainage due to the paucity of large-scale randomized control studies, several important aspects of any optimal method have been studied. In this review article, we discuss the liver volume to be drained, stent type, techniques to insert self-expanding metal stents, and approaches for proper and effective biliary drainage based on previous studies and personal experience.

• Biliary stenting
• Cholangiocarcinoma
• Hilar cholangiocarcinoma
• Klatskin's tumor
• Palliation

• Biliary obstruction
• Hepatobiliary malignancy
• Liver hilum
• Stent

• Bilateral stent
• Hilar malignant biliary obstruction
• Re-intervention
• Self-expandable metallic stent
• Stent-in-stent

• Endoscopic biliary drainage
• Malignant hilar biliary obstruction
• Self-expandable metallic stent
• Stent-in-stent method

Endoscopic palliative biliary drainage is considered as a gold standard treatment in advanced or inoperable hilar cholangiocarcinoma. Also, metal stents are preferred over plastic stents in patients with >3 months life expectancy. However, the endoscopic intervention of advanced hilar obstruction is often more challenging and complex than that of distal malignant biliary obstructions. In this literature review, we describe the issues commonly encountered during endoscopic unilateral (single) versus bilateral (multiple) biliary stenting for malignant hilar obstruction. Also, we provide technical guidance to improve the technical success rates and patient outcomes, focusing on bilateral metallic stenting techniques such as stent-in-stent or side-by-side deployment.

• Bilateral drainage
• Hilar cholangiocarcinoma
• Metal stents

Background and Aim. Malignant hilar strictures are a clinical challenge because of the current therapeutic approach and the poor prognosis. In recent years, self-expandable metallic stents have proven more effective than plastic stents for palliation of malignant hilar strictures, with the bilateral stent-in-stent technique registering a high success rate. We report our experience with Y-shaped endoscopic self-expandable metallic stents placement for treatment of advanced malignant hilar strictures. Methods. From April 2009 to August 2012, we prospectively collected data on patients treated with Y-shaped SEMS placement for advanced malignant hilar carcinoma. Data on technical success, clinical success, and complications were collected. Results. Twenty patients (9 males) were treated (mean age 64.2 ± 15.3 years). The grade of malignant hilar strictures according to the Bismuth classification was II in 5 patients (25%), IIIa in 1 (5%), and IV in 14 (70%). The mean bilirubin level was 14.7 ± 4.9 mg/dL. Technical success was achieved in all patients, with a significant reduction in bilirubin levels (2.9 ± 1.7 mg/dL). One patient experienced cholangitis as early complication, while in 2 patients stent ingrowth was observed. No stents migration was recorded. There was no procedure-related mortality. At the end of the follow-up (7.1 ± 3.1 months), 13 of the 20 patients (65%) had died. Conclusions. Our experience confirms endoscopic bilateral self-expandable metallic stents placement with stent-in-stent technique (Y-shaped configuration) as a feasible, effective, and safe procedure for palliation of unresectable malignant hilar strictures.

• bilateral biliary drainage
• endoscopic retrograde cholangiopancreatography (ERCP)
• malignant hilar biliary obstruction
• self-expandable metallic stent (SEMS)
• stent-in-stent

Biliary stenting has evolved dramatically over the past 30 years. Advancements in stent design have led to prolonged patency and improved efficacy. However, biliary stenting is still affected by occlusion, migration, anatomical difficulties, and the need for repeat procedures. Multiple novel plastic biliary stent designs have recently been introduced with the primary goals of reduced migration and improved ease of placement. Self-expandable bioabsorbable stents are currently being investigated in animal models. Although not US Food and Drug Administration approved for benign disease, fully covered self-expandable metal stents are increasingly being used in a variety of benign biliary conditions. In malignant disease, developments are being made to improve ease of placement and stent patency for both hilar and distal biliary strictures. The purpose of this review is to describe recent developments and future directions of biliary stenting.

• benign biliary strictures
• bioabsorbable stents
• drug eluting stents
• malignant biliary strictures
• plastic stents
• self-expandable metal stents

• Drainage
• Endoscopic
• Hilar cholangiocarcinoma
• Inoperable

• Bile Duct Neoplasms/surgery
• Bile Ducts, Intrahepatic/surgery
• Cholangiocarcinoma/surgery
• Cholangiopancreatography, Endoscopic Retrograde
• Drainage/adverse effects
• Drainage/instrumentation
• Drainage/methods
• Endoscopy/adverse effects
• Endoscopy/instrumentation
• Humans
• Prosthesis Design
• Stents
• Treatment Outcome