Palliative endoscopic biliary drainage is the primary treatment option for the management of patients with jaundice which results from distal malignant biliary obstruction (DMBO). In this group of patients, decompression of the bile duct (BD) allows for pain reduction, symptom relief, chemotherapy administration, improved quality of life, and increased survival rate. To reduce the unfavorable effects of BD decompression, minimally invasive surgical techniques require continuous improvement.

To develop a technique for internal-external biliary-jejunal drainage (IEBJD) and assess its effectiveness in comparison to other minimally invasive procedures in the palliative treatment of patients with DMBO.

A retrospective analysis of prospectively collected data was performed, which included 134 patients with DMBO who underwent palliative BD decompression. Biliary-jejunal drainage was developed to divert bile from the BD directly into the initial loops of the small intestine to prevent duodeno-biliary reflux. IEBJD was carried out using percutaneous transhepatic access. Percutaneous transhepatic biliary drainage (PTBD), endoscopic retrograde biliary stenting (ERBS), and internal-external transpapillary biliary drainage (IETBD) were used for the treatment of study patients. Endpoints of the study were the clinical success of the procedure, the frequency and nature of complications, and the cumulative survival rate.

There were no significant differences in the frequency of minor complications between the study groups. Significant complications occurred in 5 (17.2%) patients in the IEBJD group, in 16 (64.0%) in the ERBS group, in 9 (47.4%) in the IETBD group, and in 12 (17.4%) in the PTBD group. Cholangitis was the most common severe complication. In the IEBJD group, the course of cholangitis was characterized by a delayed onset and shorter duration as compared to other study groups. The cumulative survival rate of patients who underwent IEBJD was 2.6 times higher in comparison to those of the PTBD and IETBD groups and 20% higher in comparison to that of the ERBS group.

IEBJD has advantages over other minimally invasive BD decompression techniques and can be recommended for the palliative treatment of patients with DMBO.

• Distal malignant biliary obstruction
• Obstructive jaundice
• Bile duct decompression
• Palliative endoscopic biliary drainage
• Internal-external biliary-jejunal drainage

• anti‐reflux metal stent
• covered metal stent
• distal malignant biliary obstruction
• pancreatic cancer
• recurrent biliary obstruction

• Anti-reflux metal stent
• Covered metal stent
• Distal malignant biliary obstruction
• Pancreatic cancer
• Recurrent biliary obstruction

Early obstruction of a self‐expandable metal stent placed for distal malignant biliary obstruction is more likely to occur in the presence of duodenal invasion. An anti‐reflux self‐expandable metal stent (ARMS) has been developed for the purpose of preventing duodenal fluid reflux into the bile duct. In this study, we evaluated the usefulness and safety of a duckbill‐type ARMS (D‐ARMS) in the situation of duodenal invasion.

We retrospectively analyzed 10 consecutive patients who received D‐ARMS for distal malignant biliary obstruction with duodenal invasion. We evaluated non‐occlusion cholangitis, recurrent biliary obstruction (RBO), and adverse events after D‐ARMS placement.

There were no cases of non‐occlusion cholangitis. RBO was observed in 2 patients (20%), and time to RBO was 236 days and 117 days, respectively. The causes of RBO were overgrowth and sludge formation. The median time to RBO was 382 days (range, 117–382 days). Only one adverse event was observed (cholecystitis).

D‐ARMS shows potential as an optimal ARMS.

• anti-reflux
• biliary stent
• bionic valve
• fluid-structure interaction
• optimization

• National Natural Science Foundation of China

• anti-reflux metal stent
• biliary stenting
• duckbill shape

• anti-reflux metal stent
• distal biliary obstruction
• malignant
• recurrent biliary obstruction
• refractory

• common bile duct
• endoscopic retrograde cholangiopancreatography
• extrahepatic cholestasis
• randomized controlled trial
• stents

• Anti-reflux
• biliary stent
• cone spiral valve
• fluid-structure interaction model
• mechanical simulation

• malignant biliary obstruction
• plastic stent
• self-expandable metal stent (SEMS)

• antireflux valve
• bile duct obstruction
• expanded polytetrafluoroethylene
• malfunction
• self-expandable metal stent

• Adenocarcinoma/complications
• Cholestasis/etiology
• Cholestasis/therapy
• Female
• Humans
• Middle Aged
• Pancreatic Neoplasms/complications
• Stents/adverse effects

• common bile duct
• endoscopic retrograde cholangiopancreatography
• extrahepatic cholestasis
• pancreatic neoplasm
• stent

• Biliary obstruction
• Cholangiopancreatography
• Endoscopy
• Pancreatic neoplasms
• Stents
• endoscopic retrograde

To overcome duodenobiliary reflux induced by biliary stents, antireflux valve (ARV) biliary stents have been developed and showed improvement in stent patency. However, negative study results have also been reported because stent patency may be decreased by the malfunction of ARV itself. Given such mixed results, the true efficacy of ARV remains unknown and the mechanism of its dysfunction needs to be clearly elucidated. The aim of this study was to investigate the exact mechanism of ARV dysfunction using in vitro phantom models.

Two experimental models were designed to evaluate two important environmental factors suspected to cause ARV malfunction, i.e. bile flow and pH. Three types of ARV metal stents from different companies were used for the experiments: a funnel type ARV, a windsock type ARV, and a wine glass-shaped ARV. Ten stents of each type were tested (five stents in the bile flow phantom model, and another five stents in the duodenal pH environmental model). To determine ARV malfunction, ARV-induced flow resistance was measured using a custom-made testing device. All stents from the two models were removed every 2 weeks for 12 weeks after stent insertion and were evaluated on morphological and functional changes of the ARV.

Only ARV of wine glass-shaped ARV was morphologically changed due to silicone bond detachment in the bile flow model. All types of ARV were morphologically changed in the pH model. The morphological changes of ARV influenced the flow resistance. The antegrade pressure gradients were increased over time in the pH model (p < 0.05).

Morphological change of the ARVs may induce dysfunction of ARV metal stents, which is mainly due to duodenal pH environment. In the future, development of new ARV that is not affected by duodenal environmental factors can be expected to improve stent patency.

The online version of this article (10.1186/s12876-018-0878-8) contains supplementary material, which is available to authorized users.

• Antireflux valve
• Biliary stent
• Metal stent
• Stent

To investigate the technical safety and clinical efficacy of a double-stent system with long duodenal extension in patients with malignant extrahepatic biliary obstruction.

This prospective study enrolled 48 consecutive patients (31 men, 17 women; mean age, 61 years; age range, 31–77 years) with malignant extrahepatic biliary obstructions from May 2013 to December 2015. All patients were treated with a double-stent system with long duodenal covered extension (16 cm or 21 cm).

The stents were successfully placed in all 48 patients. There were five (10.4%) procedure-related complications. Minor complications were self-limiting hemobilia (n = 2). Major complications included acute pancreatitis (n = 1) and acute cholecystitis (n = 2). Successful internal drainage was achieved in 42 (87.5%) patients. Median patient survival and stent patency times were 92 days (95% confidence interval [CI], 61–123 days) and 83 days (95% CI, 46–120 days), respectively. Ten (23.8%) of the 42 patients presented with stent occlusion due to food impaction with biliary sludge, and required repeat intervention. Stent occlusion was more frequent in metastatic gastric cancer patients with pervious gastrectomy, but did not reach statistical significance (p = 0.069).

Percutaneous placement of a double-stent system with long duodenal extension is feasible and safe. However, this stent system does not completely prevent stent occlusion caused by food reflux.

• Biliary
• Malignancy
• Obstruction
• Stent

To compare the use of an antireflux metal stent (ARMS) with that of a conventional covered self-expandable metal stent (c-CSEMS) for initial stenting of malignant distal biliary obstruction (MDBO).

We retrospectively investigated 59 consecutive patients with unresectable MDBO undergoing initial endoscopic biliary drainage. ARMS was used in 32 patients and c-CSEMS in 27. Technical success, functional success, complications, causes of recurrent biliary obstruction (RBO), time to RBO (TRBO), and reintervention were compared between the groups.

Stent placement was technically successful in all patients. There were no significant intergroup differences in functional success (ARMS [96.9%] versus c-CSEMS [96.2%]), complications (6.2 versus 7.4%), and RBO (48.4 versus 42.3%). Food impaction was significantly less frequent for ARMS than for c-CSEMS (P = 0.037), but TRBO did not differ significantly between the groups (log-rank test, P = 0.967). The median TRBO was 180.0 [interquartile range (IQR), 114.0–349.0] days for ARMS and 137.0 [IQR, 87.0–442.0] days for c-CSEMS. In both groups, reintervention for RBO was successfully completed in all patients thus treated.

ARMS offers no advantage for initial stent placement, but food impaction is significantly prevented by the antireflux valve.

• Antireflux
• Biliary obstruction
• Cholangiopancreatography, endoscopic retrograde
• Covered
• Metal stent

• Aged
• Aged, 80 and over
• Cholangiopancreatography, Endoscopic Retrograde
• Cholestasis/etiology
• Cholestasis/surgery
• Common Bile Duct Neoplasms/complications
• Common Bile Duct Neoplasms/surgery
• Female
• Gallbladder Neoplasms/complications
• Gallbladder Neoplasms/surgery
• Humans
• Japan
• Lymphatic Metastasis
• Male
• Pancreatic Neoplasms/complications
• Pancreatic Neoplasms/surgery
• Pilot Projects
• Prosthesis Design
• Retrospective Studies
• Self Expandable Metallic Stents

Malignant obstruction of the bile duct from cholangiocarcinoma, pancreatic adenocarcinoma, or other tumors is a common problem which may cause debilitating symptoms and increase the risk of subsequent surgery. The optimal treatment - including the decision whether to treat prior to resection - depends on the type of malignancy, as well as the stage of disease. Preoperative biliary drainage is generally discouraged due to the risk of infectious complications, though some situations may benefit. Patients who require neoadjuvant therapy will require decompression for the prolonged period until attempted surgical cure. For pancreatic cancer patients, self-expanding metallic stents are superior to plastic stents for achieving lasting decompression without stent occlusion. For cholangiocarcinoma patients, treatment with percutaneous methods or nasobiliary drainage may be superior to endoscopic stent placement, with less risk of infectious complications or failure. For patients of either malignancy who have advanced disease with palliative goals only, the choice of stent for endoscopic decompression depends on estimated survival, with plastic stents favored for survival of < 4 mo. New endoscopic techniques may actually extend stent patency and patient survival for these patients by achieving local control of the obstructing tumor. Both photodynamic therapy and radiofrequency ablation may play a role in extending survival of patients with malignant biliary obstruction.

• Pancreatic neoplasms
• Cholangiocarcinoma
• Extrahepatic cholestasis
• Stents
• Catheter ablation

• Biliary tract
• Biofilms
• Occlusion
• Patency
• Stents

Benign biliary strictures comprise a heterogeneous group of diseases. The most common strictures amenable to endoscopic treatment are post-cholecystectomy, post-liver transplantation, related to primary sclerosing cholangitis and to chronic pancreatitis. Endoscopic treatment of benign biliary strictures is widely used as first line therapy, since it is effective, safe, noninvasive and repeatable. Endoscopic techniques currently used are dilation, multiple plastic stents insertion and fully covered self-expandable metal stents. The main indication for dilation alone is primary sclerosing cholangitis related strictures. In the vast majority of the remaining cases, temporary placement of multiple plastic stents with/without dilation is considered the treatment of choice. Although this approach is effective, it requires multiple endoscopic sessions due to the short duration of stent patency. Fully covered self-expandable metal stents appear as a good alternative to plastic stents, since they have an increased radial diameter, longer stent patency, easier insertion technique and similar efficacy. Recent advances in endoscopic technique and various devices have allowed successful treatment in most cases. The development of novel endoscopic techniques and devices is still ongoing.

• Benign biliary strictures
• Bile duct stricture
• Endoscopic retrograde cholangiopancreatography
• Stents
• Cholecystectomy
• Liver transplantation
• Primary sclerosing cholangitis
• Chronic pancreatitis

Many advances have been achieved in biliary stenting over the past 30 years. Endoscopic stent placement has become the primary management therapy to relieve obstruction in patients with benign or malignant biliary tract diseases. Compared with plastic stents, a self-expandable metallic stent (SEMS) has been used for management in patients with malignant strictures because of a larger lumen and longer stent patency. Recently, SEMS has been used for various benign biliary strictures and leaks. In this article, we briefly review the characteristics of SEMS as well as complications of stent placement. We review the current guidelines for managing malignant and benign biliary obstructions. Recent developments in biliary stenting are also discussed.

• Benign
• Biliary stenting
• Malignant
• Self expandable metallic stents

• Drug-eluting stents
• Endoscopy, gastrointestinal
• Stents

• Aged
• Aged, 80 and over
• Bile Duct Neoplasms/complications
• Bile Reflux/prevention & control
• Cholestasis/therapy
• Equipment Design
• Feasibility Studies
• Female
• Humans
• Male
• Metals
• Middle Aged
• Pilot Projects
• Stents

Endoscopic stenting is increasingly being used in the management of gastrointestinal luminal obstruction, and has become the current treatment of choice for the palliation of blockage caused by malignant or benign growths. A variety of stents have been developed to enhance the efficacy of the procedure, and improvements are ongoing. In this article, we review the history of, and recent advances in, gastrointestinal stenting. We describe the rationale behind the design as well as the resulting outcome for each stent type.

• Drug-eluting stents
• Endoscopy, gastrointestinal
• Stents

• SEMS
• self-expanding metallic stent

• Biliary tract diseases
• Cholestasis
• Extrahepatic
• Pancreatic neoplasms
• Stents

• Cholangiopancreatography, Endoscopic Retrograde/instrumentation
• Cholestasis/diagnosis
• Cholestasis/etiology
• Cholestasis/therapy
• Decompression, Surgical
• Drainage/instrumentation
• Drainage/methods
• Gastric Outlet Obstruction/etiology
• Gastric Outlet Obstruction/therapy
• Humans
• Jaundice, Obstructive/diagnosis
• Jaundice, Obstructive/etiology
• Jaundice, Obstructive/therapy
• Metals
• Palliative Care
• Pancreatic Neoplasms/complications
• Pancreatic Neoplasms/pathology
• Pancreatic Neoplasms/therapy
• Plastics
• Prosthesis Design
• Stents
• Time Factors
• Treatment Outcome

Cholangiocarcinoma (bile duct cancer) is the most common malignant tumor of the biliary tree. This devastating malignancy presents late, and is notoriously difficult to diagnose, thus resulting a high mortality. The majority of cholangiocarcinoma patients present with an unresectable disease, and survive less than 12 mo following diagnosis. Biliary stent placement is an effective palliative therapy for malignant biliary obstruction, which can significantly improve the quality of life, and extend the survival time of patients. Different biliary stent placement methods would closely affect the prognosis of patients. The purpose of this article is to review the treatment efficacy, insertion paths and types of biliary stents. This paper also covers emerging biliary stents including drug stents, and biliary stent combination local therapy.

• Cholangiocarcinoma
• Biliary stent
• Photodynamic therapy
• Endobiliary radiofrequency ablation

Biliary stents are widely used not only for palliative treatment of malignant biliary obstruction but also for benign biliary diseases. Each plastic stent or self-expandable metal stent (SEMS) has its own advantages, and a proper stent should be selected carefully for individual condition. To compensate and overcome several drawbacks of SEMS, functional self-expandable metal stent (FSEMS) has been developed with much progress so far. This article looks into the outcomes and defects of each stent type for benign biliary stricture and describes newly introduced FSEMSs according to their functional categories.

• Bile ducts, extrahepatic
• Biliary tract
• Drug-eluting stents
• Stents