International study of endoscopic management of distal malignant biliary obstruction combined with duodenal obstruction

Abstract

Objective: Endoscopic transpapillary or endoscopic ultrasound (EUS)-guided stent placement is used for nonresectable distal malignant biliary obstruction. We conducted a retrospective study to evaluate endoscopic biliary drainage in patients with duodenal obstruction.

Methods: We included consecutive patients who underwent endoscopic biliary drainage combined with a duodenal stent at 16 referral centers in four Asian countries. The primary outcome was time to recurrent biliary obstruction (TRBO). We assessed TRBO according to the sequence of biliary and duodenal obstruction (group 1/2/3, biliary obstruction first/concurrent/duodenal obstruction first, respectively) or the location of duodenal obstruction (type I/II/III, proximal to/affecting/distal to the ampulla, respectively). We also evaluated functional success and adverse events.

Results: We included 110 patients (group1/2/3, 67/29/14 patients; type I/II/III, 45/46/19 patients; endoscopic retrograde cholangiopancreatography [ERCP]/EUS-guided choledocoduodenostomy/EUS-guided hepaticogastrostomy, 90/10/10 patients, respectively). The median TRBO of all cases was 450 days (interquartile range, 212–666 days) and functional success was achieved in 105 cases (95%). The TRBO did not differ significantly by the timing or location of duodenal obstruction (p = .30 and .79, respectively). The TRBO of metal stents (n = 96) tended to be longer compared with plastic stents (n = 14, p = .083). Compared with ERCP, EUS-guided biliary drainage was associated with a higher rate of adverse events.

Conclusion: Transpapillary or transmural endoscopic biliary drainage with a duodenal stent was effective, irrespective of the timing or location of duodenal obstruction. A prospective study is required considering the tradeoff of technical success rate, stent patency, and adverse events (ClinicalTrials.gov number, NCT02376907).

Keywords:

• Common bile duct
• endoscopic retrograde cholangiopancreatography
• endoscopic ultrasound
• gastric outlet obstruction
• stent

Acknowledgements

We would like to appreciate the following contributors for their valuable comments and support in data collection: Hirofumi Kogure, Natsuyo Yamamoto and Kazuhiko Koike, Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Miyuki Tsuchida, Clinical Research Support Center, The University of Tokyo Hospital, Tokyo, Japan; Anthony Y.B. Teoh, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR; Hyun Jong Choi, Department of Internal Medicine, Digestive Disease Center and Research Institute, Soon Chun Hyang University School of Medicine, Seoul, Korea; Xiao Zheng, Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, P.R. China; Shinpei Doi, First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan; Hirotoshi Iwano, Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan; Ryunosuke Hakuta, Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan; Shigefumi Omuta, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan; Fumihide Itokawa, Takayoshi Tsuchiya, and Takao Itoi, Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan; Atsushi Irisawa, Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan; Rungsun Rerknimitr, Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand; Christopher Khor, Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore; Hsiu-Po Wang, Endoscopic Division, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan; Thawee Ratanachu-ek, Department of Surgery, Rajavithi Hospital, Bangkok, Thailand; Sundeep Lakhtakia, Asian Institute of Gastroenterology, Hyderabad, India; Tiing Leong Ang, Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore and Ryan Ponnudurai, Department of Gastroenterology, Prince Court Medical Centre, Kuala Lumpur, Malaysia.

Disclosure statement

The authors declare no conflicts of interest related to this article.

Additional information

Funding

This study was supported by unrestricted education grants from Century Medical Inc., FujiFilm Medical Corp. and Hitachi Medical Company. None of those companies were involved in study design, data collection and analysis, decision to publish this work or manuscript drafting.