Endoscopic therapy in extrahepatic biliary strictures

Carola Haapamäki

Research output: ThesisDoctoral ThesisCollection of Articles

Abstract

Extrahepatic biliary strictures are mainly managed using stents when treated endoscopically. At present, the main stent types in clinical practice are non expandable plastic stents (NEPS) and self-expandable metallic stents (SEMS), with an up to tenfold cost for the latter. In current praxis, SEMS are widely used for palliative management of malignant biliary strictures as they have longer patency.The role of SEMS in preoperative stenting and the management of benign biliary strictures (BBS) are unclear. The main purpose of this study was to describe the therapy outcome of metallic stenting in anastomotic strictures of liver transplanted (LT) patients, to compare stenting with NEPS and SEMS preoperatively preceding pancreaticoduodenectomy and in BBS caused by chronic pancreatitis (CP) and, finally, to describe stenting of BBS using covered SEMS (cSEMS), a new technique that has not previously been possible, particularly in patients with surgically altered anatomy. The therapy outcome of 17 LT patients with anastomotic biliary stricture or leakage treated with cSEMS was retrospectively analyzed in the piloting study (I). In Study II, the stent success and the surgical outcome of 191 patients preoperatively stented, with either NEPS or SEMS who had undergone pancreatic oduodenectomy or total pancreatectomy were analyzed in a retrospective manner. As a supplementary group, 166 preoperatively unstented and 9 percutaneously, transhepatically drained patients were evaluated concerning surgical outcome. A prospective, randomized, controlled trial was conducted in Study III to compare multiple NEPS with cSEMS therapy in biliary strictures caused by CP, with 30 patients in each group. Study IV presented three patient cases along with detailed description of equipment, devices, technique and outcome, when using cSEMS for BBS in patients with altered anatomy. The median stenting time for the LT patients (I) was 6.8 months (0.9–10.1). The overall stent migration rate was 24%; 100% for Wallstent™ (n=3), 4% for Allium™ (n=13) and 0% for a custom-made Micro-Tech (n=2) stent. There were two recurrences, but eventual stricture resolution was achieved in all patients after restenting. The median follow-up was 21.7 months (6.6–32.0) after stent removal. For the preoperatively stented patients (II), the stent failure rate was 7.4% (95% confidence interval [CI] 4.0%–12.3%) for NEPS and 3.4% (95% CI 0.1%–17.7%) for SEMS, (p=0.697). Among the NEPS stented patients, 45% with a pre-stent bilirubin level exceeding 50 μmol/l reached a preoperative level of 20 μmol/l or less, compared with 26% in the SEMS group (p=0.110). A level lower than 50 μmol/l was achieved by 80% of patients in the NEPS group and by 61% in the SEMS group (p=0.058). The bile juice bacterial scores did not differ between the differently stented patients but a statistically significant difference was found when the proportion of sterile bile juices in unstented patients with biliary obstruction (100%; n= 7/7) was compared with that of the stented patients (1%; n=1/155; p
Original languageEnglish
Place of PublicationHelsinki
Publisher
Print ISBNs978-951-51-2137-0
Electronic ISBNs978-951-51-2138-7
Publication statusPublished - 2016
MoE publication typeG5 Doctoral dissertation (article)

Fields of Science

  • 3126 Surgery, anesthesiology, intensive care, radiology

Cite this

Haapamäki, C. (2016). Endoscopic therapy in extrahepatic biliary strictures. Helsinki: [C. Haapamäki].
Haapamäki, Carola. / Endoscopic therapy in extrahepatic biliary strictures. Helsinki : [C. Haapamäki], 2016. 82 p.
@phdthesis{dc81abb3b43147249e80fe7c94f9ab1b,
title = "Endoscopic therapy in extrahepatic biliary strictures",
abstract = "Extrahepatic biliary strictures are mainly managed using stents when treated endoscopically. At present, the main stent types in clinical practice are non expandable plastic stents (NEPS) and self-expandable metallic stents (SEMS), with an up to tenfold cost for the latter. In current praxis, SEMS are widely used for palliative management of malignant biliary strictures as they have longer patency.The role of SEMS in preoperative stenting and the management of benign biliary strictures (BBS) are unclear. The main purpose of this study was to describe the therapy outcome of metallic stenting in anastomotic strictures of liver transplanted (LT) patients, to compare stenting with NEPS and SEMS preoperatively preceding pancreaticoduodenectomy and in BBS caused by chronic pancreatitis (CP) and, finally, to describe stenting of BBS using covered SEMS (cSEMS), a new technique that has not previously been possible, particularly in patients with surgically altered anatomy. The therapy outcome of 17 LT patients with anastomotic biliary stricture or leakage treated with cSEMS was retrospectively analyzed in the piloting study (I). In Study II, the stent success and the surgical outcome of 191 patients preoperatively stented, with either NEPS or SEMS who had undergone pancreatic oduodenectomy or total pancreatectomy were analyzed in a retrospective manner. As a supplementary group, 166 preoperatively unstented and 9 percutaneously, transhepatically drained patients were evaluated concerning surgical outcome. A prospective, randomized, controlled trial was conducted in Study III to compare multiple NEPS with cSEMS therapy in biliary strictures caused by CP, with 30 patients in each group. Study IV presented three patient cases along with detailed description of equipment, devices, technique and outcome, when using cSEMS for BBS in patients with altered anatomy. The median stenting time for the LT patients (I) was 6.8 months (0.9–10.1). The overall stent migration rate was 24{\%}; 100{\%} for Wallstent™ (n=3), 4{\%} for Allium™ (n=13) and 0{\%} for a custom-made Micro-Tech (n=2) stent. There were two recurrences, but eventual stricture resolution was achieved in all patients after restenting. The median follow-up was 21.7 months (6.6–32.0) after stent removal. For the preoperatively stented patients (II), the stent failure rate was 7.4{\%} (95{\%} confidence interval [CI] 4.0{\%}–12.3{\%}) for NEPS and 3.4{\%} (95{\%} CI 0.1{\%}–17.7{\%}) for SEMS, (p=0.697). Among the NEPS stented patients, 45{\%} with a pre-stent bilirubin level exceeding 50 μmol/l reached a preoperative level of 20 μmol/l or less, compared with 26{\%} in the SEMS group (p=0.110). A level lower than 50 μmol/l was achieved by 80{\%} of patients in the NEPS group and by 61{\%} in the SEMS group (p=0.058). The bile juice bacterial scores did not differ between the differently stented patients but a statistically significant difference was found when the proportion of sterile bile juices in unstented patients with biliary obstruction (100{\%}; n= 7/7) was compared with that of the stented patients (1{\%}; n=1/155; p",
keywords = "Anastomosis, Surgical, Anastomotic Leak, +therapy, Bile Duct Diseases, Bile Ducts, +surgery, Cholangiopancreatography, Endoscopic Retrograde, Cholestasis, Extrahepatic, Combined Modality Therapy, Common Bile Duct Diseases, Constriction, Pathologic, +etiology, Decompression, Surgical, +methods, Double-Balloon Enteroscopy, Endoscopy, Gastroenterostomy, Jaundice, Obstructive, Liver Transplantation, +adverse effects, Pancreatic Neoplasms, Pancreaticoduodenectomy, Pancreatitis, Chronic, +complications, Postoperative Complications, Preoperative Care, Self Expandable Metallic Stents, Stents, Sphincterotomy, Endoscopic, Treatment Outcome, 3126 Surgery, anesthesiology, intensive care, radiology",
author = "Carola Haapam{\"a}ki",
note = "M1 - 82 s. + liitteet Helsingin yliopisto Volume: Proceeding volume:",
year = "2016",
language = "English",
isbn = "978-951-51-2137-0",
publisher = "[C. Haapam{\"a}ki]",
address = "Finland",

}

Endoscopic therapy in extrahepatic biliary strictures. / Haapamäki, Carola.

Helsinki : [C. Haapamäki], 2016. 82 p.

Research output: ThesisDoctoral ThesisCollection of Articles

TY - THES

T1 - Endoscopic therapy in extrahepatic biliary strictures

AU - Haapamäki, Carola

N1 - M1 - 82 s. + liitteet Helsingin yliopisto Volume: Proceeding volume:

PY - 2016

Y1 - 2016

N2 - Extrahepatic biliary strictures are mainly managed using stents when treated endoscopically. At present, the main stent types in clinical practice are non expandable plastic stents (NEPS) and self-expandable metallic stents (SEMS), with an up to tenfold cost for the latter. In current praxis, SEMS are widely used for palliative management of malignant biliary strictures as they have longer patency.The role of SEMS in preoperative stenting and the management of benign biliary strictures (BBS) are unclear. The main purpose of this study was to describe the therapy outcome of metallic stenting in anastomotic strictures of liver transplanted (LT) patients, to compare stenting with NEPS and SEMS preoperatively preceding pancreaticoduodenectomy and in BBS caused by chronic pancreatitis (CP) and, finally, to describe stenting of BBS using covered SEMS (cSEMS), a new technique that has not previously been possible, particularly in patients with surgically altered anatomy. The therapy outcome of 17 LT patients with anastomotic biliary stricture or leakage treated with cSEMS was retrospectively analyzed in the piloting study (I). In Study II, the stent success and the surgical outcome of 191 patients preoperatively stented, with either NEPS or SEMS who had undergone pancreatic oduodenectomy or total pancreatectomy were analyzed in a retrospective manner. As a supplementary group, 166 preoperatively unstented and 9 percutaneously, transhepatically drained patients were evaluated concerning surgical outcome. A prospective, randomized, controlled trial was conducted in Study III to compare multiple NEPS with cSEMS therapy in biliary strictures caused by CP, with 30 patients in each group. Study IV presented three patient cases along with detailed description of equipment, devices, technique and outcome, when using cSEMS for BBS in patients with altered anatomy. The median stenting time for the LT patients (I) was 6.8 months (0.9–10.1). The overall stent migration rate was 24%; 100% for Wallstent™ (n=3), 4% for Allium™ (n=13) and 0% for a custom-made Micro-Tech (n=2) stent. There were two recurrences, but eventual stricture resolution was achieved in all patients after restenting. The median follow-up was 21.7 months (6.6–32.0) after stent removal. For the preoperatively stented patients (II), the stent failure rate was 7.4% (95% confidence interval [CI] 4.0%–12.3%) for NEPS and 3.4% (95% CI 0.1%–17.7%) for SEMS, (p=0.697). Among the NEPS stented patients, 45% with a pre-stent bilirubin level exceeding 50 μmol/l reached a preoperative level of 20 μmol/l or less, compared with 26% in the SEMS group (p=0.110). A level lower than 50 μmol/l was achieved by 80% of patients in the NEPS group and by 61% in the SEMS group (p=0.058). The bile juice bacterial scores did not differ between the differently stented patients but a statistically significant difference was found when the proportion of sterile bile juices in unstented patients with biliary obstruction (100%; n= 7/7) was compared with that of the stented patients (1%; n=1/155; p

AB - Extrahepatic biliary strictures are mainly managed using stents when treated endoscopically. At present, the main stent types in clinical practice are non expandable plastic stents (NEPS) and self-expandable metallic stents (SEMS), with an up to tenfold cost for the latter. In current praxis, SEMS are widely used for palliative management of malignant biliary strictures as they have longer patency.The role of SEMS in preoperative stenting and the management of benign biliary strictures (BBS) are unclear. The main purpose of this study was to describe the therapy outcome of metallic stenting in anastomotic strictures of liver transplanted (LT) patients, to compare stenting with NEPS and SEMS preoperatively preceding pancreaticoduodenectomy and in BBS caused by chronic pancreatitis (CP) and, finally, to describe stenting of BBS using covered SEMS (cSEMS), a new technique that has not previously been possible, particularly in patients with surgically altered anatomy. The therapy outcome of 17 LT patients with anastomotic biliary stricture or leakage treated with cSEMS was retrospectively analyzed in the piloting study (I). In Study II, the stent success and the surgical outcome of 191 patients preoperatively stented, with either NEPS or SEMS who had undergone pancreatic oduodenectomy or total pancreatectomy were analyzed in a retrospective manner. As a supplementary group, 166 preoperatively unstented and 9 percutaneously, transhepatically drained patients were evaluated concerning surgical outcome. A prospective, randomized, controlled trial was conducted in Study III to compare multiple NEPS with cSEMS therapy in biliary strictures caused by CP, with 30 patients in each group. Study IV presented three patient cases along with detailed description of equipment, devices, technique and outcome, when using cSEMS for BBS in patients with altered anatomy. The median stenting time for the LT patients (I) was 6.8 months (0.9–10.1). The overall stent migration rate was 24%; 100% for Wallstent™ (n=3), 4% for Allium™ (n=13) and 0% for a custom-made Micro-Tech (n=2) stent. There were two recurrences, but eventual stricture resolution was achieved in all patients after restenting. The median follow-up was 21.7 months (6.6–32.0) after stent removal. For the preoperatively stented patients (II), the stent failure rate was 7.4% (95% confidence interval [CI] 4.0%–12.3%) for NEPS and 3.4% (95% CI 0.1%–17.7%) for SEMS, (p=0.697). Among the NEPS stented patients, 45% with a pre-stent bilirubin level exceeding 50 μmol/l reached a preoperative level of 20 μmol/l or less, compared with 26% in the SEMS group (p=0.110). A level lower than 50 μmol/l was achieved by 80% of patients in the NEPS group and by 61% in the SEMS group (p=0.058). The bile juice bacterial scores did not differ between the differently stented patients but a statistically significant difference was found when the proportion of sterile bile juices in unstented patients with biliary obstruction (100%; n= 7/7) was compared with that of the stented patients (1%; n=1/155; p

KW - Anastomosis, Surgical

KW - Anastomotic Leak

KW - +therapy

KW - Bile Duct Diseases

KW - Bile Ducts

KW - +surgery

KW - Cholangiopancreatography, Endoscopic Retrograde

KW - Cholestasis, Extrahepatic

KW - Combined Modality Therapy

KW - Common Bile Duct Diseases

KW - Constriction, Pathologic

KW - +etiology

KW - Decompression, Surgical

KW - +methods

KW - Double-Balloon Enteroscopy

KW - Endoscopy

KW - Gastroenterostomy

KW - Jaundice, Obstructive

KW - Liver Transplantation

KW - +adverse effects

KW - Pancreatic Neoplasms

KW - Pancreaticoduodenectomy

KW - Pancreatitis, Chronic

KW - +complications

KW - Postoperative Complications

KW - Preoperative Care

KW - Self Expandable Metallic Stents

KW - Stents

KW - Sphincterotomy, Endoscopic

KW - Treatment Outcome

KW - 3126 Surgery, anesthesiology, intensive care, radiology

M3 - Doctoral Thesis

SN - 978-951-51-2137-0

PB - [C. Haapamäki]

CY - Helsinki

ER -

Haapamäki C. Endoscopic therapy in extrahepatic biliary strictures. Helsinki: [C. Haapamäki], 2016. 82 p.