Stent placement above the sphincter of Oddi permits implementation of neoadjuvant chemotherapy in patients with initially unresectable Klatskin tumor

 

 Permissions and Reprints

Background and study aims: Neoadjuvant chemotherapy (NAC) may lead to a successful margin-negative resection in patients with initially unresectable locally advanced Klatskin tumor (IULAKT). Use of removable plastic stents is preferable for the safe implementation of NAC in patients with IULAKT to reduce the risk of recurrent cholangitis. Our aim was to evaluate the efficacy associated with the use of plastic stents placed across the stenosis and above the papilla (above stent) during NAC.

Patients and methods: In this study, we stratified the patients into two groups chronologically with respect to the period of stent placement: above stent group (n = 17) and across stent group (n = 23) (plastic stent across the sphincter of Oddi).

Results: The median stent patency period was 99 days in the above stent group and 31 days in the across stent group (P < 0.0001). The number of stents (P = 0.017) and the rate of emerging undrained cholangitis areas (P = 0.025) were significantly reduced in the above stent group than the counterpart. Regarding time to recurrent biliary obstruction, the above stent group had a longer duration than the across stent group (log rank test, P = 0.004). Length of hospital stay was significantly shorter for the above stent group than the across stent group (P = 0.0475). Multivariate analysis revealed that above stent placement (odds ratio = 33.638, P = 0.0048) was significantly associated with stent patency over a period of 90 days.

Conclusions: Above stent placement should be considered for the relief of biliary obstruction and potentially reduces the cost for patients with IULAKT scheduled to receive NAC.

• References

• 1 Jamagin WR, Fong Y, Metatteo RP et al. Staging, Resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg 2001; 234: 507-519
  CrossrefPubMedGoogle Scholar
• 2 Finn MP, Annmarie TL, Ove BSM et al. Randomized trial of stent placed above and across the sphincter of Oddi in malignant bile duct obstruction. Gastrointest Endosc 1998; 48: 574-582
  CrossrefPubMedGoogle Scholar
• 3 Miyakawa S, Ishihara S, Horiguchi A et al. Biliary tract cancer treatment: 5548 results from the biliary tract cancer statistics registry from 1998 to 2004 in Japan. J Hepatobiliary Pancreas Science 2009; 16: 1-7
  PubMedGoogle Scholar
• 4 Ruys AT, van Beem BE, Engelbrecht MR et al. Radiological staging in patients with hilar cholangiocarcinoma: A systemic review and meta-analysis. Br J. Radiol 2012; 85: 1255-1262
  CrossrefPubMedGoogle Scholar
• 5 Kim SH, Kim IH, Kim SW. Repetitive response to gemcitabine that led to curative resection in cholangiocarcinoma. World J Gastroenterol 2009; 15: 4593-4595
  CrossrefPubMedGoogle Scholar
• 6 Kato A, Shimizu H, Ohtsuka M et al. Surgical resection after downstaging chemotherapy for initially unresectable locally advanced biliary tract cancer: A retrospective single-center study. Ann Surg Oncol 2013; 20: 318-324
  CrossrefPubMedGoogle Scholar
• 7 Weickert U, Venzke T, Konig J et al. Why do bilioduedenal plastic stents become occuluded? A clinical and pathological investigation on 100 consecutive patients. Endoscopy 2001; 33: 786-790
  Article in Thieme ConnectPubMedGoogle Scholar
• 8 Kawakami H, Kuwatani M, Onodera M et al. Endoscopic nasobiliary drainage is the most suitable preoperative biliary drainage method in the management of patients with hilar cholangiocarcinoma. J Gastroenterol 2011; 46: 242-248
  CrossrefPubMedGoogle Scholar
• 9 Liu Q, Khay G, Cotton PB. Feasibility of stent placement above the sphincter of Oddi (“inside-stent”) for patients with malignant biliary obstruction. Endoscopy 1998; 30: 687-690
  Article in Thieme ConnectPubMedGoogle Scholar
• 10 Pedersen FM, Lassen AT, Schaffalitzky de Muckadell OB. Randomized trial of stent placed above and 11across the sphincter of Oddi in malignant bile duct obstruction. Gastrointest Endosc 1998; 48: 574-579
  CrossrefPubMedGoogle Scholar
• 11 Isayama H, Hamada T, Yasuda I et al. The Tokyo criteria 2014 for transpapillary biliary biliary stenting. Digestive Endosc 2015; 27: 259-264
  PubMedGoogle Scholar
• 12 Endo I, Shimada H, Sugita M et al. Role of three dimensional imaging in operative planning for hilar cholangiocarcinoma. Surgery 2007; 142: 666-675
  CrossrefPubMedGoogle Scholar
• 13 Eisenhaiser EA, Therasse P, Bogaerts J et al. New response evaluation criteria in solid tumors: Revised RECIST guideline (version 1.1). Eur J Cancer 2009; 45: 228-247
  CrossrefPubMedGoogle Scholar
• 14 Seo H, Lee JM, Kim IH et al. Evaluation of the gross type and longitudinal extent of extrahepatic cholangiocarcinomas on contrast-enhancement multidetector row computed tomography. J Comput Assist Tomogr 2009; 33: 376-382
  CrossrefPubMedGoogle Scholar
• 15 Ishiwatari H, Hayashi T, Ono M et al. Newly designed plastic stent for endoscopic placement above the sphincter of Oddi in patients with malignant hilar biliary obstruction. Dig Endosc 2013; 25: 94-99
  PubMedGoogle Scholar
• 16 Kobayashi N, Watanabe S, Hosono K et al. Endoscopic inside stent placement is a suitable as a bridging treatment for preoperative biliary tract cancer. BMC Gastroenterol 2015; 15: 8
  CrossrefPubMedGoogle Scholar
• 17 Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complication and their management: an attempt at concensus. Gastrointest Endosc 1991; 37: 383-393
  CrossrefPubMedGoogle Scholar
• 18 Weinbren K, Mutum SS. Pathological aspects of cholangiocarcinoma. J Pathology 1983; 139: 217-238
  CrossrefPubMedGoogle Scholar
• 19 Bithmuth H, Nakache R, Diamond T. Management strategies in resection for hilar biliary cholangiocarcinoma. Ann Ssurg 1992; 215: 31-38
  PubMedGoogle Scholar
• 20 Juntermanns B, Sotiropoulos GC, Radunz S et al. Comparison of the sixth and the seventh editions of the UICC classification for perihilar cholangiocarcinoma. Ann Surg Oncol 2013; 20: 277-284
  CrossrefPubMedGoogle Scholar
• 21 Iacono C, Ruzzenente A, Campagnaro T et al. Role of preoperative biliary drainage in jaundiced patients who are candidates for pancreatoduodenectomy or hepatic resection: highlights and drawbacks. Ann Surg 2013; 257: 191-204
  CrossrefPubMedGoogle Scholar
• 22 Saxena P, Kumbhari V, Zein ME et al. Preoperative biliary drainage. Dig Endosc 2015; 27: 265-277
  CrossrefPubMedGoogle Scholar
• 23 Okamoto T, Fujioka S, Yanagisawa S et al. Placement of a metallic stent across the main duodenal papilla may predispose to cholangitis. Gastrointest Endosc 2006; 63: 792-796
  CrossrefPubMedGoogle Scholar
• 24 Hisatsune H, Yazumi S, Egawa H et al. Endoscopic management of biliary strictures after duct-to-duct biliary reconstruction in right-lobe living-donor liver transplantation. Transplantation 2003; 765: 810-815
  PubMedGoogle Scholar
• 25 Shimizu H, Kimura F, Yoshitomi H et al. Aggressive surgical resection of hilar cholangiocarcinoma of the left-side predominance: radicality and safety of left-sided hepatectomy. Ann Surg 2010; 251: 281-286
  CrossrefPubMedGoogle Scholar
• 26 Valle J, Wasan H, Palmer DH et al. Cisplatin plus gemcitabine for biliary tract cancer. N Engl J Med 2010; 362: 1273-1281
  Google Scholar
• 27 Kloek JJ, Heger M, van der Gaag NA et al. Effect of preoperative biliary drainage on coagulation and fibrinolysis in severe obstructive cholangitis. J Clin Gastroenterol 2010; 44: 646-652
  CrossrefPubMedGoogle Scholar
• 28 Yasuda I, Tomita E, Enya M et al. Can endoscopic papillary baloon dilation really preserve sphincter of Oddi function?. Gut 2001; 49: 686-691
  CrossrefPubMedGoogle Scholar
• 29 Leung JW, Liu YL, Desta T et al. Is there a synergistic effect between mixed bacterial infection in biofilm formation on biliary stents?. Gastrointest Endosc 1998; 48: 250-257
  CrossrefPubMedGoogle Scholar
• 30 Inatomi O, Bamba S, Shioya N et al. Threaded biliary inside stents are a safe and effective therapeutic option in cases of malignant hilar obstruction. BMC Gastroenterol 2013; 13: 31
  CrossrefPubMedGoogle Scholar