Endoscopic Reintervention for Recurrence of Malignant Biliary Obstruction: Developing the Best Strategy

Abstract

Drainage therapy for malignant biliary obstruction (MBO) includes trans-papillary endoscopic retrograde biliary drainage (ERBD), percutaneous transhepatic biliary drainage (PTBD), and trans-gastrointestinal endoscopic ultrasound-guided biliary drainage (EUS-BD). With the development of chemotherapy, many MBO cases end up needing endoscopic reintervention (E-RI) for recurrent biliary obstruction. To achieve a successful E-RI, it is necessary to understand the various findings regarding E-RI in MBO cases reported to date. Therefore, in this review, we focus on E-RI for ERBD of distal MBO, ERBD of hilar MBO, and EUS-BD. To plan an appropriate E-RI strategy for biliary stent occlusion for MBO, the following must be considered on a case-by-case basis: the urgency of the drainage, the cause of the occlusion, the original route of drainage (PTBD/ERBD/EUS-BD), the initial stent used (plastic stent or self-expandable metallic stent), and in the case of self-expandable metallic stents, the type used (fully covered or uncovered). Regardless of the original method of stent placement, if the inflammation caused by obstructive cholangitis is severe and/or the patient is in shock, PTBD should be considered as the first choice. Finally, it is important to keep in mind that in many cases, performing E-RI will be difficult.

Keywords: Interventional ultrasonography; Jaundice; Stent; obstructive.

Fig. 1

Endoscopic reintervention of a fully covered self-expandable metallic stent (SEMS) for distal malignant biliary obstruction. (A) Biliary cannulation through the opening of a fully covered SEMS is easy to perform. (B) In this case, the patient had obstructive cholangitis due to stent obstruction and common bile duct stones. Endoscopic retrograde cholangiography confirmed a defect due to stones. (C) A fully covered SEMS was grasped by the snare and removed without resistance. (D) Biliary cannulation after SEMS removal is relatively easy. (E) Removal of the stone was performed using a balloon catheter. (F) Stone removal was successful. (G) An attempt was then made to insert a new fully covered SEMS. The device easily passed through the stenosis. (H) New fully covered SEMS placement was successful. (I) The new fully covered SEMS was visible through fluoroscopy.

Fig. 2

Schema showing the difficulty of endoscopic reintervention using stent-in-stent (SIS) placement in hilar malignant biliary obstruction. (A) For SIS placement, the existing mesh overlaps the stenosis. (B) The guide wire can pass through the mesh of the second metallic stent (MS) detained during SIS detention. (C) However, it is necessary to pass the existing mesh in the stenosis twice to the bile duct where the first MS is placed, and it is difficult for the guide wire to pass through. (D) In addition, even if the guide wire passes, it is difficult for the device to pass.

Fig. 3

Endoscopic reintervention for endoscopic ultrasound-guided hepaticogastrostomy. (A) In endoscopic reintervention for endoscopic ultrasound-guided hepaticogastrostomy, insertion of the device through the end of the stent in the gastric lumen is difficult. (B-D) The previously indwelled stent was a fully covered self-expandable metallic stent (SEMS), which could be grasped with grasping forceps and removed through the scope. (E) The guidewire inserted through the fistula into the bile duct could be seen. (F) A new SEMS delivery chip was inserted under this guidewire. (G-I) The new SEMS replacement was successful.