The 4th Joint Session between JDDW-KDDW-TDDW3(JDDW)
Thu. November 5th   9:00 - 11:15   Room 10: Portopia Hotel Waraku
JKT3-1
 History and current strategy of endoscopic stenting for unresectable malignant distal biliary obstruction
Hiroyuki Isayama
Department of Gastroenterology, Graduate School of Medicine, Juntendo University
Introduction: Obstructive jaundice should be managed by effective and low invasive procedure. Developing of endoscopic biliary stenting was beneficial on QOL and survival in the patients with unresectable malignant biliary obstruction (MBO).
Stent development: Initially, only plastic stent had been available, and occlusion with biliary sludge and migration were the main cause of recurrence biliary obstruction (RBO). Uncovered self-expandable metallic stent (USEMS) has larger diameter (10mm) and showed low incidence of migration. However, because of mesh structure, occlusion due to tumor ingrowth was not able to prevent. Covered SEMS (CSEMS) had been developed to prevent tumor ingrowth, and removability was the additional advantage. Initial RCT comparing covered and uncovered SEMS showed superiority of CSEMS in time to RBO (TRBO). However, some RCT failed to show the superiority because of high incidence of migration.
Complications and mechanical properties of SEMS: There are 2 types of mechanical properties: radial and axial force (RF and AF). RF is well known expansion force which related with dilation of stricture. On the other hand, AF is newly proposed by the author. AF is straightening force when the stent vended, and SEMS with strong AF may cause kinking and injury of the bile duct. Strong AF may cause pancreatitis and cholecystitis as well. Each complication has particular cause, non-pancreatic cancer for pancreatitis and tumor involvement of orifice of cystic duct for cholecystitis.
Effort to prolong time to RBO: Prevention of migrations was the unresolved issue for CSEMS, and the identified risk factors were weak RF and chemotherapy. Recent development of effective chemotherapy for pancreatic and bile duct cancer may increase the incidence of migration. Flaps, flare and square flares were tried, but there was no ideal CSEMS with anti-migration. Other efforts were larger diameter SEMS (12 mm), anti-reflux system, drug eluting CSEMS, etc., but these were under development status.
Endoscopic ultrasonography (EUS)-guided biliary drainage (EUS-BD): EUS-BD was indicated for the cases with difficult/impossible/failed biliary access required biliary drainage. However, recent development of the procedures and equipment, EUS-BD is tried to perform as primary drainage procedure. Evaluation of superiority of EUS-BD to the ERCP-related biliary drainage was the next decade issue after establishment of EUS-BD.
Conclusions: There was no-ideal stent and procedure for the cases with unresectable MBO, and continuous effort was required
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