Angle of covered self-expandable metallic stents after placement is a risk factor for recurrent biliary obstruction

Kojiro Tanoue; Hirotsugu Maruyama; Yuki Ishikawa-Kakiya; Yosuke Kinoshita; Kappei Hayashi; Masafumi Yamamura; Masaki Ominami; Yuji Nadatani; Shusei Fukunaga; Koji Otani; Shuhei Hosomi; Fumio Tanaka; Noriko Kamata; Yasuaki Nagami; Koichi Taira; Toshio Watanabe; Yasuhiro Fujiwara

doi:10.4254/wjh.v14.i5.992

Angle of covered self-expandable metallic stents after placement is a risk factor for recurrent biliary obstruction

World J Hepatol. 2022 May 27;14(5):992-1005. doi: 10.4254/wjh.v14.i5.992.

Authors

Kojiro Tanoue¹, Hirotsugu Maruyama², Yuki Ishikawa-Kakiya¹, Yosuke Kinoshita¹, Kappei Hayashi¹, Masafumi Yamamura¹, Masaki Ominami¹, Yuji Nadatani¹, Shusei Fukunaga¹, Koji Otani¹, Shuhei Hosomi¹, Fumio Tanaka¹, Noriko Kamata¹, Yasuaki Nagami¹, Koichi Taira¹, Toshio Watanabe¹, Yasuhiro Fujiwara¹

Affiliations

¹ Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan.
² Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan. hiromaruyama99@gmail.com.

Abstract

Background: Studies have shown that covered self-expandable metallic stents (CSEMS) with a low axial forces after placement can cause early recurrent biliary obstruction (RBO) due to precipitating sludge formation.

Aim: To ascertain whether the angle of CSEMS after placement is a risk factor for RBO in unresectable distal malignant biliary obstruction (MBO).

Methods: Between January 2010 and March 2019, 261 consecutive patients underwent self-expandable metallic stent insertion by endoscopic retrograde cholangiopancreatography at our facility, and 87 patients were included in this study. We evaluated the risk factors for RBO, including the angle of CSEMS after placement as the primary outcome. We measured the obtuse angle of CSEMS after placement on an abdominal radiograph using the SYNAPSE PACS system. We also evaluated technical and functional success, adverse events, time to RBO (TRBO), non-RBO rate, survival time, cause of RBO, and reintervention procedure as secondary outcomes.

Results: We divided the patients into two cohorts based on the presence or absence of RBO. The angle of CSEMS after placement (per 1° and per 10°) was evaluated using the multivariate Cox proportional hazard analysis, which was an independent risk factor for RBO in unresectable distal MBO [hazard ratio, 0.97 and 0.71; 95% confidence interval (CI): 0.94-0.99 and 0.54-0.92; P = 0.01 and 0.01, respectively]. For early diagnosis of RBO, the cut-off value of the angle of CSEMS after placement using the receiver operating characteristic curve was 130° [sensitivity, 50.0%; specificity 85.5%; area under the curve 0.70 (95%CI: 0.57-0.84)]. TRBO in the < 130° angle group was significantly shorter than that in the ≥ 130° angle group (P < 0.01).

Conclusion: This study suggests that the angle of the CSEMS after placement for unresectable distal MBO is a risk factor for RBO. These novel results provide pertinent information for future stent management.

Keywords: Angle; Axial force; Covered self-expandable metallic stents; Endoscopic retrograde cholangiopancreatography; Malignant biliary obstruction; Recurrent biliary obstruction.