Gastrointest Interv 2018; 7(2): 78-84  https://doi.org/10.18528/gii180014
Which is better for unresectable malignant hilar biliary obstruction: Side-by-side versus stent-in-stent?
Itaru Naitoh,1,* Tadahisa Inoue,2 Kazuki Hayashi1
1Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
2Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuhoku, Nagoya 467-8601, Japan. E-mail address: inaito@med.nagoya-cu.ac.jp (I. Naitoh). ORCID: https://orcid.org/0000-0001-8342-886X
Received: April 26, 2018; Revised: June 22, 2018; Accepted: June 22, 2018; Published online: July 31, 2018.
© Society of Gastrointestinal Intervention. All rights reserved.

cc This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Biliary drainage is required for the management of unresectable malignant hilar biliary obstruction (UMHBO), and endoscopic transpapillary drainage is the first-line therapy because it is less invasive. Self-expandable metallic stents (SEMSs) are superior to plastic stents because they have longer stent patency and are more cost-effective. Endoscopic bilateral SEMS placement is technically challenging compared to unilateral placement. However, recent developments in devices and techniques have facilitated bilateral SEMS placement. There are two methods for bilateral hilar SEMS placement for UMHBO: side-by-side (SBS) and stent-in-stent (SIS). Sequential SBS was commonly conducted for bilateral hilar SEMS placement. In a new and thinner delivery system that was developed for SEM placement, two SEMSs could be simultaneously inserted and deployed through the working channel. This new bilateral stenting method enabled us to accomplish simultaneous SBS placement, which increased the success rate of SBS. Insertion of the guidewire and delivery of the second SEMS through the mesh of the first SEMS is challenging in SIS. Newly designed or modified SEMSs that are suitable for SIS have been developed to overcome this challenge, and these SEMSs have facilitated SIS. Uncovered SEMS has been commonly used for hilar SEMS placement, but covered SEMS (CSEMS) is another option for hilar SEMS placement, because CSEMS prevents tumor ingrowth and allows for removal of the stent for re-intervention. Therefore, CSEMS can be used for bilateral SEMS placement in SBS. There are many methods and kinds of SEMS available for bilateral SEMS placement. However, due to lack of evidence, there is no consensus on whether SBS or SIS is optimal for bilateral hilar SEMS placement. In this review, we compared various outcomes between SBS and SIS from previous studies, to clarify which method is better for bilateral SEMS placement for UMHBO.
Keywords: Cholangiopancreatography, endoscopic retrograde; Cholestasis; Klatskin tumor; Self expandable metallic stents


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