title: Outcome of self-expandable metallic stents in low-grade versus advanced hilar obstruction.
abstract: BACKGROUND
  Self-expandable metallic stents (SEMS) are known to provide a longer patency time than plastic stents for malignant biliary obstructions including hilar obstruction. However, studies that focus on the efficacy of SEMS in low-grade and advanced hilar obstructions are still scanty.
  
  
  METHODS
  Ninety four patients with malignant hilar obstructions were enrolled (six were later excluded). Patients were divided into two groups according to their Bismuth levels. Group A were patients with Bismuth I (n = 53). Group B were patients with Bismuth II, III and IV (n = 35). Technical success, complications, jaundice resolution, stent patency time, and patients' survival were analyzed.
  
  
  RESULTS
  Our intention-to-treat analysis showed that group A had a significant lower rate of post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis than group B; 16.1% versus 44.7%, (P < 0.01). Four patients from group B still had persistent jaundice. Our per protocol analysis demonstrated that median stent patency time in groups A and B were not statistically different (74 vs 60 days). Median survival time in groups A and B were also not statistically different (90 vs 75 days). In both groups, those without liver metastasis had significantly better patency and survival time than those with liver metastasis (P = 0.010 and 0.027, respectively).
  
  
  CONCLUSIONS
  In patients with hilar obstruction, liver metastasis is one of the main factors that determine survival of the patient. Patency times of SEMS in both low-grade and advanced obstructions are comparable. However, in the advanced group, there is a significant risk of post-ERCP cholangitis.
authors: Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. rungsun@pol.net
authors: Rungsun
authors: R
authors: Rerknimitr
authors: Pradermchai
authors: P
authors: Kongkam
authors: Pinit
authors: P
authors: Kullavanijaya
mesh_terms: D000368:Aged; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000295:instrumentation*; D002761:Cholangitis / Q000209:etiology; D001651:Cholestasis, Extrahepatic / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D004322:Drainage / Q000295:instrumentation; D005260:Female; D006801:Humans; D041781:Jaundice, Obstructive / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D008297:Male; D008670:Metals; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications* / Q000401:mortality / Q000473:pathology / Q000628:therapy; D011446:Prospective Studies; D011474:Prosthesis Design; D012720:Severity of Illness Index; D015607:Stents; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D008670:Metals