title: Endoscopic bilio-duodenal bypass: outcomes of primary and revision efficacy of combined metallic stents in malignant duodenal and biliary obstructions.
abstract: BACKGROUND
  Self-expandable metal stents (SEMSs) can be used for palliation of combined malignant biliary and duodenal obstructions. However, the results of the concomitant stent placement for the duration of the patients' lives, as well as the need for and efficacy of endoscopic revision, are unclear.
  
  
  OBJECTIVE
  This study evaluated the clinical effectiveness of SEMS placement for combined biliary and duodenal obstructions throughout the patients' lives and the need for endoscopic revision.
  
  
  METHODS
  This study is a retrospective multicenter study of 50 consecutive patients who underwent simultaneous or sequential SEMS placement for malignant biliary and duodenal obstructions. The data were collected to analyze the sustained relief of obstructive symptoms until the patients' death and the efficacy of endoscopic revision, as well as stent patency, adverse events, survival and prognostic factors for stent patency.
  
  
  RESULTS
  Technical and immediate clinical success was achieved in all of the patients. Duodenal stricture occurred before the papilla in 35 patients (70 %), involved the papilla in 11 patients (22 %) and was observed distal to the papilla in four patients (8 %). Initial biliary stenting was performed endoscopically in 42 patients (84 %) and percutaneously in eight patients. After combined stenting, 30 patients (60 %) required no additional intervention until the time of their death. The remaining 20 patients were successfully treated using endoscopic stent reinsertion: nine patients needed biliary revision, three patients needed duodenal restenting and eight patients needed both biliary and duodenal reinsertion. The median duodenal stent patency and median biliary stent patency were 34 and 27 weeks, respectively. The median survival after combined stent placement was 18 weeks. A Cox multivariate analysis showed that duodenal stent obstruction after combined stenting was a risk factor for biliary stent obstruction (hazard ratio 6.85; 95 % confidence interval 1.43-198.98; P = 0.025).
  
  
  CONCLUSIONS
  Endoscopic bilio-duodenal bypass is clinically effective, and the majority of the patients need no additional intervention until their death. Endoscopic revision is feasible and has a high success rate.
authors.affiliation: Department of Gastroenterology, Santo António dos Capuchos Hospital do Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal, jmtcanena@live.com.pt.
authors.forename: Jorge
authors.initials: J
authors.lastname: Canena
authors.forename: João
authors.initials: J
authors.lastname: Coimbra
authors.forename: Diana
authors.initials: D
authors.lastname: Carvalho
authors.forename: Catarina
authors.initials: C
authors.lastname: Rodrigues
authors.forename: Mário
authors.initials: M
authors.lastname: Silva
authors.forename: Mariana
authors.initials: M
authors.lastname: Costa
authors.forename: David
authors.initials: D
authors.lastname: Horta
authors.forename: António
authors.initials: A
authors.lastname: Mateus Dias
authors.forename: Isabel
authors.initials: I
authors.lastname: Seves
authors.forename: Gonçalo
authors.initials: G
authors.lastname: Ramos
authors.forename: Leonel
authors.initials: L
authors.lastname: Ricardo
authors.forename: António Pereira
authors.initials: AP
authors.lastname: Coutinho
authors.forename: Carlos
authors.initials: C
authors.lastname: Romão
authors.forename: Pedro Mota
authors.initials: PM
authors.lastname: Veiga
mesh_terms: D000293:Adolescent; D000368:Aged; D000369:Aged, 80 and over; D001662:Biliary Tract Surgical Procedures / Q000379:methods*; D002779:Cholestasis / Q000473:pathology* / Q000601:surgery; D004380:Duodenal Obstruction / Q000473:pathology* / Q000601:surgery; D004386:Duodenum / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome