title: A Comparison of Bilateral Side-by-Side Metal Stents Deployed Above and Across the Sphincter of Oddi in the Management of Malignant Hilar Biliary Obstruction.
abstract: OBJECTIVE
  The optimal method for endoscopic placement of bilateral self-expanding metal stents (SEMS) for the management of malignant hilar biliary obstruction has not been determined. The aim of this study was to compare the efficacies and complication rates between SEMS placed above and across the sphincter of Oddi (SO) in patients with malignant hilar biliary obstruction.
  
  
  METHODS
  A retrospective review of patients with malignant hilar strictures who underwent bilateral SEMS placement at 3 centers was performed. Patients were divided into 2 groups: group A (above SO, n=52) or B (across SO, n=120). Patient demographics, technical success (successful SEMS placement across the stricture), functional success (decrease in pretreatment bilirubin level), complications, stent occlusion, and patient survival in the 2 groups were evaluated.
  
  
  RESULTS
  We identified 172 patients with malignant hilar biliary obstruction (106 males, mean age 67 y). Significantly more early complications (1.9% vs. 11.7%, P=0.04) were seen in group B, mainly post-endoscopic retrograde cholangio-pancreatography pancreatitis. Mean SEMS patency periods were 33 weeks for group A and 29.6 weeks for group B (P=0.3). Occlusion rates were 50% and 45% for groups A and B (P=0.61); occlusion was due to tumor in-growth or overgrowth in all patients. SEMS occlusion was successfully treated endoscopically in 85% (22/26) patients in group A and 96% (52/54) in group B (P=0.24). The median survival time was 26 weeks in the group A and 29 weeks in group B (P=0.49).
  
  
  CONCLUSIONS
  Bilateral side-by-side SEMS placement above or below the SO results in similar success rates, stent patency duration, and stent occlusion rates. Significantly fewer complications, with a trend toward lower rates of pancreatitis, were observed for SEMS placed above the SO.
authors.affiliation: *Department of Internal Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia †Department of Internal Medicine, Division of Gastroenterology, University of Utah, Salt Lake City, UT ‡Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Pittsburgh, Pittsburgh, PA §Washington University School of Medicine, St Louis, MO.
authors.forename: Natalie
authors.initials: N
authors.lastname: Cosgrove
authors.forename: Ali A
authors.initials: AA
authors.lastname: Siddiqui
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Adler
authors.forename: Haroon
authors.initials: H
authors.lastname: Shahid
authors.forename: Avik
authors.initials: A
authors.lastname: Sarkar
authors.forename: Ashish
authors.initials: A
authors.lastname: Sharma
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Kowalski
authors.forename: David
authors.initials: D
authors.lastname: Loren
authors.forename: Matthew
authors.initials: M
authors.lastname: Warndorf
authors.forename: Jennifer
authors.initials: J
authors.lastname: Chennat
authors.forename: Satish
authors.initials: S
authors.lastname: Munigala
authors.forename: Georgios I
authors.initials: GI
authors.lastname: Papachristou
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000150:complications / Q000601:surgery*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods*; D002779:Cholestasis / Q000209:etiology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000453:epidemiology / Q000209:etiology; D012189:Retrospective Studies; D009803:Sphincter of Oddi; D015607:Stents; D015996:Survival Rate; D016896:Treatment Outcome