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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

    Deputy Editor

    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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    All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
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Evaluating the Self-Expandable Metal Stents Placement in Malignant Biliary Obstruction: A Deeper Dive

Kyong Joo Lee , Se Woo Park

Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea

Correspondence to: Se Woo Park
ORCID https://orcid.org/0000-0003-1603-7468
E-mail mdsewoopark@gmail.com

See “Efficacy Analysis of Suprapapillary versus Transpapillary Self-Expandable Metal Stents According to the Level of Obstruction in Malignant Extrahepatic Biliary Obstruction” by Sung Yong Han, et al. on page 806, Vol. 17, No. 5, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2023;17(5):672-673. https://doi.org/10.5009/gnl230340

Published online September 15, 2023, Published date September 15, 2023

Copyright © Gut and Liver.

The study1 recently published in Gut and Liver offers an in-depth look into the use of self-expandable metal stents for patients with a specific type of malignant biliary obstruction (MBO). It is essential to understand what makes this study stand out and where it might need more information. First and foremost, the study involved a large number of patients (280 in total) who had this stent placed. This large group means the researchers could gather more reliable information and make better suggestions for endoscopists in the future.

In the study, researchers were keen to understand the difference between two ways of placing the stent: suprapapillary (SPG) and transpapillary (TPG) stentings. SPG stenting, as the nomenclature suggests, is a technique where the stent is positioned above, or "supra" to, the ampulla of Vater (AOV). The AOV is a crucial anatomical landmark, marking the site where the common bile duct and pancreatic duct drain into the duodenum. The advantage of the SPG approach, as some studies suggest, lies in its potential to reduce the risk of pancreatic complications, given that the stent does not interfere directly with the pancreatic ductal system.2 However, this positioning may also leave the stent more exposed to duodenal contents, potentially affecting its longevity. In contrast, TPG stenting means the stent traverses the AOV. This approach ensures that bile has a direct route from the bile duct into the duodenum, bypassing any obstructions in its path. The TPG technique might offer more stability due to its anchoring across the papilla, but it also comes with potential challenges.3 Some researchers have voiced concerns over potential pancreatic complications given the close proximity and interaction with the pancreatic duct.

However, one of the most fundamental principles in interpreting research results is that correlation doesn't imply causation. For instance, when MBOs are located within 2 cm from the AOV, there is an observation that duodenal invasion rates also increase. Both these variables–the proximity of MBOs to the AOV and the rate of duodenal invasion–seem to show a synchronized pattern. There might be other confounding factors not considered or outlined in the study. For example, the anatomical variation of the patients, their overall comorbidities, previous anti-tumor therapy, or any other number of factors could be influencing the rate of duodenal invasion.4 Without ruling out these confounding factors, we cannot conclusively say that it is the proximity to the AOV alone that is causing the higher rates of invasion.

The study seems to imply that the shortened stent patency in cases closer to the AOV is due to increased food retention and consequent reflux.4,5 While this is a plausible theory, it remains just that–a theory–unless directly tested. At first glance, this explanation seems logical. After all, it aligns with some general understandings of the digestive system. However, as reasonable as this idea sounds, it remains an unproven theory. For this theory to be considered a confirmed fact, researchers would need to carry out specific tests to determine if a slowed passage of food in the duodenum genuinely causes these stents to fail earlier than expected. Observing both phenomena–food retention and stent failure–happening simultaneously is not sufficient to draw a definite conclusion. What is really needed is irrefutable evidence showing that one directly causes the other. Without such evidence, any claim about the connection between slowed food passage and reduced stent longevity remains speculative.

The statement addresses a comparison between the effectiveness, or patency, of two stent placement methods, SPG and TPG, particularly when dealing with MBO that are situated closer to the AOV. The gathered data seems to lean towards TPG as the preferable approach for these particular obstructions. But there's a point to ponder: even if the difference in patency between the two methods is statistically noteworthy, does it hold significance in a real-world clinical setting? To put it simply, does an extra 23 days of patency with one method over the other genuinely make a substantial difference in the overall well-being and quality of life of a patient?

Ultimately, the decision between SPG and TPG often depends on a myriad of factors including the exact location and nature of the obstruction, the patient's anatomical variations, and potential risks associated with each method. Clinicians typically weigh the benefits and drawbacks of each technique, keeping in mind both the immediate goal of relieving the obstruction and the long-term outcomes for the patient. Further studies and ongoing clinical evaluations continue to refine our understanding of these techniques, seeking to optimize patient care in the face of distal MBOs.

No potential conflict of interest relevant to this article was reported.

  1. Han SY, Lee TH, Jang SI, et al. Efficacy analysis of suprapapillary versus transpapillary self-expandable metal stents according to the level of obstruction in malignant extrahepatic biliary obstruction. Gut Liver 2023;17:806-813.
    Pubmed CrossRef
  2. Shin J, Park JS, Jeong S, Lee DH. Comparison of the clinical outcomes of suprapapillary and transpapillary stent insertion in unresectable cholangiocarcinoma with biliary obstruction. Dig Dis Sci 2020;65:1231-1238.
    Pubmed CrossRef
  3. Pécsi D, Vincze Á. Are suprapapillary biliary stents superior to transpapillary biliary stents?. Dig Dis Sci 2020;65:925-927.
    Pubmed CrossRef
  4. Kovács N, Pécsi D, Sipos Z, et al. Suprapapillary biliary stents have longer patency times than transpapillary stents: a systematic review and meta-analysis. J Clin Med 2023;12:898.
    Pubmed KoreaMed CrossRef
  5. Nam HS, Kang DH, Kim HW, et al. Efficacy and safety of limited endoscopic sphincterotomy before self-expandable metal stent insertion for malignant biliary obstruction. World J Gastroenterol 2017;23:1627-1636.
    Pubmed KoreaMed CrossRef

Article

Editorial

Gut and Liver 2023; 17(5): 672-673

Published online September 15, 2023 https://doi.org/10.5009/gnl230340

Copyright © Gut and Liver.

Evaluating the Self-Expandable Metal Stents Placement in Malignant Biliary Obstruction: A Deeper Dive

Kyong Joo Lee , Se Woo Park

Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea

Correspondence to:Se Woo Park
ORCID https://orcid.org/0000-0003-1603-7468
E-mail mdsewoopark@gmail.com

See “Efficacy Analysis of Suprapapillary versus Transpapillary Self-Expandable Metal Stents According to the Level of Obstruction in Malignant Extrahepatic Biliary Obstruction” by Sung Yong Han, et al. on page 806, Vol. 17, No. 5, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

The study1 recently published in Gut and Liver offers an in-depth look into the use of self-expandable metal stents for patients with a specific type of malignant biliary obstruction (MBO). It is essential to understand what makes this study stand out and where it might need more information. First and foremost, the study involved a large number of patients (280 in total) who had this stent placed. This large group means the researchers could gather more reliable information and make better suggestions for endoscopists in the future.

In the study, researchers were keen to understand the difference between two ways of placing the stent: suprapapillary (SPG) and transpapillary (TPG) stentings. SPG stenting, as the nomenclature suggests, is a technique where the stent is positioned above, or "supra" to, the ampulla of Vater (AOV). The AOV is a crucial anatomical landmark, marking the site where the common bile duct and pancreatic duct drain into the duodenum. The advantage of the SPG approach, as some studies suggest, lies in its potential to reduce the risk of pancreatic complications, given that the stent does not interfere directly with the pancreatic ductal system.2 However, this positioning may also leave the stent more exposed to duodenal contents, potentially affecting its longevity. In contrast, TPG stenting means the stent traverses the AOV. This approach ensures that bile has a direct route from the bile duct into the duodenum, bypassing any obstructions in its path. The TPG technique might offer more stability due to its anchoring across the papilla, but it also comes with potential challenges.3 Some researchers have voiced concerns over potential pancreatic complications given the close proximity and interaction with the pancreatic duct.

However, one of the most fundamental principles in interpreting research results is that correlation doesn't imply causation. For instance, when MBOs are located within 2 cm from the AOV, there is an observation that duodenal invasion rates also increase. Both these variables–the proximity of MBOs to the AOV and the rate of duodenal invasion–seem to show a synchronized pattern. There might be other confounding factors not considered or outlined in the study. For example, the anatomical variation of the patients, their overall comorbidities, previous anti-tumor therapy, or any other number of factors could be influencing the rate of duodenal invasion.4 Without ruling out these confounding factors, we cannot conclusively say that it is the proximity to the AOV alone that is causing the higher rates of invasion.

The study seems to imply that the shortened stent patency in cases closer to the AOV is due to increased food retention and consequent reflux.4,5 While this is a plausible theory, it remains just that–a theory–unless directly tested. At first glance, this explanation seems logical. After all, it aligns with some general understandings of the digestive system. However, as reasonable as this idea sounds, it remains an unproven theory. For this theory to be considered a confirmed fact, researchers would need to carry out specific tests to determine if a slowed passage of food in the duodenum genuinely causes these stents to fail earlier than expected. Observing both phenomena–food retention and stent failure–happening simultaneously is not sufficient to draw a definite conclusion. What is really needed is irrefutable evidence showing that one directly causes the other. Without such evidence, any claim about the connection between slowed food passage and reduced stent longevity remains speculative.

The statement addresses a comparison between the effectiveness, or patency, of two stent placement methods, SPG and TPG, particularly when dealing with MBO that are situated closer to the AOV. The gathered data seems to lean towards TPG as the preferable approach for these particular obstructions. But there's a point to ponder: even if the difference in patency between the two methods is statistically noteworthy, does it hold significance in a real-world clinical setting? To put it simply, does an extra 23 days of patency with one method over the other genuinely make a substantial difference in the overall well-being and quality of life of a patient?

Ultimately, the decision between SPG and TPG often depends on a myriad of factors including the exact location and nature of the obstruction, the patient's anatomical variations, and potential risks associated with each method. Clinicians typically weigh the benefits and drawbacks of each technique, keeping in mind both the immediate goal of relieving the obstruction and the long-term outcomes for the patient. Further studies and ongoing clinical evaluations continue to refine our understanding of these techniques, seeking to optimize patient care in the face of distal MBOs.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Han SY, Lee TH, Jang SI, et al. Efficacy analysis of suprapapillary versus transpapillary self-expandable metal stents according to the level of obstruction in malignant extrahepatic biliary obstruction. Gut Liver 2023;17:806-813.
    Pubmed CrossRef
  2. Shin J, Park JS, Jeong S, Lee DH. Comparison of the clinical outcomes of suprapapillary and transpapillary stent insertion in unresectable cholangiocarcinoma with biliary obstruction. Dig Dis Sci 2020;65:1231-1238.
    Pubmed CrossRef
  3. Pécsi D, Vincze Á. Are suprapapillary biliary stents superior to transpapillary biliary stents?. Dig Dis Sci 2020;65:925-927.
    Pubmed CrossRef
  4. Kovács N, Pécsi D, Sipos Z, et al. Suprapapillary biliary stents have longer patency times than transpapillary stents: a systematic review and meta-analysis. J Clin Med 2023;12:898.
    Pubmed KoreaMed CrossRef
  5. Nam HS, Kang DH, Kim HW, et al. Efficacy and safety of limited endoscopic sphincterotomy before self-expandable metal stent insertion for malignant biliary obstruction. World J Gastroenterol 2017;23:1627-1636.
    Pubmed KoreaMed CrossRef
Gut and Liver

Vol.18 No.4
July, 2024

pISSN 1976-2283
eISSN 2005-1212

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