{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,22]],"date-time":"2026-04-22T19:32:12Z","timestamp":1776886332970,"version":"3.51.2"},"reference-count":23,"publisher":"Public Library of Science (PLoS)","issue":"3","license":[{"start":{"date-parts":[[2021,3,29]],"date-time":"2021-03-29T00:00:00Z","timestamp":1616976000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Introduction<\/jats:title>\n<jats:p>For unresectable hilar obstruction, restoring and maintaining biliary ductal patency are crucial for improved survival and quality of life. The endoscopic placement of stents is now a mainstay of its treatment, and bilateral stenting is effective for biliary decompression. This study aimed to determine the clinical outcomes of bilateral metal stent placement using large cell-type stents and the clinical predictors of stent dysfunction in patients with malignant hilar obstruction.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>We performed a retrospective analysis of patients who underwent bilateral metal stent placement using two large cell-type stents at two academic teaching hospitals between September 2017 and February 2019. The primary outcome was stent dysfunction. Secondary outcomes included predictors related to stent dysfunction and overall survival.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>The study included 87 patients who underwent bilateral metal stent placement for malignant hilar obstruction. Technical success and clinical success were achieved in 80 patients (92.0%) and 83 patients (95.4%), respectively. During the follow-up period (median: 201, range: 18\u2013671 days), stent dysfunction occurred in 42 patients (48.3%), and the median stent patency was 199 days (95% confidence interval [CI]: 181\u2013262). In univariate analysis, age, cholangitis before stent insertion, and subsequent chemotherapy were found to be associated with the cumulative risk of stent dysfunction. In multivariate analysis, cholangitis before stent insertion (hazards ratio [HR]: 2.26, 95% CI: 1.216\u20134.209, P = 0.010) and subsequent chemotherapy (HR:\u2009 0.250, 95% CI: 0.130\u20130.482, P&lt;0.001) remained as statically significant factors associated with the cumulative risk of stent dysfunction. The median overall survival was 288 days (95% CI: 230\u2013327).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusion<\/jats:title>\n<jats:p>The bilateral placement of large cell-type stents for malignant hilar obstruction was effective with high technical and clinical success rates and acceptable patency. Cholangitis before stent insertion was associated with shorter patency, and subsequent chemotherapy was associated with longer stent patency.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0249096","type":"journal-article","created":{"date-parts":[[2021,3,29]],"date-time":"2021-03-29T17:34:45Z","timestamp":1617039285000},"page":"e0249096","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":3,"title":["Predictors of stent dysfunction in patients with bilateral metal stents for malignant hilar obstruction"],"prefix":"10.1371","volume":"16","author":[{"given":"Hoonsub","family":"So","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4382-5876","authenticated-orcid":true,"given":"Chi Hyuk","family":"Oh","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tae Jun","family":"Song","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sung Woo","family":"Ko","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jun Seong","family":"Hwang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dongwook","family":"Oh","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Do Hyun","family":"Park","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sang Soo","family":"Lee","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dong-Wan","family":"Seo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Seok Ho","family":"Dong","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sung Koo","family":"Lee","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Myung-Hwan","family":"Kim","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2021,3,29]]},"reference":[{"issue":"9935","key":"pone.0249096.ref001","doi-asserted-by":"crossref","first-page":"2168","DOI":"10.1016\/S0140-6736(13)61903-0","volume":"383","author":"N Razumilava","year":"2014","journal-title":"Cholangiocarcinoma. Lancet"},{"issue":"12","key":"pone.0249096.ref002","doi-asserted-by":"crossref","first-page":"1657","DOI":"10.1136\/gutjnl-2011-301748","article-title":"Guidelines for the diagnosis and treatment of cholangiocarcinoma: An update","volume":"61","author":"SA Khan","year":"2012","journal-title":"Gut"},{"issue":"7","key":"pone.0249096.ref003","doi-asserted-by":"crossref","first-page":"617","DOI":"10.1055\/s-0030-1256315","article-title":"Biliary stents: Models and methods for endoscopic stenting","volume":"43","author":"JM Dumonceau","year":"2011","journal-title":"Endoscopy"},{"issue":"2","key":"pone.0249096.ref004","doi-asserted-by":"crossref","first-page":"124","DOI":"10.5946\/ce.2016.023","article-title":"Current status of biliary metal stents","volume":"49","author":"HS Nam","year":"2016","journal-title":"Clin Endosc"},{"issue":"9","key":"pone.0249096.ref005","doi-asserted-by":"crossref","first-page":"910","DOI":"10.1055\/a-0659-9864","article-title":"Endoscopic biliary stenting: Indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline\u2014Updated October 2017","volume":"50","author":"JM Dumonceau","year":"2018","journal-title":"Endoscopy"},{"issue":"5","key":"pone.0249096.ref006","doi-asserted-by":"crossref","first-page":"653","DOI":"10.1007\/s00534-011-0407-4","article-title":"Endoscopic bilateral metallic stenting for malignant hilar obstruction using newly designed stents","volume":"18","author":"H Kogure","year":"2011","journal-title":"J Hepatobiliary Pancreat Sci"},{"issue":"7","key":"pone.0249096.ref007","doi-asserted-by":"crossref","first-page":"987","DOI":"10.1038\/s41395-018-0122-8","article-title":"EUS-guided biliary drainage versus ERCP for the primary palliation of malignant biliary obstruction: A multicenter randomized clinical trial","volume":"113","author":"WH Paik","year":"2018","journal-title":"Am J Gastroenterol"},{"issue":"3","key":"pone.0249096.ref008","doi-asserted-by":"crossref","first-page":"446","DOI":"10.1016\/j.gie.2009.10.027","article-title":"A lexicon for endoscopic adverse events: Report of an ASGE workshop","volume":"71","author":"PB Cotton","year":"2010","journal-title":"Gastrointest Endosc"},{"issue":"4","key":"pone.0249096.ref009","doi-asserted-by":"crossref","first-page":"350","DOI":"10.6004\/jnccn.2009.0027","article-title":"NCCN clinical practice guidelines in oncology: Hepatobiliary cancers","volume":"7","author":"AB Benson","year":"2009","journal-title":"J Natl Compr Canc Netw"},{"issue":"4","key":"pone.0249096.ref010","doi-asserted-by":"crossref","first-page":"667","DOI":"10.1007\/s004640080006","article-title":"Cost comparison of endoscopic stenting vs surgical treatment for unresectable cholangiocarcinoma","volume":"16","author":"RC, 2nd Martin","year":"2002","journal-title":"Surg Endosc"},{"issue":"6","key":"pone.0249096.ref011","first-page":"536","article-title":"Risk factors for recurrent biliary obstruction following placement of self-expandable metallic stents in patients with malignant perihilar biliary stricture","volume":"48","author":"S Miura","year":"2016","journal-title":"EndoscopyEpub 2016"},{"issue":"2","key":"pone.0249096.ref012","doi-asserted-by":"crossref","first-page":"139","DOI":"10.5946\/ce.2016.024","article-title":"Mechanisms of biliary plastic stent occlusion and efforts at prevention","volume":"49","author":"CI Kwon","year":"2016","journal-title":"Clin Endosc"},{"issue":"12","key":"pone.0249096.ref013","doi-asserted-by":"crossref","first-page":"3279","DOI":"10.1007\/s10620-012-2270-9","article-title":"Side-by-side versus stent-in-stent deployment in bilateral endoscopic metal stenting for malignant hilar biliary obstruction","volume":"57","author":"I Naitoh","year":"2012","journal-title":"Dig Dis Sci"},{"issue":"7","key":"pone.0249096.ref014","doi-asserted-by":"crossref","first-page":"827","DOI":"10.3349\/ymj.2018.59.7.827","article-title":"Clinical outcomes of bilateral stent-in-stent placement using self-expandable metallic stent for high-grade malignant hilar biliary obstruction","volume":"59","author":"JY Heo","year":"2018","journal-title":"Yonsei Med J"},{"issue":"1","key":"pone.0249096.ref015","doi-asserted-by":"crossref","first-page":"13","DOI":"10.5009\/gnl15568","article-title":"Cholangiocarcinoma: Current knowledge and new developments","volume":"11","author":"B Blechacz","year":"2017","journal-title":"Gut Liver"},{"issue":"6","key":"pone.0249096.ref016","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1007\/s12664-013-0413-3","article-title":"Bilateral and unilateral stenting for malignant hilar obstruction: A systematic review and meta-analysis","volume":"32","author":"SR Puli","year":"2013","journal-title":"Indian J Gastroenterol"},{"issue":"5","key":"pone.0249096.ref017","doi-asserted-by":"crossref","first-page":"817","DOI":"10.1016\/j.gie.2017.04.037","article-title":"Bilateral versus unilateral placement of metal stents for inoperable high-grade malignant hilar biliary strictures: A multicenter, prospective, randomized study (with video)","volume":"86","author":"TH Lee","year":"2017","journal-title":"Gastrointest Endosc"},{"issue":"4","key":"pone.0249096.ref018","doi-asserted-by":"crossref","first-page":"552","DOI":"10.1111\/j.1440-1746.2008.05750.x","article-title":"Unilateral versus bilateral endoscopic metal stenting for malignant hilar biliary obstruction","volume":"24","author":"I Naitoh","year":"2009","journal-title":"J Gastroenterol Hepatol"},{"issue":"1","key":"pone.0249096.ref019","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1111\/den.12055","article-title":"High single-session success rate of endoscopic bilateral stent-in-stent placement with modified large cell Niti-S stents for malignant hilar biliary obstruction","volume":"26","author":"H Kogure","year":"2014","journal-title":"Dig Endosc"},{"issue":"6","key":"pone.0249096.ref020","doi-asserted-by":"crossref","first-page":"722","DOI":"10.5009\/gnl17468","article-title":"Prospective multicenter study of the challenges inherent in using large cell-type stents for bilateral stent-in-stent placement in patients with inoperable malignant hilar biliary obstruction","volume":"12","author":"MJ Yang","year":"2018","journal-title":"Gut Liver"},{"issue":"6","key":"pone.0249096.ref021","doi-asserted-by":"crossref","first-page":"633","DOI":"10.1016\/S1499-3872(16)60107-8","article-title":"Endoscopic bilateral stent-in-stent placement for malignant hilar obstruction using a large cell type stent","volume":"15","author":"JM Park","year":"2016","journal-title":"Hepatobiliary Pancreat Dis Int"},{"key":"pone.0249096.ref022","doi-asserted-by":"crossref","first-page":"751","DOI":"10.1055\/s-0043-124870","article-title":"Efficacy and safety of endoscopic radiofrequency ablation for unresectable extrahepatic cholangiocarcinoma: A randomized trial","volume":"50","author":"J Yang","year":"2018","journal-title":"Endoscopy"},{"key":"pone.0249096.ref023","doi-asserted-by":"crossref","first-page":"692","DOI":"10.1111\/den.12466","article-title":"Small cell- versus large cell-sized metal stent in endoscopic bilateral stent-in-stent placement for malignant hilar biliary obstruction","volume":"27","author":"JM Lee","year":"2015","journal-title":"Dig Endosc"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0249096","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,3,29]],"date-time":"2021-03-29T17:35:10Z","timestamp":1617039310000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0249096"}},"subtitle":[],"editor":[{"given":"Gianfranco D.","family":"Alpini","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2021,3,29]]},"references-count":23,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2021,3,29]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0249096","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,3,29]]}}}