Skip to main content
Log in

Antireflux biliary stents: Are they the solution to stent occlusions?

  • Published:
Current Gastroenterology Reports Aims and scope Submit manuscript

Abstract

Endoscopic insertion of plastic or metal stents is a wellestablished treatment for malignant biliary obstruction. The major limitation of this technique is stent occlusion. Duodenobiliary reflux has been considered a key contributor to stent occlusion. The presence of plant fibers in 35% to 60% of occluded stents on confocal laser microscopy has further confirmed the presence of reflux when the stent is placed across the papilla. Antireflux stents address this problem by allowing normal antegrade flow but preventing reflux. Recent studies comparing these antireflux stents with the standard Tannenbaum stents have shown significantly prolonged patency. Although initial results are encouraging, larger randomized trials are required to establish efficacy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References and Recommended Reading

  1. Sung JY, Costerton JW, Shaffer EA: Defense system in the biliary tract against bacterial infection. Dig Dis Sci 1992, 37:689–696. The sphincter of Oddi prevents retrograde duodenal reflux and consequent bacterial cholangitis. This concept led to subsequent studies on the role of the sphincter of Oddi and duodenobiliary reflux.

    Article  PubMed  CAS  Google Scholar 

  2. Tomioka M, Iinuma H, Okinaga K: Impaired Kupffer cell function and effect of immunotherapy in obstructive jaundice. J Surg Res 2000, 92:276–282.

    Article  PubMed  CAS  Google Scholar 

  3. Scott-Conner CE, Grogan JB: The pathophysiology of biliary obstruction and its effect on phagocytic and immune function. J Surg Res 1994, 57:316–336.

    Article  PubMed  CAS  Google Scholar 

  4. Yu JL, Andersson R, Ljungh A: Protein adsorption and bacterial adhesion to biliary stent materials. J Surg Res 1996, 62:69–73.

    Article  PubMed  CAS  Google Scholar 

  5. Speer AG, Cotton PB, Rode J, et al.: Biliary stent blockage with bacterial biofilm. A light and electron microscopy study. Ann Intern Med 1988, 108:546–553. Proteins, possibly of host biliary origin, are used for adhesion to the stent surface, suggesting that bacteria alone did not cause occlusion.

    PubMed  CAS  Google Scholar 

  6. Sung JY, Leung JW, Shaffer EA, et al.: bacterial biofilm, brown pigment stone and blockage of biliary stents. J Gastroenterol Hepatol 1993, 8:28–34. The biofilm bacteria were protected from the effect of toxic bile salts by additional proteins.

    PubMed  CAS  Google Scholar 

  7. Yu JL, Andersson R, Parsson H, et al.: A bacteriologic and scanning electron microscope study after implantation of foreign bodies in the biliary tract in rats. Scand J Gastroenterol 1996, 31:175–181. Foreign bodies implanted in the bacterial tract facilitated bacterial adherence.

    PubMed  CAS  Google Scholar 

  8. Leung JW, Ling TK, Kung JL, Vallance-Owen J: The role of bacteria in the blockage of biliary stents. Gastrointest Endosc 1988, 34:19–22.

    PubMed  CAS  Google Scholar 

  9. Coene PP, Groen AK, Cheng J, et al.: Clogging of biliary endoprostheses: a new perspective. Gut 1990, 31:913–917. A direct relationship between the frictional coefficient of a polymer and the amount of material encrusted on the stent was demonstrated. Increased intraluminal turbulent flow, as in stents with side holes, was detrimental to stent patency.

    PubMed  CAS  Google Scholar 

  10. Sung JY, Leung JW, Shaffer EA, et al.: Ascending infection of the biliary tract after surgical sphincterotomy and biliary stenting. J Gastroenterol Hepatol 1992, 7:240–245.

    PubMed  CAS  Google Scholar 

  11. Rerknimitr R, Fogel EL, Kalayci C, et al.: Microbiology of bile in patients with cholangitis or cholestasis with and without plastic biliary endoprosthesis. Gastrointest Endosc 2002, 56:885–889.

    Article  PubMed  Google Scholar 

  12. Swidsinski A, Schlien P, Pernthaler A, et al.: Bacterial biofilm within diseased pancreatic and biliary tracts. Gut 2005, 54:388–395.

    Article  PubMed  CAS  Google Scholar 

  13. Leung JW, Liu YL, Desta T, et al.: Is there a synergistic effect between mixed bacterial infection in biofilm formation on biliary stents? Gastrointest Endosc 1998, 48:250–257.

    Article  PubMed  CAS  Google Scholar 

  14. Soehendra N, Reynders-Frederix V: Palliative bile duct drainage: a new endoscopic method of introducing a transpapillary drain. Endoscopy 1980, 12:8–11.

    PubMed  CAS  Google Scholar 

  15. Speer AG, Cotton PB, MacRae KD: Endoscopic management of malignant biliary obstruction: stents of 10 French gauge are preferable to stents of 8 French gauge. Gastrointest Endosc 1988, 34:412–417.

    PubMed  CAS  Google Scholar 

  16. Seitz U, Vadeyar H, Soehendra N: Prolonged patency with a new-design Teflon biliary prosthesis. Endoscopy 1994, 26:478–482.

    PubMed  CAS  Google Scholar 

  17. Binmoeller KF, Seitz U, Seifert H, et al.: The Tannenbaum stent: a new plastic biliary stent without side holes. Am J Gastroenterol 1995, 90:1764–1768.

    PubMed  CAS  Google Scholar 

  18. van Berkel AM, Boland C, Redekop WK, et al.: A prospective randomized trial of Teflon versus polyethylene stents for distal malignant biliary obstruction. Endoscopy 1998, 30:681–686.

    PubMed  Google Scholar 

  19. England RE, Martin DF, Morris J, et al.: A prospective randomised multicentre trial comparing 10 Fr Teflon Tannenbaum stents with 10 Fr polyethylene Cotton-Leung stents in patients with malignant common duct strictures. Gut 2000, 46:395–400.

    Article  PubMed  CAS  Google Scholar 

  20. Terruzzi V, Comin U, De Grazia F, et al.: Prospective randomized trial comparing Tannenbaum Teflon and standard polyethylene stents in distal malignant biliary stenosis. Gastrointest Endosc 2000, 51:23–27.

    Article  PubMed  CAS  Google Scholar 

  21. Catalano MF, Geenen JE, Lehman GA, et al.: "Tannenbaum" Teflon stents versus traditional polyethylene stents for treatment of malignant biliary stricture. Gastrointest Endosc 2002, 55:354–358. Different stent designs did not have an effect on stent patency. Subsequent reports also have not demonstrated any benefit with altering stent design.

    Article  PubMed  Google Scholar 

  22. Van Berkel AM, Huibregtse IL, Bergman JJ, et al.: A prospective randomized trial of Tannenbaum-type Teflon-coated stents versus polyethylene stents for distal malignant biliary obstruction. Eur J Gastroenterol Hepatol 2004, 16:213–217.

    Article  PubMed  Google Scholar 

  23. van Berkel AM, van Marle J, van Veen H, et al.: A scanning electron microscopic study of biliary stent materials. Gastrointest Endosc 2000, 51:19–22.

    Article  PubMed  Google Scholar 

  24. Jansen B, Goodman LP, Ruiten D: Bacterial adherence to hydrophilic polymer-coated polyurethane stents. Gastrointest Endosc 1993, 39:670–673.

    PubMed  CAS  Google Scholar 

  25. McAllister EW, Carey LC, Brady PG, et al.: The role of polymeric surface smoothness of biliary stents in bacterial adherence, biofilm deposition, and stent occlusion. Gastrointest Endosc 1993, 39:422–425.

    PubMed  CAS  Google Scholar 

  26. Costamagna G, Mutignani M, Rotondano G, et al.: Hydrophilic hydromer-coated polyurethane stents versus uncoated stents in malignant biliary obstruction: a randomized trial. Gastrointest Endosc 2000, 51:8–11. Different stent materials in view of difference in bacterial adhesion did not have an effect on stent patency. Current reports showing only a negligible role of the bacterial biofilm on bile flow confirm the reason.

    Article  PubMed  CAS  Google Scholar 

  27. Schilling D, Rink G, Arnold JC, et al.: Prospective, randomized, single-center trial comparing 3 different 10F plastic stents in malignant mid and distal bile duct strictures. Gastrointest Endosc 2003, 58:54–58.

    Article  PubMed  Google Scholar 

  28. van Berkel AM, Bruno MJ, Bergman JJ, et al.: A prospective randomized study of hydrophilic polymer-coated polyurethane versus polyethylene stents in distal malignant biliary obstruction. Endoscopy 2003, 35:478–482.

    Article  PubMed  Google Scholar 

  29. Nakamura S, Ohara H, Yamada T, et al.: Efficacy of plastic tube stents without side holes for middle and lower biliary strictures. J Clin Gastroenterol 2002, 34:77–80.

    Article  PubMed  Google Scholar 

  30. Tringali A, Mutignani M, Perri V, et al.: A prospective, randomized multicenter trial comparing DoubleLayer and polyethylene stents for malignant distal common bile duct strictures. Endoscopy 2003, 35:992–997.

    Article  PubMed  CAS  Google Scholar 

  31. Sung JY, Shaffer EA, Lam K, et al.: Hydrophobic bile salt inhibits bacterial adhesion on biliary stent material. Dig Dis Sci 1994, 39:999–1006.

    Article  PubMed  CAS  Google Scholar 

  32. Tsang TK, Pollack J, Chodash HB: Inhibition of biliary endoprostheses occlusion by ampicillin-sulbactam in an in vitro model. J Lab Clin Med 1997, 130:643–648.

    Article  PubMed  CAS  Google Scholar 

  33. Tsang TK, Pollack J, Chodash HB: Silicone-covered metal stents: an in vitro evaluation for biofilm formation and patency. Dig Dis Sci 1999, 44:1780–1785.

    Article  PubMed  CAS  Google Scholar 

  34. Leung JW, Libby ED, Morck DW, et al.: Is prophylactic ciprofloxacin effective in delaying biliary stent blockage? Gastrointest Endosc 2000, 52:175–182. Antibiotics did not prolong stent patency. This was attributed to the biofilm, which protected the encrusted bacteria.

    Article  PubMed  CAS  Google Scholar 

  35. Leung JW, Liu YL, Desta TD, et al.: In vitro evaluation of antibiotic prophylaxis in the prevention of biliary stent blockage. Gastrointest Endosc 2000, 51:296–303.

    Article  PubMed  CAS  Google Scholar 

  36. Zhang H, Tang J, Meng X, et al.: Inhibition of bacterial adherence on the surface of stents and bacterial growth in bile by bismuth dimercaprol. Dig Dis Sci 2005, 50:1046–1051.

    Article  PubMed  CAS  Google Scholar 

  37. Barrioz T, Ingrand P, Besson I, et al.: Randomised trial of prevention of biliary stent occlusion by ursodeoxycholic acid plus noorfloxaxacin. Lancet 1994, 344:581–582.

    Article  PubMed  CAS  Google Scholar 

  38. Ghosh S, Palmer KR: Prevention of biliary stent occlusion using cyclical antibiotics and ursodeoxycholic acid. Gut 1994, 35:1757–1759.

    PubMed  CAS  Google Scholar 

  39. Luman W, Ghosh S, Palmer KR: A combination of cipro-floxacin and Rowachol does not prevent biliary stent occlusion. Gastrointest Endosc 1999, 49:316–321. This study demonstrated that antibiotics and bile acids do not prolong stent patency.

    Article  PubMed  CAS  Google Scholar 

  40. Sung JJ, Sollano JD, Lai CW, et al.: Long-term ciprofloxacin treatment for the prevention of biliary stent blockage: a prospective randomized study. Am J Gastroenterol 1999, 94:3197–3201. This study demonstrated that antibiotics do not prolong stent patency. The study assumes importance in the light of recent studies demonstrating that living bacteria are protected by a layer of dead bacteria forming a physical barrier to antibiotic penetration.

    Article  PubMed  CAS  Google Scholar 

  41. Halm U, Schiefke, Fleig WE, et al.: orfloxaxacin and ursodeoxycholic acid versus ursodeoxycholic acid alone to prevent occlusion of biliary stents: a prospective, randomized trial. Endoscopy 2001, 33:491–494.

    Article  PubMed  CAS  Google Scholar 

  42. Pedersen FM, Lassen AT, Schaffalitzky de Muckadell OB: Randomized trial of stent placed above and across the sphincter of Oddi in malignant bile duct obstruction. Gastrointest Endosc 1998, 48:574–579.

    Article  PubMed  CAS  Google Scholar 

  43. Groen AK, Out T, Huibregtse K, et al.: Characterization of the content of occluded biliary endoprostheses. Endoscopy 1987, 19:57–59. Preliminary report on the presence of plant fibers in occluded stents.

    Article  PubMed  CAS  Google Scholar 

  44. Dowidar N, Kolmos HJ, Lyon H, Matzen P: Clogging of biliary endoprostheses. A morphologic and bacteriologic study. Scand J Gastroenterol 1991, 26:1137–1144. Morphologic demonstration of plant fibers in blocked stents.

    PubMed  CAS  Google Scholar 

  45. van Berkel AM, van Marle J, Groen AK, Bruno MJ: Mechanisms of biliary stent clogging: confocal laser scanning and scanning electron microscopy. Endoscopy 2005, 37:729–734. This study directly demonstrated by confocal laser screening microscopy the presence of an intraluminal network of large dietary fibers resulting from duodenal rorfloxax. The bacterial biofilm, however, was largely unstructured and had negligible effect on bile flow. These findings highlight the predominant role of duodenobiliary rorfloxax in stent clogging.

    Article  PubMed  Google Scholar 

  46. Dua KS, Shaker R: In vitro evaluation of modorfloxad biliary stent with anti-rorfloxax mechanism. Gastrointest Endosc, April 2001, 53:AB84.

    Google Scholar 

  47. Dua KS, Reddy N, Rao G, Banerjee R: Impact of reducing duodeno-biliary rorfloxax on biliary stent patency: a prospective randomized study of a biliary stent with an anti-rorfloxax valve. Gut, in press.

  48. Weickert U, Venzke T, Konig J, et al.: Why do bilioduodenal plastic stents become occluded? A clinical and pathological investigation on 100 consecutive patients. Endoscopy 2001, 33:786–790. This report on the causal role of duodenobiliary rorfloxax suggested changes in stent design to prevent rorfloxax.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to D. Nageshwar Reddy MD, DM, FAMS, FRCP.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Reddy, D.N., Banerjee, R. & Choung, O.W. Antireflux biliary stents: Are they the solution to stent occlusions?. Curr Gastroenterol Rep 8, 156–160 (2006). https://doi.org/10.1007/s11894-006-0012-x

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11894-006-0012-x

Keywords

Navigation