Abstract
Background
Although self-expandable metallic stent (SEMS) has a longer patency than plastic stent (PS) for malignant biliary obstruction, stent occlusion can occur and drainage has to be reestablished in a patient with expected long survival. However, the choices are still controversial among restenting with SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). This study was designed to determine the efficacy and outcome of PS, SEMS, and PTBD for patients with occluded SEMS.
Methods
A total of 154 ERCPs with SEMS insertion were performed at the Endoscopy Unit of Chulalongkorn University. The causes of obstructive jaundice were cholangiocarcinoma (n = 110), pancreatic cancer (n = 41), and metastatic carcinoma (n = 3). Thirty-two patients (20.9%) with occluded SEMS (uncovered SEMS = 22 and covered SEMS = 10) were identified. PS, SEMS, and PTBD were used to reestablish drainage in 11, 14, and 7 patients, respectively. The second stent was inserted as stent-in-stent. Patients with less advanced disease were preferably opted to have a second SEMS.
Results
The median stent patency of second SEMS (100 days) was significantly longer than PS (60 days) and PTBD (75 days; p < 0.05). The median survival time for patients with second SEMS (230 days) was significantly longer than patients with PS (130 days) and PTBD (150 days; p < 0.05). Subgroup analysis in hilar obstructions showed no statistical difference in second stent patency and survival between PS and SEMS. Pain that required oral narcotic developed in 71% (5/7) of PTBD patients.
Conclusions
In general, a second SEMS insertion in occluded SEMS provides a significant longer patency time than PS and PTBD. However, the benefit of SEMS as a second intervention in hilar obstructed patients is still doubtful.
Similar content being viewed by others
References
Andersen JR, Sørensen SM, Kruse A, Rokkjaer M, Matzen P (1989) Randomised trial of endoscopic stent versus operative bypass in malignant obstructive jaundice. Gut 30:1132–1135
Smith AC, Dowsett JF, Russell RC, Hatfield AR, Cotton PB (1994) Randomised trial of endoscopic stenting versus surgical bypass in malignant low bile duct obstruction. Lancet 344:1655–1660
Huibregtse K, Cheng J, Coene PP, Fockens P, Tytgat GN (1989) Endoscopic placement of expandable metal stents for biliary strictures: a preliminary report on experience with 33 patients. Endoscopy 21:280–282
Davids PH, Groen AK, Rauws EA, Tytgat GN, Huibregtse K (1992) Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 340:1488–1492
O’Brien S, Hatfield AR, Craig PI, Williams SP (1995) A three-year follow up of self expanding metal stents in the endoscopic palliation of long-term survivors with malignant biliary obstruction. Gut 36:618–621
Knyrim K, Wagner HJ, Pausch J, Vakil N (1993) A prospective, randomized, controlled trial of metal stents for malignant obstruction of the common bile duct. Endoscopy 25:207–212
Schmassmann A, von Gunten E, Knuchel J, Scheurer U, Fehr HF, Halter F (1996) Wallstents versus plastic stents in malignant biliary obstruction: effects of stent patency of the first and second stent on patient compliance and survival. Am J Gastroenterol 91:654–663
Perdue DG, Freeman ML, DiSario JA, Nelson DB, Fennerty MB, Lee JG, Overby CS, Ryan ME, Bochna GS, Snady HW, Moore JP, ERCP Outcome Study ERCOST Group (2008) Plastic versus self-expanding metallic stents for malignant hilar biliary obstruction. J Clin Gastroenterol 42:1040–1046
Rerknimitr R, Kongkam P, Kullavanijaya P (2008) Outcome of self-expandable metallic stents in low-grade versus advanced hilar obstruction. J Gastroenterol Hepatol 23:1695–1701
Tham TC, Carr-Locke DL, Vandervoort J, Wong RC, Lichtenstein DR, Van Dam J, Ruymann F, Chow S, Bosco JJ, Qaseem T, Howell D, Pleskow D, Vannerman W, Libby ED (1998) Management of occluded biliary wallstents. Gut 42:703–707
Bueno JT, Gerdes H, Kurtz RC (2003) Endoscopic management of occluded biliary wallstents: a cancer center experience. Gastrointest Endosc 58:879–884
Togawa O, Kawabe T, Isayama H, Nakai Y, Sasaki T, Arizumi T, Matsubara S, Ito Y, Yamamoto N, Sasahira N, Hirano K, Tsujino T, Toda N, Tada M, Yoshida H, Omata M (2008) Management of occluded uncovered metallic stents in patients with malignant distal biliary obstructions using covered metallic stents. J Clin Gastroenterol 42:546–549
Rogart JN, Boghos A, Rossi F, Al-Hashem H, Siddiqui UD, Jamidar P, Aslanian H (2008) Analysis of endoscopic management of occluded metal biliary stents at a single tertiary care center. Gastrointest Endosc 68:676–682
Ferrucci JT, Mueller PR, Harbin WP (1980) Percutaneous transhepatic biliary drainage. Radiology 135:1–13
Acknowledgment
The authors thank Thosporn Vimolket, MD for assistance with statistical analysis.
Disclosures
Drs. Wiriyaporn Ridtitid, Rungsun Rerknimitr, Akkawat Janchai, Pradermchai Kongkam, Sombat Treeprasertsuk, and Pinit Kullavanijaya have no conflicts of interest or financial ties to disclose.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Ridtitid, W., Rerknimitr, R., Janchai, A. et al. Outcome of second interventions for occluded metallic stents in patients with malignant biliary obstruction. Surg Endosc 24, 2216–2220 (2010). https://doi.org/10.1007/s00464-010-0931-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-010-0931-3