Temporary Placement of Fully Covered Self-expandable Metal Stents in Benign Biliary Strictures

Choong Heon Ryu; Myung-Hwan Kim; Sang Soo Lee; Do Hyun Park; Dong-Wan Seo; Sung Koo Lee

doi:10.4166/kjg.2013.62.1.49

Journal List > Korean J Gastroenterol > v.62(1) > 1007181

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Ryu, Kim, Lee, Park, Seo, and Lee: Temporary Placement of Fully Covered Self-expandable Metal Stents in Benign Biliary Strictures

Original Article

Korean J Gastroenterol 2013;62(1):49-54.

Published online: 4 October 2013

DOI: https://doi.org/10.4166/kjg.2013.62.1.49

Temporary Placement of Fully Covered Self-expandable Metal Stents in Benign Biliary Strictures

Choong Heon Ryu, Myung-Hwan Kim¹, Sang Soo Lee¹, Do Hyun Park¹, Dong-Wan Seo¹, Sung Koo Lee¹

Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Seoul, Korea

¹Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to: Myung-Hwan Kim, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa- gu, Seoul 138-736, Korea. Tel: +82-2-3010-3183, Fax: +82-2-476-0824, E-mail: mhkim@amc.seoul.kr

Received 5 April 201315 May 2013 Accepted 20 May 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Benign biliary strictures (BBSs) have been endoscopically managed with plastic stent placement. However, data regarding fully covered self-expandable metal stents (FCSEMSs) in BBS patients remain scarce in Korea.

Methods

Forty-one patients (21 men, 65.9%) with BBSs underwent FCSEMS placement between February 2007 and July 2010 in Asan Medical Center. Efficacy and safety were evaluated retrospectively. Patients were considered to have resolution if they showed evidence of stricture resolution on cholangiography and if an inflated retrieval balloon easily passed through the strictures at FCSEMS removal.

Results

The mean FCSEMS placement time was 3.2 (1.9–6.2) months. Patients were followed for a mean of 10.2 (1.0–32.0) months after FCSEMS removal. The BBS resolution rate was confirmed in 38 of 41 (92.7%) patients who underwent FCSEMS removal. After FCSEMS removal, 6 of 38 (15.8%) patients experienced symptomatic recurrent stricture and repeat stenting was performed. When a breakdown by etiology of stricture was performed, 14 of 15 (93.3%) patients with chronic pancreatitis, 17 of 19 (89.5%) with gall stone-related disease, 4 of 4 (100%) with surgical procedures, and 2 of 2 (100%) with BBSs of other etiology had resolution at FCSEMS removal. Complications related to stent therapy occurred in 12 (29%) patients, including post-ERCP pancreatitis (n=4), proximal migration (n=3), distal migration (n=3), and occlusion (n=2).

Conclusions

Temporary FCSEMS placement in BBS patients offers a potential alternative to plastic stenting. However, because of the significant complications and modest resolution rates, the potential benefits and risks should be evaluated in further investigations.

Keywords: Bile duct disease, Stent

References

1. Judah JR, Draganov PV. Endoscopic therapy of benign biliary strictures. World J Gastroenterol. 2007; 13:3531–3539.

2. Warshaw AL, Schapiro RH, Ferrucci JT Jr, Galdabini JJ. Persistent obstructive jaundice, cholangitis, and biliary cirrhosis due to common bile duct stenosis in chronic pancreatitis. Gastroenterology. 1976; 70:562–567.

3. Pitt HA, Kaufman SL, Coleman J, White RI, Cameron JL. Benign postoperative biliary strictures. Operate or dilate? Ann Surg. 1989; 210:417–425.

4. Nealon WH, Urrutia F. Longterm follow-up after bilioenteric anastomosis for benign bile duct stricture. Ann Surg. 1996; 223:639–645.

5. Davids PH, Groen AK, Rauws EA, Tytgat GN, Huibregtse K. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet. 1992; 340:1488–1492.

6. Irving JD, Adam A, Dick R, Dondelinger RF, Lunderquist A, Roche A. Gianturco expandable metallic biliary stents: results of a European clinical trial. Radiology. 1989; 172:321–326.

7. Berkelhammer C, Kortan P, Haber GB. Endoscopic biliary pros-theses as treatment for benign postoperative bile duct strictures. Gastrointest Endosc. 1989; 35:95–101.

8. Costamagna G, Pandolfi M, Mutignani M, Spada C, Perri V. Longterm results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc. 2001; 54:162–168.

9. Davids PH, Rauws EA, Coene PP, Tytgat GN, Huibregtse K. Endoscopic stenting for post-operative biliary strictures. Gastrointest Endosc. 1992; 38:12–18.

10. Draganov P, Hoffman B, Marsh W, Cotton P, Cunningham J. Longterm outcome in patients with benign biliary strictures treated endoscopically with multiple stents. Gastrointest Endosc. 2002; 55:680–686.

11. Frattaroli FM, Reggio D, Guadalaxara A, Illomei G, Pappalardo G. Benign biliary strictures: a review of 21 years of experience. J Am Coll Surg. 1996; 183:506–513.

12. Deviere J, Cremer M, Baize M, Love J, Sugai B, Vandermeeren A. Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents. Gut. 1994; 35:122–126.

13. Rossi P, Bezzi M, Salvatori FM, Maccioni F, Porcaro ML. Recurrent benign biliary strictures: management with self-expanding metallic stents. Radiology. 1990; 175:661–665.

14. van Berkel AM, Cahen DL, van Westerloo DJ, Rauws EA, Huibregtse K, Bruno MJ. Self-expanding metal stents in benign biliary strictures due to chronic pancreatitis. Endoscopy. 2004; 36:381–384.

15. Bezzi M, Zolovkins A, Cantisani V, et al. New ePTFE/FEP-covered stent in the palliative treatment of malignant biliary obstruction. J Vasc Interv Radiol. 2002; 13:581–589.

16. Isayama H, Komatsu Y, Tsujino T, et al. A prospective randomised study of "covered" versus "uncovered" diamond stents for the management of distal malignant biliary obstruction. Gut. 2004; 53:729–734.

17. Matsushita M, Takakuwa H, Nishio A, Kido M, Shimeno N. Open-biopsy-forceps technique for endoscopic removal of distally migrated and impacted biliary metallic stents. Gastrointest Endosc. 2003; 58:924–927.

18. Minami A, Fujita R. A new technique for removal of bile duct stones with an expandable metallic stent. Gastrointest Endosc. 2003; 57:945–948.

19. Wamsteker EJ, Elta GH. Migration of covered biliary self-expanding metallic stents in two patients with malignant biliary obstruction. Gastrointest Endosc. 2003; 58:792–793.

20. Cahen DL, Rauws EA, Gouma DJ, Fockens P, Bruno MJ. Removable fully covered self-expandable metal stents in the treatment of common bile duct strictures due to chronic pancreatitis: a case series. Endoscopy. 2008; 40:697–700.

21. van Boeckel PG, Vleggaar FP, Siersema PD. Plastic or metal stents for benign extrahepatic biliary strictures: a systematic review. BMC Gastroenterol. 2009; 9:96.

22. Smith MT, Sherman S, Lehman GA. Endoscopic management of benign strictures of the biliary tree. Endoscopy. 1995; 27:253–266.

23. Yamaguchi T, Ishihara T, Seza K, et al. Longterm outcome of endoscopic metallic stenting for benign biliary stenosis associated with chronic pancreatitis. World J Gastroenterol. 2006; 12:426–430.

24. Cantù P, Hookey LC, Morales A, Le Moine O, Devière J. The treatment of patients with symptomatic common bile duct stenosis secondary to chronic pancreatitis using partially covered metal stents: a pilot study. Endoscopy. 2005; 37:735–739.

25. Kahaleh M, Behm B, Clarke BW, et al. Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video). Gastrointest Endosc. 2008; 67:446–454.

26. Chaput U, Scatton O, Bichard P, et al. Temporary placement of partially covered self-expandable metal stents for anastomotic biliary strictures after liver transplantation: a prospective, multicenter study. Gastrointest Endosc. 2010; 72:1167–1174.

27. Traina M, Tarantino I, Barresi L, et al. Efficacy and safety of fully covered self-expandable metallic stents in biliary complications after liver transplantation: a preliminary study. Liver Transpl. 2009; 15:1493–1498.

28. Tarantino I, Mangiavillano B, Di Mitri R, et al. Fully covered self-expandable metallic stents in benign biliary strictures: a multicenter study on efficacy and safety. Endoscopy. 2012; 44:923–927.

29. Kahaleh M, Brijbassie A, Sethi A, et al. Multicenter trial evaluating the use of covered self-expanding metal stents in benign biliary strictures: time to revisit our therapeutic options? J Clin Gastroenterol. 2013. [Epub ahead of print].

30. Coté GA, Kumar N, Ansstas M, et al. Risk of post-ERCP pancreatitis with placement of self-expandable metallic stents. Gastrointest Endosc. 2010; 72:748–754.

31. Mahajan A, Ho H, Sauer B, et al. Temporary placement of fully covered self-expandable metal stents in benign biliary strictures: midterm evaluation (with video). Gastrointest Endosc. 2009; 70:303–309.

32. Park do H, Lee SS, Lee TH, et al. Anchoring flap versus flared end, fully covered self-expandable metal stents to prevent migration in patients with benign biliary strictures: a multicenter, prospective, comparative pilot study (with videos). Gastrointest Endosc. 2011; 73:64–70.

Table 1.

Patient Characteristics and Indications for FCSEMS Placement

Characteristic	Data
Patient (n)	41 (100)
Sex (male/female)	24/14 (65.9/34.1)
Mean age (yr)	55 (21–79)
Etiology of BBSs
Gall stone-related disease	19 (46.3)
Chronic pancreatitis	15 (36.6)
Postsurgical complication	4 (9.8)
PSC	1 (2.4)
Other	2 (4.9)
FCSEMS length (mm)
40	13 (31.7)
50	19 (46.3)
60	6 (14.6)
70/80/90	1/1/1 (2.4/2.4/2.4)
Stent time (mo)	3.2 (1.9–6.2)
Follow-up period after stent removal (mo)	10.2 (1.0–32.0)
First-line treatment	17 (41.5)
Second-line treatment	24 (58.5)
Previous cholecystectomy	19 (46.3)

Values are presented as n (%) or median (range).

FCSEMS, fully covered self-expandable metal stents; BBS, benign biliary stricture; PSC, primary sclerosing cholangitis.

Table 2.

Results from Use of FCSMS to Treat BBS

Overall rate	Stricture resolution	Recurrence	Migration
Etiologies	38/41 (92.7)	6/38 (15.8)	6/41 (14.6)
Gall stone-related disease	17/19 (89.5)	2/17 (11.8)	4/19 (21.8)
Chronic pancreatitis	14/15 (93.3)	2/14 (14.3)	0/15 (0)
Postsurgical complication	4/4 (100)	2/4 (50.0)	1/4 (2.4)
PSC	1/1 (100)	0 (0)	1/1 (100)
Other etiology	2/2 (100)	0 (0)	0 (0)
Previous treatments
No	16/17 (94.1)	1/16 (6.3)	2/17(11.8)
Yes	22/24 (91.7)	5/22 (22.7)	4/24 (16.7)
Length of stricture (cm)
1.0	1/2 (50.0)	0 (0)	0/2 (0)
1.5	7/7 (100)	2/7 (28.6)	1/7 (14.3)
2.0	15/16 (93.8)	1/15 (6.7)	1/16 (6.3)
2.5	7/8 (87.5)	1/7 (14.3)	2/8 (25.0)
3.0	4/4 (100)	1/4 (25.0)	2/4 (50.0)
3.5	4/4 (100)	1/4 (25.0)	0/4 (0)
Length of FCSEMS (cm)
4	11/13 (84.6)	3/11 (27.3)	1/13 (7.7)
5	19/19 (100)	0 (0)	3/19 (15.8)
6	5/6 (83.3)	1/5 (20.0)	1/6 (16.7)
7/8/9	3/3 (100)	2/3 (66.6)	1/3 (33.3)

Values are presented as n (%).

FCSEMS, fully covered self-expandable metal stents; BBS, benign biliary stricture; PSC, primary sclerosing cholangitis.

Table 3.

Complications Related to the Procedure and Stent

Complication	n (%)
Placement complication	6 (14.6)
Post-ERCP pancreatitis	4 (9.8)
Pain	2 (4.9)
Removal complication	2 (2.4)
Pain	2 (2.4)
Stent complication	8 (19.6)
Proximal migration	3 (7.3)
Distal migration	3 (7.3)
Occlusion	2 (4.9)

TOOLS

Similar articles