A significant number of self-expandable metal stents (SEMSs) placed to palliate malignant biliary obstruction will occlude. Few data exist as to what constitutes optimal management.
Our purpose was to review the management and outcomes of patients with biliary SEMS occlusion.
Retrospective chart review at a single tertiary care hospital.
From January 1999 to October 2005, a total of 90 patients had SEMSs placed for malignant biliary obstruction, and 27 of these occluded.
Technical success of treating SEMS occlusion, stent patency and need for reintervention, and incremental cost analysis.
A total of 60 ERCPs were performed to treat SEMS occlusions in 27 patients. The success rate was 95%; however, 52% of patients eventually required more than 1 intervention. Placing a second SEMS through the existing SEMS (n = 14) provided the lowest reocclusion rate (43% vs 55% and 100%), the longest time to reintervention (172 days vs 66 and 43 days, P = .03), and a trend toward longer survival (285 days vs 188 and 194 days) compared with plastic stent and mechanical balloon cleaning, respectively. Incremental cost analysis showed both uncovered SEMSs and plastic stents to be cost effective strategies.
Small number of patients, retrospective study.
Treatment of biliary SEMS occlusion with SEMS insertion provides for longer patency and survival, decreases the number of subsequent ERCPs by 50% compared with plastic stents, and is cost-effective.
"Studies of endoscopic palliation for malignant inoperable obstructive jaundice have demonstrated the therapeutic advantage and cost effectiveness of self-expanding metal stents compared to surgical bypass or placement of plastic stents [2, 14, 15]. The efficacy of bare metal stents is limited by the propensity for tumor ingrowth . Similarly, partially covered SEMSs remain prone to obstruction by ingrowth and overgrowth of tumor and by hyperplastic tissue response at the short bare segment at the upper end. "
[Show abstract][Hide abstract] ABSTRACT: Background and Study Aims. Endoscopic placement of self-expanding metal stents (SEMSs) is indicated for palliation of inoperable malignant biliary obstruction. A fully covered biliary SEMS (WallFlex Biliary RX Boston Scientific, Natick, USA) was assessed for palliation of extrahepatic malignant biliary obstruction. Patients and Methods. 58 patients were included in this prospective, multicenter series conducted under an FDA-approved IDE. Main outcome measurements included (1) absence of stent occlusion within six months or until death, whichever occurred first and (2) technical success, need for reintervention, bilirubin levels, stent patency, time to stent occlusion, and adverse events. Results. Technical success was achieved in 98% (57/58), with demonstrated acute removability in two patients. Adequate clinical palliation until completion of followup was achievedin 98% (54/55) of evaluable patients, with 1 reintervention due to stent obstruction after 142 days. Mean total bilirubin decreased from 8.9 mg/dL to 1.2 mg/dL at 1 month. Device-related adverse events were limited and included 2 cases of cholecystitis. One stent migrated following radiation therapy. Conclusions. The WallFlex Biliary fully covered stent yielded technically successful placement with uncomplicated acute removal where required, appropriate reduction in bilirubin levels, and low rates of stent migration and occlusion. This SEMS allows successful palliation of malignant extrahepatic biliary obstruction.
Gastroenterology Research and Practice 03/2013; 2013:642428. DOI:10.1155/2013/642428 · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In patients with a malignant biliary obstruction who require biliary drainage, a self-expandable metallic stent (SEMS) provides longer patency duration than a plastic stent (PS). Nevertheless, a stent occlusion by tumor ingrowth, tumor overgrowth and biliary sludge may develop. There are several methods to manage occluded SEMS. Endoscopic management is the preferred treatment, whereas percutaneous intervention is an alternative approach. Endoscopic treatment involves mechanical cleaning with a balloon and a second stent insertion as stent-in-stent with either PS or SEMS. Technical feasibility, patient survival and cost-effectiveness are important factors that determine the method of re-drainage and stent selection.
"(Rogart, 2010; Wasan et al, 2005; Chen et al, 2005; Boulay et al, 2010) In addition, insertion of SEMS is advised as the treatment of biliary SEMS occlusion, as it provides longer patency and survival, decreases the number of subsequent procedures by 50% (compared to plastic stents) and is costeffective . (Rogart et al, 2008) However, technical failure during ERCP is encountered in up to 10% of cases due to various factors including duodenal obstruction, anatomical variations, periampullary diverticulum and tightness of the stricture. In these cases, percutaneous transhepatic biliary drainage (PTBD) and surgical drainage are options available. "
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