Endoscopic management of malignant biliary obstruction by means of covered metallic stents: primary stent placement vs. re-intervention

Background and study aims: Recent progress in chemotherapy has prolonged the survival of patients with malignant biliary strictures, leading to increased rates of stent occlusion. Occlusion of covered metallic stents now occurs in about half of all patients with malignant biliary strictures. The removal of metallic stents followed by placement of a second stent has been attempted, but outcomes remain controversial. The aim of the current study was to evaluate the effectiveness and safety of the primary placement and secondary placement (re-intervention) of covered metallic stents and to assess the feasibility and safety of stent removal.

Patients and methods: The study included 186 patients with unresectable malignant biliary strictures who underwent primary stent placement between October 2001 and March 2010. Covered biliary self-expandable metal stents (SEMSs) were removed in 39 of these patients, and 36 underwent re-intervention. The patency times, occlusion rates of the first stent and re-intervention, success rates of stent removal, and complications were investigated.

Results: Covered SEMSs were placed in 186 patients. The median patency time of the first stent was 352 days. Stent occlusion occurred in 48.9 % of the patients and was mainly caused by debris or food residue (37 %), dislocation (19 %), and migration with hyperplasia (19 %). Stent removal was attempted in 50 patients and was successful without complication in 39 (78 %). Most of the patients in whom stent removal was unsuccessful had migration with hyperplasia. The median patency time of the second stent was 263 days. The stent patency time did not significantly differ between the first and the second stent.

Conclusions: Covered SEMSs could be safely removed at the time of stent occlusion. Patency rates were similar for initial stent placement and re-intervention.

• References

• 1 Soehendra N, Reynders-Frederix V. Palliative Gallengangdrainage. Dtsch Med Wschr 1979; 104: 206-207
• 2 Huibregtse K, Haverkamp HJ, Tytgat GN. Transpapillary positioning of a large 3.2 mm biliary endoprosthesis.. Endoscopy 1981; 13: 217-219
• 3 Huibregste K, Cheng J, Coene PP et al Endoscopic placement of expandable metal stents for biliary stricture – a preliminary report on experience with 33 patients. Endoscopy 1989; 21: 280-282
• 4 Neuhaus H, Hagenmuller F, Classen M. Self-expanding biliary stent: preliminary clinical experience. Endoscopy 1989; 21: 225-228
• 5 Davids PHP, Greon AK, Rauws EAJ et al Randomized trial of self-expandable metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 1992; 340: 1488-1492
• 6 Knyrim K, Wagner HJ, Pausch J et al A prospective, randomized, controlled trial of metal stents for malignant obstruction of the common bile duct. Endoscopy 1993; 25: 207-212
• 7 Isayama H, Komatsu Y, Tsujino T et al A prospective randomized study of “covered” versus “uncovered” diamond stents for the management of distal malignant biliary obstruction. Gut 2004; 53: 729-734
• 8 Yoon WJ, Lee JK, Lee KH et al A comparison of covered and uncovered Wallstents for the management of distal malignant biliary obstruction. Gastrointest Endosc 2006; 63: 996-1000
• 9 Park DH, Kim MH, Choi JS et al Covered versus uncovered Wallstent for malignant extrahepatic biliary obstruction: a cohort comparative analysis. Clin Gastroenterol Hepatol 2006; 4: 790-796
• 10 Telford JJ, Carr-Locke DL, Baron TH et al A randomized trial comparing uncovered and partially covered self-expandable metal stents in the palliation of distal malignant biliary obstruction. Gastrointest Endosc 2010; 72: 907-914
• 11 Kullman E, Frozanpor F, Soderlund C et al Covered versus uncovered self-expandable nitinol stents in the palliative treatment of malignant distal biliary obstruction: results from a randomized, multicenter study. Gastrointest Endosc 2010; 72: 915-923
• 12 Burris HA, Moore MJ, Andersen J et al Improvements in survival and clinical benefit with Gemcitabine as first-line therapy for patients with advanced pancreas cancer: A randomized trial. J Clin Oncol 1997; 15: 2403-2413
• 13 Moore MJ, Goldstein D, Hamm J et al Erlotinib plus Gemcitabine compared with Gemcitabine alone in patients with advanced pancreatic cancer: a phase III trial of the national cancer institute of Canada clinical trials group. J Clin Oncol 2007; 25: 1960-1966
• 14 Valle JW, Wasan H, Johnson P et al Gemcitabine alone or in combination with cisplatin in patients with advanced or metastatic cholangiocarcinomas or other biliary tract tumours: a multicenter randomized phase II study -UK ABC-01 study. Br J Cancer 2009; 101: 621-627
• 15 Valle JW, Wasan H, Palmar DH et al Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Eng J Med 2010; 362: 1273-1281
• 16 Schoefl R, Brownstone E, Reichel W et al Malignant bile duct obstruction: experience with self-expanding metal endoprotheses (Wallstents) in Austria. Endoscopy 1994; 26: 592-596
• 17 Tham TCK, Carr-Locke DL, Vandervoort J et al Management of occluded biliary Wallstents. Gastrointest Endosc 1998; 42: 703-707
• 18 Bueno JT, Gerdes H, Kurtz RC. Endoscopic management of occluded biliary Wallstents: a cancer center experience. Gastrointest Endosc 2003; 58: 879-884
• 19 Yarze JC, Poulos AM, Fritz HP et al Treatment of metallic biliary stent-induced duodenal ulceration using endoscopic laser therapy. Dig Dis Sci 1997; 42: 6-9
• 20 Demarquary JF, Dumas R, Peten EP et al Argon plasma endoscopic section of biliary metallic prostheses.. Endoscopy 2001; 33: 289-290
• 21 Vanbiervliet G, Piche T, Caroli-Bosc FX et al Endoscopic argon plasma trimming of biliary and gastrointestinal metallic stens. Endoscopy 2005; 37: 434-438
• 22 Chen YK, Jakribettuu V, Springer EW et al Safety and efficacy of argon plasma coagulation trimming of malpositioned and migrated biliary metal stents: a controlled study in the porcine model. Am J Gastroenterol 2006; 101: 2025-2030
• 23 Rerknimitr R, Naprasert P, Kongkam P et al Trimming a metallic biliary stent using an argon plasma coagulator. Cardiovasc Intervent Radiol 2007; 30: 534-536
• 24 Ahmed A, Keeffe EB, Imperial JC. A novel technique for endoscopic removal of expandable biliary Wallstent. Gastrointest Endosc 1999; 50: 279-281
• 25 Egan LJ, Baron TH. Endoscopic removal of an embedded biliary Wallstent by piecemeal extraction. Endoscopy 2000; 32: 492-494
• 26 Levy MJ, Wiersema MJ. Endoscopic removal of a biliary Wallstent with a suture-cutting device in a patient with primary pancreatic lymphoma. Endoscopy 2002; 34: 835-837
• 27 Warmsteker EJ, Elta GH. Migration of covered biliary self-expandable metallic stents in two patients with malignant biliary obstruction. Gastrointest Endosc 2003; 58: 792-793
• 28 Trentino P, Falasco G, d’Orta C et al Endoscopic removal of a metallic stent: case report. Gastrointest Endosc 2004; 59: 321-323
• 29 Kahaleh M, Tokar J, Le T et al Removal of self-expandable metallic Wallstents. Gastrointest Endosc 2004; 60: 640-644
• 30 Costamagna G, Pandolfi M. Endoscopic stenting for biliary and pancreatic malignancies. J Clin Gastroenterol 2004; 38: 59-67
• 31 Familiari P, Bulajic M, Mutignani M et al Endoscopic removal of malfunctioning biliary self-expandable metallic stents. Gastrointest Endosc 2005; 62: 903-910
• 32 Shin HP, Kim MH, Jung SW et al Endoscopic removal of biliary self-expandable metallic stents: a prospective study. Endoscopy 2006; 38: 1250-1255
• 33 Ornellas LC, Stefanidis G, Chuttani R et al Covered Wallstents for palliation of malignant biliary obstruction: primary stent placement versus reintervention. Gastrointest Endosc 2009; 70: 676-683
• 34 Arguedas MR, Heudebert GH, Stinnett AA et al Biliary stents in malignant obstructive jaundice due to pancreatic carcinoma: a cost-effectiveness analysis. Am J Gastroenterol 2002; 97: 898-904