Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video)

[Guest guest]

doi:10.1016/j.gie.2007.06.057 Copyright © 2008 American Society for Gastrointestinal Endoscopy Published by Mosby, Inc.

Original article

Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video)

Michel Kahaleh MD, FASGE, a, Behm MDa, Bridger W. e MDa, Brock MDa, M. Shami MDa, A. De La Rue PhDa, Vinay Sundaram MDa, Tokar MDa, Reid B. MDa and Yeaton MDa aCurrent affiliations: Digestive Health Center (M.K., B.B., B.W.C., A.B., V.M.S., S.D.L.R., V.S., J.T., P.Y.), the Department of Surgery (R.B.A.), University of Virginia Health System, Charlottesville, Virginia, USA Received 9 November 2006; accepted 25 June 2007. Charlottesville, Virginia, USA. Available online 20 February 2008.

Background

Benign biliary strictures (BBS) are usually managed with plastic stents, whereas placement of uncovered metallic stents has been associated with failure related to mucosal hyperplasia. Objective

We analyzed the efficacy and safety of temporary placement of a covered self-expanding metal stent (CSEMS) in BBS. Design

Patients with BBS received temporary placement of CSEMSs until adequate drainage was achieved; confirmed by resolution of symptoms, normalization of liver function tests, and imaging. Setting

Tertiary-care center with long-standing experience with CSEMSs. Patients

Seventy-nine patients with BBS secondary to chronic pancreatitis (32), calculi (24), liver transplant (16), postoperative biliary repair (3), autoimmune pancreatitis (3), and primary sclerosing cholangitis (1). Intervention

ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or a rat-tooth forceps. Main Outcome Measurements

End points were efficacy, morbidity, and clinical response. Results

CSEMSs were removed from 65 patients. Resolution of the BBS was confirmed in 59 of 65 patients (90%) after a median follow-up of 12 months after removal (range 3-26 months). If patients who were lost to follow-up, developed cancer, or expired were considered failures, then an intent-to-treat global success rate of 59 of 79 (75%) was obtained. Complications associated with placement included 3 post-ERCP pancreatitis (4%), 1 postsphincterotomy bleed (1%), and 2 pain that required CSEMS removal (2%). In 11 patients (14%), the CSEMS migrated. In 1 patient, CSEMS removal was complicated by a bile leak that was successfully managed with plastic stents. Limitation

Pilot study from a single center. Conclusions

Temporary CSEMS placement in patients with BBS offers a potential alternative to surgery.

Abbreviations: ALK, alkaline phosphatase; ALT, alanine aminotransferase; BBS, benign biliary strictures; CSEMS, covered self-expanding metal stent; LFT, liver function test; SEMS, self-expanding metal stent

Presented at Digestive Disease Week, Chicago, Illinois, May 14-18, 2005, and Washington, DC, May 20-23, 2007 (Gastrointest Endosc 2005;61:AB208, Gastrointest Endosc 2007;65:AB123).Reprint requests: Michel Kahaleh, MD, Digestive Health Center Box 800708, University of Virginia Health System, Charlottesville, VA 22908-0708.

Gastrointestinal Endoscopy Volume 67, Issue 3, March 2008, Pages 446-454