Metallic stents in benign biliary strictures: long-term effectiveness and interventional management of stent occlusion

Long-Term Efficacy of Percutaneous Internal Plastic Stent Placement for Non-anastomotic Biliary Stenosis After Liver Transplantation

PURPOSE

We aimed to evaluate the long-term efficacy of percutaneous management of non-anastomotic biliary stenosis after liver transplantation, using plastic internal biliary stents.

MATERIALS AND METHODS

This study included 35 cases (28 men, 7 women; mean age: 52.09 ± 8.13 years, range 34-68) in 33 patients who needed repeated interventional procedures because of biliary strictures. After classification of the biliary strictures, we inserted percutaneous biliary plastic stents through the T-tube or percutaneous transhepatic biliary drainage tracts. Stents were exchanged according to percutaneous methods at regular 2- to 6-month intervals. The stents were removed if the condition improved, as observed on cholangiogram as well as based on clinical findings. The median patient follow-up period after initial diagnosis and treatment was 6.04 years (range 0.29-9.95 years). We assessed treatment success rate and patient and graft survival times.

RESULTS

During the follow-up period, 14 patients (14/33, 42.42 %) were successfully treated and were tube-free. The median tube-free time, time without a stent, was 4.13 years (range 1.00-9.01). In contrast, internal plastic stents remained in 9 patients (9/33, 27.27 %) until the last follow-up. These patients had acceptable hepatic function. Among the remaining 10 patients, 3 (3/33, 9.09 %) were lost to regular follow-up and the other 7 (7/33, 21.21 %) patients died. The overall graft loss rate was 20.0 % (7/35). The median time from initial treatment to graft loss was 1.84 years (range 0.42-4.25).

CONCLUSIONS

Percutaneous plastic stents placement is technically feasible and clinically useful in patients with multiple biliary stenoses following liver transplantation.

Placement of removable metal biliary stent in post-orthotopic liver transplantation anastomotic stricture

Postoperative biliary strictures are the most common cause of benign biliary stricture in Western countries, secondary to either operative injury or bile duct anastomotic stricture following orthotopic liver transplantation (OLT). Surgery or endoscopic interventions are the mainstay of treatment for benign biliary strictures. We aim to report the outcome of 2 patients with refractory anastomotic biliary stricture post-OLT, who had successful temporary placement of a prototype removable covered self-expandable metal stent (RCSEMS). These 2 patients (both men, aged 44 and 53 years) were given temporary placement of a prototype RCSEMS (8.5 Fr gauge delivery system, 8 mm × 40 mm stent dimensions) in the common bile duct across the biliary stricture. There was no morbidity associated with stent placement and removal in these 2 cases. Clinical parameters improved after the RCSEMS placement. Long-term biliary patency was achieved in both the patients. No further biliary intervention was required within 14 and 18 mo follow-up after stent removal.

Use of the viabil covered stent in the treatment of a benign biliary stricture with the subsequent development of acute pancreatitis

The use of bare metal stents for benign biliary strictures is typically avoided due to historically poor long-term patency. Thus, in patients who are not surgical candidates, the management of benign biliary strictures can be a frustrating process. This article describes a patient who developed a common bile duct stricture following a complex endovascular thoracoabdominal aneurysm repair. The stricture was treated with the placement of a covered metallic biliary stent; a procedure complicated by the development of acute pancreatitis.

[Diagnosis and interventional therapy for ductal gallstones]

Different imaging modalities recently underwent considerable improvements for the visualization of ductal gallstones. The declining significance of endoscopic retrograde cholangiopancreatography (ERCP) has been accepted unanimously. This paradigm shift is mostly due to improvements in transabdominal ultrasound, the increased availability of endoscopic ultrasound, and the use of magnetic resonance cholangiopancreatography (MRCP). In particular, MRCP is limited only in visualizing very small intraductal gallstones due to spatial resolution restrictions, whereas the detection rate of larger concretions is comparable to that with ERCP and endoscopic ultrasound. Patients with biliary pancreatitis benefit greatly from noninvasive MRCP visualization, establishing it as the preferred imaging modality. Particularly if ductal gallstones requiring further intervention are highly suspected, ERCP is preferable to other imaging modalities. If that suspicion is moderate, MRCP would be the imaging modality of choice, and transabdominal ultrasound would be performed if ductal gallstones are considered improbable. In up to 90% of cases, removal can be achieved endoscopically. Using a percutaneous approach smaller concretions can be extracted directly. However, larger gallstones need to be broken down into smaller fragments. For lithotripsy, either cholangioscopically-guided laser or electrohydraulic procedures are easy and effective. In case of strictures due to biliodigestive anastomoses, additional papillary balloon dilatation may be required.

Systematic appraisal of the role of metallic endobiliary stents in the treatment of benign bile duct stricture

OBJECTIVE

To carry out a systematic appraisal of the current status of the use of metallic endobiliary stents in the treatment of benign biliary strictures.

METHODS

A computerized search of the MEDLINE and EMBASE databases identified 37 studies providing detailed clinical course data on outcome of metallic endobiliary stent placement in 400 patients. Pooled data were examined for etiology of stricture, indications for stent placement, procedure-related complications, and outcome with reference to stent patency.

RESULTS

The median (range) number of patients per report was 8 (2-54) with a median recruitment period of 44 (9-126) months. The most frequent indications were postoperative biliary strictures in 123 (31%), stenosed biliary-enteric anastomoses in 79 (20%), and biliary strictures following liver transplantation in 88 (22%). During a median follow up of 31 (1-111) months, 139 (35%) stents occluded, and there are little patency data beyond 2 years after deployment, with 99 (25%) known to be patent at 3 years from stent placement.

CONCLUSIONS

These pooled data on 400 patients constitute the largest collective report to date on the use of metallic endobiliary stents for benign biliary strictures. The results show a critical lack of data on long-term patency such that at the present time, metallic endobiliary stents should not be used for benign stricture in those patients with a predicted life expectancy greater than 2 years.

Systematic appraisal of the role of metallic endobiliary stents in the treatment of benign bile duct stricture

OBJECTIVE

To carry out a systematic appraisal of the current status of the use of metallic endobiliary stents in the treatment of benign biliary strictures.

METHODS

A computerized search of the MEDLINE and EMBASE databases identified 37 studies providing detailed clinical course data on outcome of metallic endobiliary stent placement in 400 patients. Pooled data were examined for etiology of stricture, indications for stent placement, procedure-related complications, and outcome with reference to stent patency.

RESULTS

The median (range) number of patients per report was 8 (2-54) with a median recruitment period of 44 (9-126) months. The most frequent indications were postoperative biliary strictures in 123 (31%), stenosed biliary-enteric anastomoses in 79 (20%), and biliary strictures following liver transplantation in 88 (22%). During a median follow up of 31 (1-111) months, 139 (35%) stents occluded, and there are little patency data beyond 2 years after deployment, with 99 (25%) known to be patent at 3 years from stent placement.

CONCLUSIONS

These pooled data on 400 patients constitute the largest collective report to date on the use of metallic endobiliary stents for benign biliary strictures. The results show a critical lack of data on long-term patency such that at the present time, metallic endobiliary stents should not be used for benign stricture in those patients with a predicted life expectancy greater than 2 years.

Traitement de la sténose biliaire par prothèse métallique

A patient presented with a cholangiocarcinoma of the common bile duct; it was initially considered unresectable leading to the placement of the metallic stent whose upper end extended beyond the convergence of the hepatic ducts. The metallic biliary stent became obstructed and so encrusted as to be unremovable; the patient required a left hepatectomy with resection of the stent and the biliary convergence in addition to a pancreatoduodenectomy in order to resect his primary lesion This difficult situation emphasizes that, whenever there is doubt as to the resectability of a biliary lesion, the decision to place a metallic stent should be the fruit of a thorough medico-surgical discussion; where there is any doubt, a plastic stent which is more easily removable should be placed.