Expansile metal stents are a safe and cost-effective alternative to conventional plastic endoprostheses in the treatment of esophageal obstruction due to inoperable cancer.

Endoscopic insertion of biliary stents is the preferred method of palliation for inoperable malignant biliary obstruction; however, migration and clogging are frequent problems with conventional endoprostheses. We sought to determine if expandable metal stents offer improved palliation compared to conventional stents. Sixty-two patients with common bile duct lesions were randomized to receive polyethylene or metal stents. Stents were placed endoscopically or by the combined percutaneous-endoscopic route. Early results (< 1 month) were similar in both groups. Long-term follow-up (n = 28 polyethylene, median: 5 months; n = 27 metal, median: 5 months) showed a higher stent failure rate in the polyethylene (n = 12; 43%) compared to the metal group (n = 6; 22%). The incidence of cholangitis was significantly higher (p < 0.05) in the polyethylene (n = 10; 36%) compared to the metal group (n = 4; 15%). Life-table analysis showed a significantly reduced incidence of stent failure (p = 0.0035) in the metal stent compared to the polyethylene group. The total duration of hospital stay for treatment of stent related problems was significantly higher in the polyethylene (11.8 +/- 3 days) compared to the metal group (4 +/- 1.9 days; p = 0.02). The costs for retreatment because of stent failure were significantly higher in the plastic (DM 5900 +/- 1516) compared to the metal group (DM 2070 +/- 977). As a result, the overall costs (treatment of stent related complications & stents) were higher in the polyethylene group (DM 6000 +/- 1500).(ABSTRACT TRUNCATED AT 250 WORDS)

This prospective and randomized trial sought to compare large-bore plastic endoprostheses (14 French) and self-expanding metal stents (24 French) in the palliative treatment of obstructive jaundice due to biliary hilar malignancies. Twenty patients with Type II-IV (Bismuth classification) hilar obstruction were randomized to treatment with either plastic or metal stents. Both treatment groups were well matched with regard to all assessed clinical criteria before stenting. Stent placement was uniformly successful in the metal group and in 88.9% of the plastic group. Early stent failure (< 30 days) occurred in two patients of the plastic stent group. Longterm (> 30 days), stent failure was observed in 50% of the plastic group and 18.2% of the metal stent group. All differences were not statistically significant. The number of re-interventions required to manage stent-related problems proved to be significantly higher in the plastic group (2.4 +/- 2.6) compared to the metal group (0.4 +/- 0.5). Hospitalization for treatment of stent complications was also significantly higher in the plastic treatment group. The costs calculated for stents and hospital stay for required re-interventions were therefore higher in the plastic stent group. In conclusion, metal stent insertion for palliation of hilar malignancies does not only offer higher success rates and higher patency rates compared to plastic stent insertion, but is also cost-effective since patients require fewer re-interventions.

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