Management of occluded biliary wallstents

Abstract

Background-Wallstents (Schneider Stent, Inc., USA) used for the palliation of malignant biliary strictures, although associated with prolonged patency, can occlude. There is no consensus regarding the optimal management of Wallstent occlusion. Aims-To evaluate the eYcacy of different endoscopic methods for managing biliary Wallstent occlusion. Methods-A multicentre retrospective study of patients managed for a biliary Wallstent occlusion. Results-Data were available for 38 patients with 44 Wallstent occlusions, all of which had initial endoscopic management. Twenty four patients had died and 14 were alive after a median follow up of 231 (30-1095) days following Wallstent occlusion. Occlusions were managed by insertion of another Wallstent in 19, insertion of a plastic stent in 20, and mechanical cleaning in five. Endoscopic management was successful in 43 (98%). Following management of the occlusion, bilirubin decreased from 6.0 (0.5-34.3) to 2.1 (0.2-27.7) mg/100 ml (p<0.05). No complications occurred. The median duration of second stent patency was 75 days (95% confidence interval 43 to 107) after insertion of another Wallstent, 90 days (71 to 109) after insertion of a plastic stent, and 34 days (30 to 38) after mechanical cleaning (NS). The respective median survivals were 70 days (22-118), 98 days (54-142), and 34 days (30-380) (NS). Incremental cost eVective analysis showed that plastic stent insertion is the most cost eVective option. Conclusion-Although all three methods are equally eVective in managing an occluded Wallstent, the most cost eVective method appears to be plastic stent insertion.

Management of an occluded biliary metallic stent

“…Many retrospective series have demonstrated that it developed in 5%-40% of patients who underwent an endoscopic palliative treatment with SEMS [14][15][16][17][18][19] . The causes of occluded SEMS include tumor ingrowth, overgrowth, sludge/debris formation and stent migration ( Table 1).…”

“…The causes of occluded SEMS include tumor ingrowth, overgrowth, sludge/debris formation and stent migration ( Table 1). The most common cause of SEMS occlusion is tumor ingrowth, which accounted for 60%-90% of all SEMS occlusion [14][15][16][17][18][19] . This complication is more common in uncovered SEMS, which has an open-mesh, resulting in tissue growing into the stent easily [20,21] .…”

“…Many studies have shown that one fourth of all SEMS occlusions resulted from tumor overgrowth [14][15][16][17][18][19] . Because tumor can grow and invade over both ends of the stent, covered and uncovered SEMSs have an equal chance to develop tumor overgrowth.…”

“…Currently, there are three endoscopic techniques that provide re-drainage for SEMS occlusion: (1) mechanical cleaning with a balloon; (2) PS insertion; and (3) SEMS insertion [14][15][16][17][18][19] .…”

“…There are several studies that used additional stent placement as stent-in-stent for a re-drainage of SEMS occlusion [14][15][16][17][18][19] . The patency times of a second stent are shown in Table 2.…”