Fully Covered Self-expandable Metal Stents are Effective and Safe to Treat Distal Malignant Biliary Strictures, Irrespective of Surgical Resectability Status

Abstract

We report a retrospective analysis of patients with malignant biliary obstruction in whom a newly released fully silicon-covered, WallFlex, self-expandable metal stent (CSEMS) was placed for biliary decompression. Between March, 2009 and March, 2010, all patients with obstructive jaundice secondary to pancreatic cancer underwent placement of a CSEMS, regardless of resectability. A CSEMS was placed across the malignant stricture. These patients were then staged for their cancer by computed tomography, magnetic resonance imaging, and/or endoscopic ultrasound-guided fine-needle aspiration. Patient found to have resectable cancer were offered a pancreaticoduodenectomy. We identified 88 patients with pancreatic cancer who received a CSEMS. Forty patients were deemed resectable and underwent surgery. Pancreaticoduodenectomy was performed in 34 of 40 patients. The CSEMS was easily removed at the time of surgical resection without any complications. The 44 unresected patients with covered SEMS were followed for a mean of 4.2 months (range, 1 to 13). The patency rate for stents was 97% at 12 months. Immediate procedural complications included post-endoscopic retrograde cholangiopancreatography pancreatitis (n=9) and duodenal perforation (n=2). Four patients (5%) had migration and 3 (3%) had stent occlusion. There were no cases of cholecystitis during the follow-up. The patients who presented with stent migration or occlusion underwent stent revision. Placement of the newly available CSEMS can be used to effectively and safely treat biliary obstructions from pancreatic carcinoma. We recommend that the CSEMS be used as an initial intervention to relieve malignant biliary obstruction, even in patients whose surgical resectability status is uncertain.