HPB O03 ERCPs and Biliary Stenting for Ductal Stone Disease: A Call for a National Database

Abstract

Abstract Background According to the European Society of Gastrointestinal Endoscopy, in the context of complicated biliary stone disease, plastic stenting of the biliary tree via endoscopic retrograde cholangiopancreatography (ERCP) temporarily provides drainage of a blocked or infected biliary system. However, there is high mortality and morbidity associated with long-term endoprostheses; cholangitis as one of the main complications. Therefore, plastic stenting should only be used for a period of up to 6 months, according to latest guidelines. Our aim was to compare Trust practice with international recommendations, identifying potential causes for prolonged stent placement in patients with choledocholithiasis, and to discuss possible solutions. Methods Patients who underwent an ERCP across a 3-year period from NHS secure server records were identified, with further analysis of patients undergoing plastic biliary stent insertion. Results Of the 1118 ERCPs performed, 281 underwent plastic stenting for choledocholithiasis. Some patients were not suitable for cholecystectomy, so stents were accepted as the ceiling of care. 29 had stents in situ for over 6 months, while waiting for surgery. Of the 75 who had proceeded to cholecystectomy, 57 subsequently had stents removed in the trust. 18 still had plastic stents in situ. 5 had stents removed elsewhere, one of whom developed cholangitis and sepsis, requiring removal of the infected stent at a tertiary centre. Two patients were no longer fit for removal, and two had spontaneously passed their stents. Conclusions Retained biliary stents is not a rarity. There are many factors leading to delays, including long waiting lists for surgery, lack of requests to the endoscopy department and patient choice. Extrapolation of this single-trust audit would suggest that many sites are not meeting international guidelines for the duration of indwelling plastic stents. We suggest the implementation of a national database to monitor all patients with biliary endoprostheses to reduce morbidity associated with retained stents. We also recommend that incidents where harm is caused by plastic stents remaining in situ for greater than six months be treated as a Never Event.