Management of Occluded Metallic Stents in Patients with Malignant Biliary Obstructions: Metallic, Plastic Stents or Percutaneous Drainage?

Abstract

Background: Self-expandable metallic stent (SEMS) has been widely used for palliative drainage in patients with unresectable malignant biliary obstruction. Although SEMS has a longer patency time than plastic stents (PS) but stent occlusion can still occur and drainage has to be re-established in patient with expected longer survival. However, the choices are still controversial among re-stenting with SEMS, PS and percutaneous transhepatic biliary drainage (PTBD). Objectives: To determine the efficacy of PS, SEMS, and PTBD as treatments for occluded SEMS and to evaluate the survival of patients with occluded first SEMS who underwent different types of re-drainage. Methods: Between 2003 and 2008, a total of 143 ERCPs with SEMS insertion were performed at the Endoscopy Unit of Chulalongkorn University. The causes of obstructive jaundice were cholangiocarcinoma (n=102), pancreatic cancer (n= 38), metastatic carcinoma (n=3). Thirty patients (20.9%) with occluded SEMS were identified and retrospectively reviewed. PS, SEMS, and PTBD were inserted to re-establish drainage in 11, 13, and 6 patients, respectively. The second stent was inserted as stent-in-stent. Results: The median patency time of second SEMS was significant longer than PS and PTBD significantly (p = 0.001). The median survival time of patients with second SEMS was significantly longer than patients with PS and PTBD (p = 0.001) (table). Conclusions: SEMS insertion for occluded SEMS in patient with malignant biliary obstruction provides a longer patency time than PS and PTBD. SEMS insertion is more appropriate in patient whose survival time after first SEMS occlusion is longer than 2 months. The prediction of second SEMS patency and survival time of the patient can be adopted from the patency of the first SEMS (>90days).