Optimizing biliary stenting in patients with distal malignant biliary obstruction.

Abstract

Endoscopic biliary stenting plays a crucial part in the management of patients with malignant biliary strictures (MBSs), not only in a palliative setting where there is metastatic disease, but also in allowing neoadjuvant chemotherapy to be given before surgery [1]. The use of self-expandable metal stents (SEMSs) is preferred to plastic stents, as SEMSs are associated with a longer patient survival, a lower risk of stent dysfunction/cholangitis, and fewer reinterventions [1]. Fully covered SEMSs (FCSEMSs) have the advantage of being less prone to obstruction owing to tissue ingrowth, which allows easier stent removal; on the other hand, migration, into the duodenal lumen or even in an intrabiliary direction, can be of a major concern [2]. Neoadjuvant chemotherapy seems to be an additional risk factor that favors migration, which relates to the reduction in tumoral tissue [3]. Another debatable concern with the use of FCSEMSs is the incidence of cholecystitis, especially in patients presenting with tumor involvement of the cystic duct [3].