Covered Self-expandable Metal Stent Placement Research Articles

Risk factors for early and late cholecystitis after covered metal stent placement for distal biliary obstruction.

Cholecystitis is a major adverse event after self-expandable metallic stent placement for distal biliary obstruction (DBO). Covered self-expandable metallic stent (CSEMS) is being increasingly used, but few studies have investigated risk factors for cholecystitis limited to CSEMS. The present study aimed to identify risk factors for cholecystitis after CSEMS. Patients who underwent initial CSEMS placement for DBO between November 2014 and September 2021 were enrolled and followed-up until death, recurrent biliary obstruction, cholecystitis, or until March 2022. Cholecystitis within 30 days of CSEMS was defined as early cholecystitis and after 30 days as late cholecystitis. Cholecystitis occurred in 51 of 339 patients (15%) after CSEMS. Forty-one patients (80.4%) had early cholecystitis, and 10 (19.6%) had late cholecystitis. Multivariate logistic regression analysis revealed that the maximum diameter of the common bile duct (CBD) (per 1 mm increase) (odds ratio [OR]: 0.87; 95% confidence interval [CI]: 0.76-1.00; p = .044), gallbladder stones (OR: 3.63; 95% CI: 1.62-8.10; p = .002), and tumor involvement in the cystic duct (CD) (OR: 4.87; 95% CI: 2.16-11.00; p < .001) were significant independent risk factors associated with early cholecystitis. No significant risk factors were identified for late cholecystitis. A smaller CBD diameter, gallbladder stones, and tumor involvement in the CD were identified as risk factors for early cholecystitis development after CSEMS.

Prophylactic endoscopic gallbladder stenting for cholecystitis after covered metal stent placement for distal biliary obstruction.

Acute cholecystitis is occasionally observed after biliary drainage using a covered self-expandable metal stent (CSEMS) for distal biliary obstruction (DBO). Gallbladder drainage prior to CSEMS placement may reduce cholecystitis. This study aimed to examine the preventive effect of endoscopic gallbladder stenting (EGBS) on cholecystitis with CSEMS. We retrospectively analyzed patients with DBO who underwent CSEMS placement across the orifice of the cystic duct between November 2014 and October 2021 and were negative for cholecystitis on biliary drainage. Prophylactic EGBS was attempted before CSEMS placement. The incidence of cholecystitis was compared between patients with and without EGBS. A total of 286 patients (128 men; median age, 75 years) were included in this study. EGBS was attempted in 32 patients before CSEMS placement, and technical success was achieved in 24 (75%) patients. Adverse events were noted in three patients (9.4%; penetration of cystic duct in one and acute pancreatitis in two). The cumulative incidence of cholecystitis was significantly lower in patients with EGBS than in those without EGBS (1 [4.2%] vs. 56 [21.4%]; p=0.045. In multivariable analysis, EGBS was a significant protective factor against cholecystitis (hazard ratio, 0.11; 95% confidence interval, 0.01-0.79; p=0.028). Although the transpapillary approach to the gallbladder is not easy for patients with DBO, EGBS is effective in preventing cholecystitis associated with CSEMS.

Efficacy and safety of covered versus uncovered self‑expandable metal stents for the palliative treatment of malignant distal biliary stricture: A long‑term retrospective study.

Both covered self-expandable metal stents (CSEMSs) and uncovered self-expandable metal stents (USEMSs) have been tried in the palliation of malignant distal biliary strictures by means of endoscopic retrograde cholangiopancreatography (ERCP); however, the comparison of efficacy and safety between them remains contested. To the best of our knowledge, no similar studies have assessed this in the Chinese population. In the present study, the clinical and endoscopic data of 238 patients (CSEMSs, n=55; USEMSs, n=183) with malignant distal biliary strictures from 2014 to 2019 were collected. The efficacy indicated by mean stent patency, stent patency rate, mean patient survival time and survival rate, and the safety indicated by adverse events after CSEMS or USEMS placement were retrospectively analyzed and compared. The mean stent patency time was significantly longer in the CSEMSs group than that in the USEMSs group (262.8±195.3 days vs. 169.5±155.7 days, P=0.002). The mean patient survival time was significantly longer in the CSEMSs group than that in the USEMSs group (273.9±197.6 days vs. 184.9±167.6 days, P=0.003). The stent patency rate and patient survival rate were significantly higher in the CSEMSs group than those in the USEMSs group at 6 and 12 months, but not at 1 and 3 months. There was no significant difference in stent dysfunction and adverse events between the two groups, although post-ERCP pancreatitis (PEP) occurred more frequently in the CSEMSs group than in the USEMSs group (18.1% vs. 8.8%, P=0.049). In conclusion, CSEMSs were better than USEMSs for malignant distal biliary strictures in terms of stent patency time and patient survival time as well as stent patency rate and patient survival rate in the long term (>6 months). Adverse events in the two groups occurred at a similar rate, although the incidence of PEP was higher in the CSEMSs group.

Outcomes after partially covered self-expandable metal stent placement for recurrent duodenal obstruction.

Outcomes of partially covered self-expandable metal stents (SEMS) as an additional stent after recurrent duodenal obstruction (RDO) have not been elucidated. In this study, we compared outcomes of partially covered and uncovered SEMS placement after RDO in patients with malignant duodenal obstruction and explored factors affecting re-recurrent obstruction and overall survival in this population. We conducted a retrospective study of patients undergoing SEMS placement for RDO at a cancer institute in Japan from July 2014 to June 2021. Clinical variables and outcomes of patients undergoing partially covered and uncovered SEMS placement were compared. Sixty-one patients underwent SEMS placement after RDO, for which the COMVI stent was used in 38 cases and uncovered stents were used in 23 cases. Stent ingrowth was the most common cause of RDO (51.4%). Stent migration only occurred after partially covered stent placement (20% vs. 0%, p = 0.018). Choice of SEMS had no impact on time to re-RDO (median 2.8 vs. 4.1months, p = 0.776) or overall survival (median 2.6 vs. 2.4months, p = 0.703). Median overall survival was longer in patients receiving chemotherapy after second stenting (4.6 vs. 1.8months, p < 0.001) and shorter in those with early RDO, regardless of the SEMS used. Use of the partially covered stent had no impact on survival or time to RDO. While outcomes after partially covered SEMS placement for RDO were not significantly different from uncovered SEMS, migration remains a concern when they are used as a second stent. Chemotherapy after second stenting was associated with longer overall survival but not with longer time to re-RDO.

Risk factors for cholecystitis after stent placement in patients with distal malignant biliary obstruction.

Limited data are available for acute cholecystitis after Self-Expandable Metallic Stent (SEMS) placement in patients with malignant distal biliary obstruction. We aimed to identify risk factors for cholecystitis. This was a retrospective, single-center study of 280 patients (336 stents) who received endoscopic SEMS placement between May 2005 and April 2016. Clinical records were used to perform risk factor analyses. Of 336 SEMS placement procedures, 25 (7.4%) led to development of cholecystitis. Logistic regression analysis revealed three independent risk factors: covered SEMS (P=.014), tumor involvement to the cystic duct (P=.017), and presence of gallstones (P=.022). Median time to cholecystitis onset was shorter with covered SEMS than with uncovered SEMS (P=.034), and in patients with pancreatic cancer compared to those with other cancers (P=.001). Severe cholecystitis developed within 30days after covered SEMS placement in three patients with pancreatic cancer without tumor involvement to the cystic duct. Use of covered SEMS might be a risk factor for cholecystitis onset within 30days after placement. Clinicians should be aware of the risk for severe cholecystitis after covered SEMS placement, even if the tumor does not invade the cystic duct.

Early Covered Self-Expandable Metal Stent Placement Is Effective for Massive Post-endoscopic Sphincterotomy Bleeding.

Placement of covered self-expandable metallic stent (CSEMS) for post-endoscopic sphincterotomy (ES) bleeding achieves excellent hemostasis results. Although CSEMS placement is typically performed after failure of conventional endoscopic combination therapy, its excellent outcomes may justify earlier placement. We aimed to examine the efficacy of "early" CSEMS placement for massive post-ES bleeding. The medical records of 2750 patients who underwent ES between 2005 and 2019 were reviewed retrospectively, and 61 patients who developed massive post-ES bleeding were enrolled. These patients were divided into those who underwent early CSEMS placement (E-CSEMS group) and those who underwent conventional endoscopic combination therapy (Conventional group). The outcomes of hemostasis procedures were compared between the groups. The primary success rates of endoscopic hemostasis were 100% (21/21) and 98% (39/40) in the E-CSEMS group and Conventional group, respectively, without significant differences (P = 1.000). However, in the E-CSEMS group, re-bleeding was significantly less frequent (5% vs. 31%; P = 0.023), the median hemostasis procedure time was significantly shorter (14min vs. 26min; P < 0.001), and transfusion after initial hemostasis treatment was less commonly required (10% vs. 38%; P = 0.034). Multivariate analyses showed that hemodialysis was associated with a significantly higher re-bleeding rate (P = 0.029), while CSEMS placement was associated with a significantly lower re-bleeding rate (P = 0.039). Early CSEMS placement may be effective for improving the clinical outcomes of massive post-ES bleeding by decreasing re-bleeding and the extent of bleeding.

Acute Biliary Obstruction After Gastroduodenal Covered Self-Expanding Metallic Stent Placement in Patients with Previous Biliary Stent Placement for Periampullary Cancer: Frequency and Protective Factors.

We aimed to evaluate the frequency and protective factors of acute biliary obstruction in patients with biliary stent placement followed by gastroduodenal covered self-expandable metallic stent (SEMS) placement owing to progression of periampullary cancer. We retrospectively reviewed 58 patients. Total bilirubin and alkaline phosphatase (ALP) levels before and after gastroduodenal covered SEMS placement were evaluated. The incidence of acute biliary obstruction correlated to age, sex, biliary stent length and type, and longitudinal and axial locations of the lower end of the biliary stent was evaluated. Postprocedural total bilirubin and ALP levels were significantly higher than preprocedural levels (2.30±2.53 vs. 1.53±1.48mg/dL; P=0.008, 331.0±248.8 vs. 258.4±195.2IU/L; P=0.008, respectively). The increase in bilirubin levels was not statistically significant in female patients or patients with a biliary stent length≥6cm or longitudinal location of the lower end of the biliary stent distal to the lower end of the gastroduodenal stent (P>0.05). Seven patients (12.1%) developed acute biliary obstruction. No patients with the lower end of the biliary stent located distal to the lower end of the gastroduodenal stent developed acute biliary obstruction (P=0.012). The incidence of acute biliary obstruction was 12.1% among patients with biliary stent placement followed by gastroduodenal covered SEMS placement. Longitudinal location of the lower end of the biliary stent distal to the lower end of the gastroduodenal stent was a protective factor.

Clinical outcome of endoscopic covered metal stenting for resolution of benign biliary stricture: Systematic review and meta-analysis.

Management of benign biliary stricture is challenging. Endoscopic therapy has evolved as the first-line treatment for various benign biliary strictures. However, covered self-expandable metal stents (CSEMS) have not been approved by the United States Food and Drug Administration for the treatment of benign biliary stricture. With this goal, we conducted the present systemic review and meta-analysis to evaluate the efficacy and safety of endoscopic stenting with CSEMS in the treatment of benign biliary stricture. Systematic review and meta-analysis by searching PubMed, MEDLINE and Embase databases. In total, 37 studies (1677 patients) fulfilled the inclusion criteria. Pooled stricture resolutions were achieved in 83% of cases. Median stent dwelling time was 4.4 months, with median endoscopic retrograde cholangiopancreatography sessions of 2.0. Stricture recurrence at 4-year follow up was 11% (95% CI, 8-14%). Pooled complication rate was 23% (95% CI, 20-26%). Placement of CSEMS is effective in the treatment of benign biliary stricture with relatively short stenting duration and low long-term stricture recurrence rate. However, more prospectively randomized studies are required to confirm the results.

Covered self-expanding metal stents for the management of common bile duct stones.

Little medical literature exists for the use of fully covered self-expanding metal stents (CSEMSs) in the management of retained common bile duct (CBD) stones. Our aim was to assess the safety and efficacy of CSEMSs for the indication of retained "difficult" CBD stones. This retrospective cases series included 44 patients (30 women; median age, 69 years [range, 24-88]) who underwent CSEMS insertion for the indication of retained "difficult" CBD stones in 2 tertiary referral centers. Patients underwent temporary placement of CSEMSs after incomplete stone clearance at ERCP. Follow-up ERCP was arranged for stent removal and subsequent attempt at duct clearance. Procedure-related adverse events were also recorded. Successful biliary drainage was achieved in all cases after CSEMS placement. Forty-two stents were removed with successful duct clearance achieved in 36 cases (82%) after a median in-stent duration of 8 weeks. There were 10 cases (22.7%) of stent migration, all noted incidentally during follow-up. One patient died of nonbiliarycauses before attempted removal. This is the largest published retrospective case series for use of CSEMSs for management of retainedCBD stone disease to date. We have shown high success rates for this indication. A well-designed, multicenter,randomized controlled trial might address the uncertainty of cost-to-benefit ratio and appropriate duration for CSEMSs to be left in situ. Specific stent modification for this indication, including wider distal flare and retrieval purse string loop, may also be useful.

Endoscopic treatment of nonstricture-related benign biliary diseases using covered self-expandable metal stents.

Nonstricture benign biliary diseases (BBDs) such as leaks, perforations, and bleeding, have been traditionally managed by placement of one or more plastic stents. Emerging data support the use of covered, self-expandable, metal stents (CSEMSs). The aim of this study was to assess the outcomes of endoscopic temporary placement of CSEMS in patients with nonstricture BBD. This was a retrospective study of CSEMS placement for BBD between May 2005 and August 2013 at two tertiary care centers. The main outcome measures were resolution of perforation, bleeding, leak, and adverse events related to CSEMS treatment. A total of 87 patients were included (median age 62 years [range 18 - 86]). Indications for stent placement were bile leaks (n = 35, 40 %), bleeding (n = 27, 31 %), perforation (n = 18, 21 %), and other conditions (n = 7, 8 %). Fully and partially covered 8 - 10-mm diameter CSEMS were placed and subsequently removed in all 87 patients (100 %). Resolution of the underlying problem was achieved for 33 bile leaks (94 %), 25 bleedings (93 %), 18 perforations (100 %), and for 3 cases with other indications (43 %). The median duration of stenting was 9 weeks in patients with biliary leaks, 3 weeks for bleeding, and 9.5 weeks for perforations. Median follow-up was 82 weeks after stent removal. Seven adverse events occurred, including cholangitis in six patients (7 %), and tissue hyperplasia leading to difficulty in the removal of a partially covered SEMS in one patient. Nonstricture BBD can be effectively and safely treated with the short term placement of CSEMS. .

Su1660 Endoscopic Treatment of Non-Stricture Related Benign Biliary Diseases Using Covered Self-Expandable Metal Stents (CSEMS)

Non-stricture, benign biliary diseases (BBD) such as leaks, perforations, and bleeding have traditionally been managed with the placement of one or more plastic stents (PS). However, emerging data support the use of covered self-expandable metal stents (CSEMS). We sought to assess outcome of endoscopic temporary placement of CSEMS in patients with non-stricture BBD.

Endoscopic Treatment of Benign Biliary Strictures Using Covered Self-Expandable Metal Stents (CSEMS)

Traditional endoscopic management of benign biliary strictures (BBS) consists of placement of one or more plastic stents. Emerging data support the use of covered self-expandable metal stents (CSEMS). We sought to assess outcome of endoscopic temporary placement of CSEMS in patients with BBS. This was a retrospective study of CSEMS placement for BBS between May 2005 and July 2012 from two tertiary care centers. A total of 145 patients (81 males, median age 59 years) with BBS were identified; 73 of which were classified as extrinsic and were caused by chronic pancreatitis, and 70 were intrinsic. Main outcome measures were resolution of stricture and adverse events (AEs) due to self-expandable metal stents (SEMS)-related therapy. Fully covered and partially covered 8-10 mm diameter SEMS were placed and subsequently removed in 121/125 (97 %) attempts in BBS (failure to remove four partially covered stents). Stricture resolution occurred in 83/125 (66 %) patients after a median stent duration of 26 weeks (median follow-up 90 weeks). Resolution of extrinsic strictures was significantly lower compared to intrinsic strictures (31/65, 48 % vs. 52/60, 87 %, p = 0.004) despite longer median stent duration (30 vs. 20 weeks). Thirty-seven AEs occurred in 25 patients (17 %), with 12 developing multiple AEs including cholangitis (n = 17), pancreatitis (n = 5), proximal stent migration (n = 3), cholecystitis (n = 2), pain requiring SEMS removal and/or hospitalization (n = 3), inability to remove (n = 4), and new stricture formation (n = 3). Benign biliary strictures can be effectively treated with CSEMS. Successful resolution of biliary strictures due to extrinsic disease is seen significantly less often than those due to intrinsic disease. Removal is successful in all patients with fully covered SEMS.

Covered Self-Expandable Metal Stents for the Treatment of Benign Biliary Strictures After Liver Transplantation: When and How?

Benign biliary strictures (BBS) may complicate biliary surgery including liver transplantation (LT) [1]. The firstline management of BBS, including anastomotic strictures after LT, now incorporates endoscopic therapy, mostly consisting of stenting [2]. Although originally designed for endoscopic palliation of malignant biliary strictures, the self-expandable metallic stent (SEMS) is a valid alternative to surgery for BBS. Patients with malignant biliary strictures who undergo treatment with metal stents have a limited life expectancy due to the poor prognosis of the underlying disease. Therefore, for patients with BBS who have a normal life expectancy, the indications for metal stent placement should differ from those applied to malignant biliary strictures. Metal stents can be divided into uncovered SEMS, partially covered SEMS, and fully covered SEMS (FCSEMS). Non-removable uncovered SEMS cannot be used for BBS due to their limited patency, since reactive hyperplastic tissue may extend through the metal mesh. Partially covered SEMS can be used for BBS to decrease the rate of stent migration; however, the uncovered portion can embed in the bile duct wall. FCSEMS are a good first choice because of their easy removal and long duration of patency due to lack of tissue hyperplasia and implantation into the biliary tree. Since frequent spontaneous stent migration is a major adverse event associated with FCSEMS, an anchoring system such as flared ends or anchoring fins has been developed [3]. In this issue of Digestive Diseases and Sciences, Kahaleh’s group reports the retrospectively analyzed outcomes of covered SEMS for 55 patients with anastomotic strictures after LT [4]. Twenty-seven of 55 (49.1 %) patients were treated with plastic stents prior to covered SEMS. The authors applied three different types of covered SEMS: partially covered SEMS (19 patients), FCSEMS with anchoring fins (21 patients), and FCSEMS with flared ends (15 patients). Endoscopic biliary sphincterotomy was performed in all patients. Although the authors endeavored to center the stent within the stricture, success was not universal. All covered SEMS were removed after 3–4 months. The technical success rate was 100 %, but the clinical success rate, as measured by stricture resolution, was unsatisfactory (60–74 %). Even after covered SEMS placement, three (5.5 %) patients eventually required surgery to resolve their biliary strictures. Notably, the stentrelated adverse event rate involving migration and occlusion was 7–24 %. Five patients with early stent occlusion required repeat stenting. Indeed, the clinical success rate of endoscopic stenting with multiple plastic stents is reportedly 87–94 % [5]. The location of the stricture is usually the most proximal aspect of the common hepatic duct in anastomotic strictures after LT, especially after living-related LT recipients, in whom the strictured segment is usually short. To achieve effective stenting with covered SEMS, the stent should be centered within the strictured bile duct segment, which might be difficult to achieve in this clinical setting. Stenting with conventional covered SEMS distal to the stricture of the recipient’s native common bile duct can abruptly stretch the duct due to the high radial force developed J. H. Moon Department of Internal Medicine, Digestive Disease Center and Research Institute, Soonchunhyang University School of Medicine, Bucheon/Seoul, Korea

Su1386 Predictive Factors for Pancreatitis and Cholecystitis in Endoscopic Covered Metal Stenting for Distal Malignant Biliary Obstruction

Pancreatitis and cholecystitis are major complications after self-expandable metal stent (SEMS) placement in distal malignant biliary obstruction. We aimed to clarify predictive factors for pancreatitis and cholecystitis after covered SEMS placement.

Comparison of the utility of covered metal stents versus uncovered metal stents in the management of malignant biliary strictures in 749 patients

Self-expandable metal stents (SEMSs) are used to relieve malignant biliary obstruction. To compare outcomes between covered self-expandable metal stents (CSEMSs) and uncovered self-expandable metal stents (USEMSs) in malignant biliary obstruction. Retrospective cohort study. Tertiary cancer center. Patients with malignant biliary obstruction. Placement of CSEMS or USEMS. Time to recurrent biliary obstruction (TRO), overall survival (OS), and adverse events. From January 2000 to June 2011, 749 patients received SEMSs: 171 CSEMSs and 578 USEMSs. At 1 year, there was no significant difference in the percentage of patients with recurrent obstruction (CSEMSs, 35% vs USEMSs, 38%) and survival (CSEMSs, 45% vs USEMSs, 49%). There was no significant difference in the median OS (CSEMSs, 10.4 months vs USEMSs, 11.8 months; P= .84) and the median TRO (CSEMSs, 15.4 months vs USEMSs, 26.3 months; P= .61). The adverse event rate was 27.5% for the CSEMS group and 27.7% for the USEMS group. Although tumor ingrowth with recurrent obstruction was more common in the USEMS group (76% vs 9%, P< .001), stent migration (36% vs 2%, P< .001) and acute pancreatitis (6% vs 1%, P< .001) were more common in the CSEMS group. Retrospective study. There was no significant difference in the patency rate or overall survival between CSEMSs and USEMSs for malignant distal biliary strictures. The CSEMS group had a significantly higher rate of migration and pancreatitis than the USEMS group. No significant SEMS-related adverse events were observed in patients undergoing neoadjuvant chemoradiation or surgical resection.

Biliary Leak in Post-Liver-Transplant Patients: Is There Any Place for Metal Stent?

Objectives. Endoscopic management of bile leak after orthotopic liver transplant (OLT) is widely accepted. Preliminary studies demonstrated encouraging results for covered self-expandable metal stents (CSEMS) in complex bile leaks. Methods. Thirty-one patients with post-OLT bile leaks underwent endoscopic temporary placement of CSEMS (3 partially CSEMS , 18 fully CSEMS with fins and 10 fully CSEMS with flare ends) between December 2003 and December 2010. Long-term clinical success and safety were evaluated. Results. Median stent indwelling and follow-up were 89 and 1,353 days for PCSEMS, 102 and 849 for FCSEMS with fins and 98 and 203 for FCSEMS with flare ends. Clinical success was achieved in 100%, 77.8%, and 70%, respectively. Postplacement complications: cholangitis (1) and proximal migration (1), both in the FCSEMS with fins. Postremoval complications were biliary strictures requiring drainage: PCSEMS (1), FCSEMS with fins (6) and with flare ends (1). There was no significant differences in the FCSEMS groups regarding clinical success, age, gender, leak location, previous treatment, stent indwelling, and complications. Conclusion. Temporary placement of CSEMS is effective to treat post-OLT biliary leaks. However, a high number of post removal biliary strictures occurred especially in the FCSEMS with fins. CSEMS cannot be recommended in this patient population.

Complex biliary stones: treatment with removable self-expandable metal stents: a new approach (with videos)

Complex biliary stones often require temporary stent placement before a repeat attempt at extraction. To date, covered self-expandable metal stents (CSEMSs) have not been formally investigated for this indication. To evaluate the efficacy and safety of CSEMSs in patients with retained complex biliary stones. Retrospective case series. Large quaternary-care center. Thirty-six patients (24 women) with complex biliary stones with incomplete stone clearance after endoscopic retrograde cholangiography (ERC) with biliary sphincterotomy. Patients with incomplete stone clearance after ERC with biliary sphincterotomy underwent temporary placement of CSEMSs, with subsequent removal before repeat stone extraction. Success achieving immediate biliary drainage and eventual complete duct clearance. Procedure-related complications were also assessed. CSEMS placement was successful in establishing immediate biliary drainage in all 36 patients. Complete duct clearance at repeat ERC was achieved in 29 of 35 patients after a mean duration of 6.4 weeks. Four of the remaining 6 patients underwent sequential CSEMS placement, with eventual duct clearance after multiple ERCPs. There were no complications related to biliary obstruction. One patient died of a nonbiliary cause. Of the total 42 CSEMSs placed, there were 4 cases (9.5%) of clinically insignificant stent migration. Single-center experience, retrospective design. CSEMSs permit management of complex biliary stones, but require multiple sessions. The cost-effectiveness of this technique needs further investigation.

Endoscopic transpapillary gallbladder drainage with replacement of a covered self-expandable metal stent

Endoscopic self-expandable metal stent (SEMS) placement has become a standard palliative therapy for patients with malignant biliary obstruction. Acute cholecystitis after SEMS placement is a serious complication. We report a patient with an acute cholecystitis after covered SEMS placement, who was managed successfully with endoscopic transpapillary gallbladder drainage (ETGBD) and replacement of the covered SEMS. An 85-year-old man with pancreatic cancer suffered from acute cholecystitis after covered SEMS placement. It was impossible to perform percutaneous transhepatic gallbladder drainage. After removal of the covered SEMS with a snare, a 7Fr double pigtail stent was placed between the gallbladder and duodenum, subsequently followed by another covered SEMS insertion into the common bile duct beside the gallbladder stent. The cholecystitis improved immediately after ETGBD. ETGBD with replacement of the covered SEMS thus proved to be effective for treatment of patients with acute cholecystitis after covered SEMS placement.

Gallbladder Stent Placement for Prevention of Cholecystitis in Patients Receiving Covered Metal Stent for Malignant Obstructive Jaundice: A Feasibility Study

Covered self-expanding metal stents (CSEMS) have been used for palliation of malignant distal biliary strictures. Occlusion of the cystic duct by CSEMS may be complicated by cholecystitis. This potentially could be prevented by placement of a transpapillary gallbladder stent (GBS). Between 11/2006 and 10/2007, a total of 73 patients (50 male) aged 65 +/- 14 years underwent CSEMS placement for palliation of malignant obstructive jaundice. In cases where CSEMS placement caused occlusion of the cystic duct, a 7 French transpapillary pigtail gallbladder stent (GBS) was inserted to prevent cholecystitis. Of the 73 patients, 18 had a prior cholecystectomy; 34 had the CSEMS placed below the cystic duct insertion. In 19 out of the 21 patients who had a CSEMS covering the cystic duct ostium, GBS placement was attempted, which was successful in 11 individuals (58%). An attempt to access the gallbladder was complicated by wire perforation of the cystic duct in three patients; one patient requiring emergent cholecystostomy tube placement. None of the patients who underwent successful GBS placement developed cholecystitis. One GBS dislodged and was repositioned. Cholecystitis occurred in two (20%) of the ten patients without transpapillary gallbladder decompression who had a CSEMS covering the cystic duct. The ideal placement of a CSEMS is below the cystic duct insertion. Should the cystic duct ostium be occluded, placement of a GBS should be considered to minimize the risk of cholecystitis.

Temporary placement of fully covered self-expandable metal stents in benign biliary strictures: midterm evaluation (with video)

Benign biliary strictures (BBS) have been endoscopically managed with placement of multiple plastic stents. Uncovered metal stents have been associated with mucosal hyperplasia and partially covered self-expandable metal stents with migration. Recently, fully covered self-expandable metal stents (CSEMSs) with anchoring fins have become available. Our purpose was to analyze the efficacy and complication rates of CSEMSs in the treatment of BBS. CSEMSs (10-mm diameter) were placed in 44 patients with BBS. CSEMSs were left in place until adequate biliary drainage was achieved, confirmed by resolution of symptoms, normalization of liver function tests, and imaging. Tertiary care center with long-standing experience with metal stents. A total of 44 patients with BBS (28 men, median age 53.5 years) were included. The preprocedure diagnoses included chronic pancreatitis (n = 19), gallstone-related strictures (n = 14), post liver transplant (n = 9), autoimmune pancreatitis (n = 1), and primary sclerosing cholangitis (n = 1). ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or rat tooth. Stricture resolution and morbidity. The median time of CSEMS placement was 3.3 months (interquartile range 3.0-4.8). Resolution of the BBS was confirmed in 34 of 41 patients (83%) after a median postremoval follow-up time of 3.8 months (interquartile range 1.2-7.7). Complications were observed in 6 (14%) patients after CSEMS placement and in 4 (9%) after CSEMS removal. Pilot study from a single center. Temporary placement of CSEMSs for BBS may offer an alternative to plastic stenting. Further investigation is required to further assess safety and long-term efficacy.