Sarah A. De La Rue

Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video)

BACKGROUND Benign biliary strictures (BBS) are usually managed with plastic stents, whereas placement of uncovered metallic stents has been associated with failure related to mucosal hyperplasia. OBJECTIVE We analyzed the efficacy and safety of temporary placement of a covered self-expanding metal stent (CSEMS) in BBS. DESIGN Patients with BBS received temporary placement of CSEMSs until adequate drainage was achieved; confirmed by resolution of symptoms, normalization of liver function tests, and imaging. SETTING Tertiary-care center with long-standing experience with CSEMSs. PATIENTS Seventy-nine patients with BBS secondary to chronic pancreatitis (32), calculi (24), liver transplant (16), postoperative biliary repair (3), autoimmune pancreatitis (3), and primary sclerosing cholangitis (1). INTERVENTION ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or a rat-tooth forceps. MAIN OUTCOME MEASUREMENTS End points were efficacy, morbidity, and clinical response. RESULTS CSEMSs were removed from 65 patients. Resolution of the BBS was confirmed in 59 of 65 patients (90%) after a median follow-up of 12 months after removal (range 3-26 months). If patients who were lost to follow-up, developed cancer, or expired were considered failures, then an intent-to-treat global success rate of 59 of 79 (75%) was obtained. Complications associated with placement included 3 post-ERCP pancreatitis (4%), 1 postsphincterotomy bleed (1%), and 2 pain that required CSEMS removal (2%). In 11 patients (14%), the CSEMS migrated. In 1 patient, CSEMS removal was complicated by a bile leak that was successfully managed with plastic stents. LIMITATION Pilot study from a single center. CONCLUSIONS Temporary CSEMS placement in patients with BBS offers a potential alternative to surgery.

Covered Self Expandable Metal Stents in Pancreatic Malignancy Regardless of Resectability: A New Concept

BACKGROUND AND STUDY AIMS The current treatment model for the management of malignant biliary obstruction is to place a plastic stent for unstaged pancreatic cancer. In patients with unresectable disease but a life expectancy of more than 6 months, self-expandable metal stents (SEMS) are favored because of their more prolonged patency. We analyzed the efficacy and cost-effectiveness of covered SEMS (CSEMS) in patients with pancreatic cancer and distal biliary obstruction without regard to surgical resectability. PATIENTS AND METHODS Between March 2001 and March 2005, 101 consecutive patients with obstructive jaundice secondary to pancreatic cancer underwent placement of a CSEMS. Patients with resectable tumor were offered pancreaticoduodenectomy. A model was developed to compare the costs of CSEMS and polyethylene and DoubleLayer stents. RESULTS A total of 21 patients underwent staging laparoscopy, of whom 16 had a resection (76%). The 85 patients who did not have a resection had a mean survival of 5.9 months (range 1-25 months) and a mean CSEMS patency duration of 5.5 months (range 1-16 months). Life-table analysis demonstrated CSEMS patency rates of 97% at 3 months, 85% at 6 months, and 68% at 12 months. In a cost model that accounted for polyethylene and DoubleLayer stent malfunction and surgical resections, initial CSEMS placement (3177 euros per patient) was a less costly intervention than either DoubleLayer stent placement (3224 euros per patient) or polyethylene stent placement with revision (3570 euros per patient). CONCLUSIONS Covered SEMS are an effective treatment for distal biliary obstructions caused by pancreatic carcinoma. Their prolonged patency and removability makes them an attractive option for biliary decompression, regardless of resectability. The strategy of initial covered SEMS placement might be the most cost-effective strategy in these patients.

Placement of Covered Self Expandable Metallic Stents in Patients with Biliary Leak: a Pilot Study

Placement of Covered Self Expandable Metallic Stents in Patients with Biliary Leak: a Pilot Study Michel Kahaleh, Vinay Sundaram, Sarah A. De La Rue, Joshua D. Hall, Andrew Brock, Jeffrey L. Tokar, Charles M. Friel, Eugene F. Foley, Reid B. Adams, Paul Yeaton Background: Current management of biliary leaks includes ERCP and biliary stenting. Some biliary leaks can nevertheless be challenging and time consuming to treat when using plastic stents, and successful treatment may require a combination of techniques. The ability to place a removable partially covered self-expandable metallic stent (SEMS) may be advantageous in the treatment of biliary leaks, regardless of their location or etiology. The SEMS could easily be deployed to either cover the leak itself or to induce a significant decrease of pressure gradient at the ampullary level, permitting resolution of a duct of Luschka leak. Methods: Eight patients with biliary leaks were considered for covered SEMS placement. Preprocedure diagnosis included duct of Luschka leak (n Z 4), leak from partial cholecystectomy (n Z 2), stump leak (n Z 1) and anastomotic leak post liver transplant (n Z 1). Efficacy, morbidity and clinical response were used as endpoints. Results: SEMS were left in place for a median time of 3 months (range: 1-4) and were removed with a snare (four patients) or a rat tooth technique (three patients), while one patient spontaneously passed the SEMS. Median time of followup post removal was 4.5 months (range: 1-8). Only one patient with partial cholecystectomy relapsed and required drainage. No patient experienced complication for either placement or removal of the SEMS. Conclusion: Temporary placement of covered SEMS when a bile leak occurs offers a potential alternative to conventional ERCP with plastic stenting, and merits further investigation. A randomized study comparing both techniques should be performed.