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

BackgroundBenign biliary strictures (BBS) are usually managed with plastic stents, whereas placement of uncovered metallic stents has been associated with failure related to mucosal hyperplasia.ObjectiveWe analyzed the efficacy and safety of temporary placement of a covered self-expanding metal stent (CSEMS) in BBS.DesignPatients with BBS received temporary placement of CSEMSs until adequate drainage was achieved; confirmed by resolution of symptoms, normalization of liver function tests, and imaging.SettingTertiary-care center with long-standing experience with CSEMSs.PatientsSeventy-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).InterventionERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or a rat-tooth forceps.Main Outcome MeasurementsEnd points were efficacy, morbidity, and clinical response.ResultsCSEMSs 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.LimitationPilot study from a single center.ConclusionsTemporary CSEMS placement in patients with BBS offers a potential alternative to surgery.