Background: Although self-expandable metallic stent (SEMS) has a longer patency than plastic stent (PS) for malignant biliary obstruction, stent occlusion can occur and drainage has to be reestablished in a patient with expected long survival. However, the choices are still controversial among restenting with SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). This study was designed to determine the efficacy and outcome of PS, SEMS, and PTBD for patients with occluded SEMS.
Methods: A total of 154 ERCPs with SEMS insertion were performed at the Endoscopy Unit of Chulalongkorn University. The causes of obstructive jaundice were cholangiocarcinoma (n = 110), pancreatic cancer (n = 41), and metastatic carcinoma (n = 3). Thirty-two patients (20.9%) with occluded SEMS (uncovered SEMS = 22 and covered SEMS = 10) were identified. PS, SEMS, and PTBD were used to reestablish drainage in 11, 14, and 7 patients, respectively. The second stent was inserted as stent-in-stent. Patients with less advanced disease were preferably opted to have a second SEMS.
Results: The median stent patency of second SEMS (100 days) was significantly longer than PS (60 days) and PTBD (75 days; p < 0.05). The median survival time for patients with second SEMS (230 days) was significantly longer than patients with PS (130 days) and PTBD (150 days; p < 0.05). Subgroup analysis in hilar obstructions showed no statistical difference in second stent patency and survival between PS and SEMS. Pain that required oral narcotic developed in 71% (5/7) of PTBD patients.
Conclusions: In general, a second SEMS insertion in occluded SEMS provides a significant longer patency time than PS and PTBD. However, the benefit of SEMS as a second intervention in hilar obstructed patients is still doubtful.