Cholecystitis in patients with a fully covered self-expandable metal stent with and without externally anchored plastic stents

We read with great interest the article by Chun et al. published in Endoscopy [11]. The authors described an evaluation of a new technique to increase stent patency by externally anchoring a double-pigtail plastic stent (DPPS) to a fully covered self-expandable metal stent (FC-SEMS) in distal malignant biliary obstruction. They found that FC-SEMSs with an externally anchored plastic stent (EPS) had longer stent patency by more than 100 days compared with FC-SEMSs placed alone (342 vs. 240 days; P=0.04). Also, the placement of an FC-SEMS with an EPS was associated with a lower incidence of SEMS migration compared with FC-SEMSs placed alone (10.8% vs. 27.7%; P=0.01).

In clinical practice, a common question in a patient with a biliary FC-SEMS and their gallbladder in situ is whether the risk of acute cholecystitis increases [22] [33]. In the present study, most patients had undergone cholecystectomy at the time of the stent insertion procedure: 116/120 (96.7%) in the FC-SEMS + EPS group vs. 61/65 (93.8%) in FC-SEMS alone group. The surprising result for us was therefore the high rate of cholecystitis in both groups, as shown in the authors’ Table 2. The authors report that 12 patients developed cholecystitis (8 in the FC-SEMS + EPS group and 4 in the FC-SEMS alone group). These data are difficult to explain because only eight patients had their gallbladder in situ (four patients in each group), indicating a number discrepancy. Also, the incidence rate of cholecystitis would be higher than that previously reported in the published literature [22] [33].

While we acknowledge that this new technique can reduce the two most common adverse events of FC-SEMS placement (obstruction and migration), we are also astonished by the high incidence of cholecystitis reported in the study.

Publication History

Article published online:
28 March 2024

• References

• 1 Chun JW, Woo SM, Han M. et al. Prolonged patency of fully covered self-expandable metal stents with an externally anchored plastic stent in distal malignant biliary obstruction. Endoscopy 2023; 55: 563-568
• 2 Jang S, Stevens T, Parsi M. et al. Association of covered metallic stents with cholecystitis and stent migration in malignant biliary stricture. Gastrointest Endosc 2018; 87: 1061-1070
• 3 Watanabe M, Okuwaki K, Woo J. et al. Cholecystitis after placement of covered self-expandable metallic stents in patients with distal malignant biliary obstructions. Clin Endosc 2021; 54: 589-595