SAFETY AND EFFECTIVENESS OF ENDOSCOPIC TRIMMING OF BILIARY METAL AND PLASTIC STENTS: A SIMPLE ADJUNCT TO ERCP IN SELECTED PATIENTS

Aims:

Endoscopic trimming of self-expandable metal stents (SEMS) using argon plasma coagulation (APC) is a valid strategy to manage migration/malposition. However, reported mechanical trimming techniques of plastic stents remain anecdotal. We aimed to describe a novel cautery-based technique for bilio-pancreatic plastic stent trimming and to assess its safety and efficacy during ERCP and related interventions.

Methods:

Review of prospectively databased ERCPs between 2010 – 2017. Inclusion: endoscopic stent trimming. Metal stents were trimmed with APC (80W, 1.2 L/min) and plastic stents with polipectomy snares (100W, Auto-Cut, pure cut) using suction to make mucosal contact for diathermic section.

Results:

Stents were trimmed during 44 procedures in 42 patients (24 male, median age 65). 3 SEMS/41 Plastic stents. SEMS: 2 transpapillary stents in patients with malignant biliary obstruction (MBO) with excessive length and 1 transmural stent was trimmed to facilitate revision. PLASTIC STENTS: 8 transmural stents (6 biliary [5 hepaticogastrostomy, 1 hepaticoduodenostomy] in MBO patients and 2 pancreaticogastrostomy in benign transection) were cut to allow cannulation prior to stent replacement. The remaining 33 transpapillary stents were trimmed because of excessive length to prevent pressure ulcer/necrosis on the opposite duodenal wall; hilar stricture was the predominant (75%) background (21 malignant/12 benign). Mild duodenal bleeding in one patient during trimming was the only complication noted. Stent trimming was successful in all cases; the intended final goal after trimming was achieved in all except in 4 cannulation attempts through a transmural plastic stent prior to replacement.

Conclusions:

We report a novel, safe technique for endoscopic trimming of bilio-pancretic plastic stents. It can be useful as an alternative to stent removal to prevent duodenal wall pressure caused by redundant transpapillary stents in complex hilar strictures and to facilitate revision of transmural stents. In our practice, plastic stent trimming was used 13 times more frequently than APC trimming of SEMS.