ERCP Topics

Metal Stents

It has been shown in several studies that metal stents remain patent considerably longer than plastic stents - and despite the greater initial material costs, they are likely to be more cost-effective, at least in patients with a longer life expectancy. In a prospective study [1], 118 patients with inoperable malignant bile duct strictures were randomly assigned to receive either metal or plastic stents. There was no significant difference in the survival between the two groups, but additional days of hospitalization, days with antibiotics, and numbers of endoscopic retrograde cholangiopancreatography (ERCP) and ultrasound examinations were higher in the plastic stent group. Two independent factors for survival were American Surgical Association (ASA) classification and the number of hepatic metastases. The data for patency rate were inconclusive, and details of the plastic stents used were not given (size, number, type). In summary, metal stents proved to be more effective.

The data reported by different groups for the patency rate vary: in one study, the patency rate of metal stents was higher than that of plastic stents [2], while in another it was almost equal, but the costs for plastic stents were lower [3]. In a third study, there was no difference, but the quality of life was better in the metal stent group [4]. Overall, optimal drainage is the most important aspect, regardless of whether metal or plastic stents are used to improve the clinical symptoms and survival [5]. In a prospective multicenter study conducted in Korea, the tumor characteristics and metal stent patency were evaluated in a cohort of 58 patients. Patency depended on the degree of stricture and time required for full expansion, but not on age, type of tumor, or length or location of the stent [6]. A European prospective multicenter study [7] including 111 patients presented an exact survey of the characteristics of metal stents in vivo. Insertion was successful in 98 %; two stents opened insufficiently, technical failure occurred in two, and one was misplaced. The median stent patency was 355 days, the median survival 174 days, and metastases had a negative impact on stent patency. Despite these excellent data for stent performance, this report lacks clinical data.

A Japanese study of 67 patients emphasized the significance of malignant flow impairment; according to this study, the rate of recurrent stenosis and costs are higher in patients with obstructing metastases - particularly metastases from gastric carcinomas - than in those with obstructing hepatobiliary carcinomas [8].

Since uncovered metal stents tended to suffer from tumor ingrowth, with occlusion after a certain time, new covered metal stents were developed. In a multicenter trial [9], experience with a silicone-coated stent was evaluated. Stent placement was satisfactory in 31 of 33 patients with different types of malignant biliary obstruction. After one month, the mean bilirubin levels had decreased from 150 μmol/l to 24 μmol/l. Early complications were minor: pain in two cases, and acute cholecystitis requiring cholecystectomy in one. After six months of follow-up, 15 patients had died, and among the 16 surviving patients three had developed obstructive jaundice - two due to partial stent migration, and one due to sludge. There was no evidence of ingrowth or overgrowth. Data from a Korean study [10] on 15 patients with a polyurethane-covered stent were poorer: one patient developed pancreatitis and one had cholangitis, and three occlusions due to sludge or overgrowth were observed.

The advantages of covered stents are evidently that they are retrievable and can also be used successfully for benign strictures [11]. It remains unclear whether the properties of covered stents are superior to those of uncovered stents. In 14 autopsy cases, including five cases in which covered metal stents had been used, better results were found in the covered group in relation to the patency rate, tumour ingrowth, debris, and number of liver abscesses [12]. In four prospective multicenter trials [13] [14] [15] [16] comparing covered metal stents with uncovered ones in a total of 303 patients, no differences in the patency rate were observed, but four cases of pancreatitis and one acute cholecystitis were noted in the group with covered stents. This should be borne in mind when considering the value of the advantage mentioned above - i. e., the ability to remove the stent more easily.

The insertion of metal stents in benign conditions such as distal bile duct stricture in chronic pancreatitis remains controversial. Over a period of 10 years, the Amsterdam group [10] placed 15 metal stents in 15 patients in whom surgery was not a favorable option. The median patency was 50 months. Two of the stents became obstructed; a plastic stent was inserted instead in one case, and one stent (the only covered one) was removed.

References

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