Fully covered self-expanding metal stents in the management of difficult common bile duct stones

Abstract

Background and objectives: plastic biliary stents are often used after an ERCP session without complete common bile duct stones (CBDS) extraction. Sometimes, the volume of biliary drainage with these stents may be insufficient. We present our experience with the use of fully covered self-expanding metal stents (FCSEMS) in the setting of incomplete CBDS extraction.Patients and methods: after an ERCP session with difficult CBDS not completely removed, biliary FCSEMS (Wallflex) were inserted in some patients when it was deemed that biliary sphincterotomy and a single plastic stent would not provide an adequate drainage.Results: a retrospective study was performed. Biliary FCSEMS were inserted in 29 patients, mean age 81 years. CBDS could not be extracted through a biliary sphincterotomy due to its large size (n = 18) or because of the presence of inflammatory distal strictures (n = 11). The greatest biliary drainage with shortest ERCP time was considered mandatory due to clinical instability of patients and/or poor tolerance to conscious sedation administered by the endoscopist. Successful biliary drainage was obtained in all cases. FCSEMS were removed after a median of 199.5 days in 16 patients with a complete CBDS extraction in 15 (93.7%). FCSEMS were not removed in the remaining 13 patients due to their clinical condition, and a wait-and-see strategy was undertaken.Conclusions: in selected cases, utilization of removable FCSEMS can be a good option for a quick and adequate biliary drainage in the setting of difficult CBDS. Because of the higher cost of these stents its use needs to be individualized.Key words: ERCP. Difficult common bile duct stones. Biliary plastic stents. Fully covered self-expanding metal stents. INTRODUCTIONFor nearly 40 years endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy has been the treatment of choice to remove common bile duct stones (CBDS). Since 2003, biliary sphincterotomy balloon dilation or sphincteroplasty is used for difficult cases with very good results (1). Complicated CBDS are usually those with more than 10 mm in diameter, multliple, impacted stones in the bile duct, concretions of hard consistency, peridiverticular situation of the ampulla, tortuosity or narrowing of the distal common bile duct and other conditions arising from the patient, like coagulation disorders (2).Plastic stents are the most used palliative method when after an ERCP session all CBDS cannot be removed. Friction between stones and stents produce the CBDS to fragment and shrink or become mud in a period of time from 3 to 6 months. Afterwards, the vast majority of CBDS can be removed fairly easily after a second ERCP session. For the remaining stones it is necessary to use certain forms of lithotripsy, such as mechanic lithotripsy. However, some CBDS may even continue without being extracted (3).Sometimes, ursodeoxycholic acid is added to plastic stents. As other solutions, such as terpene choleretic, they have the property to make more soluble cholesterol, ca...

Current endoscopic strategies for managing large bile duct stones

“…In large CBD stones where extraction was not possible and plastic stent drainage was thought to be inadequate, such as in cases of distal CBD stricture, Garcia‐Cano et al . evaluated the use of fully covered self‐expanding metal biliary stents (FCSEMS) . They concluded that successful biliary drainage could be achieved in 100% of 29 cases.…”

“…[46][47][48][49] In large CBD stones where extraction was not possible and plastic stent drainage was thought to be inadequate, such as in cases of distal CBD stricture, Garcia-Cano et al evaluated the use of fully covered self-expanding metal biliary stents (FCSEMS). 50 They concluded that successful biliary drainage could be achieved in 100% of 29 cases. FCSEMS were removed after a median of 199.5 days in 16 cases (rest were deemed to unfit for repeat procedure) of which 93.7% could have a complete stone extraction.…”

Drug-eluting fully covered self-expanding metal stent for dissolution of bile duct stones in vitro

“…Biliary stenting is a widely accepted rescue method in patients with failed stone extraction under endoscopic retrograde cholangiopancreatography (ERCP) and plastic biliary stents are commonly used around the world[1,2]. It is worth noting that fully covered self-expanding metal stents (FCSEMS) have been used in the management of difficult common bile duct stones (CBDS) and have gained satisfactory clinical outcome[3-7]. In the research of Garcia-Cano’s group[3], FCSEMS implantation was adopted after an ERCP session without complete CBDS extraction.…”

Do we really need a fully covered self-expanding metal stent for the treatment of difficult common bile duct stones?

“…7 More recently, FCSEMSs have been reported in the management of difficult CBD stones, with success rates of 82% and adverse event rates of 17%. [8][9][10] The study by Hartery et al 1 is notable for the limited use of advanced techniques of CBD stone removal (36%), by the high rate of adverse events (15%), and by the low rate of success (82%). ML or intraductal lithotripsy may allow clearance of stones from the CBD in more than 90% of cases, with an adverse event rate of less than 10%.…”