Modified non‐flared fully covered self‐expandable metal stent versus plastic stent for preoperative biliary drainage in patients with resectable malignant biliary obstruction

Abstract

Background and Aim Fully covered self‐expandable metal stents (FCSEMS) may be better than plastic stents (PS) for preoperative biliary drainage (PBD) to relieve cholangitis or jaundice for resectable malignant biliary obstruction (MBO). However, modification of current FCSEMS designed originally for nonresectable MBO is needed to be a proper stent for PBD. The aim of this study was to evaluate the possible superiority of non‐flared modified FCSEMS (M‐FCSEMS) with 12‐mm diameter and waist of central portion over PS in patients with resectable MBO. Methods Eighty‐five consecutive patients underwent PBD followed by operation from August 2015 to December 2017. In each M‐FCSEMS and PS group, 29 patients were matched for age, sex, body mass index, and preoperative albumin and bilirubin levels. Results The overall technical success rates of PBD using M‐FCSEMS and PS were 100%. The time to operation was similar between groups (18.6 ± 10.8 vs 19.3 ± 11.6 days, respectively; P = 0.843). The prevalence of PBD‐related adverse events (AEs) was 6.9% (2/29) in the M‐FCSEMS group versus 27.6% (8/29) in the PS group (P = 0.037). Re‐intervention before operation was required in 20.7% (6/29) of patients in the PS group but no patients in the M‐FCSEMS group (P = 0.023). No differences were found between perioperative AEs in the M‐FCSEMS and PS groups (27.5% vs 31.0%, respectively; P = 0.773). Conclusion Modified FCSEMS led to lower PBD‐related AEs, re‐intervention rate, and comparable perioperative AEs compared with PS. M‐FCSEMS may be a potential novel stent for PBD in patients with resectable MBO.

Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage

“…No differences were found in overall preoperative complications and postoperative outcomes between the 2 groups 47 . A more recent RCT also showed similar results 48 . In patients undergoing neoadjuvant therapy, SEMS also provides longer stent patency and less need for reintervention compared with PS 49,50 .…”

“…47 A more recent RCT also showed similar results. 48 In patients undergoing neoadjuvant therapy, SEMS also provides longer stent patency and less need for reintervention compared with PS. 49,50 Although an RCT showed that FC-SEMS had longer stent patency duration and fewer days of neoadjuvant therapy delay compared with PS and uncovered (U) SEMS, 51 another RCT showed noninferiority of U-SEMS versus FC-SEMS on achieving sustained biliary drainage.…”

Fully covered self‐expandable metallic stents versus plastic stents for preoperative biliary drainage in patients with pancreatic head cancer and the risk factors for post‐endoscopic retrograde cholangiopancreatography pancreatitis

“…On the other hand, for PBD, the choice of the optimal stent remains controversial. SEMSs are thought to be preferable for cases where the wait time for surgery is relatively long, for example, NAC cases (the wait time for surgery is 3–6 months) 14–24 . However, from meta‐analyses comparing SEMSs with PSs for PBDs, the rate of post‐endoscopic retrograde cholangiopancreatography pancreatitis (PEP) has been reported to be higher for patients receiving SEMSs than that for those receiving PSs 25,26 .…”

“…SEMSs are thought to be preferable for cases where the wait time for surgery is relatively long, for example, NAC cases (the wait time for surgery is 3–6 months). 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 However, from meta‐analyses comparing SEMSs with PSs for PBDs, the rate of post‐endoscopic retrograde cholangiopancreatography pancreatitis (PEP) has been reported to be higher for patients receiving SEMSs than that for those receiving PSs. 25 , 26 PEP can interfere with the beginning of NAC and cause adhesion around the pancreas causing difficulties during surgery.…”

Intraductal placement of a fully covered metal stent with a long string for distal malignant biliary obstruction without endoscopic sphincterotomy: Prospective multi‐center feasibility study

“…8,9 Intraductal placement of stents (i.e., placement above the duodenal papilla) can reduce duodenobiliary reflux, and may thereby achieve longer stent patency durations, lower occlusion and late adverse events rates. 10,11 If endoscopic sphincterotomy (ES) is not performed, these benefits may be more pronounced. Furthermore, avoiding ES seems to prevent stent migration as stents are unlikely to pass through the duodenal papilla in the absence of ES.…”