Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations

Abstract

Background Fully covered self-expandable metal stents (FCSEMS) have been used as a rescue therapy for several benign biliary tract conditions (BBC). Long-term stent placement commonly occurs, and prolonged FCSEMS placement is associated with the majority of the complications reported. This study evaluated the duration of stenting and the efficacy and safety of temporary FCSEMS placement for three BBCs: refractory biliary leaks, postsphincterotomy bleeding, and perforations. Methods This was a retrospective case series with longterm follow-up of 25 patients who underwent FCSEMS placement for BBCs. This study included 17 patients with postcholecystectomy refractory biliary leaks who had previously undergone unsuccessful sphincterotomy and plastic stent placement, 4 patients with difficult-to-control postsphincterotomy bleeding, and 4 patients with a perforation following endoscopic sphincterotomy. Stents were removed according to clinical evidence of problem resolution. The review included stenting duration, safe FCSEMS removal, clinical efficacy, complications, and long-term outcomes. During the follow-up period, ERCP and cholangioscopy procedures were performed to exclude the possibility of bile duct lesion development. Results Complete resolution of the initial condition was achieved in all patients. Patients with biliary leaks had a median stent duration time of 16 days (range 7-28 days). Patients with bleeding had stents removed after a median time of 6 days (range 3-15 days). Patients with perforations had their stents removed after a median time of 29.5 days (range 21-30 days). There were no complications related to stenting. Conclusions Temporary placement of a FCSEMS for 30 days or less is an effective rescue therapy for refractory biliary leaks, difficult-to-control post-endoscopic sphincterotomy bleeding, and perforations. Duration of stenting should be different for each type of condition. Stents can be safely removed, and short-term stenting is associated with the absence of early and late complications.

Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies

“…[164][165][166][167] Placing FCSEMS is technically easy and frequently very effective (Fig. 5) to control bleeding.…”

Emergencies after endoscopic procedures

“…In type I and type II perforations, surgical treatment was generally recommended, although recent successful reports of endoscopic closure with endoclips [108], combined clips and endoloops or OTSC were published [109]; particularly in type II perforations, self-expandable metal stents seems to be effective [110]. Type III and IV perforations tend to be a controlled retroperitoneal perforation; in case of leak with fluid collection, the recognizing and quick plastic stents placing for appropriate drainage, associated with antibiotics are essential [107].…”

A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos)

“…High-grade biliary leaks were defined as leaks observed fluoroscopically before intrahepatic opacification. 3 Closure of the leak was considered after the cessation of bile output, which was defined as biliary drainage of !5 mL/day in the percutaneous drains 17 and confirmed at follow-up ERCP. Failure of endotherapy was defined as the persistence of biliary drainage through the percutaneous drain or the persistence of a bile leak at follow-up ERCP.…”

“…Refractory biliary leaks were defined as leaks that failed to close after endoscopic intervention with a combination of biliary sphincterotomy and the placement of a 10F transpapillary biliary stent, regardless of the biliary leak location (cystic stump, common bile duct and/or common hepatic duct, Luschka). 17 All of the plastic stents used were at least 7 cm long. High-grade biliary leaks were defined as leaks observed fluoroscopically before intrahepatic opacification.…”

“…Adverse events were defined as any adverse event related to the ERCP or stent placement, and adverse events were carefully monitored by using previously determined definitions. 13,14,17,21 Intervention, stents, and follow-up…”