title: Management of occluded biliary Wallstents.
abstract: BACKGROUND
  Wallstents (Schneider Stent, Inc., USA) used for the palliation of malignant biliary strictures, although associated with prolonged patency, can occlude. There is no consensus regarding the optimal management of Wallstent occlusion.
  
  
  OBJECTIVE
  To evaluate the efficacy of different endoscopic methods for managing biliary Wallstent occlusion.
  
  
  METHODS
  A multicentre retrospective study of patients managed for a biliary Wallstent occlusion.
  
  
  RESULTS
  Data were available for 38 patients with 44 Wallstent occlusions, all of which had initial endoscopic management. Twenty four patients had died and 14 were alive after a median follow up of 231 (30-1095) days following Wallstent occlusion. Occlusions were managed by insertion of another Wallstent in 19, insertion of a plastic stent in 20, and mechanical cleaning in five. Endoscopic management was successful in 43 (98%). Following management of the occlusion, bilirubin decreased from 6.0 (0.5-34.3) to 2.1 (0.2-27.7) mg/100 ml (p < 0.05). No complications occurred. The median duration of second stent patency was 75 days (95% confidence interval 43 to 107) after insertion of another Wallstent, 90 days (71 to 109) after insertion of a plastic stent, and 34 days (30 to 38) after mechanical cleaning (NS). The respective median survivals were 70 days (22-118), 98 days (54-142), and 34 days (30-380) (NS). Incremental cost effective analysis showed that plastic stent insertion is the most cost effective option.
  
  
  CONCLUSIONS
  Although all three methods are equally effective in managing an occluded Wallstent, the most cost effective method appears to be plastic stent insertion.
authors.affiliation: Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: T C
authors.initials: TC
authors.lastname: Tham
authors.forename: D L
authors.initials: DL
authors.lastname: Carr-Locke
authors.forename: J
authors.initials: J
authors.lastname: Vandervoort
authors.forename: R C
authors.initials: RC
authors.lastname: Wong
authors.forename: D R
authors.initials: DR
authors.lastname: Lichtenstein
authors.forename: J
authors.initials: J
authors.lastname: Van Dam
authors.forename: F
authors.initials: F
authors.lastname: Ruymann
authors.forename: S
authors.initials: S
authors.lastname: Chow
authors.forename: J J
authors.initials: JJ
authors.lastname: Bosco
authors.forename: T
authors.initials: T
authors.lastname: Qaseem
authors.forename: D
authors.initials: D
authors.lastname: Howell
authors.forename: D
authors.initials: D
authors.lastname: Pleskow
authors.forename: W
authors.initials: W
authors.lastname: Vannerman
authors.forename: E D
authors.initials: ED
authors.lastname: Libby
mesh_terms: D002779:Cholestasis / Q000601:surgery*; D003362:Cost-Benefit Analysis; D006801:Humans; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D015607:Stents / Q000191:economics; D015996:Survival Rate