Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study.
BACKGROUND
The systematic use of metal stents to treat biliary obstruction is restricted by high cost compared with plastic stents. The aims of this study were to compare cost and efficacy of plastic stents and metal stents in the treatment of patients with malignant common bile duct strictures and to define factors that predict survival of these patients.


METHODS
One hundred eighteen patients (mean age 75 years) with malignant strictures of the common bile duct were randomized to placement of a plastic stent or metal stent. Comparisons were made with the Mann-Whitney or chi-square test as indicated; survival rates were compared with a Cox proportional hazards model.


RESULTS
There was no significant difference in survival between the two groups. Time to first obstruction was longer for patients in the metal stent group (metal stent, median not reached vs. plastic stent, 5 months; p = 0.007). The number of additional days of hospitalization, days of antibiotic therapy, and the numbers of ERCPs and transabdominal US procedures was significantly higher in the plastic stent group. After multivariate analysis, only the presence of liver metastases was independently related to survival (p < 0.0005; OR = 2.25). This variable defined a group with a shorter survival. Median survival of patients with hepatic metastasis at diagnosis was 2.7 months compared with 5.3 months for patients without liver metastasis; in the latter group, the overall cost associated with metal stents was lower than for plastic stents.


CONCLUSIONS
Metal stent placement is the most effective treatment of inoperable malignant common bile duct stricture. Placement of a metal stent is cost effective in patients without hepatic metastases, whereas a plastic stent should be placed in patients with spread of the tumor to the liver.
Kaassis
Mehdi
M
Gastroenterology Unit, University Hospital, Angers, Nice, Lyon, Strasbourg, Amiens.
Boyer
Jean
J
Dumas
Rémi
R
Ponchon
Thierry
T
Coumaros
Dimitri
D
Delcenserie
Richard
R
Canard
Jean-Marc
JM
Fritsch
Jacques
J
Rey
Jean-François
JF
Burtin
Pascal
P
D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D002780:Cholestasis, Intrahepatic / Q000401:mortality / Q000473:pathology / Q000628:therapy; D003138:Common Bile Duct Neoplasms / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008670:Metals / Q000627:therapeutic use*; D008875:Middle Aged; D009367:Neoplasm Staging; D010166:Palliative Care / Q000379:methods*; D010969:Plastics / Q000627:therapeutic use*; D011237:Predictive Value of Tests; D011336:Probability; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D015607:Stents; D016019:Survival Analysis; D016896:Treatment Outcome
D008670:Metals; D010969:Plastics