title: Bridging across the ampulla of Vater with covered self-expanding metallic stents: is it contraindicated when treating malignant gastroduodenal obstruction?
abstract: OBJECTIVE
  To determine if concern for biliary obstruction constitutes a contraindication to the placement of a covered self-expandable metallic stent (SEMS) bridging the ampulla of Vater (AOV).
  
  
  METHODS
  Retrospective review of fluoroscopic images of stent placement was performed in 62 patients (43 men; mean age, 62 years) with malignant gastroduodenal obstruction treated with a partially covered SEMS. Bare (n = 35) and covered (n = 27) stent portions were placed to bridge the AOV. Preprocedural and postprocedural bilirubin and alkaline phosphatase (ALP) levels were reviewed. The incidence of external biliary drainage tube insertion within 1 month was compared between groups. In 27 patients with postprocedural computed tomography studies, causes of bile duct dilation were evaluated.
  
  
  RESULTS
  Compared to preprocedural data, postprocedural bilirubin and ALP levels were elevated significantly in both groups (bilirubin, mg/dL, 1.8 +/- 2.3 vs 2.8 +/- 3.7, P = .02 for bare, 1.6 +/- 1.7 vs 3.6 +/- 4.4, P = .02 for covered; ALP, IU/L, 193.2 +/- 174.8 vs 292.9 +/- 293.7, P = .01 for bare, 214.7 +/- 213.3 vs 357.6 +/- 234.4, P < .01 for covered group). Changes in laboratory measurements were not significantly different between groups (bilirubin, 1.1 mg/dL +/- 2.2 and 2.2 mg/dL +/- 4.0 in bare and covered groups, respectively [P = .19]; ALP, 128.9 IU/L +/- 207.0 and 156.3 IU/L +/- 136.1, respectively [P = .56]). The incidence of external biliary drainage tube insertion was not significantly different between groups (17.1% and 25.9% in bare and covered stent groups, P = .53). The stent was the cause of bile duct dilation in only one patient.
  
  
  CONCLUSIONS
  It is suggested that it is not contraindicated to place a covered SEMS to bridge the AOV.
authors.affiliation: Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
authors.forename: So Yeon
authors.initials: SY
authors.lastname: Kim
authors.forename: Ho-Young
authors.initials: HY
authors.lastname: Song
authors.forename: Jin Hyoung
authors.initials: JH
authors.lastname: Kim
authors.forename: Kyung Rae
authors.initials: KR
authors.lastname: Kim
authors.forename: Ji Hoon
authors.initials: JH
authors.lastname: Shin
authors.forename: Seung Soo
authors.initials: SS
authors.lastname: Lee
authors.forename: Sang Woo
authors.initials: SW
authors.lastname: Park
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater / Q000601:surgery*; D000075202:Contraindications; D004380:Duodenal Obstruction / Q000601:surgery*; D005260:Female; D017219:Gastric Outlet Obstruction / Q000601:surgery*; D005770:Gastrointestinal Neoplasms / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome