title: Outcome of second interventions for occluded metallic stents in patients with malignant biliary obstruction.
abstract: BACKGROUND
  Although self-expandable metallic stent (SEMS) has a longer patency than plastic stent (PS) for malignant biliary obstruction, stent occlusion can occur and drainage has to be reestablished in a patient with expected long survival. However, the choices are still controversial among restenting with SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). This study was designed to determine the efficacy and outcome of PS, SEMS, and PTBD for patients with occluded SEMS.
  
  
  METHODS
  A total of 154 ERCPs with SEMS insertion were performed at the Endoscopy Unit of Chulalongkorn University. The causes of obstructive jaundice were cholangiocarcinoma (n = 110), pancreatic cancer (n = 41), and metastatic carcinoma (n = 3). Thirty-two patients (20.9%) with occluded SEMS (uncovered SEMS = 22 and covered SEMS = 10) were identified. PS, SEMS, and PTBD were used to reestablish drainage in 11, 14, and 7 patients, respectively. The second stent was inserted as stent-in-stent. Patients with less advanced disease were preferably opted to have a second SEMS.
  
  
  RESULTS
  The median stent patency of second SEMS (100 days) was significantly longer than PS (60 days) and PTBD (75 days; p < 0.05). The median survival time for patients with second SEMS (230 days) was significantly longer than patients with PS (130 days) and PTBD (150 days; p < 0.05). Subgroup analysis in hilar obstructions showed no statistical difference in second stent patency and survival between PS and SEMS. Pain that required oral narcotic developed in 71% (5/7) of PTBD patients.
  
  
  CONCLUSIONS
  In general, a second SEMS insertion in occluded SEMS provides a significant longer patency time than PS and PTBD. However, the benefit of SEMS as a second intervention in hilar obstructed patients is still doubtful.
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.
authors.forename: Wiriyaporn
authors.initials: W
authors.lastname: Ridtitid
authors.forename: Rungsun
authors.initials: R
authors.lastname: Rerknimitr
authors.forename: Akkawat
authors.initials: A
authors.lastname: Janchai
authors.forename: Pradermchai
authors.initials: P
authors.lastname: Kongkam
authors.forename: Sombat
authors.initials: S
authors.lastname: Treeprasertsuk
authors.forename: Pinit
authors.initials: P
authors.lastname: Kullavanijaya
mesh_terms: D000368:Aged; D001650:Bile Duct Neoplasms / Q000150:complications*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D003251:Constriction, Pathologic; D004868:Equipment Failure; D005260:Female; D006801:Humans; D041781:Jaundice, Obstructive / Q000209:etiology* / Q000628:therapy*; D008297:Male; D008670:Metals; D008875:Middle Aged; D012008:Recurrence; D019233:Retreatment; D018709:Statistics, Nonparametric; D015607:Stents; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D008670:Metals