title: Bridge to surgery using partially covered self-expandable metal stents (PCMS) in malignant biliary stricture: an acceptable paradigm?
abstract: OBJECTIVE
  Partially covered self-expanding metal stents (PCMS) have been extensively used for palliation of malignant distal biliary stricture. Many centers have been using them as a bridge to surgery (BTS) regardless of resectability with or without eventual neoadjuvant therapy. We analyzed the outcome of all patients receiving PCMS and subsequently referred for surgery in our institution.
  
  
  METHODS
  Our prospectively established pancreaticobiliary database was retrospectively analyzed to retrieve all patients with malignant biliary stricture who underwent PCMS placement and subsequently went for curative surgical attempt at our institution. Cancer type and staging, adverse events related to stent placement or surgery, type of surgery performed, time between stenting and surgery, length of postoperative hospitalization, and postoperative follow-up were recorded.
  
  
  RESULTS
  27 patients (21 men; median age 66 years, range 39-82 years) received PCMS. Indications for placement included biliary stricture related to pancreatic cancer (n=23) or other malignancies (n=4). Median time between stenting and surgery was 32 days (range 6-569 days). Median time of hospitalization post surgery was 7 days (1-40 days). All patients underwent exploratory laparoscopy, followed in 9 (33.3%) by Whipple procedure with uneventful removal of the PCMS. Eighteen patients (66.6%) had their attempted curative resection terminated early due to intraoperative evidence of metastatic spread, with 8 (30%) patients undergoing peritoneal or liver metastasis biopsy. PCMS were left in place in those 18 patients. Complications related to PCMS in the bridge-to-surgery period included migration (n=2, 7.4%) and tissue overgrowth (n=1, 3.4%), all of them managed by endoscopic removal and replacement with PCMS. Median follow-up post surgery was 210 days (range 9-1,642 days).
  
  
  CONCLUSIONS
  PCMS are an appropriate BTS option. For resectable patients, PCMS results in biliary drainage and allows for neoadjuvant treatment without portending subsequent curative resection (Whipple). For unresectable patients, long-term biliary drainage is provided by PCMS.
authors.affiliation: Digestive Health Center, University of Virginia Health System, Box 800708, Charlottesville, VA 22908-0708, USA.
authors.forename: George H
authors.initials: GH
authors.lastname: Pop
authors.forename: James A
authors.initials: JA
authors.lastname: Richter
authors.forename: Bryan
authors.initials: B
authors.lastname: Sauer
authors.forename: Michele E
authors.initials: ME
authors.lastname: Rehan
authors.forename: Henry C
authors.initials: HC
authors.lastname: Ho
authors.forename: Reid B
authors.initials: RB
authors.lastname: Adams
authors.forename: Todd
authors.initials: T
authors.lastname: Bauer
authors.forename: Vanessa M
authors.initials: VM
authors.lastname: Shami
authors.forename: Melissa S
authors.initials: MS
authors.lastname: Phillips
authors.forename: Michel
authors.initials: M
authors.lastname: Kahaleh
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002779:Cholestasis / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D020099:Coated Materials, Biocompatible; D016208:Databases, Factual; D016145:Endoscopy, Digestive System / Q000295:instrumentation* / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008670:Metals; D011300:Preoperative Care / Q000379:methods; D011474:Prosthesis Design; D011788:Quality of Life; D012189:Retrospective Studies; D018570:Risk Assessment; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014850:Waiting Lists
chemical_list: D020099:Coated Materials, Biocompatible; D008670:Metals