Management of dysfunctional covered self-expandable metallic stents in patients with malignant distal biliary obstruction.
BACKGROUND
Endoscopic placement of covered self-expandable metallic stents (CSEMSs) is effective for distal malignant biliary obstruction. However, management of dysfunctional CSEMSs has not been established.


METHODS
Between March 1998 and July 2007, a total of 74 patients who underwent endoscopic re-interventions for CSEMS dysfunction were analyzed. Second stent insertion (CSEMS or plastic stent) or mechanical cleaning of the occluded CSEMS was performed endoscopically. The period between second stent insertion and stent dysfunction or patient death (time to dysfunction; TTD) was calculated. The cleaned initial CSEMSs were analyzed as second stents.


RESULTS
Dysfunction of the second stent occurred in 17 of 37 patients (45.9%) in the CSEMS group, 16 of 20 (80.0%) in the plastic stent group, and 13 of 17 (76.5%) in the cleaning group. The median TTD of each group was 176, 57, and 46 days, respectively. The cumulative TTD was significantly higher in the CSEMS group than in the plastic stent and cleaning groups (P = 0.08). From the multivariate analysis, sludge occlusion of the first CSEMS was identified as a significant risk factor for second stent dysfunction (HR, 2.51; 95% CI, 1.19-5.46), and placement of the second CSEMS significantly reduced the risk of dysfunction (HR, 0.39; 95% CI, 0.18-0.79).


CONCLUSIONS
Insertion of a new CSEMS should be considered as the treatment of choice for the management of dysfunctional CSEMSs.
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
Osamu
O
Togawa
Hiroyuki
H
Isayama
Takeshi
T
Tsujino
Yousuke
Y
Nakai
Hirofumi
H
Kogure
Tsuyoshi
T
Hamada
Takashi
T
Sasaki
Yoko
Y
Yashima
Hiroshi
H
Yagioka
Toshihiko
T
Arizumi
Yukiko
Y
Ito
Saburo
S
Matsubara
Natsuyo
N
Yamamoto
Naoki
N
Sasahira
Kenji
K
Hirano
Nobuo
N
Toda
Minoru
M
Tada
Kazuhiko
K
Koike
D000368:Aged; D000369:Aged, 80 and over; D002779:Cholestasis / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D004067:Digestive System Neoplasms / Q000150:complications; D016145:Endoscopy, Digestive System / Q000379:methods; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008670:Metals; D008875:Middle Aged; D011474:Prosthesis Design; D011475:Prosthesis Failure; D011859:Radiography; D012008:Recurrence; D012086:Reoperation / Q000009:adverse effects / Q000379:methods; D012307:Risk Factors; D015607:Stents
D008670:Metals