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Bridge to surgery using partially covered self-expandable metal stents (PCMS) in malignant biliary stricture: an acceptable paradigm?

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Abstract

Background and aim

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).

Conclusion

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.

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Disclosures

Authors Pop, Richter, Sauer, Ho, Adams, Phillips, and Rehan have no conflicts of interest or financial ties to disclose. Dr. Bauer has received honoraria for lectures from IMER (Institute for Medical Education and Research). Dr. Shami is a consultant for Olympus. Dr. Kahaleh has received grant support from Boston Scientific, Olympus, Alveolus, Conmed, and Cook Medical, and honoraria for lectures from Boston Scientific, Olympus, and Axcan Pharma.

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Authors and Affiliations

  1. Digestive Health Center, University of Virginia Health System, Box 800708, Charlottesville, VA, 22908-0708, USA

    George H. Pop, James A. Richter, Bryan Sauer, Michele E. Rehan, Henry C. Ho, Vanessa M. Shami & Michel Kahaleh

  2. Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA

    Reid B. Adams, Todd Bauer & Melissa S. Phillips

Authors
  1. George H. Pop
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  2. James A. Richter
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  3. Bryan Sauer
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  4. Michele E. Rehan
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  5. Henry C. Ho
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  6. Reid B. Adams
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  7. Todd Bauer
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  8. Vanessa M. Shami
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  9. Melissa S. Phillips
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  10. Michel Kahaleh
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Corresponding author

Correspondence to Michel Kahaleh.

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Pop, G.H., Richter, J.A., Sauer, B. et al. Bridge to surgery using partially covered self-expandable metal stents (PCMS) in malignant biliary stricture: an acceptable paradigm?. Surg Endosc 25, 613–618 (2011). https://doi.org/10.1007/s00464-010-1231-7

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  • DOI: https://doi.org/10.1007/s00464-010-1231-7

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