Covered Metal Stents Equal to Multiple Plastic Stents for Treatment of Biliary Strictures From Chronic Pancreatitis but Require Fewer Procedures
Bret T. Petersen, MD, MASGE, reviewing Ramchandani M, et al. Gastroenterology 2021 Mar 16.
Compression of the distal bile duct within a fibrotic pancreas is one complication of chronic pancreatitis (CP), which can lead to chronic cholestasis, cholangitis, and hepatic fibrosis. Endoscopic therapy with prolonged stent placement is indicated for these benign biliary strictures. This prospective, multicenter, randomized study sought to compare outcomes 1 year after 12 months of stent use with 2 or more 8.5 Fr or 10 Fr plastic stents (PS) versus covered self-expanding metal stents (FCSEMS).
Among 80 patients randomized to FCSEMS and 84 to PS, technical success was equivalent (98.6% and 97.6%, respectively). Crossover therapy from PS to FCSEMS was required in 11 patients and from FCSEMS to PS in 10 patients. Twelve months after stent removal, sustained stricture resolution, defined by the absence of need for reintervention and alkaline phosphatase levels remaining less than twice the level at the end of therapy, was observed after FCSEMS in 75.8% of patients (47/62) and after PS in 77.1% (54/70) (P=.008, noninferiority intention-to-treat [ITT] analysis). The study design yielded more ERCPs for PS (3.9±1.3) than FCSEMS (2.6±1.3) (P<.001, ITT). The incidence of serious adverse events was equivalent in both groups (PS, 19% vs FCSEMS, 23.8%; P=.568).
COMMENTTherapeutic outcomes for metal versus plastic stent use for distal biliary strictures caused by chronic pancreatitis were equivalent across the board for all patients and anatomies. However, individualized selection based on the presence or absence of the gallbladder and, when present, the proximity of the cystic duct junction to the stricture may negate many of the risks associated with metal stents. Use of metal stents required fewer procedures and, thereby, is likely more cost-effective.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
Ramchandani M, Lakhtakia S, Costamagna G, et al. Fully covered self-expanding metal stent versus multiple plastic stents to treat benign biliary strictures secondary to chronic pancreatitis: a multicenter randomized trial. Gastroenterology 2021 Mar 16. (Epub ahead of print) (https://doi.org/10.1053/j.gastro.2021.03.015)
