Use of fully covered self-expanding metal stents for the management of benign biliary conditions.

BACKGROUND AND AIM: biliary self-expanding metal stents (SEMS) have the advantage of being inserted undeployed with very small sizes and provide, when fully opened, large diameters for biliary drainage. However, their use in benign conditions has been very limited, mainly because of difficulty in their extraction. We present our initial experience with a fully covered SEMS (Wallflex) for the management of benign problems of the bile duct. PATIENTS AND METHODS: in a prospective study, stents of 8 mm in diameter and 4, 6 or 8 cm long were inserted by means of ERCP. These SEMS were chosen when according to medical judgement it was thought that diameters greater than 10 French (3.3 mm) were needed for proper biliary drainage. Stents were extracted also endoscopically, several months later when deemed clinically appropriate. RESULTS: twenty biliary SEMS were inserted. Reasons for insertion were: large intrahepatic biliary fistula after hydatid cyst surgery (1), perforation of the papillary area following endoscopic sphincterotomy (2), coaxial insertion to achieve patency in obstructed uncovered stents inserted in benign conditions (3), benign strictures (7), multiple and large common bile duct stones that could not be extracted because of tapering and stricturing of the distal common bile duct (7). In all cases, successful biliary drainage was achieved and there were no complications from insertion. Stents were easily extracted after a mean time of 132 days (36-270) in place. Complete resolution of biliary problems was obtained in 14 patients (70%). CONCLUSIONS: in our initial experience, the fully covered Wallflex biliary stent was removed without any complication after being in place in the common bile duct for a mean time of over four months. Therefore, it could be used in the management of benign biliary conditions.

Utilización de prótesis metálicas autoexpandibles totalmente recubiertas en procesos biliares benignos / No disponible

Introducción y objetivo: las prótesis metálicas autoexpandibles biliares (PMAB) tienen la ventaja de introducirse plegadas con calibres muy pequeños y proporcionar, al abrirse completamente, diámetros grandes para el drenaje biliar. Su utilización en procesos benignos ha estado muy limitada, fundamentalmente por la dificultad en su extracción. Presentamos nuestra experiencia inicial con una PMAB totalmente recubierta (Wallflex) para tratar patología benigna de la vía biliar. Pacientes y métodos: en un estudio descriptivo prospectivo se insertaron por CPRE prótesis de 8 mm de diámetro y 4, 6 u 8 cm de longitud, cuando se consideró que para el drenaje biliar eran precisos diámetros superiores a 10 french (3,3 mm). Las prótesis se retiraron también por endoscopia varios meses después según se consideró oportuno clínicamente. Resultados: se insertaron 20 PMAB. Los motivos fueron: gran fístula biliar intrahepática tras cirugía de quiste hidatídico (1), perforación del área papilar por esfinterotomía endoscópica (2), recanalización de prótesis no recubiertas insertadas en procesos benignos (3), estenosis benignas (7), coledocolitiasis múltiples y de gran tamaño con afilamiento-estenosis del colédoco distal que no pudieron extraerse (7). En todos los casos se logró un drenaje biliar satisfactorio y no se produjeron complicaciones por la inserción. Las prótesis se extrajeron con facilidad a los 132 días de media (36-270). La resolución completa de los procesos se obtuvo en 14 pacientes (70%). Conclusiones: en nuestra experiencia inicial, la prótesis Wallflex biliar totalmente recubierta pudo extraerse sin complicaciones tras permanecer en el colédoco hasta una media de más de cuatro meses, por lo que podría utilizarse en el tratamiento de procesos biliares benignos(AU)

Background and aim: biliary self-expanding metal stents (SEMS) have the advantage of being inserted undeployed with very small sizes and provide, when fully opened, large diameters for biliary drainage. However, their use in benign conditions has been very limited, mainly because of difficulty in their extraction. We present our initial experience with a fully covered SEMS (Wallflex) for the management of benign problems of the bile duct. Patients and methods: in a prospective study, stents of 8 mm in diameter and 4, 6 or 8 cm long were inserted by means of ERCP. These SEMS were chosen when according to medical judgement it was thought that diameters greater than 10 French (3.3 mm) were needed for proper biliary drainage. Stents were extracted also endoscopically, several months later when deemed clinically appropriate. Results: twenty biliary SEMS were inserted. Reasons for insertion were: large intrahepatic biliary fistula after hydatid cyst surgery (1), perforation of the papillary area following endoscopic sphincterotomy (2), coaxial insertion to achieve patency in obstructed uncovered stents inserted in benign conditions (3), benign strictures (7), multiple and large common bile duct stones that could not be extracted because of tapering and stricturing of the distal common bile duct (7). In all cases, successful biliary drainage was achieved and there were no complications from insertion. Stents were easily extracted after a mean time of 132 days (36- 270) in place. Complete resolution of biliary problems was obtained in 14 patients (70%). Conclusions: in our initial experience, the fully covered Wallflex biliary stent was removed without any complication after being in place in the common bile duct for a mean time of over four months. Therefore, it could be used in the management of benign biliary conditions(AU)

Biliary sphincterotomy dilation for the extraction of difficult common bile duct stones

Background and aim: endoscopic retrograde cholangiopancreatography(ERCP) with biliary sphincterotomy (BS) is the usualmethod for extracting common bile duct stones. However, followingBS and by means of extraction balloons and Dormia baskets acomplete bile duct clearance cannot be achieved in all cases. Wepresent a study on the impact that hydrostatic balloon dilation of aprevious BS (BSD) may have in the extraction rate of choledocholithiasis.Patients and methods: a prospective study which included 91consecutive patients diagnosed with choledocholithiasis who underwentERCP. For stone removal, extraction balloons and Dormia basketswere used, and when necessary BSD was employed.Results: complete bile duct clearance was achieved in 86/91(94.5%) patients. BSD was used in 30 (33%) cases. In these cases,extraction was complete in 29/30 (97%); 23 (76%) patients in theBSD group had anatomic difficulties or bleeding disorders. Themost frequently used hydrostatic balloon diameter was 15 mm(60%). There were 7 (7.6%) complications: two self-limited hemorrhageepisodes in the BSD group and one episode of cholangitis,one of pancreatitis, and three of bleeding in the group inwhich BSD was not used.Conclusions: BSD is a very valuable tool for extracting commonbile duct stones. In our experience, there has been an increasein the extraction rate from 73% (Rev Esp Enferm Dig2002; 94: 340-50) to 94.5% (p = 0.0001, OR 0.1, CI 0.05-0.45), with no increase in complications(AU)